Adult scoliosis surgical treatment
When is this procedure indicated?
Patients with adult scoliosis (>18 years of age) have an indication for surgical treatment when they present with disabling pain symptoms that are resistant to medical and physical therapy and have been present for at least 6 months, especially if there is irradiation of pain to the inferior limbs with or without the presence of neurologic claudication or a neurologic deficit.
Equally important is the evaluation of the clinical and radiological picture on the presence of possible frontal and sagittal imbalances, which condition the choice of the operating program.
How is it performed?
The surgical procedure performed under general anesthesia involves the execution of an instrumented vertebral arthrodesis via posterior route, that is, the correction of the scoliotic curve and fixation of the vertebrae involved by means of special instrumentation consisting of biocompatible screws and biocompatible connectors. A bone graft is applied in order to allow a permanent union between the vertebrae of the selected cruciate area and the bone graft itself: after positioning the patient in a prone position on the arthrodesis bed, the surgical field is carefully sterilized and longitudinal thoracolumbar skin incision is made. Skeletonization of the pre-established arthrodesis area vertebral arthrodesis is performed with titanium synthesis and cobalt chrome rods, using as a graft the bone obtained from cruentation added to synthetic bone screws positioned under control of the brightness amplifier. Intervention is performed under continuous monitoring of motor and somatosensory evoked potentials. In addition to the simple arthrodesis, very often other interventions can be performed, depending on the different needs, to help solve or improve the clinical and radiographic picture: neurological decompression, posterior interbody arthrodesis with cages, lateral transpsoas interbody arthrodesis with cages, correction osteotomies of the coronal and/or sagittal plane.
The patient is usually discharged on the sixth day, in compliance with the general conditions at a specialized physiotherapy rehabilitation center. The goal is to gradually accustom the patient to strengthening muscles and exercise to re-educate posture and walking.
Subsequently, the patient is re-examined 1 month after surgery for clinical evaluations of the treatment and the performance of a control radiograph. At 4 months, if the clinical and radiographic conditions of the patient allow it, the corset may be removed. Subsequent clinical and radiographic outpatient follow-ups are scheduled at 1 year, 2 years, 5 years, and 10 years. In case of particular needs, outpatient controls are scheduled according to specific needs.
Early complications following major spine surgery affect approximately 30-40% of patients undergoing this surgery. Complications can be minor, such as surgical wound infections, urinary and respiratory infections, but can also be very serious, causing hematones, hemorrhages, re-interventions, deep infections, spondylodiscitis, osteomyelitis, Infection at the level of the synthesis media or at the level of the prosthetic media to the extent that their removal is required that in some cases can prevent the further implantation of new synthesis means or prosthesis. Another complication is fistula of cephalorachid fluid that may require the placement of an external spinal drain (DSE) or the reintervention for the intraoperative suturing of the dural breach. Irreversible neurological injuries with risk of reversible or permanent impairment of sensation, perineal anesthesia, retrograde ejaculation, sexual impotence, urinary and/or fecal incontinence, paralysis of a limb or muscle group, paralysis of the four limbs in case of injury in the cervical spine or paralysis of the lower limbs in case of injury in the thoracic or lumbar spine. Reoperation rates remain high, especially in surgical revisions of previous spine surgery.
After the period of convalescence and motor physiatric rehabilitation, the patient is generally able to return to a completely normal life, reducing to a minimum the efforts on the spinal column. IIn some cases, however, there may be persistence of joint pain or limitation of mobility of the spine (paraphysiological, depending on the number of vertebral levels included in the instrumentation), persistent pain at the level of the surgical scar, persistence of alterations in strength or sensitivity or paresthesia. Delayed consolidation or pseudo-arthrosis (i.e. lack of bone bonding), or fracture of the synthesis media, which may necessitate further surgery. IIn a small percentage of cases, overload of the segments proximal and distal to the area of arthrodesis may occur, necessitating further intervention.