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rohrer01
06-08-2010, 11:09 PM
I came across this article doing some research for myself. I thought I would share it with those of you who are considering surgery for the first time. It's about surgical outcomes for adult scoliosis patients. ;)

http://thejns.org/doi/pdf/10.3171/2009.12.FOCUS09254

Shari
06-09-2010, 01:46 AM
I read that article twice, and I'm still not sure I agree w/ it 100%. I am very curious what others here think about it. Linda R. what do you think??? I wonder what people who are thinking about having this surgery, what do you think???

Perplexed, ;)
Shari

titaniumed
06-09-2010, 02:58 AM
You would think that they would be a little more specific on complications. I mean, outcomes really have quite a bit to do with complications, don’t they? There needs to be more data.

Interesting how average age in 1981 was 30.

Ed

Pooka1
06-09-2010, 06:01 AM
You would think that they would be a little more specific on complications. I mean, outcomes really have quite a bit to do with complications, don’t they? There needs to be more data.



If most or even all of the complications are short-term and have resolved then there would be no connection between complications and outcome.

I think we know separately that the major complication that affects long term outcome is probably neurological injury. But we also know that the rate of these injuries, especially with real-time cord monitoring, is extremely low and that many of these injuries resolve.

The other major complication like infection and pseudoarthrosis are all resolved eventually as far as I know. They are not insoluble except maybe in the cases where the bone density will not allow a fusion I suppose.

So I think long-term outcome at least is largely unrelated to complication rate as a general rule (rare permanent neuro injuries are the exception). Linda will dope-slap me if I'm wrong.

Confusedmom
06-09-2010, 08:25 AM
Shari,

For those of us in the "considering" camp, this article, like all of them, is helpful but limited. I agree that most complications seem resolvable (except death:eek:), and I'm glad to see that there are positive outcomes in terms of curve reduction and improved disability.

What I STILL don't get is this idea that you do the surgery for "progression" even without significant pain. Because, it seems like from the literature, you have a decent chance of ending up with MORE chronic pain post-surgery, especially for lower curves.

Still looking for a study on outcomes of the lumbar region vs. natural history...

Evelyn

jrnyc
06-09-2010, 09:54 AM
if there are more problems than scoli to be operated on at the same time...like disc disease, then the hope is that there will be LESS pain....that is the goal...after surgery...because more problems will be resolved...

jess

rohrer01
06-09-2010, 12:23 PM
I'm not saying I agree or disagree with the article. It is what it is. It is just a collection of a bunch of data already published. They have a very large sample population, though. I agree that they aren't very clear on what constitutes a "complication" and how the complications affect outcome. It doesn't say what kind of scoli cases these docs were undertaking either. If the doc seems to have a "high" complication rate, such as Bridwell, it may "look" bad without anyone knowing the facts. I think Bridwell and Lenke ONLY take more difficult cases, so of course "complication" rates will be higher. I would not let these figures scare anyone out of surgery. I just posted it because, for me at least, it is a sobering reminder of the seriousness of what I am considering having done.

LindaRacine
06-09-2010, 10:19 PM
Total garbage. The studies go back to 1950. The surgery that is being done today has very little in common with surgeries between 1950 and 1990.

txmarinemom
06-09-2010, 10:30 PM
Total garbage. The studies go back to 1950. The surgery that is being done today has very little in common with surgeries between 1950 and 1990.

Thank you, Linda. I decided to sit on it for a day ... and your assessment is still more gentle.

You just can't lump all those studies in together, rohrer. It *isn't* what it is.

Back-out
06-10-2010, 08:37 PM
While we're at it, but I'll also turn this into a separate thread, I"ve been holding onto it, afraid to post it for fear of being too discouraging.

http://www.scoliosisjournal.com/content/3/1/9

Pooka1
06-10-2010, 09:02 PM
While we're at it, but I'll also turn this into a separate thread, I"ve been holding onto it, afraid to post it for fear of being too discouraging.

http://www.scoliosisjournal.com/content/3/1/9

This is garbage. :D

It deals mostly, if not exclusively, with historical use instrumentation. I scanned the dates and titles of the references and that's what seems to dominate though I didn't do an exhaustive review.

It is irrelevant to modern instrumentation and techniques.

This journal is notorious for publishing misleading articles because they have an agenda of attacking surgery in place of providing positive evidence for conservative and alternative treatments.

And the record for the older instrumentation is still far better than for any conservative and certainly for any alternative treatment. It's easy to lose sight of that.

Back-out
06-10-2010, 10:46 PM
This is garbage. :D

And the record for the older instrumentation is still far better than for any conservative and certainly for any alternative treatment. It's easy to lose sight of that.

I replied to your other contentions on the dedicated thread I did post.

However, while it is legitimate to claim that strictly in terms of attacking a structural problem, surgery is more effective (if it is) than other modalities, the point being made here is that the long-term consequences of surgery are both unknown and unknowable - at present. Yet surgery is inherently far more dangerous than ANY alternate methodology. (If not, please indicate how! Seriously)

One might well legitimately claim that improved quality of life for X number of years justifies the losses...There are many arguments that can be put forth, including the intolerability of known pain against even the slightest possibility of permanently reduced (i.e. tolerable) pain - or even the temporary reduction of pain combined with hope!

Truly, this is quite a legitimate argument. It is essentially the kind of benefit cancer patients are choosing when they opt for painful, dangerous therapies EVEN for cancers which are aggressive and well advanced, with a very low probability of cure (or even substantial remission).

However, cancer patients are presented with careful documentation of the odds of various treatments including side effects and chances of cure, along with a probability of error, as best it can be determined even for new treatments.

But (and this is the elephant in the room) we have no such opportunity for informed decision-making. We consult individual surgeons and are required (there's a choice?) to decide whether or not we believe HIM based on - what? TRUST!

Now there's Science at work (heavy - but sad - sarcasm).

Scoliosis patients are presented with no such statistics. All evidence is anecdotal, at best . True longitudinal studies are needed. Anything longitudinal will necessarily include older treatment modalities, which in scoliosis surgery will mean that reports are given for older instrumentation and surgical techniques too (SO DENOTED). Hey, fifteen- twenty years ago isn't antique. Furthermore, patients back then were told their treatments were state of the Art too - and far more trouble-free than anyone had a right to claim. The odds and possibility for certainty were grossly misrepresented by many, if not most, surgeons (I remember looking into surgery back then and this is what revisions forums report, too).

Just what makes today any different, except for our own wishful thinking?

To claim we are making informed decisions in any sense of the word, is inaccurate. We are making a leap of Faith! That we are rejecting alternates (largely by default, critiqueing them for not providing us with long term proof of efficacy) - does NOT mean our rejection is "scientific", either!

LindaRacine
06-10-2010, 10:52 PM
All I want is a table of stats including all SRS surgeons (over as many years as they can produce them) including patients who die of "other" causes and pateints lost to follow-up.



It already exists. Ask your SRS doctor about it. It's been published for AIS, and hopefully will one day be published for adult scoliosis.

LindaRacine
06-10-2010, 10:55 PM
From the other thread... ARGH!

Spine surgeons have never hidden their high rates of complications. They publish them so that patients are informed about their treatment options, and can therefore make fully informed decisions. On the other hand, Weiss has never published a long-term follow-up to Schroth. Why is he spending all his time trying to convince people that surgery is so bad instead of trying to prove that Schroth is good? I can guess the answer to that, so no need to answer.

If you think surgeons are hiding the facts, I'm thinking you're seeing the world through Weiss colored glasses.

Pooka1
06-11-2010, 05:13 AM
From the other thread... ARGH!

Spine surgeons have never hidden their high rates of complications. They publish them so that patients are informed about their treatment options, and can therefore make fully informed decisions. On the other hand, Weiss has never published a long-term follow-up to Schroth. Why is he spending all his time trying to convince people that surgery is so bad instead of trying to prove that Schroth is good? I can guess the answer to that, so no need to answer.

If you think surgeons are hiding the facts, I'm thinking you're seeing the world through Weiss colored glasses.

Post of the month nomination

"Weiss colored glasses!" :D:D:D

He is using dishonest tactics to scare the bunnies and has no alternative. That is not honest.

Pooka1
06-11-2010, 06:24 AM
To claim we are making informed decisions in any sense of the word, is inaccurate. We are making a leap of Faith!

That is true but to a less extent that you think.

Modern surgical instrumentation and techniques don't come out of the blue. They are simply the nth iteration to try to fix all observed problems with previous instrumentation. They represent answers or potential answers to the problems seen with the earlier instruments. There is probably no end to the tweaking. So the honest question is... are they still all better than no surgery? That answer will converge for many people based on what is known now. For some, surgeons will disagree. Surgery is too risky for some folks but not the great majority it seems.

Surgeons and researchers are the only ones honestly putting their data out there. That's because nobody else has any data, in some cases after decades. That right there is your leap of faith. It is disingenuous to attack the only game in town when we have bunnies who need help.

Science, more than just a good idea.

rohrer01
06-11-2010, 07:39 AM
For those of you who claim this is "garbage", I would like to know your reasoning. It is what it is in the sense that it is a compilation of facts. Yes, they may be older, but the "new" instrumentation as far as I know has only existed for about 10 years. That's not much time to get new statistics on long-term outcomes. I didn't post this article because I was trying to scare anyone away from surgery. I came across it randomly doing some research for myself and it made me THINK about what I am considering. So you can call it garbage if you like. I found it to be a helpful reminder of the seriousness of this particular kind of surgery. It's not per say a study, it's just a compilation of statistics already out there. So go ahead and tear it apart. I really don't care. I didn't write it. Calling it garbage isn't going to change the stats. I found some benefit for the simple fact that it made me sit back and think. Maybe someone else will do the same. If not, that's just fine.

LindaRacine
06-11-2010, 10:09 AM
For those of you who claim this is "garbage", I would like to know your reasoning. It is what it is in the sense that it is a compilation of facts. Yes, they may be older, but the "new" instrumentation as far as I know has only existed for about 10 years. That's not much time to get new statistics on long-term outcomes. I didn't post this article because I was trying to scare anyone away from surgery. I came across it randomly doing some research for myself and it made me THINK about what I am considering. So you can call it garbage if you like. I found it to be a helpful reminder of the seriousness of this particular kind of surgery. It's not per say a study, it's just a compilation of statistics already out there. So go ahead and tear it apart. I really don't care. I didn't write it. Calling it garbage isn't going to change the stats. I found some benefit for the simple fact that it made me sit back and think. Maybe someone else will do the same. If not, that's just fine.

There very well might be known or unknown complications with the latest implants. That doesn't change the fact that some of us would do anything to get out of pain. I got 8-10 pain free years out of my first implants. It was definitely worthwhile. If I get 8-10 out of my next implants, I would still consider it worthwhile. We all take in all the information we get, and we make a decision based on that information. I'm not sure why everyone feels the need to try to campain for their choice of treatment. I'm not trying to convince you to have surgery. Why are you trying to convince me to not have surgery?

Pooka1
06-11-2010, 10:35 AM
There very well might be known or unknown complications with the latest implants. That doesn't change the fact that some of us would do anything to get out of pain. I got 8-10 pain free years out of my first implants. It was definitely worthwhile. If I get 8-10 out of my next implants, I would still consider it worthwhile. We all take in all the information we get, and we make a decision based on that information. I'm not sure why everyone feels the need to try to campain for their choice of treatment. I'm not trying to convince you to have surgery. Why are you trying to convince me to not have surgery?

People who attack surgery are either not aware or are denying that it is simply the only option for certain patients.

Now it may not be the only option for a given patient but that cleary doesn't negate that it is the only option for other patients.

Weiss is said to be an orthopedic surgeon who no longer operates. It would be interesting to know the real reason why he doesn't operate any more. His grandmother invented Schroth and that could be a reason to throw in with the conservative folks. But then why get the orthopedic credential? I am wondering if it is the same reason that evolution deniers get legitimate science degrees - to gain credibility to push factually incorrect positions.

Weiss needs to publish the 90+ years of Schroth data before he bellyaches one more time about surgery. He is clearly engaged in "Look at the Wookie" tactics to distract attention from the vacuum of efficacy evidence for PT and bracing.

I don't think saying modern use instrumentation hasn't been around long enough to know the long-term should be publishable. It is a penetrating glimpse into the obvious. You can get that from your surgeon; nobody should need a journal article.

And going over historical instrumentation outcomes does have value for people with that instrumentation but the papers should clearly say it is historical instrumentation NOT used today in the title, introduction, methods, results, and discussion sections. Weiss fails to do that so it ends up misleading the poor bunnies.

hdugger
06-11-2010, 10:39 AM
There very well might be known or unknown complications with the latest implants. That doesn't change the fact that some of us would do anything to get out of pain. I got 8-10 pain free years out of my first implants. It was definitely worthwhile. If I get 8-10 out of my next implants, I would still consider it worthwhile. We all take in all the information we get, and we make a decision based on that information. I'm not sure why everyone feels the need to try to campain for their choice of treatment. I'm not trying to convince you to have surgery. Why are you trying to convince me to not have surgery?

I don't see anything in rohrer's post that in any way suggested "convincing other people not to have surgery."

CHRIS WBS
06-11-2010, 11:28 AM
I have perused this article a couple times within the last year or two. Of particular interest to me now is the statement: “Inflammatory responses to metallic instrumentation can occur independently or in conjunction with infections.” I had a very painful episode a couple weeks ago that landed me in my surgeon’s office. This was the first time since my surgery that I had to contact my surgeon about anything. I was in so much pain over a three-day period that I could not sleep, eat or go to work. When I contacted my surgeon’s nurse and explained my symptoms, I was prescribed an anti-inflammatory and asked to come in. A friend took me as I was in too much pain to drive myself. An x-ray revealed a solid fusion and all instrumentation intact. While that was a relief, I’m curious to know what triggered this pain. I took the anti-inflammatory over a few days and I’m fine now but I am wondering if I could be developing an allergy to the metal. Guess only time will tell.

hdugger
06-11-2010, 11:42 AM
Total garbage. The studies go back to 1950. The surgery that is being done today has very little in common with surgeries between 1950 and 1990.

They looked back to 1950 for studies, but of the 48 studies actually meeting their criteria and thus included in the summary, only 4 were published before 2000.

Back-out
06-11-2010, 01:01 PM
I have perused this article a couple times within the last year or two. Of particular interest to me now is the statement: “Inflammatory responses to metallic instrumentation can occur independently or in conjunction with infections.”...I am wondering if I could be developing an allergy to the metal. Guess only time will tell.

Since this is a source of anxiety to you, Chris, maybe it's worth consulting an allergist for tests. They should be able to inject some small amount of whatever substances are relevant, in the usual back test (here referring to where they pop the skin with the potential allergen to look for response).

It would be such a load off your mind to find it's not an issue and even if it is, maybe desensitization could relieve the problem. As I understand it, there is a difference between sensitivity and a true allergy, anyhow. I'm a great believer in reality testing. Why worry when it may be nothing? :)

rohrer01
06-11-2010, 03:04 PM
There very well might be known or unknown complications with the latest implants. That doesn't change the fact that some of us would do anything to get out of pain. I got 8-10 pain free years out of my first implants. It was definitely worthwhile. If I get 8-10 out of my next implants, I would still consider it worthwhile. We all take in all the information we get, and we make a decision based on that information. I'm not sure why everyone feels the need to try to campain for their choice of treatment. I'm not trying to convince you to have surgery. Why are you trying to convince me to not have surgery?

I'm not trying to convince ANYONE not to have surgery. I'm leaning toward having surgery myself. I'm also not campaigning for anything. This is just some information I came across that I thought might be useful for some in their decision making process. It made me sit back and take a look at risk benefit for myself. Like I said, I'm still leaning toward surgery as I'm sick and tired of being in pain.

I apologize if I frightened anyone. That was not my intent.

Back-out
06-11-2010, 03:05 PM
There very well might be known or unknown complications with the latest implants. That doesn't change the fact that some of us would do anything to get out of pain. I got 8-10 pain free years out of my first implants. It was definitely worthwhile. If I get 8-10 out of my next implants, I would still consider it worthwhile.

I quite agree. As far as I know (all too little) this is a great summary of the kind of outcome we can realistically hope for, on average, depending on demographic and surgeon. Better - worse, all depends.

Professionals, please tell us, WHAT it depends on, so we can best decide, under advisement! Data needs to be coordinated and made available to all.

And FWIW having a vested interested in alternate therapies doesn't necessarily disqualify a study though, yes, it should be disclosed. Why assume that those dissenting or cautionary voices have another motive besides the belief that - based on the evidence - patients are not treated with enough respect in the decision making process? They shouldn't be dismissed out of hand as merely motivated by self-seeking gain. It's circular. Why isn't their choice of a livelihood as much a function of their conscientious reading of the situation? If more information were available from within the profession, though, we wouldn't need to look elsewhere.

Back-out
06-11-2010, 03:11 PM
We all take in all the information we get, and we make a decision based on that information. I'm not sure why everyone feels the need to try to campain for their choice of treatment. I'm not trying to convince you to have surgery. Why are you trying to convince me to not have surgery?

Right - first part. I don't think ANYONE here is "campaigning" for their treatment choice, much less against surgery.

Personally, I'm campaigning in favor of more information - and not only for the patients, but for other non-surgeon physicians. FYI my internist is very down on the op, which is very upsetting to me. He urges me towards great caution, based on his information sources. I guess the surgery has a bad rep in the broader trade. Several of my docs have taken that tack.

I don't think the choice should be quite so "Darwinian" - money, smarts, education, who you know - should so much determine outcomes, insofar as surgical choice is a factor. I feel very bad for the (spinally) deformed people who are out of the loop and end up with inferior surgeons OR no surgery at all, because they don't have the wherewithal to pursue relief. Likewise, I feel for those who may approach the surgery a bit too cavalierly, because it is not presented with appropriate gravity (NOT an issue on this site!).

I hope very much meta-analyses will soon be available to both the affected public and their personal physicians. Complex spinal surgery, as intrinsically iffy as it is, has had outcomes obscured far more than necessary. I can't think of any other area of medicine where it is this difficult to find broad statistics about outcomes, to help in decision-making. Not CA or cardiac, nor even in rare diseases. It should NOT be this way. "My article" points out that only in the last few years have SRS surgeons even been REQUIRED to report pt. deaths.

This is just plain wrong. Everyone is entitled to make decisions based on available information. The fact that we are desperate is just one more reason why we shouldn't have to do so much detective work and second-guessing.

The information should not be proprietary. If there were a will, there would be a way. There are many reasons for this lack of summary information (physician privacy among them), but if the patients' right to know factored more heavily, data collection and analysis would be accomplished and published with relative ease. It WILL require a mandate, and a sea change regarding patients' ability to process complex material - with the help of their primary! Comparative surgeon and facility stats should also be available for both primary surgery and revision (THIS is the hardest nut to crack! :()

Again, I have great hopes that Lawrence Lenke will change this picture radically. Then, surgical candidates won't even be able to imagine this degree of ignorance being regarded as acceptable much less, the norm. Cancer patients would rebel if they were forced to choose an oncologist and treatment protocol based largely on trust and bedside manner, instead of hard facts about how different treatments have worked with their disease - with the grade it was discovered and their type of malignancy.:(

rohrer01
06-11-2010, 03:12 PM
Thank you, Linda. I decided to sit on it for a day ... and your assessment is still more gentle.

You just can't lump all those studies in together, rohrer. It *isn't* what it is.

I didn't lump those studies together. The publishers of the article did. I just posted it.

hdugger
06-11-2010, 04:13 PM
Again, I have great hopes that Lawrence Lenke will change this picture radically. Then, surgical candidates won't even be able to imagine this degree of ignorance being regarded as acceptable much less, the norm. Cancer patients would rebel if they were forced to choose an oncologist and treatment protocol based largely on trust and bedside manner, instead of hard facts about how different treatments have worked with their disease - with the grade it was discovered and their type of malignancy.:(

I'm not sure you can make this kind of comparison. Cancer treatment can be measured in a way that spinal surgery simply cannot. That's clearly true of chemotherapy, which can be precisely reported as to medicines/amounts/dates, etc. And it's largely true even of surgical procedures, where they can get a pretty good sense whether or not they've removed the mass of a tumor.

But . . . orthopedic surgeons are still struggling to figure out exactly how to precisely describe their procedure and measure immediate post-op success. "Fusing the spine" means completely different things, based on the surgeon, patient, tools, exact size and location of curve, etc. Measuring success after surgery, how do you know if you've fused the correct number of vertebrae? How do you know if the sagittal balance is correct? None of those things are immediately measurable immediately after surgery. You only know if it's really right many months or even years down the road.

Additionally, what exactly are the measures of success? Cancer really has only two: are you still alive, and have you had another occurrence of cancer.

What would be the equivalent, clear measures for a scoliosis patient? Neither the surgery or the disorder is likely to kill them, and it would just be a judgement call when you measured an "occurrence" after the original surgery. Is an occurrence the onset of pain? Is it some additional curving? How much? Is it the need for revision surgery.

I don't mean to let orthopedic surgeons off the hook - their literature is a real mess. But, they're also dealing with a very messy area for which crystal clear measures simply don't seem to be available.

Back-out
06-11-2010, 05:37 PM
I'm not sure you can make this kind of comparison. Cancer treatment can be measured in a way that spinal surgery simply cannot. That's clearly true of chemotherapy, which can be precisely reported as to medicines/amounts/dates, etc. And it's largely true even of surgical procedures, where they can get a pretty good sense whether or not they've removed the mass of a tumor.

It's true that chemotherapy and radiation have easier scriptors than spinal surgery. However, there is little more measurable than the architecture of scoliosis! We have specific angles for the lateral and sagittal curvature as well as degrees (grades?) of kyphosis, spondylosthesis , and other degenerative conditions.

Patients could be described and grouped medically by these factors as well as age, fusion length, and the location of their their primary curve (e.g. mine, being lumbar, seems harder to deal with especially with DDD)

Likewise, degree of correction achieved, degree of correction maintained and complications, could all be quantified and described by category and severity. Also, was the problem corrected non-surgically, was repeat surgery necessary, if so, after what interval? Surgical mortality and estimated contribution to later mortality could all be factored in, along with ratings for quality of life improvement. (There's a disability scale and I'm sure there are others).

Back-out
06-11-2010, 05:48 PM
"Fusing the spine" means completely different things, based on the surgeon, patient, tools, exact size and location of curve, etc. Measuring success after surgery, how do you know if you've fused the correct number of vertebrae? How do you know if the sagittal balance is correct? None of those things are immediately measurable immediately after surgery. You only know if it's really right many months or even years down the road.

True. And that's exactly what we need to know! As for sagittal balance, I think that's eminently quantifiable. Two pts on this site had a poor outcome there - one underwent successful revision; one is contemplating it. Both knew soon after their first op. I want to avoid their surgeons, especially it they're repeat offenders! Having flatback, I am looking for a surgeon with a good track record on lordosis creation - likewise, good at degenerative disease.

Back-out
06-11-2010, 05:49 PM
Additionally, what exactly are the measures of success? Cancer really has only two: are you still alive, and have you had another occurrence of cancer.

Disagree. Remission is the key! Very few cancers are cured outright. Cancer is increasingly considered a chronic disease, much like scoliosis. "Remission" - of pain and disability - is what spinal pts want to know too. It's very comparable. In fact, that's how I'm trying to construe this surgery now! Helps me accept.


What would be the equivalent, clear measures for a scoliosis patient? Neither the surgery or the disorder is likely to kill them, and it would just be a judgement call when you measured an "occurrence" after the original surgery. Is an occurrence the onset of pain? Is it some additional curving? How much? Is it the need for revision surgery.
All the above and more.

Back-out
06-11-2010, 05:53 PM
I don't mean to let orthopedic surgeons off the hook - their literature is a real mess. But, they're also dealing with a very messy area for which crystal clear measures simply don't seem to be available.

We need and deserve more information. It's out there. It's just not being rigorously collected and presented in meta-form OR by surgeon/facility (and sorry, docs, we have a right to know your track record!). That's all still in fairyland with the current proprietary business model, though that's not where it belongs. Who wants to be operated on P/A at a facility with double the national average for MRSAs? :eek: I figure those days between procedures, the patient is THE most vulnerable to infection. (Not to mention, if the hospital has a propensity to hygiene lapses).

This is a "no excuses" area, where the problem is that the current acceptable norms (doctor's privacy rights) supersede patients right to know for self-protection. Does not help that the well-known medical cabal protects even egregious offenders in all fields. My area suffered for years from the apocryphal alcoholic anesthetist no one turned in! :mad:

Anyhow, I believe the comparison to CA protocols is more valid than not and besides, such available outcomes research exists in ALL area but this. The reason is not that this is an "ineffable" area of Medicine. Au contraire, we're being "effed" because unacceptable discretion is regarded as normal. We're just used to it, and so we don't protest. We must! But first we need to realize we're being screwed - and not just our spines. :D

Pooka1
06-11-2010, 08:14 PM
I'm not sure you can make this kind of comparison. Cancer treatment can be measured in a way that spinal surgery simply cannot. That's clearly true of chemotherapy, which can be precisely reported as to medicines/amounts/dates, etc. And it's largely true even of surgical procedures, where they can get a pretty good sense whether or not they've removed the mass of a tumor.

But . . . orthopedic surgeons are still struggling to figure out exactly how to precisely describe their procedure and measure immediate post-op success. "Fusing the spine" means completely different things, based on the surgeon, patient, tools, exact size and location of curve, etc. Measuring success after surgery, how do you know if you've fused the correct number of vertebrae? How do you know if the sagittal balance is correct? None of those things are immediately measurable immediately after surgery. You only know if it's really right many months or even years down the road.

Additionally, what exactly are the measures of success? Cancer really has only two: are you still alive, and have you had another occurrence of cancer.

What would be the equivalent, clear measures for a scoliosis patient? Neither the surgery or the disorder is likely to kill them, and it would just be a judgement call when you measured an "occurrence" after the original surgery. Is an occurrence the onset of pain? Is it some additional curving? How much? Is it the need for revision surgery.

I don't mean to let orthopedic surgeons off the hook - their literature is a real mess. But, they're also dealing with a very messy area for which crystal clear measures simply don't seem to be available.

Nice post, well reasoned.

mamamax
06-11-2010, 08:15 PM
Rohrer01 - Personally, I do not think the information you shared with us is garbage. Surgery is a serious decision and the more information anyone has about it prior to going into it - the better. Certainly not everyone will experience serious complications, but some will - the literature supports that .. and as patients we should be aware of things that could possibly be avoided - or to quickly identify when something has gone wrong and needs immediate attention. Like this: http://jmedicalcasereports.com/content/2/1/9

Pooka1
06-11-2010, 08:22 PM
It's true that chemotherapy and radiation have easier scriptors than spinal surgery. However, there is little more measurable than the a architecture of scoliosis! We have specific angles for the lateral and sagittal curvature as well as degrees (grades?) of kyphosis, spondylosthesis , and other degenerative conditions.

Radiographic findings often don't correlate with patient satisfaction or pain levels or anything availble to the patient's conscience.


Patients could be described and grouped medically by these factors as well as age, fusion length, and the location of their their primary curve (e.g. mine, being lumbar, seems harder to deal with especially with DDD)

Likewise, degree of correction achieved, degree of correction maintained and complications, could all be quantified and described by category and severity. Also, was the problem corrected non-surgically, was repeat surgery necessary, if so, after what interval? Surgical mortality and estimated contribution to later mortality could all be factored in, along with ratings for quality of life improvement. (There's a disability scale and I'm sure there are others).

Among the top guys, the outcome is likely largely if not completely driven by the presenting condition on the table. The evidence for this is the difference in complication rate between young AIS patients and older ones. Kids tend to sail through this and are comfortably back in the swing of things in a few weeks. Adults, not so much. Also the neuromuscular cases have more complications because they come to the surgeon with more issues.

It's an argument for earlier surgery on younger healthier patients though of course that is not an option for adults now. And yes these kids have to live most of their lives with a fused spine and yes the long term is unknown. But some kids don't have a choice. I think some folks here approach this like everyone has a choice and can rationally refuse surgery. Those people don't tend to have kids whose spine never moved less than 5* a month for several months and who looked like a pretzel.

Pooka1
06-11-2010, 08:25 PM
True. And that's exactly what we need to know! As for sagittal balance, I think that's eminently quantifiable. Two pts on this site had a poor outcome there - one underwent successful revision; one is contemplating it. Both knew soon after their first op. I want to avoid their surgeons, especially it they're repeat offenders! Having flatback, I am looking for a surgeon with a good track record on lordosis creation - likewise, good at degenerative disease.

You might at least consider that NO surgeon can fix certain patients. They are not magical. The outcome among the top guys is probably largely predicted by the state of the patient's spine, not anything specific to the surgeon.

Food for thought about delaying surgery.

Pooka1
06-11-2010, 08:28 PM
The reason is not that this is an "ineffable" area of Medicine. Au contraire, we're being "effed" because unacceptable discretion is regarded as normal.

That is an extremely clever turn of phrase. I congratulate you.

rohrer01
06-12-2010, 12:30 AM
Rohrer01 - Personally, I do not think the information you shared with us is garbage. Surgery is a serious decision and the more information anyone has about it prior to going into it - the better. Certainly not everyone will experience serious complications, but some will - the literature supports that .. and as patients we should be aware of things that could possibly be avoided - or to quickly identify when something has gone wrong and needs immediate attention. Like this: http://jmedicalcasereports.com/content/2/1/9

Thank you, Mamamax. This isn't "my" article, but I know what you meant. The article you shared is scary stuff. I guess for people who read this, it is intended more for those of us in the "elective" category for scoliosis surgery. My curve surely isn't significant enough to be life threatening. I do, however, suffer from pain. Weighing the risk/benefit ratio for people like me is what I intended this thread to be about. Pain can drive a person to insanity!:eek:

Pooka1
06-12-2010, 08:48 AM
I guess for people who read this, it is intended more for those of us in the "elective" category for scoliosis surgery.

Exactly so. The people who refuse necessary surgery are either dead or extremely debilitated and probably aren't reading fora on this topic.

I think for the most part the elective and necessary groups are well identified by the surgeons. And it is up to the surgeons to convey the necessity of any operation in honest terms along with the likely outcome.

An exception is Weiss who seems to be out there away from the bulk of the top surgeons on these matters. I wonder if he ever did a fusion.