Spinal Cord Series and Cases (2017) 3:17085
https://doi.org/10.1038/s41394-017-0008-9
CASE REPORT
Revision surgery for degenerative spinal deformity: a case report
and review of the literature
Pasquale Donnarumma
1
●
Roberto Tarantino
1
●
Lorenzo Nigro
1
●
Maria Fragale
1
●
Roberto Bassani
2
●
Roberto Delfini
1
Received: 21 April 2017 / Revised: 31 August 2017 / Accepted: 4 September 2017
© International Spinal Cord Society 2017
Abstract
Introduction Management of spinal degenerative deformities always represents a challenge for the spinal surgeon.
Case presentation We report a case of revision surgery for adult scoliosis, focusing of most common errors in pre-surgical
management and criteria for reoperation. We analyzed the spino-pelvic parameters on the standing whole-spine X-ray and
the role of sagittal balance. To restore 45° of lumbar lordosis, we performed a L3 Pedicle Subtraction Osteotomy (PSO),
along with L2-L3 and L3-L4 eXtreme Lateral Interbody Fusion (XLIF).
Discussion In cases of adult scoliosis, careful preoperative planning is necessary in an attempt to avoid difficult, expensive,
and high-risk additional procedures.
Introduction
Management of spinal degenerative deformities always
represents a challenge for the spinal surgeon. A recent
analysis from a large multicenter database shows an overall
17% reoperation rate for rigid fixations [1]. The need for
reoperation may be minimized by carefully considering the
sagittal spinal alignment, spino-pelvic parameters, termi-
nation of fixation, and type of surgical procedure. We pre-
sent a case of implant failure and revision surgery,
analyzing the most common errors in pre-surgical man-
agement and criteria for reoperation.
Sagittal alignment analysis
Sagittal spino-pelvic alignment is analyzed pre-operatively
on standing whole-spine X-ray scan. Spino-pelvic para-
meters are measured as following: pelvic incidence (PI) is
defined as the angle between the perpendicular to the sacral
plate and the line connecting the midpoint of the sacral plate
to the bi-coxo-femoral axis. The PI is a morphological
parameter, considered as a constant, independent of the
spatial orientation of the pelvis. Sacral slope (SS) corre-
sponds to the angle between the sacral plate and the hor-
izontal plane. The SS is a positional parameter, varying
according to the pelvis positioning. Pelvic tilt (PT) is con-
sidered as the angle between the line connecting the mid-
point of the sacral plate to the bi-coxo-femoral axis and the
vertical plane. The PT is also a positional parameter and its
algebraic sum with the SS corresponds to the PI (PI = SS +
PT). Lumbar lordosis (LL) is defined as the extension spinal
segment above the sacral plate. Thus it is measured using
the Cobb’s method from the sacral plate to the upper end-
plate of the most incline vertebrae into the thoracolumbar
junction zone (corresponding to the inflection point where
the spine transitions from lordosis to kyphosis) [2].
Case presentation
This is a 66-year-old, normal weight female patient with
history of 10 years low back pain (post-menopausal onset at
56). Past medical history was unremarkable and there was
no history of adolescent scoliosis. Conservative treatment
with physical therapy, NSAIDs, and steroids was unsuc-
cessful. In November 2013 she presented for recent
appearance of right sciatica (GRS-Graphic Rating Scale for
* Pasquale Donnarumma
dott.pasquale.donnarumma@gmail.com
1
Department of Neurosurgery, Sapienza University, Viale del
Policlinico 115, 00161, Rome, Italy
2
IRCCS Galeazzi Orthopedic Institute, Via Riccardo Galeazzi, 4,
20161, Milan, Italy
@Phil_Robichaud
@deepthiw
@JoseServera