Techniques and Technology Improving Outcomes for Complex Scoliosis Surgeries

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In Scoliosis Surgery, Lengthy and Complex (Albuquerque Journal), Dr. Anjali Subbaswamy (a Pediatric Intensive Care Physician at UNM) answers questions regarding a patient whose pediatrician has suggested she may need surgery and is wondering what that entails.

She notes a recent observation of markedly improved conditions post-surgery, prompting her to ask her colleague  Dr. Antony Kallur (a Pediatric Spine and Orthopedics specialist formerly with UMN and currently with New Mexico Orthopaedics) what might be contributing to the improvements:

Q: My 14-year-old daughter has scoliosis and her pediatrician thinks she might need to have surgery. What does that entail?

A: The surgical repair for scoliosis is Posterior Spinal Fusion, and it is a surgery performed often in my hospital. It is a long surgery, often taking between 6 to 8 hours. The children usually, but not always, come to the Pediatric Intensive Care Unit (PICU) afterwards for postoperative care. They might stay in the PICU for 1 to 4 days, depending on how they recover. After that, they go to our inpatient Carrie Tingley Rehabilitation Unit, where they receive physical and occupational therapy. These therapies facilitate their ability to resume their activities of daily living, and also enhance their recovery. The therapists will give you exercises to continue at home. The entire hospital stay is typically 5 to 7 days.

There are 3 different kinds of pediatric scoliosis, all of which may require surgical treatment. They are idiopathic scoliosis, neuromuscular scoliosis and congenital scoliosis. Idiopathic scoliosis is by far the most common type. This affects otherwise healthy children, who have a sideways curve in their spine, which measures greater than 10 degrees. Your pediatrician may have done the Adams Forward Bend test to assess this, followed by some X-rays.

The American Academy of Orthopedic Surgeons (AAOS) provides the following information: If the spinal curve is between 25 degrees and 45 degrees and your child is still growing, your doctor may recommend bracing. Although bracing will not straighten an existing curve, it may prevent it from getting worse to the point of requiring surgery. Your doctor may recommend surgery if your child’s curve is greater than 45-50 degrees or if bracing did not stop the curve from reaching this point. Severe curves that are not treated could eventually worsen to the point where they affect lung and heart function. That is the main medical reason for intervening.

Now, here’s some good news. I have personally noticed that the patients I get from the operating room after this procedure are in much better condition than in years past. They are more stable in terms of their breathing and blood pressure, they start eating and drinking sooner after surgery, they start sitting up and getting out of bed sooner and their pain is better controlled. It is frankly amazing to me that some of these children don’t have to come to the PICU after surgery. This surgery takes a long time and involves blood loss and many hours of anesthesia. All of those factors are stressful to the body, and these children used to come out of surgery somewhat unstable. They would require active management of their fluid balance, blood pressure, pain and breathing. We would check labs and replace electrolytes and clotting factors. Nowadays, we barely do anything except watch them closely. They typically come out of the operating room breathing on their own, with stable blood pressure and good pain control. These changes are striking improvements, and prompted me to ask my colleague Dr. Antony Kallur, “What has changed?” 

Here’s Dr. Kallur’s answer:

Well, things definitely have changed for the better in a lot of ways.

First of all we understand the importance of three dimensional correction and restoration of spinal alignment. Anesthetic techniques have changed very much and are safer with newer medications and ability to keep children unconscious but maintaining baseline nerve and brain function so that we can monitor the child’s spinal cord.

Neuro-monitoring; which is now used all the time for any scoliosis surgery has made the surgery very safe reducing the incidence of neurological injury.

The surgical techniques and our understanding of how to correct the spine and the alignment that needs to be restored has made the children able to return to all activities after healing from surgery without any restriction. The implants used are advanced to help us correct the spine and maintain alignment to healing and can be placed safely. Titanium implants used now are also biocompatible and incidence of infection is negligible in healthy children. Our incidence at Carrie Tingley hospital is ‘zero’ in healthy children.

These days, the child does not need to stay in bed or use a brace after surgery. The newer instrumentation techniques mean that need to harvest child’s own bone (from the pelvic bone) as graft for achieving fusion/healing is not needed.

The recovery from scoliosis surgery has become so much easier to the child and family compared to how it was 10 to 15 years ago. So, we achieve better correction and alignment with safer surgery with a quicker recovery and return to activities. I hope things go very smoothly for your daughter!

Anjali Subbaswamy is a Pediatric Intensive Care Physician at UNM. Antony Kallur is a Pediatric and Adult Orthopedic Surgeon and Pediatric Spine Specialist at New Mexico Orthopaedics. 

New Mexico Orthopaedics is a multi-disciplinary orthopedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300 or utilize our self-scheduling tools here.

 

Spine Surgery: When Nothing Else Will Do

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Article featured on Brigham Health Hub

For many years, Diane Daigneau of Woburn, MA, was able to successfully manage her back and neck pain. Through occasional chiropractic treatments and mild pain relief medications, she was able to continue to work and play.

A few years ago, however, she discovered that circumstances can change dramatically, to the point where even the best non-surgical care fails to provide adequate relief. Such was the case during the summer of 2013, when the pain radiating through Diane’s back, neck, and arms had become so debilitating and persistent that no physician was recommending anything other than cervical spine (neck) surgery.

From Manageable to Intolerable

Diane likes making things pretty. More than that, it’s her job.

She often spends several hours hovering over a single piece of furniture while meticulously applying delicate gold or silver leafing, or some other type of elegant exterior. It’s a mentally and physically demanding job, particularly for someone who has struggled with back and neck pain. But Diane’s pain was never so bad that she ever worried about not being able to do her job or any other enjoyable pursuits. That changed suddenly during a family vacation at the end of July 2013.

Diane woke up on the second morning of her vacation with a new kind of pain. “The pain was unbearable,” says Diane. “It was something like I had never experienced before. There was nothing I could do.”

Along with intense pain, she had limited range of motion in her neck and numbness throughout her neck, shoulder, arms, and chest.

She ultimately headed back home for an MRI, which revealed that two herniated (bulging) discs were crushing nerves in her cervical spine.

A Surgical Solution

Through a colleague, Diane was referred to Brigham and Women’s Hospital spine neurosurgeon Dr. Michael Groff for a consultation. Based on her condition, Dr. Groff recommended a two-level anterior cervical discectomy (disc removal).

Dr. Groff started the procedure by approaching Diane’s spine through the front of her neck instead of through her back. There are two distinct advantages to this method. The most important is a significantly reduced risk of damaging the spinal cord. The other is less cutting of muscle, which helps to reduce postoperative pain.

Once the affected area of the spine was reached, Dr. Groff completely removed both bulging discs to take the pressure off of the nerves. Next, to maintain the integrity of the spine, he snugly inserted a graft into each area where a disc had been removed.

The carbon fiber cages used for Diane’s surgery are now the standard of care for discectomy and fusion in Dr. Groff’s practice, and a significant advance from the combined use of grafts (natural or synthetic) and titanium plates. A multi-center study, in which Dr. Groff participated, demonstrated that using a carbon fiber cage alone provides the same strength and functionality as provided by a graft and titanium plate. However, the comparative simplicity of the carbon fiber cage – less material, fewer parts – decreases operation time, reduces the impact on surrounding tissue, and minimizes manipulation of the esophagus.

No Surprises

Diane admits that her recovery hasn’t been easy, but neither has it been a surprise. “I knew all along, step by step, how things were going to be for me,” she explains. “It’s not fun, but at least you’re feeling confident that things are going in the right direction.”

Dr. Groff is similarly confident about the progress of Diane’s recovery. He told Diane that the carbon cages and fused vertebrae eventually will make her neck so strong and stable, as strong as it was before, that she could participate in extreme sports within a year.

Although she finds that claim to be reassuring, Diane doesn’t plan on jumping out of any airplanes in the near future. She’s quite happy to simply be walking, jogging, working – or waking up – without the fear of back and neck pain.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.
New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.
Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.
If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

What is Spinal Fusion?

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From WebMD

Spinal fusion is surgery to join two or more vertebrae into one single structure. The goal is to stop movement between the two bones and prevent back pain. Once they’re fused, they no longer move like they used to. This keeps you from stretching nearby nerves, ligaments, and muscles that may have caused discomfort.

Spinal fusion involves techniques designed to mimic the normal healing process of broken bones. During spinal fusion, your surgeon places bone or a bonelike material within the space between two spinal vertebrae. Metal plates, screws and rods may be used to hold the vertebrae together, so they can heal into one solid unit.

Why it’s done

Spinal fusion permanently connects two or more vertebrae in your spine to improve stability, correct a deformity or reduce pain. Your doctor may recommend spinal fusion to treat:

  • Deformities of the spine. Spinal fusion can help correct spinal deformities, such as a sideways curvature of the spine (scoliosis).
  • Spinal weakness or instability. Your spine may become unstable if there’s abnormal or excessive motion between two vertebrae. This is a common side effect of severe arthritis in the spine. Spinal fusion can be used to restore spinal stability in such cases.
  • Herniated disk. Spinal fusion may be used to stabilize the spine after removal of a damaged (herniated) disk.

Who Needs Spinal Fusion?

 

If medicines, physical therapy, and other treatments (like steroid injections) haven’t helped your back pain, this surgery might be an option. Doctors usually only recommend it if they know exactly what’s causing the problem.

Spinal fusion might help you feel better if your back pain is caused by:

  • Degenerative disk disease (the space between disks narrows; sometimes they rub together spaces)
  • Fracture (broken spinal bone)
  • Scoliosis — your spine curves abnormally to one side
  • Spinal stenosis (narrowing of the spinal canal)
  • Spondylolisthesis (forward shifting of a spinal disk)
  • Tumors or spine infection

 

How to Prepare

 

The week before your surgery, you may have some blood tests and spinal X-rays if you haven’t had any recently.

Your health care team will go over the details of your procedure. Don’t be afraid to ask questions if you don’t understand something. Your surgeon wants you to be prepared.

Here are some things to think about in the days prior to your surgery:

  • Know when to arrive at the surgery center. You’ll need someone to drive you and take you home.
  • Get a list of the medicines you can or can’t take in the days before surgery. Some drugs, like aspirin or other anti-inflammatory drugs, may be unsafe. Never stop taking any medicines without your doctor’s OK.
  • Find out if you can eat or drink anything before your procedure.
  • Get your home ready. You’ll need raised toilet seats, shower chairs, slip-on shoes, reachers, and other aids.

 

What you can expect

During spinal fusion

Surgeons perform spinal fusion while you’re under general anesthesia so you’re unconscious during the procedure. Surgeons have developed a variety of techniques for performing spinal fusion surgery. The technique your surgeon uses depends on the location of the vertebrae to be fused, the reason for the spinal fusion, and in some instances, your general health and body shape.

Generally, the procedure involves the following:

  • Incision. To gain access to the vertebrae being fused, the surgeon makes an incision in one of three locations: in your neck or back directly over your spine, on either side of your spine, or in your abdomen or throat so that your surgeon can access the spine from the front.
  • Bone graft preparation. The bone grafts that actually fuse two vertebrae together may come from a bone bank or from your own body, usually from your pelvis. If your own bone is used, the surgeon makes an incision above your pelvic bone, removes a small portion of it and then closes the incision.
  • Fusion. To fuse the vertebrae together permanently, the surgeon places the bone graft material between the vertebrae. Metal plates, screws or rods may be used to help hold the vertebrae together while the bone graft heals.

In selected cases, some surgeons use a synthetic substance instead of bone grafts. These synthetic substances help promote bone growth and speed the fusion of the vertebrae.

After spinal fusion

A hospital stay of two to three days is usually required following spinal fusion. Depending on the location and extent of your surgery, you may experience some pain and discomfort but the pain can usually be controlled well with medications.

After you go home, contact your doctor if you exhibit signs of infection, such as:

  • Redness, tenderness or swelling
  • Wound drainage
  • Shaking chills
  • Fever higher than 100.4 F (38 C)

It may take several months for the affected bones in your spine to heal and fuse together. Your doctor may recommend that you wear a brace for a time to keep your spine aligned correctly. Physical therapy can teach you how to move, sit, stand and walk in a manner that keeps your spine properly aligned.

Results

Spinal fusion is typically an effective treatment for fractures, deformities or instability in the spine. But study results are more mixed when the cause of the back or neck pain is unclear. In many cases, spinal fusion is no more effective than nonsurgical treatments for nonspecific back pain.

It can be difficult to be certain about what exactly is causing your back pain, even if a herniated disk or bone spurs show up on your X-rays. Many people have X-ray evidence of back issues that have never caused them any pain. So your pain might not be associated with whatever problem has been revealed on your imaging scans.

Even when spinal fusion provides symptom relief, it does not prevent you from developing more back pain in the future. Most of the degenerative conditions in the spine are caused by arthritis, and surgery will not cure your body of that disease.

Immobilizing a section of your spine places additional stress and strain on the areas around the fused portion. This may increase the rate at which those areas of your spine degenerate — so you may need additional spinal surgery in the future.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.