Minimally Invasive Approach for Adult Degenerative Scoliosis
Minimally Invasive Approach for Adult Degenerative Scoliosis
This patient was a 67-year-old retired man referred for 20 years of progressively worsening low-back pain, characterized as bandlike across the musculature of the lower back, radiating occasionally to the left gluteal region. He was neurologically intact and underwent unsuccessful nonoperative therapy. Radiographic imaging at initial presentation demonstrated dextroscoliosis with a coronal Cobb angle of 16°. His CSVL, SVA, PT, PI, and LL measured 1 cm, 2 cm, 24°, 74°, and 60°, respectively, which placed him in the "green" group. Additional radiographic findings included extensive degenerative disease, disc bulges, and central canal and foraminal stenosis at multiple levels. Preoperative VAS and ODI scores were 67 and 28, respectively. He was subsequently treated with L1–5 extreme lateral interbody fusion (Nuvasive, Inc.), and L1–5 percutaneous pedicle screws ("green" surgery). The patient had an uneventful postoperative course. At the most recent follow-up evaluation the patient's coronal Cobb angle, CSVL, SVA, PT, PI, and LL measured 10°, 1 cm, 0 cm, 25°, 74°, and 61°, respectively, while the VAS and ODI scores were 0 and 11.1 points, respectively (Fig. 2).
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Figure 2.
Case 7. Anteroposterior and lateral 36-inch radiographs of a patient with mild deformity (green group). A: Preoperative images of a patient with mild compensated deformity. B: Postoperative images obtained after L1–5 MIS-lateral interbody fusion and percutaneous posterior fixation showing restoration of disc height, improvement in coronal Cobb angle, and no significant change in other spinopelvic parameters.
This patient was a 58-year-old retired woman with a long history of low-back pain, bilateral gluteal pain, and paresthesias radiating to the lower extremities. The patient did not experience loss of bowel or bladder control, and nonoperative therapies were unsuccessful. Preoperative imaging demonstrated dextroscoliosis with a coronal Cobb angle of 23°, and CSVL, SVA, PT, PI, and LL measurements of 2 cm, 8 cm, 15°, 67°, and 51°, respectively, which placed her in the "yellow" group. Her preoperative VAS and ODI scores were 100 and 84, respectively. She was subsequently treated with L2–5 lateral interbody fusions, L2–3 and L3–4 ALL release, L5–S1 ALIF, with L2–iliac instrumentation ("yellow" surgery). Her postoperative course was complicated by a surgical site infection that was secondarily reopened and debrided, treated with antibiotics, and subsequently healed well. She experienced marked symptom resolution, with a postoperative coronal Cobb angle of 14°, and CSVL, SVA, PT, PI, and LL measurements of 1 cm, 0 cm, 14°, 67°, and 56°, respectively. Her postoperative VAS and ODI scores were 60 and 42, respectively (Fig. 3).
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Figure 3.
Case 12. Anteroposterior and lateral 36-inch radiographs of a patient with moderate deformity (yellow group). A: Preoperative images of a patient with moderate deformity. B: Postoperative images obtained after L2–5 MIS-lateral interbody fusion with ALL release and posterior fixation from L-2 to the ilium, showing restoration of disc height and improvement in spinopelvic parameters.
This patient was a 67-year-old man with chronic back pain with intermittent radiating symptoms in his right leg. Walking and standing aggravated the symptoms. He had tried nonoperative therapies without success. He denied any weakness or urinary incontinence. Preoperative parameters were a coronal Cobb angle of 54°, CSVL 2 cm, SVA 12 cm, PT 40°, PI 71°, and LL 35°, which placed him in the "red" group. His dual x-ray absorptiometry scan was within normal limits. He subsequently underwent lateral interbody fusions from T-12 to L-5 and an ALIF at L5–S1. He had 2 levels of ALL release at L2–3 and L3–4. This was followed by Stage II surgery, including posterior percutaneous pedicle screw fixation from T-10 to the sacrum ("yellow" surgery). Postoperative imaging demonstrated a coronal Cobb angle of 29°, CSVL 6 cm, SVA 5 cm, PT 26°, PI 71°, and LL 74°. His postoperative course was uneventful, and at the most recent follow-up evaluation his VAS score had improved from 76 to 53 and his ODI score had improved from 50 to 30 (Fig. 4).
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Figure 4.
Case 24. Anteroposterior and lateral 36-inch radiographs of a patient with severe deformity (red group). A: Preoperative images of a patient with severe deformity. B: Postoperative images obtained after T10–S1 open posterior arthrodesis with osteotomies and with MIS-lateral interbody fusion with multilevel ALL release, showing restoration of disc height and improvement in spinopelvic parameters.
Illustrative Cases
Case 7 (Green Group)
This patient was a 67-year-old retired man referred for 20 years of progressively worsening low-back pain, characterized as bandlike across the musculature of the lower back, radiating occasionally to the left gluteal region. He was neurologically intact and underwent unsuccessful nonoperative therapy. Radiographic imaging at initial presentation demonstrated dextroscoliosis with a coronal Cobb angle of 16°. His CSVL, SVA, PT, PI, and LL measured 1 cm, 2 cm, 24°, 74°, and 60°, respectively, which placed him in the "green" group. Additional radiographic findings included extensive degenerative disease, disc bulges, and central canal and foraminal stenosis at multiple levels. Preoperative VAS and ODI scores were 67 and 28, respectively. He was subsequently treated with L1–5 extreme lateral interbody fusion (Nuvasive, Inc.), and L1–5 percutaneous pedicle screws ("green" surgery). The patient had an uneventful postoperative course. At the most recent follow-up evaluation the patient's coronal Cobb angle, CSVL, SVA, PT, PI, and LL measured 10°, 1 cm, 0 cm, 25°, 74°, and 61°, respectively, while the VAS and ODI scores were 0 and 11.1 points, respectively (Fig. 2).
(Enlarge Image)
Figure 2.
Case 7. Anteroposterior and lateral 36-inch radiographs of a patient with mild deformity (green group). A: Preoperative images of a patient with mild compensated deformity. B: Postoperative images obtained after L1–5 MIS-lateral interbody fusion and percutaneous posterior fixation showing restoration of disc height, improvement in coronal Cobb angle, and no significant change in other spinopelvic parameters.
Case 12 (Yellow Group)
This patient was a 58-year-old retired woman with a long history of low-back pain, bilateral gluteal pain, and paresthesias radiating to the lower extremities. The patient did not experience loss of bowel or bladder control, and nonoperative therapies were unsuccessful. Preoperative imaging demonstrated dextroscoliosis with a coronal Cobb angle of 23°, and CSVL, SVA, PT, PI, and LL measurements of 2 cm, 8 cm, 15°, 67°, and 51°, respectively, which placed her in the "yellow" group. Her preoperative VAS and ODI scores were 100 and 84, respectively. She was subsequently treated with L2–5 lateral interbody fusions, L2–3 and L3–4 ALL release, L5–S1 ALIF, with L2–iliac instrumentation ("yellow" surgery). Her postoperative course was complicated by a surgical site infection that was secondarily reopened and debrided, treated with antibiotics, and subsequently healed well. She experienced marked symptom resolution, with a postoperative coronal Cobb angle of 14°, and CSVL, SVA, PT, PI, and LL measurements of 1 cm, 0 cm, 14°, 67°, and 56°, respectively. Her postoperative VAS and ODI scores were 60 and 42, respectively (Fig. 3).
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Figure 3.
Case 12. Anteroposterior and lateral 36-inch radiographs of a patient with moderate deformity (yellow group). A: Preoperative images of a patient with moderate deformity. B: Postoperative images obtained after L2–5 MIS-lateral interbody fusion with ALL release and posterior fixation from L-2 to the ilium, showing restoration of disc height and improvement in spinopelvic parameters.
Case 24 (Red Undertreated Group)
This patient was a 67-year-old man with chronic back pain with intermittent radiating symptoms in his right leg. Walking and standing aggravated the symptoms. He had tried nonoperative therapies without success. He denied any weakness or urinary incontinence. Preoperative parameters were a coronal Cobb angle of 54°, CSVL 2 cm, SVA 12 cm, PT 40°, PI 71°, and LL 35°, which placed him in the "red" group. His dual x-ray absorptiometry scan was within normal limits. He subsequently underwent lateral interbody fusions from T-12 to L-5 and an ALIF at L5–S1. He had 2 levels of ALL release at L2–3 and L3–4. This was followed by Stage II surgery, including posterior percutaneous pedicle screw fixation from T-10 to the sacrum ("yellow" surgery). Postoperative imaging demonstrated a coronal Cobb angle of 29°, CSVL 6 cm, SVA 5 cm, PT 26°, PI 71°, and LL 74°. His postoperative course was uneventful, and at the most recent follow-up evaluation his VAS score had improved from 76 to 53 and his ODI score had improved from 50 to 30 (Fig. 4).
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Figure 4.
Case 24. Anteroposterior and lateral 36-inch radiographs of a patient with severe deformity (red group). A: Preoperative images of a patient with severe deformity. B: Postoperative images obtained after T10–S1 open posterior arthrodesis with osteotomies and with MIS-lateral interbody fusion with multilevel ALL release, showing restoration of disc height and improvement in spinopelvic parameters.