Saturday, April 18, 2009

Keith's 3 month postop visit with excellent pain relief and quality of life. Considering spinal surgery in the higher risk patient.

Keith is a 68 yo man who had a lumbar scoliosis and spondylolisthesis and severe spinal stenosis at multiple levels with an extremely poor quality of life.  He was referred to me by Dr. Kittelburger at the Pain Clinic here at Duke Raleigh Hospital.  Keith was in agony with severe back and leg pain and trouble walking, that was getting worse. 
While it was clear that Keith had a fixable surgical problem, and a very poor quality of life which was getting worse, and also had failed all conservative treatments, his decision for surgery was complicated by the fact that he only had one lung, having one lung removed for mesothelioma.  
Keith had heard that I was capable of doing the surgery much more efficiently than other surgeons with less experience, which he and his referring anesthesiologist knew would be critical for him to get through the surgery. 
After getting an extremely thorough evaluation performed on Keith with the help of pulmonologists, and many others, we had a heart to heart talk reviewing all of the risks and benefits, and he and his wife decided they still wanted to move forward with surgery, and I agreed to do it.  The pulmonologist helped to maximize his pulmonary function preoperatively with steroids and other medications to get him in tip top shape.  I must admit that there are times it takes me extra time to weigh the pluses and minuses for surgery, and there are times where I have to decide that I can't help someone with surgery if their medical condition makes the surgery too risky, and I most certainly never want to do harm.  But it's sometimes a tough decision that I often need to work through with the help of other consultants, prayer, and follow-up visits.  

His surgery three months ago went very smoothly, taking only around 3 hours for a 7 level instrumentation and fusion with 4 level laminectomy.  He was extubated right away, and had no pulmonary or other complications, and only spent a few days in the hospital.  I never rush through surgery, but I have learned how to become more and more efficient in the operating room, and have built a team around me that works with me doing hundreds of surgeries together each year.  I view doing surgery like a military mission:  you need to decide when and if to "attack", plan out mission well, pull together your best team, and carry out the mission rapidly and effectively, with backup strategies already in place for "what if's" that may occur during surgery. In a sense, whenever you do a surgery, you are "invading" the body, so it is important to get in there and get the job done, but get out as soon as possible!  As a result, our team often performs scoliosis and kyphosis surgery and reconstructive surgery in about half the time as predicted by our patients who have seen other surgeons.  That helps decrease blood loss (which is often half of predicted), decrease chance and amount of blood transfusion,  decrease risk of infection, as well as other perioperative risks.  This is often important whether you are 12 years old, 22, 32, 42 or 62 or 82.

Seeing Keith in clinic yesterday reminded me that it is most definitely worthwhile helping patients that are higher risk.  He was back in clinic walking without any assistance, standing up straight with both he and his wife smiling and very thankful.  He looked like a different person!!  His wife looked better too!  He and his wife share their story, and send "thanks" to all of the nurses, doctors and others who helped care for him before, during and after this surgery which has given him back his quality of life.

Fortunately, most of the patients I get to care for are adolescent and young and middle-aged adults, who do not have significant comorbidities.  We have advanced computer systems and preoperative evaluation tools at Hey Clinic that helps us do an extremely thorough preoperative assessment, that helps to direct our preop workup.  However, there are a few percentage of people where the decision for surgery is tougher, where the surgeon, as well as the patient and family has to weigh the potential benefits vs. the risks involved moving forward with the "journey" of spinal surgery.  It takes "Two to Tango":  The patient and family AND the surgeon need to decide that they are all willing to go through the journey together, in close partnership.  If you are a patient or family considering a major surgery, it's important to realize that your surgeon is a person too, and has a tough job sometimes weighing all of the risks and benefits, along with you to decide when he/she thinks it is appropriate whether or not to do surgery.  Doing surgery on someone is a long-term commitment on both sides -- not always just a simple "just fix it" and move on.  

When facing a tough decision about surgery, I am often reminded of the risky case my orthopaedic surgeon took on to piece together my crushed left leg, which ended up taking 11 surgeries to fix, with me almost dying a couple times with sepsis, and spending over 3 months in the hospital.   His fellow surgeons and hospital administrators and nurses  probably wondered why he took these risks, and used all of these resources and hospital time, and whether or not it was worth it:  He could have done a simple 30 minute amputation the first night, or just not taken on my surgery at all and be done with it.  Instead, because he had so much experience successfully piecing together mangled extremities during the Israeli war, he knew he had a shot at saving my leg.  He took on my surgery, and persevered through multiple surgeries and lots and lots of complications and tons of visits.  The end result was that I was able to walk again on my own two feet, and even run and bike again.  

Now, 31 years later, that left leg has held me up without any trouble for over 5,000 surgeries that I have performed, and allows me to enjoy exercise every day.  I stand on that left leg all day long, sometimes for 7+ hours straight, helping others, and thankful that my orthopaedic surgeons were willing to take some risk to help me.

So, I prayerfully made decision to help Keith over 3 months ago, and now he is doing great and very thankful.  I do thank all of the people who helped me preoperatively assess Keith, and the excellent anesthesia and postoperative physicians, nurses, respiratory therapists, physical and occupational therapists, and Hey Clinic staff who helped.

Lloyd A. Hey, MD MS
Spine Surgeon
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC  USA
Member, Scoliosis Research Society (SRS)

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