Friday, December 21, 2007

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

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