Monday, September 5, 2011

Week in Review. New "U-Rod" Technique for Proximal Junctional Kyphosis

Between earth quakes and major hurricanes, Hey Clinic has remained very busy the past 10 days or so since I’ve had a moment to sit down with my feet up to reflect.

Somehow I missed the whole earthquake thing... Although others at Hey Clinic felt it!

The hurricane was a much bigger deal, and still is a very big deal for many of our patients and families not just in North Carolina, but to our north and east.

I mentioned in a previous blog that I’ve been working on a new technique to help fix severe kyphosis at the the cervico-thoracic junction.  One of the potential complications from kyphosis and some scoliosis surgeries is that patients can develop a fracture and/or spondylolisthesis/slippage at the top of the fusion.  This is called proximal junctional kyphosis or PJK.  We see it mostly in our older guests who have more osteoporosis, although I’ve seen it happen in some younger patients as well and even a couple teenagers.  

Often the way we fix this is by using a tapered rod, which goes from a standard 5.5 or 6 mm in diameter down to a smaller diameter to allow for fixation to the cervical spine.  These rods, however, can appear a bit too weak when you are trying to lever the spine into a better non-kyphotic posture, even though we also do a bone wedge or osteotomy to help free up the spine so it will be able to move.  

Wearing my engineer hat, I remembering success many of us had using Luque boxes, which were a very strong stainless steel rectangle we used to use for spine fracture treatment with sublaminar wires.  We can’t even get Luque boxes anymore, and the small supply we had at “Big Duke” have apparently been used up!  I wondered if we could use a Luque Box like construct to help provide a strong reinforcement at top of the construct which could then be connected to the old hardware. The lower cervical spine could be connected to this frame using sublaminar strong fibrous tapes called “Universal Clamps” from Zimmer, and also pedicle screws as needed in the upper thoracic and possibly C7 as well.  

I created a bunch of these “U Rods” using both cobalt chrome and titanium rods from Pioneer, and as mentioned previously, used a large vice and a slightly larger tube to help fashion the U-Rod to the proper shape.

Our first U-Rod surgery was done a couple months ago.  I just saw that physician patient back for follow-up, and she is doing extremely well.  She was actually bringing her son in for an appointment, who needs scoliosis surgery as well for a large thoracolumbar curve!

This past week I did two additional U-Rod cases --- one in a woman in her 70’s who had PJK at top of a complex scoliosis reconstruction.  Her pictures before and after her correction with the U-Rod are shown here in the blog --- a very dramatic correction to her deformity.  Before surgery, she could not put her head flat on the bed, requiring 3 pillows for support.  At the end of surgery, her head sat flat!

On Friday, I did U-Rod #3 --- for Tim — a young man in his 20’s with spastic quadriplegia.  I actually knew Tim’s original pediatric orthopaedic surgeon — Dr. Jim  Sanders — from our training years at Boston Children’s Hospital.  We’ve stayed in touch through Scoliosis Research Society.  When Dr. Sanders moved away from Baptist / Bowman Gray, he asked me to look out for Tim.  Tim did great after Dr. Sander’s scoliosis surgery, but after getting a Baclofen pump inserted to help with his spasticity, Tim’s head began to fall forward with proximal junctional kyphosis.  It became increasingly painful, and made it very difficult for him to function, including eating, using his computer, or seeing other people.  His head was bent down 90 degrees.  His head was falling forward and over to the side, and his neck pain was becoming intolerable as well.

Friday I did a pedicle subtraction osteotomy of his proximal thoracic spine, and used the U-Rod technique to help correct his upper kyphosis and scoliosis.  I also took out his old Baclofen pump and tubing.  The surgery took about 5 hours, plus another hour for me to get out the pump from his anterior abdominal wall.  However, it was totally cool when we turned Tim onto his hospital bed --- He was looking straight ahead!

Saturday morning I saw him on rounds and saw Tim sitting straight up in bed.  The nurses were treating him to fresh Dunkin’ Donuts, and he had a very big grin on his face  I was able to correct some of the thoracic hump on his back as well, which his mom thinks will help him with positioning in his wheel chair.

So the big question is — what should we call this new instrumentation technique?  As I was driving home late Friday evening I came up with a name that would at least get a good laugh:  the “HEY U!!” Technique.  All kidding aside, I really do like the strength that this new technique provides, taking advantage of the solid rod forming a built-in cross-link that can actually be used to mount a sublaminar band or strong fiber wire suture.  Sublaminar fixation with bands really helps to spread the load.  We’ll obviously follow these first three out clinically, and tweak the technique I’m sure, but perhaps this technique might help another surgeon somewhere else.  

The great thing about it too is that it might be helpful even in the developing world, where access to things like tapered rods and cervical lateral mass or small pedicle screw instrumentation might not be available.  

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

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