Wednesday, March 24, 2010

15 yo gentleman artist from South Carolina straightened up this am

Austin was a featured artist on my blog a few months ago for his dr.
hey cartoon he left on our table cover in exam room.

He had a 55 degree high thoracic curve

His surgery went well. Great correction!

Austin: this is my artwork. Scoliosis sculpture!

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery.

Sunday, March 21, 2010

Friday's Smiles / Dr. Bill from Michigan Gives Residence Inn a Plug, and gets ride to RDU Airport w/ Dr. Hey

This past Friday, we saw some very straight and smiley teenagers after scoliosis and kyphosis surgery. Her X-Ray shows that her spine is really perfectly straight now, and she is super pleased with her new posture. The new double simultaneous rod scoliosis correction technique that I’ve been perfecting over this past year or so is really getting some nice corrections.

We also saw Julie and her husband and son Caleb, who we talked about a few months ago. She had a really severe kyphoscoliosis at bottom junction of her Harrington Rod requiring a very complex pedicle subtraction osteotomy and reconstruction. Her whole family radiated lots of positive energy in our clinic — her husband, much bigger than me, gave me a huge bear hug and told me that “you have given me my wife, and Caleb’s mom back!."

We saw Suzanne back, who had severe kyphosis and thoracic spinal stenosis with myelopathy. She is standing up straight, and looking and feeling so much better.

We saw John back, after his 2 level ACDF doing well. You can hardly see the small scar on the left side of his neck, just 3 months out from surgery. We use a special microsurgery minimally invasive technique, taking great care to stay in the skin lines, which allows the small incision to blend in nicely over time to be practically invisible. His arm and neck pain is gone. His wife was a scoliosis guest of ours, who works as a nurse.

Vladamir was in with his wife, doing very well after his degenerative scoliosis and spinal stenosis repair, which has allowed him to get back into walking again.

It was great to see Gail back for follow-up after her flat back anterior-posterior reconstruction, looking and feeling great.

This week I also saw one of my physician patients named Bill who came back to see me from Michigan who we fixed with a severe kyphosis. He was very psyched and surprised when I offered to give him a ride back to the airport to RDU, which is on my way home (something I’ve been able to do quite often!). I picked Bill up from the Residence Inn, which is one of the many hotels right near Hey Clinic and Duke Raleigh Hospital where many of our out of town guests stay. Bill gave the Residence Inn very high marks, and recommends it highly. He arrived late the night before his appointment, and asked the lady at the desk where he could go for some fast food. The woman behind the desk actually took Bill into the kitchen and fixed him a huge sandwich and got him a drink, even though it was slightly after midnight!!

Bill and I enjoyed the extra few minutes of sharing on the short 18 minute drive from Hey Clinic. When I first picked him up at his hotel, however, he did give me some grief about my car — a 2004 Diesel Volkswagen Jetta. Bill told me he was expecting something a little more upscale / sportier, and shared a picture of his classic convertible red BMW on his smartphone. Oh well. Sorry Bill --- I like my environmentally friendly VW, which gets 48 miles per gallon, can burn bio-diesel, goes 600 miles on one small tank, and gets me where I want to go with all 100 horse power! Despite my lack of a cool car, we shared about our kids, and spending time boating and going to beach growing up. At the end of the day we would probably all agree that family and friends are more important than cool cars.

We enjoyed having Katrina this week with us in clinic — hopefully one of the things she learned, in addition to anatomy and pathophysiology is that all of us at Hey Clinic really enjoy what we do, and enjoy getting to know our guests over time. It is also a great joy to see people back after surgery doing well, and thankful to the many people who helped them get there.

On Sundays, we rest up and take a look at the week ahead --- several adolescent scoliosis and kyphosis surgeries this week. More news to follow. Hope all of you have a great week ahead.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Katrina's 31 Things I Learned from Shadowing at Hey Clinic on Friday

When I was growing up, my dad and mom loved to teach and inspire and learn — which they definitely passed onto me and my brother and sister.
I’ve done a lot of learning and teaching and inspiring since then, including during residency and fellowship at Harvard, fellowship at Duke, faculty at Duke, and now Hey Clinic for the past 5+ years.
One of the special things we do at Hey Clinic is have “interns” join us for a day, a week or more — many of whom are former scoliosis guests of ours who do school projects to explore career options with us.
Katrina has been with us for several weeks, but spent her first full day with me in clinic.
One of the things I used to always challenge my residents and fellows to do was to “Learn at least 3 things every day.” -- I would have them write down what they learned on an index card. After their first surgery with me, or first day on rounds, they’d be scribbling way more than 3 things.
On Friday, I challenged Katrina, a 16 yo Junior in High School to jot down what she learned, to see if she could learn at least 3 things.
Well, she did WAY better than that!

Here is her list of things she learned from one day at Hey Clinic.
She is pictured with me at Hey Clinic, proudly holding up her “Learning List” at the end of a busy clinic!
Strong work, Katrina!
Keep learning!

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery
Member, Scoliosis Research Society (

Date: Sat, 20 Mar 2010 03:34:11 -0400
To: Lloyd Hey <>
Subject: Katrina's 31 Things I Learned from Shadowing

Dr. Hey,

Attached is my list of 31 Things I Learned from Shadowing. I know I originally said I had 35 things, but when I got home, my unintelligible handwriting prevented me from understanding 4 of them... :)

Thank you SO MUCH for allowing me to come in and follow you around all day. It was a huge privilege and such a great day!! Please thank your entire staff for me too, because they are amazing!

Katrina Wertz

(Shadowing at the Hey Clinic: March 19 – 8am-3:50pm)

1. “The Grocery Cart Sign”

· Learn to carry Dr. Hey’s business cards around at all times. You never know when you will be shopping in Harris Teeter and notice that the woman standing next to you in line probably suffers from spinal stenosis because she is forced to lean forward while gripping her grocery cart in order to keep standing and walking. This helps take pressure off spinal nerves.

2. Quality of Life

· You should be able to stand for about 30 minutes at a time without experiencing significant pain. If your pain is so severe that you find yourself unable to do your daily activities, your quality of life is not good.

3. Treat the person, not the X-ray.

· In the end, whose testimony matters more? The living patient or the speechless photograph?

4. Danger of the Spinal Cord vs. Nerves

· Watch out for the spinal cord above all else. It’s a fragile gift from God!

5. Why Doctors Do Those Seemingly Silly Reflex Tests

· When a doctor looks at an MRI, he has a special secret that most of us don’t know. He already knows what he is looking for! He is not studying the MRI for answers; the MRI is merely confirming what he already suspects. Remember earlier in the appointment when the doctor did those reflex tests on you? At the same time, he was also noting areas of weakness, areas that directly appertain to specific nerves. Now he is cognizant of which nerves he needs to pay attention to on the MRI!

6. Nerves regenerate 1 millimeter per day.

· Positive: they can heal

· Negative: they could take a while…

7. History of a Patient

· Being aware of the history of a patient is vitally important to a doctor’s assessment and planned course of action.

8. “The Glacier Analogy”

· Think of the slip of a vertebra like the earth’s tectonic plates shifting. If 1 vertebra slides over another, the space within spinal canal or around the nerve roots often gets smaller (stenosis).

9. How Do Doctors Fix…?

· Doctors fix stenosis by laminectomy. Doctors fix slips of the vertebrae by reconstructive surgery using hardware and bone grafts.

10. Two Functions of the Spine

· “Mechanical” à stability and motion

· “Electrical” à impulses from the nerves

11. On X-rays, arrows are bad…

· Enough said.

12. Three Views on an MRI

· “Loaf of Bread” = Axial (horizontal view seen from the top)

· “Side” = Sagittal (vertical view seen from the side)

· “No Cool Nickname” = Coronal (vertical view seen from the front)

13. The spinal cord stops at L1 (it does not continue all the way down the spine).

· I didn’t know that!

14. It Takes 2 to Tango.

· This is basically an unofficial contract between you and the doctor before surgery. You as the patient are immeasurably important and deserve the full attention, expertise, and care of the doctor. But we all know that one person can’t tango by themselves… well, actually I guess they could, but it would turn out poorly J So, you as the patient also need to “get tuned up for the game.” That means eating well, sleeping well, and just following the doctor’s instructions… well.

15. “The Leaning Tower of Pisa Analogy”

· In deciding to operate on a patient, don’t fix 1 problem and leave another. What would happen to the Leaning Tower of Pisa if someone decided to remove the bottom section to correct its lean? The Tower would collapse and now you are left with a bigger problem!

16. The Disc That’s Not Really a Disc

· A vacuum disc, which is actually just gas, is a sign of disc degeneration.

17. Who Has a Risk of Blindness from Surgery?

· Those who are severely obese

· Those who are brittle diabetics

· Those who are in surgery for longer than 6 hours

18. It’s better to be proactive rather than reactive.

· A good example appears with scoliosis in children. Just because a child may be done growing does not mean that his or her scoliosis is done growing. Therefore, continue to get periodical check-ups just to be sure everything is doing well.

19. Pain and its Positions

· Pain can be better lying down instead of standing up because when lying down, the load is taken off of your spine.

20. The Neck Challenge

· Most people can easily crane their neck to look up at the sky. But what if I told you to keep looking up at the sky in that same position for the next 2 hours? Or 20 hours? Thoracic kyphosis patients constantly endure this craning of the neck. It’s no wonder that they often complain of neck pain – their necks have to work overtime to compensate for their back problem!

21. Don’t just blindly knock something out… know specifically where the pain is coming from and what you want to treat.

22. Factors in Predicting Scoliosis Progression in Children

· How big the curve is currently

· How much more the child will grow

23. Tests are not for fun. The doctor should only order one for a patient if it could change what he plans to do.

24. Smoking and Surgery

· Quitting smoking (or at least temporarily) before a surgery helps cut down the possible medical complications afterwards.

· In general, smoking and surgery don’t mix!

25. Surgery to correct kyphosis is less likely to result in paralysis than surgery to correct scoliosis.

26. Post-Op Pain

· It is common to experience some rib/side pain after surgery (even a few months later). The reason for this is because it is not just your spine that must become used to its new position. The ribcage too is slowly settling into its new orientation.

27. 5 Questions to Ask Before Surgery (you need a green light on all 5 for Dr. Hey to agree to operate!)

· Quality of life is unacceptable

· Conservative treatment has been ineffective

· There is a fixable problem

· Patient is medically able

· Patient understands the possible risks

28. A patient’s pre-op nutritional status has a huge effect on surgical consequences.

29. Braces after surgery are optional—although now you have braces that are already inside!

30. It is important to give the patient your undivided attention, listening to their symptoms and their perspectives. It is important to share stories and past experiences with the patient, making them feel more at ease and confident in your opinion. It is important to be honest with the patient and “lay all the cards out on the table.” It is important to be compassionate of the patient, letting them know that this is not just a job to you.

31. It is important to make the patient feel like you would drop everything to care for them.

Dr. Hey’s Clinic has taught me all of this and much, much more. It’s my favorite office to go to and is staffed by the most incredible people in the world. This is a special place to be.

Friday, March 19, 2010

Thanks for Many Kindnesses from Gail, who had flat back syndrome fixed at Hey Clinic

We had a really great clinic today, seeing a many of our guests back for follow-up, all over the age spectrum.
It was great to see Gail, who is about 3 months out from her anterior/posterior flat back reconstruction.
Gail had emailed me back in December with her story to thank the staff and give her an update for her progress at that point, but that work of thanks never quite made it to our blog world! Here it is now, with Gail’s permission.
Great to see you today Gail!
Have a great spring.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery.

Subject: Thanks for your many kindnesses

Dear Dr. Hey, Hey Clinic staff, and Raleigh Duke Hospital,

Since it’s a bout midway in my first eight weeks of recovery I wanted to let you know that my recovery is proceeding exceptionally well..My initial contact with you was a request for a second opinion. Having had a previous surgery at “Big Duke” , I wanted to determine if the treatment for my flat back was still surgery, what kind of surgery, and what would likely be the outcome. In addition to responding to your comprehensive form I independently wrote a detailed chronology of my long standing lumbar naturopathies .

My problems had been further exacerbated by our relocation from NY to AZ , and finally NC over the past 7 years as my severely degenerated lumbar spine continued to deteriorate. I had endured numerous conservative therapies from strength/conditioning, steroids, both oral and injected, nerve blocks, high radiofrequency ablations, electrical stim, and of course, oral medications for inflammation, spasm control, and pain. I shared that both previous surgeries had improved the quality of my life as it was, but there was so more to do, and in a downward spiraling environment . I didn’t want to hold anything back giving you the opportunity to tell me my expectations for further improvement were unrealistic. The odds given my age, fitness level, and opoid tolerance would make me a poor surgical candidate.

As it happened you felt I was a good risk and we proceeded with the surgery on November ll. I had very positive experiences at my visits to the Clinic and at the Raleigh Duke Hospital. I want to sincerely thank you, Dr. Hey, Jennifer, and Dr Watters for your superior surgical skills. I also wish to thank Dr. Rieker from Pain Management for his efforts to manage my discomfort, the kindness of the physical and occupational therapists for their patience , and finally the many nurses whose caring and helpfulness made my stay productive and comfortable. Through all of your efforts I am now already enjoying a more pain free existence.

I would like to extend my sincere best wishes to you all for a wonderful holiday .

Warmest Regards,


Thursday, March 18, 2010

Severe kyphosis in 41 yo woman who had previous kyphoscoliosis surgery fixed today

Well, I am definitely back from my week off last week!  It was a great week off seeing family, touring NYC, visiting Florida, and going to New Orleans for the AAOS national Orthopaedic meeting.  I saw a bunch of my old resident and faculty friends at the Harvard Orthopaedic Reunion, including Dr. Mike Millis from Boston Children’s, Mark Umlas from Miami, Kevin Schrock, and several others.  

It’s good to be back home, and at Hey Clinic and the operating room again.

Today we did a complex revision kyphsoscoliosis surgery, which involved fixing an over 45 degree acute deformity.
Patient had acute angulation at one disc space that was toward bottom of fusion. She had some hardware removed elsewhere, and some hardware also revised, but her kyphosis and pain progressed.
Today I revised this by removing all of the old hardware (two different types), and put in new hardware from T4 down to ilium.  I then decompressed the nerves at several levels, then did complex osteotomy, similar to a pedicle subtraction osteotomy, but actually through the acutely angulated disc space of L23!  Even under general anesthesia, she had a huge hump in that lumbar area, which did not reduce even after removing all of the posterior elements (Smith Peterson osteotomy).  After removing a good portion of the disc from both sides, I could gently lever the kyphosis out with the 2 cobalt chrome rods.  The finished “product” is shown, with a lateral photograph of her whole spine tilted 90 degrees to match her preop photograph I took this morning.  The hump is gone.  The X-Rays also show hump is gone, with complete restoration of the original disc spacing and posture.

Her surgery took around 4 hours and 30 minutes.
Her EBL was 2600 with 960 cc cell saver returned.
1 unit of PRBC’s were transfused at end of surgery.
Her evoked potential monitoring was normal throughout surgery.

After surgery, her family was thrilled to see her new posture.
This young lady has a chance to stand up straight tomorrow, and start new life getting over significant pain and deformity.

Yesterday we did a complex T23 laminectomy and extension fusion for a gentleman with progressive myelopathy above a long fusion due to osteoporosis and adjacent level failure.
Next week we are helping several teenagers with adolescent idiopathic scoliosis.

A great day, and a great week back!

Hope you are all doing well.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery


Thursday, March 11, 2010

Really good questions asked by Miami dad of 13 yo girl with 42 degree adolescent idiopathic scoliosis (AIS) and back pain

We saw a young lady in clinic with her mom last week who had a painful 42 degree scoliosis which had progressed from 39 degrees just a few months before.
Her dad lives down in Miami, so we sent him clinic note electronically, and he wrote back with questions, which were really good!

I’ll share his questions and my answers below:

I just left you voice mail at 7:50 p when I got back to hotel after taking my son out for dinner.

I’ll be up until 9:30 or so tonight, and you are welcome to call me tonight tomorrow after 9:10, when I land in New Orleans and go to our annual AAOS Meeting.

Just to get you some answers in the meantime to your questions to avoid any delays:

> First of all, I understand this is a serious and worsening problem, but I
> would hate for my daughter to go through surgery unless it is absolutely
> necessary.  What I read suggested that a brace should be 90% effective with
> curvatures between 25 and 40 degrees.  Is it too late to still look at that
> option?

A:  Given the size of her curve (just over 40 deg), and her growth remaining (skeletal and chronological age 13), the chance of the brace doing anything at all at this point is actually quite slim.  There are also some real “costs” involved with bracing, including some possible psychological effects in the teenagers, and problems with compliance over the several years it would need to be worn for 18 hours a day.  The brace can have some effect on slowing progression of curve, but does not solve the deformity.  We need to think about treating the whole person, not just the curve itself.   The “vibe” we got from Gabbie was that bracing was not something she would be very agreeable to try and be compliant with.  Given all of these factors together, if she was my daughter, I would not force her or encourage her to wear a brace at this point.  I’ve written a longer article about bracing with some good quoted references, and how my approach to bracing has evolved over the years in my blog:

> If we went ahead with the surgery, I assume it would be the fusion surgery,
> how many vertebrae would have to be fused?  I understand that those vertebrae
> would no longer grow, and that should have little impact on her future overall
> growth, but it still worries me a little bit.  Is there a loss of flexibility,
> long lasting pain/discomfort, or increased potential for future injury in that
> area.

A:  Very good question.  Probably 9 vertebra would be fused, but actually those vertebra still grow a little even after instrumentation and fusion.  Each spine segment at her age does not grow very much, and the effect on her overall growth would be minimal, especially since the surgery helps make her a little taller by straightening the curve out.  There is no significant noticeable loss of flexibility, and long lasting pain and discomfort or injury is exceedingly rare.  One of my pre-med students wrote a very good article about growth rates in fusion surgery which is on my blog:

> My next question is about timing for the surgery.  Is there reason to push for
> the surgery to be done this month?  If we wait until the summer, would the
> situation become significantly worse?  I know Gabrielle wants to do the
> surgery as soon as possible, because she is very uncomfortable, but I'm
> wondering if she would be more uncomfortable trying to go back to school just
> 10 days after having back surgery, or would she be better off waiting until
> the end of the school year when she could have more recovery time.

A:  Another excellent question.  From a curve progression perspective, anytime in next few months is probably fine.  However, because she is in pain, and because for some teenagers it is helpful to not have the “black cloud” of a surgery hanging over them for months ahead of time, and the fact that most teenagers are only out of school for a couple of weeks, it could make sense to go ahead and get it fixed sooner.  That also allows her to be in great shape when summer time comes around as well. Either way is ok with us.

> I am also curious about insurance.  If/when we decide to go through with the
> surgery do we need to get any kind of pre-authorization from the insurance
> company.  One of the reasons I am asking is that from what I understand this
> surgery is not usually done for curvatures less than 40 degrees.  I would hate
> to get too deep into this just to find out that insurance won't cover it, or
> considers it "elective."  I would obviously like to fight that battle (if need
> be) before we are faced with huge medical bills.

A:  Yes, our office would take care of the pre-certification for surgery, which is never a problem.  Curves less than 40 degrees can be fixed especially if they are painful despite conservative treatments.  Your daughter’s curve is just over 40 degrees.  We could do the pre-certification as soon as we get a date for surgery, and my office would take care of getting you an up front estimate so you understand deductibles, etc.  My office manager, Jennifer,  can handle this for you.  By working things out ahead of time, we can avoid any bad surprises.  

> I guess my final question (for now) is what do you see as the likely results
> of the surgery.  I understand that the probability of coming out of this with
> a perfectly straight spine are nil, but what sort of improvement could we
> realistically expect to see?  Also, what are the chances of needing future
> surgeries?  And could you please explain to me how fixing the upper curve
> would result in a straightening of the lower curve.  I believe you when you
> say it will happen, I just don't understand it.

A:  More great questions!  Given her age and curve size and likely flexibility of her curve, I should be able to get a really awesome correction, which is pretty darn close to perfectly straight, with remarkable elimination of her back “hump”, by derotating her spine, pulling out the sunken in part of her chest wall, and pressing down on the “hump” side.   I don’t think I can recall a family that was not really pleased with the final correction of the deformity.  Most are downright blown away with joy right after surgery when I show them the intra-operative X-Rays, and when they see their daughter or son get out of bed for first time within 18 hours of surgery, with the “hump” largely or completely gone.  Some additional rib remodeling occurs over a few weeks after surgery, leading to an even better chest symmetry.  It can also take a few weeks for the compensatory curves above and below the fusion to get used to the new posture.

The chance of her needing further surgery, especially for her curve type is very low.  In actuality, by straightening the curve now when she is younger, the lower curve straightens out naturally, since it is not structural, but is just curved since it is connected to the structural deformity in her thoracic area.  Like a “slinky”, the lower part has to “follow” the upper part.  If the upper part is curved, the lower part has to curve as well. If the upper part is straightened, the lower part, in her case, naturally straightens out on its own.  We test this with some bending films which show us how flexible each of the curves are, which helps guide fusion levels.

Look forward to following up with you on phone and/or email and meeting you in person.


Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Tuesday, March 9, 2010

Touring Art Schools!

Day 2 without doing surgery. Hangin' in there pretty well. (a few
"shakes" but enjoying the break)I think I found a great place to
display dome of my scoliosis hardware sculptures at the NY museum of
Modern Art (MOMA).
I am not sure what the process would be to submit my work, but there
was a very simple string art thing there with just some ouch pins and
a simple polygon --- I think my scoliosis correction rods are much
more artistic!

Now we are tourin. Art schools. Art humor was up in the cafe --- I
read a grea biography on Michaelangelo a couple years ago when touring
around Italy. Michaelangelo practiced drawing and human anatomy all
the time.

Hope all of you are doing well.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Monday, March 8, 2010

The dream -- Rousseau

Dreaming about jungle scene

Van gogh swirling energy

Very cool. Dr. Hey having fun in NYC

Museum of Modern Art. NYC

No surgery today or this week! It'd break time!
Right now I am in an art museum at MOMA in NYC. The picture shows
Monet's Water Lillies painting which is about 20 feet long and 6 or 7
feet high.
Beautiful impressionistic reflections of sky and clouds amidst the
floating flowers.


You can get lost in this painting.

Hope everyone is having a good week.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Friday, March 5, 2010

Spine Surgery Humor

Sometimes my staff feel that I need a little humor in the middle of
our busy clinic. Here is a rare spine surgery cartoon they shared this
afternoon! While we do straighten some mighty crooked spines, we
don't ever remove them!

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Wednesday, March 3, 2010

Lumbar scoliosis and spinal stenosis fixed this afternoon

28 degree scoliosis w stenosis and Spondylolisthesis.
T12-iac wing instrumentation and fusion w 3 level lumbar laminectomy.
Total surgical time: 2 hrs 45 minutes.
Ebl: 1100 cc.
Blood transfused: none.
No XLIF needed.

Dr. Lloyd Hey
Hey Clinic

13 YO young lady w 40 degree Thoracolumbar adolescent idiopathic scoliosis fixed today

Surgical time: 3 hr 10 min.
Complications: none.
Ebl: 600.
Cell saver: 250.
Correction: excellent.

Dr. Lloyd Hey
Hey Clinic For Scoliosis an Spine Surgery

Monday, March 1, 2010

26 YO man w history of adolescent idiopathic scoliosis fixed today

Had progressive back pain.
T5-L1 instrumentation and fusion this morning with evoked potential
Surgical time: 2 hrs 40 minutes.
Correction: excellent.
Ebl: 500 cc.
Blood transfused: none.
Complications: none.
Did not require XLIF.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery.