Sunday, December 9, 2007

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

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