Content uploaded by Thomas C Schuler
Author content
All content in this area was uploaded by Thomas C Schuler on Sep 05, 2014
Content may be subject to copyright.
SPINE (MATTHEW E. CUNNINGHAM, SECTION EDITOR)
Adult spine deformity
Christopher R. Good &Joshua D. Auerbach &
Patrick T. O’Leary &Thomas C. Schuler
Published online: 7 October 2011
#Springer Science+Business Media, LLC 2011
Abstract Adult spinal deformity may occur as the result of
a number of conditions and patients may present with a
heterogeneous group of symptoms. Multiple etiologies may
cause spinal deformity; however, symptoms are associated
with progressive and asymmetric degeneration of the spinal
elements potentially leading to neural element compression.
Symptoms and clinical presentation vary and may be
related to progressive deformity, axial back pain, and/or
neurologic symptoms. Spinal deformity is becoming more
common as adults 55–64 years of age are the fastest
growing proportion of the U.S. population. As the
percentage of elderly in the United States accelerates, more
patients are expected to present with painful spinal
conditions, potentially requiring spinal surgery. The deci-
sion between operative and nonoperative treatment for adult
spinal deformity is based on the severity and type of the
patient’s symptoms as well as the magnitude and risk of
potential interventions.
Keywords Spine deformity .Adult .Scoliosis .Kyphosis .
Spine surgery .Sagittal imbalance .Osteotomy .Posterior-
only surgery .Spine reconstruction
Introduction
Adult spinal deformity is becoming increasingly prevalent
in the elderly population. Multiple etiologies may be
involved; however, symptoms are associated with progres-
sive and asymmetric degeneration of the discs, facet joints,
and other spinal elements potentially leading to neural
element compression. Symptoms and clinical presentation
vary and may be related to progressive deformity, axial
back pain, or neurologic symptoms. Spinal deformity is
defined as a curvature in the spine where the alignment is
outside of defined normal limits.
Adult spinal deformity may occur as a result of a number
of conditions, each of which ultimately lead to an
imbalance of the structural support of the spinal column.
Abnormal curvature may occur in the sagittal plane
(kyphosis, lordosis) causing imbalance to the patient’s front
or back or in the coronal plane (scoliosis) causing
imbalance to the patient’s right or left side. The magnitude
of the curvature of the spine is measured using Cobb angle
measurements. Axial plane deformity is measured by
degrees of rotation from the frontal or sagittal plane.
Curvatures may be defined as structural or compensatory.
Structural curves are defined as rigid inflexible curves, often
referred to as major curves. Compensatory curves occur in
response to structural curves as the body attempts to
maintain postural balance. Compensatory curves, also
called minor curves, are usually smaller and flexible on
dynamic x-rays. Spinal deformities usually progress and
C. R. Good (*):T. C. Schuler
Virginia Spine Institute,
1831 Wiehle Avenue,
Reston, VA 20190, USA
e-mail: crgood@SpineMD.com
URL: www.spineMD.com
J. D. Auerbach
Department of Orthopaedics, Bronx-Lebanon Hospital Center,
Albert Einstein College of Medicine,
1650 Grand Concourse, 7th Floor,
Bronx, NY 10457, USA
P. T. O ’Leary
Midwest Orthopaedic Center,
6000 N. Allen Rd,
Peoria, IL 61614, USA
Curr Rev Musculoskelet Med (2011) 4:159–167
DOI 10.1007/s12178-011-9101-z
multiple factors may accelerate this process. Patients with
preexisting spinal deformity or with weakened vertebra
due to osteoporosis or osteopenia are at increased risk for
rapid curve progression as these factors decrease the
resiliency of the spine and increase the lever arm
amplifying the magnitude of the forces across the spine.
Osteoporosis may occur as the result of decreased bone
formation with associated continued or accelerated bone
resorption leading to relative decrease in overall bone mass.
In a more advanced setting, osteoporosis may lead to collapse
of the vertebral bodies which may lead to rapid progression of
spinal deformity. Increasing magnitude of the spinal deformity
leads to increasing stress on the weakened vertebral bodies.
This weakening or loss of support of the spine may also play a
role in the increased magnitude of the symptoms, related to the
spinal deformity. Additionally, paraspinal muscles typically
atrophy with age, thus further weakening any secondary
dynamic support for the aging spine.
Scheuermann’s disease is a well known cause of thoracic
kyphosis that occurs as a result of loss of ventral vertebral
body height and narrowing of the disc interspaces.
Although the exact etiology is still unknown, spinal
deformity along with accelerated disc degeneration and
increased intradiscal pressure may lead to progressive
spinal deformity and pain.
Nonoperative treatment for adult spinal deformity
includes a physical conditioning program, spinal manipu-
lation, pharmacologic agents for symptoms management,
the use of orthotics or braces, and more invasive modalities
including epidural steroid injections and joint injections.
Operative treatment may be contemplated for patients with
progressive symptoms despite nonoperative conservative
treatment. Surgical treatment options usually include
decompression and instrumented stabilization with either
an anterior, posterior, or a combined approach. The details
of the surgical procedure must be based on the location of
the pathology and the symptoms for each specific patient.
The incidence of complication is significant and patient
comorbidities and risk for complications must be considered
when discussing potential for surgical intervention.
In the previous decades most attention was given to
treatment of scoliosis during childhood and adolescent
years with most surgeons avoiding surgical intervention for
adult spinal deformities. Treatment of adult spinal deformity
has been associated with increased perioperative morbidity
and higher incidence of neurologic deficits. In the past,
the risk/benefit ratio has trended toward nonoperative
conservative treatment for most surgeons, however;
recent advances in surgical technique, instrumentation,
neurologic monitoring, as well as improved diagnostic
imaging, perioperative anesthesia, and intensive care
have led toward increasing utilization of surgical
treatment for patients with adult deformity.
Evaluation and diagnosis
Adult spinal deformity is typically studied with standing
full length 36″posterior-anterior, and lateral radiographs
and may need to be repeated over time to monitor for curve
progression. Cobb angles are measured on these radio-
graphs providing coronal and sagittal alignment and global
alignment is measured using plumb line. Dynamic radio-
graphs including flexion-extension views, supine, and
prone films also help to assess flexibility of curves and
the ability for adjacent segments to compensate. Additional
information relating to bony anatomy may be obtained in
CT scan, while magnetic resonate imaging of the spine
provides additional information about the neural elements,
discs and other soft tissues.
Selection of appropriate treatment can be challenging
because patients with adult spinal deformity may complain
of a heterogeneous group of symptoms. In addition,
multiple medical, social, and environmental factors must
also be evaluated to determine the best treatment option for
each particular patient. Patients with a history of tobacco
use, pulmonary, coronary, or vascular disease, diabetes,
nutritional deficiencies, osteoporosis, psychiatric disease, or
lack of social support have been shown to correlate
with increased surgical risk and poor clinical outcomes.
When evaluating patients with spinal deformity, it is
always important to rule out other potential causes of
spinal deformity including traumatic, neuromuscular, or
inflammatory etiologies.
Non operative treatment versus operative treatment
Clinical management of patients with adult spinal deformity
is becoming increasingly important because of the increasing
number of the older patients in our population as well as
increased expectations for activity levels and function in these
patients. There has been increasing utilization of both
nonoperative and operative treatment for patients with adult
spinal deformity. The decision between operative and nonop-
erative treatment for adult spinal deformity may be difficult
for surgeons and patients. Decisions are based on multiple
issues including progressive deformity, pain, cosmesis, as well
as the magnitude of potential intervention. A decision for
surgical intervention can be based on clinical symptoms,
appearance, pain, functional limitations, and social issues.
These are weighed against the potential risks and limitations
related to the proposed surgical treatment [1].
Patients with poor general health and increasing risk for
surgical treatment are more likely to receive a recom-
mendation for nonoperative management. Patients with
increased body mass index (BMI) are also less likely to
receive surgical intervention. This may be related to
hesitancy on the part of the surgeon to undertake a
160 Curr Rev Musculoskelet Med (2011) 4:159–167
major reconstruction procedure in an obese patient. This
may also be related to the fact that obesity may
somewhat hide the clinical appearance of the deformity,
therefore diminishing the concern or desire for surgical
intervention. Although many patients make their decisions
based on their level of pain, some studies have shown similar
levels of pain in patients who select nonsurgical and surgical
treatment [2]. In one study, Glassman, et al. found that
patients with components with radicular leg pain were more
likely to proceed with surgical treatment whereas patients
with back pain did not show a difference between surgical or
nonsurgical treatment. The study also noted that surgical
patients were more likely to report a change in their body
habitus over the past 10 years or to be dissatisfied with the
shape of their spine whereas nonsurgical patients were more
likely to report their deformity was stable and did not affect
personal relationships [3].
The evidenced-based approach to clinical decision
making in medicine has expanded recently. As such,
attempts to compare the efficacy of surgical versus
nonsurgical treatment for patients with adult spinal
deformity have been undertaken. At this point, defini-
tive information regarding differential between the
treatments is still not available. At this time few studies
have attempted to determine to what extent adult
patients are helped with nonoperative and operative
treatment for spinal deformity.
The best comparative study at this time was conducted
by Bridwell and colleagues who studied patients with adult
to scoliosis treated with either nonoperative or operative
treatment to determine if treatment improved quality of life
at two-year follow-up. In this prospective multicenter
evidenced based medicine study [4••], they followed 160
consecutive patients for a period of 2 years after enrollment.
At the 2 year follow-up visit, 95% of operative patients and
45% of nonoperative patients were available for follow-up.
Quality of life measures including Oswestry Disability
Index (ODI) and Scoliosis Research Society (SRS) and
numericalbackandlegpainscoreswerefollowed.The
nonoperative patients did not improve during this time
period and a non-significant decline in quality of life
scores was common. Significant improvement in quality
of life measures were noted in the operative group. The
authors reported that it appeared that common nonoper-
ative treatment did not change quality of life measures
with adult symptomatic lumbar scoliosis at 2 year
follow-up. However, their conclusions were limited by
the fact that only 45% of the nonoperative group was
available at 2 year follow-up despite an extensive effort
to locate data for this group. Of note, the demographics
for the nonoperative patients who were followed versus
those lost to follow-up were identical on initial
enrollment into the study.
Non operative treatment
In general, asymptomatic patients with spinal deformities
do not require formal treatment although periodic follow-up
may be required to monitor for curve progression. Nonsurgi-
cal interventions include yoga, physical therapy, chiropractic
manipulation and other maintenance routines. However, these
treatments have unproven efficacy in patients with adult spinal
deformity. Pharmacologic agents may decrease pain and
increase quality of life but can be associated with adverse
effects. The use of narcotic analgesics must be carefully
monitored, especially given the potential need for long term
use of the medications. The use of spinal bracing may provide
benefit for temporary exacerbation of symptoms; however,
long term use has raised concerns for muscle deconditioning/
atrophy without any effect on curve progression.
In a recent systematic review of clinical studies
evaluating conservative treatment for adult spinal deformity,
Everett et al. [1] concluded that “Surgeons are often very
conservative in the treatment of adult scoliosis because of
increased complication rate and marginal bone quality in this
patient population. At present there is currently a lack of
consensus on the indications for conservative treatments for
adult spinal deformity.”They found that current evidence is
indeterminate with level 4 evidence on the role of physical
therapy, chiropractic treatment, and bracing and level 3
evidence on the use of injections for treatment of adult
deformity.
Surgical treatment
Patients with spinal deformity present with a number of
different clinical presentations and surgical strategies
encompass a broad range of approaches and options.
Patients commonly have symptoms that result from a
combination of degenerative spondylosis, progressive
deformity, as well as neurologic symptoms. Each
surgical intervention must be tailored based on the
specific pathology that is symptomatic for each patient.
Careful preoperative planning is important to limit the
risks of perioperative complications and maximize the
chance for long term clinical success. In some cases
surgical management of spinal deformity and degenera-
tive disease cannot be accomplished with one single
procedure and in some cases long term management of
this medical condition may involve the need for
multiple surgical treatments [5].
Yadla et al. recently published adult scoliosis surgery
outcomes: a systematic review. In this review [6•], they
performed a systematic review of 49 articles on patients
undergoing adult spinal deformity surgery. Data for 3,299
patients was included and average follow-up was 3.6 years.
Average curve correction with surgery was 26.6° (40.7%
Curr Rev Musculoskelet Med (2011) 4:159–167 161
improvement) and mean total pre-op ODI was 41.2 with
average postoperative reduction to 15.7; mean pre-operative
SRS-30 equivalent score was 97.1 with mean postoperative
decrease of 23.1. There was 897 complications for 2175
patients (41.2%) and 319 pseudoarthroses (12.9%). Despite
the lack of randomized prospective date, this review did
conclude that surgery for adult scoliosis was associated
with improvement in clinical outcomes and radiographic
parameters at 2 years follow-up.
Adults 55 to 64 years of age are projected to be a fast
growing proportion of the U.S. population over the next
10 years and as the percentage of elderly in the United
States accelerates, more patients are expected to present
with painful spinal conditions, potentially requiring spinal
surgery. Spinal reconstructive surgery in the older age
group has been associated with increased complications [7]
with some reports indicating nearly two times greater
potential for complications than those undergoing surgery
without fusion. In addition, increasing age and increasing
number of levels fused have been found to be significant
risk factors for complications in patients over the age of
65 years [8].
In many cases, treatment of adult spinal deformity
requires a multilevel fusion procedure. These patients also
commonly require multilevel decompressive procedures for
stenosis or complex spinal osteotomies for correction of
spinal deformity. Surgical blood loss, surgical time, length
of hospital stay, and length of overall recovery are elevated
in these patients when compared with more common single
level degenerative conditions. Dobbs, et al. presented their
series of 46 patients over the age of 60 who underwent
thoracic or lumbar arthrodesis of five levels or greater with
a mean follow-up of 4.2 years. Average number of levels
fused was 9 (range 5–16) and overall complications in this
patient population was 37% with a major complication rate
of 20%. Increasing age was a significant risk factor, with
patients over the age of 69 years having higher
complication rates [9]. In their study, clinical outcome at
final follow-up was improved with ODI scores changing
from 49 to 25 for a mean improvement of 24 (49%, p-
value <0.00001). This study demonstrates the increasing
complexity and potential for complications in this patient
group while also demonstrating significant improvement
in patient reported functional outcomes for patients
undergoing these procedures [9].
The rate of complications reported by Dobbs is similar to
Benz, et.al, who reported an overall complication rate of
40% with serious complication rate of 12% in patients
undergoing lumbar decompression over the age of 70 years
[10]. In a similar report, Smith et al. performed a
retrospective review of a multicenter database identifying
incidence of complications and outcome measurements of
adult patients undergoing spinal deformity reconstruction
surgery [11•]. The study included 206 patients included
with minimum 2 year follow-up. Increasing complication
rates were noted with increasing age. Patients aged 24–
44 years old had 17% complication rate; 45–64 years old
had 42% complication rate; and patients 65–85 years had
71% complication rate (p-value <0.00001). When all age
groups were examined together, significant improvement in
outcome studies were noted including ODI, SRS-22, back
pain, and leg pain at 2 year follow-up. Improvement in ODI
and leg pain were significantly greater amongst elderly
patients with greater improvement in SF12 and SRS-22
when compared to younger patients. This study demon-
strates the potential benefit for surgical treatment for adult
scoliosis and suggests that despite having greater risk for
complications, the elderly may obtain greater improvement
in pain and disability with surgical reconstruction.
Blood loss in adult spinal deformity spine surgery
Intraoperative blood loss is an important concern for patients
undergoing spinal deformity reconstructive surgery. Increas-
ing blood loss during surgery may lead to the need for whole
blood, platelet, and factor transfusions. Although blood
screening has improved the safety of these transfusions,
potential reactions and infectious risks persist. Large blood
loss can lead to increased surgical time and complications
associated with multiple blood transfusions including swelling,
increased surgical time, pulmonary edema, or shock.
Intraoperative administration of antifibrinolytic agents
has gained popularity as a means to manage intraoperative
blood loss. The antifibrinolytic agent Aprotinin is a serum
protein inhibitor first used to reduce blood loss in major
cardiac surgery. Use of Aprotinin in spinal deformity
surgery was shown to decrease blood loss. However, more
recently its use has become controversial due to the
association with significant postoperative complications
including renal failure, myocardial infarction, cerebral
vascular accident, and death. Other agents including
tranexamic acid (TXA) and aminocaproic acid (Amicar)
have been utilized to decrease intraoperative blood loss and
minimize complications. Tranexamic acid and Amicar have
been well tolerated [12].
Recent reports of the use of tranexamic acid and
aminocaproic acid have demonstrated that they are safe
and effective, potentially reducing not only transfusion
related complications but also operative expenses. Elwatidy
et al. found the prophylactic use of tranexamic acid led to a
49% reduction of blood loss and 80% reduction of blood
transfusion when compared to placebo after cervical and
lumbar surgeries with no complications related to the use of
TXA [13].
In a recent meta analysis, Elgafy et al. reviewed 90
studies with 17 meeting inclusion criteria. They found a
162 Curr Rev Musculoskelet Med (2011) 4:159–167
high level of evidence to support the use antifibrinolytic
medications to reduced blood loss and limit the need for
transfusion during and after adult spine surgery. Based on
their review, a recommendation was also made against the
use of Amicar in spine surgery due the increased
complications. The use of Cell Saver, Recombinant Factor
VIIa, activated growth factor platelet gel, and normovole-
mic hemodilution were all evaluated as methods to prevent
blood loss and were found to have very low evidence to
support their efficacy [14••].
Biologics in adult spinal deformity surgery
The use of biologic agents to stimulate spine fusion is a
major focus in current spinal deformity research. Many
surgeons are now trending away from the use of iliac crest
bone graft and using a combination of locally harvested
autogenous bone and allograft for posterior fusion. Harvest-
ing adequate iliac crest bone graft to achieve fusion is a
potentially major limitation, especially for larger multi-level
surgeries. The osteoinductive protein rhBMP-2 (Infuse;
Medtronic, Spinal and Biologics) has received FDA
approval for anterior lumbar interbody fusion and several
investigational device exemptions (IDE) and physician
directed studies have demonstrated promising outcomes
for posterior interbody and posterolateral spine fusion.
Cahill, et. al. published an initial study involving 46
patients who underwent posterolateral lumbar fusion with
the use of rhBMP-2. This technique yielded a 95% rate of
fusion when compared with 70% fusion rate with iliac crest
bone graft [15]. In the same year, Carreon et. al. reviewed
the use of rhBMP-2 versus iliac crest bone graft for lumbar
spine fusion in patients over 60 years of age. In this
randomized clinical trial, patients over 60 years old at the
time of the surgery were treated with decompression and
posterolateral fusion. Patients were randomized with either
iliac crest bone graft or rhBMP-2. Patients treated with iliac
crest bone graft had an increased rate of complications and
need for additional treatment including the need for
revision surgery when compared to rhBMP-2. A lower
clinical improvement and higher cost of treatment were
seen in patients who received iliac crest bone graft
compared with those who received rhBMP-2 for
posterolateral lumbar fusion [16].
The use of bone morphogenetic protein may carry the
most important benefit for patients undergoing long spinal
deformity fusion. One major spinal deformity center
published results for patients undergoing long spinal
deformity fusion to the sacrum. They report a pseudoarth-
rosis rate of 28% in patients who received iliac crest bone
graft versus only 4% of patients who were treated with
rhBMP-2 [17]. In another study, Dimar, et. al. published
their results for the use of BMP in 463 patients who
underwent scoliosis surgery. Radiographic fusion was
achieved in 96% of patients compared to 89% of patients
managed with iliac crest bone graft alone [18].
Multiple studies have reviewed the concerns for adverse
effects surrounding the use of bone morphogenetic protein.
The most commonly reported side effect includes transient
radiculitis, vertebral body bone resorption, sterile seroma/
fluid collection, and heterotopic bone formation. Many of
these local side effects are felt to be related to the dose of
BMP. More recent discussion has focused on the use of
lower doses of rhBMP-2 in an effort to potentially lower
the risk of local side effects. While much focus has
remained on the use of the osteoinductive protein, the use
of other bone graft substances, such as platelet-rich plasma
(PRP) and mesenchymal stem cells for bone healing have
been studied. Currently no studies have shown these
measures alone are sufficient to achieve spinal fusion.
Posterior-only surgery for adult spinal deformity
Combined anterior/posterior (A/P) fusion has traditionally
been used to treat severe adult scoliosis deformities. These
combined procedures include an anterior release with fusion
which is performed via a thoracotomy or thoracoabdominal
approach followed by a posterior spinal instrumentation and
fusion. This combined approach has been promoted to provide
increased fusion rates and better deformity correction [19–21],
however, the anterior thoracoabdominal approach has been
shown to cause significant morbidity and complications in
the adult patient [22]. Anterior thoracotomy/thoracoabdomi-
nal approaches negatively impact pulmonary function, may
require additional operative time and anesthesia [2], and have
been associated with significant morbidity and complications
[23,24].
Posterior-only (Post-only) fixation with the use of
modern surgical techniques and implants has demonstrated
similar correction rates to that of anterior release and
posterior fusion in adolescent scoliosis [25]. It has also
been shown to have similar deformity correction as
combined A/P fusion for the treatment of adolescent
idiopathic scoliosis curves more than 90° [26–28]. Post-
only surgery with thoracic pedicle screws has also been
shown to provide better curve correction in Scheuermann’s
kyphosis, with less operating time, less operative blood
loss, and fewer complications than circumferential fusion
[29]. With the advent of new instrumentation techniques
and increasing experience with placing segmental pedicle
screws, coupled with multiplanar osteotomies and trans-
foraminal lumbar interbody fusion, our practice has trended
away from the use of multilevel anterior surgery for the
treatment of adult spinal deformity. In some cases anterior
lumbar interbody fusion performed through a small
retroperitoneal incision may be utilized to maximize
Curr Rev Musculoskelet Med (2011) 4:159–167 163
lordosis and interbody fusion at the levels at greatest risk
for pseudoarthrosis (Fig. 1). At this point, many adult spinal
deformities are treated via an all posterior surgical
approach. This includes bilateral implant fixation at nearly
all levels, osteotomies, and transforaminal lumbar interbody
fusions as needed to correct deformities, and the use of
BMP-2 to augment posterior surgical fusions.
In a recent series, Posterior-only adult scoliosis surgery
was found to avoid the morbidity of a thoracoabdominal
approach while achieving similar correction to combined
anterior-posterior surgery with decreased blood loss, operative
time, and length of stay in the hospital. Complications,
radiographic and clinical outcomes were similar at over 2-
year follow-up [30•].
Osteotomies in adult spinal deformity
A growing number of studies have compared various
osteotomy techniques for correction of coronal and sagittal
spinal deformities. The use of multiple posterior column
osteotomies, versus three-column osteotomies has been
reviewed. While it is clear that greater correction of the
deformity is achieved with three column osteotomy (pedicle
subtraction osteotomy/vertebral column resection) these
techniques are associated with increased complexity, higher
complication rate, and greater neurologic risk. The use of
multiple single column posterior osteotomy and three
column posterior osteotomy has grown, particularly in
relation to the surgical treatment of sagittal imbalance
where osteotomy has perhaps its greatest importance.
Controversy remains with regard to the impact of
thoracolumbar fusion extending up to the upper or lower
thoracic spine [31•]. Long term evaluation of the choice of
distal fusion level for adult spinal deformity have shown
improved long term outcomes favoring an extension of
fusion to the sacrum versus stopping at the L5 level for
most of the adult population [32]. There are some situations
where long deformity fusions ending at L5 are clearly to be
avoided which include patients with spondylolisthesis,
previous laminectomy, spinal stenosis, or an oblique take-
off at the L5/S1 level. Long spinal deformity fusion down
to sacrum carries theoretical additional risks and morbidity
including prolonged surgical time, higher risk of pseu-
doarthrosis at L5/S1, greater blood loss, and higher risk of
fixation failure. However, including the L5/S1 level at the
time of the definitive surgery may alleviate the potential for
future breakdown and need for revision surgery.
Complications
The Scoliosis Research Studying Morbidity and Mortality
Committee recently analyzed rates of postoperative infection
across its members. 108,419 cases were identified with 0.8%
of superficial infection and 1.3% rate of deep wound infection.
The committee concluded that “post surgical infection, even
amongst skilled spine surgeons, is an inherent potential
complication.”Higher deep infection rates were noted in
patients with degenerative scoliosis and kyphosis.
Postoperative blindness has been noted to complicate long
spinal deformity surgery performed with patients in the prone
position at approximately 1:1000 (0.1%). This is a potentially
devastating complication. Current recommendations to mini-
mize risk include keeping the eyes positioned higher than the
rest of the body, maintaining all pressure off the eyes and face,
and avoiding prolonged periods of hypotension, and extensive
blood loss (Table 1).
Fig. 1 X-rays of a patient with
progressive adult idiopathic
scoliosis before and after
thoracolumbar reconstruction
T10-pelvis. Correction was
performed through anterior
lumbar interbody fusion L4-
Sacrum followed by segmental
posterior pedicle screw instru-
mentation with iliac screw
fixation and transforaminal
lumbar interbody fusion (TLIF).
Post-operative radiographs show
significant correction of the
deformity with excellent coronal
and sagittal imbalance
164 Curr Rev Musculoskelet Med (2011) 4:159–167
Conclusion
Adult spinal deformity may occur as the result of a
number of conditions and patients may present with a
heterogeneous group of symptoms. Multiple etiologies
may cause spinal deformity; however, symptoms are
associated with progressive and asymmetric degenera-
tion of the spinal elements potentially leading to neural
Table 1 Complications of adult
spinal deformity surgery with
avoidance and management
options
Possible Complication Management
Hemorrhage Careful preoperative patient positioning
Meticulous hemostasis during exposure
Intraoperative blood salvage
Preoperative autologous blood donation
Intraoperative administration of antifibrinolytic agents
Cerebrospinal fluid leak Careful exposure / decompression
Repair primarily if possible
Onlay dural graft material
Fibrin glue derivatives
CSF diversion for continued leak
Screw malposition Maximize visualization of relevant anatomy
Intraoperative use of fluoroscopy / x-ray
Feel pedicle boarders through decompression
Ischemic Optic Neuropathy Preoperative patient counseling
Careful prone positioning (eyes higher than the heart)
Avoid pressure on the face / eyes (Gardner Wells Tongs)
Avoid intraoperative hypotension / anemia
Cardiopulmonary Complications Preoperative medical optimization
Diligent multidisciplinary monitoring and management
Early mobilization after surgery
Pulmonary toilet
Thromboembolic Events Preoperative medical optimization
Removable IVC filter for high risk patients
Mechanical DVT prophylaxis intra and postoperatively
Pharmacological thrombosis prophylaxis for high risk
Early mobilization after surgery
Infection Preoperative antibiotics
Careful skin preparation
Irrigate with antibiotic solution frequently
Postoperative wound drainage
Layered wound closure
Excise damaged muscle tissue
Pseudoarthrosis Pre-operative behavior modification
Nicotine cessation
Osteoporosis management
Meticulous arthrodesis technique
Interbody arthrodesis at lower fusion levels
Consider biologic enhancement of fusion
Avoid anti-inflammatory agents
Curr Rev Musculoskelet Med (2011) 4:159–167 165
element compression. Symptoms and clinical presenta-
tion vary and may be related to progressive deformity,
axial back pain, and/or neurologic symptoms. As the
percentage of elderly in the United States accelerates,
more patients are expected to present with painful spinal
conditions, potentially requiring spinal surgery. The
decision between operative and nonoperative treatment
for adult spinal deformity is based on the severity and
type of the patient’s symptoms as well as the magnitude
and risk of potential interventions.
In general, asymptomatic patients with spinal deformities
do not require formal treatment although periodic follow-up
may be required to monitor for curve progression. Nonsur-
gical interventions include yoga, physical therapy, chiro-
practic manipulation and other maintenance routines.
However, these treatments have unproven efficacy in
patients with adult spinal deformity. Multiple studies have
shown that reconstructive surgery for adult scoliosis does
lead to improvements in patient quality of life and pain
levels. Despite having greater risk for complications, the
elderly may obtain the highest levels of improvement in
pain and disability with surgical reconstruction.
Disclosures
CR Good: none; JD Auerbach: consultant for Paradigm
Spine, Synthes Spine, Medacta, MCRA, LLC; PT O’Leary:
none; TC Schuler: none.
References
Papers of particular interest, published recently, have been
highlighted as:
•Of importance
•• Of major importance
1. Everett CR, Patel RK. A systematic review of nonsurgical
treatment in adult scoliosis. Spine. 2007;32(19 Suppl):S130–4.
2. Glassman SD, Berven S, Kostuik J, et al. Nonsurgical resource
utilization in adult spinal deformity. Spine. 2006;31:941–7.
3. Glassman SD, Schwab FJ, Bridwell KH, et al. The selection of
operative versus nonoperative treatment in patients with adult
scoliosis. Spine. 2007;32:93–7.
4. •• Bridwell KH, Glassman S, Horton W, et al. Does treatment
(nonoperative and operative) improve the two-year quality of life
in patients with adult symptomatic lumbar scoliosis: a prospective
multicenter evidence-based medicine study. Spine. 2009;34(20):
2171–78. Prospective multicenter evidenced based medicine study
following 160 consecutive patients for a period of two years after
enrollment. Quality of life measures including Oswestry Disability
Index (ODI) and Scoliosis Research Society (SRS) and numerical
back and leg pain scores were followed. The nonoperative
patients did not improve during this time period and a non-
significant decline in quality of life scores was common.
Significant improvement in quality of life measures were noted
in the operative group. The authors reported that it appeared that
common nonoperative treatment did not change quality of life
measures with adult symptomatic lumbar scoliosis at two year
follow-up.
5. Baron EM, Berven SH, Bridwell KH, et al. Adult spinal deformity
focus issue: summary statement. Spine. 2006;31(19):S202.
6. •Ylada S, Maltenfort MG, Ratliff JK, et al. Adult scoliosis
surgery outcomes: a systematic review. Neurosurg Focus. 2010;28
(3): E3. A systematic review of 49 articles on 3,299 patients
undergoing adult spinal deformity surgery. Average curve
correction with surgery was 26.6° (40.7% improvement) and
mean total pre-op ODI was 41.2 with average postoperative
reduction to 15.7 and mean pre-operative SRS-30 equivalent
score was 97.1 with mean postoperative decrease of 23.1. There
was 897 complications for 2175 patients (41.2%)and 319
pseudoarthroses (12.9%). Despite the lack of randomized pro-
spective date, this review did conclude that surgery for adult
scoliosis was associated with improvement in clinical outcomes
and radiographic parameters at the at least two years follow-up.
7. Deyo RA, Cherkin DC, Loeser, et al. Morbidity and mortality in
association with operations on the lumbar spine: the influence of
age diagnosis and procedure. J Bone Surg Am. 1992;74:536–43.
8. Carreon LY, Puno RM, Dimar JR, et al. Perioperative complica-
tions of posterior lumbar decompression and arthrodesis in older
patients. J Bone Surg Am. 2003;85:2089–92.
9. Dobbs MD, Lenke LG, Cheh G, et al. Adult spinal deformity
surgery: complications and outcomes in patients over age 60.
Spine. 2007;32(20):2238–44.
10. Benz RJ, Ibrahim ZK, Afshar P, et al. Predicting complications in
elderly patients undergoing lumbar decompression. Clin Orthop.
2001;384:116–21.
11. •Smith JS, Shaffrey CI, Glassman SD, et al. Risk-benefit analysis
assessment of surgery for adult scoliosis: an analysis based on
patient age. Spine. 2011;36(10): 817–24. A retrospective review of
a multicenter database identifying incidence of complications and
outcome measurements of 206 adult patients undergoing spinal
deformity reconstruction surgery.Increasing complication rates
were noted with increasing age. When all age groups were
examined together, significant improvement in outcomes were
noted including ODI, SRS-22, back pain, and leg pain at 2 year
follow-up. Improvement in ODI and leg pain were significantly
greater amongst elderly patients with greater improvement in
SS12 and SRS-22 when compared to younger patients. This study
demonstrates the potential benefit for surgical treatment for adult
scoliosis and suggests that despite having greater risk for
complications, the elderly may obtain greater improvement of
disability and pain with surgical reconstruction.
12. Urban MK, Beckman J, Gordon M, et al. The efficacy of
antifibrinolytics in reduction of blood loss during complex adult
reconstructive spine surgery. Spine. 2001;26:1152–7.
13. Elwatidy S, Jamjoom Z, Elgamal E, et al. Efficacy and safety of
prophylactic large doses of tranexamic acid in spine surgery.
Spine. 2008;33(24):2577–80.
14. •• Elgafy H, Bransford RJ, McGuire RJ, et al. Are there effective
measures to decrease massive hemorrhage in major spine fusion
surgery? Spine. 2010;35(95):S47-56. A Meta Analysis reviewing
90 studies with 17 meeting inclusion criteria. They found a high
level of evidence to support the use antifibrinolytic medications to
reduced blood loss and the need for transfusion during and after
adult spine surgery. The use of CellSaver, Recumbent Factor VIIa,
activated growth factor platelet gel, and normovolemic hemodi-
lution were all evaluated as methods to prevent blood loss and
were found to have very low evidence to support their efficacy.
15. Cahill KS, Chi JH, Day A, et al. Prevalance, complications, and
hospital charges associated with use of bone-morphogenetic
protein in spinal fusion procedures. JAMA. 2009;302:58–66.
166 Curr Rev Musculoskelet Med (2011) 4:159–167
16. Carreon LY, Glassman SD, Djurasovic M, et al. RhBMP-2 versus
iliac crest bone graft for lumbar spine fusion in patients over
60 years of age: a cost utility study. Spine. 2009;34(3):238–43.
17. Maeda T, Buchowski JM, Kim YJ, et al. Long adult spinal
deformity fusion to the sacrum using rhBMP-2 versus autogenous
iliac crest bone graft. Spine. 2009;34:2205–12.
18. Dimar JR, Glassman SD, Burkus JK, et al. Clinical and
radiographic analysis of an optimized rhBMP-2 formulation as
an autograft replacement in posterolateral lumbr spine arthrodesis.
JBJS. 2009;91:1377–86.
19. Bradford DS, Tay BK, Hu SS. Adult scoliosis: surgical indica-
tions, operative management, complications, and outcomes. Spine.
1999;24:2617–29.
20. Byrd III JA, Scoles PV, Winter RB, et al. Adult idiopathic
scoliosis treated by anterior and posterior spinal fusion. J Bone
Joint Surg Am. 1987;69:843–50.
21. Dick J, Boachie-Adjei O, Wilson M. One-stage versus two-stage
anterior and posterior spinal reconstruction in adults. Comparison
of outcomes including nutritional status, complication rates,
hospital costs, and other factors. Spine. 1992;17:S310–6.
22. Horton WC, Bridwell KH, Glassman SD, et al. The morbidity of
anterior exposure for spinal deformity in adults: an analysis of
patient-based outcomes and complications in 112 consecutive
cases. Paper 32, Presented at the Scoliosis Research Society 40th
Annual Meeting, Miami, FL, October 2005.
23. Lapp MA, Bridwell KH, Lenke LG, et al. Long-term
complications in adult spinal deformity patients having
combined surgery a comparison of primary to revision
patients. Spine. 2001;26:973–83.
24. Newton PO, Faro FD, Gollogly S, et al. Results of preoperative
pulmonary function testing of adolescents with idiopathic scoliosis.
A study of six hundred and thirty-one patients. J Bone Joint Surg Am.
2005;87:1937–46.
25. Luhmann SJ, Lenke LG, Kim YJ, et al. Thoracic adolescent
idiopathic scoliosis curves between 70° and 100°: is anterior
release necessary? Spine. 2005;30:2061–7.
26. Dobbs MB, Lenke LG, Kim YJ, et al. Anterior/posterior spinal
instrumentation versus posterior instrumentation alone for the
treatment of adolescent idiopathic scoliotic curves more than 90
degrees. Spine. 2006;31:2386–91.
27. Schwab F, Lafage V, Farcy JP, et al. Surgical rates and operative
outcome analysis in thoracolumbar and lumbar major adult
scoliosis: application of the new adult deformity classification.
Spine. 2007;32:2723–30.
28. Watanabe K, Lenke LG, Bridwell KH, et al. Comparison of
radiographic outcomes for the treatment of scoliotic curves greater
than 100 degrees: wires versus hooks versus screws. Spine.
2008;33:1084–92.
29. Lee SS, Lenke LG, Kuklo TR, et al. Comparison of Scheuermann
kyphosis correction by posterior-only thoracic pedicle screw
fixation versus combined anterior/posterior fusion. Spine.
2006;31:2316–21.
30. •Good CR, Lenke LG, O’Leary PT, Pichelmann M, Keeler KA,
Bridwell KH, Baldus C, Koester L. Can posterior only surgery
replace combined anterior (thoracotomy/thoracoabdominal) /pos-
terior approaches for adult scoliosis? Spine. 2010;35(2):210–8. In
a matched cohort analysis comparing A/P surgery versus
posterior surgery alone for primary adult scoliosis, Post-
only fusion provided the same deformity correction with
similar complications, radiographic and clinical outcomes at
over 2-year follow-up. OR time, EBL, and hospital LOS were
significantly lower in the Post-only group.
31. •O’Leary PT, Bridwell KH, Good CR, Lenke LG, Buchowski
JM, Kim YJ, Flynn J. Risk factors and outcomes for
catastrophic failures at the top of long pedicle screw
constructs (FPSC): a matched cohort analysis performed at
a single center. Spine. 2009;34(20):2134–39. A matched
cohort analysis evaluation 13 patients who developed fractures
at or above pedicle screw constructs found that factors that
increased the risk of FPSC included obesity and older age.
Osteopenia increased the risk as evidenced by BMD (based on
17 patients) and the older age of these patients. Neuro deficits
were severe.
32. Bridwell KH, Anderson PA, Boden SD, et al. Specialty
update: what’s new in spine surgery. JBJS. 2010;92:2017–
28.
Curr Rev Musculoskelet Med (2011) 4:159–167 167
