Surgical correction of severe adult lumbar scoliosis (major curves ≥ 75°): retrospective analysis with minimum 2-year follow-up

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OBJECTIVE

Prior reports have demonstrated the efficacy of surgical correction for adult lumbar scoliosis. Many of these reports focused on mild to moderate scoliosis. The authors’ objective was to report their experience and to assess outcomes and complications after deformity correction for severe adult scoliosis.

METHODS

The authors retrospectively analyzed consecutive adult scoliosis patients with major thoracolumbar/lumbar (TL/L) curves ≥ 75° who underwent deformity correction at their institution. Those eligible with a minimum 2 years of follow-up were included. Demographic, surgical, coronal and sagittal plane radiographic measurements, and health-related quality of life (HRQL) scores were analyzed.

RESULTS

Among 26 potentially eligible patients, 22 (85%) had a minimum 2 years of follow-up (range 24–89 months) and were included in the study (mean age 57 ± 11 years; 91% women). The cohort comprised 16 (73%), 4 (18%), and 2 (9%) patients with adult idiopathic scoliosis, de novo degenerative scoliosis, and iatrogenic scoliosis, respectively. The surgical approach was posterior-only and multistage anterior-posterior in 18 (82%) and 4 (18%) patients, respectively. Three-column osteotomy was performed in 5 (23%) patients. Transforaminal and anterior lumbar interbody fusion were performed in 14 (64%) and 4 (18%) patients, respectively. All patients had sacropelvic fixation with uppermost instrumented vertebra in the lower thoracic spine (46% [10/22]) versus upper thoracic spine (55% [12/22]). The mean fusion length was 14 ± 3 levels. Preoperative major TL/L and lumbosacral fractional (L4–S1) curves were corrected from 83° ± 8° to 28° ± 13° (p < 0.001) and 34° ± 8° to 13° ± 6° (p < 0.001), respectively. Global coronal and sagittal balance significantly improved from 5 ± 4 cm to 1 ± 1 cm (p = 0.001) and 9 ± 8 cm to 2 ± 3 cm (p < 0.001), respectively. Pelvic tilt significantly improved from 33° ± 9° to 23° ± 10° (p < 0.001). Significant improvement in HRQL measures included the following: Scoliosis Research Society (SRS) pain score (p = 0.009), SRS appearance score (p = 0.004), and SF-12/SF-36 physical component summary (PCS) score (p = 0.026). Transient and persistent neurological deficits occurred in 8 (36%) and 2 (9%) patients, respectively. Rod fracture/pseudarthrosis occurred in 6 (27%) patients (supplemental rods were utilized more recently in 23%). Revisions were performed in 7 (32%) patients.

CONCLUSIONS

In this single-center surgical series for severe adult scoliosis (major curves ≥ 75°), a posterior-only or multistage anterior-posterior approach provided major curve correction of 66% and significant improvements in global coronal and sagittal spinopelvic alignment. Significant improvements were also demonstrated in HRQL measures (SRS pain, SRS appearance, and SF-12/SF-36 PCS). Complications and revisions were comparable to those of other reports involving less severe scoliosis. The results of this study warrant future prospective multicenter studies to further delineate outcomes and complication risks for severe adult scoliosis correction.

ABBREVIATIONS ALIF = anterior lumbar interbody fusion; ASD = adult spinal deformity; BMI = body mass index; EBL = estimated blood loss; HRQL = health-related quality of life; LL = lumbar lordosis; LLIF = lateral lumbar interbody fusion; MCID = minimum clinically important difference; ODI = Oswestry Disability Index; PCS = physical component summary; PI = pelvic incidence; PSO = pedicle subtraction osteotomy; rhBMP-2 = recombinant human bone morphogenetic protein–2; SPO = Smith-Petersen osteotomy; SRS = Scoliosis Research Society; TLIF = transforaminal lumbar interbody fusion; TL/L = thoracolumbar/lumbar; VCR = vertebral column resection.

Article Information

Correspondence Thomas J. Buell: University of Virginia Health System, Charlottesville, VA. tjb4p@hscmail.mcc.virginia.edu.

INCLUDE WHEN CITING Published online June 21, 2019; DOI: 10.3171/2019.3.SPINE1966.

Disclosures Thomas J. Buell: honorarium from Wolters Kluwer. Christopher I. Shaffrey: consultant for Medtronic, NuVasive, Zimmer Biomet, EOS, Siemens, and K2M; royalties from Medtronic, NuVasive, and Zimmer Biomet; stockholder in NuVasive; grants from NIH, DOD, and NACTN. Justin S. Smith: royalties from Zimmer Biomet; consultant for Zimmer Biomet, Cerapedics, NuVasive, K2M, and AlloSource; honorarium from Zimmer Biomet, NuVasive, and K2M; research support from DePuy Synthes and ISSGF; and fellowship support from NREF and AOSpine. Chun-Po Yen: consultant for NuVasive.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flowchart diagram for operative planning. This basic flowchart provides a general outline of our preoperative decision-making process and surgical planning when treating adults with severe TL/L scoliosis. Once the decision for surgical treatment is made, we suggest obtaining dynamic images to assess curve flexibility. In this study, the flexibility of the major TL/L curve was determined using supine imaging and calculated with the formula below (asterisk). Our results demonstrated that patients who underwent posterior-only approach with multilevel SPOs/TLIF had significantly greater curve flexibility than patients who underwent staged anterior-posterior operations or 3-column osteotomies (3CO) (48% vs 25%, p < 0.001). Therefore, for treating similar patients, we suggest using a minimum curve flexibility threshold of approximately 40% before considering posterior-only surgery with multilevel SPOs/TLIF. Less flexible curves (i.e., rigid deformity) may require anterior release of the scoliotic curve or 3CO to obtain adequate alignment correction. For rigid deformity patients with prior multilevel thoracolumbar or lumbar posterior instrumentation/fusion, we typically prefer posterior-only surgery with 3CO. In these patients, an anterior curve release may fail to adequately “loosen” the posteriorly instrumented and fused spine. In contrast, for rigid deformity patients without prior multilevel instrumented fusions, an anterior approach can provide direct operative access to adequately release scoliotic curves for subsequent posterior correction and instrumentation. *Curve flexibility (%) = [(standing Cobb angle − supine Cobb angle)/standing Cobb angle] × 100%. **Dense anterior or lateral bridging osteophytes and severely narrowed disc spaces (making TLIF difficult) are also factors that we consider more amenable to a staged approach with anterior curve release. Figure is available in color online only.

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    Patient 2. Posterior-only surgery. This 58-year-old woman (BMI 23.1 kg/m2) with a history of de novo degenerative adult scoliosis presented with rapidly progressive thoracolumbar kyphoscoliosis, intractable axial back pain, and lower extremity radicular pain refractory to conservative management. The following preoperative measurements were made (A and B): 78° thoracolumbar major curve from T10 to L3 (curve apex T12–L1), 46° fractional lumbosacral curve, 37° thoracic curve from T3 to T9, −3.8-cm global coronal balance, 8.8-cm sagittal vertical axis (SVA), 48° pelvic tilt, 60° LL, 15° PI-LL mismatch, and 61° thoracic kyphosis. The thoracolumbar major curve appeared relatively flexible on supine imaging (inset in B), and there were lateral bridging osteophytes only at L2–3 on preoperative CT imaging (C); therefore, we felt the curve could be adequately mobilized from a posterior-only approach. The patient underwent posterior-only surgery with careful attention focused on posterior release of segments around the thoracolumbar junctional apex of the scoliotic deformity (SPOs from T9 to L4). We also performed bilateral transpedicular instrumentation with iliac fixation and multilevel TLIF at L4–5 and L5–1 using 10 × 14 × 2–mm, 12° lordotic cages. Final lumbar alignment was achieved with sequential compression and in situ rod bending. The following postoperative measurements were made (D and E): 12° thoracolumbar major curve from T10 to L3 (curve apex T12–L1), 11° fractional lumbosacral curve, 2° thoracic curve from T3 to T9, 3-cm global coronal balance, −1-cm SVA, 22° pelvic tilt, 68° LL, 7° PI-LL mismatch, and 37° thoracic kyphosis. During hospitalization the patient was treated with anticoagulation for postoperative acute pulmonary embolism. After discharge she made an excellent recovery with minimal pain. AP = anterior-posterior. Figure is available in color online only.

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    Patient 17. Multistage anterior-posterior surgery. This 48-year-old man (BMI 21.8 kg/m2) with untreated idiopathic scoliosis presented with progressive worsening of thoracolumbar kyphoscoliosis (the thoracolumbar major curve had increased 20° over several years) and axial back pain refractory to conservative management. The following preoperative measurements were made (A and B): 88° thoracolumbar major curve from T10 to L3 (curve apex L1), 35° fractional lumbosacral curve, 27° thoracic curve from T4 to T8, −2.6-cm global coronal balance, 7-cm SVA, 32° pelvic tilt, 5° LL, 52° PI-LL mismatch, and 4° thoracic kyphosis. The thoracolumbar major curve appeared relatively rigid on supine imaging (inset in A). Also, there were multilevel, dense anterior and lateral bridged traction osteophytes apparent on the preoperative CT scans (C and D); therefore, the patient underwent a multistage anterior-posterior approach for anterior release of the major curve, deformity correction in coronal and sagittal planes, and circumferential fusion. Briefly, operative steps first included placing the patient in the lateral decubitus position (convexity side up) for a left flank retroperitoneal approach to the thoracolumbar junction and upper lumbar spine. The annulus and anterior longitudinal ligament were transversely incised, and radical discectomies were performed at T12–L1, L1–2, and L2–3. Then the right-sided concavity of the scoliotic curve was carefully separated using serial spreaders. Small Cobb elevators and osteotomes were used to transect bridging osteophytes, which significantly loosened the thoracolumbar curve. Interbody arthrodesis at these levels (T12–L1, L1–2, and L2–3) was performed using a combination of rhBMP-2 (4 mg per level) with cancellous bone allograft packed meticulously along the concavity. Immediately following hemostasis and closure, the patient was repositioned supine for an anterior paramedian abdominal incision and retroperitoneal approach to the lower lumbar spine. L3–4, L4–5, and L5–S1 radical discectomies, interbody instrumentation (15-mm cage spacers per level), and arthrodesis (rhBMP-2: 4 mg per level) were performed. Within a week of anterior surgery, the patient returned for posterior segmental instrumentation from T3 to sacrum and bilateral iliac fixation. Posterior releases via multilevel T6–S1 SPOs were completed to obtain further loosening of the spine. Then 5.5-mm cobalt chromium rods were carefully selected and contoured. A combination of rod rotation maneuvers, cantilever forces, and compression with in situ rod bending was utilized to correct the patient’s deformity in both coronal and sagittal planes. Then the posterior elements were decorticated for arthrodesis using rh-BMP-2, cancellous bone allograft, and bone autograft. Postoperative measurements improved and were as follows (E and F): 39° thoracolumbar major curve, 24° fractional lumbosacral curve, 16° thoracic curve, 0-cm global coronal balance, 3.5-cm SVA, 19° pelvic tilt, 67° LL, −10° PI-LL mismatch, and 32° thoracic kyphosis. The patient recovered without significant complication, and his axial back pain improved. Figure is available in color online only.

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