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