Adult Idiopathic Scoliosis

Dr. Traian Ursu MD,

MS(Orth),

Prof. Dr. D.
Antonescu
Foisor Orthopaedics Hospital
Bucharest
ROMANIA

Dec. 2004
 • Adult Idiopathic Scoliosis (AdIS)
covers by definition all the scoliosis
type deformities that appear after the
cease of skeletal growth and do not
have a congenital or neurological
etiology.

Dec. 2004
 • Mainly there are 3 types of
AdIS
– Young patients without
degenerative changes with
AdIS
– Adults with degenerative
extensive changes developed
under a pre-existing deformity
– Adults without any deformity
up to 40 years of age that are
presenting with a de novo
degenerative scoliosis.

Dec. 2004
 Natural history of the AdIS
• Curves greater than 600 Cobb can
progress with more than 10 per year
even at the adult age.
• De novo curves usually progress up to
3,30 per year.
• The adult curves usually progress in
the lumbar area.
• At patients of 20 to 30 years of age
the curves can be stable or can
progress
• Patients over 40 years of age usually
present with degenerative changes at
the disk level, ligaments and the
curves tend to increase quite fast.

Dec. 2004
 Indications for conservatory treatment
• Here we usually include:
– Anti-inflammatory treatment
– Medical therapy (gymnastics)
– Orthopaedic braces of different types but
usually in a discontinuous manner.
• None of the above methods influence the
natural evolution of the AdIS.
• Therefore the indication of conservatory
treatment is on patients with low curves
or at patients with contraindications for
surgical treatment (organic or
psychosocial).

Dec. 2004
 Indications of the surgical treatment
• Severe deformity (>600 Cobb), with rotation
or sagital imbalance;
• Progression of the scoliosis curve;
• Pain;
• Respiratory dysfunction related to the
scoliosis deformity.
Dec. 2004
 • In severe lumbar curves
associated symptoms:
– Radicular type pain,
– Lumbar canal stenosis,
– Foraminal stenosis,
– Rotatory dislocations.

• The patient must be

relatively healthy and very
important emotional stable.

Dec. 2004
 Pre operator evaluation of the
patient:
• Careful evaluation of the cardio-
respiratory function;
• At elderly patients usually
hipercaloric diet pre operator;
• The standard set of x-rays from
the AIS;
• Can also at hyperextension films,
Ferguson view for the lumbar-
sacral junction when the
pathology us related to that
segment;
Dec. 2004
 Pre operator evaluation of the
patient:
• 3D CT for the lumbar
stenosis, MRI of the lumbar
spine;
• Discogram for the last lumbar
level of the
arthrodesis/instrumentation is
not universally recognized
and it does not give
reproducible results.

Dec. 2004
 Instrumentations used
• XIA

• Under L3 always
pedicular (poliaxial)
screws and
instrumented each
segment.

Dec. 2004
 18
18
16
14
12
10 Young adult
8 De novo
6 5 Degenerative
4
4
2
0
Patients

• Medium age 37,4 years ;

• 18 females and 9 males;
• Between 2001-2002

Dec. 2004
 • Mean curves have varied
between 680 – 980 with a
medium at 740 Cobb.
• In degenerative curves with
diminished bending tests
the correction achieved was
less.

Dec. 2004
 • Vertebral rotation can
be evaluated but did
not change much after
surgery. Exception
lumbar curves of
degenerative scoliosis.

Dec. 2004
 • As in AIS the critical
instrumented level is
L3-L4.

Dec. 2004
 • Anterior procedures: 7

• Posterior procedures: 16

• Combined procedures of
anterior and posterior
surgery 4.

Dec. 2004
 • Patients have been
mobilized 2-4 days
post operator.

• 1 patient requested a
thoracic-lumbar brace
post operator –
instrumentation to the
sacrum.

Dec. 2004
 • The minimum correction on the whole lot
was 20% and maximum 58% with a
medium of 44%;
• A better correction was achieved in anterior
lumbar instrumentations or circumferential.
• SF 36 under evaluation.

Dec. 2004
 • Mean blood loss 1100
ml with 300 ml greater
compared with our
study on AIS – intra
operator.
• No post-operator
comparison was made
bearing in mind that
not all our patients
were drained.

Dec. 2004
 • Mean intervention
time was 4 h and 30
min – 1 hour more
compared to AIS)

Dec. 2004
 20 19
18
16
No pain - ve ry
14 good
12 Occasional pain
- good
10 Same pain as
8 before
Worsened
6 5
4
2 2
1
0

From SF 36 at 1 year FU

Dec. 2004
 We had 6 complications:

 Post-op 2 patients with superficial

infections of the wound that requested re-
intervention but with no implant removal;
 2 dynamic ileuses at patient operated with
anterior lumbar approach;
 2 late complications at 1 year with breakage
of pedicular screw in long instrumentations
for scoliosis both screws at L4.

Dec. 2004
 Conclusions

Dec. 2004
 Levels of fusion in the young adult

• Between 20-35 years usually there

are no degenerative changes in the
lumbar area;
• The usual principles are the same
as in AIS;
• The superior and the inferior limit
must be a stable neutral vertebra;
• The sagital curves must be
corrected as close as possible to
the physiological aspect;
• Very important the lumbar lordosis
must be preserved or
reconstructed.
Dec. 2004
 Levels of fusion in an adult
• Over 35 years there are
degenerative changes;
• The segments between L3 and
sacrum do not have the same
mobility;
• All segments with changes:
rotatory dislocation, lumbar
stenosis, preexistent
laminectomy, spondilolysis must
be included in the fusion area.

Dec. 2004
 The planning in the sagital view
• The most important goal
of the surgery is the regain
of the normal curves in
this plan;
• There are several papers
suggesting that a reduction
of the lumbar lordosis can
lead to accelerated
degenerescence of the
below levels.

Dec. 2004
 Types of surgery
• The type of surgery anterior,
posterior, circumferential is as
difficult to decide as it is in AIS;
• Criteria that must be taken into
account:
– Magnitude of the curve;
– Flexibility of the curve;
– Sagital balance of the patient.
• The lumbar curves tend to
receive more anterior surgery
for correction.

Dec. 2004
 • Kyphotic segments need
anterior approach and
anterior grafting;
• Thoracic curves are better
controlled with posterior
approach;
• Rotatory dislocations are
better approached from
posterior using as good as
possible the
ligamentotacsis – the
classical approach here s
anterior surgery;
• Severely imbalanced
curves can correct by
triplane osteotomies or
even vertebral resections;;
• Staged surgery can take
up to 8 hours (8-12 grey
Dec. 2004zone).
 Thank you

Dec. 2004