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.