13 year old female, active athlete
Low back pain when participates in athletics
Left trunk shift
Right shoulder is higher than the left
Near the end of skeletal growth
Due to the magnitude of her deformity and skeletal age, surgery was discussed and, after discussions with patient and family, a posterior spinal fusion of only the lumbar curve was discussed.
Before surgery is performed it is essential to determine the overall alignment of the spine and its flexibility. A series of 6 radiographic images is completed which aids in selection of the fusion location and length (number of vertebra). At our pediatric spine center the following radiographs are commonly obtained before scoliosis surgery:
Standing front view
Supine (laying down) front view
Push Prone (laying face down with pushing on the body to straighten the curves)
Standing side view
Side-bending front view to the left
Side-bending front view to the right
After obtaining these radiographs, examining the patient and talking with the patient and family a posterior spinal fusion from T11 (red arrow) to L3 (yellow arrow) was decided.
A lumbar only fusion was completed to L3. The curve above this, thoracic, spontaneously improves in response to the straightening of the lumbar curve.
One question that is often asked is “why is there still some curve left?”. Because we do not actively correct the spine above and below the fusion we must consider this during our surgical planning and performance of the surgery. The spine above and below will only move slightly during surgery, so making the surgical fusion perfectly straight may cause problems above and below which can negatively impact the outcome of surgery, both short-term and long-term. What we are shooting for is a balanced spine, which smoothly transitions from unfused to fused to unfused spine. A globally balanced patient, meaning the head is centered over the pelvis (white line) provides optimal alignment short-term and long-term.
Stopping at L3 at the lower end will provide more low back motion than going lower to L4. Sometimes surgery has to go to L4 to optimize short-term and long-term outcomes, but for this patient we could stop at L3.
At 2 years after surgery the patient is doing well and is participating in varsity-level athletics without pain and functioning at the highest level.
Here she is at 6 years after surgery. She is pain-free and having a successful college athletic experience. Also, notice the improvement of her hip/body alignment. She is no longer standing the left, and is nicely balanced with symmetric hip contour.