• HPI: 38-year-old woman comes to clinic for evaluation of a thoracic kyphotic deformity. She states that she was diagnosed with a "scoliosis" during grade school and was never evaluated further. She has been living with this over her lifetime and has developed increasing discomfort and pain in the thoracic area of her spine over the last year primarily while sitting down or while lying down. She has difficulty lying on her back and can only sleep while lying on her side. Otherwise, she does not have any pain at rest and does not take any medications for pain or this discomfort. She will take Tylenol p.r.n. for pain control. She has completed all conservative therapies with diligence and without improvement in her symptoms. She is miserable and hoping to get her pain taken care of. 

    PMH: 
    1. Diabetes 

    Family Hx: 
    All other relatives are deceased (no remarkable history). 

    Medications: 
    1. Multivitamin 

    Social History: 
    School teacher. Four children – all healthy. No alcohol or other drug use. 

    Neurological Exam: 
    Awake, alert, fully oriented, cooperative and conversant, and able to provide a full and detailed history. 
    5/5 motor examination in her upper and lower extremities. 
    Normal reflexes. 
    Sensation is grossly intact to light touch. 
    With the patient standing, she has an exaggerated lordosis in her back and in her lumbar area and a prominent kyphosis in the upper thoracic region. There is a minimal scoliotic curve towards the left in her thoracolumbar area. The patient is in neutral sagittal balance and alignment, and her shoulders are squared over her hips. The left shoulder is slightly raised and elevated compared to the right side. 
    With flexion, extension and lateral bending, there is no exaggeration of symptoms and there was mild mobility of her kyphotic deformity with gentle compression of the thoracic-kyphotic prominence. 
    Long Tract Signs: negative

    Figure 1-3 (Below) CT spine: spontaneous arthrodesis of T9 and T10. Significant osteophtyes at T10/T11 and T11/T12 

    MRI (no images available): no tether or neural axis anomalies.

    Figure 1.

    Figure 2.

    Figure 3.

    1. What is your recommendation to this patient?

    2. What approach do you select?

    3. If you choose to include posterior approach, how many levels do you include in your fusion (apex of kyphosis is T10).

    4. Do you augment your posterior hardware with hooks, cement, etc or use pedicle screws only?

    5. Do you perform his surgery with intra-operative neuromonitoring?

    6. Please add any suggestions or comments regarding this case:

    • POSTERIOR VERTEBRAL OSTEOTOMY ( SUBSTRACTION ) IS A GOOD OPTION AS WELL PLUS SCREWS
    • this is a difficult surgery and proper counseling of the patient is essential with regard to complication in particular neurological.
    • this is surgically correctible

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