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Evaluation and treatment of adult spinal deformity

Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

Robert F. Heary

T he first record of scoliosis was by Hippocrates. In ancient times traction was attempted, unsuccessfully, to correct scoliotic deformity. In the 16th century, Ambroise Paré is credited with describing the first application of a brace to treat scoliosis. Paré used an iron corset to correct coronal-plane deformity. In 1962, Harrington 20 reported the first successful use of spinal implants in the correction of scoliosis. As such, the modern era of deformity correction involving the placement of spinal instrumentation began. The Scoliosis Research Society, the

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Robert F. Heary and Reza J. Karimi

L umbar scoliosis is increasingly recognized as a cause of debility in the adult population. 3 , 8 , 17 , 20 , 22 , 25 In contrast to thoracic scoliosis, in which the deformity itself is often the cause of concern for the patient, in lumbar scoliosis, the most frequent presenting complaint is radicular pain caused by nerve root compression. 22 The causes of lumbar scoliotic deformities can be categorized as idiopathic, degenerative, or iatrogenic due to factors following prior unsuccessful spinal surgery. 1 , 17 In each of these categories, there is a

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Robert F. Heary and Christopher M. Bono

several forms. Conceptually, the procedure must be “lordogenic”—that is, it must produce lordosis. This can be achieved by lengthening the anterior elements, shortening the posterior elements, or a combination of the two. Pedicle subtraction osteotomy was developed to achieve significant deformity correction. In a single-stage, posterior-approach procedure, portions of the VB and posterior neural arch are resected. 2 , 5 , 14 , 24 Conceptually the procedure entails a shortening of the posterior elements but, in reality, it involves shortening of portions of the

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Robert F. Heary

, used predominantly in the thoracic spine for placing larger screws into smaller pedicles, is ignored in this meta-analysis. No attempt was made to assess screw size. The clinical significance of placing a screw entirely within a pedicle is not clear from the wealth of published data on this topic. If a navigation advocate places smaller screws to remain intrapedicular, will maneuvers such as deformity correction be helped or hindered? This topic is not covered, and it bears much clinical import. While the authors of the meta-analysis state that radiographic

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Nitin Agarwal, Robert F. Heary and Prateek Agarwal

P edicle screw fixation is a frequently used surgical technique for treating conditions ranging from spine deformity to fracture stabilization. 7 , 12 , 23 , 27 , 43 , 44 , 50 , 69 Previous publications have reported pedicle screw instrumentation to be both biomechanically and clinically superior to the use of hooks in spinal surgery. 34 , 35 , 37 , 42 , 43 , 65 , 70 Pedicle screws, compared with hooks, have a demonstrated higher stiffness and improved pullout strength. 4 , 28 Furthermore, the use of pedicle screws in surgery to treat spinal deformity has

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Robert F. Heary, Paul A. Anderson and Paul M. Arnold

performed from anterior, posterior, and combined anterior-posterior approaches. Since the treatment of lumbar spinal stenosis has increasingly involved older patients, with their frequent medical comorbidities, strategies that limit approach-related morbidity, through the use of minimally invasive approaches, have enabled surgical treatment to include elderly individuals who might not have been considered candidates for surgical intervention in the past. Furthermore, some patients who have a combination of stenosis and spinal deformity or scoliosis are able to undergo

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Robert F. Heary, Christopher M. Bono and Margaret Black

P edicle screws can be used to stabilize the thoracic spine for various diagnoses including infection, malignancy, trauma, and deformity. 1, 2, 5–7, 10, 13–15, 23 They offer the biomechanical advantage of three-column stabilization, which, in some cases, can obviate the need for anterior column reconstruction. Although hook or wire constructs can be effective, they are limited to stabilization of the posterior column. With severe VB destruction, hook- or wire-based posterior column stabilization may be prone to late-onset kyphosis and early-onset hardware

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Rachid Assina, Neil J. Majmundar, Yehuda Herschman and Robert F. Heary

they are obese or concerned about postoperative sexual function. Patients with central canal stenosis, spondylolisthesis greater than Grade I, and scoliotic deformity with axial rotation are not considered candidates for the procedure. Some of the most common complications associated with a traditional open ALIF approach are vascular injury, postsympathectomy syndrome, and retrograde ejaculation. 2 , 5 , 8 , 9 , 14 , 19 There is a high incidence, between 2% and 15%, of vascular injury with this approach secondary to the mobilization of the great vessels

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Gaurav Gupta, Robert F. Heary and Jennifer Michaels

established, was referred for evaluation of longstanding and progressive neurological deficits including incontinence of urine. Her early motor development was notable only for a delay in walking until 18 months of age, but subsequent motor development and function appeared normal until high school. At 16 years of age, the patient was referred for orthopedic and podiatric care. She underwent corrective surgery for a toe deformity, but no diagnosis was offered. By 20 years of age, she had bilateral foot drop. She received a diagnosis of CMT hereditary neuropathy and was

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Daipayan Guha, Robert F. Heary and Mohammed F. Shamji

.3 61.0 4.5 ± 2.9 2.4 ± 1.4 46.7 JOA = Japanese Orthopaedic Association (lumbar pain score); SF-36 PF/BP = 36-ltem Short Form Health Survey, Physical Functioning/Bodily Pain component; VAS = visual analog scale. * % Δ denotes percent change between pre- and postoperative scores; positive values indicate improvement in clinical outcome. All other values are expressed as the mean ± SD. Radiographic Progression and Reoperation Table 4 delineates the radiographic outcome of progressive deformity and the incidence of reoperation. The overall incidence