Disclosures 7/31/2012. What is Degenerative Lumbar Scoliosis. Degenerative Lumbar Scoliosis: Presentation and Treatment Options

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1 7/31/2012 Degenerative Lumbar Scoliosis: Presentation and Treatment Options Jacob M. Buchowski, M.D., M.S. Associate Professor of Orthopaedic and Neurological Surgery Director, Center for Spinal Tumors Washington University in St. Louis St. Louis, Missouri VuMedi Webinar: Multi-Center Grand Rounds Spine Deformity Case Discussion July 31, 2012 Disclosures Consultant: Stryker, Inc. (<$10,000 per year) CoreLink, Inc. (<$10,000 per year) Globus Medical, Inc. (<$20,000 per year) Teaching Arrangements: Stryker, Inc. ($10,000-20,000 per year) Globus Medical, Inc. (<$10,000 per year) DePuy, Inc. (<$20,000 per year) K2M, Inc. (<$10,000 per year) Institutional Research Support: CSSG/K2M, Inc. What is Degenerative Lumbar Scoliosis Spinal deformity in a skeletally mature patient Cobb angle >10 in coronal plane Deformity due to asymmetric degenerative changes affecting: Discs Facet joints

2 7/31/2012 Etiology Asymmetric degeneration, which then leads to: Increased asymmetric load Progression of degeneration and deformity Scoliosis Kyphosis May create mono- or multisegmental instability and finally spinal stenosis Deformity progression supported by osteoporosis Particularly in post-menopausal women Patient Presentation Most often with back pain Often with leg pain and claudication symptoms Rarely with neurological deficit Limited exercise/activity tolerance Imbalance - coronal and/or sagittal Usually not with questions related to cosmesis Radiographic Features Curve is mid-lumbar spine (L2-L3) Fractional lumbosacral curve present (L4-Sacrum) Hallmark is rotatory subluxation of adjacent vertebrae >10º Cobb measurement Sagittal plane variable but often hypolordotic/kyphotic 2

3 7/31/2012 Spinal Stenosis Spinal stenosis can be: Central Lateral recess Foraminal Foraminal stenosis most common in: Concavity of midlumbar curve Fractional lumbosacral curve Surgical Treatment When nonoperative treatment fails OR Documented curve progression (especially if substantial) Wide spectrum of surgical treatment options Surgical Treatment Decisions Clinical complaints Radiographic features Subluxation Imbalance Osteoporosis Overall health of patient Patient expectations/desires 3

4 7/31/2012 Surgical Treatment Options 1. Decompression alone 2. Limited PSF ± Decompression 3. PSF lumbar curve ± Decompression 4. PSF lumbar curve ± ASF ± Decompression 5. PSF lumbar and thoracic spine ± ASF ± Decompression 6. PSF lumbar and thoracic spine + osteotomy(ies) ± ASF ± Decompression Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. PSF Formal Posterior Approach Increasing role of minimally invasive options Percutaneous screw fixation and deformity correction Hybrid open/muscle splitting approaches Increasing role for biologics ASF Formal Anterior Approach Wide array of options to perform an anterior fusion Formal anterior/anterolateral approach (i.e. TA/Retroperitoneal approach) TLIF/PLIF Far lateral approach (i.e. XLIF/DLIF) AxiaLIF/TranS1 4

5 7/31/2012 Surgical Options Decompression alone Decompression w/limited PSF Decompression w/psf lumbar curve ± Decompression w/psf lumbar curve + ASF ± Decompression w/psf lumbar & thoracic spine ± ASF ± Decompression w/psf w/lumbar osteotomy(ies) ± ASF Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. 59 y.o. male w/ LBP and Left Leg Pain 59 y.o. male w/ LBP and Left Leg Pain Rx: Microdiscectomy 5

6 7/31/2012 Indications for Decompression Alone Central and lateral recess stenosis Stable spine radiographically Minimal/absent rotatory subluxations Osteophytes present Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. Surgical Options Decompression alone Decompression w/limited PSF Decompression w/psf lumbar curve ± Decompression w/psf lumbar curve + ASF ± Decompression w/psf lumbar & thoracic spine ± ASF ± Decompression w/psf w/lumbar osteotomy(ies) ± ASF Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. 73 y.o. Woman with L Leg Pain 6

7 7/31/ y.o. Woman with L Leg Pain PSF L4-L5 and Decompression Indications for Decompression with Limited PSF Central/lateral recess/foraminal stenosis Rotatory subluxations at stenotic levels Lack of stabilizing osteophytes Minimal back pain/deformity complaints Disadvantage: risk of transition syndrome Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. 7

8 7/31/2012 Surgical Options Decompression alone Decompression w/limited PSF Decompression w/psf lumbar curve ± Decompression w/psf lumbar curve + ASF ± Decompression w/psf lumbar & thoracic spine ± ASF ± Decompression w/psf w/lumbar osteotomy(ies) ± ASF Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. 73 y.o. Female with Back and Right Leg Pain Foraminal stenosis L4-L5 73 y.o. Female with Back and Right Leg Pain 8

9 7/31/2012 PSF T11-L5, Decompression L2-L5 Indications for Decompression with PSF Lumbar Curve ± stenosis Severe rotatory subluxations/ unstable spine back pain/deformity complaints Adequate sagittal alignment (lordosis) Adequate bone stock (osteoporosis) Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. Surgical Options Decompression alone Decompression w/limited PSF Decompression w/psf lumbar curve ± Decompression w/psf lumbar curve + ASF ± Decompression w/psf lumbar & thoracic spine ± ASF ± Decompression w/psf w/lumbar osteotomy(ies) ± ASF Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. 9

10 7/31/2012 PSF T10-S1 and TLIFs L3-S1 Indications for PSF lumbar curve + ASF ± stenosis Severe rotatory subluxations - unstable spine Back pain/deformity complaints Lumbar hypolordosis/sagittal imbalance Remember ASF doesn t necessarily mean formal anterior approach Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. Surgical Options Decompression alone Decompression w/limited PSF Decompression w/psf lumbar curve ± Decompression w/psf lumbar curve + ASF ± Decompression w/psf lumbar & thoracic spine ± ASF ± Decompression w/psf w/lumbar osteotomy(ies) ± ASF Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. 10

11 7/31/2012 PSF T4-S1/ASF L4-S1 Indications for PSF Lumbar and Thoracic Spine + ASF ± stenosis Severe rotatory subluxations - unstable spine Back pain/deformity complaints Lumbar hypolordosis/sagittal imbalance Remember ASF doesn t necessarily mean formal anterior approach Thoracic kyphosis Global coronal and/or sagittal imbalance Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. Surgical Options Decompression alone Decompression w/limited PSF Decompression w/psf lumbar curve ± Decompression w/psf lumbar curve + ASF ± Decompression w/psf lumbar & thoracic spine ± ASF ± Decompression w/psf w/lumbar osteotomy(ies) ± ASF Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. 11

12 7/31/2012 Revision PSF & L3 PSO, ASF Indications for ± PSF w/lumbar osteotomy(ies) ± ASF ± Stenosis Unstable spines Poor regional and global sagittal balance Thoracic hyperkyphosis Fixed deformity Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28(3):E1. Conclusions Degenerative scoliosis has a broad spectrum of presenting symptoms and radiographs Separate out treatment of stenosis vs. treatment of deformity Surgical treatment revolves around choosing the right operation for the right patient at the right time Sometimes there is more than one correct surgical option 12

13 7/31/2012 Conclusions Six types of surgical procedures are possible with many factors determining the best treatment for each patient: Decomp alone Decomp w/limited PSF Decomp w/psf lumbar curve ± Decomp w/psf lumbar curve + ASF ± Decomp w/psf lumbar & thoracic spine ± ASF ± Decomp w/psf w/lumbar osteotomy(ies) ± ASF Conclusions ASF doesn t always mean anterior approach Increasing role for minimally invasive approaches (both posterior and anterior) Increasing reliance on biologics to achieve fusion Case Example 62 y.o. presents with de novo scoliosis and left L4-L5 lateral recess stenosis with associated left L5 radiculopathy Failed nonoperative treatment and would like to proceed with surgery 13

14 7/31/ Left L4-L5 Lateral Recess Stenosis Case Example She undergoes PSF L1-L5 with decompression at L4-L5 Does very well postop with resolution of left leg pain Five Years Postop. Doing well! 14

15 7/31/ yr PO yr PO Almost 10 Years Postop. Develops a long sweeping junctional deformity above w/ increasing back pain. 10 Years Postop. Develops a long sweeping junctional deformity above w/ increasing back pain. What to do now? Appropriate surgical treatment for this patient is: 1 Extend fusion to the upper thoracic spine 2 Extend fusion to the upper thoracic spine and down to the sacrum/pelvis 3 Couple the above with SPOs 4 Couple the above with thoracic VCR or lumbar PSO 15

16 7/31/2012 Case Example Because the patient s symptoms were thought to be due to the degenerative changes above AND to avoid the morbidity of extending someone to the sacrum/ilium, the fusion was extended to the upper thoracic spine only She tolerated the procedure well with no complications yr po yr po One Year Following Revision. Doing well! Postop SRS-22 Scores Broken Into Domains One Year Following Revision To Upper Thoracic Spine Score Potential Scores Pain Function Self-Image Mental Health Satisfaction 16

17 7/31/2012 Postop Oswestry Score One Year Following Revision To Upper Thoracic Spine 100 Score Potential Preop Preop Postop Preop Postop yr PO yr po yr PO yr po One Year Following Revision. Doing well! yr po yr po Two Years Following Revision Starting to have LBP and left leg pain 17

18 7/31/ yr po yr po Recumbent Laterals Vacuum Disc at L5-S1 What to do now? yr po yr po Two Years Following Extension to S1/Ilium with ALIF at L5-S1 Doing well. 18

19 7/31/2012 Preop Postop Preop Postop yrs po index op yr po yrs po index op yr po Result At 16 Years Following Index Procedure Preop Postop Preop Postop Acknowledgements Larry Lenke, M.D. Keith Bridwell, M.D. 19

20 7/31/2012 Thank You! 20

21 Multicenter Deformity Case Rounds Vumedi-Sagittal Plane Cases Christopher Ames MD Associate Professor Director of Spine Tumor and Deformity Surgery UCSF Department of Neurosurgery Disclosures Consultant Medtronic, Stryker, Depuy Purpose To bring a comprehensive spinal deformity curriculum to the web To allow discussions simulating preop case rounds format Part 2 of 3 1

22 Schwab SRS ASD Angular changes at base of spine Ondra Technique for PSO planning Ondra Spine 2006 Pelvic Parameters SDSG Radiographic Measurement Manual 2

23 Reciprocal Changes of Pelvis PT and planning Location of Osteotomy and Impact PSO level correlated to PT correction but not to SVA correction PSO degree correlated to LL change, TK change and PT change 3

24 Taking Thoracic Change into Account? Schwab Osteotomy Classification Clinically Relevant x-ray parameters Alignment Objectives SVA < 5cm PT < 25 degrees PI LL < 10 Heterogeneous study designs Prospective multi-centric (SVA) Prospective mono-centric (PT) Retrospective multi-centric (LL-PI) 4

25 52 female with NF 1 Case 1 Multiple prior fusion surgeries Severe standing imbalance No Hip Flexion Contracture 5

26 Ondra Formula Example SVA 12cm PI 68 LL 18 PT 38 Sagittal Planning Case 2 62 yo female Severe LBP Fatigue in PM leaning farther forward Maintains retroversion when ambulating PI 72 SVA 11 (11cm) PT 52 (30 ) LL 0 TK 18 (+13) 6

27 Schwab Osteotomy Classification PI 72 SVA 0 PT 18 LL 70 TK 35 7

28 Coronal Plane Recontruction Vumedi Vedat Deviren MD Associate Professor Spine Center UCSF Department of Orthopaedic Surgery Disclosures Consultant Nuvasive, Stryker, Depuy Each case is unique and requires individual attention Most often they are tri-dimensional Adult Deformity 1

29 Adult Scoliosis Unlike AIS secondary curves usually stiff Balance is a significant concern in Adult with less compensatory ability in this plane Coronal Decompensation Correlating Radiographs and Function Increased pain/dysfunction Coronal imbalance (>5cm from C7 plumb line) Lumbar hypolordosis (<35 degrees of lordosis) Sagittal imbalance (>4cm from C7 plumb line) Disability was an independent of the magnitude of curve Ploumis et al, Spine patients 2

30 Predicting Health Status 76 F non surgical 73 F surgical SF-12 Vitality SRS-30 Activity ODI Walking Nonsurgical Surgical Modifying Factors for Surgical Strategy Presenting clinical symptoms Magnitude and Rigidity of Deformity Release/osteotomies Fixation Strategies Medical Comorbidities Osteoporosis Cardiopulmonary disease Frailty Modifying Factors for Surgical Strategy Presenting clinical symptoms Magnitude and Rigidity of Deformity Release/osteotomies Fixation Strategies Medical Comorbidities Osteoporosis Cardiopulmonary disease Frailty 3

31 Adult Deformity Anterior release/posterior osteotomy Posterior extension osteotomy (SPO) Pedicle subtraction osteotomy (PSO) Vertebral column resection (VCR) Flexibility 1) Flexible Deformity deformity corrects simply by being in a supine or prone position 2) Rigid Deformity: totally inflexible deformity with no correction in the recumbent position, 3) Some where between a deformity that partially corrects through mobile segments, but not entirely Dynamic Radiographic Studies Lateral Bending Less flexible than adult idiopathic scoliosis Traction Evaluating Flexibility Can reveal extent of autofusion from degeneration 4

32 Flexibility Preoperative evaluation Structural characteristic Major curve Compensatory curve Rigidity of curve Anterior release? Approaches PSF or ASF Determination fusion levels distal proximal Predictors of Flexibility in Thoracolumbar and Lumbar Idiopathic Scoliosis, Spine2003 Objective: Evaluate possible predictors of flexibility in patients with TL and L curve by side bending X-rays 14 years 47 to % Predictors of Flexibility in Thoracolumbar and Lumbar Idiopathic Scoliosis 5

33 34 year 55 to 22 60% Predictors of Flexibility in Thoracolumbar and Lumbar Idiopathic Scoliosis 47 year old 65 to 35 46% Predictors of Flexibility in Thoracolumbar and Lumbar Idiopathic Scoliosis Conclusion Age and Curve magnitude are the main predictors of flexibility Aging and degeneration of spine significantly decrease lumbosacral curve flexibility 6

34 Case study: 13 yo female Progressive T:78 degree L: 85 degree Flexible curve 8 years follow up Case study: Double major curve treated with posterior spinal fusion 43 yo female Progressive deformity Case: Semi rigid Deformity Facet release 7

35 68 / female Anterior (lateral) release Chronic back/leg pain/15 years Treatment Options Posterior Instrumentation/Fusion TLIF/Posterior I/Fusion ALIF/Posterior I/Fusion XLIF/Posterior I/Fusion 8

36 Degenerative Scoliosis Plan L2-L5 XLIF/T10-S1 PSF Plan? Do you stick to plan? Shorter Fusion Post-op x-rays (AP and lateral) 62 y F 75 degree curve Severe back pain Significant disability 9

37 47 degree after XLIF 10

38 degree 57 yo female Degree Selective fusion T12-L5 11

39 1 year later Less surgery may lead to more surgery 12

40 Attention to LS curve 69-year-old woman complaining of low back, bilateral hip and left leg pain. Rigid LS curve Preop 5.2 cm Post-XLIF 7.4 cm 13

41 Post PSF 2.2 cm Conclusion Evaluating flexibility is critical on surgery planning Attention to Rigid Lumbosacral rigid curve Balance is more important than curve it self. 14

42 VuMedi Webinar Multi-Center Grand Rounds Spine Deformity Case Discussions Complications and Revision Cases Christopher I. Shaffrey, MD Harrison Distinguished Professor Departments of Neurosurgery and Orthopaedic Surgery University of Virginia Disclosures Medtronic- Consultant, royalties Depuy- Consultant Biomet- Consultant Nuvasive- Consultant AO- Fellowship support, Grant support NIH- Grant support Department of Defense- Grant support NACTN- Grant support Case y/o woman with history of minimally invasive decompression at L3-4 and L4-5 for back pain and mild radicular pain in 2004 Back pain increased and in 2007 underwent redo decompression and L2-5 fusion complicated by durotomy Progressive difficulty standing upright ODI=72, VAS=9, SRS- 22= 56 1

43 10.4 cm 11.1 cm PI=54 0 PT=28 0 Case 1. Neutral Extension Flexion 2

44 Solution Removal of prior L2-5 instrumentation Repair of dural laceration with patch T10 to iliac instrumentation L5S1 TLIF L2 extended PSO 3

45 Case y/o female with history of untreated thoracolumbar scoliosis In 2006 underwent 2 stage; anterior thoracoabdominal fusion followed by T2 to iliac instrumentation and fusion Surgery complicated by deep wound infection treated by irrigation and debridement X 5 (staph aureus) Over next two years draining sinuses opened on multiple occasions despite suppressive antibiotics Instrumentation eventually removed with wound healing After removal, significant postural abnormality developed 4

46 Case 2. Surgical Intervention Planned Stage 1: L5-S1 followed by placement of posterior instrumentation T2 to ilium with intraoperative culture Stage 2: Multiple thoracic SPOs and L2 vertebral column resection procedure What type of prophylactic antibiotics? What type of spinal instrumentation? What bone fusion substrate? Value of TPN between stages? 5

47 Case 2. Cultures after stage 1 negative Value of pulse lavage irrigation? Duration of prophylactic antiobiotics after each stage Need for suppressive antibiotics? 6

48 Case 2. What Now? 1. Open wound with I and D 2. Open wound, I and D, pack wound 3. Open wound, I and D, remove implants 4. Open wound, I and D, VAC What to do about graft material? What to do about anterior implant and graft? Case 3. 05/05/05 67-year-old man who has longstanding history of LBP for >30 years Former special forces officer In 2004, he underwent L3-4 laminectomy for his back and leg pain CTM multilevel central canal and neural foraminal stenosis VAS back 7-9/10, ODI 48 7

49 8

50 Case 3. 06/28/2005 L2 partial inferior laminectomy, L3 and L4 redo laminectomies, right sided L5S1 laminectomy, left L3-4 and L4-5 TLIF right L5S1 TLIF with allograft spacers T11 to iliac instrumentation (5.5 titanium rods) T11 to iliac fusion using iliac crest bone graft, allograft and Infuse rh-bmp-2 (6 mg at each TLIF site, 18 mg posteriorly) 08/15/05 10/15/05 Was doing well with minimal pain and neurologically intact Two week history of right greater than left progressive lower extremity weakness with gradual loss of the ability to ambulate Now using walker to ambulate 9

51 Case 3. 10/17/05 Removal of prior T11 pedicle screws, right-sided intraoperative T11 vertebroplasty T5 through T11 instrumentation with end to end connectors T10 and T11 laminectomies with wide decompression T5 through T11 arthrodesis using a combination of local bone graft, allograft bone, and InFUSE rh-bmp-2 (12 mg) 10

52 03/19/07 Gradually regained strength in legs and was ambulating without assistance One month prior to presentation heard a pop and has had increasing back pain and inability to stand in an upright posture 03/19/07 04/11/2007 ALIF L4-L5 and L5-S1 with removal of prior TLIF spacers and placement of femoral ring allograft spacers using Infuse rh-bmp-2 (6 mg per level) Posterior re-exposure, replacement of several loose screws with L1 through S1 and iliac instrumentation revision, removal of broken rods, reinstrumentation of L1 through S1 with replacement of iliac screws L2 through sacral additional fusion using Infuse rh-bmp-2 (12 mg) 11

53 05/17/07 10/23/08 11/24/2011 Presents again with progressive myelopathy with difficulty walking, now using walker again One year history of increasing back pain and increasing forward posture 12

54 11/29/2011 Removal of entirety of previously placed T5 through sacral instrumentation removal of bilateral iliac screws Re-instrumentation T3 through S1 including placement of new bilateral iliac screws (6.0 mm CoCr rods) SPO at T12-L1 level with T5 and T6 partial laminectomies for decompression of the spinal cord with T3 through S1 posterior and posterolateral arthrodesis using Infuse rhbmp 2 (6 large kits- 72 mg BMP plus master graft) 13

55 03/28/12 Thank You 14

56 Pediatric Deformity Amer F. Samdani, MD Chief of Surgery Shriners Hospitals for Children--Philadelphia Philadelphia, PA Consultant: Depuy Stryker Zimmer SpineGuard Disclosures Outline Case(s) #1- Adolescent Idiopathic Scoliosis: Level Selection Case #2- Severe Syndromic Scoliosis: Surgical Approaches Case #3- Congenital Scoliosis and Intraspinal Anomalies 1

57 AIS: Level Selection 13 yo girl with progressive scoliosis PT: T2-T5= 39º MT: T6-L1= 52º Lumbar: L1-L4= 28º Sagittal: T5-12= 25º Physical examination Trunk shift to right Left shoulder> right Inclinometer=18º Lenke 1AN Lenke Classification: Fuse Structural Curves Surgical Plan T2 to L2 PSF using cobalt chrome rods T2- left shoulder higher than right L2- touched by CSVL Ponte osteotomies T5 to T12 Direct vertebral body derotation 2

58 Postop Films Selecting Upper Level 12 year old girl w/ juvenile idiopathic scoliosis From Puerto Rico Followed for 2 years Left hip dysplasia/leg length discrepancy Case Example 3

59 Pre-operative Radiographs Surgical Plan T2-L3 PSF 6 level Ponte osteotomies Bilateral thoracoplasties (rib osteotomies) 2 posterior disc releases Rod derotation, direct vertebral body derotation, compression/distraction Cables Post-operative Standing Films 4

60 UIV = T2 L shoulder high preop (absolute) PT curve structural Marked correction planned for MT curve Proximal kyphosis present (T2-T5 >20º) UIV = T3 Shoulders level pre-op/ slight right shoulder evaluation PT curve structural Marked correction of MT curve planned Mild proximal kyphosis present (T2-T º) Level shoulders Courtesy of Dr. Lenke UIV = T4/T5 Right shoulder high pre-op Non structural PT curve No proximal kyphosis noted Right shoulder high Courtesy of Dr. Lenke 5

61 Patient IP 14 yo girl with a progressive idiopathic scoliosis PE Marked trunk shift to the right Inclinometer of 24 Left shoulder higher than right Preoperative Bends T2 to L3 PSF Concern Not enough correction of upper curve and drive left shoulder very high Plan T2 to L3 PSF Ponte s T4,5,6 and T9,10,11 Tip Worked on upper curve first and placed short concave distraction rod Preop Plan 6

62 Postoperative Films Selecting Distal Level Generally, touched by CSVL Suk: End/neutral vertebra analysis Spine 2003 LIV Selection 7

63 Dr. Suk s Method NV = or >1 level below EV Fuse to NV NV 2 levels below EV Fuse to NV - 1 NV EV 1 Distal Level Selection 13 yo with Lenke 3C pattern T4 to T10 72 degrees T11 to L4 56 degrees Inclinometer Thoracic 18 Lumber

64 Summary Proximal level Shoulder heights Kyphosis Magnitude of main thoracic curve Distal level Generally, touched by CSVL Try hard for selective fusion or stop at L3 Junctional kyphosis Case Presentation: Neurofibromatosis 16 y.o. with NF Severe scoliosis 140 Marked trunk shift K.B. 9

65 Surgical Plan Thoughts? T2 to L4 PSF Stage 1 Ponte osteotomies Placement of pedicle screws Halo-Gravity traction in between stages Stage 2 VCR T9 Neuromonitoring Stable SSEPs/MEPs both procedures Halo Gravity Traction Improves Nutritional/pulmonary status Curve correction? Timing? Usually 2-6 weeks Nutritional or pulmonary compromise Start at onset May not aid with curve correction unless prior release Koller et al, Eur Spine J 2012 Sponseller et al, Spine

66 Case Presentation: Severe Scoliosis and Intraspinal Anomalies 19 y.o. woman with severe congenital scoliosis Diastematomyelia Large syrinx Age 10 partial removal of diastematomyelia Loss of signals, operation aborted Inability to walk for one month Full recovery L.K. Clinical Photos 11

67 October 2011 CT MRI April

68 Surgical Plan Thoughts? Remove diastematomyelia? Shen et al SRS patients with diastematomyelia underwent deformity surgery None prophylactically removed No neurological injuries Syringomyelia? Consider spinal cord shortening procedure Outcome of Operative Treatment for Spinal Deformity in Patients with Syringomyelia: A Comparison Study to AIS Patients Sucato et al, SRS patients with syringomyelia and scoliosis compared with 82 patients with AIS Less reliable rate of obtaining signals and more alerts but similar correction However, no quantification of syrinx size Intraoperative T2 to L4 PSF Osteotomies Rib mass resection Intraoperative small MEPs, SSEPs T7 vertebrectomy with cage Prepared for D-wave monitoring Multiple wake-ups After instrumentation Correction 13

69 Postoperative 14