Adult Spinal Deformity Robert Hart. Dept. Orthopaedics and Rehab OHSU
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1 Adult Spinal Deformity 2010 Robert Hart Dept. Orthopaedics and Rehab OHSU
2 What is Adult Spinal Deformity? Untreated Idiopathic Scoliosis Flat Back Syndrome Adjacent Segment Stenosis Non-Union Degenerative Scoliosis Other (Kyphosing Conditions, Neuropathic, Cervico-thoracic)
3 Evolution of Surgical Approach to Adult Spinal Deformity Personal Learning Curve Evolution in Implant Design Evolution in OR/Peri-op Assistance Other Technical Advances (BMP) Expansion of Referral Base Migration of Practice Patterns
4 What do I do now that I didn t do when I started? Increased number of levels fused (T3,T10, S1) Screws over hooks Increased number of screws Increased interbody fusion Increased pelvic fixation Less aggressive decompression Increased curve correction
5 Specific Issues in Adult Deformity Surgery Choosing the Proximal Level Protecting the Proximal Level The Fate of L5/S1 Pelvic Fixation Restoring/Maintaining Lordosis Getting a Solid Fusion
6 Choosing Proximal Level L1 vs. T10 vs. T3 Avoid Stopping at Deformity Osteoporosis Age Higher if Needed to Manage Balance
7 78 yo Woman Incapacitating Back Pain Balance Issues
8 Bending Views
9 S/P T2-S1 PSF PLIF L5/S1
10 64 YO Female 8 Months S/P L3/5 Lam + PSF Persistent LE/Back Pain
11 S/P L2-L4 Lam/PSF Segmental Inst L2-S1 Prophyllactic Vertebroplasty T12/L1/L2
12 Protecting Proximal Junction Vertebral Body Augmentation Supplementary Wire Fixation Proximal Hooks Under-correction Proximally T3 vs. T10
13 Case Example: 78 YO Japanese Woman S/P Open Lam/Fusion Osteoporotic Burst Fx Parkinson s Disease
14 S/P PSF T10-L5 Multiple Augmentation Segmental Screws Sublaminar Wire Restore Sagittal Balance Excellent Result at 2 years
15 The Fate of L5-S1 Potential for Degeneration L5/S1 is the Hardest Level to Fuse Is L4/5 Less Prone to Non-Union? Does it Require More Additional Surgery? Increased Strength of Fixation and Correction
16 68 yo woman Incapacitating Neurogenic Claudication
17 CT Myelogram 1/2 2/3 3/4 4/5 5/1
18 S/P L1-L5 PSF Selective Laminectomy/TLIF Recurrent Symptoms at 3 Years 12/1 5/1
19 Revision L5/S1 PLIF
20 Pevic Fixation S1 Screws Are Inadequate Trans-Iliac Bar PSIS Iliac Screws S2 Iliac Screws
21 Sacro-Pelvic Zones *Courtesy M.O Brien, MD
22 Iliac Bolt Fixation Pivot Point McCord et al., 1992 Biomechanically Strongest Fixation Ability to Manipulate Pelvis
23 56 YO Female S/P L5-S1 ALIF Revised to PSF for Non-Union
24 S/P ALIF L3-L5 PSF T3-S1 Segmental Inst + Trans-Iliac Bar
25 54 YO Female S/P T2-T12 Fusion Lumbar Claudication/Back Pain
26 S/P ALIF L3-S1 PSF T12-S1 Laminectomy L3 Segmental Inst + Pelvic Fixation
27 Getting Adequate Lordosis Segmental Screws Aggressive Facetectomy/Ligament Resection Osteotomies (SPO, PSO, VCR) SPO + TLIF Impact of Pelvic Incidence
28 64 YO Male Powerlifter S/P L3-S1 PSF
29 S/P T9-L3 PSF ALIF T12-L3 Good Clinical Result
30 2 Years 8 Months Post-Op Recurrent Disabling Thigh Pain Mild Quadriceps Weakness
31 S/P Post Osteotomy L3 TLIF L3/4 Post Inst L4-S1
32 Flat-Back Syndrome Classically Due to Distraction Through Lumbar Spine Increasingly Due To Short Segment Fusions With Adjacent Collapse Disabling Due to Need for Hip/Knee Flexion
33 73 yo Female Unable to Obtain Upright Stance S/P 5 Prior Lumbar Surgeries
34 S/P L3 PSO T9-Pelvis Fusion Complication: Deep Wound Infection
35 Technique Pedicle Subtraction Osteotomy
36
37 History of Present Illness 74 Year Old Woman S/P L5-S1 Fusion Revised to L3-S1 Fusion Osteoporotic Fractures Proximally S/P Kyphoplasty of T12/L1/L2 Pain Pump Placement Enormous MS Contin Oral Regimen Ritalin to Stay Awake Otherwise Healthy, Previously Very Active
38
39 HWR L3-L5 T3-Pelvis Fusion Unilateral Pelvic Bolt Catheter Removal VCR T12/L1 Staged ALIF T11-L2 & L2/3
40
41 Gaining Solid Fusion ICBG Bone Marrow BMP + ICBMA + Allograft Chips Anterior Column Support
42 Pre-Operative Imaging
43 Post-Operative Imaging
44 Post-Operative Clinical Photo
45 38 yo Female Remote Fusion to L4 S/P ALIF L4/5 & L5/S1 Non-Union L5/S1 Flat Back Deformity
46 S/P L5/S1 ALIF Pedicle Subtraction Osteotomy L3 T11-S1 Fixation
47 And Finally A Cervical Case
48 58 Year Old Woman MVA with Type 2 Dens Fracture Central Spinal Cord Injury Delayed Dropped Head Syndrome S/P C3-C7 360 Fusion Non-Union C6/C7 Persistent Inability to Obtain Lateral Gaze Posterior Wound Dehiscence
49 Injury MRI/CT Scan
50 3 Months S/P C1/C2 PSF Early Sub-Axial Degenerative Disk Disease With Kyphosis
51 Moved to Idaho 1 Year Later S/P ACDF C3/4-C5/6 With PSF C3-C7 Non-Union C6/7 Inability to Maintain Upright Head Position
52 S/P C7 Corpectomy HWR C3-C7 Osteotomy C7/T1 PSF C2-T5
53 Conclusions Variable Pathology Outcomes Demonstrations in Process High Complication Rate High Satisfaction Rate Better than a Degenerative Back Pain Clinic
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