Original ArticlePosterior Multiple-Level Asymmetrical Ponte Osteotomies for Rigid Adult Idiopathic Scoliosis
Introduction
Adult idiopathic scoliosis (AdIS) is a spine deformity that does not develop de novo in patients older than 18 years old, that is, the untreated patient with adolescent idiopathic scoliosis (AIS) who followed the natural history with aging. The prevalence rate is about 2%−4% among adults younger than 45 years old.1 Some patients with AdIS may not proceed with surgical treatment since they are asymptomatic in their early age. Meanwhile, many patients and families chose to delay surgery because of their concerns regarding the influence on spinal growth, daily activities, patients' studies, and psychological states.2, 3 However, untreated or uncontrolled spinal deformities may lead to pulmonary functional impairment, symptoms of pain, and radiculopathy due to the curve progression as patients age.
Despite advances in technology that have allowed many spine surgeries to be performed, spinal correction surgery has always been a challenging and risky procedure. When it comes to adults, the curve flexibility of patients with AdIS, unlike patients with AIS, will decrease with aging, and the treatment outcome often is characterized by lower correction outcome. Therefore, maintaining the balance between the aggressive procedures to enhance the correction outcome and their potential risks is important, as quality and safety are a priority consideration of patients and families.
It has become increasingly common to correct these deformities with all pedicle screw constructs via posterior-only approaches in recent years.4, 5, 6 Meanwhile, since the Smith−Petersen osteotomy was described in 1945, osteotomy technology in the decades to follow has been greatly developed.7 However, correction and flexibility were not achieved by Smith−Petersen osteotomy shortening the posterior column but lengthening the anterior column, which may increase the risk of neurologic complications.8 As Ponte et al.9 further expanded the resection of posterior elements and described the Ponte osteotomy in 1984, it has been widely used in the treatment of spine deformity by a shortening of the posterior column, particularly in sagittal correction.10 It is a versatile technique that can be performed safely and rapidly to enhance curve flexibility and correction of gradual kyphosis or scoliosis.10, 11, 12, 13, 14, 15 Although a single-segment Ponte osteotomy may provide limited correction capability, this procedure can be applied to multiple segments with minimal bleeding and risks. However, to the best of our knowledge, there is no literature to report about the potential value of multiple-level asymmetrical Ponte osteotomies (MAPO) for rigid AdIS. Thus, the purpose of this study was to evaluate the efficacy and safety of posterior MAPO for rigid AdIS.
Section snippets
Study Sample
A retrospective study was conducted to evaluate radiologic and clinical outcomes for adult patients with rigid idiopathic scoliosis (flexibility of main curve <25%), who underwent one-stage posterior MAPO with a minimum of 2 years' follow-up between February 2009 and November 2015 after appropriate institutional review board approval. Exclusion criteria included other etiologies of scoliosis, history of spinal surgery, or anterior release.
Data Collection
The surgical issues (fusion levels, pedicle screws
Results
A total of 49 patients (10 male and 39 female) with rigid AdIS was included and 36 patients reached the severe standard (the Cobb angle of the main curve >80°). The average follow-up was 28.37 ± 6.98 months, and the detailed demographic data and preoperative characteristics of the curve in this case series are summarized (Tables 1 and 2). The average segments of multiple-level Ponte osteotomies that patients received were 4.39 ± 0.95 (range from 3 to 6). The average fusion levels of these
Discussion
It is now well established that untreated scoliosis in adults, especially the severe and rigid types, can lead to pain, neurologic symptoms, cardiopulmonary compromise, progression of deformity, trunk imbalance, or daily living disability. However, delaying surgery into adulthood is not uncommon due to concerns from patients and family members. Moreover, unlike a moderate and flexible spine in patients with AIS, the spine of patients with AdIS is stiffer, which make the surgery for adult
Conclusions
The surgical procedure of multiple-level asymmetrical Ponte osteotomy is a safe, easy-to-operate, and effective technique that can correct spine deformity to some extent and restore the spinal alignment with reduced operation time, blood loss, and complications and may offer an appropriate option to address the problems of rigid adult idiopathic scoliosis.
References (26)
- et al.
Untreated thoracic curve in adult idiopathic scoliosis: what are patients' concerns?
Spine Deform
(2016) - et al.
Do Ponte osteotomies enhance correction in adolescent idiopathic scoliosis? An analysis of 191 Lenke 1A and 1B curves
Spine Deformity
(2015) - et al.
Quantification of increase in three-dimensional spine flexibility following sequential Ponte osteotomies in a cadaveric model
Spine Deformity
(2013) - et al.
The true Ponte osteotomy: by the one who developed it
Spine Deform
(2018) - et al.
Factors affecting curve flexibility in skeletally immature and mature idiopathic scoliosis
J Orthop Sci
(2011) - et al.
Surgery for the adolescent idiopathic scoliosis patients after skeletal maturity: early versus late surgery
Spine Deformity
(2019) - et al.
Ponte osteotomies with pedicle screw instrumentation in the treatment of adolescent idiopathic scoliosis
Spine Deformity
(2013) - et al.
Segmental characteristics of main thoracic curves in patients with severe adolescent idiopathic scoliosis
World Neurosurg
(2018) - et al.
Impact of increasing age on outcomes of spinal fusion in adult idiopathic scoliosis
World Neurosurg
(2016) - et al.
Idiopathic scoliosis
Neurosurgery
(2008)
Comparison of surgical outcome of adolescent idiopathic scoliosis and young adult idiopathic scoliosis: a match-pair analysis of 160 patients
Spine (Phila Pa 1976)
Osteotomies in the posterior-only treatment of complex adult spinal deformity: a comparative review
Neurosurg Focus
The posterior approach for lumbar and thoracolumbar adolescent idiopathic scoliosis: posterior shortening and pedicle screws
Spine (Phila Pa 1976)
Cited by (8)
Apical Vertebras Distribution Modifier for Coronal Balance Classification in Adult Idiopathic Scoliosis
2023, Journal of Personalized MedicineSequential correction using satellite rod for the treatment of severe rigid spinal deformity: a retrospective study of 19 cases
2022, European Journal of Medical ResearchHi-PoAD technique for Adolescent Idiopathic Scoliosis in Adult: Personal case series
2021, European Spine Journal
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.