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Degenerative Scoliosis

What is Adult Degenerative Scoliosis?

Adult degenerative scoliosis is a condition where a right-left or lateral curve develops in a previously straight spine secondary to advanced degenerative disc disease. This curvature occurs as a result of deterioration (or degeneration) of the disc space and joints in the back of the spine. As the joints degenerate they create a misalignment in the back, resulting in a bend or curvature. This misalignment of the spine can cause back and/or leg pain due to muscle fatigue and nerve impingement and may lead to a condition known as lumbar (lower back) stenosis. Adult degenerative scoliosis is more common in the lower back and most frequently occurs in people over 65 years of age.

Symptoms

  • Pain in the back and/or legs
  • Spinal deformity
  • Pain may occur on one or both sides
  • Pain that worsens when standing or walking
  • Lying down relieves pressure on the spine and reduces pain
  • Uneven shoulders or waist
  • Shoulder blade protrusion

Diagnosing Adult Degenerative Scoliosis

Your doctor will perform a physical examination to identify areas of pain and weakness, and will evaluate your balance and the overall movement of your spine. Your doctor will also collect information about the history of your symptoms, including medicine you have taken for your condition. After your examination, your doctor may use tests to help establish his or her diagnosis. Some of these tests include x-Ray, CT (computed tomography) scan, and MRI (magnetic resonance imaging). Together, all of these techniques help to confirm a diagnosis of adult degenerative scoliosis.

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Treating Adult Degenerative Scoliosis

The following provides an overview of standard non-surgical and surgical treatments for adult degenerative scoliosis.

Non-Surgical Treatment

If adult degenerative scoliosis is established as a diagnosis, your doctor will likely recommend one or more of the following treatments:

  • Physical therapy and strengthening exercises.
  • Medications and analgesics to reduce pain and swelling. Typical medications include non-steroidal anti-inflammatory drugs (NSAIDs).
  • Injections (corticosteroids) of anti-inflammatory and/or numbing agents directly into the affected area to help reduce the pain and swelling.
  • Rest and a restriction of physical activity.
  • A back brace to help control pain, though it will not correct the deformity.

Your doctor can discuss recommended treatment options based on your individual needs.

Surgical Treatment

Patients suffering from scoliosis often undergo surgery to restore proper alignment and disc height. During the procedure the surgeon removes most of the disc between the two or more vertebrae that are to be stabilized and implants a spacer to restore correct spinal alignment. The surgeon also implants bone-forming cells that bridge the space between the vertebrae and allow the bones to grow together. Increased stability and restoration of alignment often result in significant pain relief.

Posterior Lumbar Interbody Fusion (PLIF)

In a PLIF procedure, the spine is approached from the back of the body, allowing for direct access to problematic nerves and potential placement of screws and rods in addition to the intervertebral fusion (connection of two or more vertebrae) through one approach.  The muscles lying over the spine are opened and spread from the middle out to both sides and some vertebral bone is removed, relieving pressure on the nerves and providing access to the intervertebral disc.  Traditionally, this approach requires significant muscle, bone, and ligament dissection and/or disruption, which can sometimes lead to pain and desensitization of the back muscles after surgery.

Transforaminal Lumbar Interbody Fusion (TLIF)

A traditional TLIF procedure is essentially a modification of a PLIF procedure where the muscle is dissected from the middle out to the side, but only to one side instead of both such as in a PLIF, sparing trauma to the opposite side.

NuVasive® MAS® Transforaminal Lumbar Interbody Fusion (TLIF)

The NuVasive MAS TLIF provides surgical tools that allow for a less disruptive approach without compromising the surgical access and ultimate surgical goals. Minimally disruptive surgical procedures attempt to minimize approach-related muscle pain by avoiding release of the muscle from its bony attachment. A MAS TLIF surgical approach starts at an angle to the spine and bluntly splits (rather than cuts) back muscles on just one side.

NuVasive XLIF®

The NuVasive XLIF procedure avoids muscle pain almost entirely by approaching the spine from the side rather than from the back. The side trunk muscles (abdominal obliques) are more forgiving, and approaching from there allows for a less painful postoperative recovery. Under these oblique muscles is a space between the abdomen and the back muscles called the retroperitoneal space. At the bottom of this space lies the psoas muscle, covering the sides of the vertebrae. This muscle helps with bending at the hip. It is through this space and through this muscle that the surgeon will reach the spine. The spinal nerves that exit the spine and travel to the legs through the psoas muscle (lumbar plexus) will be monitored throughout the surgery using surgeon-directed, real-time EMG nerve avoidance technology (NVM5®).

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Is XLIF Right For Me?

Your physician might determine that the XLIF procedure is a good option for you if you require an intervertebral fusion at any lumbar level between L2 and L5, if you do not require direct nerve decompression through the same approach, and you would benefit from a less disruptive procedure. Example pathologies include:

  • Degenerative disc disease (DDD) with instability
  • Recurrent disc herniation
  • Adjacent level syndrome (problems at a level adjacent to a previous fusion surgery)
  • Degenerative spondylolisthesis secondary to advanced DDD (slip of one vertebra forward over another)
  • Degenerative scoliosis secondary to advanced DDD (right/left curvature of the spine)

XLIF Potential Complications

Your physician might determine that the XLIF procedure is not a good option for you if you are not a good candidate for fusion surgery in general due to other medical conditions.

There are a few specific instances where the XLIF procedure cannot be performed. These instances include: some deformities with significant rotation, high-grade spondylolisthesis, and bilateral retroperitoneal scarring (from a prior abscess or abdominal surgery). Additionally, the XLIF procedure cannot be performed on the disc between the 5th lumbar and 1st sacral vertebrae.

Not everyone may be a good candidate for the XLIF procedure. Each patient should be treated individually, and a discussion of suitability should take place between patient and physician, as with any surgery.

Despite its advantages, your physician may decide that the XLIF procedure is not the most appropriate approach for you. Any generally accepted contraindication to fusion may include the following:

  • Systemic infection
  • Osteoporosis
  • Significant comorbidities
  • L5-S1
  • Lumbar deformities with >30° rotation
  • Degenerative spondylolisthesis > grade 3
  • Bilateral retroperitoneal scarring (e.g., abscess or prior surgery)
  • Need for direct posterior decompression through same approach (Second posterior microdecompression not contraindicated)

XLIF surgical procedure

Approaching the Spine

After you are positioned on your side and draped, an x-ray is taken of your spine to show the location of the operative disc space. The skin is marked at this location to indicate the site of the side incision. A separate small incision will first be made toward your back. The surgeon will use his or her finger through this incision to feel the space in your side through which the instruments will pass. The finger will also guide the tubular dilators into safe position within this space. As the tubes are advanced through the muscle on the side of the vertebrae (psoas muscle), x-ray pictures and NVM5® nerve monitoring help to guide them to the appropriate spot on the spine and away from nearby nerves. Once the tubes are in place, a tissue retractor (called the MaXcess® retractor) is advanced over them, locked to the surgical table, and held open to provide lighted visibility and instrument access to the disc space.

Intervertebral Disc Removal and Preparation

With the intervertebral disc now visible and accessible, the surgeon prepares the disc space for fusion by making a hole in the outer annulus, removing most of the nucleus and the annulus on the opposite side (but leaving the annulus in the front and back), and removing the cartilage from the ends of the vertebrae to reveal the bony surface beneath. Several x-rays may be taken during the disc removal to ensure adequate preparation.

Intervertebral Stabilization

With the disc space prepared, the surgeon then places a large stabilizing implant into the empty space to restore the proper disc height and support the loads put on that spinal segment. Once the intervertebral implant is in position, the retractor is removed and final confirmation x-rays are taken to document spinal alignment. The small skin incisions are closed with a few stitches and a bandage.

If further stabilization is required from behind, the surgeon might then move you to a face-down position to perform a second procedure from the back. This second procedure is also sometimes done at a later date, if deemed necessary after initial results.

 

 

Note: References to specific products as components of an XLIF procedure or other surgical procedure/approach do not imply that such products have FDA regulatory clearance or approval for all of the pathologies or indications described. The surgical procedures described on this website may not require the use of some or all of the NuVasive products found on this website. Please refer to the professional product labeling of the NuVasive products for their specific FDA cleared or approved indications of use.

Is MAS TLIF Right For Me?

Only your physician can determine if the MAS TLIF procedure is right for you. MAS TLIF may be an option if you require an intervertebral fusion at any lumbar level between L2 and S1 for the treatment of the following conditions:

  • Neurologic symptoms (e.g., leg pain, numbness, bladder dysfunction, etc.)
  • Degenerative disc disease (DDD)
  • Recurrent disc herniation
  • Degenerative spondylolisthesis secondary to advanced DDD (slip of one vertebra
    over another)
  • Degenerative stenosis secondary to advanced DDD (narrowing of space around nerves)

MAS TLIF Potential Complications

Your physician might determine that a MAS TLIF procedure is not a good option for you if you are not a good candidate for fusion surgery in general due to other medical conditions, which may include the following:

  • Infection, local to the operative site
  • Signs of local inflammation
  • Patients with known sensitivity to the materials implanted
  • Patients who are unwilling to restrict activities or follow medical advice
  • Patients with physical or medical conditions that would prohibit beneficial surgical outcome
  • Use with components of other systems, unless otherwise specified
  • Any condition that precludes or compromises the procedure

MAS TLIF SURGICAL PROCEDURE

Approaching the Spine

After you are positioned on your belly and draped, an x-ray is taken of your spine to show the location of the operative disc space. An initial dilator is advanced and used to feel the bony target points. Once the target spot on the spine is reached and confirmed with an x-ray, sequentially larger tubes are advanced to widen the exposure. Finally, the NuVasive MaXcess® retractor is advanced, locked to the surgical table and held open to provide lighted visibility and instrument access to the disc space.

Intervertebral Disc Removal and Preparation

After removing some bone and taking pressure off of the nerves, the intervertebral disc is visible and accessible. The surgeon then prepares the disc for fusion by removing much of the intervertebral disc and removing the cartilage from the end of the vertebrae to reveal the bony surface beneath. X-rays may be taken during the disc removal to ensure adequate preparation.

Intervertebral Stabilization

With the disc space prepared, the surgeon places an intervertebral implant into the empty space to restore the proper disc height and support the loads put on that spinal segment. Once the intervertebral implant is in position, the retractor is widened to expose from the vertebra above to the vertebra below for the placement of fixation instrumentation (pedicle screws).  The NuVasive  SpheRx® pedicle screws may be placed through the MaXcess retractor using the NVM5® system, which assists with implant placement by monitoring nerve activity throughout the surgical procedure.

Once the screw construct is completed on that side, the retractor is removed and SpheRx DBR® pedicle screws are implanted through a small incision on the opposite side, also using NVM5.

The final result will be a construct with an interbody implant between the vertebral bodies, where the fusion will occur, and pedicle screw fixation posteriorly to stabilize. The two small skin incisions are closed with a few stitches and a bandage.

 

 

Note: References to specific products as components of a TLIF procedure or other surgical procedure/approach do not imply that such products have FDA regulatory clearance or approval for all of the pathologies or indications described. The surgical procedures described on this website may not require the use of some or all of the NuVasive products found on this website. Please refer to the professional product labeling of the NuVasive products for their specific FDA cleared or approved indications of use.

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What to Expect Before MAS® Surgery

The best preparation for any surgery is being sure that all of your questions are answered. You should also be sure to inform your physician of any health problems you may have or medications that you are taking prior to the procedure.

Once you have been admitted to the hospital, you will be taken to a pre-op room and prepared for surgery. This may include instruction about the surgery and cleansing of your surgical site, as well as instruction about the postoperative period. You may meet with the anesthesiologist to discuss your anesthesia. Finally, you will be prepared for intraoperative nerve monitoring, which will involve the placement of electrodes on the skin overlying some muscles in your legs. Placing the electrodes will require cleaning and light abrasion of the skin. This monitoring will help with the safe placement of interbody implants and instrumentation.

You will then be taken to the operating room and anesthesia will be induced. Once the anesthetic has been successfully administered, you will be positioned on your stomach for the surgery.

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What to Expect After MAS® Surgery

After surgery, you will wake up in the recovery room where your vital signs will be monitored and your immediate postoperative condition will be carefully watched. Most patients stay in the recovery room between one and three hours after surgery. Once the anesthesiologist determines that you are recovering from the anesthetic and doing well, you will be returned to your room in the hospital.

It is normal for your incision wounds to be sore immediately after surgery. The nursing staff will monitor you to make sure that your vital signs are stable and there is no problem with either the wound or nerve function in your legs.

Because this procedure is less disruptive than conventional posterior surgery, most patients are able to get up and walk around the evening after surgery.

Most MAS surgical patients are discharged from the hospital the next day, but your physician and health care team will determine the best postoperative course for you, depending on your comfort and any other health problems you might have. Your physician will discuss with you any pain medications to take home as well as a prescribed program of activities. In general, the MAS TLIF surgery results in a quick recovery and return to normal activities.

Generally, fusion patients are seen again in the physician’s office about ten days to two weeks after surgery. If during that first week after surgery you have any questions or problems, you should call him/her at the office immediately. You will then return for follow-up appointments at various intervals up to two years or more to assess fusion progress.

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