Case Report
Symptomatic progression of degenerative scoliosis after decompression and limited fusion surgery for lumbar spinal stenosis

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Abstract

Significant degenerative scoliosis together with lumbar spinal stenosis increases the complexity of planning a surgical intervention for iatrogenic instability may be introduced by decompression in the midst of the curve, especially at or near the curve apex, that may lead to more rapid progression of a deformity, especially if surgery is at, or is near, the apex of the curve and a listhesis is present. Surgical options include simple laminectomy, a laminectomy with limited fusion, or an extensive fusion that addresses the overall curve, but there is no consensus as to the best approach. There is scant information in the literature about specific instances of failure of a limited surgical approach from which any instructive lessons may be learned. We report a surgical failure in a 59-year-old woman with degenerative lumbar stenosis and scoliosis from L3–5 and L3–4 disc herniation treated with a simple hemilaminectomy and discectomy, a subsequent fusion for symptomatic progression of deformity, and a third surgery to fuse the entire scoliotic curve after development of severe deformity, pain, and neurological deficits. We conclude that surgical decision-making should take into consideration any risk factors for deformity progression as well as overall sagittal and coronal balance and advise that similar patients be followed for a lengthy period following surgery to monitor for stability.

Introduction

Lumbar spinal stenosis (LSS) is a major cause of pain and disability that is increasing in frequency with the aging population. Coincident degenerative lumbar scoliosis (DLS) increases the complexity of surgical planning: decompression within the curve may introduce iatrogenic instability and progression of deformity, especially at or near the apex of a curve or a listhesis[1], [2] There is no consensus if optimal surgical management should be simple decompression, short-segment fusion, or extensive surgery addressing the overall curve. Discourse about this clinical problem is limited by lack of information about the incidence of deformity progression following decompressive surgery; moreover, the literature contains few examples of treatment failure from which instructive lessons can be learned.4 We present a patient with LSS with DLS wherein symptomatic progression of deformity occurred following simple decompression and a subsequent short-segment fusion.

Section snippets

Case report

A 59-year-old woman complained of worsening low back and right leg pain unresponsive to epidural steroid injection (ESI) and physical therapy. Neurologic examination demonstrated right L4 dermatomal sensory loss and a diminished right knee jerk. Imaging studies (Fig. 1) showed L3–5 LSS, mild DLS, and disc extrusion at right L4/5. She underwent a right-sided L3–5 hemilaminectomy and discectomy with good symptom relief.

Seven months later, she represented with recurrent low back and right leg pain

Discussion

Degenerative scoliosis increases the complexity of surgical decision-making in patients with lumbar spinal stenosis. Degenerative curves may progress at a rate of 3% per year1 and numerous factors are suspected of influencing progression, including osteoporosis, lateral listhesis, Cobb angles exceeding 30°, absence of stabilizing lateral osteophytes, asymmetrical disc degeneration, and the relationship of L5 to the intercrest line.[1], [4], [5] The optimal surgical treatment is unclear. Many

Conclusions

Coincident degenerative LSS and DLS is a challenging clinical problem for which the surgeon must balance the risk of postoperative deformity progression with the risks of expanding the scope of surgery with extensive fusion and instrumentation. We report a patient in whom limited surgical treatment led to clinical failure requiring additional surgeries. Our experience supports the recommendation to more broadly address a degenerative scoliotic curve if there is clinical concern of deformity

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