CASE PRESENTATION
A 17-year-old boy from Shiraz, Iran, presented to our outpatient clinic
with a kyphotic deformity in the lumbar region, which had begun
developing two years beforehand. The patient also mentioned enuresis and
non-significant low back pain in the upper lumbar region, which was
intermittent and not radicular. The patient had no weakness,
paresthesia, hyposthesia, numbness, or gait problems. The past medical,
allergy, drug, and surgical history was unremarkable. The patient had
left school and worked as a mechanic. In terms of family history, he had
a sister who died of hepatic failure at the age of 13. The patient did
not use tobacco, opium, or any specific substances. No domestic, social,
financial or psychological problems were reported.
On physical examination, the patient had normal cranial nerves, normal
muscle power (all 5/5), normal deep tendon reflexes (all 2+), bilateral
downward plantar reflex, negative Hoffman sign, no sensory level, no
saddle hypoesthesia, and no incontinency or hesitancy. A kyphotic gait
was observed. The preoperative radiographic evaluation of the patient
revealed a lumbar lordosis (LL) of 49°, sacral slope (SS) of 21°, pelvic
incidence (PI) of 33°, and pelvic tilt (PT) of 11° (Fig. 1A). The
patient had a sagittal vertical axis (SVA) of 1.21cm (Fig. 1B), a
thoracic kyphosis (TK) of 70° and thoracic local kyphosis (TLK) of 85°
(Fig. 1C). The preoperative CT-scan of the thoracic space revealed
several Schmorl’s nodules and sclerotic endplates (Fig. 1D). The
magnetic resounance imganing (MRI) revelaed wedging of the three
adjacent endplates, and disc space narrowing in thoracic spine (Fig. 1E,
F). As the TK was less than 75°, the patient was treated with a thoracic
lumbar sacral orthoses (TLSO) brace for six months, which had no
positive effects on his symptoms. Thus, he was scheduled for an elective
surgical fixation and correction of the thoracolumbar kyphosis. A
preoperative diagnosis of kyphotic deformation in the sagittal plane
with 93° Cobb’s angle was made. The patient underwent surgery with
intraoperative neuromonitoring through posterior-only approach.
Bilateral pedicular screw fixation of T3 to L3 (except T10) was
performed along with removal of inferior facet and spinous process and
part of laminae of T5 to L2 (Smith-Peterson osteotomy). T10 pedicle
subtraction osteotomy was also done for better correction. Two rods were
applied bilaterally and open reduction of deformity was performed. The
patient had an uneventful postoperative course and was discharged on
fourth postoperative day with a TLSO brace. The postoperative imaging
revealed a LL of 60°, SS of 35°, PI of 49°, and PT of 14°, all improved
compared to preoperative parameters (Fig. 2A). The TK and TLK decreased
to 40° and 9°, respectively (Fig. 2B). The SVA also increased to 5.06cm
(Fig. 2C). Table 1 compares the sagittal balance parameters of the
patient pre- and postoperatively.
The remarkable change in the physical examination was a normal gait,
while enuresis was also relieved. In follow-up, he had normal lower
extremity motor and sensory function with improved function of the
sphincters. At 6-month postoperative visit, he had normal motor,
sensory, sphincter, and gate function with no sign of adjacent segment
disease was found. The patient was doing well without any complications
at 1-year follow-up.