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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



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



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.)



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.



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



Major surgical complications

56%-75%

Unplanned reoperation rates

18-58%

Unproven benefits regarding

improvement of HRQOL



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



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



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)



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)



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



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



The results demonstrated an appreciable highrate of

Postoperative pain (32.3%)

Bulging(43.5%),

Functional disturbance (24.2%),



The Role of the Less Invasive Lateral

Approach for Adult Deformity

Surgery?



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.



Fusion to L5 vs. S1



CASE EXAMPLES



83 yrs Retired Atty.



Imbalance and Back and Leg Pain



Post op



(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



53



T8-T12 : 42 degT12-L4: 53 deg



B S 24 Months Post op

•

SRS22: 3.3• VAS:4/10

• ODI: 22%



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.



73

65

33

12

4



4078

53

3712



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



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



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



Thank You

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