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

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