Adult degenerative scoliosis: evaluation and management

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  • 1 Harris Methodist Fort Worth, Neurological Surgery, North Texas Neurological and Spine Center, Fort Worth, Texas; and
  • 2 Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
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Degenerative scoliosis is a prevalent issue among the aging population. Controversy remains over the role of surgical intervention in patients with this disease. The authors discuss a suitable approach to help guide surgical treatment, including decompression, instrumented posterior spinal fusion, anterior spinal fusion, and osteotomy. These treatment options are based on clinical analysis, radiographic analysis of the mechanical stability of the deformity, given pain generators, and necessary sagittal balance. The high potential complication rates appear to be outweighed by the eventual successful clinical outcomes in patients suitable for operative intervention. This approach has had favorable outcomes and could help resolve the controversy.

Abbreviations used in this paper: ADS = adult degenerative scoliosis; AIS = adolescent idiopathic scoliosis; ASF = anterior spinal fusion; TLIF = transforaminal lumbar interbody fusion.

Degenerative scoliosis is a prevalent issue among the aging population. Controversy remains over the role of surgical intervention in patients with this disease. The authors discuss a suitable approach to help guide surgical treatment, including decompression, instrumented posterior spinal fusion, anterior spinal fusion, and osteotomy. These treatment options are based on clinical analysis, radiographic analysis of the mechanical stability of the deformity, given pain generators, and necessary sagittal balance. The high potential complication rates appear to be outweighed by the eventual successful clinical outcomes in patients suitable for operative intervention. This approach has had favorable outcomes and could help resolve the controversy.

Abbreviations used in this paper: ADS = adult degenerative scoliosis; AIS = adolescent idiopathic scoliosis; ASF = anterior spinal fusion; TLIF = transforaminal lumbar interbody fusion.

Generally, scoliosis can be divided into 2 types: nonstructural and structural. The nonstructural type includes postural, hysterical, sciatic, inflammatory, and compensatory scoliosis, and some of these can become structural. The key is that the curve has no rotatory component. On the other hand, structural scoliosis includes congenital, neuromuscular, idiopathic, de novo, traumatic, and iatrogenic types among others. Our focus is on structural scoliosis in the adult population—more specifically, de novo ADS.

Adult scoliosis is a spinal deformity in a skeletally mature individual, with a curve measuring > 10° according to the Cobb method.12 Scoliosis in adults can be further divided into idiopathic and de novo types. Adult idiopathic scoliosis refers to a patient with a history of AIS with increasing symptoms or progression of the deformity into adulthood. In ADS, the curve develops during adulthood due to the degeneration of spinal motion segments.4,14 Generally, the deformity begins as the intervertebral disc starts to deteriorate, with ensuing degeneration and eventual lack of competency of the posterior elements, especially the facet joints.25 Thereafter, axial rotation of the involved spinal segments leads to lateral olisthesis, and ligamentous laxity occurs.

Demographics

Adult scoliosis prevalence ranges from 1 to 10%.17,24,28 This new-onset deformity is observed in more than 30% of elderly patients with no history of spinal abnormalities.4,27 Degenerative scoliosis is typically diagnosed in patients older than 40 years and without a history of AIS.27 These are lumbar curves measuring > 10° with associated distal fractional curves. Although these lumbar curves are not associated with structural thoracic curves, compensatory thoracic curves can occur. As in AIS, curve prevalence in ADS is inversely proportional to curve magnitude. The prevalence of 10°, 10–20°, and > 20° curves is 64, 44, and 24%, respectively. These curves have roughly a 1:1 female/male ratio and are rarely present before the age of 40 years, with a mean age of 70.5 years at the time of presentation.14

Natural History

Patients with ADS typically present in the 6th decade with symptoms of spinal stenosis. They can also present with a history of back pain that is worsening, radiculopathy, or a combination. Symptoms from spinal stenosis in this group of patients are not relieved by forward posture, as has been noted in those with neurogenic claudication not associated with scoliosis, unless a patient sits with his or her trunk supported by the arms. This distinction is important because the prognosis and treatment of ADS are different from those in patients with degenerative spinal stenosis. Similar to AIS curves, which can progress into adulthood, ADS curves tend to progress 1–6° per year (average 3° per year).25 Osteopenia seems to play a role in this progression, but this hypothesis has been refuted.26,27,31 Nonetheless, certain parameters do appear to factor into curve progression.25 Patient age and sex do not affect curve progression in this category of defomity.18 Curves with Cobb angles > 30°, an apical rotation greater than Grade II, a lateral olisthesis > 6 mm, and an intercrest line through L-5 appear to have a higher degree of progression.25

Evaluation

A thorough history and general physical examination are completed. More specifically, a history of idiopathic scoliosis is elicited to discount the possibility of a degenerative idiopathic deformity. In addition, patients are asked if they have experienced any changes in body habitus, gait, or how their clothes fit. Pain is investigated in terms of its initial onset, location, duration, characteristics, aggravating/relieving factors, and any previous modalities of treatment. A crucial question is whether the pain is purely axial or is also radicular in nature. Axial pain is more likely associated with the degree of radiographic lateral subluxation and sagittal imbalance, and therefore may require inclusion of the lumbar deformity (lateral subluxation) as well as extensive sagittal realignment. With radicular pain, it is important to note whether the location of the pain is the same as that of the concavity. Moreover, it helps to determine if leg pain stems from central or lateral recess (entrance zone, midzone, or exit zone) stenosis or both, as the latter may require greater bone decompression and probably instrumented fusion at the area of decompression. Finally, pain can include both the lower back and the extremities, and the operative approach should be tailored accordingly.

Patients are examined in their underwear and, for females, bra. As patients stand with hips and knees fully extended, they are observed at an appropriate distance and any trunk shift is noted. The relationship of the patient's head to the pelvis is also noted when evaluating overall coronal and sagittal balance. Any shoulder or pelvic asymmetry is documented. Forward and lateral bending maneuvers help assess the curve's rigidity, which is an important factor in terms of prognosis. Leg-length discrepancy and pelvic obliquity are evaluated. When leg-length discrepancy is the likely cause of the deformity, a shoe lift is used to reevaluate the patient to see if the curve can be corrected, although such correction is unlikely in stiffer curves. A neurological examination, including all cranial nerves, motor strength, reflexes, sensory modalities, and gait, is performed. A vascular examination, using Doppler ultrasonography if needed, is performed. Sacroiliac joints and trochanters are palpated and evaluated for any hip or knee contractures, and the degree of flexibility is noted. Finally, cardiopulmonary, bone quality, nutritional, and general health statuses are evaluated to determine if the patient is a suitable operative candidate.

Radiographic Evaluation

Full-length standing anteroposterior and lateral radiographs are obtained.22 Supine long cassette radiographs—removing gravity from the trunk—are obtained if operative intervention is planned, as these images quickly show the degree of correction spontaneously occurring. These curves typically have an L2–3 apex and are associated with lateral olisthesis, rotatory subluxation, and minimal structural vertebral deformity. They tend to have lumbar hypolordosis and short reciprocating curves without significant scoliosis above the lumbar levels. A fractional curve, L-4 to the sacrum, is also typically evident (Fig. 1). Computed tomography myelograms and MR images are also obtained. The former are particularly useful in this older age group, as some patients cannot undergo MR imaging studies because of cardiac pacemaker placement. Provocative testing helps to elucidate the pain generators, which can include facet/nerve root blocks and discograms. Such testing helps to further determine whether the structural deformity and/or the other pathologies are the primary pain generators, which in turn helps to determine the necessary portions of pathology that should be addressed, would best relieve the patient's symptoms, and produce a successful clinical outcome.15 Appropriate Cobb angle measurements as well as the parameters of spinopelvic balance are calculated for surgical planning. In this group of patients, sagittal balance is of the utmost importance as it has been correlated with successful clinical outcomes.16 Additionally, the degree of rotatory subluxation and olisthesis is quantified, and osteophytes are noted.22 The latter is crucial in terms of radiographic mechanical stability and helps in planning the type of operative intervention required for a given patient.

Fig. 1.
Fig. 1.

Radiograph demonstrating features of fractional degenerative lumbar scoliosis.

Treatment

Nonoperative Treatment Options

Nonoperative management is started provided that there are no significant stenotic, radicular, and/or back pain symptoms, including curves < 30° with < 2 mm of subluxation with anterior osteophytes.13 Patients undergoing such procedures usually have reasonable sagittal and coronal balance. Patients are asked to get involved in a low-impact muscle-strengthening endurance program. The use of nonsteroidal antiinflammatory drugs is instituted as needed, and based on DEXA scan findings, appropriate referral for osteopenia/porosis treatment is requested. Epidural and/or selective nerve root injections are carefully considered based on clinical findings and neuroradiographic studies. Bracing really has no role in this population. It is not likely to halt curve progression, as the mode of progression is usually not spinal growth but transverse instability, and its method of temporary pain relief will be outweighed by deconditioning.30 Operative intervention is offered to those who do not meet the above criteria, who fail conservative pain management, and/or those whose disease progresses.

Indications for Operative Intervention

Patients whose nonoperative pain management has failed are considered for surgical treatment. Specific treatment options are offered when correlation occurs between clinical and specific radiographic findings, particularly, L-3 and L-4 endplate angulations, lumbar lordosis, thoracolumbar kyphosis, and lateral olisthesis.28 Lumbar curves with > 30–40° and/or 6 mm of olisthesis on presentation are also considered for operative intervention. Moreover, curve progression as well as progressive neurological deficits are indicators for surgical intervention.25 Patients whose curves progress more than 10° and/or have an increase in subluxation > 3 mm with increasing clinical symptomatology are offered surgical options.

Six Levels of Operative Treatment: Lenke-Silva Treatment Levels I–VI

Six distinct levels of operative treatment are available for ASD and include the following: I, decompression alone; II, decompression and limited instrumented posterior spinal fusion; III, decompression and lumbar curve instrumented fusion; IV, decompression with anterior and posterior spinal instrumented fusion; V, thoracic instrumentation and fusion extension; and VI, inclusion of osteotomies for specific deformities. A matrix is presented to help sort the patient's symptoms and radiographs into these 6 levels of treatment (Table 1).

TABLE 1:

Lenke-Silva levels of treatment for operative ADS: clinically and radiographically based decision making matrix*

SymptomNonop ManagementLevel ILevel IILevel IIILevel IVLevel VLevel VI
neurogenic claudication/radiculopathyminimal++++++
back painminimalminimal+/−++++
ant osteophytes++
olisthesis++++
coronal Cobb (<30º)++++
lumbar kyphosis+++
global imbalance+ (flexible)+ (stiff/fused)

* See text (Six Levels of Operative Treatment: Lenke-Silva Treatment Levels I–VI) for specific descriptions of levels of treatment. Abbreviations: ant = anterior; + = present; − = absent.

Level I treatment consists of decompression alone, which is usually suitable for patients with neurogenic claudication due to central stenosis and requiring a limited decompression. Radiographically, anterior osteophytes should be present with no more than 2 mm of subluxation and reasonable sagittal/coronal balance. Additionally, there should be minimal or no back pain and/or deformity complaints, and the curve should be < 30° without thoracic hyperkyphosis and/or imbalance (Fig. 2). However, decompression alone for stenosis with associated scoliosis can lead to deformity progression and worsening of symptoms.

Fig. 2.
Fig. 2.

Lenke-Silva Treatment Level I. A and B: Images obtained in a 62-year-old male with neurogenic claudication. C–F: Computed tomography myelograms of L2–3, L3–4, L4–5, and L5–S1 showing spinal stenosis. G and H: Five-year postoperative radiographs demonstrating maintained alignment from L-2 to the sacrum.

Level II treatment involves adding instrumentation limited to the area of the decompression in patients with the above symptoms (requiring extensive decompression) and curves < 30°, more than 2 mm of subluxation, and no anterior osteophytes in the area of decompression. Again, there should be no back pain/deformity symptoms or thoracic hyperkyphosis in a relatively well-balanced patient (Fig. 3). In a series of 55 consecutive patients with ADS treated using decompression alone (Level I, 16 patients) versus decompression with limited instrumented fusion (Level II, 39 patients), the Level I patients were older and had smaller curves (Table 2). At a minimum 2-year follow-up, 62% of Level I versus 82% of Level II patients reported a good–excellent result (p < 0.05). By 5 years of follow-up, 12 of the 16 Level I patients had recurrent stenosis, whereas 14 of the 39 Level II patients had adjacent level stenosis; the stenosis rate was greater in the Level I than in the Level II patients (p = 0.008) (Cheh G, Lenke LG, Bridwell KH, et al., presented at the Scoliosis Research Society Annual Meeting, 2006).

Fig. 3.
Fig. 3.

Lenke-Silva Treatment Level II. A and B: Radiographs obtained in a 73-year-old male, showing spinal stenosis from L-3 to L-5 and a rotary subluxation at L3–4. He was treated with decompression and a posterior spinal fusion from L-3 to L-5. C and D: At 4 years postoperatively, he had a solid fusion from L-3 to L-5 with slight disc degeneration at L2–3.

TABLE 2:

Patient demographics comparing Lenke-Silva Treatment Level I with Level II*

CharacteristicTreatment Level ITreatment Level IIp Value
age at surgery (yrs)75.0 ± 666.3 ± 7.60.01
average follow-up (yrs)4.6 ± 2.74.6 ± 2.40.39
preop curve magnitude (°)16.0 ± 622.0 ± 80.23
postop curve change (°)3.0 ± 41.0 ± 80.5

* Values are presented as mean ± SD unless otherwise indicated.

For Level III treatment, the entire lumbar curve in addition to the necessary decompressions is included in the instrumented fusion when symptoms of primary back pain are associated with the spinal deformity. Here, the clinical correlation of pain with the location of the curve becomes very important in terms of further selecting the appropriate operative treatment. Typically, these curves are > 45°, have > 2 mm of subluxation, and lack anterior osteophytes in the operative region, although there is reasonable coronal and sagittal balance (Fig. 4). Anterior spinal fusion via a TLIF approach can be an important adjunct at the lower ends of the construct when fusing to the lumbosacral junction.

Fig. 4.
Fig. 4.

Lenke-Silva Treatment Level III. A–D: Images obtained in a 49-year-old female with degenerative lumbar scoliosis and associated back and leg pain. She underwent a T-11 to the sacrum posterior spinal fusion with TLIFs at L2–3 and L5–S1.

Level IV treatment consists of anterior and posterior fusion of the lumbar spine. Anterior spinal fusion has played a significant role in correcting lumbar hypokyphosis and imbalance. In addition, it adds indirect decompression via foraminal distraction. It helps decrease pseudarthrosis, especially in smokers, patients with diabetes, and osteopenic patients. In the latter group, it also helps prevent posterior instrumentation failure by load sharing, especially in obese patients. Note, however, that there is increased mobility from a formal anterior approach in older patients. Hence, an ASF is selectively recommended for patients with severe stenosis, back pain, and deformity symptoms with mild sagittal imbalance. There should be no anterior osteophytes or thoracic hyperkyphosis and > 2 mm of subluxation (Fig. 5).

Fig. 5.
Fig. 5.

Lenke-Silva Treatment Level IV. A–D: Images obtained 59-year-old female with a 58° ADS lumbar curve who underwent a same-day L-2 to the sacrum ASF and a T-12 to the sacrum posterior spinal fusion for correction of her deformity.

Level V treatment involves extending the fusion and instrumentation into the thoracic region in patients satisfying the aforementioned criteria and having thoracic hyperkyphosis and/or thoracic decompensation. In addition, those with global and/or coronal imbalance become candidates for thoracic extension of their fusion/instrumentation (Fig. 6). Very often, osteotomies can be particularly useful in this subgroup of patients.

Fig. 6.
Fig. 6.

Lenke-Silva Treatment Level V. A and B: Images obtained in a 75-year-old female with degenerative lumbar scoliosis and associated coronal and sagittal imbalance. She underwent a posterior spinal fusion from T-2 to the sacrum and TLIFs at L4–5 and L5–S1. C and D: At 3 years postoperatively, her alignment was nicely restored and maintained. E–H: Preoperative and postoperative clinical photos demonstrating restored coronal and sagittal alignment/balance.

Osteotomy Choices: Treatment Level VI

Patients whose deformity demonstrates > 30% correction on bending radiographs do not require osteotomies, as they are considered flexible. Curves that are corrected < 30% are considered stiff deformities and might require osteotomies. However, many deformities are rigid, and patients are not clinically balanced or they have already undergone fusion. It is this group of patients that may also require osteotomies, because the deformities are stuck. Osteotomies can aid not only in clinically rebalancing the patient, but also in decreasing the load placed on the instrumentation at the metal-bone interface. Rebalancing the spine is of the utmost clinical importance as a significant link has been found between it and outcomes.1 The intelligent use of osteotomies begins with the judicious evaluation of both clinical and radiographic coronal and sagittal balance and is the main component of Level VI treatment. Cases of sagittal imbalance can be classified into Type I or II.7

Type I sagittal imbalance refers to patients who are globally balanced but in whom a segmental portion of the spine is flat or kyphotic. In contrast, Type II sagittal imbalance refers to global and segmental imbalance. When sagittal and coronal imbalance coexist, they can also be classified into Type A or B.7 With Type A imbalance, the patient's shoulders and pelvis are tilted in opposite directions. Conversely, with Type B imbalance, both the shoulders and the pelvis tilt in the same direction. Once the latter situation is recognized in the rigid spine, then alternative options of bone resection techniques can be determined.

With Type I sagittal imbalance, Smith-Petersen osteotomies are typically indicated, provided that mobility at the disc space is adequate to permit extension.29 If the disc space is not sufficiently mobile but bone stock is adequate, then anterior releases with a concomitant morselized graft can be used. If bone stock is inadequate, then anterior structural grafts are used. The latter can also be used for Type II imbalances when Smith-Petersen osteotomies will permit the weight-bearing line to fall within 3 cm of the sacrum (Fig. 7). Another alternative for Type II imbalance is a pedicle subtraction osteotomy, which is useful when bone stock is poor as well as in smokers and diabetic patients because bone-on-bone contact occurs at the time of osteotomy closure, with high fusion rates of the vertebral body. Typically, it affords ~ 30° of lordotic correction; hence, it is often suitable for global imbalance correction without the need for anterior releases or structural grafting.12 Anterior support may be necessary when fusing to the sacrum, but with current techniques, this can easily be achieved via a posterior-only approach.19 The precise amount of bone resection to achieve a balanced spine is readily calculated using simple trigonometric calculations.23 Asymmetrical pedicle subtraction osteotomies are often useful in correcting Type A biplanar deformities. The more radical vertebral column resection technique is often necessary for the rare Type B deformities.6,21

Fig. 7.
Fig. 7.

Lenke-Silva Treatment Level VI. A and B: Images obtained in a 63-year-old female with lumbar degenerative scoliosis. Two months after surgery, which was performed elsewhere, early L-5 screw pullout developed as did subsequent severe sagittal imbalance. The patient then underwent a revision posterior spinal fusion, an L-3 pedicle subtraction osteotomy, and an ASF. C and D: At 3 years postoperatively, images revealed corrected sagittal balance. E–H: Preoperative and postoperative clinical photos demonstrating excellent coronal and sagittal balance.

Fusion Levels

Proximal fusion levels should start at a neutral and stable vertebra, as defined by the center sacral vertical line.8,9,20 The fusion should never stop at a rotatory subluxation. Furthermore, the thoracic physiological apex must be avoided.5 Hence, the fusion should stop well below T-10 or well above T5–6. Similarly, distal fusion levels should begin at a neutral and stable vertebra and should never end at a rotatory subluxation. One could end the fusion at L-5; however, it must be extended to the sacrum if there is an oblique take-off of L-5 on the sacrum—typical with fractional curves > 15°—advanced degeneration of the L-5/S-1 intervertebral disc, L5–S1 spondylolysis, or previous decompression at this segment. Additionally, fusion at T-12 and above should be considered for extension to the ilium/S-1. Again, fractional curves > 15° must be included in the distal fusion to achieve balance.

Complications

Among spinal deformity surgeries, adult deformity corrective procedures carry a high complication rate.3,10,32 Often this group of patients has multiple comorbidities, and the operations are more involved to achieve appropriate balance and proper load sharing on the instrumentation, the latter being particularly important in osteopenic patients. Such complications include infections, CSF leaks (especially among revision cases), implant failures, junctional kyphosis, adjacent segment degeneration, and pseudarthrosis. Systemic complications include myocardial infarction, pneumonia, ileus, urinary tract infections, deep venous thrombosis, and superior mesentery artery syndrome. Blindness is a particularly ominous but an exceedingly rare complication. Hence, even when the appropriate techniques and postoperative care are undertaken, complications can still be somewhat high; however, the clinical outcomes appear to support such risks in appropriately selected patients.2 A comparative chart of the most helpful references for ADS evaluation and treatment is featured in Table 3.

TABLE 3:

Recommended references for ADS demographics, evaluation, and treatment*

Authors & YearNo. of PatientsStudy DesignConclusion
demographics
Benner & Ehni, 197914retrospective, case reportafter decompressive procedures for degenerative scoliosis, patients w/ continued back pain & possible mechanical instability should undergo augmentation w/ instrumented fusion
Grubb et al., 198821reviewpatients w/de novo scoliosis typically present in the 6th decade of life; progression is likely due to degenerative changes, not necessarily bone demineralization
Kobayashi et al., 200660prospective, community-based cohortde novo scoliosis is becoming one of the most prevalent findings in the aging spine; vertebral index, disc index, and lateral osteophyte difference: the latter 2, and not the former, were found to be independent predictors of de novo scoliosis
Ploumis et al., 2007NAreviewprevalence of degenerative scoliosis in aging population is increasing; the goal is the least intervention that will provide pain relief & improvement in functional lifestyle
nonoperative treatment
van Dam, 1988NAinstructionalthis patient population presents surgical challenge; complaints of pain must be carefully investigated; the high complication rate requires careful preop evaluation & surgical skill; spinal instrumentation is a very important adjunct
Everett & Patel, 2007NAreviewalthough conservative care in general may be useful, evidence supporting this hypothesis is lacking
natural history/treatment
Schwab et al., 200295prospectiveradiographic criteria should be developed to guide treatment of this patient population; olisthesis, L-3 and L-4 endplate obliquity, lumbar lordosis, & thoracolumbar kyphosis appear to correlate w/ pain development
Korovessis et al., 199491retrospective, case reportlat spondylolisthesis of the apical vertebra, Harrington factor, & disc index were related to scoliosis progression
Pritchett & Bortel, 1993200retrospective, case reportrelationship of L-5 to the intercrestal line, Cobb angle, & degree of apical rotation serve as valuable progression markers
radiographic evaluation
Cobb, 1948NAinstructionalgold standard & cornerstone of radiographic evaluation of patients w/ deformity
Bernhardt & Bridwell, 1989102retrospectivewide range of normal sagittal alignment, permitting more objective evaluation of hypokyphosis & lordosis often seen in scoliosis
O'Brien et al., 2004NAinstructionalexcellent overall guide for evaluation of pertinent radiographic parameter used in evaluation of patients w/ deformity
osteotomies
Ahn et al., 200283prospective, clinical trialsignificant association is found btwn outcomes & radiographic correction; radiographic parameters should be goal of spinal osteotomies
Bradford & Tribus, 199724retrospectivefixed, decompensated spinal deformity may be safely corrected via vertebral column resection, w/ transient complication not outweighing the benefits
Bridwell et al., 2004102retrospectivein patients w/ fixed imbalance, pedicle subtraction osteotomy is an important adjunct; however, comorbidities, pseudarthrosis at the thoracic spine, & breakdown at caudal fusion end lead to worse clinical outcomes
Lenke et al., 200935retrospective review of prospectively accrued patient cohortvertebral column resection is challenging & safe technique that permits a posterior-only approach of severe spinal deformities; motor evoked potential recording is a mandatory monitoring modality
Ondra et al., 200615retrospective comparative studysimple mathematic equations permit reliable determination of the degree of pedicle subtraction; osteotomy needed for correction of sagittal imbalance
Silva et al., 2008NAinstructional, book chapteroverall review of generally used posterior-only osteotomies in deformity treatment
fusion levels
Lenke & Bridwell, 199195retrospectivecareful curve analysis, including objective evaluation of curve parameters, is essential to prevent postop decompensation; standing anteroposterior radiographs important
Bridwell & Lenke, 19946instructional/review, book chaptercareful attention should be paid when placing instrumentation at critical vertebrae btwn deformity curves; this will help to avoid decompensation; certain parameter at L-3 can help in deciding to end instrumentation at this level, saving fusion levels
Bridwell et al., 20047data reviewexcellent review of overall curve analysis & decision making for choosing instrumentation & fusion levels in scoliosis/deformity surgery

* NA = not applicable.

† Total of 5225 articles.

‡ Illustrative cases.

Conclusions

Demographically and clinically, ADS is a very important entity to the deformity surgeon. An appropriate history and workup guide treatment, differentiating the therapy for stenosis from that for a deformity. Six different levels of treatment (Lenke-Silva Treatment Levels I–VI) of increasing complexity are available to the surgeon. More specifically, these levels of treatment help to decide when to address the stenosis alone and when to include the deformity. Viable options based on clinical and radiographic stability as well as balance and revision status include nonoperative management, decompression, instrumented posterior spinal fusion, ASF, and osteotomy. Restoring lumbar lordosis and sagittal balance take precedence over scoliosis correction. Although higher complication rates are expected, a beneficial outcome in properly selected patients is also anticipated.

Disclosure

Dr. Lenke was a consultant for Medtronic until January 2009, and is a patent holder with Medtronic.

Author contributions to the study and manuscript preparation include the following. Conception and design: FE Silva. Critically revising the article: LG Lenke. Reviewed final version of the manuscript and approved it for submission: LG Lenke. Administrative/technical/material support: LG Lenke.

Acknowledgment

The authors acknowledge Jennifer Roth for her assistance in preparing this manuscript.

References

  • 1

    Ahn UM, , Ahn NU, , Buchowski JM, , Kebaish KM, , Lee JH, & Song ES, : Functional outcome and radiographic correction after spinal osteotomy. Spine 27:13031311, 2002

    • Search Google Scholar
    • Export Citation
  • 2

    Albert TJ, , Purtill J, , Mesa J, , McIntosh T, & Balderston RA: Health outcome assessment before and after adult deformity surgery. A prospective study. Spine 20:20022005, 1995

    • Search Google Scholar
    • Export Citation
  • 3

    Baron EM, & Albert TJ: Medical complications of surgical treatment of adult spinal deformity and how to avoid them. Spine 31:19 Suppl S106S118, 2006

    • Search Google Scholar
    • Export Citation
  • 4

    Benner B, & Ehni G: Degenerative lumbar scoliosis. Spine 4:548552, 1979

  • 5

    Bernhardt M, & Bridwell KH: Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 14:717721, 1989

    • Search Google Scholar
    • Export Citation
  • 6

    Bradford DS, & Tribus CB: Vertebral column resection for the treatment of rigid coronal decompensation. Spine 22:15901599, 1997

  • 7

    Bridwell KH, Adult spinal deformity revision surgery. Heary RF, & Albert TJ: Spinal Deformity: The Essentials ed 1 New York, Thieme, 2007. 240248

    • Search Google Scholar
    • Export Citation
  • 8

    Bridwell KH: Selection of instrumentation and fusion levels for scoliosis: where to start and where to stop. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine 1:18, 2004

    • Search Google Scholar
    • Export Citation
  • 9

    Bridwell KH, & Lenke LG, Prevention and treatment of decompensation. When can levels be saved and selective fusion be performed in idiopathic scoliosis. Farcy JPC: Complex Spinal Deformities, Spine: State of the Art Reviews, Vol. 8, No. 3 Philadelphia, Hanley and Belfus, 1994. 643657

    • Search Google Scholar
    • Export Citation
  • 10

    Bridwell KH, , Lenke LG, , Baldus C, & Blanke K: Major intraoperative neurologic deficits in pediatric and adult spinal deformity patients. Incidence and etiology at one institution. Spine 23:324331, 1998

    • Search Google Scholar
    • Export Citation
  • 11

    Bridwell KH, , Lewis SJ, , Rinella A, , Lenke LG, , Baldus C, & Blanke K: Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. Surgical technique. J Bone Joint Surg Am 86-A:Suppl 1 4450, 2004

    • Search Google Scholar
    • Export Citation
  • 12

    Cobb JR: Outline for the study of scoliosis. Instructional course lectures. American Academy of Orthopedic Surgeons 5:261275, 1948

  • 13

    Everett CR, & Patel RK: A systematic literature review of nonsurgical treatment in adult scoliosis. Spine 32:19 Suppl S130S134, 2007

  • 14

    Grubb SA, , Lipscomb HJ, & Coonrad RW: Degenerative adult onset scoliosis. Spine 13:241245, 1988

  • 15

    Grubb SA, , Lipscomb HJ, & Suh PB: Results of surgical treatment of painful adult scoliosis. Spine 19:16191627, 1994

  • 16

    Jackson RP, , Peterson MD, , McManus AC, & Hales C: Compensatory spinopelvic balance over the hip axis and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients. Spine 23:17501767, 1998

    • Search Google Scholar
    • Export Citation
  • 17

    Kobayashi T, , Atsuta Y, , Takemitsu M, , Matsuno T, & Takeda N: A prospective study of de novo scoliosis in a community based cohort. Spine 31:178182, 2006

    • Search Google Scholar
    • Export Citation
  • 18

    Korovessis P, , Piperos G, , Sidiropoulos P, & Dimas A: Adult idiopathic lumbar scoliosis. A formula for prediction of progression and review of the literature. Spine 19:19261932, 1994

    • Search Google Scholar
    • Export Citation
  • 19

    Kuklo TR, , Bridwell KH, , Lewis SJ, , Baldus C, , Blanke K, & Iffrig TM, : Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws. Spine 26:19761983, 2001

    • Search Google Scholar
    • Export Citation
  • 20

    Lenke LG, & Bridwell KH: Achieving coronal balance using Cotrel-Dubousset instrumentation (C-D.I.). 8th Proceeding of the International Congress on Cotrel-Dubousset Instrumentation Montpellier, France, Sauramps Medical Publishers, 2732, 1991

    • Search Google Scholar
    • Export Citation
  • 21

    Lenke LG, , O'Leary PT, , Bridwell KH, , Sides BA, , Koester LA, & Blanke KM: Posterior vertebral column resection for severe pediatric deformity: minimum two-year follow-up of thirty-five consecutive patients. Spine 34:22132221, 2009

    • Search Google Scholar
    • Export Citation
  • 22

    O'Brien MF, , Kuklo TR, , Blanke KM, & Lenke LG: Adult deformity. Spinal Deformity Study Group Radiographic Measurements Manual Memphis, TN, Medtronic Sofamor Danek USA, 2004. 7194

    • Search Google Scholar
    • Export Citation
  • 23

    Ondra SL, , Marzouk S, , Koski T, , Silva F, & Salehi S: Mathematical calculation of pedicle subtraction osteotomy size to allow precision correction of fixed sagittal deformity. Spine 31:E973E979, 2006

    • Search Google Scholar
    • Export Citation
  • 24

    Ploumis A, , Transfledt EE, & Denis F: Degenerative lumbar scoliosis associated with spinal stenosis. Spine J 7:428436, 2007

  • 25

    Pritchett JW, & Bortel DT: Degenerative symptomatic lumbar scoliosis. Spine 18:700703, 1993

  • 26

    Riseborough EJ: Scoliosis in adults. Curr Pract Orthop Surg 7:3655, 1977

  • 27

    Robin GC, , Span Y, , Steinberg R, , Makin M, & Menczel J: Scoliosis in the elderly: a follow-up study. Spine 7:355359, 1982

  • 28

    Schwab FJ, , Smith VA, , Biserni M, , Gamez L, , Farcy JP, & Pagala M: Adult scoliosis: a quantitative radiographic and clinical analysis. Spine 27:387392, 2002

    • Search Google Scholar
    • Export Citation
  • 29

    Silva FE, , Bridwell KH, & Lenke LG, Thoracic Smith-Petersen osteotomy versus pedicle subtraction osteotomy for posterior-only treatment of thoracic kyphosis. Mummaneni PV, , Lenke LG, & Haid RW Jr: Spinal Deformity. A Guide to Surgical Planning and Management St. Louis, MO, Quality Medical Publishing, 2008. 40928

    • Search Google Scholar
    • Export Citation
  • 30

    van Dam BE: Nonoperative treatment of adult scoliosis. Orthop Clin North Am 19:347351, 1988

  • 31

    Vanderpool DW, , James JI, & Wynne-Davies R: Scoliosis in the elderly. J Bone Joint Surg Am 51:446455, 1969

  • 32

    Williams EL: Postoperative blindness. Anesthesiol Clin North America 20:605622, 2002

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Contributor Notes

Address correspondence to: Fernando E. Silva, M.D., Harris Methodist Fort Worth, Neurological Surgery, North Texas Neurosurgical and Spine Center, 1300 West Terrell Avenue, Suite 300, Fort Worth, Texas 76104. email: fesr1md@yahoo.com.
  • View in gallery

    Radiograph demonstrating features of fractional degenerative lumbar scoliosis.

  • View in gallery

    Lenke-Silva Treatment Level I. A and B: Images obtained in a 62-year-old male with neurogenic claudication. C–F: Computed tomography myelograms of L2–3, L3–4, L4–5, and L5–S1 showing spinal stenosis. G and H: Five-year postoperative radiographs demonstrating maintained alignment from L-2 to the sacrum.

  • View in gallery

    Lenke-Silva Treatment Level II. A and B: Radiographs obtained in a 73-year-old male, showing spinal stenosis from L-3 to L-5 and a rotary subluxation at L3–4. He was treated with decompression and a posterior spinal fusion from L-3 to L-5. C and D: At 4 years postoperatively, he had a solid fusion from L-3 to L-5 with slight disc degeneration at L2–3.

  • View in gallery

    Lenke-Silva Treatment Level III. A–D: Images obtained in a 49-year-old female with degenerative lumbar scoliosis and associated back and leg pain. She underwent a T-11 to the sacrum posterior spinal fusion with TLIFs at L2–3 and L5–S1.

  • View in gallery

    Lenke-Silva Treatment Level IV. A–D: Images obtained 59-year-old female with a 58° ADS lumbar curve who underwent a same-day L-2 to the sacrum ASF and a T-12 to the sacrum posterior spinal fusion for correction of her deformity.

  • View in gallery

    Lenke-Silva Treatment Level V. A and B: Images obtained in a 75-year-old female with degenerative lumbar scoliosis and associated coronal and sagittal imbalance. She underwent a posterior spinal fusion from T-2 to the sacrum and TLIFs at L4–5 and L5–S1. C and D: At 3 years postoperatively, her alignment was nicely restored and maintained. E–H: Preoperative and postoperative clinical photos demonstrating restored coronal and sagittal alignment/balance.

  • View in gallery

    Lenke-Silva Treatment Level VI. A and B: Images obtained in a 63-year-old female with lumbar degenerative scoliosis. Two months after surgery, which was performed elsewhere, early L-5 screw pullout developed as did subsequent severe sagittal imbalance. The patient then underwent a revision posterior spinal fusion, an L-3 pedicle subtraction osteotomy, and an ASF. C and D: At 3 years postoperatively, images revealed corrected sagittal balance. E–H: Preoperative and postoperative clinical photos demonstrating excellent coronal and sagittal balance.

  • 1

    Ahn UM, , Ahn NU, , Buchowski JM, , Kebaish KM, , Lee JH, & Song ES, : Functional outcome and radiographic correction after spinal osteotomy. Spine 27:13031311, 2002

    • Search Google Scholar
    • Export Citation
  • 2

    Albert TJ, , Purtill J, , Mesa J, , McIntosh T, & Balderston RA: Health outcome assessment before and after adult deformity surgery. A prospective study. Spine 20:20022005, 1995

    • Search Google Scholar
    • Export Citation
  • 3

    Baron EM, & Albert TJ: Medical complications of surgical treatment of adult spinal deformity and how to avoid them. Spine 31:19 Suppl S106S118, 2006

    • Search Google Scholar
    • Export Citation
  • 4

    Benner B, & Ehni G: Degenerative lumbar scoliosis. Spine 4:548552, 1979

  • 5

    Bernhardt M, & Bridwell KH: Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 14:717721, 1989

    • Search Google Scholar
    • Export Citation
  • 6

    Bradford DS, & Tribus CB: Vertebral column resection for the treatment of rigid coronal decompensation. Spine 22:15901599, 1997

  • 7

    Bridwell KH, Adult spinal deformity revision surgery. Heary RF, & Albert TJ: Spinal Deformity: The Essentials ed 1 New York, Thieme, 2007. 240248

    • Search Google Scholar
    • Export Citation
  • 8

    Bridwell KH: Selection of instrumentation and fusion levels for scoliosis: where to start and where to stop. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine 1:18, 2004

    • Search Google Scholar
    • Export Citation
  • 9

    Bridwell KH, & Lenke LG, Prevention and treatment of decompensation. When can levels be saved and selective fusion be performed in idiopathic scoliosis. Farcy JPC: Complex Spinal Deformities, Spine: State of the Art Reviews, Vol. 8, No. 3 Philadelphia, Hanley and Belfus, 1994. 643657

    • Search Google Scholar
    • Export Citation
  • 10

    Bridwell KH, , Lenke LG, , Baldus C, & Blanke K: Major intraoperative neurologic deficits in pediatric and adult spinal deformity patients. Incidence and etiology at one institution. Spine 23:324331, 1998

    • Search Google Scholar
    • Export Citation
  • 11

    Bridwell KH, , Lewis SJ, , Rinella A, , Lenke LG, , Baldus C, & Blanke K: Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. Surgical technique. J Bone Joint Surg Am 86-A:Suppl 1 4450, 2004

    • Search Google Scholar
    • Export Citation
  • 12

    Cobb JR: Outline for the study of scoliosis. Instructional course lectures. American Academy of Orthopedic Surgeons 5:261275, 1948

  • 13

    Everett CR, & Patel RK: A systematic literature review of nonsurgical treatment in adult scoliosis. Spine 32:19 Suppl S130S134, 2007

  • 14

    Grubb SA, , Lipscomb HJ, & Coonrad RW: Degenerative adult onset scoliosis. Spine 13:241245, 1988

  • 15

    Grubb SA, , Lipscomb HJ, & Suh PB: Results of surgical treatment of painful adult scoliosis. Spine 19:16191627, 1994

  • 16

    Jackson RP, , Peterson MD, , McManus AC, & Hales C: Compensatory spinopelvic balance over the hip axis and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients. Spine 23:17501767, 1998

    • Search Google Scholar
    • Export Citation
  • 17

    Kobayashi T, , Atsuta Y, , Takemitsu M, , Matsuno T, & Takeda N: A prospective study of de novo scoliosis in a community based cohort. Spine 31:178182, 2006

    • Search Google Scholar
    • Export Citation
  • 18

    Korovessis P, , Piperos G, , Sidiropoulos P, & Dimas A: Adult idiopathic lumbar scoliosis. A formula for prediction of progression and review of the literature. Spine 19:19261932, 1994

    • Search Google Scholar
    • Export Citation
  • 19

    Kuklo TR, , Bridwell KH, , Lewis SJ, , Baldus C, , Blanke K, & Iffrig TM, : Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws. Spine 26:19761983, 2001

    • Search Google Scholar
    • Export Citation
  • 20

    Lenke LG, & Bridwell KH: Achieving coronal balance using Cotrel-Dubousset instrumentation (C-D.I.). 8th Proceeding of the International Congress on Cotrel-Dubousset Instrumentation Montpellier, France, Sauramps Medical Publishers, 2732, 1991

    • Search Google Scholar
    • Export Citation
  • 21

    Lenke LG, , O'Leary PT, , Bridwell KH, , Sides BA, , Koester LA, & Blanke KM: Posterior vertebral column resection for severe pediatric deformity: minimum two-year follow-up of thirty-five consecutive patients. Spine 34:22132221, 2009

    • Search Google Scholar
    • Export Citation
  • 22

    O'Brien MF, , Kuklo TR, , Blanke KM, & Lenke LG: Adult deformity. Spinal Deformity Study Group Radiographic Measurements Manual Memphis, TN, Medtronic Sofamor Danek USA, 2004. 7194

    • Search Google Scholar
    • Export Citation
  • 23

    Ondra SL, , Marzouk S, , Koski T, , Silva F, & Salehi S: Mathematical calculation of pedicle subtraction osteotomy size to allow precision correction of fixed sagittal deformity. Spine 31:E973E979, 2006

    • Search Google Scholar
    • Export Citation
  • 24

    Ploumis A, , Transfledt EE, & Denis F: Degenerative lumbar scoliosis associated with spinal stenosis. Spine J 7:428436, 2007

  • 25

    Pritchett JW, & Bortel DT: Degenerative symptomatic lumbar scoliosis. Spine 18:700703, 1993

  • 26

    Riseborough EJ: Scoliosis in adults. Curr Pract Orthop Surg 7:3655, 1977

  • 27

    Robin GC, , Span Y, , Steinberg R, , Makin M, & Menczel J: Scoliosis in the elderly: a follow-up study. Spine 7:355359, 1982

  • 28

    Schwab FJ, , Smith VA, , Biserni M, , Gamez L, , Farcy JP, & Pagala M: Adult scoliosis: a quantitative radiographic and clinical analysis. Spine 27:387392, 2002

    • Search Google Scholar
    • Export Citation
  • 29

    Silva FE, , Bridwell KH, & Lenke LG, Thoracic Smith-Petersen osteotomy versus pedicle subtraction osteotomy for posterior-only treatment of thoracic kyphosis. Mummaneni PV, , Lenke LG, & Haid RW Jr: Spinal Deformity. A Guide to Surgical Planning and Management St. Louis, MO, Quality Medical Publishing, 2008. 40928

    • Search Google Scholar
    • Export Citation
  • 30

    van Dam BE: Nonoperative treatment of adult scoliosis. Orthop Clin North Am 19:347351, 1988

  • 31

    Vanderpool DW, , James JI, & Wynne-Davies R: Scoliosis in the elderly. J Bone Joint Surg Am 51:446455, 1969

  • 32

    Williams EL: Postoperative blindness. Anesthesiol Clin North America 20:605622, 2002

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