Dr. Lloyd Hey's Blog: Scoliosis and Spine Care, Aviation Safety and Quality "Standard Work"

How can we care for scoliosis and kyphosis and spondylolisthesis better with conservative care like physical therapy, high-tech scoliosis braces, exercise and other techniques? What can be done to improve surgical care, and understand choices for surgery, learning from those around the world? How can we learn from aviation and from Deming's principles of "Standard Work" to constantly improve spine and all healthcare?

Thursday, September 25, 2008

Today's Hey Clinic Scoliosis Surgery: 46 yo 30 yrs sp Harrington Rod Fusion with Flat Back Syndrome and Severe Stenosis

Today we

Surgery Today: 13 yo young man with severe Scheuermann's Kyphosis

This morning we helped Hunter and his family.
Hunter just recently turned 13, and has had increasing severe kyphosis.
His X-Rays showed significant wedging of several thoracic vertebra, suggesting Scheuermann's Kyphosis.
This morning I restored Hunter's original normal shape through a posterior instrumentation and fusion using cobalt chrome rods and thoracic pedicle screw instrumentation.
His surgery took approximately three hours.
He required no blood transfusion.
He was able to go to a private room where his mom and dad can stay with him tonight.
His correction was excellent.
He will spend probably 2 nights in the hospital.

--------
Lloyd A. Hey, MD MS
Spine Surgeon
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC USA
http://www.heyclinic.com
Member, Scoliosis Research Society (SRS) http://www.srs.org

Surgery Today: 13 yo young man with severe Scheuermann's Kyphosis

Tuesday, September 23, 2008

Interview w/ 12 yo adolescent 3 months after thoracolumbar scoliosis surgery back playing sports

_________
Lloyd A. Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC USA
http://www.heyclinic.com
Member, Scoliosis Research Society (SRS)
http://www.srs.org

Monday, September 22, 2008

Fwd: Emily 12 yo Adolescent Scoliosis Email and Pictures. Are you Stiff after Scoliosis Surgery?

From: Nick
Date: September 21, 2008 10:41:16 PM EDT
To: Dr. Hey
Subject: Emily's Email and Pictures

Hello Dr. Hey:

We got your message Friday evening and our family email address is >>>>>

After we met Friday, I had my first Softball tournament since the weekend before my surgery. We did really well. We finished 2nd and lost the final game 5-4. I played every inning of all 9 games except for 2 innings in the first game. The first 2 games of every tournament are pool games and teams try to play everyone on their roster. I do not have the complet numbers for the tournament, but I batted .475 and played first base thru the whole tournament. In the Semi-final game, we were down 4-3 in the final inning and I hit the game tying RBI and scored the game winning run. My dad told me I was a little rusty, since my average last year was .504. I anchored 4 double plays and only had 2 errors in the field. My back feels great. I have had no tightness this weekend. My parents were concerned that with the 3 month layoff, I would be stiff, but I feel just like I did before my surgery.

All of my friends are amazed at how well I am doing. They were very happy to hear the good news I got Friday.

Also, another patient of yours, Bob ______, was at the tournament. We were playing his daughter, Amber, in the Championship game. Mr. L_____ has been very concerned sine my diagnosis and surgery. He could not get over the fact that I was playing and how limber and quick I was.

There is one draw back from the Surgery, because I am 2 inches taller, my "Strike Zone" is bigger. So Umpires are calling more "low strikes" on me. HaHa.

Thank you for all of your help in getting me better. I am sending a couple of pictures from the game.

Sincerely,

Emily

--------

Lloyd A. Hey, MD MS

Spine Surgeon

Hey Clinic for Scoliosis and Spine Surgery

Raleigh, NC USA

http://www.heyclinic.com

O: 919 790-1717

M: 919 215 0170

Member, Scoliosis Research Society (SRS) http://www.srs.org

Hey Clinic Surgery Today: 13 yo boy with severe Sheuermann's Kyphosis Now Straight

Adolescent Scoliosis Patient back playing competitive softball within first 3 months of surgery. FW: Hey Clinic

From: Nick
Sent: Monday, September 22, 2008 2:42 PM
To: Meredith Railey
Subject: Re: Hey Clinic

Hey Meredith

So you were able to get the photos. Great! Thank you again for all ya'll have done. We were very proud this weekend and every one was amazed. Emily has been involved with travel softball for 6 years, and all of these girls from all over the state are like one giant family. When word got out this April about Emily, everyone from all these teams called or stopped by to give her encouragement and to let us know they were praying about her. After the first two games Saturday morning, everyone was coming around and congratulating her on the recovery and expressed amazement. And she had a very good tournament to start of with.

We had a lot of prayers and they were answered. Thanks again to everyone in the office.

Jill

----------------------

Lloyd A. Hey, MD MS

Hey Clinic for Scoliosis and Spine Surgery

Raleigh, NC USA

http://www.heyclinic.com

O: 919 790-1717

M: 919 215 0170

Member, Scoliosis Research Society (SRS) http://www.srs.org

Friday, September 19, 2008

Lifelong Spine Care at Hey Clinic. The age range of success stories seen today in clinic

At Hey Clinic, we do life-long scoliosis care, from small children, through adolescent, young adult, middle-aged adults, and older adults.

In the picture above, we can see an example of the age range of guests we have served, and seen in clinic just today and yesterday.

Each guest and their family has their own goals, and receives different benefits from getting their scoliosis fixed. Some of the guests below have been featured in previous blogs, including Mary, from Princeton NJ who got a phenomenal correction from a thoracolumbar sacral instrumentation and fusion, now with excellent posture and ability to return to active walking program, and ability to go back to work at at a Princeton "Think Tank". We also saw Candice, who is a grad student with thoracic scoliosis with hypokyphosis / lordosis which we were able to fix to pull her chest wall out to a normal shape. Our 12 year-old was also only 3 months out, and played 3 different sports this summer after her surgery, and is also playing sports this fall as well.

Monday this week I saw a very nice 14 yo girl from Indiana with severe Scheuermann's kyphosis, measuring almost 85 degrees, who found us through Molly, our Michigan teenager who came down this summer to get her kyphosis fixed.

It has been a very busy week at Hey Clinic, and now it's time to recharge the batteries.

Lifelong Spine Care at Hey Clinic

Lloyd A. Hey, MD MS

http://www.heyclinic.com

Hey Clinic for Scoliosis and Spine Surgery

Raleigh, NC USA

Member, Scoliosis Research Society (SRS) http://www.srs.org

Sunday, September 14, 2008

Preoperative questions about possible lost flexibility (stiffness) after scoliosis spinal fusion.

I received this email earlier this afternoon from an approximately woman with a collapsing thoracolumbar scoliosis with increasing back and hip pain who has tried all conservative therapies, and is not considering spinal instrumentation and fusion, with lumbar laminectomies and osteotomies.
She had a few more questions, and had been in touch with some of my other patients who were in the same “boat” as she was just a few months ago, and are now recovering well after surgery.

Hopefully her questions and my answers may be helpful for many others out there who have similar questions!

Lloyd A. Hey, MD MS
http://www.heyclinic.com
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC USA
Member, Scoliosis Research Society (SRS) http://www.srs.org
------------------------

On Sep 14, 2008, at 3:22 PM, Embarq Customer wrote:

Thanks so much for the phone call and email. However, I could not pull up the websides and wonder if your office could check on these websides for me, as I would like to see the videos.

I have contacted two of the ladies and they have nothing but praise for their surgeries performed by you. I was very encouraged and hopefully can schedule surgery in the fall.

I do have a couple of concerns which we did not discuss. (Just forgot to ask.) How about flexibility after surgery? Also, I have quite a lot of pain in my right hip (in the joint) as well as down the outside of my thigh. (I had an injection in the right groin in April that greatly relieved the pain, though I still have some.) I had an MRI in June which I brought to your office and I'm not sure it was viewed, but nothing shows up that would cause hip pain, so are we to assume this pain is caused by the spinal disorder? What are your thoughts on this? I am hoping surgery will relieve pain in the hip as well as back. I also would like to check on my insurance plans, which I can discuss with the front office.

With many thanks for your interest and the helpful discussion we had in your office. We were greatly impressed.

N_______

---------- DR. HEY’S RESPONSE ---------

N______,

I am glad you were able to get a hold of the other ladies who have had similar surgery.

I just got back from our international Scoliosis Research Society (SRS) Meeting in Salt Lake City, and several new papers were presented documenting marked improvements of quality of life with adult scoliosis surgery. There was also one paper presented on flexibility postop after spinal fusion, but that paper was in adolescent scoliosis, and did not really address functional range of motion, but a couple of tests typically used by physical therapists to assess spinal flexion and side bending distances only.

ANSWER TO QUESTION #1: LOSING FLEXIBILITY WITH FUSION?
a. LIMITING FLEXIBILITY DURING HEALING PERIOD. We do limit your extreme bending, lifting and twisting during the first 6 months to a year until your fusion is well healed to prevent hardware loosening or breakage. However, once your fusion is healed, we allow you to return to all preoperative activities. Surprisingly, however, most patients have no difficulty with their overall body range of motion, and activities of daily living regarding bending and flexibility. There are several reasons why this is true.
b. SPINE BENDS A LITTLE, HIPS BEND A LOT. Your spine itself only bends a few degrees at each level. Most of your flexibility for bending occurs at the hip joints which are not affected by the surgery.
c. YOUR SPINE IS PRETTY STIFF NOW. Your spine already is even less flexible, or barely flexible due to the collapse and degeneration in the area that we are fixing, since your scoliosis has caused it to twist, and lose virtually all of it's bending ability.
d. PAIN IS LIMITING YOUR FLEXIBILITY AND ACTIVITY. The pain that is associated with the collapse and severe degeneration greatly limits functional range of motion, causing your muscles and brain working together to stop you from bending or twisting due to the pain. Although your spine has a little motion left in the collapsed zone, your brain says "Don't bend that spine, 'cause it'll hurt", and causes muscles to stiffen to prevent worse pain from occurring. When we can eliminate the bone from rubbing on the bone and hitting the nerves in between, the pain is greatly decreased or eliminated, allowing less pain and more FUNCTIONAL motion and activities of daily living.

So, in my experience over past 14 yrs of practice and thousands of scoliosis surgical cases, I have had only 2 patients who had some moderate complaints of difficulty reaching their bottom area after surgery. These patients had very long torsos/trunks and wide buttock and who had horrible totally collapsed kyphotic thoracic and lumbar spines which I was able to correct, restoring excellent standing posture. However, when I lengthened their torso back to it's proper length, they had some difficulty reaching down around their buttock area, because their arms were relatively too short to reach. We were able to make some adaptations with occupational therapy so they could manage their own self-care. Fortunately your curve type, severity and body habitus, I have not had any people have this problem.

QUESTION #2: HIP PAIN.
A: You are absolutely correct. Your hip pain is very likely referred pain coming from your pinched nerves (stenosis) going to that area of your body. This stenosis is being caused by the spinal collapse (scoliosis) and bone slipping over the bone (spondylolisthesis) and the buildup of thickened ligament and facet joints and disc which encroach on the nerves causing the lumbar spinal stenosis. By opening up the central canal, and freeing up the nerve roots both centrally, and out the lateral recess and foramen on both sides, the pain going to the hip and leg is usually eliminated or significantly reduced. It is important, however, to check a hip X-Ray, which we could see on your spine X-Ray, and show that your hip joint is ok. I just saw a case last week where the pain was indeed caused by a worn out hip joint (osteoarthritis) of the hip. This patient needed a hip replacement!

I hope this helps.
I'll look into the website access issue for you

Take care,
Dr. Hey

----------
Lloyd A. Hey, MD MS
http://www.heyclinic.com
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC USA
Member, Scoliosis Research Society (SRS) http://www.srs.org

Saturday, September 13, 2008

Dr. John Hall awarded Lifetime Achievement Award, Scoliosis Research Society 2008. Many thanks Dr. Hall for your inspiration and training and example.

I have spent the past several days here in Salt Lake City, attending the annual Scoliosis Research Society (SRS) Meeting.
As always, the papers and posters were excellent, and the ability to interact with scoliosis surgeons from all over the world has been wonderful.

While the conference and interactions have been great, the best part of the trip has been seeing Dr. John Hall again. Less than an hour ago, I got a chance to catch up for a few minutes with Dr. Hall after he was awarded the Lifetime Achievement Award here at SRS. In Dr. Hall’s talk, he humbly shared how he has had a lifetime of learning from others and from clinical experience. My heart was filled with thanksgiving for Dr. Hall, who has been one of my primary mentors and inspirations since I was a Junior Resident at Children’s Hospital, Boston at Harvard Medical School. Dr. Hall inspired me and trained me in scoliosis surgery years ago, and also supported my academic career, supporting me to obtain a degree in Clinical Epidemiology, and encouraged me to use my engineering and computer skills to enhance clinical care of patients, and to also help conduct research and quality improvement.

I have, and still continue to try to inspire the next generation, passing on in some small way what I have received from great leaders like Dr. Hall, who received training and inspiration from the generation before, including Paul Harrington and many others.

Thanks, Dr. Hall for your inspiration and example of excellence.

Lloyd A. Hey, MD MS
http://www.heyclinic.com
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC USA

Wednesday, September 10, 2008

Encouraging note from West Virginia a few days after revision decompression surgery with excellent relief.

------ Forwarded Message
From: Pauline
Date: Wed, 10 Sep 2008 09:36:47 -0700 (PDT)
To: Lloyd Hey <>

Hi Dr. Hey,

Just a note to let you know we made a very uneventful trip home. I was pretty tired but other than that I WAS WONDERFUL. We wanted to tell you and Jacqi bye before we left but thought you were probably in surgery. So, I chose to do it this way.

I can't thank you enough for being so kind to me when I kept telling you the pain was much worse. Your kindness, patience, and encouragement was far beyond belief. (I have never experienced this with any other M.D. who was in charge of caring for my back.) Each time I contacted you by e-mail, phone, etc., you kept telling me you would stand by me in this. I am sorry ... I know I was a royal pain and each time I contacted you, I thought "Dr. Hey is gonna get tired of hearing this time after time" but you WERE there for me. You are a special person in addition to being a wonderful, competent, and persistent physician. I know Monday was a long day for you. I know you get tired, too. I guess my husband and I are gonna have to bring you, your wife and children to WV for a week or two of rest! Here in WV we could hide you and allow you to get some rest.

I had to take a break from the computer because sitting is not on my list of things I can do comfortably. Will see you on 10/23 for followup.

PLEASE, TAKE CARE,

Pauline A.


------ End of Forwarded Message

Wednesday, September 3, 2008

FW: Debra"s four weeks out scoliosis photo

From: Debra
Sent: Tuesday, September 02, 2008 11:30 PM
To: Dr. Lloyd Hey
Subject: Debra H_____'s four weeks out photo

Dr Hey, We sent you a before and after pictures of Debra's surgery.
Her surgery was July 28. The after photo is about 4 weeks out. The
results are better than we ever expected. Needless to say we are amazed
with both corrections you made to her back. One of Debra's goal was to
be able to wear a two piece bathing suit. It looks like she will be
shopping soon. Thank EVERYBODY there. We will see you next week for our
6 week checkup. Matt & Debra

_______________
Lloyd A. Hey, MD MS
http://www.heyclinic.com
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC USA

Monday, September 1, 2008

To What Degree Does Posterior Scoliosis Instrumentation and Fusion Limit Growth?

Chris Moore was a Summer Intern over the past few months at Hey Clinic, and did an awesome job! He is a mechanical engineer working in healthcare product development, and is in the process of completing his coursework to enter into a full-time healthcare career. He did an outstanding job this summer, helping out with our biomechanical research on better scoliosis instrumentation techniques, and also spent a lot of time with us in the operating room and in the clinic. He also wrote up the following paper in response to several questions we received from parents of scoliosis patients who were considering surgery. Chris’ summary of the literature helped many parents and adolescent scoliosis patients feel much more comfortable that they would not lose a lot of growth in most cases of spinal fusions. While many families and some consulting doctors do bring up the issue of concerns about “stunted growth” from scoliosis or kyphosis fusion surgery, virtually all families and patients are very pleasantly surprised at their child’s new improved height and posture after surgery. I have not had any patients or families with any concerns about short stature or short trunk years down the road after fusion.

Great Job, Chris, and best of luck as you complete your course work, and pursue a career as a “hands on” healthcare provider. You will be great!

Lloyd A. Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery.
Raleigh, NC USA
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To What Degree Does Posterior Scoliosis Instrumentation and Fusion Limit Growth?

By W Chris Moore, Lloyd A. Hey, MD MS
September 1, 2008
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC USA
http://www.heyclinic.com

Adolescent Idiopathic Scoliosis (AIS) is characterized by an abnormal curvature of the spine brought on by undetermined causes. While much research has been dedicated to proving causality for AIS, results remain inconclusive. One fact that has been proven is the greatest progression of the spinal deformity (mostly measured using the Cobb angle) occurs during periods of peak growth in the vertebral body. In fact, spinal development is not occurring at a constant rate and it actually fluctuates over a human’s infantile, juvenile, and adolescent periods.1 Therefore, understanding when the greatest growth velocity occurs is important for physicians determining how to best treat a patient. Knowing that scoliosis often progresses after reaching a Cobb angle of 40 degrees , scoliosis surgeons will usually recommend correcting a patient’s scoliosis curve through posterior hardware fusion. Due to the large amount of growth remaining in children under age 6-8 years of age, posterior fusion surgery alone is often avoided, since the continued anterior growth of the spine could result in new deformity called “crankshaft phenomenon.” To avoid this problem in the younger child, surgery may be delayed, or “growing rods” inserted temporarily, or anterior/posterior fusion is performed to stop the anterior growth and subsequent possible crankshaft phenomenon (rare). Crankshaft phenomenon does not appear to be an issue with posterior fusion in children age 8 or above in most cases, since the amount of anterior growth along the discs is less. In this article, we will be focusing on the adolescent population, rather than this younger group, under age 6-8. For many adolescent scoliosis patients and their parents, understanding the potential impact of spinal fusion can have on their remaining growth can be important as they consider timing of scoliosis or kyphosis surgery.

Methods
A common scoliosis correction, such as a T5-L1 fusion, will encompass a total of eight thoracic vertebrae, eight thoracic discs, and one lumbar vertebra. Determining the inhibited growth of a patient with this type of fusion will require knowledge of the growth rates of each type of vertebrae and discs included. Growth rates of vertebrae are dependent on a patient’s age and sex. Although, according to Dimeglio and Ferran’s study2, the longitudinal growth rate of thoracic vertebrae is 0.8mm per year on average, while the lumbar vertebrae average 1.1mm per year. Roaf3 and Taylor4 estimate thoracic intervertebral discs have average growth rates between 0.2 and 0.6mm per year and lumbar disc growth rates of 0.3 to 0.8mm per year. Using these figures as an estimate of annual growth rate, a fusion from T5-L1 would appear to restrict 11.1mm (0.44 in) of growth per year. However, this calculation can not be assumed correct for each year of a patient’s development since the rate of growth is, as mentioned previously, not consistent throughout adolescence. In fact, according to studies published by Wever et al5, who measured spinal growth from T1 to L4 of 60 patients, the maximum growth velocity of a female’s spine occurred between the ages of 11.5 and 12.5 years, and for the six male patients included in the study, the maximum growth velocity occurred at the age of 15. At these times, the mean maximum growth velocity for females was 18.3mm per year and 26.1 mm per year from T1 to L4. By comparison, if we calculate the growth of this section of spine using Dimeglio, Ferran, Roaf, and Taylor’s average growth rates, the growth is determined to be 21.05 mm per year which is within the range of Wever’s estimated growth. This shows some consistency between the two estimation methods.

Therefore, to accurately deduce how much growth will be impeded by a T5 – L1 fusion, one must consider how much growth remains when they have the correction surgery. Several charts from Wever’s journal article reveal average growth curves for adolescent females which is useful for determining this amount. Figure 1 provides useful data about the overall growth rate of T1-L4 per year from ages 9 through 18 of the females studied.
Using Dimeglio, Ferran, Roaf, and Taylor’s growth rates merely as a ratio of growth for thoracic vertebrae, thoracic discs, lumbar vertebrae and lumbar discs; it is possible to extrapolate each vertebral body’s growth rate per year.

Results
The growth tables shown in Table 1 were generated using the Wever (ref 5) growth data in Figure 1 in conjunction with growth ratios from Dimeglio and Ferran2, Roaf3, and Taylor4.

Discussion
So what can this data provide? For a female patient, the length of their fusion and their current age can predict how much remaining growth is restricted. Simply multiply the number of discs/vertebrae included in the fusion by their respective remaining growth values and sum up the values.

Example T5-L1 Fusion: (See Figure 2 with Spine Diagram.)

A female having this procedure at age 9 would expect 56.8 mm (2.2in) of growth inhibited by the fusion; however, a female at age 14 would expect 17.7mm (0.7in) of inhibited growth for the fusion region. Once again these are estimates of averages and can only be applied to female patients. While Weaver (ref 5) does provide growth data on male development, male growth curves were not generated because the sample size was too small (only six males were followed in the case study). Additional searches for male growth data were unsuccessful and must be obtained before estimating similar fusion implications. Once again, Weaver5 does state that among the six males studied, the maximum growth velocity of the spine occurred at age 15 compared with the females maximum growth velocity occurring at 11.5–12.5. Therefore it is reasonable to believe the remaining growth of adolescent boys would be greater than for females of the same age. Those seeking to understand spinal development better would be benefited by conducting a new study which tracks the growth rates of males. Also, the inhibited growth presented in this document does not take into account the additional growth that may continue to occur once the hardware is implanted. Searches for this information were also conducted but were unsuccessful. Lastly, it is important to remember that straightening a patient’s spine with a severe scoliosis curve will inherently provide “growth” by instantaneously adding inches to a patient through the straightening their curve, which could add anywhere from a half an inch up to over 3 inches in height in severe kyphosis or double scoliosis surgery corrections.

References:

1. Sarwark, J. and C. E. Aubin (2007). "Growth considerations of the immature spine." J Bone Joint Surg Am 89 Suppl 1: 8-13.

2. Dimeglio, A. and J. L. Ferran (1990). "[Three-dimensional analysis of the hip during growth]." Acta Orthop Belg 56(1 Pt A): 111-4.

3. Roaf, R. (1960). "Vertebral growth and its mechanical control." J Bone Joint Surg Br 42-B: 40-59.

4. Taylor, J. R. (1975). "Growth of human intervertebral discs and vertebral bodies." J Anat 120(Pt 1): 49-68.

5. Wever, D. J., K. A. Tonseth, et al. (2002). "Curve progression and spinal growth in brace treated idiopathic scoliosis." Stud Health Technol Inform 91: 387-92.