Saturday, January 24, 2015

Does scoliosis surgery really help teenagers and adults to feel better about themselves and their posture, and ensure better quality of life?

We had great clinic yesterday, with lots of thankful 6 week postop visits from our pre-Christmas scoliosis "blitz" we had.  It was so great to see so many precious teens and their parents back for follow-up with kids back to school, looking great and feeling great.  We've also done a bunch of revision scoliosis and kyphosis surgeries recently, including some folks who traveled quite a ways to come to Hey Clinic.  Their stories are below as well and on our YouTube Channel.  One patient named Matt shared how upset he was going through high school very self-conscious of his posture.  Now at age 24, he is standing up straight with less pain, 7 years after his original surgery, which was in part complicated by some collapse above and below his old fusion.

Gotta get to bed, but enjoy some of these stories and pictures below.
All the videos below were shot this past Friday at Hey Clinic, except Matt's, which was shared with me from the week before.  You can see why I love my job, getting to be a part of these precious family's journeys through a crucial period.

Lloyd A. Hey, MD MS  -- Hey Clinic for Scoliosis and Spine Surgery

Saturday, January 10, 2015

Hey Clinic Celebrates 10 Year Anniversary This Week! So many precious patients, families and co-workers to be thankful for.

This week marks a special time for Hey Clinic -- our 10 year anniversary for opening up our doors as a lifelong scoliosis center!  Today is the first day I've had a few minutes to sit down and reflect on that, after a very busy several weeks.  The text that I got this morning was a good way to start:

I got the following text from a scoliosis mom from Nevada earlier today, whose daughter Jackie had scoliosis surgery with us at Hey Clinic earlier this fall, which she gave me permission to share with all of you:
"Dr Hey-  Jackie is doing GREAT after her surgery!  This is her first regular season game this year.  She is in black.  So hard to get a good action shot!  Hope you got her xrays and that all looked good. Have a great weekend."

It was way back in 1989, while working as a resident for Dr. John Hall, Dr. John Emans and others at Boston Children's Hospital at Harvard that I got the idea of serving patients with scoliosis, kyphosis and other deformities across the whole life spectrum -- not just as children/adolescent (pediatric) or adult.  While I saw the patients at Children's getting great care, there was this awkward period when those scoliosis patients grew up -- either without surgery, who had been observed and/or braced, or patients who had surgery.  Where do they go as an adult?  Do they just find an adult spine surgeon?  Or just do nothing and hope for the best?

No, there should be a better way --- caring for scoliosis and other spinal deformities from age 0 to 100, and developing a long-term relationship with the scoliosis patient and family.  I pursued this vision through pediatric scoliosis training with Dr. Hall, Emans and others at Boston Children's Hospital, and then with adult orthopedic surgery and neurosurgery spine fellowship training at Duke University Medical Center, with Dr. William Richardson, Dr. Dennis Turner, Dr. Wilkins, Dr. Cook, Dr. Alan Friedman and others.  I then joined the faculty at Duke, where I served for almost 10 years, where I focused on serving patients with spinal deformity, including patients with complex revision spinal deformity surgery.  

But it was 10 years ago this week that I moved my practice from Duke Medical Center in Durham to the Duke Raleigh Hospital Campus, and opened up the Hey Clinic for Scoliosis and Spine Surgery -- an independent clinic focused on delivering high quality, compassionate scoliosis care across all ages.  We've served thousands of families since then, helping patients with conservative treatment, minimally invasive treatments, as well as performing thousands of scoliosis surgeries at both Duke Raleigh Hospital, and WakeMed Children's Hospital.  Boy have we learned a lot, and grown a lot, and improved a lot.   We've developed our own custom electronic health record (EHR) for scoliosis, we've had weekly quality improvement meetings every week now for many years, where we apply our our Deming-Inspired Continuous Quality Improvement methodologies to continuously learn and improve -- not just in the clinic, but across the continuum of care.  

I've worked with my SRS colleagues from around the world on developing newer techniques for scoliosis surgery safety, and ways of getting kids, adolescents and adults straighter, and with a better long-term quality of life. The learning never stops.  

After 10 years at Hey Clinic, 19+ years of practice, and 25 years since I was inspired and mentored by Dr. Hall and Emans, I must say that I still love my "job" every day, which doesn't feel like a job at all… just an amazing opportunity to be a part of a really important web of relationships where I can contribute and help make a difference for the long run… and bring a smile to a child, teenager, or even an older adult to get their wish to "Get It Straight!"

Jonathan and his mom standing up straight
going home from WakeMed after 2 months
While I am not a good writer / blogger, and haven't gotten much better at that since high school ( I really didn't have a good high school English experience).   Maybe that's one reason why I went to engineering school, and not liberal arts school!  However, I have definitely always been a "tinkerer" / "fix it" kind of person growing up, and have definitely been blessed to be able to gradually improve/perfect the "craft" of scoliosis care and surgery.  This has come from a constant commitment to continually learn, and continually focus on getting better, not just as the surgeon / craftsman, but also as a team leader and team member.  Great scoliosis care is definitely a team sport, and we've been honing our team both at Hey Clinic and with our hospital and other care partners with a constant effort to make things better and safer over time for our patients and families.

One of my most special memories from 2014 was caring for Jonathan, a 10, now 11 yo boy with a connective tissue disorder, who had a scoliosis and kyphosis over 130 degrees.  He was unable to gain weight since his stomach and intestines were being crushed by his scoliosis and kyphosis.  He also had breathing issues doe to poor lung capacity.  And he also had many previous surgeries with history of infections and lots of scar tissue.  Some medical centers actually turned him down for even considering surgery.  Well, this fall we finished an incredible journey with Jonathan, his amazing family, and the WakeMed Children's Hospital, at the Raleigh Campus.  Jonathan was placed in axial traction for several weeks, actually gained over 14 lbs, had improved pulmonary function and then looked like a completely different kid!  I then fixed his scoliosis this past December, and after some time in the PICU and on the floor, he actually went home the Friday before Christmas, after a huge celebration lunch for Jonathan, his family, and the wonderful WakeMed staff.  This journey is well documented by Jonathan's dad Mike and mom Jennifer on his Caring Bridge site, which his folks said was ok to share with all of you here on the blog: Jonathan is back home now, still gaining weight, and back to school, and off all the narcotics, and always has a big smile.  His incision has healed well, and he is breathing well, and has a whole new posture!

I do thank God, my family, my mentors, SRS and other colleagues, Hey Clinic staff, hospital staff, and all of our patients and families who have made this journey so far absolutely a joy and a blessing.  Many years ago after I was hit by a car and spent months in the hospital with a horrible leg fracture and multiple surgeries, I felt that God was going to take that bad thing and turn it into a good thing where I could use my tinkering gifts to help serve patients --- Hey Clinic has been, and will continue to be a great Living Learning Laboratory to keep working to make that an ever better reality for many patients to come.  I am humbled to see what God has done so far through so many awesome people I've had a chance to know and serve with.  

So for now it's time to go to bed, and get up and round at WakeMed and Duke Raleigh Hospital.  One of my patients actually traveled across the country for a revision scoliosis surgery, and got his wish for a straight spine after 7 years.  While we suggest to our out of state patients seeking scoliosis care to always consider the SRS.ORG website to find a scoliosis surgeon near them, some, like Jackie, and others still choose to make the trip to Hey Clinic.  If they do, we always strive to make it worth the trip by using our compassion, experience, and team-centered quality control processes to deliver the outcome and patient and family experience that brings a smile and lasting results for long-term quality of life, good posture and appearance, as well as curve correction and prevention.

Thanks to all of you who have helped Hey Clinic over these past years in so many ways, including prayer, encouragement, hard work, innovation, service, late nights, early mornings, some sweat… but many smiles and laughs along the way as well.  A big part of the Joy in the Journey is who we get to Journey with!  And you all are a great joy to all of us.

Lloyd A. Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery

Sunday, October 26, 2014

Can realignment of adolescent idiopathic scoliosis actually help prevent and/or reverse disc damage to lower lumbar discs?

For my last 19+ years of practice at both Duke Medical Center, and Hey Clinic, I have had a lot of experience caring caring for the full age spectrum of scoliosis, from 3yo congenital scoliosis, early onset scoliosis AIS, Scheuermann's kyphosis and adult deformity.   This "natural history" experience has given me long-range insight on how to counsel patients and families in the younger age groups, seeing well beyond what most pediatric orthopedic surgeon would see in their career caring for patients up through 18.

I am also always on the lookout for the latest research on the disc biology, biomechanics, and basic science as well as clinical studies that look at the issue of curve progression, disc degeneration as a function of spinal alignment, and facet arthritis causes for accelerated wear that we often see in scoliosis later in life.

Recently at our Scoliosis Research Society Meeting in Anchorage Alaska, Dr. LaFage gave a very nice podium presentation looking at 3D analysis of the lumbar disc MRI images before and after adolescent idiopathic scoliosis (AIS) surgery.  Doing special volumetric analysis, she was able to show that the lumbar discs below the main curve in adolescent idiopathic scoliosis showed some signs of dehydration prior to scoliosis surgery. This might suggest that there is some early damage being caused by the misalignment of the vertebral bodies above and below the disc, which can put excessive stress on the disc affecting the extracellular proteoglycan matrix, as well as the possible cartilage cells that maintain that matrix.  (My undergraduate thesis work at MIT in Bio-Electrical Engineering actually focused on cartilage biomechanics, and how to measure in the lab the affect of mechanical loading and natural electric fields on cartilage growth and regeneration... more on that another time)  What is really cool about Dr. Lafage's research is that she was able to show that over the 2 years after scoliosis surgery, the lumbar discs actually REHYDRATED after the surgical realignment of the spine above the discs.  This happened at ALL  lumbar levels when the pelvic incidence was low (most common in AIS), and in some levels with high pelvic incidence (PI).  This research suggests that the realignment was actually REVERSING the early damage to the lumbar discs, which would be our hope to allow those lower 2-4 lumbar discs to last the patient another 80+ years!  Dr. LaFage did show that the degree of the effect of the rehydration was affected by the underlying pelvic parameters, which have to do with how sloped the starting point of the lumbar spine is (Pelvic Incidence)  

This research is consistent with the natural history I've observed in many patients, who seem to do very well after AIS surgery with correction of not only their primary curve but the compensatory curves above and below which are not fused, but correct on their own in response to the correction of the primary curve(s).  These patients in most cases will maintain their lumbar disc height and have very little or any lumbar pain.  This is in contrast to the patients who never had their adolescent idiopathic curves fixed, who later in life can have not only progression of their primary curve, but also collapse of the lower lumbar discs, which were actually "normal" and outside of the scoliosis area to begin with.  These patients in some cases are in so much pain and/or have documented ongoing progressive deformity that surgery is needed to fix not only the primary curve, but now the worn out discs and facet joints in the lower lumbar area -- necessitating a larger surgery with fusion all the way down to the pelvis / iliac wings.  

While it is tough to considering having your child/adolescent have a major spine surgery as a healthy asymptomatic adult, it probably does make sense to seek out possible second opinions especially who can help you and your child, and spouse figure out what is best for the LONG run... the VERY LONG RUN -- the next 80+ years.  You only get one set of discs and facet joints, and decades of misalignment can definitely take a toll, just as a misaligned car can cause car tires to wear out well before the expected 80,000 miles.   

This issue of premature lumbar disc damage and destruction is especially and issue with the thoracolumbar curves, since they involve more misalignment of the lumbar discs.  The degree of trunk shift (asymmetric "hour glass") also has a major affect on the biomechanical loads on the lower lumbar discs, due to the increased "moment arm" of the axis of body weight which applies additional torque / stress on those lower lumbar discs.  So, it is good to take a wholistic view of the spinal alignment, not just looking at curve magnitudes but overall trunk balance, and as Dr. LaFage points out, other measurements like pelvic parameters which could affect stress on the lower discs and wear and tear.

Here is a video of Dr. LaFage's presentation with her wonderful French accent.  Enjoy!

Lloyd A. Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery

Sunday, October 19, 2014

Encouraging Word for the PreMeds: "Dr. Diet, Dr. Quiet, and Dr. Happy"

I've been reading a very good book called "God's Hotel" by Dr. Victoria Sweet that was suggested to me by Dr. Jeff Baker, a wonderful Duke Pediatrician, who is also a medical historian, with a PhD, no less.  Jeff had suggested this book as a good way to learn more about the the history of medicine, during the "pre-modern" era.

In the book, Dr. Sweet not only shares what she learned about healthcare in the mid-evil times, she shares about her experience practicing in the modern days, but working at an old almshouse in San Francisco called Laguna Honda.  If I could summarize her main findings it would be that perhaps we "threw out the baby with the bathwater" when we switched from Pre-Modern to modern medicine within the last 150 years.  She describes how modern medicine does not tell us much about the heart/soul of the patient which we can tell is gone when a patient dies, and they leave their body behind like some left over clothes.  She also talks about how Pre-modern medicine had a better feel for balance, and also for understanding the energy/spirit level of each patient -- something you can't quantify with an MRI or blood work, but you can sense it.

I was also struck by the common sense interventions that were always a part of Pre-Medicine treatment:  "Dr. Diet, Dr. Quiet and Dr. Happy"  :  Diet, Sleep, and happiness treatments.  Physicians used to give treatments for these things.  

It reminds me how important it is for all of us, even doctors, and pre-meds wanting to be doctors some day to listen to this advice as well:  Eat well, get enough sleep, and do things that nurture your heart and soul and grow it over time.  I've read several books on the importance of sleep, after being fed a lot of bad information during med school and residency about "sleep is for wimps"  -- it's not.  You need your sleep to learn, to serve and to not be miserable!!!  Get your sleep!!

Diet and exercise habits are also super important -- lessons I've learned a lot about personally in last 20 years.  The fuel you put into your car really matters -- if you put gas into a diesel car, like I did one day many years ago (sleep deprived!!), your car doesn't run real well!!

Exercise is key --  seek to get 30 minutes of exercise at least 5 days a week.  Try to do it in the morning since you are less likely to skip it.  You can combine this with daily encouraging devotional reading, so you are getting a 2 for 1!  This helps get your endorphins going which power you through the day.  It also helps with weight management as you get older.

This past week I did some special "Dr. Happy" margin time by taking off a few days to go to the mountains of North Carolina and just hang out watching the fall leaves, and the water run down 5 different water falls, and just feel the warmth of huge solid boulders below me.   I almost canceled the time because there is always so many patient things that come up, but I knew I needed the time to regenerate, and also to encourage my family.   Spending time outside in the beauty of God's creation is good for the soul, especially this fall.  Time with family was also very, very precious.  Lori and I really enjoyed hiking around the Cornell campus and down and around the gorges -- something we enjoyed together during our high pressure college Pre Med days.  I had been studying in the book of Psalms how God is our Rock and our Refuge in Psalm 18 ---

"The LORD is my rock, my fortress and my deliverer; my God is my rock, in whom I take refuge, my shield and the horn of my salvation, my stronghold."

Actually climbing between a couple of big rocks, and sitting on a big rock for quite a while did give comfort --- I could imagine the comfort it would be to be able to wedge myself in between 2 big rocks in a storm.  Rocks and Fortresses are like the earth's magnetic field -- so constant, and we can always count on them.  We need these external references to keep us on track, and to keep us safe, and solid, away from the high anxiety of feeling all alone.

Combining special verses that I have been meditating on, with real world experiences out in the beauty of nature is really good for the soul.  Pre-Modern Medicine knew this.  We all know this somehow on the inside.

So, if you are a stressed out pre-med out there, or stressed out surgical intern, here is your prescription from Dr. Hey, standing in for Dr. Happy:  Take a half hour off sometime this week, lie down on a warm rock somewhere, or maybe a leaf covered lawn, and look up at the sky and the trees, take several clearing breaths, listen to the birds.... and remind yourself how wonderful it is to be alive, and enjoy this beautiful world!

Then go encourage another student to join you next time.

Now, for me, it is time for "Dr. Quiet" to get some sleep before 2 very important surgeries for 2 very  precious people: one adult, and one child.  

Have a good week!

Lloyd A. Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery

Monday, October 13, 2014

Does scoliosis surgery really help quality of life? Weaving together daily experiences with patients and families with Joy in the Journey.

Wow, we had a HUGE amount of interest in my blog last night.  I just got home from surgery and a hospital meeting and only have a few minutes to share before I have to get to bed for big surgeries tomorrow.  Whew I am tired, but it has been a great day!

My hope in the weeks to come is to weave together my ongoing wonderful experiences I am having with patients and families together with my excerpts of my talk I gave at Cornell University recently, where I shared about "Finding and Maintaining your Joy and Idealism through your medical career journey" with the Phi Delta Epsilon Society for pre-meds.

One of the big take home messages you will likely learn, as I have, is there is MUCH we can learn from out patients and families to grow our own hearts and souls, and to both experience and grow in compassion and faith.

Today I did a big scoliosis surgery, and also did a second opinion for a lady in her 20's who had scoliosis surgery done a few years ago, and now had broken rods, and collapsing posture, and back pain.  I made some room in my schedule for her early morning today, and showed her how kyphosis was a big part of her deformity -- 78 degrees  -- in addition to the scoliosis and broken rods.  We're going to get a CT scan done, to look for pseudarthrosis, but given her spinal collapse and pain, she could likely benefit from a revision surgery, restoring her posture, correcting both the kyphosis and scoliosis and replacing the broken hardware with a stronger construct and new fusion.  There is hope!

I also saw one of my patients from Florida who is 2 weeks postop after having a proximal junctional kyphosis fixed due to her osteoporosis at the thoracolumbar junction.  Her posture now is beautiful and she is walking so much better and standing up straight with much less pain already. She is heading back to Boynton Beach, FL after short stay in rehab here in Raleigh, NC.  

Here are a few patient stories from this past week which should be an encouragement.

Sandy shares a special piece of artwork she did for me recently, which in part touches again on the fact that modern medicine and faith can work together.

More to come.
Have a good night!
Lloyd A. Hey, MD MS