Tuesday, September 11, 2007

Hey Clinic Postop Visit: Nancy doing great after scoliosis and stenosis repair and CABG

Earlier this week we saw one of our favorite patients named "Nancy" from Raleigh. Nancy was sent to us by another lovely lady from Raleigh who had her spine fixed at Hey Clinic, and Nancy has sent us several patients over the past couple of months.

Nancy sailed through her lumbar scoliosis and stenosis surgery with ease, with minimal blood loss. Her preoperative work-up was unremarkable. After surgery she was noted to have some mild hypotension on postop day 1, and had excellent Hospitalist and cordiologist f/u. Just to be on the safe side, a cardiac catheterization was performed which showed a 98% blockage to left main artery to her heart, without any significant muscle wall abnormality.

She was then transferred to WakeMed where she had a coronary artery bypass (CABG) performed, and did just great after surgery.

She is now doing great, walking unlimited distances, and back to a full life. Her case is a good example of the underlying cardio-vascular disease that we try to identify preoperatively, but cannot always be fully determined unless we performed cardiac catheterizations on all patients, which would have a lot of risk and expense and discomfort. Exercise stress tests are usually difficult or impossible to perform on many patients, since their spine prevents them from significant exercise. Chemically-induced stress tests are sometimes ordered preoperatively for patients who are at risk.

One of the things we talk about preoperatively as a part of our decision-making process for surgery is the risks vs. benefits of surgery. Major medical complications, such as a heart attack, or stroke, though rare, can occur during or after major surgery, especially in the older adult. That is one reason why it is helpful to have major spinal surgery when you are younger, rather than older, to decrease the risk of major medical complications, since your heart, lungs, and vessels tend to be more prone to failure as people age.

When we discuss the decision-making process regarding surgery with our patients and their families at Hey Clinic, we discuss 5 factors that need to be considered:
1. Unacceptable quality of life, often continuing to get worse over time, or having a progressive spinal deformity such as scoliosis.
2. Failure of appropriate conservative therapy.
3. Have a fixable problem, such as stenosis and/or spondylolisthesis or
4. Be medically able to withstand the surgery required.
5. Understand the benefits vs. the risks for the treatment options.

It also emphasizes the importance of minimizing the perioperative risk by having a skilled scoliosis/spine team performing the surgery with minimal anesthesia time and blood loss. The shorter you can keep the surgery, with the least amount of blood loss leads to the least amount of stress on the heart and other organs.

In the past, I have taught my residents and fellows to think about surgery like planning a military mission behind enemy lines.

1. You want to try negotiations, or non-military solutions first to the problem. (Conservative Therapy, when appropriate).

2. You want to make sure ahead of time that you understand what the problem is, and that it is likely a fixable problem.

3. You want to get your best "Top Gun" leader and team together with the best equipment. You want to plan out your mission thoroughly.

4. You want to execute the plan thoroughly, but also execute it swiftly, and then get your rescued person (patient) and team back to safety as soon as possible.

If Nancy would have had a 6 or 8 hour surgery as opposed to the 3 hour surgery she did have, her blood loss would have been much higher, as well as the stress on her heart, and her final outcome may have not been as happy as it was. That is why we are always seeking to improve our effectiveness inside and outside the Operating Room, so we can deliver the best results with the least amount of risk.

I am thankful for our skilled team, who helped Nancy sail through her lumbar scoliosis and stenosis surgery even though her underlying cardiac condition was more severe than anticipated preoperatively. We need to always do our best to work with internal medicine physicians, cardiologists, anesthesiologists and others to pre-test patients before surgery, and also do our best to execute our surgical plan in the most effective and efficient
way to decrease the stress on the body.

You are looking great Nancy!
Many thanks to Dr. Joe Falsone, Cardiologist, and our wonderful Hospitalist Team at Duke Raleigh, and the wonderful cardiac surgeons, nurses and others at Duke Raleigh and WakeMed for their care of Nancy and her family.

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

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