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.