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

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39 HWR L3-L5 T3-Pelvis Fusion Unilateral Pelvic Bolt Catheter Removal VCR T12/L1 Staged ALIF T11-L2 & L2/3

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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