Sunday, October 26, 2014

Can realignment of adolescent idiopathic scoliosis actually help prevent and/or reverse disc damage to lower lumbar discs?

For my last 19+ years of practice at both Duke Medical Center, and Hey Clinic, I have had a lot of experience caring caring for the full age spectrum of scoliosis, from 3yo congenital scoliosis, early onset scoliosis AIS, Scheuermann's kyphosis and adult deformity.   This "natural history" experience has given me long-range insight on how to counsel patients and families in the younger age groups, seeing well beyond what most pediatric orthopedic surgeon would see in their career caring for patients up through 18.

I am also always on the lookout for the latest research on the disc biology, biomechanics, and basic science as well as clinical studies that look at the issue of curve progression, disc degeneration as a function of spinal alignment, and facet arthritis causes for accelerated wear that we often see in scoliosis later in life.

Recently at our Scoliosis Research Society Meeting in Anchorage Alaska, Dr. LaFage gave a very nice podium presentation looking at 3D analysis of the lumbar disc MRI images before and after adolescent idiopathic scoliosis (AIS) surgery.  Doing special volumetric analysis, she was able to show that the lumbar discs below the main curve in adolescent idiopathic scoliosis showed some signs of dehydration prior to scoliosis surgery. This might suggest that there is some early damage being caused by the misalignment of the vertebral bodies above and below the disc, which can put excessive stress on the disc affecting the extracellular proteoglycan matrix, as well as the possible cartilage cells that maintain that matrix.  (My undergraduate thesis work at MIT in Bio-Electrical Engineering actually focused on cartilage biomechanics, and how to measure in the lab the affect of mechanical loading and natural electric fields on cartilage growth and regeneration... more on that another time)  What is really cool about Dr. Lafage's research is that she was able to show that over the 2 years after scoliosis surgery, the lumbar discs actually REHYDRATED after the surgical realignment of the spine above the discs.  This happened at ALL  lumbar levels when the pelvic incidence was low (most common in AIS), and in some levels with high pelvic incidence (PI).  This research suggests that the realignment was actually REVERSING the early damage to the lumbar discs, which would be our hope to allow those lower 2-4 lumbar discs to last the patient another 80+ years!  Dr. LaFage did show that the degree of the effect of the rehydration was affected by the underlying pelvic parameters, which have to do with how sloped the starting point of the lumbar spine is (Pelvic Incidence)  

This research is consistent with the natural history I've observed in many patients, who seem to do very well after AIS surgery with correction of not only their primary curve but the compensatory curves above and below which are not fused, but correct on their own in response to the correction of the primary curve(s).  These patients in most cases will maintain their lumbar disc height and have very little or any lumbar pain.  This is in contrast to the patients who never had their adolescent idiopathic curves fixed, who later in life can have not only progression of their primary curve, but also collapse of the lower lumbar discs, which were actually "normal" and outside of the scoliosis area to begin with.  These patients in some cases are in so much pain and/or have documented ongoing progressive deformity that surgery is needed to fix not only the primary curve, but now the worn out discs and facet joints in the lower lumbar area -- necessitating a larger surgery with fusion all the way down to the pelvis / iliac wings.  

While it is tough to considering having your child/adolescent have a major spine surgery as a healthy asymptomatic adult, it probably does make sense to seek out possible second opinions especially who can help you and your child, and spouse figure out what is best for the LONG run... the VERY LONG RUN -- the next 80+ years.  You only get one set of discs and facet joints, and decades of misalignment can definitely take a toll, just as a misaligned car can cause car tires to wear out well before the expected 80,000 miles.   

This issue of premature lumbar disc damage and destruction is especially and issue with the thoracolumbar curves, since they involve more misalignment of the lumbar discs.  The degree of trunk shift (asymmetric "hour glass") also has a major affect on the biomechanical loads on the lower lumbar discs, due to the increased "moment arm" of the axis of body weight which applies additional torque / stress on those lower lumbar discs.  So, it is good to take a wholistic view of the spinal alignment, not just looking at curve magnitudes but overall trunk balance, and as Dr. LaFage points out, other measurements like pelvic parameters which could affect stress on the lower discs and wear and tear.

Here is a video of Dr. LaFage's presentation with her wonderful French accent.  Enjoy!

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

Sunday, October 19, 2014

Encouraging Word for the PreMeds: "Dr. Diet, Dr. Quiet, and Dr. Happy"

I've been reading a very good book called "God's Hotel" by Dr. Victoria Sweet that was suggested to me by Dr. Jeff Baker, a wonderful Duke Pediatrician, who is also a medical historian, with a PhD, no less.  Jeff had suggested this book as a good way to learn more about the the history of medicine, during the "pre-modern" era.

In the book, Dr. Sweet not only shares what she learned about healthcare in the mid-evil times, she shares about her experience practicing in the modern days, but working at an old almshouse in San Francisco called Laguna Honda.  If I could summarize her main findings it would be that perhaps we "threw out the baby with the bathwater" when we switched from Pre-Modern to modern medicine within the last 150 years.  She describes how modern medicine does not tell us much about the heart/soul of the patient which we can tell is gone when a patient dies, and they leave their body behind like some left over clothes.  She also talks about how Pre-modern medicine had a better feel for balance, and also for understanding the energy/spirit level of each patient -- something you can't quantify with an MRI or blood work, but you can sense it.

I was also struck by the common sense interventions that were always a part of Pre-Medicine treatment:  "Dr. Diet, Dr. Quiet and Dr. Happy"  :  Diet, Sleep, and happiness treatments.  Physicians used to give treatments for these things.  

It reminds me how important it is for all of us, even doctors, and pre-meds wanting to be doctors some day to listen to this advice as well:  Eat well, get enough sleep, and do things that nurture your heart and soul and grow it over time.  I've read several books on the importance of sleep, after being fed a lot of bad information during med school and residency about "sleep is for wimps"  -- it's not.  You need your sleep to learn, to serve and to not be miserable!!!  Get your sleep!!

Diet and exercise habits are also super important -- lessons I've learned a lot about personally in last 20 years.  The fuel you put into your car really matters -- if you put gas into a diesel car, like I did one day many years ago (sleep deprived!!), your car doesn't run real well!!

Exercise is key --  seek to get 30 minutes of exercise at least 5 days a week.  Try to do it in the morning since you are less likely to skip it.  You can combine this with daily encouraging devotional reading, so you are getting a 2 for 1!  This helps get your endorphins going which power you through the day.  It also helps with weight management as you get older.

This past week I did some special "Dr. Happy" margin time by taking off a few days to go to the mountains of North Carolina and just hang out watching the fall leaves, and the water run down 5 different water falls, and just feel the warmth of huge solid boulders below me.   I almost canceled the time because there is always so many patient things that come up, but I knew I needed the time to regenerate, and also to encourage my family.   Spending time outside in the beauty of God's creation is good for the soul, especially this fall.  Time with family was also very, very precious.  Lori and I really enjoyed hiking around the Cornell campus and down and around the gorges -- something we enjoyed together during our high pressure college Pre Med days.  I had been studying in the book of Psalms how God is our Rock and our Refuge in Psalm 18 ---

"The LORD is my rock, my fortress and my deliverer; my God is my rock, in whom I take refuge, my shield and the horn of my salvation, my stronghold."

Actually climbing between a couple of big rocks, and sitting on a big rock for quite a while did give comfort --- I could imagine the comfort it would be to be able to wedge myself in between 2 big rocks in a storm.  Rocks and Fortresses are like the earth's magnetic field -- so constant, and we can always count on them.  We need these external references to keep us on track, and to keep us safe, and solid, away from the high anxiety of feeling all alone.

Combining special verses that I have been meditating on, with real world experiences out in the beauty of nature is really good for the soul.  Pre-Modern Medicine knew this.  We all know this somehow on the inside.

So, if you are a stressed out pre-med out there, or stressed out surgical intern, here is your prescription from Dr. Hey, standing in for Dr. Happy:  Take a half hour off sometime this week, lie down on a warm rock somewhere, or maybe a leaf covered lawn, and look up at the sky and the trees, take several clearing breaths, listen to the birds.... and remind yourself how wonderful it is to be alive, and enjoy this beautiful world!

Then go encourage another student to join you next time.

Now, for me, it is time for "Dr. Quiet" to get some sleep before 2 very important surgeries for 2 very  precious people: one adult, and one child.  

Have a good week!

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

Monday, October 13, 2014

Does scoliosis surgery really help quality of life? Weaving together daily experiences with patients and families with Joy in the Journey.

Wow, we had a HUGE amount of interest in my blog last night.  I just got home from surgery and a hospital meeting and only have a few minutes to share before I have to get to bed for big surgeries tomorrow.  Whew I am tired, but it has been a great day!

My hope in the weeks to come is to weave together my ongoing wonderful experiences I am having with patients and families together with my excerpts of my talk I gave at Cornell University recently, where I shared about "Finding and Maintaining your Joy and Idealism through your medical career journey" with the Phi Delta Epsilon Society for pre-meds.

One of the big take home messages you will likely learn, as I have, is there is MUCH we can learn from out patients and families to grow our own hearts and souls, and to both experience and grow in compassion and faith.

Today I did a big scoliosis surgery, and also did a second opinion for a lady in her 20's who had scoliosis surgery done a few years ago, and now had broken rods, and collapsing posture, and back pain.  I made some room in my schedule for her early morning today, and showed her how kyphosis was a big part of her deformity -- 78 degrees  -- in addition to the scoliosis and broken rods.  We're going to get a CT scan done, to look for pseudarthrosis, but given her spinal collapse and pain, she could likely benefit from a revision surgery, restoring her posture, correcting both the kyphosis and scoliosis and replacing the broken hardware with a stronger construct and new fusion.  There is hope!

I also saw one of my patients from Florida who is 2 weeks postop after having a proximal junctional kyphosis fixed due to her osteoporosis at the thoracolumbar junction.  Her posture now is beautiful and she is walking so much better and standing up straight with much less pain already. She is heading back to Boynton Beach, FL after short stay in rehab here in Raleigh, NC.  

Here are a few patient stories from this past week which should be an encouragement.

Sandy shares a special piece of artwork she did for me recently, which in part touches again on the fact that modern medicine and faith can work together.

More to come.
Have a good night!
Lloyd A. Hey, MD MS

Sunday, October 12, 2014

What is Life Long Effect of Scoliosis? 40 year old scoliosis patient tells his story from childhood, adolescent diagnosis through surgery recently

42 yo woman with 89 degree preop kyphosis corrected by Dr. Hey October 2014

40 yo thoracolumbar curve fixed by Dr. Hey Oct 6 2014 (6.5h)
This week we performed scoliosis surgery on two 13 yo young ladies with adolescent idiopathic scoliosis and a 40 yo gentleman with 73 degree thoracolumbar scoliosis, and a 42 yo woman with a 89 degree kyphosis.  All 4 patients are home now, both teens went home after 3 nights in the hospital, with very nice straight spines!  The 42 yo woman had lost 6 inches in height in last few years, with rheumatoid arthritis and ankylosing spondylitis. Her pain was becoming excruciating, and her deformity was just crippling for her.  Her desire to live was waining.  Her surgery went very well, requiring 9 osteotomies, and a lot of my best deformity tricks to get her straightened up nicely.  She has a completely new posture, and was sitting up in the chair the first morning after surgery with a whole new outlook on life.

As I get older and have more and more experience treating thousands patients with scoliosis and kyphosis across the whole age spectrum from child, adolescent through adult, I am continually impressed how it is often so much easier and usually better to "catch" the scoliosis earlier during adolescence or young adulthood before the degenerative changes combined especially with thoracolumbar imbalance leads to cascade of possible curve progression, curve and chest wall stiffening, and pain and issues with self-image and posture, as well as possible cardio-pulmonary affects later in life.  If you are the parent of a scoliosis teenager concerned about your child needing scoliosis surgery, be sure to read "B"'s story below -- there are risks to scoliosis surgery, but there are also risks for NOT doing scoliosis surgery as well, in the short run and the long run.  Whatever decisions you make either way will affect your child for the next 80+ years.  I also remember what Dr. John Hall told me as Chief Resident at Boston Children's the day I asked him why he wasn't doing adult scoliosis anymore:  "Lloyd, it's just too hard!"  Adolescents and younger adults heal quicker, with less chance for medical or wound complications, and tend to get much better curve and chest wall corrections -- and more years to enjoy the improved posture with a shorter fusion.

13 yo with thoracolumbar curve fixed October 7 2014 Dr. Hey (3h)

This week we had sort of an "adolescent scoliosis sandwich"  -- two 13 yo scoliosis surgeries on Tuesday, and a 40 yo scoliosis on Monday and a 42 yo on Wednesday.  The fact that we could get two adolescent surgeries done on one day as opposed to one adult surgery should tell you something -- adult scoliosis surgery is usually harder and takes more time -- often twice as long as the adolescents, and usually involves needing to fuse more segments, and in some cases fusing all the way down to the ilium/pelvis.  So this week, for example, I fixed a 13 yo with a progressive thoracolumbar curve, with a fusion down to L3, got her very close to perfectly straight, which saved her bottom 3 discs, which should now last a lifetime, and her "humps" are gone, and "hourglass" figure restored for the next 80+ years.  The 40 yo gentleman named "B", who shares his story below had a 6 hour surgery for the same type curve as the 13 yo had, but had progressed during his adulthood to 73 degrees and had become very painful, disfiguring and greatly affecting his quality of life -- ever since he was a young teenager!!  These patients turned out to be in rooms right next to each other postop, and both did well postop, but their life stories have been, and will always be much different.

The 40 yo gentleman who had the 73 degree scoliosis told me postop day 1 how happy he was to have his surgery done, and his nice new posture.  He told me he would write up his story this week before he left the hospital…. which he did, and I received this Friday, as he was going home.  I always love to hear my patients stories, since I have been a patient myself -- each story is unique, although there are some elements that always seem to repeat.  B's story is a good follow-up to the dialogue I had with the Cornell students last week as we talked about compassion, and following your internal compass, and being more sensitive to the heart and soul of your patients, and your own.  While I never force my faith on anyone, I know that faith has been important in my own recovery from major trauma, and is often the key foundation for many of my patients.  At the very least, we, as physicians should be open to hear their stories and be respectful of their beliefs.  It is interesting to see in B's story given below that he, like many of my patients does not see a conflict between faith and modern medicine -- they can actually work together.  In B's life, he indeed sees God working THROUGH healthcare providers and modern medicine --- something I had felt as a patient many years ago.  When we think of what might allow these future physicians to not end up in the unhappy 94% of doctors disenchanted with their jobs as we discussed in the recent WSJ article, it seems that one antidote could be for more physicians in training to realize that maybe they too could be "administering God's grace in its various forms" (1 Peter 4).

So for my new friends at Cornell University that I met last week, enjoy B's story and stay in touch!

Time for bed.  Enjoy my patient B's story below.  Thoracolumbar scoliosis surgery tomorrow morning, as well as second opinion for broken scoliosis hardware on a young lady coming in from central NC, for second opinion for revision surgery.

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

40 yo B's Scoliosis Story

My name is B________; I am 40 years old and have been living with scoliosis for as long as I can
remember. I was diagnosed with this condition at 11 years old. At the time, of course I did not know 
what it really meant to have scoliosis nor did I realize the impact this condition would have in my life for the years to come. Upon this diagnosis, my loving parents immediately began searching for the most experienced and knowledgeable doctor in New Jersey to treat this condition. They were informed that surgery is an option but there would be a fifty percent chance that the surgery may result in paralysis.   We opted for the second option which was to wear a back brace 24/7 to assist in correction of the curve. 

Needless to say that as a pre-teen/teenager the brace was certainly not part of the image that I was trying to portrait. Therefore; I wore the brace only when I was home or when my parents harass me to put it  on. As I got older I became increasingly sub-conscious about my appearance and the curve of my back; I also noticed that my posture was not normal. I leaned to one side, my left shoulder was significantly higher than the right shoulder, and there was an abnormal bulge on the left side of my stomach (in my rib hump). I started to feel a sense of shame and began hiding my body as much as I could by wearing bigger size clothes and/or multiple layers of clothing. Going to the pool, beach or partaking in any activity that requires having to reveal my upper body was extremely painful and uncomfortable. Not to mention the pain I often felt due to my condition.

As the years passed I surrendered to my condition and had accepted this as ‘my normal’. I even conditioned my mind to endure most of the pain and to be grateful for life no matter how it comes. I gave my life to Jesus Christ in 2004 and received baptism in 2007 and started my journey to a greater 
knowledge of the Lord and His word. As I read ‘His’ Word I made a decision to believe what the Word said about me and my health. It says that I ‘should be in good health, as I am well with my soul.’ 3 John 1:2 and most importantly it says that ‘whatever I ask in prayer, believes that I have received it, and it will be mine.’ Mark 11:24. I started praying for good health, a straight back (something that I NEVER thought could happen), and no more pain in my body. I know that this was not going to happen by divine intervention as I believe that God uses His people to do His work here on earth (My wife often says that we are God’s hands and feet-we are here to be used by Him). Therefore I started praying that God leads me to ‘the’ Dr. that he has already picked to assist in this healing process. In April 2014, the pain started to increase and had become more consistent and was accompanied with numbness in my neck and legs. I decided to go back and see a doctor that I had seen a few years ago in attempt to discover if there are any changes in the curve and what options I now have to assist with this progression of my condition.   He informed me that there was a slight increase in the curve (approximately 5 %) which he will monitor and suggested that start on steroid injection to help relieve that pain. I respected his medical opinion but felt that God wanted me to be completely healed not a healing but a complete permanent healing that is ordain by Him. I kept praying and started to do some research of scoliosis doctors in the area. 

I remember one morning driving to work, I was praying to God to help me find ‘My’ spine doctor; I have lived with this condition all of my life and was ready for my healing. Later on in the day I came across Dr. Hey website which included several reviews from people who had received treatment from him. I read several testimonial from his patients about his work and his faith; he is a ‘Christian’ and he ‘prays’ before and after he perform his surgeries. I couldn’t believe it- God has such a sense of humor. When He does something; He makes sure you know that it is ‘Him’ that is doing it. With excitement I contacted the Hey Clinic that afternoon and scheduled an appointment with Dr. Hey, but unfortunately I had to wait close to 2 months to see him. That evening my wife went to a speaking engagement with a friend (whom is also a physician) and was talking to her friend about the recent sensations that I have been experiencing and asked her if she knew of any doctor that specializes in scoliosis. She stated that she had lunch with a physical therapist that day and he informed her that “if anybody has scoliosis then the best person to go to is Dr. Hey.” When my wife told me this, I thanked God for ‘confirmation.’

I decided not to move forward with the suggestion of the other doctor to start steroid injection therapy and waited to meet with Dr. Hey to obtain a second opinion. As I walk into the Hey Clinic for my 1st consultation a feeling of comfort and excitement rushed through my body; I instantly felt as if this is exactly where God needed me to be at this very time and space in life. Dr. Hey reviewed my documents and x-rays and was able to immediately determine to root cause of the pain and numbness stating that the degree of my curvature increased by night degrees from 4 years prior and provided several options and surgery was one of the options. Believing in God’s plan for my life and His promise, I decided that surgery would be the best option at this time. Dr. Hey provided me with all the information and resources that I needed to make this decision including the opportunity to speak to a patient that had undergone a similar surgery and God gave me the strength and the peace to proceed with my decision to do the surgery.

October 6, 2014: The day of the surgery I was full with excitement; my family and I arrived at the hospital at 5:30 am to begin pre-op preparation, by 7:30 Dr. Hey met us in the pre-op room where he prayed and asked God ‘to use him as an vessel and to work thru him to ensure the success of this surgery.’ There is peace in knowing that the surgeon is not going to perform this surgery by strength alone but have welcome the strength of the Most High to take on what his strength is incapable of doing. The surgery lasted approximately seven hours as my lower back discs were completely damaged and required additional attention. At 4:30 pm Dr. Hey completely the surgery and happily reported that my surgery was ‘blessed by God from the beginning until the very end.’ Praise be to God. 

I am so thankful to Dr. Hey for fulfilling his purpose here on earth allowing himself to be used as a 
vessel by God to heal His people. I am thankful that he surrenders his mind and talent over to the Lord to be used for His Glory. Thankful that God used him to bring restoration to my life, not only physical restoration but also spiritual restoration as this experience greatly increased my faith and trust in the Lord.

Friday, October 3, 2014

Cornell University's PreMed Lecture: Phi Delta Epsilon on "Finding and Maintaining Joy and Idealism in the Journey through Medicine"

Yesterday evening, my wife Lori and I were the invited guests for Cornell University Phi Delta Episolon's PreMed Lecture, where I spoke on:

"Finding and Maintaining Joy and Idealism in the Journey through Medicine"

We had a wonderful group of students there, who all participated in the discussion, starting with my first question:  "What are the top three character traits you find in a great physician?"

There was general agreement with the first 3 ones offered:
1.  Empathy/Compassion
2.  Resilience - don't give up
3.  Innovation and Learning

We had about 15 students come up to talk to Lori and I after the talk, and share how the talk moved them to consider how they can build a foundation for compassion during their college pre-med years.  

I appreciate everyone coming out for the talk
More later.
Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery