Text Book Reading Section X_ Adult

Deformity in “THE SPINE” by

Rothman- Simeone and Herkowitz
By: Lanny Fargo Tjioe, Said Jamallulaid, and Musyarafah
Jamil
Resident: dr. Iswahyudi and dr. Mirza Ariandi
Supervisor: Dr. dr. Karya Triko Biakto, Sp. OT (K) Spine
 1. Adult Isthmic
Spondylolisthesis
Text book reading
Said Jamalullail Bin Ali
C014172193
Supervisor: dr Karya Triko Biakto, Sp. OT (K) Spine
 Introduction
• Spondylolisthesis is the ventral (or anterior)
displacement of one vertebra relative to the
subjacent vertebra
• Spondylolysis is a defect in the pars
interarticularis due to congenital,
traumatic,dysplastic, or neoplastic etiologies.
• Spondylolysis generally considered to occur
prior to appearance of spondylolisthesis
 Classification
• Meyerding classification
The classification is based on slip percentage:
grade 1, less than 25%;
grade 2, 26% to 50%;
grade 3, 51% to 75%,
grade 4, 76% to 100%,
grade 5, greater than 100% or spondyloptosis
• Classification BY Wiltse, based on etiology
1. dysplastic
2. istmic
3. degenarative
4. traumatic
5. neoplastic
 Natural history/Incidence
• Fredrickson et al reported a prospective, population-
based study of 500 schoolchildren from northern
Pennsylvania they reported an incidence of lumbar
spondylolysis of 4.4% and spondylolisthesis of 2.6% in
children younger than 6 years. At adulthood, the
incidence of lumbar spondylolysis was found to be
5.4% and spondylolisthesis was 4%.
• Two-thirds of the spondylolysis cases were found in
males, and greater than 90% occurred at L5–S1.
• They reported that pars defects did not typically heal,
and slippage occurred throughout the follow-up
period.
 Patophysiology
• The primary pathologic entity in isthmic spondylolisthesis is a
defect in the pars interarticularis, a critical structural
component of the posterior element of the vertebra
• The pars is the ntersection of the lamina, inferior and superior
articular processes, and pedicle.
• A spondylolysis essentially divides the neural arch
• Etiologies for spondylolysis are numerous but
many believe that the vast majority are due to
stress fractures of the pars interarticularis
• Biomechanical studies have shown this region
is exposed to the highest extension forces in
the lumbar spine
• This region of bone is the weakest structural
component of the posterior neural arch
 Repetitive lumbar The stress is
extension loading sustained or
spondylolysis
appears to result in excessive and if the
develops
alocalized stress bone is unable to
reaction heal
• Study shows that Individual without spondylolysis
has an increase in cranial-to-caudal intrafacet
distance in which they concluded allowed for overlap
of lamina during lordosis
• Individuals in whom spondylolysis was found showed
relatively lower intrafacet distances, potentially
resulting in impingement of the L4 inferior articular
process on the pars of L5
 Biomechanics
• During radiographic assessment of patients,
lumbar lordosis (LL), pelvic incidence (PI),
sacral slope (SS), and pelvic tilt (PT) are most
commonly measured
• PI is signiicantly greaterin individuals with
isthmic spondylolisthesis and correlates
linearly with higher (Meyerding) slip
severities.
• Individuals with sthmic spondylolisthesis stand
with increased SS, PT, and LL.
• LL are an important factor in the amount of
shear stress on the L5 lamina and pars.
 Diagnosis
History
• Most individuals with spondylolysis are asymptomatic.
While it is the most common cause of LBP in children,
the same does not hold true in the adult population
• Moller and Hedlund reported on 201 patients with
isthmic spondylolysis and found that their patients
presented with back pain only in 27%, back pain and
sciatica in 65%, and sciatica only in 8% of individuals.
• Back pain may be positional and may be worsened with
standing and/or lumbar extension maneuvers, while it
may be relieved with forward flexion or sitting.
Physical Examination
• There are no pathognomonic physical examination
findings for isthmic spondylolisthesis.
• Lumbar extension will often elicit LBP, lower
extremity radicular complaints, or both.
• There can be a palpable or visible step-of in cases of
highgrade slips. The step-of occurs between the L4
and L5 spinous processes as the posterior elements
of L5 remain dorsal and in line with the S1 spinous
process
 Imaging
• Routine radiographic images can detect
spondylolysis, especially if spondylolisthesis is
present,
• slip severity can be measured on lateral images.
• If spondylolysis is suspected but not visualized,
oblique radiographic images 45 degrees to the
sagittal plane can be obtainedthat can detect up
to 96% of pars defects
• Abnormalities in the “neck of the Scotty dog” is
the hallmark radiographic finding
 CT- Scan
• Computed tomography (CT) scans are the best
imaging modality to clearly visualize and define a
spondylolysis
• On axial images, spondylolysis appears as
discontinuity of the posterior neural arch and can
be diferentiated from the adjacent facet joints
• Sagittal reformatted images best show the pars
defect as being distinct from facet joints and are
the definitive finding in spondylolysis
 MRI
• Magnetic resonance imaging (MRI) is increasingly
used as the primary imaging modality in patients
with LBP with or without radiculopathy.
• However, compared to CT scans, routine MRI
sequences used for lumbar imaging may be less
accurate for detecting spondylolysis, especially if
no spondylolisthesis is present
• Sagittal T1-weighted images provide the greatest
level of contrast between hyperintense bone
marrow and the signal void of bony cortex at the
pars defect
 Differential diagnosis
• The diferential diagnoses for isthmic
spondylolisthesis are those of its clinical
presentations: LBP and sciatica
• First, spinal trauma, tumors, and infections
should be ruled out.
• Next, degenerative disc disease, spondylosis,
spinal stenosis, or disc herniation should be
considered.
• Other causes include systemic diagnoses, such as
rheumatoid arthritis and spondyloarthropathies,
Treatment
 Nonoperative Treatment
• Initial treatment for patient presenting with
acute LBP should be nonoperative
• The mainstays are patient education, activity
modification, and medications such as
nonsteroidal antiinlammatory drugs.
• The addition of physical therapy and exercise
can be considered when early treatments fail
and LBP becomes more long-standing
 Operative Treatment
Indication
• Severe, persistent back and/or lower
extremity pain that is associated with
functional limitations
• Progressive motor weakness
• Cauda equina syndrome
• Failure of non operative treatment
Contraindication
• Active infection
• Life threatening medical condition
• Broad range of relative contraindications
related to an increased potential for
perioperative complications or poor
outcomes—include morbid obesity, cigarette
smoking
 Surgery
• The goals of operative intervention in isthmic
spondylolisthesis are to decompress neural elements
and stabilize the afected motion segment
• Typically, surgery involves stabilization traditionally
performed with posterior in situ fusion techniques with
or without pedicle screw instrumentation and
sometimes without decompression.
• Supplemental anterior column support using interbody
fusion techniques approached posteriorly (posterior
lumbar interbody fusion [PLIF]) or anteriorly (anterior
lumbar interbody fusion represent the most popular
form of surgical treatment in the United States
 Decompresion
• Gill laminectomy entails removal of the entire
posterior arch and the hypertrophied
fibrocartilaginous tissue at the pars, as well as
partial facetectomies to decompress the nerve
root.
• Long-term results of laminectomy alone have
not been favorable, leading most experts to
believe that addition of fusion is required in
most cases to obtain good clinical outcomes
 Fusion
• The primary operative intervention in isthmic
spondylolisthesis is segmental fusion.
• Surgical treatment, specifically spinal fusion,
for the management of painful isthmic
spondylolisthesis provides longterm beneits
for pain, disability, and global quality-of-life
measures.
 Direct Pars Repair
• Direct pars repair is a potential option in younger
patients with no evidence of disc degeneration or
spondylolisthesis and in whom pain is believed to arise
mainly from the pars defect
• The key operative principles are debridement of the
defect, bone grating, and providing adequate
compression and stability of the defect for
osteosynthesis
• Supplemental fixation is most oten used; methods
include translaminar screws, translaminar wires, and
pedicle screw/sublaminar hook constructs
• There appears to be debate in the literature
regarding the deal operative procedure for the
treatment of isthmic spondylolisthes
• A critical goal in treatment of isthmic
spondylolisthesis, particularly at L5–S1, is to
achieve fusion
• An interbody device can increase foraminal
dimensions and arrest the repeated lexion and
extension movements on the nerve root,
which should reduce radicular pain.
2. Adult scoliosis

Musyarafah Jamil
Adult scoliosis encompasses a broad spectrum
of deformity in the mature spine. It can result
from scoliosis in childhood or arise de novo
from degenerative changes within the spinal
motion segments
 Impact of adult scoliosis
• Health-related quality of life decreased :
chronic back pain, limitation
• Cost to treating adult deformity in 2005 $86
billion (US helath care system)
 Classifying adult scoliosis
• Useful to 1) accurately characterize a
deformity pattern 2) guide treatment and
decision making, 3) reporting of results
• Broadly classified into 1) scoliosis that existed
before skeletal maturity 2) scoliosis that
developed after skeletal maturity, or de novo
scoliosis.
• Terminology Committee of the Scoliosis
Research Society in 1969
• King et al in 1983
• The Lenke Classification
• Schwab et al
• Scoliosis Research Society Classification of
Adult Spinal Deformity
 Clinical presentation
• The clinical presentation are an important
consideration in the patient’s decision to pursue
care (glassman et al, pekmezci et al)
• Symptomatic: 1) back pain 2) radicular
symptoms, 3) deformity, 4)progression of the
deformity 5)coronal or sagittal imbalance 6)
neural compromise
• Malalignment in coronal, axial and sagittal planes
• Goal of care: 1) improve prensent pain and
disability 2) deformity/progression of deformity
 Clinical evaluation
• History of onset and progression of deformity
• Current symptoms :pain (duration, sources,
severity, VAS), activity, and walking tolerance
(used of walking aids, gait disturbance),
deformity and detection of neural deficits
• Deformity : waist asymmetry, trunk shift, and
relative heights of iliac crests, flexibility of
deformity, clavicle asymmetry, side view –lumbar
lordosis, sagittal profile, hip or knee extension,
and Thomas test
 Radiographic evaluation
• 36-inch posteroanterior (PA) and lateral views
radiographic : coronal and sagittal balance, must
include C7 vertebrae and center of femoral head.
• Lateral flexion-extenson film : sagital plane
flexibility anf indetify fixed kyphotic deformities
• Supine side-bending film flexibility of deformities,
-traction radiographs, the push prone technique,
and fulcrum-bending technique
• CT scan (facet arthropathy)
• MRI (decompression of neural elements,
intervertebral disc degeneration)
 Treatment of adult scoliosis
• Non operatif (include analgesics, orthotics,
physical therapy, manual manipulation, activity
modification, behavioral therapy, and
injections) has limited evidence to support
efficacy.
• Dickson et al : non operative group has
significantly more pain and functional limitation
than grup who chose surgery
• Smith et al, Glasssman et al, no improvement of
symptops over 2 year follow up
• Operatif : 1) more complex and 2) technically
difficult due to age and medical comorbidities
of the patient 3) high complications often
need to re-operation
• Indication: 1. Pain that is unresponsive to
nonoperative care 2) Functional limitations
that are unresponsive to nonoperative care 3)
Progression of deformity 4)Neural impairment
• Preoperative assessment include: cardiac and
pumonal, neuropathic, myopathic weakness,
bone quality, nutritional status, obesity, and
tobacco use
• Also consider patient’s social, financial, and
psychologic well-being (recovery process)
• Specific strategies: 1) decompression alone 2)
decompression with a limited fusion
• Surgical approaches: 1) anterior only, 2)
anterior and posterior 3) posterior only
• Surgical complications: has to be informed to
the patient before, 1) neural injury, 2) vascular
injury 3) infection 4) failure of fixation 5)
decompensation above or below the fusion
3. Fixed Sagittal Imbalance

Lanny Fargo Tjioe (C014172184)

 Introduction
• Fixed sagittal imbalance global loss of spine
alignment and an inability to compensate for
it through flexibility in the lumbar or thoracic
spine a pitched-forward posture
• Etiology both natural processes
ankylosing spondylitis and iatrogenically after
spinal surgery

Ankylosing spondylitis with severe loss
of natural lordosis in the lumbar spine,
leading to a rigid bent- forward posture
Standing radiographs of a patient with Harrington rods implanted
to treat adolescent scoliosis. The lateral image shows the loss of
curvature at the thoracolumbar junction and the general loss of
lumbar lordosis and sagittal balance as a result of the combination
of the rigid rods and the natural degenerative changes that lead to
loss of lumbar lordosis.
Etiology
“Latback syndrome”
A.Spinal trauma.
Any fracture along the
length of the spinal column
especially those near the
thoracolumbar junction
kyphotic deformity pain
and loss of natural sagittal
curvature. A compression
fracture is the MOST Compression fractures at the thoracolumbar levels,
COMMON cause leading to significant fixed kyphosis.
The patient underwent Smith-Petersen osteotomies at
T9, T10, L1,L2, L3, and L4, as well as fusion from T9 to
S1. The patient also underwent laminectomy at T12–L1,
three-column osteotomy at T12, and vertebroplasty
augmentation at T8 and T9.
B. Inflamatory and Rheumatologic.
1.Ankylosing spondylitis is the most
frequent before the deformity occurs 
varieties of stiffness in sagittal imbalance
2.Lumbar Lordotic is often greatly
decrease a concomitant increase in
thoracic and/ or cervical kyphosis
C. Kyphosis post infection
D. Kyphosis or Congenital Scoliosis
E. The failure in forming anterior/ lateral segment or
vertebra segmentation
 Evaluation looking the deformity of spine
HISTORY TAKING
1. Focal back pain around the deformity or neurologic
symptoms extending into the lower extremities,
suggestive of concomitant stenosis or nerve
compression  revision decompression at the time
of corrective surgery
2. Fatigue, poor endurance, difficulty with horizontal
gaze, and an inability to perform activities of daily
living
 PHYSICAL EXAMINATION
• A thorough neurological examination,
assessment of balance, and gait
• The examination should be done sitting and
supine to isolate the deformity and to assess
flexibility of the deformity
• A neurologic exam should be done to confirm any
nerve compression resulting in sensory or motor
deficit. If the deformity is in spinal cord territory
(generally above L1), one should pay particular
attention to reflex and pathologic reflex testing
 Radiographic Assessment
• Initial imaging should include
standing long cassette
radiographic (36 inches):
1. To assess global alignment
2. To establish the sagittal
vertical axis (SVA) as well as
regional imaging of the
thoracic and lumbar spine
3. Imaging of the pelvis and
sacrum to assess thoracic
kyphosis (TK) and LL as well as
sacral parameters pelvic
insidense (PI), pelvic tilt
(PT),and sacral slope (SS)
Standing lateral
radiograph of a patient
with a significant fixed
kyphotic deformity to
the thoracolumbar
spine who presented
with fatigue,
pain, and neurologic
symptoms. Radiographic
analysis of the sagittal
curves found a normal
sagittal vertical axis of
1.7 cm, a lumbar
lordosis of –48 degrees,
and a pelvic incidence of
50 degrees but a pelvic
tilt of 29 degrees,
suggesting some
compensatory posturing
in the pelvis.
4. Flexibility of the deformity can be assessed by
comparing standing and supine radiographs.
5. Often, computed tomography (CT) is utilized to
assess partial or complete fusion of the spinal
deformity.
6. Additionally, magnetic resonance imaging (MRI) is
crucial for assessment of neural, vascular, and
ligamentous anatomy.
• The SVA is the most often cited method to assess sagittal balance.
• The measurement can be achieved on a standing sagittal cassette of
the spine by extending a vertical line from the vertebral body of C7 and
measuring its relationship to the vertebral body at S1. In patients with
normal sagittal balance, this line should lie within the vertebral body at
S1. Negative values indicate an SVA behind the posterior superior edge
of S1, while positive values indicate anterior location.
• In asymptomatic patients, Jackson reported that SVA ofset >2.5 cm
was beyond the normal range.
• Generally, a value that > 5 cm anterior is considered detrimental to
quality of life
• SVA has been found to vary with age, with recent studies showing that
SVA moves anteriorly as a result of degenerative changes, resulting in
loss of LL.
• Clinically, SVA has shown the strongest correlation with quality-of-life
measures
Radiographic Measurement to Assess
Curvature in the Sagittal Plane
 Varies Normal Value in Lordotic
Lumbar
• Bernhardt and Bridwell -14 until -69 (standard deviation,
+/- 12 degrees) in a series of 102 asymptomatic adolescent
patients
• In a series on 100 healthy French volunteers, Stagnara et al.
found values ranging from −32 to −84, with an average of −50
degrees of LL.
• Jackson compared asymptomatic and symptomatic patients,
noting a statistical diference in the amount of LL from 60.9 to
56.3, respectively
• variability seen in LL in normal patients may be the result of natural
variations in PI
• PI is deined as the angle between a line drawn perpendicular to the
surface of the superior endplate of the sacrum and a line connecting
the midpoint of the superior endplate of the sacrum to the center of
the femoral head. Often this angle is used preoperatively to deine
diferent pelvic morphologies and understand the ideal LL for a given
morphotype.
• One can examine at the amount of TK present. TK is defined as the
Cobb angle between T1 and T12. These values have been found to
range from about 20 to 70 degrees in normal individuals.
• Ideally, TK values compensate for LL to maintain a normal SVA. But
there is still a significant defect
• As the spine moves forward with rigid spinal deformity,
there is an increased onus on the musculature of the hips
and pelvis to compensate to maintain vertical alignment.
• Another angles are PT, PI, and SS (PI = PT + SS)
a. SS is deined as the angle between the superior endplate of
the sacrum and the
Horizontal
b. PT is deined as the angle between a vertical line and a line
from the midpoint of the sacral plate and the center of the
femoral head.
An individual can increase his or her PT to compensate for a
rigid deformity by increasing pelvic retroversion, hip
hyperextension, and knee lexion, centering the spine over the
pelvis and maintaining a normal SVA.
• The SVA of the cervical spine is measured
from the centroid of the dens (C2) to the
posterior superior corner of C7
• T1 tilt has been examined in cervical
deformity.
• The chin-brow angle is used to measure
horizontal gaze and deformity in ixed cervical
or cervicothoracic deformity
 SURGICAL MANAGEMENT
• The goal of surgery is to restore normal spinal balance and alignment in
the sagittal and coronal planes (establish normal spinopelvic harmony)
• SVA has the strongest correlation with quality-of-life measures.
• The surgeon should attempt to restore SVA to less than 5 cm.
• Normalized PT (<25 degrees) is crucial for eicient ambulation
• The relationship between LL and PI is related to natural spinopelvic
morphology
• The formula LL = PI ± 9 degrees allows the surgeon a rough idea of the
amount of LL to gain to match the normal patient’s spinopelvic
morphotype
• Rose et al. used TK in conjunction with PI and LL as preoperative
measures to determine what amount of LL correction was necessary to
provide adequate correction at 2 years in patients undergoing pedicle
subtraction osteotomy (PSO).
 SURGICAL TECHNIQUE
• Open corrective procedures are the workhorse of
rigid deformity surgery
• The aim is correct deformity primarily by
shortening the posterior column
• These include the Smith-Petersen osteotomy
(SPO), PSO, extensile PSO (Fig. 73.6), and the
vertebral column resection (VCR). Invariably,
greater correction is gained by removing
increasing amounts of posterior bony and
ligamentous tissue.
• Surgical technique for pedicle
subtraction osteotomy.
(A)Left, Initial resection of the
posterior elements and
surrounding pedicles. Right,
Decancellation of the pedicles and
the vertebral body.
(B)Left, Resection of the pedicles lush
to the posterior vertebral body.
Right, Greensticking and resecting
of the posterior vertebral cortex.
(C)Left, Resection of the lateral walls.
Note the V-shaped wedge. Right,
Central canal enlargement.
Closure of the osteotomy and inal
instrumentation
 Technique
• The surgeon begins by removing the
supraspinous and interspinous ligaments and
portions of the spinous processes at the
desired level of correction.
• The ligamentum lavum and the superior and
inferior articular processes are then removed.
• Next, the surgeon provides posterior
compression by closing the wedge resection
with posterior instrumentation.
 Surgery Technique
It is useful to break down large surgical procedures into
phases. For complex osteotomies, the phases are
(1) exposure;
(2) removal/(re)instrumentation, which is subdivided to
the upper construct with or without cement
augmentation and the sacropelvic construct;
(3) revision/primary decompression;
(4) osteotomy;
(5) closure of osteotomy;
(6) assessment of spinal balance;
(7) bone grating and closure; and
(8) Postoperative avoidance of complications.
 Cervical/Cervicothoracic Posterior
Osteotomies
• Initially, attempts to correct rigid deformity in
the cervical spine were seen only in patients
with ankylosing spondylitis.
 Midcervical Osteotomy for Fixed
Sagittal Imbalance
• Generally, in the territory of the vertebral
artery (C2–C6), anterior and posterior
approaches are utilized.
 Vertebral Column Resection
• This procedure removes the posterior
elements entirely and all but an anterior
cortical shell of the vertebral body.
 Summary
• Fixed sagittal imbalance is a cause of signiicant disability and
distress to patients.
• It is important for the surgeon to understand the disease
process that leads to fixed sagittal imbalance and understand
the changes in thoracolumbar and spinopelvic alignment that
occur.
• In patients undergoing surgery, restoring spinopelvic harmony
is paramount. Radiographic measures of sagittal balance can
be assessed through radiographic measures of the spine.
• Recently, there has been more efort into using minimally
invasive approaches for deformity correction with less
morbidity
THANK YOU