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sacket
06-24-2010, 03:48 PM
did any of you all experience an increase in kyphosis in the unfused portion of the upper back after scoliosis surgery? i am fused up to t5, and i'm afraid the unfused portion of my upper back will start hunching over, and that there won't be anything i can do about it.

thanks.

LindaRacine
06-24-2010, 04:20 PM
did any of you all experience an increase in kyphosis in the unfused portion of the upper back after scoliosis surgery? i am fused up to t5, and i'm afraid the unfused portion of my upper back will start hunching over, and that there won't be anything i can do about it.

thanks.

Spine (Phila Pa 1976). 2010 Jan 15;35(2):219-26.

Revision rates following primary adult spinal deformity surgery: six hundred forty-three consecutive patients followed-up to twenty-two years postoperative.
Pichelmann MA, Lenke LG, Bridwell KH, Good CR, O'Leary PT, Sides BA.

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA.

Abstract
STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze the prevalence of and reasons for unanticipated revision surgery in an adult spinal deformity population treated at one institution. SUMMARY OF BACKGROUND DATA: No recent studies exist that analyze the rate or reason for unanticipated revision surgery for adult spinal deformity patients over a long period. METHODS: All patients presenting for primary instrumented spinal fusion with a diagnosis of adult deformity at a single institution from 1985 to 2008 were reviewed using a prospectively acquired database. All surgical patients with instrumented fusion of > or =5 levels using hooks, hybrid, or screw-only constructs were identified. Patient charts and radiographs were reviewed to provide information as to the indication for initial and any subsequent reoperation. A total of 643 patients underwent primary instrumented fusion for a diagnosis of adult idiopathic scoliosis (n = 432), de novo degenerative scoliosis (n = 104), adult kyphotic disease (n = 63), or neuromuscular scoliosis (n = 45). The mean age was 37.9 years (range, 18-84). Mean follow-up for the entire cohort was 4.7 years, and 8.2 years for the subset of the cohort requiring reoperation (range, 1 month-22.3 years). RESULTS: A total of 58 of 643 patients (9.0%) underwent at least one revision surgery and 15 of 643 (2.3%) had more than one revision (mean 1.3; range, 1-3). The mean time to the first revision was 4.0 years (range, 1 week-19.7 years). The most common reasons for revision were pseudarthrosis (24/643 = 3.7%; 24/58 = 41.4%), curve progression (13/643 = 2.0%; 13/58 = 20.7%), infection (9/643 = 1.4%; 9/58 = 15.5%), and painful/prominent implants (4/643 = 0.6%; 4/58 = 6.9%). Uncommon reasons consisted of adjacent segment degeneration (3), implant failure (3), neurologic deficit (1), and coronal imbalance (1). Revision rates over the follow-up period were: 0 to 2 years (26/58 = 44.8%), 2 to 5 years (17/58 = 29.3%), 5 to 10 years (7/58 = 12.1%), >10 years (8/58 = 13.8%). CONCLUSION: Repeat surgical intervention following definitive spinal instrumented fusion for primary adult deformity performed at a single institution demonstrated a relatively low rate of 9.0%. The most common reasons for revision were predictable and included pseudarthrosis, proximal or distal curve progression, and infection.

PMID: 20038867 [PubMed - indexed for MEDLINE]

LindaRacine
06-24-2010, 04:21 PM
Spine (Phila Pa 1976). 2009 Apr 15;34(8):832-9.

Reoperation after primary fusion for adult spinal deformity: rate, reason, and timing.
Mok JM, Cloyd JM, Bradford DS, Hu SS, Deviren V, Smith JA, Tay B, Berven SH.

Department of Orthopedic Surgery, University of California, San Francisco, CA 94143-0728, USA.

Abstract
STUDY DESIGN: Retrospective cohort study of consecutive patients undergoing primary fusion with segmental fixation for adult spinal deformity. OBJECTIVE: We sought to determine the survivorship of primary fusion for adult spinal deformity and identify patient-specific predictors of complications requiring reoperation. SUMMARY OF BACKGROUND DATA: Compared with the adolescent population, surgery for adult deformity is often more complex and technically difficult, contributing to a high reported rate of complications that can result in the need for reoperation. Reported complication rates vary widely. METHODS: From 1999-2004 all patients who underwent primary instrumented fusion for nonparalytic adult spinal deformity at a single center were included. Inclusion criteria included minimum age at surgery of 20 years and minimum fusion length of 4 motion segments. Surgical, demographic, and comorbidity data were recorded. Reoperation was defined as any additional surgery involving levels of the spine operated on during the index procedure and/or adjacent levels. Comparisons were performed between patients who required reoperation and those who did not. RESULTS: Eighty-nine patients met inclusion criteria. Endpoint (minimum 2 years follow-up or reoperation) was reached for 91%. Mean follow-up was 3.8 years. Cumulative reoperation rate was 25.8%. Survival was 86.4% at 1 year, 77.2% at 2 years, and 75.2% at 3 years. Reasons for reoperation included infection (n = 8), pseudarthrosis (n = 3), adjacent segment problems (n = 5), implant failure (n = 4), and removal of painful implants (n = 3). Multivariate analysis showed smoking was significantly higher in the reoperation group. CONCLUSION: Using a strict definition of reoperation for a well-defined cohort, in the presence of relevant risk factors, many patients undergoing primary fusion for adult spinal deformity required reoperation. The results indicate that complex medical and surgical factors contribute to the treatment challenges posed by patients with adult spinal deformity. This represents the largest cohort reported to date of patients undergoing primary fusion using third-generation instrumentation techniques.

PMID: 19365253 [PubMed - indexed for MEDLINE]

Back-out
06-24-2010, 04:39 PM
Those are great studies and I wish there were more such.
How do you think their stats compare to those of the general population of patients (with age and surgical difficulty factored in)?

I can't help thinking pts at those two facilities must fare much better than average - one of the main reasons I want to go to Lenke/Bridwell despite the considerable distance (and if I could afford it, I'd swing out West too!).

I wish the HSS would publish such a longitudinal review.

LindaRacine
06-24-2010, 07:39 PM
Those are great studies and I wish there were more such.
How do you think their stats compare to those of the general population of patients (with age and surgical difficulty factored in)?

I can't help thinking pts at those two facilities must fare much better than average - one of the main reasons I want to go to Lenke/Bridwell despite the considerable distance (and if I could afford it, I'd swing out West too!).

I wish the HSS would publish such a longitudinal review.

I don't know about WUSTL, but at UCSF the average age of all patients coming into the clinic is probably about 60-70 years. Both institutions do far more complicated cases than the standard deformity clinic.

By the way, adjacent segment disease includes degeneration both above and below the fusion, so you can see that the incidence is relatively small. I suspect it is MUCH higher when the spine surgeon does a lot fewer surgeries (especially adult surgeries).

Back-out
06-24-2010, 08:09 PM
I don't know about WUSTL, but at UCSF the average age of all patients coming into the clinic is probably about 60-70 years. Both institutions do far more complicated cases than the standard deformity clinic.

Just what I figured and why I thought it good to allow for that in interpreting their results.

By the way, adjacent segment disease includes degeneration both above and below the fusion, so you can see that the incidence is relatively small. I suspect it is MUCH higher when the spine surgeon does a lot fewer surgeries (especially adult surgeries).
I know. Girardi mentioned that to me too, but I figured if they go to the pelvis, there wouldn't be much to degenerate on the bottom - except, of course, for the possibility of a pelvic fracture. :eek:

As for the top, I guess that risk exists, especially since I already start with degenerated disks everywhere (as per myelogram results), tho' thoracic is overall best. Cervical doesn't look all that great...I'm more concerned abt infection risk.

Your "suspicion" is why I most seek a surgeon who does plenty of complex "adult" spines.

I sure wish I could get to UCSF! Say, DO they take BCBS? And do they have any special housing arrangements making stay-overs cheaper than ordinary hotels for pts. and helpers?

LindaRacine
06-24-2010, 08:25 PM
Here's another one out of WUSTL that has quite a different outcome:

Spine (Phila Pa 1976). 2008 Sep 15;33(20):2179-84.
Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up.

Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G.

Washington University Medical Center, St. Louis, Missouri, USA.
Abstract

STUDY DESIGN: A retrospective study. OBJECTIVE: To analyze time-dependent change of, prevalence of, and risk factors for proximal junctional kyphosis (PJK) in adult spinal deformity after long (> or =5 vertebrae) segmental posterior spinal instrumented fusion with a minimum 5-year postoperative follow-up. SUMMARY OF BACKGROUND DATA: No study has focused on time-dependent long-term proximal junctional change in adult spinal deformity after segmental posterior spinal instrumented fusion with minimum 5-year follow-up. METHODS: Clinical and radiographic data of 161 (140 women/21 men) adult spinal deformity patients with minimum 5-year follow-up (average 7.8 years, range 5-19.8 years) treated with long posterior spinal instrumentation and fusion were analyzed. Radiographic measurements included sagittal Cobb angle at the proximal junction on preoperative, 8-weeks postoperation, 2-year postoperation, and ultimate follow-up (> or =5 years). Postoperative SRS outcome scores were also evaluated. RESULTS: The prevalence of PJK at 7.8 years postoperation was 39% (62/161 patients). The PJK group (n = 62) demonstrated a significant increase in proximal junctional angle at 8 weeks (59%), between 2 years postoperation and ultimate postoperation (35%), and in thoracic kyphosis (T5-T12) at ultimate follow-up (P = 0.001). However, the sagittal vertical axis change at ultimate follow-up did not correlate with PJK (P = 0.53). Older age at surgery >55 years (vs. < or =55 years) and combined anterior and posterior spinal fusion (vs. posterior only) demonstrated significantly higher PJK prevalence (P = 0.001, 0.041, respectively). The SRS outcome scores did not demonstrate significant differences with the exception of the self-image domain when PJK exceeded 20 degrees. CONCLUSION: The prevalence of PJK at 7.8 years postoperation was 39%. PJK progressed significantly within 8 weeks postoperation (59%) and between 2 years postoperation and ultimate follow-up (35%). Older age at surgery (>55 years) and combined anterior and posterior spinal fusion were identified as risk factors for developing PJK. The SRS outcome instrument was not adversely affected by PJK, except when PJK exceeded 20 degrees.

PMID: 18794759 [PubMed - indexed for MEDLINE]

Please note, by the way, that so far the abstracts I've posted are looking at revision surgeries. The actual incidence of adjacent segment disease is probably much higher, as a lot of people with PJK never have it fixed. (I have PJK and probably won't have it fixed.)

LindaRacine
06-24-2010, 08:29 PM
Here's one that is not a revision surgery paper.

Spine (Phila Pa 1976). 2005 Jul 15;30(14):1643-9.
Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis.

Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C 2nd.

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
Abstract

STUDY DESIGN: To analyze patient outcomes and risk factors associated with proximal junctional kyphosis (PJK) in adults undergoing long posterior spinal fusion. OBJECTIVES: To determine the incidence of PJK and its effect on patient outcomes and to identify any risk factors associated with developing PJK. SUMMARY OF BACKGROUND DATA: The incidence of PJK and its affect on outcomes in adult deformity patients is unknown. No study has concentrated on outcomes of patients with PJK. Risk factors for developing PJK are unknown. METHODS: Radiographic data on 81 consecutive adult deformity patients with minimum 2-year follow-up (average 5.3 years, range 2-16 years) treated with long instrumented segmental posterior spinal fusion was collected. Preoperative diagnosis was adult scoliosis, sagittal imbalance or both. Radiographic measurements analyzed included the sagittal Cobb angle at the proximal junction on preoperative, early postoperative, and final follow-up standing long cassette radiographs. Additional measurements used for analysis included the C7-Sacrum sagittal plumb and the T5-T12 sagittal Cobb. Postoperative SRS-24 scores were available on 73 patients. RESULTS: Incidence of PJK as defined was 26%. Patients with PJK did not have lower outcomes scores. PJK did not produce a more positive sagittal C7 plumb. PJK was more common at T3 in the upper thoracic spine. CONCLUSIONS: Incidence of proximal junctional kyphosis was high, but SRS-24 scores were not significantly affected in patients with PJK. The sagittal C7 plumb was not significantly more positive in PJK patients. No patient, radiographic, or instrumentation variables were identified as risk factors for developing PJK.

PMID: 16025035 [PubMed - indexed for MEDLINE]

LindaRacine
06-24-2010, 08:38 PM
Yes, the UCSF surgeons take BC/BS, as do the vast majority of the country's surgeons. If you have an HMO plan, however, I doubt you'd get referred to San Francisco.

As far as I know, the deals on San Francisco hotels are still going to be a lot more $ than what you're being quoted elsewhere.

--Linda

Back-out
06-24-2010, 08:41 PM
So, to summarize the above, it looks like the overall odds are ~ 40% at study's endpoint, for developing PJK OR thoracic kyphosis, and extrapolating, much higher for pts > 55 yrs, undergoing P/A approach. Also, that this starts developing almost immediately post-surgery and steadily worsens.

Now I know why 2/3 surgeons wanted to fuse me from T4 down instead of T10 even though, above T10 "everything is fine" (per third surgeon). I wonder if the higher fusion would prevent this occurring in me and/or if targeted PT could reduce the risk.

I was especially interested in the sentence before you started bolding:
The SRS outcome scores did not demonstrate significant differences with the exception of the self-image domain when PJK exceeded 20 degrees.

In other words, patients developing this problem were nonetheless deemed to be doing fine EXCEPT FOR SELF-IMAGE! :(

Back-out
06-24-2010, 08:46 PM
Brilliant question, sacket! :o

jrnyc
06-24-2010, 08:57 PM
i asked Dr L. whether i was likely to need revision surgery, since he will start my fusion at T11...he said he didnt think so...and he wouldnt fuse more of my back based on the chance something might happen...
i liked his answer...

jess

Sharon C
06-25-2010, 01:01 AM
Well, I recently posted on the revision portion of this site about my worsening kyphosis after 5 years. I was 54 at the time of my surgery, and was fused A/P from T-5 to L-4. I am now wondering if it wouldn't be wise just to fuse all the way up, but I guess that's not how it's done, and perhaps with good reason. Why anticipate trouble before it actually occurs? I just saw my surgeon for the first time in over 2 1/2 years a couple of weeks ago. Unfortunately, the x-ray folks weren't there, so I had to get those later and will see Doc again on July 2nd. To my untrained eye, my kyphotic curve looks very much worse than those years ago. I feel it everyday as I try to stand and have to fight my neck to keep my head erect. I suspected from comments on this site that I might also have saggital imbalance, but Doc doesn't think so. I would be delighted if I only have to deal with the "upper" surgery and only one means of entry, as opposed to the alternative. Thanks, Linda, for the informative studies, though it's amazing I could muddle through all the "shop talk." I was wondering if the "blame" if there is any, needs to be placed upon the surgeon, or if the nature of the beast is such that there are so many variables in a surgery this complex that one has to shoot one's best shot and hope for the best. My husband and I suspect the latter. At this point, I just want to be able to walk upright comfortably again, and I'm willing to endure whatever it takes to accomplish that, as I am unable to accept that my current physiology is what I will be stuck with forever.
I am so grateful for this site and everyone herein!!!!

Back-out
06-25-2010, 08:53 PM
Linda, hoping you see this...

I posted my last reply to you. in a cross-post while you were getting ready to put up the second Washington U review of PJK and I confess I'm COMPLETELY confused.

First, my comment only applies to the first study.

Second, you say that all your (first three) links including the first PJK link were of a revision cohort.

I must have finally burnt out on all this, but I have tried to reread both of them, and I don't see anywhere it says the first one is a population of revision pts.

Also (and this is more embarrassing) I can't really tell them apart meaningfully . :o :o . I'll try to reread them when less is going on here, but meanwhile, I wonder if you can supply any simple pointers as to what their different purposes and conclusions were.

Flummoxed utterly
:confused:
Amanda

jrnyc
06-25-2010, 09:06 PM
hi Sharon
i'm so sorry to hear of the problems you are having with the newly developed kyphosis...i already am "particularly hypokyphotic in thoracic spine", but have "good overall balance" per my surgeon...he wants to fuse T11-pelvis, and says he wont assume future problems in upper portion not being fused, because there is no guarantee it will happen...
i really dont think it is the fault of the surgeon when it happens...and i trust the guy enough to go with his decision, if/when i have it done...
that said, it is rotten that it happened to you...am wondering if you have any interest in seeking help from a pain management doctor, or whether you are considering revision surgery only...?

hope you feel better
jess

LindaRacine
06-25-2010, 10:09 PM
Linda, hoping you see this...

I posted my last reply to you. in a cross-post while you were getting ready to put up the second Washington U review of PJK and I confess I'm COMPLETELY confused.

First, my comment only applies to the first study.

Second, you say that all your (first three) links including the first PJK link were of a revision cohort.

I must have finally burnt out on all this, but I have tried to reread both of them, and I don't see anywhere it says the first one is a population of revision pts.

Also (and this is more embarrassing) I can't really tell them apart meaningfully . :o :o . I'll try to reread them when less is going on here, but meanwhile, I wonder if you can supply any simple pointers as to what their different purposes and conclusions were.

Flummoxed utterly
:confused:
Amanda
Sorry, I wasn't clear. On the first one, I think I was simply thinking about the 3 patients being out of the patients who had revision (3 out of 58, or 5%), and not 3 patients out of 643.

It's impossible to know for certain how the WUSTL or UCSF stats compare to other surgeons or centers. I would guess their rates are lower, but I don't know that for certain. Something to remember is that both WUSTL and UCSF treat far more difficult cases than other centers, so their complication rates are bound to be higher.

As I said previously, there are an awful lot of us with PJK, but I think most of us are unlikely to find it bothersome enough to actually have it fixed.

Be careful about trying to learn too much about all the potential complications, as you may go into overload. There are some horrible things that can happen during this, or any big surgery. For adults, the percentage of people who have complications (both short-term and long-term) bad enough to require additional surgery is probably somewhere in the neighborhood of 25-30%. (That's just a guess.) What you really need to think about is that if you're one of the people who have a really bad outcome, statistics are totally meaningless. That's why I think it's very important to know that, as an adult, one better be damn sure that one has thought long and hard about it being the right choice, before signing up for surgery.

--Linda

Sharon C
06-26-2010, 01:47 AM
Kind of you to reply.
Really, pain is not my main issue. Apparently, I'm told, I have a very high pain threshold (at least physically; the wine takes care of the rest ;) But now I'm getting lower and lower to the ground to acommodate the ever increasing curve of my upper spine, and it's not only uncomfortable, it's emotionally debilitating. I feel like a leper, freak, 20 year OLDER lady than I am. I want to enjoy my vacation by the beach with my husband and walk a mile without a cane. Hell, I'd like to walk a BLOCK without a cane. I know I am very fortunate and there are those worse off than I am, but this is MY life and I think it can be better and I am ready to explore my options. The alternative is to hunch over, moan and groan and be miserable. Not a life worth the trouble, in my humble opinion. I'll keep you all posted about what I decide and the results. In the end, I guess, we all just need to find a doc we basically trust, comes with some decent references, and also fits into our financial capabilites. Too bad we can't all ship off to Paris, NY, or wherever to employ the "surgeon to the stars," but that's not my reality. So, I'll be realistic, hopeful, and maybe even a little lucky, and stand straight and tall and all without a walker, cane, or the hand of a loved one; though that's always a plus:)
Sharon

LindaRacine
06-26-2010, 12:09 PM
Well, I recently posted on the revision portion of this site about my worsening kyphosis after 5 years. I was 54 at the time of my surgery, and was fused A/P from T-5 to L-4. I am now wondering if it wouldn't be wise just to fuse all the way up, but I guess that's not how it's done, and perhaps with good reason. Why anticipate trouble before it actually occurs? I just saw my surgeon for the first time in over 2 1/2 years a couple of weeks ago. Unfortunately, the x-ray folks weren't there, so I had to get those later and will see Doc again on July 2nd. To my untrained eye, my kyphotic curve looks very much worse than those years ago. I feel it everyday as I try to stand and have to fight my neck to keep my head erect. I suspected from comments on this site that I might also have saggital imbalance, but Doc doesn't think so. I would be delighted if I only have to deal with the "upper" surgery and only one means of entry, as opposed to the alternative. Thanks, Linda, for the informative studies, though it's amazing I could muddle through all the "shop talk." I was wondering if the "blame" if there is any, needs to be placed upon the surgeon, or if the nature of the beast is such that there are so many variables in a surgery this complex that one has to shoot one's best shot and hope for the best. My husband and I suspect the latter. At this point, I just want to be able to walk upright comfortably again, and I'm willing to endure whatever it takes to accomplish that, as I am unable to accept that my current physiology is what I will be stuck with forever.
I am so grateful for this site and everyone herein!!!!
Hi Sharon...

I think there's probably a big difference between the best surgeons and the worse surgeons. Picking the right levels to fuse is really important. However, as you can see from the research out of St. Louis and San Francisco, proximal junctional kyphosis occurs sometimes, even for the best surgeons.

Regards,
Linda

sacket
06-26-2010, 01:23 PM
hey sharon! i was fused from t5 to l4 too. i just had surgery about five weeks ago. at first i thought i was imagining that the unfused portion of my upper back was hunching forward, but now i'm really starting to wonder because it's becoming more noticeable to me. it started with the sensation that my head wasn't sitting square over my shoulders. mirror confirmed this. :]

to all: would fusing higher up (e.g. to t2 or higher) prevent/correct this? obviously it's too early for me to do anything about it. looks like i'll have to endure a few years of it getting worse before anything gets done.

i am starting physical therapy next week. do you think that would help?

thanks for posting the studies linda. can you translate for me from the studies about how soon after surgery kyphosis develops in those that get it?

LindaRacine
06-26-2010, 04:17 PM
hey sharon! i was fused from t5 to l4 too. i just had surgery about five weeks ago. at first i thought i was imagining that the unfused portion of my upper back was hunching forward, but now i'm really starting to wonder because it's becoming more noticeable to me. it started with the sensation that my head wasn't sitting square over my shoulders. mirror confirmed this. :]

to all: would fusing higher up (e.g. to t2 or higher) prevent/correct this? obviously it's too early for me to do anything about it. looks like i'll have to endure a few years of it getting worse before anything gets done.

i am starting physical therapy next week. do you think that would help?

thanks for posting the studies linda. can you translate for me from the studies about how soon after surgery kyphosis develops in those that get it?
Hi...

It's not mentioned in any of the abstracts (at least that I can tell).

If you can see something awry in the mirror, it sounds to me like you might have something other than PJK.Are you saying that your head isn't centered over your pelvis? In PJK, the head and neck are forward of your torso.

--Linda

Back-out
06-26-2010, 04:31 PM
Hi Sharon...

I think there's probably a big difference between the best surgeons and the worse surgeons.

No "probably" about it! And membership in SRS is no guarantee of quality - just a minimum standard, like board certification.


Picking the right levels to fuse is really important.

No kidding. And the thing is, it's seeming more and more apparent that there may not really be a "right" level in the long run. It's just one more way of defining a trade-off. Example: a shorter fusion might be seen as yielding greater flexibility, a safer operation and more certainty about fusing properly, against a more stable correction, less of the above quantities and less chance of requiring re-operation.

The choice sounds like a result of an individual surgeon's judgment (based on his experience and reading of the literature). possibly incorporating the patient's primary objectives. If the patient "wants it all" in her/his correction, s/he has to give up flexibility and greater security in other ways. The recent discussions of Gupta's "conservative" surgical approach illustrates such trade offs.

I've been wondering about how to define "conservative" versus whatever the opposite is in a surgeon, and I think fusion length may be one of the main measures. I've heard Bridwell described as conservative too, and I guess that he too will recommend a less radical correction and easier surgical experience for me.

It seems to be like so much else, a question of risk tolerance. The surgeon's and your own.

However, only a foolish patient would push a surgeon to go beyond his initial recommendations, since responsible surgeons must be basing their recommendations not only on their reading of the stats, but their comfort level in what they personally feel they can achieve!

I assume that a difference in average fusion length (what they'd recommend for the same patient), reflects a real difference between what given surgeons can achieve in tackling the same presentation.

For me, this translates to regret that I cannot afford to wait for Lenke to fit me in instead of Bridwell. I believe Lenke is probably more able to achieve greater correction than Bridwell (with the same degree of safety - stability of results and patient morbidity).

Back-out
06-26-2010, 04:34 PM
Linda (hoping again you see this) is my impression correct that with current operating techniques, older patients with a long P/A fusion, are pretty much assured of getting PJK? That they might as well expect it?
Like sacket, though, I wonder if a (still) longer fusion starting higher on the T-spine, could prevent this.

Based on your own experience (how far up did they start your fusion?), if you had it to do over again, would you have chosen the trade-off that seems to exist in this issue?

That is, would you have preferred to have had a longer fusion if it would have meant avoiding PJK, or would you still have elected to have things as they turned out? That is, knowing in advance you'd develop PJK would you still have preferred to retain greater flexibility, and for your surgery and recovery to be that much easier and safer?

I realize, especially for younger pts, it's not at all cut and dried (BAD metaphor!) , but supposing it had been presented this way - what would you have chosen? Naturally, I'm trying to compare the two outcomes AS EXPERIENCED, since I have absolutely no idea about what PJK translates to in pain, cosmesis, and loss of function. In fact, I can't quite picture what it is - for example, what X-rays with and without would look like. (Kind of sounds like it turns into something like a "dowager's hump").

LindaRacine
06-26-2010, 08:57 PM
Linda (hoping again you see this) is my impression correct that with current operating techniques, older patients with a long P/A fusion, are pretty much assured of getting PJK? That they might as well expect it?
Not at all. There are times when it's likely, and times when it's not.

Like sacket, though, I wonder if a (still) longer fusion starting higher on the T-spine, could prevent this.
Yes, if you have your entire spine fused, you'll almost certainly not get PJK. ;-)


Based on your own experience (how far up did they start your fusion?), if you had it to do over again, would you have chosen the trade-off that seems to exist in this issue?

That is, would you have preferred to have had a longer fusion if it would have meant avoiding PJK, or would you still have elected to have things as they turned out? That is, knowing in advance you'd develop PJK would you still have preferred to retain greater flexibility, and for your surgery and recovery to be that much easier and safer?

I realize, especially for younger pts, it's not at all cut and dried (BAD metaphor!) , but supposing it had been presented this way - what would you have chosen? Naturally, I'm trying to compare the two outcomes AS EXPERIENCED, since I have absolutely no idea about what PJK translates to in pain, cosmesis, and loss of function.

My fusion starts at T4. It's entirely possible that if my fusion started at T3, I wouldn't have PJK, but there's no way to know that for certain. If you do a Medline search on PJK, you'll find several additional studies that talk about choosing levels. I think, however, that there's no way you'll ever fully understand the intricacies of selecting the best levels. If you find a surgeon you can trust, my advice would be to leave it up to him/her to make that decision.


In fact, I can't quite picture what it is - for example, what X-rays with and without would look like. (Kind of sounds like it turns into something like a "dowager's hump").
It looks like kyphosis, but sometimes has a sharper angle. Here's an xray:

http://static.spineuniverse.com/displaygraphic.php/4213/shaffrey_s1failure_fig6b-99.jpg

Back-out
06-26-2010, 10:19 PM
Linda

It looks like kyphosis, but sometimes has a sharper angle. Here's an xray:

http://static.spineuniverse.com/disp...e_fig6b-99.jpg

Ooh. That's a lot worse than I thought. That looks like real sagittal imbalance. That doesn't look like something the SRS scoring system would have waved away saying it left the patient OK except for patient self-image. An angle that sharp would make it hard to walk and look straight ahead too.

Hoping most PJK is loads milder! (again, "dowager's hump" material)
But boy! You can sure see the difference between fused and unfused portions. Can't help wondering what that patient looked like sideways BEFORE her surgery! :eek:

titaniumed
07-14-2010, 08:52 PM
This is a great thread....

It explains why I couldnít get my surgeon to fuse lower on me.....not even T4.

It seems that the more I read on this subject, and on sagittal imbalance, it seems that the "amounts" of plumb line deviation seem to be significant. Like several inches, which is huge.

Anyone who goes through surgery should be monitored by their surgeons to watch and see if PJK or sagittal imbalance issues happen quickly. (Under 2 months) I donít know how long it would take if an issue arose, I know my surgeons were not keen on going back in so soon after I thought I had an incisional hernia. It turned out to be gall issues, but they were going to wait, and wait awhile...

I saw my surgeon 3 times within 2 months of being released from the hospital, and a few times up till 1 year post.

Again, some good advise from Linda. Even though I turned out great, and I'm extremely greatful, she reminds me of how lucky I really am.
Ed

Sharon C
07-14-2010, 09:59 PM
Nice vaca picts, btw!

I'm going to see Dr Menmuir THIS FRIDAY the 16th. I'll be very interested in his take on my condition. As I mentioned before, Dr Fry said if I were his wife, he would advise me not to persue more surgery at this time. He acknowledges the kyphosis, but says he'd go in and take all my old hardware out (have to ask him why next time!) go through the front of my chest, and then I might still have my neck fall forward in the future! So, instead of a relatively lesser surgery, it would be even nastier than the original one (my words, not his.) I can't wrap my head around that scenario right now, so if Dr. Menmuir concurs, I think I might just settle into the idea of having to walk bent over and/or with support until the technology improves. If he thinks he can help with a lesser procedure, however, I'll get a 3rd opinion from Dr Grupta at UC Davis. You ARE very lucky yours went so well, and you're very generous to share your thoughts and experiences on this forum. :)

Regards,
Sharon

titaniumed
07-15-2010, 07:24 PM
Hi Sharon

Glad you enjoyed the pics.

I hope things go ok tomorrow with Dr Menmuir. Be sure to let me know what he says, in a PM or e-mail. titaniumed@hotmail.com

Dr Menmuir is from South Africa. Its funny, at Twin Cities, several of the scoli Doctors and professors are also from South Africa.... Older ones who probably trained with Dr Moe...

He saved my life. I would give him my right arm.
Ed

Susie*Bee
07-15-2010, 07:34 PM
Sharon-- we are all so concerned, I hope you will post at least a little something about your appointment for the rest of us too. Thinking of you!

golfnut
07-15-2010, 07:40 PM
Well, this thread is really scaring me. I don't want to have more of a self image problem after going through this tough surgery. The kyphosis appears to be very common in older patients, such as me. Once, again, I hope I'm not going to regret having this surgery.

Back-out
07-15-2010, 07:43 PM
I can see why you were willing to move to CA to be near him, if necessary, Ed. It's no joke having a surgeon far away. How could you have stayed in such close touch with him right after your surgery, otherwise? (Much more than he or any of them requires, I'm sure).

And also he would never have been able to have your PT overseen so closely (at home? Wow!).

It is clearly an advantage in avoiding these things, to actually have your surgeon look in on you like this - early on. No way is it the same, talking on the phone or even sending images.

Yet what surgeon would suggest a patient just drop in for a check-in if they live a thousand+ miles away - and so soon after the original surgery? I'm starting to think maybe there's something to be said for subletting a place in the area for the first few months. Considering the kind of intimate oversight it would permit - and safety... And I'm not a bit sure it would be much pricier than a few airfare trips back and forth, patient and helper.

In my case, I'd also be sure of having PT people familiar with long fusions - def. not the case in the boonies here. The risk factor of needing to fall back on my DANGEROUS local hospital in the event of straight medical complications is yet another issue.

Thoughts?

titaniumed
07-15-2010, 09:26 PM
Amanda

I was ready to move to San Francisco if necessary. This was Before Dr Menmuir came to Reno.... Before he moved here, there were no scoli specialists here. My old non-scoli ortho suggested that I head down to San Francisco. (UCSF) after I was in trouble. That was in 2002.

Around 2005, I called down cause I was hurting big time, and he retired(my old non-scoli ortho) and the girl told me that they had a new scoli specialist and that was when I first met Dr Menmuir.

My thoughts? The first thing that needs to be addressed is insurance. When you leave a state, things can get complicated, and some insurances will only cover 50%. My tab was 765K.

In my case, I would have moved to California, obtained insurance, then started planning. It would have been temporary, but then again, I probably would have stayed in San Francisco, its such a great city. I've known about Dr Bradford and his group for a long time...

I had some complications, they happen. My pain was so bad, I just had to get it done, and prayed that nothing would happen. Thatís all we can do sometimes. I was also talking to Dr Shelokov before he passed.

I knew Dr Menmuir was good. It took several meetings, there were no guarantees, he was straight up and right on with everything he has ever said to me. He wanted me "online" studying scoliosis. There are so many things to know, and Surgeons are very busy people....

My PT was walking. I did PT on my broken shoulder 8 months after my scoli surgeries. I wanted to wait till my spine fused at 6 months and took it very easy till that time. The nurses and PT girl came out to my house since I was tired of the hospital, and I didnít want to do a rehab hospital. I'm sure the insurance company was pleased since I saved them quite a chunk, and I didnít want to use any more available insurance monies in case I needed more. I was having gall issues, that I thought was an incisional hernia at the time.

I agree with you. It would be best to be close to your surgeon and a decent hospital. Some travel, and travel great distance, but its easier when everything is 15 minutes away. In San Fran, if you need a liver, they make you move. It happened to a friend of mine. His tab was $2million.

You are doing a great job at being active and researching scoliosis... I will give you a 10.

If any of you get CTs, get burned copies of your digitals.They are your property! I have had Doctors lose my records years ago!!!!!!!!!! You donít want to be doing these all the time. This goes for x-rays also. Date them.
Ed

Back-out
07-16-2010, 10:22 PM
Thanks for the wealth of good advice, Ed. I hadn't been aware your thoughts on moving predated finding Dr. Menmuir. You sure " rose to the occasion" of your wipe-out surgery, and your being here to tell the tale really means something.

You accepted the maximum challenge, and got run over by that surgery truck prior to being kind of reincarnated. But in being effectively taken apart and reassembled, you did it RIGHT. No point in doing it half way, anyhow - as long as one can physically and mentally withstand it.

Makes me wonder about how one can arrive at a meeting of the minds in planning what's to be done, though. Your surgeon didn't want to leave a stone (as in vertebra) unturned in giving you the best chance for a complete recovery. For YOUR post-surgical goals.

And he knew that's what suited you too. No stop-gap measures. Others seem to prefer to take fewer risks - as they see it, anyhow. Hence, they fuse less. I'm sure your going into it in tip top physical shape (being active) figured heavily in what he thought you could tolerate too. "Tip top" except for that little matter of living in agony, that is! :o

This is why I asked in a recent thread, about the meaning of "conservative" in this surgery. Seems that less surgery is tantamount to conservative in the lingo, but in another way it's the opposite. In terms of the target concern of this thread, for example.

I appreciate your giving me a 10 for effort in research. The problem is, if one doesn't somehow engage the surgeon's interest, it's hard-impossible to get answers. Your advice abt emails (ways back) was good. Will do. :)

Starting to panic just a bit. OK, more than a bit...But having survivors (and thrivers) like you around, helps. Thanks!

Back-out
07-16-2010, 10:27 PM
To addL

***
Comments on saving images helps too - practical advice is important. A surgeon performing very specialized surgery on me ten years ago, didn't arrange for his records to be saved after he retired - not more than the legally mandated 7 years. Now I don't know what rib was harvested for a graft (among much else - I'm sure they can figure out which rib is missing)! Yep, record-keeping matters! :rolleyes:

And, very true about insurance. Misunderstanding abt mine, I think . I can go anywhere with my BCBS plan (as it stands now. BRRR). Hence, time pressure. More time to process all this would have helped. A certain amount of incubation....I've only had since March. Blech.

titaniumed
07-17-2010, 12:12 PM
Ribs grow back, and they grow back quickly! This is why scolis need to be extra careful in the first few months right after surgery. Bone grows fast!

X-rays will show breaks, fractures of the past.... itís a permanent record.

Scoliosis surgical patients need to plan on doing nothing for a few months, especially if the surgery is serious. No laundry, no step stools, no nothing. Just full concentration on healing with a positive attitude.

There are no studies on "rate of fusion" or "integrety of fusion" at specific times. I have read about fusion studies in cadavers, but it seems to make sense that fusion "healing rates" are most critical immediately after surgery. Osteoblasts, in high gear!

My recovery involved a non-linear amount of physical effort....Walking carefully, with slow increases of physical activity. No bending, no lifting, for months... My tests of endurance came later, I was in no hurry, you only have one shot at this.

I need to add "take it easy" to my signature. Also, "Access down low, from the front is best" for comedic effect....
Ed

Susie*Bee
07-17-2010, 01:10 PM
Love it, Ed-- the new line... :D

Back-out
07-17-2010, 03:37 PM
Really excellent advice, Ed. We need you to sock it to us. Too many women are afraid of appearing to nit-pick or second guess others, but in this area it's doing no one a favor to come on too soft. People won't be as cautious as they need to be.

I get the feeling reading many posts that moms especially, tend to do too much early on, afraid of being seen as wimps or imposing on others - not fulfilling their responsibilities (and making others mad at them).

Maybe it would across better if the emphasis were laid on how much of a negative effect it will have on our kids/spouses down the road if we DON'T take care of ourselves now. These are the same kids who will have the burden of our care later on if we're invalided (if they accept it, that is).

It couldn't be more serious. And education is too much of a do it yourself proposition IMO. Women need to spare themselves at first. Period. What's the cost of housekeeping help compared with nursing care later on? And to insure the success of a 1/2 million - 3/4 million $ surgery (not even putting a price on our pain and basic family/s.other care at first)?

Worse still if we're creating the need for even more surgery later on.

Paying for help emptying dishwashers and doing laundry for a few months are NOTHING up against this kind of a potential loss. It's worth using disposables and buying frozen food - WITHOUT GUILT!

One of the problems are it's an "invisible handicap". We should wear our X-rays on our backs so people would see what we're up against. And something else to remind ourSELVES of what it's worth.

Susie*Bee
07-17-2010, 04:26 PM
One of the problems are it's an "invisible handicap". We should wear our X-rays on our backs so people would see what we're up against. And something else to remind ourSELVES of what it's worth.

So true! And there are a few of us that posted our "before and after's" at work so that others could see. One look at the lateral x-rays with those wicked looking screws is enough for most people to back off and give you a little lee-way or understanding if you're having an achey day... My curves weren't bad, but when I look at my digital x-rays and how my upper back/neck was out of line, (and that's not even where my major curve was) and on down... and my lateral listhesis at L3/L4, no wonder by the end of each day I was miserable. :eek:

I will say a hearty "AMEN" to Ed's "do nothing" except heal for awhile. Walk, heal, walk, heal, etc. Your body needs all its energy to heal. The walking helps boost it into that mode. You have to eat right. Ed posted his award winning recipe for some super duper protein shakes awhile back. (No, I never tried them, but I'm sure they're great.) And you have to do those very easy beginning PT exercises they will probably start you on in the hospital or right after you get home. (Really basic PT). No lifting, no housework, no twisting, no bending. But try not to do any of the "work" that you think you should do. The world will go on spinning without your house being clean. ;)

Confusedmom
07-17-2010, 04:38 PM
"Access down low, from the front is best"

All comedy aside, do you really believe this is true, Ed? My primary doctor has recommended this A/P procedure to me, but 3 others (including Bridwell in St. Louis) recommend posterior only. Someone else posted recently on the site that Bridwell & Lenke are getting away from anterior procedures except when absolutely necessary. Love to hear more on this.

Evelyn

LindaRacine
07-17-2010, 05:31 PM
All comedy aside, do you really believe this is true, Ed? My primary doctor has recommended this A/P procedure to me, but 3 others (including Bridwell in St. Louis) recommend posterior only. Someone else posted recently on the site that Bridwell & Lenke are getting away from anterior procedures except when absolutely necessary. Love to hear more on this.

Evelyn

Evelyn....

I think you may have misunderstood about Bridwell and Lenke. They probably do little or no big open anterior procedures, but they probably do a lot of minimally invasive anterior procedures.

Regards,
Linda

Back-out
07-17-2010, 06:00 PM
Tit-Ed:

seems to make sense that fusion "healing rates" are most critical immediately after surgery. Osteoblasts, in high gear!

And ESPECIALLY if we've just been given a boost of BMP!! No, we don't personally pay for it for the most part, but someone shelled out the ~ $60K for that BMP. Why waste it?


My recovery involved a non-linear amount of physical effort....Walking carefully, with slow increases of physical activity. No bending, no lifting, for months... My tests of endurance came later, I was in no hurry, you only have one shot at this.

Just wanted to repeat Ed's invaluable words.
Ladies, your families need you to be there for yourselves now or you can't be there for them, later.

Stats show most Americans don't plan for the future, especially LT care. Extrapolating our spinal problems to the future, says our group are running much more risk than average of needing extensive care later. (Insurance companies know this. Just try to get private LT care insurance! A recent debacle).

But we can reduce that risk by our choices. It's NOT just the luck of the draw.

Don't push yourselves or take chances now. It's not worth the risk for us AND OUR FAMILIES. The cost: benefit ratio massively favors investing in aids to make life easier for us - especially in those first critical months after surgery.

Why else did God invent blenders, microwaves, paper plates (styrofoam is going too far :p) ? Not much is costlier than labor. But if it comes down to it, home-maker services now are cheaper than nursing home care later. "Later" is not that far off. Your kids will thank you if you can remain independent.

The main thing we need to salvage is US.
The focus MUST be on healing and safety - and that curve is steepest at first.

Doodles
07-17-2010, 10:01 PM
Just for the record mine was all posterior with Dr. Lenke and I got the impression that's pretty much the way he does it now--reach around technique. Janet

leahdragonfly
07-17-2010, 11:04 PM
This is an interesting thread and it has me wondering----so what exactly do you DO all day long for months after surgery if you shouldn't be doing ANYTHING around the house? I know you rest in bed a lot for awhile, and I know you walk, and I know personal care will be slow and pain-staking at first. But how are you spending the rest of your time (please tell me, Ed!). Reading, watching TV, something else? I am a very active person (and busy with an 8 and 5 y/o), and it sounds like I need to plan for the post-op period.

I am planning to go back to work on careful, limited duty at 3-4 months post-op, if possible.

LindaRacine
07-18-2010, 12:01 AM
Gayle...

I think that's the toughest part of the whole process. I found it to be far more boring than at any other time in my life. I had grand plans of reading tons of books and watching tons of movies. What I found was that I couldn't concentrate of much of anything.

Regards,
Linda

golfnut
07-18-2010, 07:17 AM
Gayle,
I, too, am very active physically and socially and have thought about how bored I will be between taking walks & resting. Since it will be January, the weather outside can be "iffy" for long walks, so laps in our small house will be a little dull. I will hope for a mild winter so I can get outside. I thought about bringing home preparations from school from my former colleagues just to be useful and pass the time, but that would mainly involve having my head looking downward for cutting, printing, coloring, etc. Now that I'm worrying about developing a kyphosis above the fusion, I may not volunteer for the teachers! Reading and using the computer also have my head looking downward.

Back-out
07-18-2010, 09:46 AM
Gayle...

I think that's the toughest part of the whole process. I found it to be far more boring than at any other time in my life. I had grand plans of reading tons of books and watching tons of movies. What I found was that I couldn't concentrate of much of anything.

Regards,
Linda
Linda,

How long did this period of poor concentration last and what do you attribute it to? :eek:

Thanks!

Susie*Bee
07-18-2010, 03:31 PM
Well, I'm definitely not Ed, but I'll write a little anyway -- or a lot-- sorry! I did a lot of reading after my surgery... you have to pick easy reading; no deep stuff. Since I'm "into" children's literature (elementary librarian) and I believe the last Harry Potter was coming out (or the next one???) I re-read all the ones leading up to it, read a bunch of other similarly longish books that I could put down if I didn't want to continue, etc. I remember Pam /TXmarinemom) saying she was going to load up on vampire books-- before I knew about the twilight saga and wondered about her...!)

After my surgery, when I was feeling a little more up to it, we went shopping and I picked out a cross stitch kit that kept me occupied for hundreds of hours, I'm sure. It's easy to bring that up towards you, and not have to look down. NO, I never finished it, but it's a beaut. Maybe some day I'll finish working on it. I would have loved to do some scrap booking, but I couldn't lean forward over a table. Try to think of some things you can do short term... A teacher friend broke her hip this past year and was out for a little while. I stopped by B&N and picked up a book of word type puzzles that looked like fun for an adult lady. Try to find a variety of things that you can do. I like reading recipes every once in a while. (Yes, I'm probably strange... or maybe there's no probably to it.) Make yourself a box (that you can reach) of this and that sort of things-- easy to watch chick flicks, short books, deck of cards for old fashioned solitaire, thank you notes for all that food people will bring in (hopefully), etc. You'll be able to manicure your fingernails, if you're into that. Buy what you need. Catch up on some snail mail correspondence. Look through your old yearbooks. Just try to have things ready and waiting for you. I'm sure you can fill your time up if you think about it and have some of it ready to go. Most of these ideas may be pretty dumb, but I'm trying to help you brainstorm. I KNOW it's a long time... but you can get through it.

As far as not being able to look down to read, I often place a pillow or two on my lap and bring the book up to me, to a comfortable level. That could probably work with a laptop too, as long as it doesn't slip off. There's often more than one way to skin a cat. ;)

PS-- my husband bought me this little table thing that is sort of like a tv tray, at the drug store, after my surgery. My lap top has been on it ever since, right here in a comfy spot at my couch. It's at a perfect height for me. I do not have to look down. The table's height is adjustable and you can also slant it for writing if you wish. I think the cost was about $20-$25. One nice thing about it is that it has a U shaped base, so my feet don't get tangled in it. I often used it also to rest my books on... In fact, if you click on the "and pics of me" in my signature and look at my "3 months post op" pic, you will see me doing my good ol' cross stitch and there's my trusty ol' lap top table. :) I've also got my brace on, but that was in a different thread today, I think... (you can see a little smidge of it peeking out the top of my shirt.) Good luck!

Back-out
07-18-2010, 04:08 PM
Well, I'm definitely not Ed, but I'll write a little anyway -- or a lot-- sorry! I did a lot of reading after my surgery... you have to pick easy reading; no deep stuff. Since I'm "into" children's literature (elementary librarian) and I believe the last Harry Potter was coming out (or the next one???) I re-read all the ones leading up to it, read a bunch of other similarly longish books

Well, I've got things bass ackwards as so often, having recently finished the Harry Potter series and just put down Swiss Family Robinson (and other kiddie classics - but there are always more, especially since I'm sleeping in my son's old bedroom with the wall to wall bookshelves full).

James Herriot too (love them!). Escapist, relatively mindless literature takes my mind off things, especially if they're upbeat. Have a bunch of Pearl Buck in my Amazon "basket" to check out along with Scoliosis books! And tomorrow I'm sending some Travis McGee to an old boyfriend about to have major surgery for cancer. That's HIS thing!

Just one problem. I found myself REALLY getting my hackles up at all the H.P. references to "hunch-backed witches". Guess I have my politically-correct fixations too. :p (What should she say? :D "Spinally challenged cougars"?)

LindaRacine
09-04-2010, 12:58 PM
Spine (Phila Pa 1976). 2010 Aug 26. [Epub ahead of print]
Changes in Radiographic and Clinical Outcomes With Primary Treatment Adult Spinal Deformity Surgeries From Two Years to Three- to Five-Years Follow-up.

Bridwell KH, Baldus C, Berven S, Edwards C 2nd, Glassman S, Hamill C, Horton W, Lenke LG, Ondra S, Schwab F, Shaffrey C, Wootten D.

From *Washington University School of Medicine, St. Louis, MO; daggerUniversity California-San Francisco, San Francisco, CA; double daggerThe Maryland Spine Center, Baltimore, MD; section signSpine Institute, Louisville, KY; paragraph signState University of New York at Buffalo, Amherst, NY parallelEmory Orthopaedics & Spine Center, Atlanta, GA; **Northwestern University Medical School, Chicago, IL; daggerdaggerNYU-Hospital for Joint Diseases, New York, NY; double daggerdouble daggerUniversity of Virginia Medical Center, Charlottesville, VA; and section sign section signMedtronic Spinal & Biologics, Memphis, TN.
Abstract

STUDY DESIGN.: Retrospective analysis of data entered prospectively into a multicenter database-clinical and radiographic outcomes assessment. OBJECTIVE.: Our hypothesis is that between the 2-year and the 3- to 5-year points surgically treated adult spinal deformity patients will show significant reduction in outcomes by Scoliosis Research Society (SRS), Oswestry Disability Index (ODI), and numerical rating scale back and leg pain scores and will show increasing thoracic kyphosis, loss of lumbar lordosis, and loss of coronal and sagittal balance. SUMMARY OF BACKGROUND DATA.: Most analyses of primary presentation adult spinal deformity surgery assess 2-year follow-up. However, it is established that in some patients unfavorable events occur between the 2-year and 5-year points. METHODS.: The cohort of 113 patients entered into a multicenter database with complete preoperative, 2-year, and 3- to 5-year data. All patients who had adult spinal deformity and surgical treatment represented their first reconstruction. Diagnoses were scoliosis (82.5%), kyphosis (10%), and scoliosis and kyphosis combined (7.5%). Outcome measures and basic radiographic parameters (curve size, thoracic and lumbar sagittal plane, coronal and sagittal balance) were assessed at those 3 time intervals. Complications (pseudarthrosis/implant failure, infection, and junctional deformities) were assessed at the 2-year and the 3- to 5-year (mean, 3.76 years) points. RESULTS.: The mean major curve Cobb angle (preoperative, 57 degrees ; 2-year, 29 degrees ; 3-5 year, 26 degrees ); thoracic kyphosis T5 to T12 (30 degrees , 31 degrees , 32 degrees ) and lumbar lordosis T12 to sacrum (48 degrees , 49 degrees , 51 degrees ) did not change from the 2-year to ultimate follow-up. Likewise, coronal and sagittal balance parameters were the same at 2-year and ultimate follow-up. SRS total scores and modified ODI were similar at the 2 year and final follow-up (SRS: 3.89-3.88; ODI: 19-18). Preoperative SRS total score was 3.17. Six patients demonstrated complications at the 2-year point and additional 9 patients demonstrated complications at the 3- to 5-year point. Those 9 patients with complications at ultimate follow-up demonstrated significant deterioration in their ODI and SRS scores when compared with the patients who did not have complications at ultimate follow-up. CONCLUSION.: Contrary to our hypothesis, we could not establish deterioration in mean radiographic or clinical outcomes between the 2-year and 3- to 5-year follow-up points when analyzing the group as a whole. However, for the 9 patients who experienced complications between 3- and 5-year follow-up, their outcomes were significantly worse than for the other 104 patients.One should not anticipate an overall radiographic and clinical deterioration of the outcomes of surgically treated primary presentation adult spinal deformity patients in this studied time interval. However, close to 10% of patients will experience a new complication at the 3- to 5-year point, most commonly implant failure/nonunion and/or junctional kyphosis, which will negatively effect the patient-reported outcome.

PMID: 20802383 [PubMed - as supplied by publisher]

mgs
09-05-2010, 05:13 AM
I am surprised that a non-union could go for 3 - 5 years without any symptom that would cause suspicion. I am 1 year post-op, and (as of my appt Thurs) there is a question of non-union. Sometime in Jan, I had a hunch that something wasn't right.

JenniferG
09-06-2010, 12:02 AM
I am sorry to hear that mgs. Please let us know how it turns out.

I, too, am surprised it could take 3-5 years to notice a non fusion problem. Just when I thought I was outta the woods!

Ryy
10-11-2010, 12:08 PM
I'm really worried that i'm developing pjk. I'm 3 wk out of surgery, fused T3-L3 for kyphosis. My curve was pretty high up. My neck seems to stick out forward more than normal. If i relax all my muscles, my neck faces down instead of straight ahead. Is there anything that anyone can recommend for me to do now that might help stop pjk this early on? I try and tuck my chin in as much as possible. My post op appt is in a week. Any input? Hopefully i'm just being paranoid. Thanks

LindaRacine
01-07-2012, 10:41 AM
I've been waiting for the paper below to be published for a long time. We're going into a trial with Transition implants next week.

Spine (Phila Pa 1976). 2011 Dec 28. [Epub ahead of print]
The Use of a Transition Rod May Prevent Proximal Junctional Kyphosis in the Thoracic Spine Following Scoliosis Surgery: A Finite Element Analysis.
Cahill PJ, Wang W, Asghar J, Booker R, Betz RR, Ramsey C, Baran G.
Source
1Shriners Hospitals for Children, Philadelphia, 3551 North Broad Street, Philadelphia, PA 19140 2Temple University College of Engineering, Philadelphia, PA 3Albert Einstein Medical Center, Department of Orthopaedic Surgery, Philadelphia, PA.
Abstract
Study Design. Finite element analysisObjective. Via finite element analysis: 1) to demonstrate the abnormal forces present at the top of a scoliosis construct, 2) to demonstrate the importance of an intact interspinous and supraspinous ligament (ISL/SSL) complex, and 3) to evaluate a transition rod (a rod that has a short taper to a smaller diameter at one end) as an implant solution to diminish these pathomechanics, regardless of the integrity of the ISL/SSL complex.Summary of Background Data. The pathophysiology of increased nucleus pressure and increased angular displacement may contribute to proximal junctional kyphosis. Furthermore, high implant stress can be demonstrated at the upper end of the construct, possibly leading to risk of implant failure.Methods. A finite element model was constructed to simulate a thoracic spinal fusion. The model was altered to remove the ISL/SSL complex at the level above the construct. Lastly, the model was altered again by extending the construct one level superior with a transition rod. The angular displacement, the maximum pressure in the nucleus, and stress within the implant were extracted from computational results under two conditions: load control and displacement control. The testing was performed with both titanium and stainless steel implants.Results. Pressure in the nucleus and angular displacement are all increased when the ISL/SSL complex is removed immediately above the instrumented levels, while the screw pull-out force and maximum stress within the screw is decreased. The nucleus pressure increases by over 50%. The angular displacement increases 19-26%. This absence of the ISL/SSL complex simulates the clinical scenario that occurs when these structures are iatrogenically detached. Abnormal mechanics can be restored to normal level by extending the construct rostral one level with a transition rod. Furthermore, the elevated nucleus pressure and angular displacement noted even when the ISL/SSL complex is intact can be avoided with the use of a transition rod. Under the same bending moment (3 Nm), the nucleus pressure at the level immediately cephalad is up to 23% lower than the pressure in a standard construct. The angular displacement is 18-19% less than the standard construct. The maximum implant stress is also decreased by as much as 60%.Conclusions. Finite element modeling suggests that the pathomechanics at the proximal end of a scoliosis construct may be diminished by preserving the ISL/SSL complex and possibly completely eliminated with the use of rods with a diameter transition at the most proximal level.

Pooka1
01-07-2012, 11:19 AM
Hey Linda, I saw that abstract but didn't post it because it is still in the mathematical modeling stage.

That said, I thought Dr. Hey blogged about a case of actually using a tapered rod for this situation but I can't find it. I must be confusing it with the u-rod technique for the same problem...

http://drlloydhey.blogspot.com/2011/09/week-in-review-new-u-rod-technique-for.html

Pooka1
01-07-2012, 11:21 AM
Oh hey I was right... he talks about using tapered rods before developing the u-rod. I'm thinking, though, that it must be different than what those guys are modeling.


Often the way we fix this is by using a tapered rod, which goes from a standard 5.5 or 6 mm in diameter down to a smaller diameter to allow for fixation to the cervical spine. These rods, however, can appear a bit too weak when you are trying to lever the spine into a better non-kyphotic posture, even though we also do a bone wedge or osteotomy to help free up the spine so it will be able to move.

LindaRacine
01-07-2012, 11:40 AM
Oh hey I was right... he talks about using tapered rods before developing the u-rod. I'm thinking, though, that it must be different than what those guys are modeling.

Yes, I think this is different, but not sure how. I'm going to try to find the time to watch one of the first surgeries that are done.

--Linda

golfnut
01-07-2012, 11:49 AM
The transitional rod sure makes sense. How long would it be before surgeons would use it? I am worried about the pressure of a golf swing on the top vertebrae of my fusion.

LindaRacine
01-07-2012, 11:53 AM
It's already approved for use. The manufacturer (Globus) needs some of the big centers to get trained on it, and publish some post market results. I think it typically takes at least a few years from the start of the trial, to start seeing new implants in more general use.