Lumbosacral osteotomy to correct PI-LL mismatch in the presence of abnormally high pelvic incidence
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CASE REPORT
Lumbosacral osteotomy to correct PI‑LL mismatch in the presence of abnormally high pelvic incidence So Kato1 · Stephen J Lewis1,2 · Sam Keshen1 · Nasir Quraishi1,3 Received: 20 January 2020 / Accepted: 8 September 2020 © Scoliosis Research Society 2020
Abstract Study design A case report. Summary of background data It is important to achieve optimal sagittal balance in spinal deformity surgery by matching LL to PI. A Lumbar osteotomy to increase lordosis is often the method used to achieve this in adult patients. However, in patients with high PI with compensatory lumbar hyperlordosis, providing further lordosis does not address the root cause. The paper will describe a technique of lumbosacral osteotomy to address sagittal malalignment with associated coronal imbalance and pelvic incidence (PI)—lumbar lordosis (LL) mismatch. Methods A 16-year-old female patient presented with low back pain and right leg pain. Standing anteroposterior X-ray showed scoliosis with a Cobb angle of 34º and 5.7 cm of coronal imbalance. Lateral X-ray showed a sacralized L5 with a PI of 85º and LL of 47º. Pedicle subtraction osteotomy through the sacralized L5 addressed the malalignment secondary to a high PI-LL mismatch of 38º. Results Following alar resection, an osteotomy was performed below the L5 pedicles. The cranial parts including the superior endplate and intervertebral disc were removed. Osteotomy closure was achieved using the central rod technique. L5 incidence was reduced from 59º to 33º with reduced coronal malalignment. Back pain was significantly improved and PI-LL mismatch was improved to 10º two years post-operatively with no local loss of sagittal correction. Conclusions A lumbosacral osteotomy at the lumbosacral junction is useful to improve high PI – LL mismatch in patients with abnormally high PI with compensatory lumbar hyperlordosis. Keywords Pedicle subtraction osteotomy · Sagittal alignment · Lumbar lordosis · Pelvic incidence · L5 incidence · PI-LL mismatch · Sacral osteotomy
Introduction Matching lumbar lordosis (LL) to pelvic incidence (PI) to within 10º is one of the key radiographic components associated with successful outcome in adult spinal deformity * Stephen J Lewis [email protected] 1
Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
2
Arthritis Program, Division of Orthopaedics Surgery, Toronto Western Hospital, University Health Network, East Wing 1‑E442, 399 Bathurst St, Toronto, ON M5T 2S8, Canada
3
Nottingham University Hospital, 748 Mansfield Road, Queen’s Medical Centre Campus, Woodthorpe, Nottingham NG5 3FZ, UK
surgeries [1]. With very few pediatric cases requiring fusions to the sacrum, PI-LL is not as important an issue in pediatric deformity. We report a case with a very high PI-LL mismatch secondary to a congenital lumbosacral deformity associated with an atypical thoracolumbar scoliosis and coronal imbalance. Addressing the lumbosacral deformity led to significant improvement in the patient’s symptoms and reported
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