Adult spinal deformity is an increasingly common condition in the United States and worldwide. As the population ages and continues to live longer, the prevalence of this disease continues to rise. Patients no longer want to be confined to wheelchairs or live with debilitating pain and more frequently patients, independent of age, wish to continue living an active lifestyle. Hence, the goal of spinal deformity surgery is to address the needs these patients by restoring normal spinal alignment, reducing pain, and enabling a more physically active life.
Spinal deformity arises when the spinal column is not properly aligned. Normal alignment is necessary to maintain posture, protect the spinal cord and associated spinal nerves, and enables a person to ambulate safely. Abnormal alignment can result in the coronal plane (scoliosis) or the sagittal plane (kyphosis).
In scoliosis, the spinal column is no longer straight and there are one or more curves in the spinal column. Frequently, the shoulders are not level and the head may not be centered on the pelvis. This condition can occur during adolescence (adolescent idiopathic scoliosis) or adult life (adult degenerative scoliosis). In kyphosis, the spinal column has lost its normal curvature and the spine, along with the head, is positioned too far forward. In either condition, the spinal column is no longer aligned in the most physiologic manner, which leads to increased pain and disability.
Finally, scoliosis and kyphosis may result from previous spine surgery such as a laminectomy or fusion. This disorder is commonly referred to failed back or post-laminectomy syndrome and is characterized by significant pain, loss of normal alignment, and disability.
Spinal deformity is evaluated using long-cassette x-rays, frequently called scoliosis films. These special x-rays provide an image of the entire spine, head, and pelvis in both the frontal (coronal) view and side (sagittal) view. These x-rays will be used to perform a number of measurements that are considered critical to spinal alignment. These parameters include the sagittal vertical axis (SVA, a measure of how far a patients head lies in front of the pelvis,) thoracic kyphosis (TK, a measure of how much the middle section of the spine is curved forward), lumbar lordosis (LL, a measure of much the lowest part of the spine is curved backward), and pelvic incidence (PI, a measure of how angled the base of the spine is in relation to the hips).
These parameters will be used in conjunction to determine the global alignment of the spine and determine if any of these measures are out of “normal” balance. For example, a patient may have loss of lordosis in the lumbar spine due to either aging or previous surgery. This measure is closely related to the pelvic incidence. If there is significant loss of lumbar lordosis, a patient is considered to have a lumbar to pelvis mismatch, which is associated with increased pain and disability.
Magnetic resonance imaging (MRI) and computed tomography scans (CT scan) will also be obtained to determine if there is any associated compression of the neural structures such as the spinal cord or spinal nerves. Finally, a DEXA scan may also be ordered to determine a patient’s bone density.
As with most spinal conditions, conservative management should be attempted first. This may include physical therapy, aqua therapy, walking, analgesic oral medications, acupuncture, as well as epidural or facet joint injections. The goal of these therapies is to reduce pain while at the same time improve the level of functioning. None the less, these therapies in general have not been shown to be very effective in treating the symptoms of patients who suffer from spinal deformity.
The decision to proceed with surgical intervention should be a mutual decision by the surgeon and patient. In general, patients with progressive spinal deformities, debilitating pain, nervous system compromise, and significant functional limitations may be appropriate for operative intervention.
Surgical intervention in spinal deformity varies widely and draws from all aspects and techniques of modern spinal surgery. Frequently, interbody fusion using either a minimally invasive anterior or lateral approach is utilized to aid in the restoration of normal spinal curvature while also increasing the area for fusion. Almost always, utilizing either a minimally invasive (through the skin) or open approach, a posterior fusion is performed using screws and rods to align the spine and maintain this alignment while the patient’s own body fuses (glues) the vertebra. Finally, various osteomies (bone cuts) may be used to enable spinal realignment depending on the severity and rigidity of the spinal curvature/kyphosis.
Spinal deformity surgery is associated with significant risks. However, at the same time, correcting spinal alignment and restoring physiologic spinal balance has been shown to significantly reduce pain and disability as well as improve the level of functioning. Furthermore, studies have shown that these benefits are durable and are maintained years after surgery.
At UCLA, the Spinal Deformity Program is comprised of several multi-disciplinary members including surgeons, anesthesiologists, neurologists, intensive care physicians, pain management experts, cardiologists, physical therapists, and bone health specialists. The singular goal of this group is to evaluate each patient carefully, identify any risk factors prior to surgery, determine the optimal treatment plan, and ensure the safest possible experience for the patient.
We continued to monitor and analyze our outcomes using patient reported questionnaires in an effort to continually improve the care we provide. Below is a sampling of patients who have gone through the UCLA Spinal Deformity Program and the outcomes they reported:
In summary, patients who undergo spinal deformity surgery at UCLA have demonstrated the following outcomes: