Thoracolumbar curvature treated with anterior correction

History:The patient was a 16 year old girl with known idiopathic scoliosis that presented for consultation. According to the mother, the patient was a full term delivery, had a normal development and never complained of back pain or discomfort. Upon initial diagnosis of a scoliosis, a brace was prescribed. This was worn for nearly a year but progression of scoliosis was noted by x-ray evaluation (15 degrees over the past year). The patient also felt her trunk was leaning progressively to the left. There was no family history of scoliosis.

Physical Examination:The patient was a healthy appearing adolescent. She walked with a normal gait and was well balanced in the sagittal plane although a slight shift to the left was noticeable in the frontal plane. Examination of the back revealed no abnormal skin marking but marked asymmetry of the trunk with a fullness on the left that became more noticeable with forward bending (Adam's test). Lower extremity evaluation was unremarkable.

Radiographic Evaluation:Standing radiographs of the spine revealed a left-sided thoracolumbar scoliosis measuring approximately 50 degrees (see figure 1) . A compensatory right-sided thoracic curvature of 25 degrees was also present. Imbalance of the spine with a shift to the left of 5 centimeters was present. There was no evidence of spondylolysis or spondylolisthesis.

Treatment Options:Scoliosis with a spinal curvature of around 50 degrees can be treated in a number of ways. If progression of the deformity has occurred and/or significant remaining growth is expected then surgical correction can be considered. Additionally, curvatures, which lead to imbalance of the trunk or shoulders, may benefit from surgical correction to regain proper balance.

This patient unfortunately had a combination of progressive deformity (worsening scoliosis) and trunk imbalance. Although continued bracing is an option, this is unlikely to re-establish proper balance and will most likely not avoid gradual progression of the scoliotic curvature.

Surgical treatment for thoracolumbar curvatures can be pursued in a number of different ways. In the past severe scoliotic curvatures were nearly always treated with posterior spinal fusion (operated through an incision in the back). Another option, however, is to treat the scoliosis from an anterior approach (incision in the front). The advantages of an anterior approach include: shorter spinal fusion, preservation of the posterior muscles, rapid recovery.

Discussion:After thorough discussions with the family, a decision was made to proceed with surgery. Given the thoracolumbar deformity with trunk imbalance, it was felt that an anterior short correction with instrumentation and fusion could offer good correction.

As planned, the patient had an anterior surgical procedure, which obtained a balanced correction of her spine. She had a brief hospital stay of 3 days and her incision healed quickly. Upon follow-up x-rays revealed a nicely corrected and balanced spine.