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8/7/2019 Akbarnia Scoliosis
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Degenerative Scoliosis
Case presentations and Debate• Clinical Professor, University of California, San Diego
•Medical Director, San Diego Centerfor Spinal Disorders La Jolla, California
Behrooz A. Akbarnia, MD
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Behrooz A. Akbarnia, MD
Clinical Professor, University of California, San Diego
Medical Director, San Diego Center for Spinal Disorders
La Jolla, California
Society for Progress and Innovations for the Near East (SPINE)
Beirut , Lebanon, June 23, 2010
Degenerative Scoliosis
Case presentations and Debate
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Adult Patients are Different
Curve stiffness
Degeneration of the discs
Osteoporosis
Spinal imbalance bothcoronal and sagittal
Rotary subluxation
Spinal stenosis
Higher rate of complications(pulmonary etc.)
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Proposed definition
Degenerative Scoliosis is a coronal
plane deformity measuring greater
than 15 degrees with a lumbar
major curve, without a structuraldeformity in the thoracic spine.
Patients are greater than 35 years
of age at presentation and have noknown history of scoliosis before
skeletal maturity.
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Key Points Significant variability in treatment is a reflection
of uncertainty regarding outcomes
Literature offers limited guidance regardingoperative and non-operative strategies
Key decisions include: – Role of operative and non-operative care
– Role of decompression vs decompression with fusion
– Role of limited fusion
– Role of anterior surgery
Identification of factors that predict complicationsand outcomes will permit appropriate stratificationof cases
Impact of care on quality of life remainsundetermined
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Major surgical complications
56%-75%
Unplanned reoperation rates
18-58%
Unproven benefits regarding
improvement of HRQOL
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Adult ScoliosisFrank J. Schwab ,Vinson A. Smith ,Michele Biserni ,Lorenzo
Gamez ,Jean-Pierre C. Farcy ,Murali Pagala Spine 2007
Surgical rates and operative outcome analysisin adult scoliosis
– Multicenter prospective study(784 pts) Adults
Min 20° coronal Cobb
– Radigraphic measures
– SRS-22/SF-12/ODI
– 268 operative cases
111: 1-yr f/u
45: 2-yr f/u
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Adult ScoliosisSchwab et al 2007
Sagittal balance:
– Worse balance
higher likelihood of fusion to sacrum higher likelihood of osteotomy
higher likelihood of posterior only surgery
Subluxation: – Greater subluxation more likely to have A-P
fusion
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Stratified by age (<50, 50-65, >65)
290 patients (137 op)
WHO GETS OPERATIVE TREATMENT
– Younger correlated with worse coronal deformity
– Older correlated with increased disability (HQRL)
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Advantages of Ant. and Post.Approach
for Adult Spinal Deformity Creation of a load sharing environment for
segmental implants
Reduction of lateral olisthesis
Restoration of segmental lordosis
Improvement of sagittal balance
Improved fusion rates in difficult cases
(absence of post. elements, revisions, L5-S1)
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Historical Indications for A/P Fusion
in TL/L Adult Deformity
Condition Radiographic Value
Coronal Deformity >45º Cobb angle
Apical Translation >3 cm from the center sacral vertebral
line (CSVL)
Lateral Olisthesis >5 mm
Sagittal Deformity <20º lordosis Cobb angle measuredT12-S1
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SRS M&M ReportCoe et al Spine 2006
Overall complication rate 5.7%
PSF (221 of 4,369) 5.1%
APSF (82 of 801) 10.1%
(P<0.0001)
AIS Patients
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The results demonstrated an appreciable highrate of
Postoperative pain (32.3%)
Bulging(43.5%),
Functional disturbance (24.2%),
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The Role of the Less Invasive Lateral
Approach for Adult Deformity
Surgery?
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Suk S, et al: Spine 2006
– Stopping at or distal to T11 increases risk of adjacent segmentkyphosis (50% PJK)
Swank S, et al: JBJS 1981
– Fusions from L1or L2 to the sacrum have an unacceptable rate of mechanical failure (7/20)
Simmons ED, et al: SRS 2005
– 60% adjacent segment “topping off” in long fusions with cephaladlevel of L1,L2
Glattes CG, et al: Spine 2005
– 26% incidence of PJK in long adult deformity constructs. Highestat T3. Little impact on clinical outcome.
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Fusion to L5 vs. S1
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CASE EXAMPLES
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83 yrs Retired Atty.
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Imbalance and Back and Leg Pain
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Post op
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(BS)
59 year old female with adult IS
Curve from T12-L4 of 53°,
bends to 42°.
MRI showed degeneration of the
L4/5 disc.
Underwent a 5-level LIF
(T12/L1, L1/2, L2/3, L3/4, L4/5)and posterior spinal fusion from
T10 to L5
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53
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T8-T12 : 42 degT12-L4: 53 deg
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B S 24 Months Post op
•
SRS22: 3.3• VAS:4/10
• ODI: 22%
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Case #2
74 yo female diagnosed with scoliosis at age
12. underwent brace management until 18.
Since then has done well until the last couple
of years.
She now has severe debilitating back pain.
Also notes 4 inch loss of height in the last
couple of years.
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73
65
33
12
4
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4078
53
3712
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Stand alone LIF84 y.o, female
T11-L4: 36T5-T11: 16
Coronal balance :
2.5
Sagittal balance :9.5
ODI: 47
SRS-22: 3
VAS: 6/10
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T11-L4: 30
T5-T11: 5
Coronal balance : 2
Sagittal balance :6.2
6 Wks outcomes
ODI: 11SRS-22: 4.5
VAS: 1/10
18 months
outcomes
ODI: 8
SRS-22: 4.55
VAS: 0.5/10
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Variability in Surgical Strategy Surgical strategies for the management of
degenerative scoliosis are variable
The presence of variability in surgical
strategies is clear evidence of the absence of an evidence-based approach
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Thank You