Tuesday, January 31, 2012

74 yo who had adolescent scoliosis "in dark ages" now w severe pain

In between adolescent scoliosis surgeries yesterday, I saw this very healthy 74 yo woman who is now really suffering with long-term consequences of untreated and un-monitored progressive scoliosis.

This lady used to hike all the time all across country in every state except Nebraska!

But in recent years, her quality of life has taken a real "nose dive" with increasing severe low back that makes even basic activities of daily living unbearable.

In addition to her large scoliosis, she has also developed a spondylolisthesis also w stenosis at L45.

This is a good example of the long-term consequences of scoliosis which can eventually greatly affect quality of life. When treated earlier as an adolescent or younger adult, such deformities can be treated less invasively, and improve quality of life as well as posture many years in advance. Realignment of the spine in earlier years can help prevent the lower collapse which can lead to stenosis, spondylolisthesis, and the need for larger surgeries all the way down to pelvis.

While surgery is still quite possible in the older adult, there are greater risks due to osteoporosis which can lead to spinal fractures, as well as increased medical risks, and slower recovery times. This is yet another reason why scoliosis and kyphosis should be tracked throughout life with regular X-Rays and exams with at a scoliosis center or spinal deformity physician/surgeon to look for any signs of curve progression. It is also to look for signs of decreasing quality of life and neurologic function like spinal claudication, which can occur in the older adult with progressive spinal stenosis.

Even though this lady may have developed her scoliosis initially in the "Dark Ages" of scoliosis over 60 years ago, before the dawn of spinal instrumentation, there is still hope for better quality of life now. It is also important for all adults with scoliosis and kyphosis to be periodically checked, usually once every 5 years for older adults, and once a year or so for adults under 25 to try to determine if curves are progressing.

While we enjoy caring for people with spinal deformity of all ages at Hey Clinic, there are definitely advantages to stay on top of this problem earlier rather than later.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery


Monday, January 30, 2012

13 yo double curve scoliosis fixed.this morning. Adolescent idiopathic double curve 71 and 59 degrees.

Surgical time 2 hr 40 min
Ebl: 350 cc.
Blood transfused: none.
Complications: none.
Surgical Team:
Circulating Nurse Extraordinaire: Nurse Kelly
PA Assist: Rachel Robinson, PAC,
Scrub Techs: Sandra and Motorcycle Dan "Scrubs"
Cell Saver: Carolyn
Anesthesia: Dr. Atasoy.

Tunes: Sandra's choice -- Pandora with Nicole C. Mullen Radio. Afternoon choice was Dan's, which was 80's Rock and Roll.

When we showed mom and dad the X-Ray (see above), after surgery with her corrected spine, they both said "WOW!!!" out loud! That's always awesome to see the parents reaction.

Physical therapy student Jessica Pincus was our student observer for the day and had a blast with us. She was definitely fully engaged in the surgery and asked lots of good questions. She will actually be helping to take care of these adolescent patients tomorrow, with a much deeper understanding of what the treatment is all about. This picture was taken right after surgery when the incision was closed and sterile dressing applied, ready to turn.

In between surgeries, I saw two consults, one of which was a 74 yo woman who suffered with a progressive deforming thoracolumbar scoliosis for years and years. Now she has a 70 degree curve, and a spondylolisthesis and severe spinal stenosis..... She said she developed scoliosis in the "dark ages" 60+ years ago, which is why she was never screened or treated. There is still hope for this patient, but it sure is easier and safer and better to fix when you are younger. What a contrast from my morning and afternoon surgery today.

This afternoon we fixed a 12 yo with similar double curve. Her EBL was 500 cc, and received no blood transfusions. Surgical time 2 hr 45 minutes.

Both of these young ladies went to our Duke Raleigh Hospital orthopedic floor to private adjoining rooms, where there are large rooms with pullout bed for mom or dad to sleep, and another large foldout recliner if both parents want to stay! ICU is rarely if ever necessary postop. Both will be up and walking around tomorrow.

Tomorrow morning I see a second opinion for kyphosis surgery in an adolescent patient before going off to surgery.

Time to get some rest.

Dr. Lloyd Hey

Friday, January 27, 2012

55 yo retired school principle w moderate low back pain w adolescent idiopathic scoliosis

Never diagnosed w scoliosis as a child or adolescent. Diagnosed on her first job physical exam.

She also had spine fracture from being thrown in a tornado 150 feet e upper thoracic fracture age 27. That has caused some increased kyphosis.

We will be treating her back pain conservatively with a special back brace, special scoliosis physical therapy and home exercise program, and follow-up with us in a year with repeat X-Rays. Hopefully we can get her quality of life up into acceptable area, and her curve could remain stable. In meantime, she knows we are here if she needs us, should she have another bad back pain flare with her scoliosis.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Wednesday, January 25, 2012

15 yo young lady seen for second opinion this morning with painful thoracolumbar scoliosis for second opinion

Saw this young lady with her mom in clinic. She was seen elsewhere and told not to worry about her scoliosis, because her curve was only in the 20 degree range.
However, patient had reported significant low back pain that was greatly affecting her quality of life, and nothing was suggested for that.

When I saw her today, she had a 2 inch trunk shift to the left, causing her "hour glass" to be out of shape, with one hip appearing to stick out on the right. Her motor strength and sensation was normal, but she did have thoracolumbar hump on scoliometer.

Her X-Rays confirm that her curve was 26 degrees, which isn't huge, but because of the location of the curve, she did have nearly a 5 cm trunk shift to the left. I explained how this type of trunk shift can be associated with back pain. Note the green lines drawn along outer edge of pelvis, and relationship to her rib cage! On one side, it is shifted over 4.5 cm.

We got her started on a conservative program, including seeing a special scoliosis physical therapist for home training program, a special lightweight back brace, NSAID medications, and follow-up to recheck her trunk shift and scoliosis progression.

We also talked at length about the importance of tracking this curve as she gets older, since these thoracolumbar curves with large trunk shifts can lead to progressive painful curves in adulthood with severe progression of lumbar disc degeneration. If the curve does continue to progress, or if pain worsens despite conservative treatment, scoliosis surgery can help get her "hour glass" centered again, and thereby center the loads better so the back muscles don't have to work so hard. It can also decrease the loading on the lower lumbar discs, which might save her from needing a bigger scoliosis surgery as an adult, which might even have to include the pelvis/ilium.

Patient and mom were very appreciative and definitely understand better why she is hurting, with good conservative treatment plan underway.
Adolescents CAN have pain with scoliosis, even if the curve is below the 40 degree range. Conservative treatment is often effective to help the pain and allow them to get back into their active sport life and school life.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Tuesday, January 24, 2012

31 yo woman w severe kyohoscoliosis fixed this am

This 31 yo woman came up from Charleston, SC with her husband and mom.

Charleston is a beautiful city, about 5 hours away by car.

Today's surgery:

EBL 650 CC

Mom and husband Kevin were blown away by how great the post-reduction x-ray looked compared to her severe kypho-scoliosis preop.


Now back to clinic after a little lunch to see 2 more scoliosis consults and a scoliosis postop.

This afternoon, I'm operating on another 31 yo young lady from South Carolina -- This one from Polly's Island -- with a lumbo-sacral L5S1 spondylolisthesis.

Hey Clinic for Scoliosis and Spine Surgery

Raleigh, NC USA


Wednesday, January 18, 2012

Jackie doing great, walking great just 2 days after his complex revision extension instrumentation and fusion.

He'll be heading home tomorrow morning!

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

Woman and daughter drop in to Hey Clinic yesterday 15 years after complex cervico-thoracic kyphoscoliosis surgery to say "thanks"

Kathleen, now 89 years old, and her daughter literally dropped into our clinic late yesterday afternoon. She lives many hours away from Hey Clinic, but was visiting an ophthalmologist in Cary to have eye surgery. She was telling the surgeon there about me and the surgery I performed for her years ago. She then told her daughter that she wanted to go and "see Dr. Hey right now" -- so they jumped in the car after their appointment and drove the extra 10 miles to Hey Clinic in North Raleigh.

I am usually NEVER in clinic at 4:30 on a Monday through Thursday, but usually in OR 12 hard at work. But this day finished a little early, after doing an ACDF on a nurse from South Carolina who also has history of kyphosis. I remembered her and her daughter right away! What a blessing it was to see her, and to hear how her surgery changed her life. I was only in practice at Duke Medical Center for about two years in 1997 when I tackled her kyphoscoliosis surgery involving her neck and upper thoracic spine. Her head was literally in her chest, and twisted around about 75 degrees. She could basically not do anything, and was losing weight because she would choke on her food commonly, requiring her husband to do the Heimlich Maneuver. I remembered that she considered suicide her only way out. I also remember spending a lot of time trying to figure out whether it was even fixable or not, and how to handle this in a lady who was over 70 years old with osteoporosis concerns. The sublaminar wire technique with the old Luque box seemed like best option, and was really probably the ONLY option at that point since none of us were doing pedicle screws or lateral mass screws in the cervical spine in 1997.

She wanted to share her testimony with her daughter, which is given with her permission in video below. Her story brought tears to Tracy's eyes, who has worked with me for quite some time here in Hey Clinic --- a real encouragement to all of us at Hey Clinic, and to other spinal deformity surgeons through Scoliosis Research Society (SRS.ORG) to continue to help patients of all ages who have major quality of life challenges.

While I haven't seen Kathleen for over 13 years now, I remember her and her daughter well, and have actually recently been recalling her sublaminar wire and Luque box technique as I have been developing the new "U-Rod" technique, as well as sublaminar fiber wire techniques with more flexible rods to help treat patients with this condition. In fact, tomorrow I have another severe cervico-thoracic kyphosis case in patient with severe spastic quadriplegia. The mom emailed me a couple days ago and asked if I had ever done a "U-Rod" up to C2. I could only recall one going up to C4. Well, in actuality, Kathleen had a "U-Rod" -like construct, or more appropriately an "O-ROD" construct up to C2 with sublaminar wire which changed her life for the past 15 years and has held up wonderfully.

It amazes me how tough challenges, learning, innovation, repetitive experience and follow-up all work together to help figure out the next challenge. Each one is like a puzzle: at the time it can be difficult, but afterward, when you see the end result, it usually brings real joy and satisfaction to see the difference it makes in the lives of real people and their families. That solved challenge then provides greater experience and lessons learned that helps me face the next patient in need with more tools and growing wisdom to know what might be done. Surgery is NOT always an option. and I do not recommend surgery for everyone I see. But the long series of surgeries I have planned out and carried out since starting out at Duke in 1995, and years of training before that in Boston (Children's Hospital, etc) and at Duke have provided an ever-growing toolbox of skills that help me each day to serve better.

It keeps life interesting and rewarding.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Tuesday, January 17, 2012

Friend of adult scoliosis patient shares her story

---------- Forwarded message ----------
From: "Robin
Date: Jan 17, 2012 11:07 AM
Subject: testimonial
To: "Lloyd. Hey"

Dear Dr. Hey,

 When I assisted my dear 79 year-old friend for her first appointment at the Hey Clinic, I had no idea what to expect.

I had always thought  of back surgery as dangerous and an operation that yielded minor results.

 Upon watching you explain how you intended to straighten her spine and give her the option of living pain-free, I was amazed.

You seem to know backs better than you know your own name.  I left confident that you may very well be the best spine surgeon in the country.

 When I brought my friend Birgit for her surgery, I was almost dumbstruck by the care and detail that was given her.  After she was rolled into

the operating room and before I got home, your nurse called to inform me that Birgit was relaxed and surgery was to begin.

 Throughout her surgery, I received a call every hour and that was a comfort and relief.  It was wonderful to hear your voice while Birgit was in recovery teling me that she did well and should be walking by late afternoon.

 I appreciate how well you and your staff took care of my dear friend and can report that she is taller, her face is free from the pain

she dealt with every day and she is visibly happier.  The results of her surgery and the blessing of your gift have given Birgit a new quality of life and we both, are forever thankful.

 I will never forget how we held hands and prayed for all involved in her surgery, that it would go well with God's guidance.  I have never ever experienced that in any hospital or before any surgery. 

 You are truly amazing and anyone who needs competent, faithful and expert spinal care, should consider you first and foremost.

 Thank you so very much,

Robin . CEO and Founder

McDavid Public Relations and MPG, LLC

Monday, January 16, 2012

Kyphosis surgery today for Proximal Junctional Kyphosis (PJK) with new fiber wire technique to prevent PJK at top

I just finished helping Suzanne, who is a 63 yo woman with history of previous revision T11-Iliac wing instrumentation and fusion.
She did great for quite a while, but then developed proximal junctional kyphosis of 26 degrees at level just above her fusion with severe pain, deformity and thoracic spinal stenosis.

We fixed this today using a thoracic osteotomy, and extension instrumentation and fusion with a more flexible titanium rod, and a special less invasive technique at the top to gently transfer the load to the top T2 segment using sub laminar fiber wire wrapped twice around the lamina on each side to form a "lasso".  At recent SRS meeting this fall in Loiusville, many of us from around the around the world brainstormed during a special seminar on PJK to come up with new solutions, and this idea was spurred on by that dialogue as well as discussions with our NC State Bioengineering lab where we are building special computer models (finite element models) of the human spine with instrumentation constructs.

I was able to get a complete correction of that 26 degree junctional kyphosis with use of the osteotomy, laminectomy and instrumentation techniques.

New technique worked smoothly.  Brittaney was my assist this morning and did a great job along with motorcycle Dan "Scrubs" my scrub tech, and Sandra, and of course, Nurse Kelly!

We will be tracking the outcomes of this patient, along with our other patients as we continue to seek to improve surgical techniques to increase quality of life while decreasing complications and using scarce resources wisely.

Lloyd A. Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery

Sunday, January 15, 2012

Comment from adolescent scoliosis young lady from Florida

I got this comment from "T Bass" from Florida.

t.bass has left a new comment on your post "14 young lady with adolescent idiopathic scoliosis...":

Hi I had a couple questions about scoliosis surgery and I don't really.know how this blog thing works but yeah I am 13 and have been informed that I need surgery on my back I was just told Thursday but the guy could not tell me much cause he was not a surgeon I have started a blog on my scoliosis because my dad recomdemed that I should. Is there anythings I should know about it how long would it take to heal what would I be capable of doing after. Well thanks :)

Dear T Bass,
Thanks for your blog comment! It is good to reach out for people to talk to about your possible scoliosis surgery. If you drop me a message through our "CONTACT US" button at http://www.heyclinic.com, we could possibly talk over the phone with you and your folks if it is ok with your parents. I do this sometimes over Skype with out of town people, which is sorta fun. You could then write up your questions and answers and could post them on your blog. Obviously, my comments will have to be fairly general without seeing you and your x-rays.

It is important to talk to your doctor and/or his/her nurse about the specifics of your surgery, and recovery. However, there is also great information on the Scoliosis Research Foundation (http://www.srs.org) website.

Take care!

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC

Wednesday, January 11, 2012

Heres his mri. Severe stenosis L45 w facet gapping

Had iliotibial band surgery but still had leg pain

Check out how big these osteophytes are on right!  One osteophyte is draping down to level beloe as body attempted to heal across worn out levels.
Leg pain likely from severe spinal stenosis.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Sunday, January 8, 2012

Hey Clinic Week In Review: From Urgent Calls at Gas Stations on days off, through smile-filled clinic. Physician Assistant Opening.

After a very busy couple of weeks around Christmas focused mostly on surgery for our adolescent idiopathic scoliosis patients who were out of school and needing surgery, I took a few days off after New Year's to recharge, and get some projects done around the house.

On Wednesday this week, I was on my way to Lowe's Hardware, and fueling up my little diesel Jetta when a call came in from neurosurgeon from Rocky Mount. He had a woman that he saw with progressive severe weakness in both legs to point where she could not walk. I had done scoliosis surgery for this woman years before, and she had done well. Now she had a new problem with a likely severe thoracic spinal stenosis with myelopathy. As soon as the neurosurgeon started to describe her symptoms, a "switch" went off in my mind, which flips me into emergency triage mode. My home repair projects were now off the list: emergent spine repair goes to top of list. From the gas station, I got in touch with patient and family, had them run to pick up the MRI and X-Ray discs, and get on their way to hospital without eating or drinking anything. Call then to the hospital to book surgery, and to Hey Clinic to give them heads up. I arrived at the hospital and switched out of my home project jeans and flannel shirt to my other work clothes: the blue scrubs, size medium, with the blue Crocs. I get to preop just as the patient arrives. I examine her quickly. She can just barely stand on her right leg, and her left leg is completely weak. This is serious. Her husband hands me the discs, which I load into my laptop there in preop. The image to the right pops up on my screen and I see the "villain" -- an extremely tight stenosis crushing her thoracic spinal cord a couple levels above where her scoliosis fusion was done.

We get her back for surgery, and her evoked potential monitoring shows really no signals in either lower extremity. In surgery, I find a HUGE facet cyst coming off her left T10-11 facet joint, which formed a huge egg-like mass over 2cm in diameter, crushing in on her cord. This is by far the biggest facet cyst I have ever seen, at a very dangerous location. I decompressed the two tight levels, and her evoked potential monitoring started to show some signs of life in both lower extremities. Cool. I then extended the fusion up 3 levels to stabilize this zone. Postop she started to improve right away, regaining her feeling and strength over her few days in the hospital. She was discharged to rehab yesterday with nearly full strength in both legs and walking well! A great start to 2012.

I did 2 elective surgeries on Thursday, which included a lumbar scoliosis on a gentleman from Florida, who also had severe multilevel stenosis. He did very well postop, and went home to stay with his sister who lives in Beaufort for a couple weeks. I also did 2 level ACDF on Thursday on a 38 yo with severe neck and arm pain. She did well and went home Friday after staying overnight.

In clinic Friday, I saw a bunch of postops, including several adolescents and young adults who had spinal deformity surgery.

This young lady with severe spastic quadriplegia cerebral palsy is now several months postop from a thoraco-lumbar sacral-iliac wing instrumentation and fusion. She was ALL smiles in clinic, in part because of her new erect sitting posture and much improved comfort and appearance, but also because of her new boyfriend! Love is great. Apparently she got to go to a Duke basketball game recently, which was a lot of fun.

This young lady was back with her family after her adolescent idiopathic scoliosis (AIS) surgery with a beautiful posture. It is definitely a family effort and journey to go through scoliosis surgery, and it is great for me to see how each family rises to the occasion to encourage and help their family member through the process.

This lady had adolescent idiopathic scoliosis that was never treated. As an adult, her scoliosis collapsed terribly, causing severe pain, trouble standing and walking and a very abnormal posture. She is now three years out from surgery with a great standing posture.

It is important to continue to have your scoliosis checked as an adult on a regular basis, even if you are "done growing" and your pediatrician may have told you not to worry about progression. With accelerated disc degeneration which can occur with scoliosis, the curves can definitely start to collapse, and do so in an accelerated fashion. This collapse can then also result in severe leg symptoms with spinal stenosis.

This lady had a degenerative scoliosis with severe spinal stenosis, and had trouble even walking around house preop. She now stands up straight and is graduating, and can walk long distances without significant pain.

This young lady had spina bifida / myelomeningoceole as a newborn, with early detethering and meningocele closure and fusion as a child, with some chronic spinal cord deficits. She then had collapsing scoliosis as a young adult, with worsening neurologic status and had surgery with me a couple years ago. It was great to see them back. She has made dramatic improvements with excellent physical therapy, personal drive, and family support.

Here is another one of our postop adolescent idiopathic scoliosis patients back for follow-up visit, with a beautiful posture and doing well in school and with sports/exercise. I have actually done spinal surgery on her mom as well, who was there with her today, and also quite thankful for her own surgical results, before she entrusted her daughter to us for her surgery!

This man and his wife came all the way back from Maryland for his six-week postop visit, in large part because they were just so thankful for his excellent pain relief. For most of our out of State guests, we try to minimize the need for lots of travel by getting imaging done locally and then sent to us, and then talking on phone/Skype and/or via email. This gentleman had severe adjacent level spinal stenosis and spondylolisthesis from a surgery performed in Maryland years ago. Preoperatively he got to the point where he could not do his carpentry and his quality of life was horrible. He was sent to us by a family in Maryland that I had helped with surgery over six years ago. This other family actually helped this man financially to get the surgery done down here in North Carolina -- an incredible act of generosity to help a neighbor.

This young lady from the Outer Banks 3.5 hours away was back with her husband for her six week postop. She had flat back syndrome with collapse below an old scoliosis fusion, and had history of adolescent idiopathic scoliosis. She now looks and feels awesome, with her normal "sway" returned to her low back, and is getting back to a much improved quality of life and outlook. Both her and her husband were extremely thankful, and wanted to make the long drive to say "Thanks" to the whole Hey Clinic Team. She has an anterior ALIF at L45 and L5S1 as well as posterior thoracolumbar-sacral-iliac wing instrumentation posteriorly. She is back into a very active exercise program.

This young lady had a severe kyphosis as a young teenager, which I fixed for her years ago. Unfortunately she developed a problem called proximal junctional kyphosis (PJK) above her fusion over past couple years, which is known complication from especially kyphosis and some scoliosis surgeries. I did a revision extension instrumentation and fusion for her, going up to the cervical-thoracic junction. Her posture has now been restored to normal, with also relief of the severe pain she had developed in that upper thoracic area. She is working toward becoming an occupational therapist, and I am sure will be a compassionate and excellent caregiver. Her family has been incredibly supportive of her.

This lady was also back for postop follow-up for her lumbar scoliosis. Her posture now looks great and strength restored.

Saturday I did one urgent surgery on a 38 yo from Wilmington, NC. He is now doing well.
Yesterday afternoon I had a relaxing afternoon with a walk through the Duke Forest with the dogs and family -- 65 degrees and sunny!

Today after church I've been reviewing applicants for an opening we have for a physician assistant (PA) for Hey Clinic. If you know of any good physician assistants who may want to join our team to help us serve our patients, please let us know. You can find more information about the opening on the TAPA website: http://www.trianglepas.org/Home/EMPLOYMENT.

Hope you are all doing well!

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery