The JRGOSCASE CORNERis submittedby Gladden Society Member,BlakeK. Montgomery, MD. Dr.Montgomery is the recipient of the JRGOS OrthoPediatrics Traveling Fellowship Award. He spent his timevisiting the pediatric spine surgeons at Rady Children’s Hospital in San Diego, California, Drs. Michael Kelly and Peter Newton.
Dr. Montgomery was selected as a Gladden Representative to last year’sOrthopaedic Research Society (ORS) Clinician Scholar Career Development Program (CSCDP) with JRGOS Faculty, Dr. Addisu Mesfin, Chair of the JRGOS Scientific Committee.
Dr. Montgomery is an Assistant Professor in the Department of Orthopaedic Surgery, Washington University in St. Louis and Shriners Children’s St. Louis.
Case Presentation
This is a 14-year post-menarchal female presented to clinic for scoliosis evaluation. She had previously tried a scoliosis brace, but stopped wearing it due to brace discomfort. She had occasional back pain, but denied bowel or bladder issues, radicular pain, numbness, or tingling. Parents reported a strong family history of scoliosis with multiple family members diagnosed with scoliosis. On exam, her right shoulder was elevated, she had a 13 degree right rib raise and a 10 degree left loin raise. She had normal strength and sensation and normal reflexes.
Diagnostic Imaging
The patient was diagnosed with adolescent idiopathic scoliosis (Lenke 2BN). Her thoracic curve was 55 degrees which placed her at an increased risk of curve progression. A preoperative spine MRI was obtained and was unremarkable.
Treatment Plan
After discussing the natural history of scoliosis, the patient and family elected for surgery. The patient underwent a posterior spine instrumented fusion from T2-L1. T2 was selected as the upper instrumented vertebrae due to the proximal kyphosis. L1 was selected as the lowest instrumented vertebrae because it is the stable vertebrae in the coronal plane and it is below the stable sagittal vertebrae in the sagittal plane. Deformity correction was achieved via differential rod contouring, segmental derotation, and compression/distraction.
After surgery, the patient was instructed to avoid sports and extreme lifting, bending, and twisting for 6 months to allow time for the fusion to mature. After 6 months she was released to full activities without restrictions.
Pearls
·Assessing the sagittal profile is important, especially the amount of kyphosis between T2-5 and T10-L2. Kyphosis >20 degrees at T2-T5 or T10-L2 should be included within the fusion to decrease the chance ofjunctional kyphosis.
·Ensure the planned lowest instrumented vertebrae includes the stable sagittal vertebrae. Not including the stable sagittal vertebrae leads to higher rates of distal junctional kyphosis.
·If performing a selective thoracic fusion, ensure that the thoracic curve is the primary curve. One of the most important factors is thoracic apical translation compared to lumbar apical translation (ratio should be >1.2).
