Tuesday, September 18, 2012

11 yo scoliosis straightened up nicely -- intra op photo

Our 11 yo scoliosis patient straightened up nicely with less invasive, shorter fusion.  She had good preop bending X-Rays showing her upper curve bends out nicely, as well as lowest part of her lumbar curve.

Surgical time:  2 hours 15 minutes.
EBL:  300
Correction:  very nice.

Out to talk to family.  They should be quite happy!

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

40 yo woman with painful thoracolumbar curve fixed yesterday; 11 yo 50 degree thoracolumbar adolescent idiopathic scoliosis (AIS) to be fixed this morning

Yesterday we straightened up a 40 yo woman with painful collapsing thoracolumbar scoliosis, just under 40 degrees.  She had been suffering with back pain for quite some time, and it was definitely affecting her posture and appearance.  She developed a lateral spondylolisthesis at L34 as a result of the curve, with the L3 vertebra gradually sliding downhill on the sloped L4 vertebra, resulting in progressive disc degeneration and facet arthritis.

Her surgery went very well, and fortunately as shown on her MRI, her L45 and L5S1 discs were still in good shape, so we could stop her fusion at L4 rather than going to the pelvis/iliac wing.    We got her straightened up quite nicely, and her big hump on lower left back is gone, and "hourglass" figure restored.

This morning I am at WakeMed, here to straighten up an 11 yo young lady who has the same curve as the woman we straightened up yesterday.  This young lady has a 50 degree curve already, which is why we are fixing it now.  Will get you an update later.  Time to scrub in!

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

Monday, September 10, 2012

Back from SRS. This morning's scoliosis surgeey

Got back to Raleigh Saturday afternoon from SRS in Chicago.
Had to cancel first scoliosis surgery, so moved up second surgery for our 58 yo woman w very painful collapsing scoliosis.
Time to suit up. Good to be back w to clinic and OR Room 12!
If you get a chance, sign up for eText at Srs.org. awesome free online spine textbook!!!
Lloyd A Hey, MD MS

Friday, September 7, 2012

Art Institute of Chicago!!!

Very cool!


I am riding bus to Art Institute here in Chicago after another action-packed day at SRS international scoliosis meeting.

After the meeting, i quickly changed into my running gear and ran down to the Navy Yard. It looked kinda windy out on the water w lots of white caps, but i was running in the lee of the buildings. As i got out to the point of dock, all of a sudden i was hit ny a blast of wind that literally stopped me in my tracks!!  Moving forward seemed impossible!  I stuck my arms out to see if i could just take flight, but was unsuccessful.

Rest of run went great. Pretty city!

Dr. Lloyd Hey
Hey Clinic

Wednesday, September 5, 2012

Day 2 Scoliosis Research Society 2012

My day today at the SRS Meeting here in Chicago started at 6:45 am with breakfast, and looking over many of the poster presentations, and having a wonderful meeting with Steve Schwab from SurgiMap regarding their spinal deformity measurement software.  We are working on ways to integrate tools like SurgiMap into our Hey Clinic comprehensive quality control information system and electronic health record as we continue to weave outcome assessment and quality improvement into patient and family care.

The actual presentations got started at 8:00 sharp, and have been literally going all day, including a luncheon symposium.  Major focus today was on what changes have occurred in the last 10 years in spinal deformity treatment for children, adolescents and adults, and what challenges still remain for the next 10 years.

A couple of key takeaway points I found was when Dr. Peter Newton from San Diego Children's Hospital talked about genetic testing for scoliosis using the ScoliScore, and how the possible benefit is not worth the $2,900 cost of the test, since it doesn't significantly change the need for careful follow-up.  That was my opinion from the very beginning of the commercialization process of this test, first released a few years ago at SRS.  At the end of the day, having an experienced scoliosis team, combined with careful follow-up is the only way to really know which way and how far the curve is going to go!

I got a chance to see a couple of my old friends from Boston Children's Hospital, including John Emans and Tim Hresko --- both doing very well.  Continue to be very thankful for the great training and mentorship I received there in residency, fellowship and chief residency, and always enjoy to go back.  Got a chance to review a possible adolescent revision surgery with Dr. Emans, which was very helpful as usual!

Several good talks about the benefits vs. risks/costs of scoliosis bracing for adolescent idiopathic scoliosis (AIS), with special note of the lack of really tight, very long-term well controlled studies to confirm efficacy.  There is certainly some evidence that it could have some benefit of slowing curve progression and decreasing the rate of surgery at least at point of skeletal maturity.  However, other data was presented to show that compliance as well as psychological and emotional effects are possible with bracing that can last well beyond the bracing period.  This is all consistent with our family-oriented, personalized, thorough dialogue we have with scoliosis families before prescribing the brace so that the adolescent or younger child as well as the parents are fully informed and are not just rushed off to the brace shop.

Late afternoon I went to a smaller symposium on case presentations for adult spinal deformity.  I heard good comments and case presentations from Dr. Chris Shaffrey from UVA, and Dr. Khaled Kebaish from Johns Hopkins, and an interesting case presentation from a surgeon from Glen Cove Community Hospital where I was treated many years ago.  I got a chance to share about some of our latest biomechanical and clinical innovations we have been working on at Hey Clinic, including new Proximal Junctional Kyphosis (PJK) surgical techniques, including the use of less invasive fixation and more flexible rods to help in this effort.  Several scoliosis surgeons from Japan came up to me after the talk and agreed with our approach, and have been working on other sublaminar techniques even at bottom of long constructs, combined with more flexible rods in these more complex deformity cases.  How awesome is this, to be able to share with doctors half way around the world, to continue to improve our ability to diagnose and treat children, adolescents and adults with spinal deformity!  The SRS is definitely a very supportive international community to accomplish this mission.

Dr. Lloyd Hey

SRS - Scoliosis Research Society Begins!

Well, some people are into motorcycles or cars, some are into music, and some are into fishing.... but... for those of us who are REALLY into scoliosis and kyphosis, the annual Scoliosis Research Society is the absolute must go to "Rock Concert!"

I just walked into this huge hall here at Chicago Sheraton, and I must admit, my heart jumps with excitement!  Shortly this hall will be filled with spinal deformity experts from around the world.  Even though I've been in this scoliosis world for over 20+ years, there is still more to learn, and more to share.

Yesterday's SRS Adult Deformity Committee Meeting was really good, catching up with Dr. Steve Glassman and others.  Sig Berven did a great job as Chair, with new scoliosis outcomes database being discussed and planned to enable all SRS members to collect prospective outcome data integrated in their practice.  I am hoping to use my epidemiology, information systems, and quality control engineering background combined with 20+ years of innovation to help in this effort.  An Adult Spinal Deformity Treatment option paper is also being developed, with the hope of using it to help guide patients and families and policy makers on the process of helping spinal deformity patients make decisions around their treatment options, including surgery.

Had a nice dinner last night overlooking the water at the Navy Yard, while catching up with my son on the mobile.  While Chicago is known as the "windy city", the winds were quite gentle, with sailboats just scooting gently along -- bright sky above!

The clock is ticking down, and the conference is about to begin!

Lloyd A. Hey, MD MS

Tuesday, September 4, 2012

Francesca, Summer College Intern Hey Clinic Answers

Dear Dr. Hey,

Here are my responses to your questions:
1.     1. I’ll list off a baker’s dozen (in no particular order):
1.     The patient’s history is the most important information you need in order to figure out a course of action.
2.     The procedure for the physical examination performed on each patient; I was particularly struck by how simple each exercise was and yet how helpful it was in determining the condition of the patient (for instance, strength tests and asking them to walk across the hall normally/on their toes/on their heels). For some reason I have always imagined diagnosis as a long complicated process but in many cases it’s quite simple, especially when you can easily isolate the location of the problem with a series of physical tests.
3.     That 90% of your cases are resolved conservatively and without surgery.
4.     Connecting emotionally and not just professionally with the patients and their families is pivotal to gaining their trust.
5.     I knew that an operation is not a one-person task, but it was fascinating to learn about the role of each person in the OR and how everybody works together like a team to make everybody else’s role go as smoothly as possible.
6.     It’s the patient’s decision in the end, not the surgeon’s: you can provide advice and educate the patient on their options, but it needs to be clear that the decision for a course of action is in the patient’s hands.
7.     A useful introduction to reading x-rays and some MRIs.
8.     What goes into a post-op.
9.     How one maps out the spine: the cervical, thoracic and lumbar regions and how to analyze different risks for a surgery patient based on the region that will be operated on (for instance, cervical operations contain a larger risk for paralysis.)
10. How to prep someone for surgery (especially in the role of the anesthesiologists.)
11. The simplest (most elegant) surgical and diagnostic techniques are the most practical.
12. All the precautions taken to ensure patient comfort and to minimize the risk of infection as well as blood loss.
13. TAKE CARE OF A PROBLEM WHILE IT’S STILL SMALL! And when given the option between muffling a problem and fixing it, fix it.

2.     2. I define compassion as seeing pain or discomfort in another individual and making a genuine effort to be a part of the solution. I saw it all over the place these past few days: in the OR when you did everything possible to minimize the patient’s pain, prior to and post surgeries when speaking and praying with the patients’ families, in clinic when communicating with the patients and relating with them on a personal level. You were able to appeal to each case personally and really reached out to each individual and what was important to them. It was also very nice to see that the patient’s family and friends were integrated into the healing process as they were given regular updates and educated on exactly what the patient was going through and why. Every day you improve the quality of life of multiple patients, which is what makes healthcare an extremely compassionate profession. I think all the thank you cards and pictures around your office speak for themselves on each patient’s deep appreciation for compassionate, high-quality healthcare. Self-sacrifice relates to compassion in that you are sacrificing time that could be spent with family, friends, or relaxing, traveling, and doing hobbies. Like you said, there isn’t much downtime in the clinic and hospital. However, the passion with which everyone worked every day made it clear that the benefits of the job, the satisfaction of saving and improving priceless lives every single day, far outweigh the inability to for instance, sleep in, or spend the day on the lake, or hang out with friends every day.

3.     3. One particular experience that struck me was how quickly you were able to gain the French man (I am terrible with names, which is something I need to improve on, but I believe it was either Edgar or Oscar)’s trust and how that quickly changed his opinion on his health care. He came to you with a handful of negative experiences with other doctors and clinics, but you were extremely approachable and honest with him from the start, explaining exactly what was medically wrong with him, offering more possibilities than just surgery to help him out, which really seemed to set his mind at ease. Every physician has their own opinion, but it’s really important to remember that ultimately you can only guide them in deciding what to do and educate them. Like you said, there are a lot of doctors out there who would propose surgery as the solution to an issue that could potentially be fixed much more conservatively. Another memorable experience was with the 16-year-old boy. There are so many factors that go into someone’s decision about whether or not they are going to undergo a surgery, and knowing and understanding these factors (for instance, the passing of the boy’s father) is essential. Not emotionally appealing to a patient could lead exactly to the French man’s experience with other doctors: a lack of trust and negative experiences, which carry a significant psychological toll on the patient.

4.     4. Studying seriously is important to build knowledge about the human body. Spending time with friends and family, helps learning how to listen to people and how to communicate with others. Interacting with people of all ages in addition, gives a chance to be exposed to different perspectives and learn how to communicate with people of different backgrounds. Finally, spending time with kind professionals like you in the summer, puts all the above in a realistic medical setting. Physically, staying fit (which in my case will be accomplished by running track for UChicago) and eating well are key to a healthy and happy future.

Thank you very much for giving me such a great opportunity this summer. I will be out of town (Canada) from tomorrow morning through September 5th. I head back to Chicago in the afternoon September 15th, and I have appointments in the afternoon on September 10th and in the morning on the 11th. Any other day and time before the 15th would work for me, so we could meet whenever and wherever is most convenient for you.
Thanks again!

Off to Scoliosis Research Society, Chicago

I am sitting in the "Golden Crown" Family Restaurant in Lansing, Illinois, about 30 minutes south of Chicago.  I've got my laptop open, connected with my Verizon phone Hotspot.  Just sent back the Baked Scrod, which was really quite inedible. First time in my whole life I've sent something back! The Cobb salad just arrived and looks good.  Coffee is ok.  Just landed this morning from RDU, after smooth flight into Lansing Municipal.  John took really good care of me there.

I am on my way to the Scoliosis Research Society (SRS.ORG) Meeting in Chicago.  The SRS website is a great source of information, and can also be used to find a scoliosis surgeon in your area ---- ANYWHERE IN THE WORLD!  I serve on the SRS Adult Deformity Committee, which meets this afternoon.  There should be a very good white paper coming out shortly on the indications for scoliosis surgery in the adult.  I am also interested in exploring the continuity between the pediatric and adult deformity population, including how we can seek to intervene earlier to help save motion segments in the lower lumbar spine, with less invasive approaches.

I will try to share some highlights from SRS over next few days on the blog!

Had a long talk this weekend with mom of an adolescent idiopathic scoliosis patient, who had surgery performed elsewhere, and has large residual deformity with pain.  Discussed various treatment options.  Revision surgery is sometimes indicated for pain and imbalance, and to help improve loads on lower lumbar spine for disc preservation.  If you are going to consider revision, it is helpful to do it sooner rather than later, since not only does the postero-lateral fusion get more solid with time, but the anterior discs become stiffer and stiffer, eventually turning virtually to bone.  To correct deformity at that point could require a more invasive osteotomy, like a vertebral body resection or VCR.

We have done quite a few revision deformity surgeries, for both kyphosis and scoliosis.  In many cases, however, after we evaluate the patient we might suggest not proceeding with revision surgery and just following it conservatively.

Now that Labor Day is passed, I want to say Thank You to all of our Summer Interns who served at Hey Clinic this summer!  You guys were just awesome.  Francesca just finished up with us, and sent me an email to share what she learned this summer.

Well, I am going to get back to finish my Cobb salad and head North to Chicago!  Looking forward to see Dr. Sig Berven and others at the meeting.

Dr. Lloyd Hey