Saturday, December 22, 2012

124 Degree Adolescent Idiopathic Scoliosis in 20 yo young lady

I apologize for not blogging sooner, but this is the first time I have had a moment to put my feet up for the last couple weeks as we have all been quite busy caring for many scoliosis and kyphosis patients of all ages at Hey Clinic and Duke Raleigh Hospital.  Over the next couple weeks, I'll get a chance to catch up on some of the stories and will share some of them with you here on the blog.

Kayla's story is quite dramatic.  At some point Kayla and her mom may get a chance to write up their full story to share with all of you.  The short story is that Kayla was diagnosed with scoliosis when she was around 8 or 9 years old, and then was braced for a period of time.  Her pediatric orthopedic surgeon decided to stop practicing, and Kayla's mom did not really have somewhere else to take her.  When Kayla was 11, she saw another doctor who told her that she needed surgery right away because the curve was getting very big.  Kayla's mom was very concerned though, because Kayla in her mind had much more growth remaining and the surgery might stunt her growth.  She was especially concerned about this because Kayla's brother grew well into college.  Apparently the orthopaedic surgeon at that time didn't explain to Kayla and her mom about remaining growth and the possible risks of delaying Kayla's surgery, and Kayla's mom was really against surgery.

So, Kayla just grew up, but as she got to be in her later teens began to develop severe low back pain, and a very obvious severe deformity.

As the pain got to be too much to handle, she went and saw another spine surgeon this fall in Charleston, SC, who then texted me with her X-Rays from his clinic.  The curve was so big that he could not be confident of the curve measurement.

cord abnormalities.

We then saw her and her mom at Hey Clinic.  Her curve measured around 124 degrees and she had severe collapse.  Pulmonary function tests showed that the scoliosis was definitely having a large effect on her pulmonary capacity.  The MRI showed the severe deformity but no spinal cord abnormalities.

A couple weeks ago, Kayla and her mom came up from South Carolina for her surgery.  Her surgery took around 9 hours, and involved making several complex osteotomies around the apex of her deformities, including a partial vertebral column resection, and pedicle subtraction osteotomy.  A bony tether was identified along the apex of her deformity on the left thoracic side, which probably occurred during early childhood, and set her up for this very severe deformity.

While the surgery was long, she did very well with good cardiopulmonary and evoked potential monitoring function.  4 levels of the spinal cord were exposed along the apex of the deformity to complete the osteotomies.  As shown in postop X-Ray above,  were able to get a very good correction, and she is how several inches taller, and in good balance, very pleased with her new posture.

She did well postoperatively, but was in the hospital for about  a week, returning home to South Carolina earlier this week.  Both Kayla and her mom were thankful for care they received at Duke Raleigh Hospital.

We are all thankful Kayla has done so well after this major reconstruction.  While it is truly amazing what can be done with modern scoliosis surgery, there is no doubt that "a stitch in time saves nine".  Cases like Kayla should encourage families who have children with possible scoliosis to ensure their children do get screened and continue with follow-up X-Rays and examinations and earlier treatment.  This helps to decrease risk, and maximize correction and long-term outcome.  Yesterday in clinic, for example, I saw at least 4 postop patients who I corrected with curves like Kayla who I fixed when the child was 9-12 years old, who had about a 3-4 hour surgery, with much less risk, and much easier recovery, shorter fusions, and better final correction.  Here ia a photo of one of these children I fixed a year ago this week, doing great, with no visible deformity.  She had her surgery when she was 12, with preop curves around 60 degrees.  Usually we prefer to fix these curves when they are in the 40's.

In previous blogs, we have talked about the issue of remaining growth, and when we have to worry about that, and consider growing rods or Shilla Technique instrumentation, which both allow for growth with the hardware guiding the scoliosis during further growth.  This is usually an issue for children under age 8 or  9, who still have significan spine and chest wall growth remaining.  The key thing to realize is that different parts of your body grow at different rates during the entire growth process. For example, babies start off with relatively large heads (which is one reason they look cute!), and the rest of the body grows relatively quicker over time, so the head ends up being smaller relative to rest of the body.  Similarly, the spine grows more slowly during adolescence, with most of the remaining growth coming in the lower extremities.  Some growth can occur in the spine in the area where the fusion occurs, which actually may help make the curve get somewhat straighter, and the area of the spine outside the fusion also grows normally after spinal fusion.  The scoliosis correction itself obviously creates a sudden "growth spurt" on the operating table, as the lost height through the curve is restored as curves are straightened out.   In the old days, before we had strong segmental instrumentation, there was concern about a problem called "crankshaft phenomenon", where the spine could potentially curve around the Harrington rod, causing some increased deformity after fusion in very young children.  That problem seems to not occur with modern pedicle screw segmental instrumentation.

In any case, seeing X-Rays like Kayla's should certainly motivate any parent to keep a close eye on their children's curves with the help of your local scoliosis expert.  You can find scoliosis experts near you through the Scoliosis Research Society ( website.  I wanted to thank my SRS colleagues Dr. Sig Berven, Dr. Steve Glassman and Dr. Larry Lenke for their preoperative input on Kayla's surgical plan options.

Get well soon Kayla and have a good Christmas!

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