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ADULT SPINAL DEFORMITY

Definition
Adult spinal deformity is defined by the Scoliosis Research
Society as a spinal deformity with any etiology in a skeletally
mature patient.

Scoliosis is defined as lateral deviation of the normal vertical


line of the spine of greater than 10 when measured on
radiographs.
Indications and Treatment Goals

The primary goals in treating adult spinal deformity are to gain


spinal balance, halt the progression of deformity, reduce pain,
and improve the patients healthrelated quality of life (HRQL).
Treatment should improve the patients outcome above the natural
history of the disease and avoid any deleterious long-term
effects.
The only study of the natural history of adult scoliosis
evaluated patients with untreated adolescent idiopathic
scoliosis. At a mean follow-up of 51 years (range, 44 to 61
years), the authors reported mean cobb angles of 84, 89,
and 49 for the thoracic, thoracolumbar, and lumbar spines,
respectively. The study showed no difference in survival rates
compared with the general population
Patient Evaluation

Clinical Evaluation Low back pain is the most common


symptom reported by patients with adult spinal deformity.
Symptoms of low back pain are also common in the general
population and cannot be immediately attributed to scoliosis.
A thorough history and examination is necessary to rule out
other potential causes
In general, patients younger than 40 years with adult scoliosis
present with symptoms similar to those of younger patients
with adolescent idiopathic scoliosis.
Typically, a patients primary concerns are the probability for
curve progression and the potential for long-term sequelae,
poor cosmesis, and low back pain. The etiology of these
symptoms should be evaluated in a manner similar to that
used in evaluating patients without scoliosis.
In addition to a thorough neurologic evaluation, a
physical examination should be performed to evaluate
gait and standing balance. Observing the patients gait
permits an evaluation of spinal balance while in motion.
Many patients with scoliosis may stand erect in sagittal and
coronal balance; however, ambulation causes fatigue,
which may result in positive sagittal imbalance. Because
patients with fixed sagittal imbalance often pitch forward
progressively when ambulating any distance, hip and knee
range of motion should be closely examined.
In general, adults with spinal deformity should be clinically
evaluated in a manner similar to that used for patients
presenting with a spinal disorder. The source of the patients
complaint, such as low back or leg pain, should be evaluated
first. The unique dimensions of a deformity, whether it is
scoliosis or fixed sagittal imbalance, should then be
considered in the overall evaluation and treatment plan.
Radiographic Evaluation

Standing, 36-inch PA and lateral radiographs are needed to


evaluate adult spinal deformity. The knees should be fully
extended for the lateral radiograph to ensure accurate
assessment of sagittal balance. The cervical, thoracic, and
lumbar spines as well as the pelvis and hip joints should be
visible. Cobb angles, coronal and sagittal balance, and pelvic
incidence should be measured and recorded (Figures 1
through 3).
Radiographs taken with the patient bending can be used to
assess the flexibility of coronal plane deformities and may aid
in surgical decision making, especially in younger adults who
can be classified with the Lenke system
Types of Adult Spinal Deformity

Any spinal disorder or disease that leads to scoliosis or


coronal or sagittal imbalance in a skeletally mature patient is
considered an adult spinal deformity. The most common
categories are adult idiopathic scoliosis, adult de novo
scoliosis, and fixed sagittal imbalance.
Adult Scoliosis
Adult idiopathic scoliosis is defined as scoliosis in a
skeletally mature patient that existed in childhood or
adolescence. Adult de novo scoliosis, or degenerative
scoliosis as it is commonly termed, is a condition that did not
existent before skeletal maturity and developed in adulthood.
The overall prevalence of adult scoliosis increases with age.
Adult degenerative scoliosis predominantly develops in the
thoracolumbar spine however, compensatory curves can also
develop in the thoracic spine. The incidence of low back pain
in patients with untreated adolescent idiopathic scoliosis
(mean age, 66 years) was higher than in a matched cohort
(67% versus 35%). Most of the patients rated the intensity of
pain as low or moderate
Nonsurgical Treatment There is little consensus and only
weak evidence for the effectiveness of any one nonsurgical
treatment method for adult scoliosis and adult deformity in
general. Typically, the recommended nonsurgical treatment is
based on the chief symptoms reported by the patient. If low
back pain is the main symptom, a structured physical therapy
program based on the patients physical capabilities is
recommended, with emphasis on core strengthening and
spinal balance.
Surgical Treatment The surgical decision-making process for
adult scoliosis is difficult. The procedures are often complex,
full recovery can take up to 1 year, and complication rates as
high as 20% have been reported in older patients. Patients are
often confused about their prognosis and fearful of the
potential effects of scoliosis on their general health and
appearance. Taking time to discuss the natural history of the
condition
Curve Correction
Although there is evidence that coronal imbalance greater
than 4 to 5 cm correlates with a reduced health status, there is
no evidence that surgical correction of coronal imbalance
correlates with improved outcomes. The most important
predictor of outcomes is spinal sagittal balance however,
restoring lumbar lordosis to achieve sagittal balance often
requires some degree of curve correction.
Selection of Fusion Levels
Selecting the appropriate cephalad and caudad levels for
fusion remains an area of controversy. In a patient younger
than 40 years with adult idiopathic scoliosis, the selection of
fusion levels correlates more closely with recommendations
for adolescent idiopathic scoliosis.
Approach
In the traditional treatment of scoliosis, anterior release
combined with or without anterior fusion was believed to
improve curve correction and restore alignment, especially in
patients with a rigid curve. However, the anterior
thoracolumbar approach can be associated with morbidity.
Decompression
Up to 64% of patients with adult scoliosis present with
reports of leg pain associated with stenosis. Adequate neural
decompression is the first treathment priority.
Limited Decompression and Fusion
The role for limited decompression without fusion and
decompression with limited fusion in adult scoliosis is not
well defined. Typically, the patient being considered for
treatment with a limited approach is older, has unilateral or
bilateral leg pain symptoms secondary to lumbar stenosis, and
minimal or no back pain. The goal of a focused treatment is
to address the primary symptomatic pathology (lumbar
stenosis) without causing iatrogenic instability and rapid
curve progression.e first treatment priority.
Fixed Sagittal Imbalance Syndrome Fixed sagittal imbalance
is defined as radiographic sagittal imbalance of more than 5
cm. This syndrome has multiple etiologies (Table 1),
Treatment
The recommended surgical treatment of fixed sagittal
imbalance is dependent on the amount of positive sagittal
imbalance, the degree of flexibility of the deformity, and
whether the kyphosis is focal (limited to a few spinal
segments; for example, posttraumatic kyphosis) or
multilevel (involving several spinal segments; for example,
Scheuermann kyphosis)
Interbody Fusion
Interbody fusion is limited to use in patients with minor
sagittal imbalance (6 to 8 cm). Two thirds of lumbar lordosis
occurs through the L4-L5 and the L5-S1 segments. Lumbar
lordosis can be improved by restoring the disk height at L4-
L5 and L5-S1 through the use of structural interbody allograft
or cages.
Because of the technical challenges and potential
complications of inserting larger grafts or cages through the
posterior approaches (transforaminal or posterior lumbar
interbody fusions), anterior lumbar interbody fusion is
preferred by many surgeons as a more effective method of
regaining lordosis. For example, in a patient with a prior
thoracolumbar fusion extending to L4 with disk degeneration
and sagittal imbalance of 8 cm, an anterior lumbar interbody
fusion at L4-L5 and L5-S1 may restore enough lordosis to
obtain sagittal balance.
Smith-Petersen Osteotomy
Smith-Petersen osteotomies are usually performed at multiple
levels and can restore as much as 10 of lordosis per level
depending on the amount of disk mobility. A Smith-Petersen
osteotomy will not be successful if there is anterior fusion,
and/or will provide minimal correction if there is minimal
disk height associated with large osteophytes.
Smith-Petersen osteotomies can be added to the anterior
lumbar interbody fusion or used in conjunction with a pedicle
subtraction osteotomy to increase the magnitude of lordosis
correction. Smith-Petersen osteotomies are commonly used to
treat Scheuermann kyphosis, lesser degrees of thoracolumbar
kyphosis, and can be used as a method of restoring lordosis
and improving correction in thoracolumbar scoliosis.
Pedicle Subtraction Osteotomy
A pedicle subtraction osteotomy is indicated in patients with
more severe sagittal imbalance (> 12 cm). A correction of 30 to
35 can be expected in the lumbar spine and 25 in the thoracic
spine. These osteotomies are effective in treating focal kyphosis
and can be used to treat severe scoliosis, with an asymmetric
correction in the sagittal and coronal planes
Vertebral Column Resection
Vertebral column resections are indicated for the corection of
rigid, angular kyphosis in the thoracic spine; severe rigid
scoliosis; congenital kyphosis; hemivertebrae resection in the
thoracic and lumbar spines; and kyphotic deformity
associated with tumor, fracture, or infection in the thoracic
spine.
Neuromuscular Adult Scoliosis
Neuromuscular adult scoliosis covers a broad range of
conditions, including cerebral palsy, spinal muscle atrophy,
Duchenne muscular dystrophy, poliomyelitis, and paraplegia.
Adult-onset conditions such as multiple sclerosis and
Parkinson disease, which cause general weakness and balance
problems, can also cause neuromuscular-type deformities.
The deformity can occur in any region of the spine, with the
patient presenting with kyphosis, lordosis, and/or sagittal and
coronal imbalance. Often, there is a long sweeping type
deformity, which may be flexible in the young adult patient.
The deformities associated with multiple sclerosis and
Parkinson disease may be flexible at the early onset of the
disease in middle-aged and older adults but may become
progressively rigid with time.
Pain, halting deformity progression, and achieving spinal balance are the
goals of treatment. In a patient who is confined to a wheelchair, sitting
balance is key to allowing efficient use of the upper extremities and
preventing skin breakdown. Because a high rate of surgical
complications occurs in this group of patients, proper counseling
regarding expected outcomes is important. In one of the few studies
evaluating spinal surgery in patients with Parkinson disease, the rate of
revision surgery was 86% and the infection rate was 14%.
Intraoperative Neurophysiologic Monitoring
The evidence in support of the routine use of intraoperative
neurophysiologic monitoring during the treatment of spinal
deformity has strengthened. Its use aids in the early detection
of impending spinal cord injury and may prevent worsening
postoperative morbidity. A study of more than 1,000 patients
(mean age, 14 years) surgically treated for adolescent
idiopathic scoliosis showed that changes in transcranial
electric motorevoked potentials were detected earlier than
changes in somatosensory-evoked potentials
Twenty-six patients had decreases in amplitude of 65% in
transcranial electric motor-evoked potentials during posterior
instrumentation and corrective maneuvers. Nine (35%) of
these patients (0.8% of the study group) had a transient motor
or sensory deficit postoperatively, all of which were detected
by transcranial electric motorevoked potentials.
Challenges

The Aging Spine


The rate of complications in adult deformity surgery increase
as the complexity of the surgery increases. As the population
ages, there has been an increase in the number of older
patients who are being surgically treated for major spinal
deformities. Many complications are related to medical
comorbidities and osteoporosis. The rate of major
complications in patients older than 60 years was 20% in one
series, with the rate of complications significantly increasing
in patients older than 69 years.
Corrective Osteotomies
Pedicle Subtraction osteotomies and vertebral column
resections allow the correction of rigid sagittal and coronal
deformities, but there are increased risks with these
techniques. The incidence of neurologic deficits was as high
as 11% in one study, but most of the injuries were limited to
the nerve root levels and eventually resolved.
The rate of pseudarthrosis with pedicle subtraction
osteotomies was reported as high as 28% at 5-year follow-up;
however, after revision surgery the HRQL measures
improved and were not significantly different from those of
patients without psuedoarthosis. Vertebral column resections
are associated with a higher rate of neurologic deficits and
intraoperative neurophysiologic monitoring changes
Pseudarthrosis
Pseudarthrosis continues to be a major challenge and is one
of the main complications in multilevel, adult deformity
surgery. With longer term follow-up, the rate of
pseudarthrosis increases. It has been reported to be 17% in
one large series and as high as 24% in a recent report, with
only 25% of the cases of pseudarthrosis detected within the 2-
year follow-up period.
Future Directions
Over the next several years there will be a demand for better-
quality scientific evidence that surgical treatment in adult
spinal deformity is making a clinically significant
improvement in the lives of patients. Large clinical series
have shown that sagittal balance is a key predictor of
improvement in HRQL. As the understanding of the role of
pelvic parameters in determining sagittal balance increases,
orthopaedic surgeons may become more adept at
individualizing surgical interventions to restore spinal
balance.
The treatment of adult spinal deformity is complex. The
indications for surgical treatment should not be based on
radiographs alone. Many patients can tolerate high magnitude
curves and function well. Treatment recommendations should
be individualized and the impact of the deformity on the
patients daily function and quality of life should be
considered.