Correction of Adult Scoliosis Via a Posterior-Only Approach
Correction of Adult Scoliosis Via a Posterior-Only Approach
Object: Adult scoliosis is a pathologically different entity from adolescent idiopathic scoliosis. The curves are more rigid, and rotational deformity and multilevel sagittal vertebral slippages compound the coronal malalignment. To correct these deformities, a surgical anterior release procedure is usually required, as well as posterior instrumentation-assisted fusion. This exposes the patient to the risks of a second procedure and of a thoracotomy or laparotomy. To decrease these risks, the authors have performed an anterior release, posterior release, and reduction via a posterior-only approach. The purpose of this study was to analyze quantitatively the degree of pre- and postoperative coronal deformity, the extent of correction, and related complications.
Methods: Data obtained in 20 patients with adult scoliosis were retrospectively studied. Patients presented with persistent back or lower-extremity pain, progressive deformity, or progressive neurological deficit. Sixteen patients underwent Gill-type laminectomy, radical discectomy (including fracture of any anterior and lateral osteophytes), and posterior lumbar interbody fusion (PLIF) of all apical and adjacent segments. One to four anterior release procedures were performed in each patient. Posterior instrumentation was placed over three to 15 levels. Autograft was obtained from the laminectomy sites and posterior iliac crest for fusion. There were no deaths; all patients were followed for a minimum of 1 year. The mean coronal Cobb angle improved from 36° to 14.7°. All spondylolisthetic lesions were reduced to at least Grade I. At the most recent follow-up examination, evidence of fusion was demonstrated in all patients. Reoperation for adjacent-segment failure, cephalad to the highest level of fusion, was required in two cases.
Conclusions: In many cases of adult scoliosis, a satisfactory multiplanar correction may be obtained via a single posterior approach and by using extended PLIF techniques. Cephalad adjacent-segment failure remains a significant problem in patients with osteoporosis, and routine extension of posterior instrumentation to the upper thoracic spine should be considered in these cases.
Adult patients with scoliosis often present with a rigid curve, which can be associated with complex rotational deformity and multilevel sagittal spondiolistheses. The disease often progresses over time and can lead to cosmetic and psychological problems, back pain, radiculopathy, spinal claudication, and ultimately spinal instability and cardiopulmonary compromise. Although primary treatment is conservative, including spinal orthoses, physical rehabilitation, and pain control, these measures often fail, or patients may not be candidates for such therapy. In such cases, surgery is recommended. Surgical interventions have included posterior instrumentation and fusion alone, anterior instrumentation and fusion alone, and anterior release (to restore spinal flexibility) combined with posterior fusion.
Although all methods have been successful, surgical correction is hampered by the rigidity of the curvatures, which may necessitate anterior release. Combined approaches, while often more successful in treating the deformity, have the increased risks in elderly and frail patients of a second significant operation, including a second induction of general anesthesia, increased operating time, and excessive blood loss. Surgery in adults with scoliosis is technically more demanding than similar surgery in adolescents. In adults the curves are more rigid, the bones more osteopenic (making instrumentation more difficult), and the patients generally more frail and in poorer health than adolescents. Higher complication rates in adults have been documented. Complications inherent to the retroperitoneal approach include abdominal visceral, great vessel, and superior hypogastric nerve plexus injury. Transthoracic approach-induced complications include injury to the great vessels, pulmonary complications, chylothorax, and the postthoracotomy pain syndrome.
In an effort to decrease the risks of combined procedures while maintaining the ability to satisfactorily reduce complex deformities, we performed anterior and posterior release, instrumentation placement, and reduction of spinal deformity via a single posterior approach.
Object: Adult scoliosis is a pathologically different entity from adolescent idiopathic scoliosis. The curves are more rigid, and rotational deformity and multilevel sagittal vertebral slippages compound the coronal malalignment. To correct these deformities, a surgical anterior release procedure is usually required, as well as posterior instrumentation-assisted fusion. This exposes the patient to the risks of a second procedure and of a thoracotomy or laparotomy. To decrease these risks, the authors have performed an anterior release, posterior release, and reduction via a posterior-only approach. The purpose of this study was to analyze quantitatively the degree of pre- and postoperative coronal deformity, the extent of correction, and related complications.
Methods: Data obtained in 20 patients with adult scoliosis were retrospectively studied. Patients presented with persistent back or lower-extremity pain, progressive deformity, or progressive neurological deficit. Sixteen patients underwent Gill-type laminectomy, radical discectomy (including fracture of any anterior and lateral osteophytes), and posterior lumbar interbody fusion (PLIF) of all apical and adjacent segments. One to four anterior release procedures were performed in each patient. Posterior instrumentation was placed over three to 15 levels. Autograft was obtained from the laminectomy sites and posterior iliac crest for fusion. There were no deaths; all patients were followed for a minimum of 1 year. The mean coronal Cobb angle improved from 36° to 14.7°. All spondylolisthetic lesions were reduced to at least Grade I. At the most recent follow-up examination, evidence of fusion was demonstrated in all patients. Reoperation for adjacent-segment failure, cephalad to the highest level of fusion, was required in two cases.
Conclusions: In many cases of adult scoliosis, a satisfactory multiplanar correction may be obtained via a single posterior approach and by using extended PLIF techniques. Cephalad adjacent-segment failure remains a significant problem in patients with osteoporosis, and routine extension of posterior instrumentation to the upper thoracic spine should be considered in these cases.
Adult patients with scoliosis often present with a rigid curve, which can be associated with complex rotational deformity and multilevel sagittal spondiolistheses. The disease often progresses over time and can lead to cosmetic and psychological problems, back pain, radiculopathy, spinal claudication, and ultimately spinal instability and cardiopulmonary compromise. Although primary treatment is conservative, including spinal orthoses, physical rehabilitation, and pain control, these measures often fail, or patients may not be candidates for such therapy. In such cases, surgery is recommended. Surgical interventions have included posterior instrumentation and fusion alone, anterior instrumentation and fusion alone, and anterior release (to restore spinal flexibility) combined with posterior fusion.
Although all methods have been successful, surgical correction is hampered by the rigidity of the curvatures, which may necessitate anterior release. Combined approaches, while often more successful in treating the deformity, have the increased risks in elderly and frail patients of a second significant operation, including a second induction of general anesthesia, increased operating time, and excessive blood loss. Surgery in adults with scoliosis is technically more demanding than similar surgery in adolescents. In adults the curves are more rigid, the bones more osteopenic (making instrumentation more difficult), and the patients generally more frail and in poorer health than adolescents. Higher complication rates in adults have been documented. Complications inherent to the retroperitoneal approach include abdominal visceral, great vessel, and superior hypogastric nerve plexus injury. Transthoracic approach-induced complications include injury to the great vessels, pulmonary complications, chylothorax, and the postthoracotomy pain syndrome.
In an effort to decrease the risks of combined procedures while maintaining the ability to satisfactorily reduce complex deformities, we performed anterior and posterior release, instrumentation placement, and reduction of spinal deformity via a single posterior approach.
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