It's Friday night, and I just got a chance to put my feet up after a really good, but very busy first week of 2013. Our scoliosis surgery this week included 15 yo Thomas, who had a 64 degree collapsing adolescent idiopathic scoliosis and Down's Syndrome. I did his surgery over at WakeMed on Tuesday. His surgery took about 4 hours, and as shown on our preop and intra-op X-Ray on the left, we got a nice correction. He's done really well preop, up roaming around with no assistance yesterday and today spending just the first night in PICU. His EBL was 400 cc, and he had no blood transfusions. He had a left thoracic curve pattern, which is often associated with neurologic issues like tethered cord and other congenital spinal abnormalities like diastematomyelia. Fortunately we checked his cervical and thoracic and lumbar MRI's which showed no abnormalities.
Even though his MRI's were OK, we were not able to get any Motor Evoked Potentials on him at beginning of surgery, and the stimulation for sensory evoke potentials caused his legs to jump dramatically --- something was definitely abnormal with his "wiring." Fortunately, I was able to work closely with the anesthesiologist, neurologist from evoked potentials and anesthesiologist to work out a solution to get some monitoring done while also getting this boy's surgery done without a problem. Never a dull moment. The more you work around the neurologic system, the more miraculous and wonderful and mysterious it can be!
Other interesting surgeries this week included a L1 pedicle subtraction osteotomy (PSO) with T3-Iliac wing extension instrumentation and fusion for a lady with a severe proximal junctional kyphosis. I did her surgery yesterday, and the "kink" is now out of her back, and she's getting up with her fracture straightened up and stabilized with pressure off the spinal cord. After her surgery yesterday, I did a 2 level ACDF on an executive from West Virginia with severe burning pain down both arms to hands, with numbness, neck pain and trouble sleeping. His surgery took about 90 minutes, and he was SO happy in recovery room last night. The anesthesiologist saw me in the hallway this morning as I was headed up to his room and told me that the patient told him he felt great, and wanted to head on back to West Virginia ASAP this morning!
I also fixed up a lady who had a high grade L5S1 spondylolisthesis with severe spinal stenosis and trouble walking. She is recovering very well after Gill Procedure, L5 foraminotomies laminectomies, and posterior-only approach -- a less invasive way compared with going front and back. She is recovering well.
This week I also saw Justin, and his mom. Justin is a teenage lacrosse player, who had a very severe upper thoracic congenital scoliosis with growing severe shoulder asymmetry. His preop X-Ray reminded me of a patient I got to help treat as Dr. John Hall's Chief Resident at Boston Children's years ago. I actually brought Justin's X-Rays to a Boston Children's Hospital Grice Lecture Conference, where I presented his case to Boston Children's Orthopaedics alumni --- many of which are leaders in the field now and/or Chairmen around the country and around the world. I got lots of different opinions on how to best help Justin, but everyone thought it would be hard....
Well, it was pretty hard, doing a upper thoracic osteotomy with congenital vertebral body hemivertebra excision, and complex instrumentation due to his quite mis-shapen vertebrae. He had one of the worst thoracic hypokyphosis deformities I had ever seen, requiring special instrumentation techniques to pull his chest wall "out" where it was sunken in toward the heart and lungs. He has done great postop, and is very pleased with his new posture and chest shape.
Justin is also an avid lacrosse player, and by doing a very strong construct, we were able to allow him to go back and play lacrosse starting back within a couple of months of his surgery, similar to Lexi who we treated from Baltimore. Justin's mom and dad were very concerned that Justin's Lacrosse would be OVER if he had his scoliosis fixed, and even considered waiting until he was in college to have his scoliosis fixed. They are not glad they had it done when he was still growing, and get it fixed when curve was smaller.
I also saw a bunch of second opinions for scoliosis, spondylolisthesis and cervical spine surgeries this week. I saw two young ladies in their 40's, who had surgical opinions elsewhere 5-10 years earlier, and were told by the surgeon that they would need a 12 hour anterior/posterior spinal reconstruction with several days in ICU intubated and a week or 2 or more in hospital. This totally scared them away from considering surgery, even though they were already having significant back pain and were definitely affected by the posture being quite mis-aligned. When I told them that their scoliosis could be fixed in about 5 hours, with no anterior approach needed, and little or not ICU stay. One of these young ladies actually started to cry a little when she heard that her curves and pain were actually treatable with a reasonable surgical approach. All of a sudden there was hope, where she had felt hopeless over several years. The spine doctor this patient saw is a very good spine doctor in Durham, NC, but he does not specialize in scoliosis, and does very few if any scoliosis cases, which makes his surgical times much longer, and makes him more pessimistic about the outcome. It is quite important to see a surgeon who specializes in scoliosis when getting a first or second or third opinion regarding your scoliosis or kyphosis treatment. A good place to find someone to help you is at http://www.srs.org, where you can find physicians who treat children, adults, or both with spinal deformity. Both of these ladies also had chiropractic treatment which actually has helped them with their back pain over the years, but has become less effective over past year. We get quite a few referrals from chiropractors, and I've been supportive of chiropractic care for the low back pain aspect of scoliosis.
Years ago when I was Chief Resident at Boston Children's and was in charge of the resident educational conferences, I invited a chiropractor to come in and teach us more about what they do to our orthopaedic residents. In general most orthopedic and neurosurgeon residents I have helped train are always very dubious about chiropractors --- I actually learned a lot by working with chiropractors over the years, and do think they can help with low back pain, even low back pain associated w scoliosis. I do agree, though, with 99% of chiropractors and that chiropractic treatment is NOT effective for treating / improving the curves of scoliosis and kyphosis.
I saw several cervical spine patients for second opinion this week, including a guy today with a "flash lesion" in his spinal cord with cord edema, and severe numbness going down his left arm to his index and thumb. He has tight stenosis at C34 where the cord is edematous, but also had severe foraminal stenosis especially at C56 on the left side. I spent quite a bit of time going over all his images, and his physical exam findings, which included 3+ myelopathic reflexes in both lower extremities and continuous clonus in both ankles -- a sign that his spinal cord was not working properly with that cord pinch and edema. He had a ski trip planned to Steamboat --- not a good time to fall down on your head right now for him until he gets this fixed. His procedure will be a C34, C45 C56 ACDF with plating. This coming week we have 3 ACDF surgeries planned, ranging from 2 level to 4 level ACDF's .
Today in clinic we saw a bunch of postop patients and a few interesting surgical consults. We saw Neal for his One Year Graduation visit for his L4-Iliac wing instrumentation and fusion for spondylolisthesis and severe pain. Neal has been "gunning" to be the "Poster Child" for Hey Clinic with his rapid and full recovery. He's been able to return to the sports he loves, including kayaking, and has only occasional pain. He had suffered for over 20+ years with pain and limited quality of life. Neal runs a local chamber of commerce, and is absolutely a fountain of positive energy. What a blessing it has been to care for him this past year --- but now he's officially graduated from Hey Clinic, and also officially noted as the "Poster Child."
I also saw Barry back for his 6 month follow-up today, who is very successful pharma executive who works in the Philadelphia area. Barry also had an incredibly long history of increasing pain and trouble walking, and also has made a very rapid recovery, returning back to work traveling to/from Philadelphia within 6 weeks from surgery, and doing an a aggressive several mile walking program. After avoiding exercise and walking for years, Barry now takes a 3-5 mile walk every day at lunchtime along the Schuykill River! A new joy for him. I had shared Neal's story with Barry before Barry's surgery, so I went ahead and introduced these guys to each other. Since they are both very competitive businessmen, they BOTH wanted the "Poster Child" award. I ended up deciding to give it to Neal, since he is one year out and Barry is only 6 months. I've actually known Barry for several years, and it was a blessing to have him come up to me at a Christmas party recently with a big smile standing up straight, and tell me how the surgery has really changed his life for the better. Words of encouragement like that are helpful after a long week.
I also saw Hope, a retired nurse, back for her one year anniversary after her scoliosis surgery. She is also doing very well, keeping up with her exercise program and working on maintaining her good posture.
She is in her 70's, and has a very big improvement in quality of life.
This young lady in her 40's is just 6 weeks postop from her T4-Iliac wing reconstruction. You can see from before and after X-Rays that we got a very nice correction of deformity, which has made a huge difference in her posture. She also is doing very well advancing on her exercise program. You can tell from her smile, and her husband's smile that she is doing well. She is heading back to work as a dental hygienist his coming week. We used some of our latest research out of NC State's Department of Mechanical Engineering Finite Element Analysis Modeling lab to come up with the best construct for her to maximize correction while minimizing risk, including risk of hardware failure / rod breakage. Her husband has been awesome through the process, and really understands the bio-mechanics behind the "bending/lifting/twisting" restrictions that are beneficial during the fusion process to help minimize the loads while the bone knits together around where the hardware is holding things together. The bone actually heals up and over a lot of the hardware, forming very much like a "rebar" construct you see in concrete.
These two will be moving out to Charlotte, NC soon, but will be back to see us in a few months for her 6 month follow-up. We reviewed with her what exercises she can do in the gym, and which weight machines to use and not use, etc.
It would have been nice to fix her scoliosis with a shorter fusion, but her lower discs had already worn out too badly ---- good motivation to fix your scoliosis when you are younger and before you have done too much damage to the lower levels.
I saw Amanda and her mom from Charleston, SC today as well in clinic. She's a young lady who had scoliosis surgery 6 weeks ago referred to us by Dr. Steve Poletti in Charleston. Steve, like some of our other referring neurosurgical and orthopaedic referring physicians are very kind to send us initial X-Rays and MRI's for me to take a look at before the patients come up for an appointment. I got a chance to fly Amanda and her mom home after Amanda's surgery back to Charleston, which the mom said really made the whole experience much more tolerable --- a 45 minute smooth ride, as opposed to a 5 hour car ride! During my "spare time" I sometimes get a chance to do charity flights also for Angel Flights, where we transport mostly children to and from their doctor's appointments who are unable to afford the transportation, and often live in remote areas more easily reachable with smaller aircraft -- this is a great charity to support!
And so ends another exciting week at Hey Clinic. All hands were definitely all on deck from the full Hey Clinic Team, who work so hard each week serving new guests and existing guests with excellence and compassion. So thankful for all of them. This is definitely a team sport.
Hope you all have a good weekend. I'm going to spend part of this weekend preparing a talk I need to give next weekend in Charlotte, while also catching up with family and a few odd jobs around the house.
Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery
http://www.heyclinic.com
PS: Don't worry: We always ask permission before publishing photos of me with patients and their families. All of these families pictured above gave their enthusiastic permission to have their photos included in this week's blog!
"t think a year ago I could barely walk let alone climb to the top of Diamond Head in Honolulu in flip flops. Thank you Dr. Hey. Jim
Today was my first day back to work after a nice almost 2 week break. I went back to work this past Friday and saw a bunch of consults, including a 9 yo young lady who we are treating in a brace for her early onset scoliosis (EOS). Her curve is not changing at all! She actually doesn't mind her brace at all and has decorated it with dolphin and other stickers, as well as lots of great well wishes from family and friends! The patient and her parents said it was ok to share this picture with her and her brace. One of the things appreciate about Hey Clinic is how we take the time to get to know the child or adolescent as well as the family to help counsel the family with what choices make sense -- taking the whole patient into consideration. One thing is for sure: convincing a 7 or 8 or 9 yo to wear a brace is much easier than most 12 or 13 year olds! We often use special probability growth charts, and discuss the child's daily schedule and how the brace may or may not impact on them during the day. There is no doubt though: wearing a scoliosis brace is a big decision, and it is worth the time to discuss it first before spending a lot of money and possible family tension. No matter what age, you need to get buy-in from the person who is going to have to wear it and explain WHY and for HOW LONG and also that the brace is NOT A GUARANTEE that curve will not progress and possibly need surgery in future.
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.
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.
