Monday, January 28, 2013

This past week in review! Seeing Kayla for her 6 week postop check

This blog is a chance for me to reflect on powerful experiences, and memorable patients and families which I don't want to forget.  Life can be so busy, rushing by with one thing after another that probably all of us don't take enough time to reflect, and be more aware of all of the special people who cross our path, and become a part of our life.  For some of you, I understand, it is interesting to read these stories and see some of the pictures of the special people I've had a chance to meet recently, or have known like family over many years at Duke and Hey Clinic.

One of my happiest moments this week was seeing Kayla and her mom from South Carolina back for her 6 week postop visit this past Friday.  Kayla is the 20 yo young lady who had two curves, both over 120 degrees, that I corrected with a single 9 hour surgery at Duke Raleigh Hospital.  Her previous blog entry from her surgery and her preop story can be found by clicking HERE.  Whew.  That was a day!  Preop, I got helpful input from several Scoliosis Research Society (SRS.ORG) colleagues, including Dr. Steve Glassman, Dr. Sig Berven, and Dr. Larry Lenke.  SRS not only does great research to help improve scoliosis care, it is an international supportive network of scoliosis experts who actually collaborate and help each other serve patients better as well.  Each of us has different strengths and "tricks of the trade"  -- which we can share and come up with new solutions.  Many thanks to Steve, Sig and Larry for their help --- the end result was worth the time!

Kayla was just so happy with her new posture, already feeling much better than preop and looking great --- 3 inches taller!  Notice how her trunk is now balanced over her pelvis (the hourglass figure is back, and the big creases are gone), her shoulders are nice and level, and her chest also is derotated considerably, improving her posture from the front as well as the back.  The "humps" have been reduced down to reasonable bumps that she's very happy with. We all had many thanksgivings as Kayla now begins to start a whole new chapter of her life.  Her before and after clinical photos and X-Rays made her mom go "Wow"!

Many thanks also to my highly skilled scoliosis surgical team in Room 12 at Duke Raleigh Hospital that work with me day in and day out four days a week to help folks like Kayla and her mom.  Thanks to the awesome nurses, physical and occupational therapists from our Orthopaedic / Scoliosis / Spine Unit at Duke Raleigh Hospital who also do such a great job with our adolescent, young adult and older adult guests and their families.

You're lookin' great Kayla!  Look forward to see you back again in a few months.

Thankfully, most of the guests we see at Hey Clinic have curves that are less than 120 degrees.  There are obviously lots of benefits of catching the curve earlier!  We started off Monday morning last week with a family who drove 5 and a half hours the Sunday before so they could meet with me for a second opinion at 7:30 am before I went in for surgery that day.    She's a very nice 12 yo girl who was just recently diagnosed with scoliosis, put into a brace, and very quickly had her curve continue to progress until now it was about 60 degrees!  As shown in photos below, you can see her big trunk shift the the right, with a large right hump.  With forward bend, she has a very large rib hump with the Scoliometer reading over 20 degrees.  She has not started to have her period yet, and her Risser Score is 0, showing that she has a lot of growth remaining.

We had a very good dialogue about her scoliosis, and concerns about her remaining growth.  The curve is now way too big for bracing, and surgical correction sooner rather than later will give her the best possible correction with the least risk, and also likely preserve more "motion segments" which is important later in life.  As we have discussed in PREVIOUS BLOGS, surgery will not "stunt" her growth -- she will actually have a huge growth spurt on day of surgery, and her spine can continue to grow normally outside the fusion area, and also can grow somewhat within the fusion area, which could even help straighten the curve a bit more.  Most of the longitudinal growth at her age occurs at hips and knees, with less growth occurring in the spine at this stage of development.  Please check out Chris Moore's excellent blog entry on this topic (click here for more on spine growth).

I was sent another young lady shown on the left here with a similar curve this past week, who was already seen by an excellent local spine surgeon, who measured to have a 30 degree curve, and had a brace ordered and fitted and then sent to us for further follow-up.

My nurse practitioner and I remeasured the outside X-Rays and actually found the curve to be around 46 degrees, which is actually too big for bracing.  You can see her similar trunk shift to the right as our young lady above with a similar thoracolumbar curve.  We do see quite a few second opinions for scoliosis, not just before surgery, but before bracing as well.  We measure so many scoliosis and kyphosis X-Rays every day using special software that it helps us possibly end up with different readings from the outside radiologist, pediatric orthopedic surgeon, neurosurgeon or chiropractor.  It is also important to make sure that the X-Rays are taken properly with the right equipment, preferably in a "PA" posterior-anterior beam shot rather than "AP" ---- this gives less radiation to the breast area.  We always try to use outside films and import them into our custom information system database and electronic health record, but sometimes we do need to get additional images, such as a lateral image, if not done by the outside doctor or clinic.  Mom was bummin' out a little bit here, since she did have a high out of pocket expense for the brace, which her teenage daughter wasn't exactly psyched to wear anyway!  Spending some extra time talking about bracing with the adolescent and family is time well spent before making a major investment in a piece of plastic sculpture that may not make it out of his/her closet!

 Last week or so we also helped this lady with severe athetoid cerebral palsy, manifested mostly with scoliosis in her neck region, due to unbalanced muscle forces.  Take a look at her CT scan that shows how this imbalance of forces led to her cervical spine discs and facet joints completely wearing out!  We were able do to a multilevel cervical ACDF procedure to decompress her nerves and spinal cord, while also help greatly diminish her neck pain!  She is also thankful that she can now hold her head up straighter.  

Another really interesting patient we helped this past week is this 66 yo lady who came to us with progressive weakness and clumsiness in her arms and legs.  Her X-Rays showed a slightly increased atlanto-dens interval (ADI), which only moved a couple millimeters with flexion-extension.  Her MRI showed a severe pinch of the spinal cord at C1 with cord changes suggesting myelomalacia, or "flash lesion" in the spinal cord. Not good.  In general, one might consider doing a laminectomy as well as an instrumentation and fusion for this problem, but I was curious to see if we could come up with a less invasive option to help preserve her neck range of motion and flexion-extension, and also have a surgery with less risk.  I actually took about 3 hours one afternoon and early evening last week, and got into "study mode" in our Duke Raleigh Hospital Doctor's Lounge combing through hundreds of articles to find case reports of patients like this that were actually treated with less invasive laminectomy only procedures.  3 papers in particular -- one from Italy, and two from Japan gave me great hope that the less invasive way was the way to go,  when combined with my biomechanical understanding of the underlying stability of the C1-2 joint based on the flexion-extension films.  Dr. Bob Wheeless, one of my former Duke Residents, and original author of the "Wheeless Textbook of Orthopaedics" Online Textbook, popped in to say "hello" when I was in my study mode, with 2 computers open, articles printed out and strewn around, and obviously deep in thought.  Bob, a fellow "Nerd" like me was impressed and psyched to hear what I had learned so far.  Bob's wife used to work for my lab at Duke, the Center for Clinical Effectiveness years ago.

So, I was able to give this lady a call before her surgery, and propose the less invasive approach, explaining the risks vs benefits, and she was psyched to give it a try.  As a result, her surgery actually took about an hour as opposed to several hours, she had much less risk, and her recovery was very quick -- going home the next morning with good neck motion and her arms and legs coming back to life!  I told my family that evening that I ended up spending probably 5 times more time planning her surgery than it took me to do the surgery itself!  For my student readers, just remember that the learning never stops, and you can always continue to enjoy digging up new ways to solve complex problems.

I saw a bunch of postop patients back in clinic this past week, including this 40 yo woman to the left, who is so pleased that we were able to restore her posture and get her curves down to nearly perfectly straight!  She had been told that usually you don't get much correction for adult scoliosis compared to kids / adolescents, and there is some truth to that ---  the curves are definitely more flexible in the younger group, which is a good reason to fix them earlier rather than later.  However, there are quite a few tricks that can be used, including osteotomies, and special instrumentation techniques that can allow us to get really awesome corrections in a lot of adults.

We enjoyed having Dylan with us this past week, a pre-Med from UNC who got a chance to see surgery for the first time, and hang out with us in clinic.  He wrote up his experience just spending 6 hours with our team, and I was blown away by what he learned not just about the spine/medical facts, but about what should drive you as a compassionate physician.  Great job Dylan.  We'll hopefully get to share your learning in future blog.

ICE STORM FRIDAY!  This past Friday we were dealing with an impending ice storm in the Raleigh-Durham area, and I really wanted to close the clinic by noon to let my staff get home, and ensure my patients didn't get trapped on the side of the road.  We had a really bad ice storm here back in January 2005, which left all of our roads like a skating rink, and hundreds of students and others trapped!!  I ended up deciding to sleep in my office that night, since my anterior-posterior reconstruction patient for surgery who had arrived from out of town would have been totally HOSED if I could not make it in.  Anyway, Shelbi at my front desk told me that we couldn't really close early, since one of our adolescent scoliosis patients was coming all the way from Asheville, NC to see us (5.5 hr drive), and the mom had to also go to UNC in the morning to see a doctor herself, and would come over ASAP.

During the day on Friday, we saw a bunch of postop patients, including Adreanna, who is a 17 yo young lady who had a very complex congenital scoliosis at her lumbosacral junction who was back for her one year follow-up looking and feeling great!  Man, a lot of planning went into her osteotomies.  Great to see you Adreanna!

I also got to see Abby back.  Abby is in her 30's, and I did a complex anterior/posterior revision scoliosis for her 5 years ago, and she is still doing well and just wanted a checkup.  I wrote a blog about Abby when I was doing Christmas Eve shopping at her jewelry store about 3 years ago.  You can see that blog by clicking HERE.  Since then, Abby had some news to share:  she had a new baby boy!  So, if you wonder whether you can have a baby and carry a baby to term, and successfully deliver a baby --- even after complex scoliosis surgery -- Abby will tell you "YES", although in her case her obstetrician recommended C-section due to the pelvic fixation.  Abby was even able to have a spinal anesthesia for her C-section, but it required a little extra effort from the anesthesiologist to get it in with the spinal fusion.

Toward the end of the clinic I saw George and his wife -- he's doing great just a few weeks postop from a revision extension decompression fusion with TLIF.  He's a very active guy, and needs to be reined in a bit postop to ensure he doesn't overdo it.  Both he and his wife gave me a big hug, and handed me a dozen eggs from their own chickens.  The eggs were absolutely huge!!

So time kept ticking away past noon, and still no sign of our family travelling from Asheville.  The snow and ice were definitely falling outside, and the traffic report sounded bad.  I hoped and prayed this family was not stranded somewhere along the way.  But then, just around 2 pm, they arrived!  Well, her doctor appointment at UNC took longer than expected, but we all did hang out until 2pm and saw her and her mom.  They were WAY thankful that we waited, and we got her and her scoliosis squared away.

After doing my late afternoon rounds (carrying my eggs out to the car first), I made the drive home which was definitely a challenge.  I had about an inch of ice on my little VW Jetta by the time I got home, but the car stayed on the road well.  I saw lots of SUV's and other cars off in the woods along the way --- we don't do winter too well here in North Carolina!

During the day on Friday in clinic, one of my friends who is a spine surgeon in Raleigh contacted me via email to help his "best man" in his wedding who has a son with scoliosis from Louisiana.  Friday evening once I got home and had some dinner I was able to look at the clinical photos and X-Rays that were sent to me, remeasure them, and then call the dad back in Louisiana and go over the results.  Out of State second opinions like this are common for us at Hey Clinic.  Always remember there may be a scoliosis expert near you that you can find at SRS.ORG, but for some families they like our Hey Clinic approach and team and choose to make the trip, starting first with an email / phone consultation.  This physician family will actually be coming out for a visit in mid-February, and we will arrange for a hospital tour of Duke Raleigh Hospital with our Patient Navigator Holly.  Our clinic is less than 20 minutes from RDU Airport, and some folks come in and out the same day.  There are convenient hotels across the street from Hey Clinic, which sits right next to Duke Raleigh Hospital.

On Sunday morning I got an anxious scoliosis mom email sent to Hey Clinic at 4:15 am, which I saw at 7:30 am when I was sitting down to have a cup of coffee.  "Contact me ASAP!!", she said.  Well, I felt led to drop her a quick text back, and she returned the call about 9:30 am, and we agreed to meet this morning at 7:30 at my office before surgery.  Her 12 yo daughter Celeste has a significant 50 degree double curve with severe back pain, which is rapidly progressing.  She texted me later today and thanked me for getting her in so soon and giving her, and Celeste peace of mind and a good plan to get her straightened up sometime soon.

Probably my most memorable scene from this past week was on Tuesday, just before doing scoliosis on Madelyne, a very sweet young girl with a rapidly progressive scoliosis currently just over 40 degrees.

Madelyne's parents actually did something you may want to consider:  they actually scheduled a separate appointent to come in and meet with me before Madelyne's surgery to ask questions without Madelyne being there.  They had some other questions, and felt more comfortable doing this dialogue with just the 3 of us.  They left feeling very peaceful about the upcoming surgery.

On Tuesday morning, Madelyne was in the nice private room in preop where we put our scoliosis patients with their parents.  I went over everything with the family, and had a brief prayer with them at their request, and shook each of their hands.  As I was just exiting the door, Madelyne's dad asked me to wait just a minute.... I thought he had one more question.  Instead, he grabbed my hand, looked me in the eye and said, "I know you will take great care of my daughter... I have all the faith in the world in you and your team... but do remember how precious Madelyne is to all of us."

"I definitely understand, and will take excellent care of your daughter", was my reply with a gentle smile.

As I walked away, I took a deep breath and thought about this extra "Dad Encounter" I just had.  Life is so precious.  Family is so precious.  We're not just straightening up spines here, we are caring for precious people and families, which create precious moments like this.    I have no idea whether my mom or dad grabbed my orthopaedic surgeon's hand before any one of my 11 surgeries that I had on my badly damaged leg when I was a teen, but I know they were at least thinking about it.

Little Madelyne's surgery went really well, taking less than 3 hours and got her scoliosis straightened up beautifully.  I saw both her mom and dad who stayed with her in her private room twice a day, every day.  After the surgery, her dad shook my hand more than once --- this time it wasn't to ask -- it was just to say "thanks" for taking care of his precious daughter.

So it has been good to catch up a bit.   It has been a blessed week or two.  Slowing down and processing what I've experienced and learned helps energize me for the day and week ahead.  Some day when I may not be able to be in the fray each day as I am now I will likely look back at these blogs and remember the incredible journey with incredible people I have had the chance to experience.  Otherwise I fear I'd forget these precious times.

If this is encouraging or helpful for someone out there, that is wonderful.  I especially like to inspire that next generation of compassionate physicians and other healthcare providers who are taking a study break from Organic Chemistry or some other premed class.  Hang in there, and remember that it is more than just the science:  medicine and surgery gives you this unbelievable privilege to connect with patients and families in an incredibly special way.  Take time to find good mentors, and develop your HEART as well as your mind during your training years.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

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