History: At
the time of the first encounter the patient was a 45-year-old
lady who presented for consultation due to gradually increasing
pain and spinal deformity. The patient stated that at the
age of 12 she was diagnosed with idiopathic scoliosis. She
was first treated by an exercise program and then placed
for 9 months in a body cast. Due to progression of her scoliosis
she underwent surgery at the age of 14. Unfortunately revision
surgeries were necessary over the following years to treat
increasing deformity and increasing discomfort. Her last
surgery was performed to remove instrumentation in her spine
that was felt to be a source of pain. Despite the numerous
surgeries the patient noted increasing pain and a sensation
of increasing deformity and poor balance. Her pain, which
at first was mainly in the back began to involve leg pain
and weakness.
Physical Examination:On
examination the patient was noted to walk with a limp and
in need of a cane. She required the assistance of another
person to be transferred to an examination table. In the
standing position the patient was significantly off-balance
when seen from the front (trunk shift to the right) and
from the side (trunk pitched forward with hips and knees
flexed). The observation of the back showed overlapping
scars, a right elevated shoulder and a marked deformity
of the upper spine which was twisted to the left. Lower
extremity examination revealed sensitivity to be decreased
in the left leg with a decreased ankle jerk reflex on that
side.
Radiographic Evaluation:Standing
X-rays were difficult to obtain due to the deformity and
patient ability to stand comfortably. A spinal fusion was
noted to extend from the first thoracic vertebra to the
4th Lumbar vertebra with a typical Flatback and severe kypho-scoliosis
(malalignment in both the frontal and sagittal planes).
(figures 1,2,3,4)
The MRI of the lumbar spine showed a moderate stenosis at
both the L4-L5 and L5-S1 levels. The review of a bone scan
demonstrated areas of increased isotope uptake at the bottom
of the spine consistent with osteoarthritis and in the middle
of the fusion suggesting a pseudarthrosis.
Treatment Options:The
treatment options available for complex cases of flatback
generally range from analgesics, therapy and pain modalities
to temporary bracing and possibly surgery. In this case
pain management and therapy had already been pursued and
judged as not acceptable in order to pursue an active life
style. Surgical revision surgery is another option in the
setting of marked spinal malalignment. The goals of such
an intervention would be to ideally address the following:
the pseudarthrosis, the malalignment in the frontal plane
(ie. the trunk imbalance), the malalignment in the sagittal
plane (the flatback). The exact surgical technique might
include the following:
-
Repair of the pseudarthrosis with instrumentation
/ bone graft and surgical decompression to L5-S1.
This may improve the focal pain from the pseudarthrosis
and nerve irritation symptoms but does not address
or correct the real problem of malalignment.
-
Performing osteotomies in both the thoracic and lumbar
spines to correct the poor balance and re-fuse the
spine to L4. Although this does not involve a direct
decompression at L5-S1 such an approach is based
upon the principle that fusion ending on a degenerated
disc (if properly balanced) can offer advantages
over a fusion extended to the sacrum. Motion at
the L5-S1 level is preserved and nerve root symptoms
related to subtle instability and traction can be
reversed with a well aligned fusion.
-
Performing osteotomies in both the thoracic and lumbar
spines to correct the poor balance and re-fuse the
spine to L5. This approach, in the setting of markedly
degenerated lumbar discs offers re-balancing the
spine and ensuring lasting decompression of the
affected nerves. Although motion is lost in the
lowest spinal level the trade off is a stable and
balanced spine.
DiscussionIn
this complex case non-operative measures had not lead to
any relief and the patient noted progressive disability
over time with limitation in all activities. The patient
wished to proceed with a surgical approach after careful
review of all options and thorough discussions of risks
and potential benefits. It was felt that in order to maximize
the chances of lasting relief it would be crucial to obtain
the following: solid fusion , alignment of the head above
the pelvis in all planes, reduced magnitude of the deformity
and decompression of the nerves at L4 -L5 and L5-S1 levels.
Due to the markedly degenerated discs at L4-L5 and L5-S1
it was felt that realignment without extension of the fusion
to the sacrum would only offer temporizing treatment due
to the advanced degeneration at L5-S1. In some cases a shorter
fusion can be very successful however, in this case this
was felt to be a risky proposition.
Treatment and Results: As
planned the patient was treated with anterior and posterior
approaches to the spine. Multiple osteotomies were necessary
to balance the spine and an extension of the fusion to the
sacrum was performed. Following the posterior surgery a
slight displacement of an interbody bone graft necessitated
revision during the same hospitalization. The patient experienced
an excellent recovery, her pain markedly decreased after
surgery and was nearly completely resolved at one year follow
up . Spinal alignment was restored, the fusion healed solidly
and the patient has resumed her professional activities
on a full time basis. (figures 5,6)
Flatback
Medical Condition
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