Friday, December 21, 2007

Andrea comes back for postop kyphosis visit, and shares her kyphoscoliosis English Project

Andrea and her mom were back for postoperative follow-up for her kyphosis correction I performed for her.
She has had other Blog entries earlier this year, with her dramatic change in posture, as well as quality of life as a teen-ager.

She actually did a several month project for an English class that included a “shadowing” program with Jaclyn, one of my physician assistants.
Today in clinic she showed us her final project, and told us about her 6 minute Power Point presentation on kyphosis and scoliosis.
She actually had to present her whole project, including a kyphosis and scoliosis educational brochure to a team of judges.
Andrea proudly shared that she got a perfect “100” on her project.

Over the years I have had several adolescent scoliosis and kyphosis patients do science and other projects with me and my staff.
We have also had many former patients and family members participate in our “shadowing” program, some of whom have already made it clear they want to work at Hey Clinic when they grow up and be a physician assistant or physician, or physical therapist, or radiographic technologist.

Strong work, Andrea!!
Andrea wants to be a school teacher when she grows up.
I can see already that she is developing the right skill set to be a very effective teacher!

Take care Andrea, and have a wonderful Christmas.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

30 yo woman with severe kyphoscoliosis. Hypo-kyphosis, Hyper-kyphosis.

I had seen this 30 yo woman years ago at Duke, and had recommended surgery, since she had documented progressive scoliosis, and had increasing pain.
However, at that time she was not ready for surgery.
Since then, she has had another child, her third, and her pain has gotten worse as well as her posture.
She has an unusual curve pattern with a severe R thoracic scoliosis, but also severe kyphosis as well.

She now has to take Methadone once a day due to the pain, and is still working, with some difficulty as a waitress.
She is now ready for surgery, and wants it fixed now before it gets any bigger, and also correctly pointed out that it is safer and you get a better correction with an easier recovery if the kyphoscoliosis is fixed when you are younger.
As you get older, the curves tend to get stiffer which makes the correction more difficult, with less possible final correction.

This case points out the importance of looking at the whole 3-dimensional deformity for every patient.  This woman’s thoracic kyphosis needs to be addressed as well as the scoliosis which is very apparent on the AP view.  However, most patients with thoracic scoliosis are actually hypo-kyphotic, rather than hyper-kyphotic.  Yesterday, for example, I saw an 11 yo boy who had 40 degree scoliosis, who had severe hyphokyphosis of his thoracic spine to the point where his thoracic spine was actually sunken in, or lordotic.  These severe hypo-kyphotic scoliosis spines result in severe changes in lung volume, since the anterior-posterior (AP) diameter of the chest cavity is severely diminished.

During my almost 13 years caring for children, adolescents, and adults with scoliosis, I have seen several young adult patients who had documented progressive curves who ended up declining surgery for a variety of reasons.  Several of these patients have then returned a few years later, like this patient, now ready for surgery.  Some of these patients actually worried when they came back that I would be “mad” at them for not taking their advice years before.  I always reassure them that I would never be upset or mad with them if they opt to not have surgery.   I am not the “boss” -- they are the boss.  I am just here to serve them in any way I can.

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

Heather, 12 yo scoliosis patient comes back for follow-up at Hey Clinic doing great. Inpatient Scoliosis Update.

Heather had her scoliosis surgery back on August 20th this year.
She's 12 years old, and had a severe double curve.
Postoperatively, she did just great, and was able to start school 2 weeks after her surgery.
Her posture is now excellent, and she is not having any significant pain, and is back to all of her activities, doing well in school.
She hasn’t decided for sure what she is going to be when she grows up.
I told her I’d give her another year to decide.
Heather expressed some interest in seeing some of our surgical videos.  I have to do some searching around this Christmas break to see if I can find some of her footage from her surgery this August.

Some of my teen-age patients especially enjoy having some of their surgery filmed.  Some have even created their own life story before, during and after scoliosis/kyphosis surgery.  One of my patients named Michelle did an amazing job on such a video.  She actually narrated her whole scoliosis story, including introducing her whole family on camera in the preoperative area, with a huge smile on her face, explaining why she was excited about getting her curve fixed.  The final scene in her movie was about 6 months later at the pool in the summertime, as she dove into the pool with a bikini suit, and talked about her new posture and its effect on her life.

Years ago when I was still on faculty at “Big Duke”, Duke Medical Center, I was filmed for the Discovery Channel performing a double scoliosis surgery for a young woman with a severe curve.  That was QUITE an experience, to be shared another time.

Now we use video, including a special camera mounted in a sterile light handle to broadcast the view over the surgical field so the rest of the operating room can see, along with nursing and pre-med, physical therapy, and other students and orientees who can watch the surgery at a safe distance from the sterile field on a big screen HD monitor.

Just so our blog readers do not get confused:  There are 2 recent Hey Clinic adolescent scoliosis patients who are on the Blog named “Heather” -- both with large double curves.  The Heather who had her surgery in August is 12 years old, and the Heather who had surgery this week is 17.  The dad of the 17 yo “Heather Scoli” dropped into clinic today to drop off some wonderful cookies to our staff, and got a chance to meet the 12 you “Heather Scoli” and her mom who was there at the same time.

On another note, our scoliosis surgery patient “Chelsea” from Wednesday this week went home to Wilmington NC this afternoon doing well.  She went home around 50 hours after surgery, walking and eating well, and did well in the “Home Bound” Room today, where she practiced climbing stairs and getting in and out of a test automobile.  We never rush our patients out of the hospital, which is a real blessing, but it is amazing how quickly our adolescent and young adult scoliosis and kyphosis patients are up and around, and wanting to go home.

Our 17 yo “Heather” who had her double curve scoliosis fixed yesterday did very well with physical and occupational therapy today as well, and will go home tomorrow or Sunday when she is ready.

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

Hey Clinic Team Photo with Santa

Today was the last day of clinic at Hey Clinic for 2007, and there was much Christmas cheer at Hey Clinic.
Someone brought in red Christmas hats in for everyone in our clinic, including me, Dr. Hey.
I initially declined the opportunity to wear the red hat.  I don’t think I have ever worn a red Santa hat before, actually.
However, I eventually caved into peer pressure, and while standing out in our “Family Room” where our guests gather, I put on my red had while fixing myself a cup of coffee.
As soon as the hat touched my head, magic happened...
Much to my surprise, within 2 seconds of my donning of the great Christmas hat I heard a very loud “HO HO HO!!!”  and in walks a very jolly Santa Claus with 3 helper elves, spreading much good cheer and candy canes.
There seemed to be a very direct cause-effect with the Christmas hat and Santa appearing.
Santa then posed for a picture with our whole Hey Clinic Team, including our newest team member Janara!

2007 has been a blessed third year as Hey Clinic.
I shared with our whole Hey Clinic team how thankful I am for all of them, and how important it is that we all work together synergistically to best serve the patients and their families from all over the country.  We have learned a lot this year, and have made a lot of improvements, and look forward to a wonderful 2008.

Many thanks to Craig and Will from Synthes who brought us lunch today, and are always faithful providing the necessary equipment in the operating room.
Thanks also to all of the caring nurses, therapists, administrators, scrub techs, nursing assistants, secretaries, case managers at Duke Raleigh Hospital and WakeMed Hospital who serve our pediatric, adolescent and adult patients with compassion and skill.

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

Thursday, December 20, 2007

What is it like to talk to the doctor right after your daughter has scoliosis surgery?

Today, Katie, our “pre-Med” intern, who is shadowing me this week, caught a glimpse of what it was like for Heather’s parents to talk to Dr. Hey immediately after Heather’s scoliosis surgery today.
After several years of scoliosis tracking, then bracing, then awaiting surgery — how will Heather’s parents respond when they see the new X-Ray taken after her scoliosis is corrected?
It is so precious to be a part of special moments like this.

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

Heather's Scoliosis Surgery December 20 2007 with Dr. Lloyd Hey

Heather got here early this morning to Duke Raleigh Hospital, with her whole family for her scoliosis surgery.
Heather is 17, and was treated in a night brace for a year and a half, but her double curve scoliosis continued to progress.
Her surgery today went very well.
Her fusion is from T4-L3.
Correction was over 90%.
Estimated Blood Loss:  650 cc.
Cell Saver recycled to patient:  250 cc.
Blood transfused:  None.
Surgical time:  0936-1259:  3 hours, 23 minutes.
Complications: None.
Evoked Sensory and Motor Testing: Normal.
Postop Check:  Doing well, in large Ortho Spine Room, with family with her, sleeping comfortably 5pm.

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

Wednesday, December 19, 2007

14 yo Chelsea has her scoliosis surgery today with Dr. Hey, Hey Clinic

We fixed Chelsea’s right thoracic scoliosis this morning, after taking a bunch of pictures of Chelsea with her family, and many members of our scoliosis team, including Ruth, who does a great job with our evoked potential monitoring.
Her surgery took just under 3 hours, and the estimated blood loss (EBL) was 600 cc, with no blood transfusion necessary.
Her evoked potential motor and sensory monitoring was normal throughout, and we obtained a very nice correction.
She is doing well up on the Duke Raleigh Hospital Orthopaedic/Spine unit, with her family staying with her in the large private room with 2 full beds and pull out chair.
The picture on the right shows Chelsea just a few hours after surgey with her family in her room.
She will be getting up and around tomorrow, and probably home Friday or Saturday.

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

Layla, 14 yo girl goes home from hospital today, postop day #2 after scoliosis surgery with Dr. Hey, Hey Clinic

Layla had her scoliosis surgery Monday this week, and got up quickly with physical therapy yesterday, and met all of her goals to go home today!
She got her height checked today by the physical therapist, and she is now almost 2 inches taller (1.75 inches).
Her posture looks wonderful, and her postoperative X-Ray show an excellent correction of her double curve.
Her parents stayed with her in the large private room that has 2 full-size beds.
You look great, Layla!

Have a great Christmas!

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

Tuesday, December 18, 2007

2 14 yo girls having scoliosis surgery 50 years (and 1 day!) apart. Exploring 50 yo time capsule of non-instrumented fusion.

Yesterday I operated on a lovely young lady who had a 50 degree thoracolumbar scoliosis with severe imbalance.
Today I did a complex spinal reconstruction on a 64 yo woman, who had a non-instrumented spinal fusion done 50 years ago, when she was 14, and now had severe collapse with an almost 90 degree kyphoscoliosis
The story these 2 women will be able to share later this week of their differing experiences would make good reading:
The patient who had scoliosis surgery 50 years ago spent a year or so in the hospital in traction, and in body casts.
Over the past 50 years, she continued to “shrink” in height, since the lower half of her fusion never quite healed.
She developed increasing back pain and leg pain, and trouble standing and walking.
Today, instead of a simple 3 hour surgery, which led to a near-perfect correction of the spinal curve in the adolescent young lady yesterday, I reconstructed the 64 you woman with a 7 hour and 45 minute anterior/posterior spinal reconstruction, and 5 level laminectomy and osteotomy.
Both patients did very well with surgery, but the 14 yo who had her original scoliosis surgery yesterday will have a much quicker recovery, going home tomorrow or Thursday, and a better long-term outcome with a solid fusion, and well-balanced solid instrumented fusion.

A lot has changed for the better in scoliosis surgery in the past 50 years, thanks to the efforts and innovation and research of many caring scoliosis physicians, many of whom have been involved with the Scoliosis Research Society (SRS) over the years, including my scoliosis mentor Dr. John Hall, from Children’s Hospital, Boston, and Dr. John Emans, also from Children’s Hospital.

The innovation and learning, however, is far from over.  Even in today’s surgery, I used some new innovations with stronger titanium alloy rods, and special buttressing techniques at the bottom of the construct which help to improve the correction, while decreasing chances for rod breakage and screw loosening.  The “upward spiral” of improving scoliosis care is never-ending.

I really do enjoy taking care of the full spectrum of scoliosis and kyphosis patients — from the  youngest toddlers, through the teen-ager and young adult, through the older adult.  Each group has it’s own challenges and rewards.

On evening rounds after my long day reconstructing Catherine’s very crooked spine today, I saw Layla, the 14 yo girl who had her surgery just yesterday with her dad.  She was eating, and resting comfortably, and had been up walking  a couple of times today with minimal assistance, and no back brace.

I wondered what it would be like to go in a time machine, back 50 yrs ago to Catherine’s first postop night, when she was 14.  How long did her surgery take?  When did they put her in the cast?  Why were parents only allowed to visit so infrequently, like once a week?  What did kids do on those long days and weeks and months in the hospital?  Were the cast changes painful?  What was it like to wear a cast for several weeks or months without a shower?  Over the years I have enjoyed talking to my scoliosis patients who had surgery done 20, 30, 40, 50 and even 60 years ago, and see how they described their experiences, through the eyes of the child.  

In surgery today, I felt like I got a glimpse of that time machine, through the “time capsule” that I got a chance to see looking at her old spinal fusion that was done 50 years ago.  The upper part of her thoracic spine had healed quite solidly, but was still very twisted and deformed. The lower portion of her curve never healed, and over the decades had collapsed into a very twisted and deformed spiral, crushing many of her spinal nerves in the process.  Her apex of the curve at the thoracolumbar junction was rotated almost 90 degrees, with severe kyphosis as well.  Her curve, now stiff with the years barely budged, compared to the fully flexible 14 yo Layla’s curve yesterday.

These two scoliosis ladies may end up meeting up on the Ortho/Spine Unit tomorrow or Thursday when we have our end of year “Thank You” lunch for the staff.
Layla’s goal is to go back to school in a couple weeks, and get back to all her activities almost right away.
Catherine will get back to her walking, and plans to ride on the back of her friend Tom’s motorcycle this spring!

One thing is for sure:  It is much better to fix scoliosis curves when people are younger and more flexible, and have more years to enjoy the improved posture and self-image.
Surgery is certainly far more effective now than it was years ago, and will continue to improve as we try to continually perfect the surgical techniques, hardware, biologic materials, and the process of care.

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

Monday, December 17, 2007

Hey Clinic Dec 17 07 AM Surgery: "LW", 14 yo with severe scoliosis with R trunk shift. T5-L4 Instrumentation and Fusion with before and after photos.

This morning we helped "LW", who is a delightful 14 yo girl with a 50 degree
thoracolumbar scoliosis with severe trunk shift.
Her surgery went from T5 down to L4 with thoracic and lumbar pedicle
Her surgical time was exactly 180 minutes (3 hours)
Estimated Blood Loss (EBL): 1100 cc
Cell Saver recycled: 650 cc
Evoked Potenial: Normal sensory and motor throughout
Correction of curve: 90+% (see photos above)
Postop location: PACU, then private room on spine/orthopaedic unit with two
beds in each room, so parents may stay with her.
Parents feelings right after surgery: big relief! Wonderful correction.

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

Sunday, December 9, 2007

7 yo boy with 60 degree scoliosis, clubfoot, and great desire to use digital cameras

On Friday, I saw a delightful boy originally from India who is the adopted child of a wonderful family from Durham, NC.
He has a 60 degree scoliosis, which has remained stable since last visit.
We are hoping that he can gain some additional weight and size before having to fix the scoliosis.
In the meantime, we are trying to arrange for additional treatment for his severe clubfoot on R.

This young boy LOVES to shoot pictures with digital cameras, and also likes to play with spinal instrumentation.
Perhaps he too will be a scoliosis surgeon some day, and have a successful Blog?

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

Happy HEY CLINIC Anniversary for Anterior/Posterior Reconstruction for Physical Therapist!

I saw my good friend and retired physical therapist Janet back in clinic this past Friday.
A year or so ago, I performed a  3 level anterior instrumentation, followed by posterior multilevel decompression, osteotomies and instrumentation for her.

She had suffered for MANY years with her back, and was petrified of surgery.  Petrified.  Scared to Death.  Absolutely No Way Petrified.  Petrified in part from what she had seen over the years working as a physical therapist.
However, her back eventually got to the point where pain medications, and exercise and braces, and everything else just didn’t help, and her quality of life became unbearable.
She had severe flat back syndrome, with multi level spondylolisthesis and spinal stenosis and degenerative scoliosis.

She is now doing just great, and came in with a real big smile with her wonderful red Christmas sweater.
What a blessing to see you back, doing so well, Janet!!

On the same day I saw Janet, I saw one of my Duke physician patients for a postop visit as well, who is also doing great after revision scoliosis surgery.  I have had the privilege to take care of many healthcare professionals over the years, including physicians, nurses, physical therapists, chiropracters, dentists, and others.  I have also taken care of the CHILDREN of many physicians and nurses, including some of the adolescent scoliosis patients who come from out of state.

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

Happy 1 year Anniversary for 2 level ACDF: Anterior Cervical Discectomy and Fusion

On Friday we saw a bunch of 1 year follow-ups.
One of them was this gentleman, now 1 year status post a 2 level C56 C67 ACDF.
He is doing great, still with complete relief of his arm pain.
He has full motor strength, and sensation.
He has returned to a very active lifestyle, including golf.

We do a lot of big scoliosis and kyphosis surgeries, and revision surgeries @ Hey Clinic.
However, we do help others with simpler problems, such as neck or low back disc herniations.

We also treat almost 80 percent of our new patients successfully with conservative therapy, including many adolescent patients who are sent to us from local pediatricians or family practitioners.

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

Hey Clinic Surgery Dec 4 2007: 38 yo woman with severe back pain sp prev scoliosis fusion now

On December 4th, I performed an anterior/posterior reconstruction for a 38 yo young lady from the coast of North Carolina.
She had previous scoliosis surgery in 2004, but developed increasing low back pain.
She does have a history of smoking, which can contribute to disc degeneration.

I performed an anterior removal of her lower 2 remaining discs at L45 and L5S1, and replaced them with titanium anterior lumbar interbody fusion (ALIF) Synthes cages packed with bone graft.
After completing the anterior procedure, she was turned prone, and I extended her fusion down to the sacrum and ilium with titanium hardware.
I also performed posterior osteotomies at L4 and L5, which allowed me to create greater lumbar lordosis when combined with the anterior cages “strutting up” the front portion of the spine.
I actually used the operating room table in a special way to enhance the lumbar lordosis during rod placement.
Total surgical time was 6 hours.
She did not need to go to ICU, but to our spine/orthopaedic unit which allows family members to sleep in same room on a real bed!

Postoperatively, she did just great, with better standing posture, and good relief of her previous discogenic pain L45 and L5S1.
One of the things the patient had noticed when her 2 lower discs settled over the past 3 years, is that she lost her normal lower back and buttock shape.
You can see on her preop standing lateral X-ray where I put the 3 red arrows that her skin line is relatively straight down across the lower lumbar area and buttock.
Postoperatively, you can see clinical photo which shows a normal-appearing lower back and buttock contour — the flat back is is gone!!

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

Hey Clinic Dec 3 2007 Surgery: 38 yo woman from Alabama sp scoliosis surgery in FL and previous SI joint fusion with persistent low back and R hip/leg pain now for Revision Scoliosis Surgery

This 38 yo woman named Rebecca had a minimally invasive scoliosis surgery in Florida, and a sacro-iliac fusion done elsewhere presented to Hey Clinic with persistent low back and R hip and leg pain.
Her pain has actually been progressive, and did not improve either with the first scoliosis fusion L2-L4, nor with the SI joint fusion, even though the SI joint injection appeared to help.
Her X-Rays at Hey Clinic revealed a severe asymmetric disc collapse at L45 below her previous scoliosis fusion, and her SI joint instrumentation on the R.

On December 3rd, I removed her existing posterior spinal and SI joint hardware, and placed new TLIF transforaminal interbody spacers in L45 and L5S1, and then extended her fusion down to sacrum and ilium.
An excellent correction of the deformity was obtained.
Surgical time was approximaely 4.5 hours.
When I showed the intra-operative X-rays to the patient’s young daughter and her husband, her young daughter yelled out:  “WOW, THAT’S STRAIGHT!!!”.  I think she has the motivation to be a future excellent scoliosis surgeon!

Postoperatively, Rebecca did just great, with excellent relief of her preoperative back and “SI Joint” and leg pain.
She was actually only in the hospital for a couple nights, and then made the long trip back to Alabama, with a one night stay in Georgia on the way home.

There are several good things that can be learned from this case:
  1. It is often very difficult to localize the source of pain in lumbo-sacral, SI Joint area.  Referred pain often occurs from lower lumbar area that causes pain down across SI joint and buttock and even posterior thigh area.
  2. Minimally Invasive scoliosis surgery has not proven to have better long-term outcomes over midline incision. “Minimally Invasive” fusions for scoliosis usually involve 2 scars approximately 2-4 inches off the midline, which may in fact be cosmetically less appealling than one central incision.  It is more important to ensure that all of the proper levels are fused than to use “minimally invasive” techniques.
  3. The SI joint is frequently blamed as a pain generator, and sometimes is even blamed for being “unstable” or “subluxating”.  However, the SI joint is actually an incredibly strong joint, with a strong fibrous union over approximately 2/3 of it’s surface area.  In my experience, the only patients I have seen with significant SI joint subluxation have been in extremely severe motor vehicle crashes.  I have seen one patient in past 15 years who required SI joint fusion for degenerative changes below long scoliosis fusion in a woman with a long history of spastic diplegia.

Take care, Rebecca and family, and have a very Merry Christmas with your family in Alabama!

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

Hey Clinic Nov 20 2007 Surgery: Preop/Postop Clinical Photos and X-Rays for anterior/posterior revision kyphoscoliosis surgery for woman with prior Harrington Rod Fusion

A couple week’s back I briefly described a complex anterior/posterior reconstruction we did for a very nice 54 yo woman from Florida (near Tampa).
This young lady had a Harrington Rod instrumentation and fusion done many years ago, and over the past 10+ years has developed progressive severe back pain, and trouble with increasing kyphotic posture.  
When you look at her preoperative clinical photograph, you can see that she stands with a typical “flat back” stance, with knees slightly flexed, but still is bent forward when you compare her torso to doorframe behind her.  In addition, she has significant kyphosis above her previous fusion in thoracic spine area which is quite evident in preoperative photo, and X-Rays.  In short, she has collapsed into kyphosis both above, and below her previous Harrington Rod fusion, and now also has spinal stenosis below her old fusion.  Due to the severe progressive pain, she was on a significant amount of oral narcotic medication, which was becoming less and less effective.
To fix these problems, I started off anterior, removing L45 and L5S1 discs, and “jacking up” the anterior disc spaces with ALIF titanium cages and bone graft.
I then turned her over, after closing the anterior incision, and removed the Harrington rods.
I then did multiple posterior osteotomies in the thoracic and lumbar area, to allow for better correction of deformity, and then instrumented her spine from T3 all the way down to the sacrum and ilium with titanium alloy pedicle screw instrumentation and bone graft.
Her total surgical time was a little over 8 hrs for both the anterior and posterior combined procedures.
Postoperatively, she did very well, with both her and her family noticing her improved posture right away.  She is also quite a bit taller, and can walk better due to better balance.
She went home to Florida about a week after surgery, and is doing well at home.

Her pre and postop X-Rays shown above show the marked imrovement in her “sagital balance”, or in layman’s terms, her balance from the side view.  She is no longer pitched forward with flatback, and thoracic kyphosis.  Her thoracic kyphosis is now normal, and her overall body shape is markedly improved.  One way we measure the degree of sagital balance is by dropping a “plumb line” vertically from C7, and seeing where this line ends up relative to the L5S1 disc space.  In a balanced person, C7 should sit over the top of the L5S1 disc space.  I represent that plumb line with the red vertical liine.  On the preoperative Xray, C7 sits over 12 cm in front of the L5S1 disc space.  Postoperatively, the C7 sits normally over L5S1 disc.

When people are out of balance anteriorly, with “flat back syndrome” or significant kyphosis, it is very tiring and often painful.  The pain, in part, is due to extreme muscle fatigue as the paraspinal and other muscles struggle to hold up the “Leaning Tower of Pisa” of the tilted torso.  Many people find it hard to walk more than very short distances, since they often have to walk with their knees very slightly bent, which takes a huge amount of energy.  Kyphosis and “Flat Back Syndrome” also greatly affects self-image and appearance in several ways:  1) Forward-tilting posture, 2) loss of normal lower lumbar/buttock contour (“no buttock syndrome”), and 3)  pronounced thoracic “hump” in patients like this woman who have thoracic as well as lumbar kyphosis.

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

Hey Clinic Surgery Nov 29 2007: 14 yo young man with R thoracic idiopathic scoliosis 56 degrees

A couple weeks ago we helped a nice young man who had a 55 degree scoliosis when initially diagnosed with scoliosis.  He is a very muscular, athletic young man, which in part hid some of his curve, but does emphasize again the importance of scoliosis screenings.  Parents and children/adolescents are often a bit upset when they are surprised with a big curve on initial evaluation that needs surgery.
This young gentleman did just great.
His surgical time was 3 hrs 15 minutes.
No blood transfusions, cell saver only.
Was able to stay on regular scoliosis/orthopedic floor with his parents the first and second night without ICU stay.
Went home after 2 nights in the hospital.
His curve was stiff, but we were still able to get good correction.
He will be going back to school soon.
He showered when he got home from hospital.

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

Hey Clinic Surgery Nov 10 2007: 48 yo woman with painful collapsing 64 degree kyphoscoliosis, reconstructed T3-Iliac Wing Instrumentation and fusion with osteotomies.

It has been a busy few weeks @ Hey Clinic, and I am a bit behind on the Blog...sorry for the delay for our many loyal readers!
Here are some preop/postop pictures for a nice young lady named Debbie from North Carolina who had a very painful, and noticable collapsing kyphoscoliosis.
We were fortunate to get an excellent correction, through a posterior-only approach, using multi-level osteotomies to help get a better correction in both the front and side “planes”.
She did very well postoperatively, and is now quite a bit taller.  She had a little trouble with postoperative ilius, which is when the intestines stop their normal peristalsis due to swelling, pain medication, lack of movement, and lumbar surgery.  Eventually her intestines “woke up”, and she was advanced on her diet and went home very happy, with a whole new posture.
You can help prevent or decrease the duration of ilius by giving yourself a good bowel cleanout prior to surgery, and try to minimize use of narcotics, and ambulate as much as possible after surgery.

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

Wednesday, November 21, 2007

Hey Clinic Surgery Nov 21: 54 yo woman sp Harrington Rod fusion years ago with kyphosis above and below fusion with stenosis: Anterior/Posterior Reconstruction with Osteotomies

Yesterday we performed a complex anterior L45, L5S1 cage instrumentation and fusion followed immediately by posterior T3-Iliac wing instrumentation and fusion with multilevel posterior thoracic osteotomies, lumbar osteotomies, lumbar laminectomies, and removal of old Harrington Rods for this 54 yo woman from Florida who had severe deformity, and sever pain, on high dose morphine preoperatively.
Her surgery went very well, taking approximately 8.5 hours in total.
She was up walking today in ICU, and was extubated this morning.
The photos above show her preop and intraoperative X Rays and clinical photos, which show marked improvement in her kyphosis.
I have rotated her photo of her posture at the end of surgery so that you can see the change in her posture from preop.
She will likely head home Sat/Sun after Thanksgiving from Duke Raleigh Hospital.

Lloyd A Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC USA

Sunday, November 18, 2007

39 yo gentleman with long history of thoracic kyphosis with corrective surgery last week with Hey Clinic

This past week we helped a 39 yo athletic gentleman from Oklahoma who had long history of back pain related to an abnormally large thoracic kyphosis.  I have followed this patient for many years now, and his symptoms of pain have worsened over the past few years, although his thoracic curve has remained fairly stable around 61 degrees or so.

Over the years, he has experienced pain in thoracic region, as well as in the neck and lower back region that has inhibited his quality of life.  It has also affected his self-image, and has concerns about future possible progression since he has had older family members who have had significant kyphotic deformity.

This past week, we performed a T1-L1 posterior instrumentation and fusion with instrumentation, and were able to get a significant correction of his kyphosis.

In the series of pictures above, you can see his kyphosis on the OR table at the start of surgery.  Even when he is lying down prone, his kyphosis is quite noticable.
The second picture shows the two titanium rods inserted at top of the spine, which are then gradually brought down one section at a time to do a gradual reduction of the kyphosis.
The final picture shows the posture after the rods are inserted with improvement in the overall contour.

This had a dramatic effect on his appearance when standing.

He and his wifee are flying back to Oklahoma tomorrow with a whole new posture, about an inch taller!

As we have discussed in other Blogs, an abnormally large thoracic kyphosis can cause pain over the thoracic area, as well as in the lumbar area and the cervical area that need to go into hyper-lordosis to “compensate” for the thoracic kyphosis, which can cause pain.

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

Jaclyn gives a short talk on adult scoliosis curve progression and pain with patient at Hey Clinic

We spend a lot of time at Hey Clinic listening to patients, examining, reviewing images, and teaching and learning with our patients and their families.
This past week, Jaclyn, one of our Hey Clinic physician assistants took some time with one of our younger adult scoliosis patients to explain how adult scoliosis can progress later in life, and in some cases exponentially increase in curve size and symptoms (pain, trouble standing and walking, and posture/appearance).

I think you will enjoy this brief video.

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

"A Stitch In Time Saves 9": Why adult as well as adolescent patients should be followed regularly for evidence of scoliosis and kyphosis progression

This past week, as always,  we saw several younger and older adult patients with scoliosis, as well as adolescents and younger children with scoliosis.
There were a couple of adult patients, however, that were quite memorable.
This patient pictured above had a Harrington Rod fusion done many years ago, and did very well until about 10 years ago when she had some increasing pain.
Over past 4-5 years, she has noticed some changes in her posture, with the most significant change being during past year or 2.
She was not followed routinely for her scoliosis and kyphosis.
She then saught several opinions, who told her that she was not treatable, and put her in a molded brace only.
Her posture continues to fall over the right side, and forward into kyphosis, and her walking ability and pain continue to worsen.

You can see the dramatic change in her X-Rays over just a 5 year period.

LESSON #1: Adult scoliosis curves can be very stable over many years, or progress very slowly, but due to ongoing wear and tear on the discs and facet joints with the asymmetric loading of the curves, the spine can develop segments that become unstable, and begin to collapse and loosen, allowing the curves and slippages (spondylolisthesis) to progress, sometimes dramatically.

LESSON #2: All adults, as well as children and adolescents require follow-up examinations and X-Rays on a regular basis, even if the scoliosis has been “fixed”, as in this case, since the levels above and/or below the fused/instrumented levels can collapse.

LESSON #3: Once progression of the adult curve has been documented, it is better to fix the curves early with surgery, rather than waiting until later.  As you can tell from this woman’s standing posture and current X-Ray, her scolioisis will be difficult to fix, requiring pedicle subtraction osteotomies, cages, and multilevel instrumentation with some removal of her old hardware. Adult scoliosis surgery is always easier when caught earlier since:
  1. Curves are smaller.
  2. Patients are less debilitated, so they recover quicker.
  3. Medically their hearts and lungs are younger, and more able to handle big surgeries.
  4. Patients suffer for fewer months, and are able to get back to decent quality of life.
  5. Patients also have longer to enjoy their new posture and self image / appearance
  6. Bone quality is better with less osteoporosis which allows hardware to hold better to bone, and also decreases chances of fractures at adjacent vertebral levels.
  7. Bones/Fusions tend to heal better.

LESSON #4: If your orthopaedic or neurosurgical spine surgeon tell you that your scoliosis and/or kyphosis is “NOT FIXABLE”, do further research and get second and third opinions from surgeons that have significant experience in adult spinal deformity.  The Scoliosis Research Society (SRS) website is a good place to look here.  You can also ask your local doctors and search the web for your regional scoliosis centers.   I have seen many patients like this one above who have had their treatment delayed because they were told that “NOTHING COULD BE DONE,” which then causes problems with Lesson #3 above.

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

Tuesday, November 13, 2007

78 degree scoliosis surgical correction in 60 yo nurse practioner: Hey Clinic Surgery Nov 13 2007. Jac's 2nd Anniversary w/ Hey Clinic

Today we helped a 60 yo nurse with severe progressive thoracolumbar scoliosis which has increased to 78 degrees recently with severe pain.
Procedure:  T4-Iliac wing instrumentation and fusion with L1-5 laminectomy, L3 L4 osteotomies, L5S1 TLIF.
Her surgery took approximately 6 hours skin to skin.
Bone quality: excellent.
Estimated Blood loss 1800 cc
Cell Saver 800 cc
Blood Transfused: None.
Complications: None.
Correction: approx 75 percent with excellent lumbar lordosis
Postop Location: ICU, extubated in operating room prior to transfer to PACU.
Postop Check: doing well, full motor and sensory, with minimal drain output and good pain control.
Will be up standing and walking tomorrow.

This curve would have been easier to fix when it was a little smaller and she was a bit younger, but with the osteotomies, and some patience with the rod contouring, etc we were able to get a well-balanced result with good curve correction.

We had our awesome OR team with us today in our laminar flow Room 12, including PA Jaclyn, celebrating her second anniversary with us at Hey Clinic tomorrow, Nov 14.  Congratulations Jaclyn!  Many thanks to rest of our wonderful OR team, including Scrub Sandra, Scrub Sheila, Scrub Rob, Nurse Kelly, Cell Saver Tech Tamika and many others.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC USA

Zachary goes home, sitting up straight!

Zachary is a 9 yo boy who had surgery six days ago at WakeMed in Raleigh NC for severe kyphosis, secondary to brain injury due to “shaken baby syndrome”.  He actually sustained a couple of thoracic fractures at that time, and with his severe brain injury, has gradually slumped forward into severe kyphosis with growth.  His thoracic kyphosis was around 90 degrees preop.
Last Wednesday, I performed a T1-L3 Instrumentation and fusion with multiple osteotomies.
He did well with surgery, and did very well up on the WakeMed PICU for one night, and a few nights on the regular pediatric floor.
Zachary’s new posture is quite evident, and even meant that Zach needed to get used to swallowing his own saliva, which used to just run out of the front of his mouth, since his head hung down so low.
He definitely sits up much better in his chair as well.
We delayed his discharge back to the children’s rehab where he lives a bit since they were having a bit of a flu epidemic.
Thanks to all the caring nurses and doctors and others who helped Zachary this past week!

Dr. Lloyd Hey

Saturday, November 10, 2007

Sylvia, who suffered with severe kyphoscoliosis shares her story and pictures after recent reconstructive surgery with Dr. Hey

We saw Sylvia from New Bern NC at Hey Clinic on Friday, who was looking great after her recent kyphoscoliosis surgery. She shares her story in this short video clip from clinic, along with photos of herself before surgery.

You look great Sylvia!
Dr. Lloyd Hey

Tracy's Talk On Compassion @ Hey Clinic Weekly Quality Meeting Thu Nov 8 2007

Tracy, one of our Hey Clinic associates,  shared with us this week in our weekly Quality Conference, on the meaning of “Compassion”, one of our Core Values.
Thanks for sharing from the heart, Tracy!
Dr. Lloyd Hey

Compassion by definition is a
feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the suffering. Not to be confused with empathy, as being compassionate towards another takes it one step further – coming up with a solution to help that person.  Compassion is often characterized through actions.  These acts generally take into consideration the pain of others and attempt to alleviate the pain or fix the problem.  (such as with surgery, medications, or to just lend a helping hand, etc). Often people have a lack of compassion if their own pain albeit mental or physical is so great that they can not recognize the pain of others.  In the healthcare industry, compassion for others is key.  It’s the name of the game.  Whether it be for a patient who is suffering or a coworker who is struggling with an issue, compassion is imperative.  If we stop thinking negatively about someone, we can have a clearer view of the good qualities in that person.  Being negative only hurts you on the inside. Negativity, anger, gossip, etc. causes one to feel shame at the end of the day rather than leaving you with a rewarding feeling.  We should remember that we may not know anything about the circumstances in a person’s life or what that person might be struggling with.  While compassion with our patients and coworkers is important, we all must remember to have self-compassion as well. Knowing that you work hard and give it all you’ve got on a daily basis will give you the confidence you need to help someone else.  You must believe in yourself.  You will not be perfect always.  The flesh is weak and we all fail at times; but being too hard on yourself will trickle into all areas of your life and others’ lives.  I recommend a book titled, “Don’t Die On My Shift” written by William Sayers.  It is a true story of a patient with polio and was in an iron lung (respirator) for 13 years.  His only view of the world was from a mirror on the iron lung.  He describes being in excruciating pain and asking a nurse for water.  The nurse kept walking by, saying, “I’m not your nurse.”  We often must remember that although our patients, coworkers, and even our own self may seem “crazy” at times, we are all God’s creatures and should be treated as such.  Always keep in mind that you are everyone’s “nurse”, even your own. You may make the difference between unhappiness and true happiness for someone.    

Wednesday, November 7, 2007

Hey Clinic Surgery Wed Nov 7 2007 @ Wakemed: 9 yo Zachary w/ 90 degree kyphoscoliosis gets straightened up.

A few weeks back I had a Blog entry regarding Zachary, a wonderful 9 yo boy, who was the victim of “Shaken Baby Syndrome” as an infant, with severe brain injury and subsequent severe motor and other deficits.
He had a couple of thoracic fractures at that time, and has developed a huge kyphoscoliosis to the point where he cannot sit in his wheelchair, and is experiencing significant pain, and cannot be braced.
Today, we did posterior reconstructive surgery using pediatric pedicle screw instrumentation from T1-L3.
Zachary did just great.  Estimated total blood loss was 400 cc.  He received one pint of blood, and 123 cc of cell saver and had a postoperative hemoglobin of 12.
His curve was very stiff, not correcting significantly when he was prone.
Extra care was needed to position him, given his severe kyphosis.
I performed 4 posterior thoracic osteotomies to try to free up the spinal mobility to aid in the correction of the deformity.
The spinal correction was performed in a step-wise fashion, starting at the top and then working my way down the spine, attaching the rods to the screws on each side, while gently pressing down on the rods like a lever.
Intra-operative radiograph as well as postoperative physical examination shows excellent correction of his kyphoscoliosis.
Zachary was extubated immediately after surgery, and is doing well tonight in the WakeMed Pediatric Intensive Care Unit (PICU)

Many thanks to the wonderful team who helped out today in OR 9 at WakeMed Raleigh, which included:  Katherine who assisted me as FNA, Yan Yan and Sheila as scrub techs, Vondella and Angela who helped out as nurse circulators, Martin and Melissa who were our CRNA and SRNA, and Dr. Jeremy who was our anesthesiologist.

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

Saturday, November 3, 2007

Hey Clinic Surgery Nov 1: Carolyn's Anterior/Posterior Reconstruction for pseudarthrosis and "Flat Back Syndrome"

Carolyn is a delightful 64 yo woman from Georgia who had an L3-S1 posterior instrumentation and fusion performed elsewhere, who suffers with flat back syndrome, with low back pain and trouble walking.
Her X-Rays and CT scan suggest possible pseudarthrosis at the L5S1 level, where she also has an anterior spondylolisthesis.  Her lumbar lordosis preop measures 40 degrees.
This past Thursday, we performed an anterior L5S1 disc removal and fusion using an “ALIF” interbody titanium spacer, followed by a posterior removal of old instrumentation with removal of old hardware, and revision L2-S1-Iliac wing instrumentation and fusion with decompressive laminectomies at L2 and L5 where she had stenosis.  Her S1 sacral screws were both very loose, and were removed and replaced, along with the remaining hardware.   I performed a posterior osteotomy at L2 and L5 to help improve lordosis as well as the placement of the anterior cage at L5S1 which helped to “jack up” that disc level anteriorly.

Her surgery went very smoothly, and was all completed on one day, but in two stages, with the anterior procedure performed first.  Total surgical time was approximately 5 hours.
Intra-operative radiographs showed her lumbar lordosis improved to 58 degrees, from 40 degrees preop, and you could actually see a noticable improvement in her lower back contour at the end of surgery.
Postoperatively, she has done very well, and stood up for first time yesterday, and stood up perfectly straight!
Her preoperative posture problem was really the result of the “toggling” of screws at S1, causing pain which caused her to pitch forward, on top of a fairly low fixed lumbar lordosis as well, and the spinal stenosis that also causes people to want to pitch forward away from the nerve pinch.

All three of these issues were addressed with our reconstructive surgery.

She will spend the weekend with us at Duke Raleigh Hospital getting physical and occupational therapy twice a day, while her very supportive husband gets to stay with her in the large “suite” rooms, which have 2 full beds for patient, as well as family member.  She will likely get discharged Monday, and possibly stay around in Raleigh for a couple days before heading home to Georgia.

Correcting flat back syndrome is one of the most rewarding things we do with Hey Clinic.  Allowing someone to stand up straight again not only affects their appearance and self-image, but has a great effect on quality of life in terms of standing and walking distance, pain, and endurance.  Pain can sometimes even be caused up in the neck region with flat back syndrome, since the neck has to hyperextend in order for person to look where they are going, which strains the neck, aggravating existing neck arthritis and neural impingement.

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

Thursday, October 25, 2007

Great Motivation to take your calcium every day. Today's urgent surgery for L1 burst fracture with severe osteoporosis with L1 vertebroplasty

This afternoon, we helped a 70 yo woman, who had a fall back in July with increasing back pain.
Her husband had been noticing some increasing kyphosis over past couple of years.
After the fall this July, she started to have severe debilitating back pain.
A week ago, she had vertebroplasty done for fracture at L1.
Her pain got worse, not better, and she was admitted to outside hospital where she was in so much pain, she could not even sit up.

Her studies showed an unstable burst fracture, with 50 percent canal compromise and evidence of toggling at that level.  She also had severe thoracic kyphosis and lumbar scoliosis with severe osteoporosis.
Basically, what she really needed was a total spine replacement, which is not possible.

To fix this problem, a short fusion would not work, given her poor bone quality and deformities.
We were able to stabilize the fractures and improve her deformity by performing a T3-Iliac wing instrumentation and fusion, with L1 decompression.
Her surgery went very well, and took about 4 and a half hours.

Her family was very thankful.
She is doing well in ICU tonight.
Tomorrow, she can start to get up, now that her spine is stable.

Please be sure, whatever your age, that you take calcium with vitamin D every day.
It is a great investment to help prevent this type of pain and suffering in the long run.

Lloyd A Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC  USA