Treatment of scoliosis in the adult thoracolumbar spine with special reference to fusion to the sacrum.

The major indication for operative intervention in adults with lumbar and thoracolumbar curves is pain. A careful analysis of the pain, including a careful history and the use of discography and facet blocks, has greatly enhanced the success rate both in terms of correction and relief of symptoms postoperatively. Zielke instrumentation is the preferred surgical technique for thoracolumbar curves that do not require extension of the fusion to the sacrum. Cotrel-Dubousset fixation is particularly advocated in those cases that show evidence of spinal stenosis and require posterior decompression or in cases of rigid kyphoscoliosis following an anterior release. Fusions of the sacrum require a combined anterior and posterior approach. Iatrogenic loss of lumbar lordosis can be prevented by careful attention to detail and posterior instrumentation with preservation of lumbar lordosis, contouring of rods, and hyperextension of spine and hips at the time of surgery. Loss of lumbar lordosis, which may result in marked fatigue and pain as well as a deformity often worse than the initial one, can be corrected, preferably by a combined anterior and posterior approach (Fig. 5).