Revision Spine Surgery and Neglected Spinal Deformity

Revision spine surgery is needed when an earlier operation has not achieved its goal or has failed over time: screws that have loosened, a deformity correction that stopped short, or a new problem above or below a fusion. Neglected spinal deformity, a curve or hump left untreated until it is severe, is its close relative. Both demand longer, more complex operations than the timely surgery they replace.

Dr. Puneet Girdhar, then Vice Chairman & Head, Spine Surgery at BLK-Max Super Speciality Hospital, New Delhi, India, and his team see many patients in both groups. Over the last five to ten years, he told the masterclass, he has seen a lot of revision patients, alongside children and adults who present late with deformities that could have been corrected far more simply years earlier. This article sets out the signs that should prompt early referral for spinal deformity, and four cases from the session that show what happens when the window is missed. The full framework of indications is in the complete guide to indications for spine surgery.

Spinal deformity signs that should prompt referral

Scoliosis is a sideways curvature of the spine, usually with rotation of the vertebrae. Coming from an orthopaedic background, Dr. Girdhar's team regards scoliosis and kyphosis correction as core work, in children and adults alike. The clinical signs that should raise suspicion are visible without any equipment:

• One shoulder higher than the other.
• The head not centred over the pelvis.
• One hip appearing raised or more prominent.
• An uneven waist.
• Changes in the skin over the spine, such as hairy patches, discoloration or dimples, which can signal an underlying congenital abnormality.
• The whole body leaning to one side, which he called the "Leaning Tower of Pisa" sign.

The 40-degree threshold

In Dr. Girdhar's practice, most patients whose curves exceed 40 degrees will need surgery, particularly when they present before skeletal maturity, because the curve can keep progressing while the child grows. Children with curves short of that threshold need close observation, with X-rays every six months. If the curve crosses 40 degrees, in his view, the child needs to see a spine surgeon and have it corrected without delay. Scoliosis Research Society guidance generally reserves surgery for curves above about 45 to 50 degrees.

His centre treats the full range of deformity: congenital, idiopathic, ankylosing spondylitis, neglected deformities, the kyphosis that follows healed spinal tuberculosis, and revisions of earlier operations. Patients arrive at every age. Some come in time, like a child of 11 with a flexible curve who achieved a complete correction. Others come at 17, 18, 24 or 30, and Dr. Girdhar has operated on a patient of 48 for a deformity endured for many years.

Neglected hemivertebra: why operating at four or five matters

A hemivertebra is a congenital malformation in which one side of a vertebra fails to form, leaving a wedge that tilts the spine. At the junction of the thoracic and lumbar spine it produces a progressive curve and a hump.

Dr. Girdhar's position on timing was unequivocal. A hemivertebra could be excised at four or five years of age, and these children should be operated on early. At that stage the hemivertebra can be removed with a short fixation, in an operation of three to four hours. Any child with a hemivertebra at the dorsolumbar junction and any sign of deformity should be referred soon.

In practice, children present late, usually because of a lack of awareness. One patient he showed presented at 16 or 17 with a neglected dorsolumbar hemivertebra, shoulder imbalance, scoliosis and a severe kyphotic hump. By then the deformity was a full kyphoscoliosis, and the operation required was a vertebral column resection: the removal of an entire vertebra to allow the spine to be realigned. With ultrasonic osteotomes cutting the bone precisely, the correction was achieved and the patient was on her feet and walking by the second day after surgery, with no neurological deficit.

Another child, aged 10, had a hump from a neglected congenital hemivertebra that also required a vertebral column resection. Dr. Girdhar described this as a cure for life: the child can now live normally, without the risk of future paralysis, progressive deformity or the cosmetic and psychological burden of a hump. He pointed out that many children with neglected deformities, for psychosocial, economic and awareness reasons, end up with a severe hump that need not have developed. An operation of this kind takes about ten hours and depends on precision, technology, neuromonitoring and a well-drilled team.

Post-tubercular kyphosis: when healed TB keeps deforming the spine

Spinal tuberculosis destroys the front of the vertebrae. In a growing child, the infection may be cured by medication, yet the deformity continues: with at-risk signs in a young child, growth itself drives a progressive kyphosis even after the disease has healed.

Dr. Girdhar described a young girl from Africa who had been treated conservatively for spinal tuberculosis around the age of six. When she reached his centre, the infection had healed (there was no active disease), but she had an almost 90-degree kyphosis in the mid-thoracic spine. The worsening angle had stretched and thinned the spinal cord. She had spastic paraparesis, a stiff weakness of both legs, and had started to dribble urine.

This is a difficult operation precisely because the disease is healed: the spine is rigid and cannot simply be pulled straight. The procedure took eight to ten hours:

1. A two-level laminectomy and fixation, placed correctly in a kyphotic spine.
2. A vertebral column resection, removing the entire vertebral body from the front and decompressing the cord from both sides.
3. A cage in place of the resected vertebra, with the spinal cord left completely free.

The outcome depends on three goals: decompressing the spinal cord, stabilising the spine and, most important, correcting the deformity. All three were achieved. Within six months she was walking, after a wheelchair-bound life that was heading towards being bedridden, and her bladder control was returning. Children, Dr. Girdhar observed, have an extraordinary ability to recover when they are treated properly.

Early-onset scoliosis: growing rods

Very young children can have curves of 60, 70 or 80 degrees. Waiting until skeletal maturity is not an option, but fusing a young spine stops its growth. For these children Dr. Girdhar uses a growth-guidance construct, a modified Shilla procedure:

• The apex of the curve is fixed, arresting growth on its convex side.
• Screws are placed two or three levels above and two levels below.
• Rods that can slide through connectors allow the spine to lengthen as the child grows, so the child gains height while the curve is held.

All of this is done under neuromonitoring, where every signal matters.

Revision spine surgery after lumbar fixation: loose screws and a compressed cord

A patient who had undergone fixation from L2 to S1 developed upper motor neuron signs (such as brisk reflexes and spasticity) and paraparesis (weakness of both legs). The assumption had been that the problem came from the lumbar spine. It did not. The cord was swollen (oedema) between D11 and D12, in the thoracic spine above the fusion.

At surgery, the upper two screws were loose: the segment above the old fixation had become unstable. Dr. Girdhar extended the fixation upwards and performed a two-level decompression at D10-D11 and D11-D12, where an ossified ligamentum flavum, the yellow ligament at the back of the canal turned to bone, was compressing the cord and had to be excised. After a paraparetic, wheelchair-bound life, the patient was on her feet and walking within four to five days and was regaining neurological function quickly.

The lesson he drew is one every referring doctor should keep: upper motor neuron signs mean the problem lies higher up, in the spinal cord. Do not neglect them. The referral framework behind this is set out in when back and neck pain needs a spine surgeon.

Revision scoliosis surgery: a correction that stopped at the apex

The case closest to Dr. Girdhar's heart was a young woman in her twenties who had been operated on for idiopathic scoliosis at the age of 12. Her idiopathic scoliosis was not, in his view, difficult to treat, but the first operation had not achieved its aim. The construct stopped at the apex of the curve, with a couple of hooks and no density of screws around the apex, and it did not extend to the upper thoracic spine. Because children fuse quickly once their tissues are disturbed, the spine had become a single solid fusion mass, in his words like one rod or a femur bone. Above it, the shoulder imbalance and the hump had progressed.

She had waited 12 years and studied the options in detail, and spent an hour and a half with Dr. Girdhar discussing which osteotomies and corrections were possible. The revision was constrained on every side: a dense fusion mass, scarring, existing implants, very thin pedicles and limited blood volume in a slight patient weighing about 39 kg. The team extended the construct all the way up, performed multiple osteotomies (controlled cuts through bone) and corrected the curve, achieving reasonably good shoulder balance. She was walking on the first day after surgery. Her hump is gone, and she is very happy with the result.

Cervicothoracic deformity and the reality of blood loss

A deformity at the cervicothoracic junction, centred at D1 and combining scoliosis and kyphosis, required another vertebral column resection, with multiple-level laminectomy, decompression and corpectomy (removal of a vertebral body) with a cage placed in front. Coronal and sagittal balance were both restored, and the patient has done well.

Dr. Girdhar was candid about what such operations cost the patient physiologically. The X-ray may look modest, but these are long operations, with blood loss of 1.5 to 2 litres at times and at least 800 to 1,000 ml that cannot be avoided. Modern anaesthesia makes eight to twelve hour operations possible, but a centre undertaking them needs the full infrastructure: neuromonitoring, ultrasonic bone cutting, intraoperative imaging and an experienced team.

What these cases mean for referral

The cases share one pattern: an earlier, simpler opportunity was missed. A hemivertebra excisable in three to four hours at the age of four or five became a vertebral column resection in adolescence. Tuberculosis cured with medication still produced a 90-degree kyphosis as the deformity progressed with growth. Upper motor neuron signs were attributed to the lumbar spine. A childhood correction that stopped at the apex cost a young woman 12 years.

For referring doctors, the practical rules are simple. Examine the back of every child with a shoulder or waist asymmetry. Refer any child with a hemivertebra and a visible deformity early. Monitor curves with X-rays every six months and refer by 40 degrees, Dr. Girdhar's threshold. Follow children treated for spinal tuberculosis through growth. Treat any upper motor neuron sign as a spinal cord problem.

Treatment-cost guidance is on the pages for scoliosis and spinal deformity correction and revision deformity correction surgery. Dr. Girdhar's August 2025 masterclass covers deformity in children from another angle in scoliosis and kyphosis in children. The techniques used for slips, stenosis and fractures are in surgery for spondylolisthesis, stenosis and spinal fractures.