Debate: Degenerative Scoliosis

The operative treatment of adult lumbar degenerative scoliosis is a formidable challenge to the spinal deformity surgeon. Recent reports indicate that the major surgical complication rate of adult lumbar scoliosis fused to the sacrum ranges from 56% to 75%, and the unplanned reoperation rate ranges from 18% to 58%. In addition, complication rates are further increased by advanced age and medical comorbidities. The improvement in pain and physical activity achieved by fusion has not been as extensively published as other orthopedic procedures such as total hip arthroplasty. The decision to operate on an elderly patient with significant comorbidities must weigh the high complication and reoperation rates against anticipated improvement. If surgery is contemplated, one must consider complete preoperative medical evaluation. Postoperative care also must involve an appropriate interdisciplinary team and include established care patterns for at-risk patients. The surgical procedure itself may need modification to achieve lesser goals than would be attempted in a more robust patient. An informed consent discussion should include the patient and her support group. Risks and complications must be fully understood, and the patient will ultimately choose between those risks and her quality of life. The surgeon should offer options and probabilities, but the patient must bear the consequences of that choice. Case Presentation: Behrooz A. Akbarnia, MD A 65-year-old woman presents with a progressive lumbar curve. The patient has significant radiculopathy and neurogenic claudication. The patient has failed standard nonoperative treatments and states, “I cannot live like this.” Imaging studies show rotatory subluxation at L3–L4, fixed tilt at L4–L5, marked spinal stenosis at both of those segments, and foraminal stenosis at L5–S1. At a minimum, surgery will require multiple-level decompression and fusion and instrumentation from the distal thoracic spine to the sacrum. She is an insulin-dependent diabetic, well controlled. She quit smoking 5 years ago, is 5′4″ in height and weighs 200 lb. The decision to proceed with surgery may result in too high a likelihood of complications, whereas not proceeding with surgery decreases the chance of improving her quality of life (Figures 1, 2). Thus, the debate becomes whether to operate or not to operate.Figure 1: Preoperative anteroposterior (A) and lateral (B) radiographs showing significant loss of coronal and sagittal balance as well as degenerative lumbar scoliosis, rotatory subluxation, and fixed tilt at L4–L5.Figure 2: Preoperative CT/myelogram confirming significant degenerative stenosis at L4–L5, L5–S1.The following paragraphs represent each debaters argument for their side of the debate. To Operate: James W. Ogilvie, MD This case illustrates a frequent dilemma for the adult spine surgeon: a potentially high-risk patient with a difficult, but treatable lesion. Assuming that all reasonable nonsurgical options have been exhausted, surgery must be viewed as the balance between quality of life and the possibility of surgical complications including death. Nonintervention also has its risks of decreased mobility with its negative implications for general health and depression from debilitating pain or neurologic deficits. A decision-making process must include risk stratification at several levels. The first decision is to consider the diabetic patient in general. The average longevity for a diabetic female is 70.7 years, which is considerably shorter than for nondiabetics, but still represents 6 additional years of this patient’s life. It is noteworthy that patients with diabetes at the age of 85 are less active (32%) than their nondiabetic counterparts (42%). This highlights the fact that there are 85-year-old patients with diabetes that can be evaluated for their activity level. By implication, the 65-year-old patient in this debate may have several decades of life ahead. It has been documented that, although patients with diabetes have a higher complication rate, they generally do well in surgery.1 Even with diabetes, spine surgery is reasonable in geriatric patients.2 Patients with diabetes have a greater in-hospital morbidity and mortality in a group of elderly hip fracture patients, but they do regain mobility in a similar fashion to nondiabetics. This study was over the period 1987 to 1996, and few details are given of the medical parameters mentioned in the following discussion. Can a lesser procedure be done? However, it is not uncommon to encounter patients who have had a “conservative surgery,” which was composed of decompression that destabilized a motion segment. The result is a patient with postoperative spondylolisthesis, worsening symptoms, prolonged convalescence, and increasing disuse atrophy of bone and muscle that has crossed the threshold into the “no surgery” category. Would a transforaminal lumbar interbody fusion (TLIF) allow decompression, deformity correction, and interbody fusion without an anterior approach? By using the TLIF approach, a circumferential fusion can be obtained with minimal retraction of nerve roots and dura while allowing for wide decompression of the subarticular recesses and foramens.3 In addition to noting the lesser cost, studies have shown that those undergoing TLIF have fewer complications than those undergoing anteroposterior surgery in the first year following surgery. This procedure, which can be done with a minimally invasive surgical approach, requires less surgical exposure than standard lumbar fusion techniques without compromising the objectives of decompression, stabilization, and deformity correction.4 This allows earlier postoperative mobilization of the patient. In short, would a base hit suffice instead of a home run? The use of pedicle instrumentation is necessary for the TLIF procedure and usually allows brace-free recovery. The presence of dual-energy x-ray absorptiometry scan documented osteoporosis, >2 standard deviation below age-matched controls, may preclude their use. Internal fixation is an important adjunct to any proposed surgery in this patient, and the inability to use it may obviate surgery. Obesity, more than 20% above the ideal body mass index, generally increases the incidence of surgical complications. Morbid obesity, greater than 100 lb above the ideal weight, presents the combination of increased wound infection, greater stress on spine instrumentation with higher failure rates, difficulty in postoperation mobilization, and greater risk of deep vein thrombosis and pulmonary embolism and is usually a contraindication to multilevel spine surgery. If this patient is to have surgery, there is a presumption that convalescence will be longer than the younger, better-conditioned spine patient, and strong consideration should be given to postoperative anticoagulation. Would the use of bone morphogenic protein (BMP) shorten the operating time and morbidity? The use of osteoinductive agents can improve fusion rates and decrease donor site morbidity. Although the comorbidities of diabetes, obesity, and multilevel fusion have not been specifically addressed in studies of BMP and its cost-effectiveness, inductive logic suggests that in may be of value in this clinical situation. There are two particular categories of concern in diabetic patients. The first addresses ischemic vascular episodes during surgery and in the immediate postoperative period. The metrics of cardiovascular risk stratification are well known. If there are two or more of the following features [1) history of ischemic heart disease, 2) a complex surgical procedure, 3) insulin-dependent diabetes mellitus, 4) creatinine greater than 2 mg/dL, 5) a history of CVA, or 6) a history of congestive heart failure], a cardiac stress or isotope test is indicated.5 This patient has, at a minimum, criteria 2 and 3 and therefore requires a thorough cardiology evaluation. The results may preclude surgery. In Japanese patients with diabetes, there is no association between mortality from ischemic heart disease and glycosylation, but there is a correlation with diabetic retinopathy and/or massive proteinuria and ischemic heart disease.6 Those features are not known in the above patient but are critical parameters in patient selection. The surgeon must have the support of dedicated internists or endocrinologists, intensivists, anesthesiologists, and cardiologists for perioperative care.7 A perioperative β-blocker protocol has shown to result in fewer cardiac complications and is indicated in this setting.8 Any member of the care team, surgeon, cardiologist, anesthesiologist, or internist may advise against a surgical procedure based on their own individual judgment. Those decisions must be parametric and based on the current standard of care. The second concern is wound infection in the immediate postoperative period. Serum glucose levels are closely related to wound infections in patients with diabetes. Tight glycemic control by continuous insulin infusion is both cost-effective and has been shown to be effective in reducing wound infection rates in cardiac surgery patients.9 This should be considered in any insulin-dependent diabetic who is undergoing surgery. Particularly in the obese diabetic, superficial wound healing is problematic. Retraction of wound edges can result in epidermal necrosis, and retracting fat can cause triglycerides and free fatty acids to be released into the wound. These do not produce an environment conducive to healing. Vacuum-assisted wound closure has been demonstrated to be useful in closing diabetic foot wounds. This may be an appropriate adjunct for the diabetic, overweight spine patient. The ultimate informed consent is a decision between the surgeon and the patient along with her family support group. Each patient has their own perspective on life itself versus the quality of life, and there are few absolute guidelines. Surgeons may not choose to assume the legal, emotional, and physical challenges of treating high-risk patients such as this one. Although that is a personal decision, the words of the American essayist Donald Shedd come to mind, “All boats are safe in (the) harbor, but that is not why we build ships.” Would I do surgery? Possibly. Would I do further preoperative evaluation? Yes. Would I offer surgery? That depends on the medical evaluation and discussion with the patient. Not to Operate: K. W. Hammerberg, MD The patient is 65 years old with a progressive lumbar scoliosis. The severity of her symptoms and limitation of function are not given. She does have multiple comorbidities including diabetes, obesity, and a recent smoking history. This case represents a typical scenario of an older patient with extensive degenerative changes superimposed on what probably once was a modest idiopathic adolescent curve. In clinical practice, the rotatory subluxations and the segmental loss of lordosis seem to be the most significant components of the deformity in terms of pain generation and symptoms. In my experience, these represent a global perturbation of spinal balance which cannot be satisfactorily addressed by local procedures. I would agree that at a minimum the patient would require multilevel decompression and fusion with instrumentation from the distal thoracic spine to the sacrum. The need for anterior spinal reconstruction is another debate. The decision to operate on this patient must be shared by the patient, the patient’s family, and the surgeon. The decision is based on a balance between the severity of the patient’s symptoms, the natural history of the disease process, and the outcomes of the intended intervention. The generally accepted indications for surgery are pain refractory to nonoperative management, pulmonary or neurologic compromise secondary to the deformity, and possibly the magnitude of the deformity. Similar to this patient, the chief complaints of the majority of older patients who present for evaluation are pain and limitation of physical function. In other words, they complain of diminished quality of life. Therefore, surgical intervention is an elective procedure and not an absolute. In addition, it is frequently difficult to distinguish whether the diminished quality of life is due to deformity-related problems or to the general aging process and associated comorbidities. The natural history of lumbar curves in the elderly is probably one of continued progression. Schwab et al recently reported a 68% prevalence rate of scoliosis in a group of elderly patients with no previous history of spinal deformity.10 Pain does seem to be associated with lumbar curves. However, there appears to be a discrepancy between the association of pain with increasing age, and no correlation between pain and increasing curve magnitude. A surgical recommendation based solely on curve magnitude does not appear well supported. The outcomes of a surgical procedure include the anticipated complication rate and the expected levels of effectiveness. Level I studies, randomized clinical trials, provide the highest level of evidence for decision-making. In analyzing the outcomes for adult lumbar scoliosis surgery, almost all of the studies are relatively low, Level IV, case series reports providing the treating surgeon only limited evidence for decision-making. Recent case series of lumbar scoliosis fused to the sacrum demonstrate a high complication rate and only modest improvement in clinical parameters. Emani et al reported 34% perioperative and 37% late complication rates with an 18% unplanned reoperation rate.11 Edwards et al compared long fusions to L5 with fusions to S1.12 The sacral cohort was more problematic with 33% medical morbidity, 42% pseudarthrosis, and 58% unplanned reoperation rates. Other studies analyzing adult lumbar scoliosis surgery in general note that complications increase with increasing age and the presence of multiple comorbidities.13–15 Our patient must be regarded as a high-risk candidate for surgical complications. Complications such as pseudarthrosis and infection have been shown to have a negative impact on the outcome of the surgical intervention. An interesting retrospective, comparative study was reported by Dickson et al in 199516; they compared self-reported pain and functional status between a group of operated patients and a group who were offered surgery but declined. The average age of the patients was 56 years; fusion levels were not specified. The study had a number of significant limitations but concluded that the operated patients had better outcomes. Severe postoperative pain was reported by 35% of the operated patients compared to 70% of the nonoperated. This comparison would seem to favor surgery, but the preoperative pain status was not indicated. As well, the high rate of severe residual pain does not reflect favorably on the effectiveness of surgery. The operated patients reported perceived improvement in physical, functional, and self-care activities. However, there was no statistically significant difference in the scores for actual physical, functional, or self-care performance between the 2 groups. The operated group have a complication rate and unplanned reoperation compared to for the nonoperative group. interesting study was reported by et al in The outcomes of a series of adult deformity were evaluated with preoperative and postoperative self-reported health and function. The patients demonstrated statistically significant improvement in of health on the although the actual improvement in the scores was only to In the et al the modest improvement documented by scores for adult deformity surgery in to total hip the improvement in pain for scoliosis surgery versus for total hip and improvement in physical function for scoliosis surgery versus for total hip the as to whether adult scoliosis surgery is as minimally effective as it appears or whether the is to its Would a outcome such as the be a more The is to pain and physical but not to and deformity. to patient, important are and deformity in a obese of pain and improvement in physical activity are important but only modest can be anticipated at a significant risk and should be with this patient and family but her quality of life is A modest improvement in pain and function be the risks in an older adult by deformity-related However, the of surgical intervention in with only to symptoms is is the of surgery in the limited patient with multiple in the surgical risks would be the and the outcomes most Even a patient may “I on like the surgeon is not given but has an to the patient an informed In the patient with complaints that can be such as a stenosis or nerve a limited intervention can be of However, decompression without should be In more active patients, this in an more complex The use of bone morphogenic protein and other may the pseudarthrosis rate but will not the patient’s age or other significant comorbidities. scoliosis surgery in has high complication and reoperation rates. of the fusion to the sacrum further increases these Complications have been shown to increase with age and additional medical on the clinical The effectiveness of surgery to improve pain and physical activity in similar patients has been demonstrated to be modest with a high The need for outcome studies to the of to the surgical treatment of adult spinal deformity is As the general life increases in age becomes less of an for surgical decision-making. are more and more with the dilemma of indications for surgery in geriatric patients with spinal who to active into life. comorbidities such as diabetes, cardiac and history of smoking the decision to operate or not to operate becomes more important for the treating surgeon of the significant risks associated with both the natural history of progressive spine deformity in the becomes we can balance the risks of the treatment we choose with expected outcomes. and debate this important in to for an and to for surgical intervention in progressive adult scoliosis, in those fusion to the sacrum and/or is There is general that the rate of complications for this surgery is comorbidities The improvement in pain and level of physical activity following fusion to the sacrum in a 65-year-old patient has not been extensively compared with other orthopedic procedures such as total hip However, in the decision, one must the patient’s limitations and of her progressive I agree with that surgery must be viewed as the balance between quality of life and surgical complications. As the treating surgeon, we should each risk against the expected outcomes. the of diabetes to this that spine surgery is a reasonable in geriatric patients with diabetes in comparison to of the other comorbidities and the patient generally from surgery. The other that the treating surgeon should is whether or not lesser surgery such as decompression or limited fusion provide reasonable and for the patient. do these patients require more extensive surgery including anterior decompression, and we should fully is the patient’s symptoms. complaints such as pain a major in the treatment it pain or pain that is more are the functional should not why this patient has come to in the first If treatment of one of her symptoms, such as requires extensive decompression in presence of significant deformity, would to fusion and instrumentation is If her decompression is limited and does not the of the a limited surgery may be all As the decision for surgery should be a shared one. The surgeon as well as the patient and the family should have an of the limitations of surgical the natural history of the deformity, and the outcomes of intended intervention. It appears that there are few absolute for the of a candidate for surgical intervention. Each patient is and should be considered The results of nonoperative care including physical and treatment should be well documented and outcomes those and surgery is the procedure, and expected outcomes should be with the patient and her The surgeon is to advise the patient as to what or is the most appropriate surgical or nonsurgical The patient’s is also important to the discussion. The patient to be in or her and in this age group should be considered only progressive physical pulmonary or neurologic compromise It also should be pain and limitation in physical activity are due to the deformity or the aging There is no evidence that clinical symptoms with curve the decision to proceed with surgery solely on the of the curve is not well supported. surgery is considered as an the decision process should include risk should be of comorbidities and should include medical and cardiovascular Risks such as high the need for or other should be addressed and surgery. In addition, health risks should be by the patient’s medical team surgery. all of the above have been the surgeon should have an informed consent discussion with the patient and or her support group such as her adult to the patient’s previous and the patient’s to have surgery. The expected outcomes as well as the risks and complications of the proposed procedure should be the patient is for the ultimate decision surgery, the surgeon has a to or her in a and and the patient to a The proposed procedure be to lesser goals it would result in fewer risks in a high-risk patient. In this patient, of the need for a multilevel decompression, fusion would be necessary This patient a anterior and surgery. The anterior of multilevel and fusion from to L5 using at and The procedure extensive decompression from to spinal fusion and instrumentation from the sacrum with fixation using a and lumbar interbody fusion of the L5–S1. bone was for was achieved by a combination of and Postoperative anteroposterior (A) and lateral (B) radiographs following decompression, anterior and and instrumentation to the the improvement in the curve magnitude and coronal and sagittal of this of surgery, the surgeon should be and in treating adult deformity patients. In addition, an support team such as anesthesiologist, and internist and support in the operating is one should be for a high rate of complications and should each complication debaters to details in the preoperative of the patient and her support group in and the risks with the expected outcomes. the is based on Level clinical studies using outcome are necessary to provide to patients and in the process of whether or not to surgery. The for her with of the