Blog Post: Idiopathic Scoliosis – Lumbar (5CN Curve Pattern)                     5-9-2021

 

14 year old female with progressive, painful thoracolumbar curve

Highly athletic, three sport athlete.  She has tried physical therapy for 3 months but has not helped decrease the intensity or frequency of her back pain.

Participating in her sports is becoming difficult and is having back pain which is interfering with normal activities she does day-to-day.

She has a 49 degree thoracolumbar curve and a very small 16 degree thoracic curve

She is almost fully grown (Risser 4)

 

 

On sidebending radiographs the 49 degree thoracolumbar curve decreases to 21 degrees.  The main thoracic 16 degree curve decreases to only 6 degrees.

 

 

The next question is: how should the scoliosis be treated?

A summary of important points about this patient:

               Physical therapy was tried but did not help.

               She is nearly fully grown, very little spinal growth remains

               Only has one curve to treat, the 49 degree thoracolumbar curve

               A curve greater than 40 degrees in the thoracolumbar region is very likely to continue to get                                  worse over time, even when she is done growing.

 

What are the treatment options:

               Nonsurgical:

Physical Therapy: can help with back pain in some patients.  However, for this patient she has tried physical therapy and didn’t get any decrease in her back pain.  So this is not a good option for her

Bracing: due to her being almost fully grown bracing will not be of any lasting benefit, so this also is not a good option.

 

               Surgical:

                              Growth modulation surgeries, such as Vertebral Body Tethering or ApiFix: Since she doesn’t have any significant growth remaining these devices will hold the curve straighter for awhile.  However it is important to remember these devices will fatigue and break of pull off the bone.  Since there isn’t much growth remaining the spine will then collapse back to the preoperative curve position.  So these are not good options for this patient.

                              Spine fusion: this can be done by either fusing the front (anterior) or the back (posterior) of the spine.  Over the last 15 years there has been a shift toward most of these being done only to the back of the spine, called a posterior spinal fusion.  This shift has occurred due to surgeons’ adoption of pedicle screws for fixation.  There is now little difference in outcomes between anterior and posterior spinal fusions for these thoracolumbar curves.

 

 

After discussion with the patient and her family the decision was to proceed with a posterior spinal fusion.  For thoracolumbar curves we can do a limited, short fusion and for this patient means going from the T10 vertebra down to the L3 vertebra.  The radiographs below are from 3 days after surgery, notice the shoulders are tilted, with the right shoulder being higher.

 

 

You can see the shoulders are level in the preoperative radiographs but the right shoulder is higher after surgery.  Why? There are two reasons.  First, when the thoracolumbar curve is corrected it is lengthening more the right than the left side of the spine. Second, there is a small thoracic curve above the fusion.  So if the right side of the spine is lengthened more than the left side and there is a slight curve to the right, this means the right shoulder will be elevated after surgery.

 

 

Since the curve above the fusion is so flexible we expect the upper curve to straighten, and at the one year postoperative visit her shoulders are now level.

 

 

As you see below the main thoracic curve slowly straightens and the shoulder become level!

 

 

This case highlights that it takes some time, up to one year after surgery for the body to rebalance itself and straighten curves and balance shoulders.