Sunday, June 26, 2011

Dr. Hey's past week in review. Biomechanical Models, Tinkering, and Adolescent Scoliosis at Age 40.

All 4 of our adolescent idiopathic scoliosis surgery patients went home by Friday this week, having had their surgery Mon-Wednesday! Great families, and all very pleased with the care they received at Duke Raleigh Hospital. My daughter actually helped film David's surgery, and provided a copy for him and his PreMed Sister as they headed home to Winston-Salem. She literally narrated the video, asking me lots of questions, just like they did when I was filmed for the Discovery Channel doing scoliosis surgery at Duke Medical Center years ago. What a joy it was to have my daughter with me psyched to watch me at work. I will never forget that day. It was like my "home world" broke into my "work world" -- it felt almost like a dream!

When my daughter was very young, maybe 4 or 5 years old, used to come on rounds with me at Duke University Medical Center, and used to make get well cards for every single one of my patients in the hospital. She would ask me as we were driving into the hospital "Daddy, how many patients do you have in the hospital?" I would say "7". She would carefully count out 7 pieces of blank paper, then carefully make up a card for reach one, with picture on front and inscription inside which would say "Get Well Soon. I love you. " After we finished rounds, we would always go for a ride on the electric train which connected Duke North with Duke South. She would ride up front and we'd pretend we were at Disney World riding the Monorail!

Well, now that little girl has grown up, and is getting a chance to see what daddy does in the operating room, as she considers serving others in the future in the healthcare field.

I spent a lot of time with a very nice 40 yo woman with a 56 degree long right thoracolumbar curve. She was at Hey Clinic with her husband seeking a second opinion regarding her painful, and possibly progressive scoliosis. She was diagnosed with scoliosis as a teenager, braced and never had surgery. She thinks her curve was around 25-30 degrees when she was done growing.

She did well for many years, but over past 8 years or so has noted increasing lower back and mid back pain. It has increasingly affected her quality of life, so she cannot kayak, take long walks, garden and do some household chores. She thinks her posture may have changed a bit with a bigger hump appearing on the right.

We spent a long time going over all of her films, and carefully measuring all of them and putting them into our database and special scoliosis electronic medical record (EMR or EHR for Electronic Health Record).

We talked about importance of tracking the curve over time. Her curve has progressed 8 degrees over past few years, which is more than the expected 1 degree per year for most curves if they are progressing.

She came into clinic very concerned about risks of surgery, but was also very concerned about the risk of doing nothing, since her quality of life now is not acceptable, and things seem to be progressing.

We answered all her questions, and she's going to think things over. We took over an hour with her, showed all her films up on big screen and discussed in detail what were the benefits vs. the risks of doing scoliosis surgery now as opposed to later, or not at all.

This couple really seemed to appreciate the time my physician assistant and I took to go over her particular situation, and equip them with the information they need to make an educated decision now, or sometime in future.

This also illustrates importance of screening for, and following scoliosis in younger people, especially during the adolescent and young adult years. If this woman would have had her scoliosis fixed years ago before the lowest levels of her spine became degenerative, we could have more likely fixed it with a shorter fusion, preserving the bottom 2-3 discs. As people get into their late 30's and 40's, often those lowest discs have degenerated so much that they must be included in the fusion -- not the end of the world, but it sure is nice to have "a stitch in time that saves nine!" - or that saves some mobile disc spaces.

Also saw a bunch of our smiling teenage scoliosis patients back for follow-up from the large group of adolescents we "straightened up" last summer! They all looked great, and were very happy and very smiley and VERY active with sports and camps and dancing.... What a joy it is to care for any patient, especially these younger folks.

Saw a 26 yo woman who has a collapsing scoliosis almost 90 degrees now 13 years after having her adolescent scoliosis surgery performed elsewhere, which was complicated by intra-operative loss of evoked potential monitoring and wake up test with paralysis. They took out all the hardware and just put in bone graft. She woke up paralyzed, but has made remarkable recovery since then, able to ambulate with cane but some remaining spasticity. Unfortunately now she has severe pain and deformity, since the curves have continued to progress since the fusions done without instrumentation have high likelihood of progression. We're getting CT scan to check quality of fusion, and to take closer look at cause of her progressive pain.

Did urgent/emergent surgery yesterday on woman with progressive spondylolisthesis above scoliosis fusion. Came up with a new technique for correcting kyphosis in both the cervico-thoracic junction and thoracic spine at the same time using a specially contoured "U-Rod" --- using technique similar to Luque Rod technique, but using Zimmer Universal Clamps. She got an excellent correction of deformity, excellent relief of pain, and went home today! In order to create this special U-Rod, I had to do a very special bend using my big vice I brought in from home, and a piece of pipe I bought from Lowe's Hardware Saturday morning that I used as a lever to help make the proper U bend that I needed to match the cervical spine. I then contoured the rod into the proper cervical lordosis and thoracic kyphosis. Once the rod was contoured, it was washed and sterilized and was ready for surgery! This single rod was then placed with the top of the "U" up at C4, and the 30 cm lengths coming down over the thoracic spine. It was attached using the Universal Clamps and the pedicle screw instrumentation.

The overall surgery took about 5 hours, with about an hour and a half setup time. I spend A LOT of time preparing for this surgery, doing drawings, talking to instrument reps, and mentally going over each step of the surgery in my mind. I learned this mental preparation from my Dad, who is a flight instructor, who encouraged me to mentally practice landings and other maneuvers in my mind even before I got into the airplane. It really helped. Friday evening though, at dinner, and even later that evening and night, I could tell that my mind was still churning, working out all the details, and "what if''s" --- woke up even that night going over things one more, until I had it just right.

Really appreciate my physician assistant Rachel staying all day to help, and the excellent staff at Duke Raleigh Hospital who worked together with me as well. We all had a good time together, and got a great job done and really helped relieve some suffering while preventing bigger problems that were brewing, including a spinal cord pinch at the level of the spondylolisthesis.

What a joy it was to see her this morning with her husband -- both with a big smile, as she showed off how well she could now move both arms up over her head without any pain.

As many of you know, I started "tinkering" at a very young age, fixing just about anything: lawnmowers, go-carts, outboards, inboards and more. That led to me "tinkering" with the Hoffman external fixator on my left leg which was not strong enough to hold my complex Grade IIIB tibia fracture still -- leading to new design using triangular structure which was much stronger and helped it to heal. This led to my desire to combine engineering with my patient experience to help future patients who had complex problems as I did, which set my course throuth MIT Engineering, HST Program at Harvard-MIT, and Harvard for Medical School, Residency, Chief Residency and Fellowship at Boston Children's Hospital.

This week we also helped out a young lady who had a pseudarthrosis of a scoliosis fusion. Using our biomechanics lab at NC State with Professor Andre Mazzoleni and his graduate student, we were able to create a finite element computer model using this patient's spine parameters, and were able to measure the relative strength of revising her fusion using anterior ALIF technique vs. TLIF technique. This interesting research revealed that we could get very close to the ALIF strength, but with the much less invasive TLIF technique if we focused on getting the TLIF as far anterior as possible. This would also have comparable strength to the XLIF technique. So, we were able to use the lab to help a physical therapist patient and her MD husband to make a very educated choice on which way to go with their surgery. The TLIF technique worked great, and she went home after just 2 nights in the hospital feeling great!

Many thanks to Professor Andre Mazzoleni and his grad student from NC State University Dept Mechanical Engineering who put in countless hours to create this new computer model to help us in our decision analysis. Look forward to further research together with you which will help patients and surgeons in the future.

After all this, I was pretty darn tired by last night. Got home about 6:30 pm, and had restful day today after rounding this morning at Duke Raleigh Hospital. Slept in til 7:20, Rounded at Duke Raleigh Hospital, had good church service with family and lunch out. Caught up on some things around the house, took a long walk, had a swim, and caught up on email and the Blog!

Hope you all have a great week and a great 4th of July.
We have a busy week coming up, and hope to send you an update later this week before the long weekend.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

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