ADULT DEFORMITY SURGERY

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CASE PRESENTATION

Isthmic Type Spondylolisthesis


Spondylolysis-Isthmic Spondylolisthesis

History Summary

  • 23 year old man
  • Professional Footballer
  • Had to quit playing because of Severe Right-Sided Lower Back Pain
  • Extensive Physiotherapy - No help
  • Pain management failed

The patient was a 23 year old professional footballer who was forced to quit playing because of severe right sided lower back pain. Extensive physiotherapy and Pars injections had failed to improve his pain.

Lumbar spine X-rays revealed that the patient was suffering from Grade I Isthmic Type Spondylolisthesis. After failure of nonoperative treatments the patient underwent an MIS Transforaminal Interbody Fusion (MIS TLIF). Immediately after surgery his pain has resolved. 

Six months after the operation following extensive post-operative rehabilitation he returned to playing football.

 
DETAILS   

 
 

Diagnosis - Lumbar Spine X Rays

  • Grade I Isthmic Type Spondylolisthesis
  • Read more: http://www.britscoliosissoc.org.uk/patient-information/spondylolysis

Spino-Pelvic Alignment

Consultant Spinal Surgeon  in Liverpool and Wirral

 

Consultant Spinal Surgeon  in Liverpool and Wirral

Consultant Spinal Surgeon  in Liverpool and Wirral

 

Flexion & Extension Lumbar X Rays

Consultant Spinal Surgeon in Liverpool and Wirral

MRI-No nerve compression

Consultant Spinal Surgeon in Liverpool and Wirral

Consultant Spinal Surgeon  in Liverpool and Wirral

 

 

 

CT scan-Bilateral L4 Pars Fractures

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TREATMENT OPTIONS

Non-surgical

  • Pars Injections-Had very short term relief
  • Physiotherapy post-injection -No help

Surgical

  • Bilateral Pars screw fixation?

- Not indicated because of the instability

  • MIS Transforaminal Interbody Fusion (MIS TLIF)

- Decided to proceed with this option

- Discussed possibility to return playing after extensive post-operative rehabilitation

 

 

Intraoperative Fluoroscopic Images

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6 Months Post-operative Follow-up

  • Patient asymptomatic
  • No back/leg pain
  • Starting running/cycling
  • Lost significant weight gained in the last few months
  • Training with personal trainer

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Self Reported Clinical Outcomes

Consultant Spinal Surgeon  in Liverpool and Wirral

 

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 in CASE PRESENTATION

            Scheuermann`s Kyphosis Correction


Scheuermann`s Kyphosis in Adult Patient

History Summary

  • 26 years old man
  • Complains of back pain
  • Cosmetic concerns-prominent back
  • Tried pain medication
  • Physiotherapy

The patient was a 26 year-old man who experienced back pain and had serious cosmetic concerns as to a prominent curve in the back. The patient had tried various pain medication and physiotherapy but these had not helped to alleviate the pain.

The patient underwent analysis of the deformity using electronic surgical planning software. The cause of the deformity was attributed to an increased Thoracic Kyphosis (Scheuermann`s disease).

Surgery consisted of posterior spinal fusion which resulted in correction of the kyphotic deformity. The Lumbar Lordosis decreased from 83 to 52 degrees, whilst the Thoracic Kyphosis decreased from 82 to 45 degrees. Normal alignment was attained. The cosmetic result was also very satisfactory for the patient.

 
DETAILS   
 

 

Diagnosis - Scheuermann`s Kyphosis

  • Read more about this condition: http://www.britscoliosissoc.org.uk/patient-information/kyphosis

Consultant Spinal Surgeon  in Liverpool and Wirral

Consultant Spinal Surgeon  in Liverpool and Wirral

 

 

Analysis of The Deformity Using Electronic Surgical Planning Software

  • Increased Thoracic Kyphosis: Primary cause of Deformity
  • Compensatory Hyper-lordosis

Surgical Planning

  • Removal of Compensatory Lordosis reveals magnitude of deformity

 

 

 

 

Global Sagittal Alignment Goals

Osteotomies Plan

 

 

Osteotomies Plan Continued...

 

 

 

 FINAL RESULT

Before Surgery

Consultant Spinal Surgeon  in Liverpool and Wirral

After Surgery

 Corrections

  • Correction of Primary Deformity: Thoracic Kyphosis decreased from 82 to 45 degrees
  • Reversal of Compensatory Hyper-lordosis: Decrease of Lumbar Lordosis from 83 to 52 degrees

 

Result: Normal Age Adjusted Alignment Achieved 

BEFORE

AFTER

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Complex Adult Spinal Deformity 


BACKGROUND OF THE CONDITION

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DEFINITION. Spinal sagittal imbalance, is deformity of the spine in the sagittal plane. In nowadays  it is a major cause of pain and disability among patients presenting to the spine clinic in daily practice. Normal sagittal spinal balance is a result of mutual relationship of the different spinal regions and the articulation of the pelvis and the spine in the sagittal plane.

ETIOLOGY. The most common driver of the sagittal plane deformity is the loss of the physiologic lumbar curve. This can be caused by severe disc degeneration , trauma (post-traumatic) or following lumbar surgery (iatrogenic).

COMPENSATORY MECHANISMS. Variations in the spine sagittal alignment can be compensated by compensatory mechanisms occurring in the spine, pelvis and lower limbs.

The aim of these mechanisms is to allow the individual to keep an erect position. These mechanisms can be effective and allow maintenance of the erect position (compensatory sagittal mal-alignment)  but at long term cause muscular fatigue, pain and disability.  Once the compensatory mechanisms are exhausted surgical intervention is often required.

OPERATIVE TREATMENT. Surgical treatment of adult sagittal imbalance is a complex procedure. Requires detailed preoperative planning and is performed from surgeons with experience in Adult Spinal Deformity.

       

 

 


 Cone of Economy

               Dubousset. Spine 2006

 Principles of Sagittal Alignment

 

  The ability of each individual to stay within

  the center of the Cone of Economy is vital in

  order to perform activities of daily living

  without pain

 

      CASE PRESENTATION

               Sagittal Plane Imbalance Correction

History

  • 63 years old man
  • Previous surgery 7 years ago following fall which resulted in a fracture of the L2 vertebra
  •  Presented with inability to stand straight
  • In severe disability

 

 

 Preoperative Assessment

 

Whole Spine X Rays

show loss of correction since the initial surgery 

 

 Imaging studies (MRI, CT) confirm 

Fixed Sagittal Imbalance 

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Preoperative Analysis of Global Alignment & Proportion Score 

Indicates that the patient has severe sagittal mal-alignment with the maximum score of disproportion

 

PLAN

AMOUNT OF CORRECTION REQUIRED

Correction of sagittal mal-alignment in this case requires at least 40 degrees of lumbal curve (lordosis) increase.

Considering the mal-alignment in this particular case is fixed, the only way to achieve improvement of lordosis is by performing Osteotomies

 

 

Preoperative Planning Using Electronic Software 

Has the advantage to simulate the surgical interventions and predict better the final outcome

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       Surgical Plan 2 stages surgery

1st        Stage : Anterior Lumbar Interbody Fusion (ALIF) 

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        and the second stage of a pedicle subtraction            osteotomy (PSO)

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 FINAL RESULT

 

 

 

Final Postoperative

X Rays

Correction of Sagittal plane malalignemnt with improvement of lumbar lordosis of about 60 degrees

 

 

 

Preop to Postoperative

photography

 

 

 

 

   Preop to Postoperative

           X Rays

 

 

 

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Preop to Postoperative

Comparison of

GAP Score