What are the surgical goals for this patient with adult spinal deformity?
Based on Schwab et al. - 3 goals (bascially the optimal sagittal modifier values)
SVA < 5cm
PI - LL < 10 deg [to achieve spinopelvic harmony]
Pelvic tilt. < 20
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What is the most reliable predictor of clinical symptoms in ASD?
Saggital Vertical Axis
Because it is the most reliable predictor of clinical symptoms - Glassman et al. 2005, Schwab et al. 2009
The most efficient way to accomplish this goal is to increase lumbar lordosis through anterior lengthening (interbody spacers) or to shorten the posterior column (pedicle subtraction osteotomy).
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What is the surgical strategy?
Long posterior construct
Prox. = neutral vertebrae (no rotation)
Dist. = L5/ S1
Correct sagittal deformities with osteotomies to achieve goals sagittal goals
KIV anterior release if extremely rigid curves
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What complications from scoliosis surgery?
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Early complications
Neurologic - paraplegia 1:1000
Dural injury
infection - Proprionibacterium acnes most common organism for delayed infection
SMA syndrome [AKA Cast syndrome] - compression of 3rd part of duodenum due to compression between SMA and Aorta when spine is straightened β intenstinal obstruction
DVT, PE
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Late complications
Flat back syndrome - failure to restore lordosis or kyphosis leading to early fatigability and back pain
Pseudoarthrosis/ non union
Hardware failure
Junctional failure
Adjacent segment disease
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[Young] Crankshaft phenomenon - rare now due to pedicle screws ability to catch anterior vertebral body
Rotational deformity of spine created by continued Anterior spinal growth in setting of posterior spinal fusion
Can occur in your patients when PSF is performed alone and anterior column is allowed continued growth
Avoid by fusing anterior also
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What are the challenges in degen scoliosis vs idiopathic scoliosis?
Patient Factors
Co-morbids
Elderly - osteoporosis - pre op, intra and post op optimization
Disease Factors
Has more kyphosis - Need to restore sagittal balance with osteotomies to correct kyphosis
More rigid curves - higher risk of pull out during reduction - may need more use of multiaxial screws to help with reduction and pedicle screw techniques