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LindaRacine
07-03-2010, 11:08 AM
J Neurosurg Spine. 2010 May;12(5):443-6.
Morbidity and mortality in the surgical treatment of 10,329 adults with degenerative lumbar stenosis.

Fu KM, Smith JS, Polly DW Jr, Perra JH, Sansur CA, Berven SH, Broadstone PA, Choma TJ, Goytan MJ, Noordeen HH, Knapp DR Jr, Hart RA, Zeller RD, Donaldson WF 3rd, Boachie-Adjei O, Shaffrey CI.

Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
Abstract

OBJECT: The purpose of this study was to evaluate the prospectively collected Scoliosis Research Society (SRS) database to assess the incidences of morbidity and mortality (M&M) in the operative treatment of degenerative lumbar stenosis, one of the most common procedures performed by spine surgeons. METHODS: All patients who underwent surgical treatment for degenerative lumbar stenosis between 2004 and 2007 were identified from the SRS M&M database. Inclusion criteria for analysis included an age >or= 21 years and no history of lumbar surgery. Patients were treated with either decompression alone or decompression with concomitant fusion. Statistical comparisons were performed using a 2-sided Fisher exact test. RESULTS: Of the 10,329 patients who met the inclusion criteria, 6609 (64%) were treated with decompression alone, and 3720 (36%) were treated with decompression and fusion. Among those who underwent fusion, instrumentation was placed in 3377 (91%). The overall mean patient age was 63 +/- 13 years (range 21-96 years). Seven hundred nineteen complications (7.0%), including 13 deaths (0.1%), were identified. New neurological deficits were reported in 0.6% of patients. Deaths were related to cardiac (4 cases), respiratory (5 cases), pulmonary embolus (2 cases), and sepsis (1 case) etiologies, and a perforated gastric ulcer (1 case). Complication rates did not differ based on patient age or whether fusion was performed. Minimally invasive procedures were associated with fewer complications and fewer new neurological deficits (p = 0.01 and 0.03, respectively). CONCLUSIONS: The results from this analysis of the SRS M&M database provide surgeons with useful information for preoperative counseling of patients contemplating surgical intervention for symptomatic degenerative lumbar stenosis.

Back-out
07-03-2010, 03:46 PM
I guess this is one of Dr. Shaffrey's very useful contributions to the professional literature (who else besides his brother is at UVA?). Very interesting, Linda, though I'm not positive what the main points are for professionals - I know what I most noticed.

Unless I missed something (quite possible) there is only the implication - it's not explicit - that these patients also had scoliosis, since the cases were taken from the SRS database.

What was of greatest personal interest, is that

a) age did NOT make a difference in the complications rate - and the cohort extended to age 96! ( FWIW I know a woman past 90, suffering from a failed spinal surgery she underwent fairly recently - not that anyone had great hopes).

That IS surprising and - for those of us who are older - heartening. Sometimes, I feel my demographic is doomed to everything coming out a good deal worse.

b) spinal stenosis is a frequent problem in patients with scoliosis - apparently surgically treated with OR without fusion! In fact, this must be the main focus of the study - how scoliosis patients fare if only the stenosis is treated. I recall you've previously indicated this is a subject of interest/controversy among the surgeons. You said current thinking is that decompression alone destabilizes a scoliotic spine. This study reinforces that conclusion.

I have both and wonder what the pros and cons are of dealing with the stenosis alone. I never thought of doing it without a fusion in the twisted part of my spine (as in sig., I DID have cervical stenosis treated with M.I. decompression there - good thing too or what would my options be now, looking at a long fusion?)

Except for the surprising bit about age. I don't think the complications, including death, are startlingly different from anything I've read before.

Back-out
07-03-2010, 04:02 PM
It IS very interesting that this study confirms the speculation that a minimally invasive approach worked overall better than standard surgery. This is not surprising to me since the article deals with relatively short fusions, confined to the lumbar area . If a patient's condition can be treated minimally invasively, all such patients should recover better after MI surgery. Less anaesthesia time, blood loss, muscle damage etc lead to less danger on all fronts!

I already read (and linked) an article about a patient - that former basketball player - who had a super serious lumbar fusion done minimally invasively. Highlights, it was ten hours long, using very heavy instrumentation including 8" stainless steel bolts.

Also I watched referenced and discussed a video of a M. I. lumbar fusion (done by Dr Fessler of U Chicago). He specifically said that:

a) lumbar fusion surgery could be done very successfully using a M.I approach as long as the surgeon was extremely experienced in the technique - someone like him. The difference the surgeon makes in outcomes with ALL radical spinal surgery is hardly news, though it cannot be overstated for those of us still in the arranging/deciding end of things!

Dr. Fessler said that
b) current state of the Art does NOT permit doing a longer fusion using a M I. approach (This is what I especially took from the interview, regretfully. One always remembers what is personally relevant, I guess).

Incidentally, Dr Fessler was actually interviewed while he was performing a M.I lumbar fusion! I've tried several times since to retrieve the video-interview. Unfortunately, though, it seems to have been deleted from the U. Chicago's online reference library. Shame, as the contents don't appear available in text form.

I'm still confused about the difference between degenerative scoliosis and idiopathic - I'm sure I should know by now (I assume this is a related topic here, as the article title refers to "degenerative" conditions). The last surgeon I saw explicitly stressed that DDD (degenerative disk disease) is so common among scoliosis patients that he objected to the term itself, stating it was NOT a "disease" but a result of the scoliosis.

Pooka1
07-03-2010, 04:52 PM
I'm still confused about the difference between degenerative scoliosis and idiopathic - I'm sure I should know by now (I assume this is a related topic here, as the article title refers to "degenerative" conditions.

That's a good question. I'd like to know the difference between "degenerative" and "untreated" scoliosis. Maybe they are the same thing except for extremely small curves.


The last surgeon I saw explicitly stressed that DDD (degenerative disk disease) is so common among scoliosis patients that he objected to the term itself, stating it was NOT a "disease" but a result of the scoliosis.

I have read that DDD is like death and taxes... if you live long enough it is inevitable. So clearly it is not limited to scoliosis cases. What I'm gleaning from the testimonials is that people with scoliosis may have a propensity to get DDD at a far earlier average age than the general public and may have on average far worse cases. I don't know that but that's what it seems.

And I think adjacent level disease is an iatrogenic form of DDD. I think.

jrnyc
07-03-2010, 05:03 PM
i have heard pain doctors minimize degenerative disc disease, saying the same.."if you live long enough, most people get that anyway"...however...it can be extremely debilitating, excruciatingly painful.... and...i know people who lived into their 90's who did not ever develop it!!
my pain doctor minimizes it...he doesnt want me to have surgery...i let it go in one ear and out the other...and try not to let it bother me....
my surgeon said that my pain is increasing because of my discs...at the moment, my curves are the same, but discs are getting worse :(

jess

rohrer01
07-03-2010, 07:02 PM
My ex-husband developed a mild scoliosis as a result of arthritis and DDD. Maybe that is the difference? If the scoliosis comes first, then it is idiopathic, and if it is caused by another problem then it is degenerative scoliosis. That's my guess. I've always thought of it that way. The problem lies when scoliosis isn't detected until there is other degeneration, then who knows which came first...:confused:

jrnyc
07-03-2010, 11:26 PM
hmmm..i believe degenerative is more age related...while idiopathic is more adolescent related...if you look it up on internet...that is one of differences talked about...

jess

Pooka1
07-04-2010, 11:06 AM
Here's a short piece on degenerative scoliosis...

http://www.spine-health.com/conditions/scoliosis/degenerative-scoliosis


Degenerative scoliosis comes about as the result of degeneration in the disc space and paired facet joints posteriorly (in the back of the spine). As the joints degenerate they turn and create a bend in the back, resulting in the classic scoliotic curve.

Whereas idiopathic scoliosis is much more common in the thoracic spine (mid back), degenerative scoliosis is much more common in the lumbar spine (lower back). It occurs most frequently in people over 65 years of age.

Symptoms and diagnosis

Unlike idiopathic scoliosis, degenerative scoliosis can be a cause of back pain. The pain mainly results from degeneration in the joints leading to arthritis. However, there are a lot of people who have a degenerative scoliosis who have no pain, so it is not always a cause of pain. What needs to be decided is if the patient has a degenerative scoliosis that is causing pain, or if they have back pain and an incidental finding of scoliosis. Other causes of back pain first need to be ruled out (such as a typical muscle strain).

Okay so I take from this that degenerative scoliosis is specifically NOT idiopathic... it is a curve due to degeneration in the discs/facet joints which collapses that portion of the spine. Thus not idiopathic. It is osteoarthritis in the spine.

But I still think there is a connection to IS... the curve due to IS may exacerbate the process of disc/facet degeneration, either everywhere in the unfused spine or only at the top and bottom of a fused spine. If true, that would explain any earlier/worse incidence of DD in untreated scoliosis.

And I am not so sure I was correct about degenerative scoliosis including iatrogenic causes as in adjacent level disease. That may be just disc damage absent arthritis.

Back-out
07-04-2010, 11:47 AM
The more I look at that abstract, the weirder I think it is, that it refers throughout only to patients having degenerative stenosis treated surgically, but nowhere does is explicitly state these are scoliosis patients.

Maybe it's one of those things, where the abstract is a poor summary of the original - here, in that they never thought to completely note the patient markers,

jrnyc
07-04-2010, 12:10 PM
typing in "idiopathic scoliosis vs degenerative scoliosis" on internet repeatedly mentions adult more degenerative and idiopathic more teen aged...

since idiopathic means cause unknown, i dont think it means as much...in other words, if it wasnt genetic, and not caused by injury, then it is often cause unknown...

when i look back, i remember things that were difficult for me to do in ballet, that i now realize were difficult because i had scoli...when first diagnosed, i didnt think i had it as a child, but now realize i did! certain turns and other things that were so hard for me in ballet i now see were impossible to execute well due to imbalance in the 2 sides of my body! i didnt know at the time, but i was fighting a losing battle...that, plus weak ankles...dancers' curse...made it inevitable that i would quit dance...:(
soooo...now i'm thinking my idiopathic turned into degenerative...:rolleyes:

jess

LindaRacine
07-04-2010, 03:40 PM
The more I look at that abstract, the weirder I think it is, that it refers throughout only to patients having degenerative stenosis treated surgically, but nowhere does is explicitly state these are scoliosis patients.

Maybe it's one of those things, where the abstract is a poor summary of the original - here, in that they never thought to completely note the patient markers,
The Title of the article, and the subject of this string is "Complications in Degenerative Scoliosis Surgery."

LindaRacine
07-04-2010, 03:44 PM
Sharon...

When scoliosis is diagnosed in an older individual, it's impossible to know whether the degeneration came first or the curve came first, unless there are prior xrays showing a curved or straight spine. It doesn't really matter in the long run. This paper is a study of people with scoliosis who have obvious degenerative changes. I believe professionals now feel that 70% of adults over the age of 70 have degenerative scoliosis.

--Linda

LindaRacine
07-04-2010, 03:47 PM
typing in "idiopathic scoliosis vs degenerative scoliosis" on internet repeatedly mentions adult more degenerative and idiopathic more teen aged...

since idiopathic means cause unknown, i dont think it means as much...in other words, if it wasnt genetic, and not caused by injury, then it is often cause unknown...

when i look back, i remember things that were difficult for me to do in ballet, that i now realize were difficult because i had scoli...when first diagnosed, i didnt think i had it as a child, but now realize i did! certain turns and other things that were so hard for me in ballet i now see were impossible to execute well due to imbalance in the 2 sides of my body! i didnt know at the time, but i was fighting a losing battle...that, plus weak ankles...dancers' curse...made it inevitable that i would quit dance...:(
soooo...now i'm thinking my idiopathic turned into degenerative...:rolleyes:

jess
Jess...

What happened in my own case, and in the case of many others I've met, is that I wasn't diagnosed until I was in my 30s. When I was a kid, all of my clothes had to be hemmed using a floor marker, which is a good indication that my curve was present at that time.

--Linda

Pooka1
07-04-2010, 03:52 PM
Sharon...

When scoliosis is diagnosed in an older individual, it's impossible to know whether the degeneration came first or the curve came first, unless there are prior xrays showing a curved or straight spine. It doesn't really matter in the long run.

Really? I wonder if you even get large curves just from degenerative scoliosis in later life if there isn't a pre-existing curve.


This paper is a study of people with scoliosis who have obvious degenerative changes. I believe professionals now feel that 70% of adults over the age of 70 have degenerative scoliosis.

Yes and how does that compare to younger age groups with idiopathic scoliosis? Does a higher percentage of people with untreated scoliosis also develop degenerative scoliosis earlier and worse than in people without scoliosis due to the imbalance over time? I wonder what really happens to the people who have curves in the 30s and even 20s over time w.r.t. development of degenerative changes. That might impact treatment decisions.

LindaRacine
07-04-2010, 03:52 PM
I have both and wonder what the pros and cons are of dealing with the stenosis alone. I never thought of doing it without a fusion in the twisted part of my spine.
Decompression without fusion in individuals with scoliosis very often results in an increased curvature, and/or adding more levels to the curvature. I actually wish that wasn't the case, as I'd do it in a heartbeat.

LindaRacine
07-04-2010, 03:59 PM
Yes and how does that compare to younger age groups with idiopathic scoliosis? Does a higher percentage of people with untreated scoliosis also develop degenerative scoliosis earlier and worse than in people without scoliosis due to the imbalance over time? I wonder what really happens to the people who have curves in the 30s and even 20s over time w.r.t. development of degenerative changes. That might impact treatment decisions.

As far as I know, there's no really good natural history paper. This is what comes closest:

Spine (Phila Pa 1976). 1992 Sep;17(9):1091-6.
Long-term follow-up of patients with untreated scoliosis. A study of mortality, causes of death, and symptoms.

Pehrsson K, Larsson S, Oden A, Nachemson A.

Department of Lung Medicine, Renströmska Hospital, Göteborg, Sweden.
Abstract

The mortality and causes of death in 115 patients (80 women), born 1902-1937, with untreated scoliosis were compared to the expected according to official Swedish statistics. Subgrouping for cause and onset of scoliosis was done. Fifty-five patients had died; 21 of respiratory failure and 17 of cardiovascular diseases. The mortality was significantly (P less than 0.001) increased. The increased risk was apparent at 40-50 years of age. The mortality was significantly increased in infantile (P less than 0.001) and juvenile (P less than 0.01) scoliosis but not in adolescent scoliosis. The mortality was also increased in post-polio scoliosis, scoliosis combined with rickets and scoliosis of unknown etiology indicating an increased mortality in idiopathic scoliosis. Among the surviving patients anti-hypertensive treatment was frequent (23 of 50).

PMID: 1411763 [PubMed - indexed for MEDLINE]

I'll have to check the full paper out and see if they mention the % of people in the control group who ended up with scoliosis. (I just had the thought that some number of people in the control would have had undiagnosed scoliosis when they were young.) There's no great way to know who had no scoliosis when they were younger, unless they have scoliosis films taken as a teenager.

--Linda

Pooka1
07-04-2010, 04:09 PM
That's a good one for mortality. I wonder what the deal is w.r.t. morbidity. That is, maybe there would be less mincing around with adult cases if it was known that even moderate cases at relatively young ages would all be destined for degenerative scoliosis on top of idiopathic absent fusion surgery. So maybe a case can be made to do fusion earlier on smaller curves if it is known that most/all of these people will need it later for degeneration when they are older and the surgery is dicier.

And on this general subject of when to fuse due to morbidity if not mortality, I wish there was some way to determine if earlier fusion on less vertebrae will avoid later fusion on more vertebrae. I am haunted by the thought that maybe my kids could have had 4-6 vertebrae around the apex fused instead of 10 vertebrae each. Has anyone ever tried to study this? Maybe they have and maybe the answer is known. Maybe the reason they don't fuse smaller curves is not just the likelihood they won't progress but also because early fusion doesn't often stop progression. Also crankshaft is an issue.

Fusing less vertebra doesn't seem like as much an issue in T curves as in L curves where you really want to limit the number of vertebrae.

(edited for clarity)

LindaRacine
07-04-2010, 04:35 PM
That's a good one for mortality. I wonder what he deal is w.r.t. morbidity. That is, maybe there would be less mincing around with adult cases if it was known that even moderate cases at relatively young ages would all be destined for degenerative scoliosis on top of idiopathic absent fusion surgery. So maybe a case can be made to do fusion earlier on smaller curves if it is known that most/all of these people will need it later for degeneration when they are older and the surgery is dicier.
I totally agree. It would be so helpful to know what happens with each group (scoliosis v. straight) in 50-70 years. We do, however, see a lot of people with degenerative scoliosis who don't require surgery, or who choose not to have surgery. So, I don't think fusing everyone with scoliosis would ever be appropriate.


And on this general subject of when to fuse due to morbidity if not mortality, I wish there was some way to determine if earlier fusion on less vertebrae will avoid later fusion on more vertebrae. I am haunted by the thought that maybe my kids could have had 4-6 vertebrae around the apex fused instead of 10 vertebrae each. Has anyone ever tried to study this? Maybe they have and maybe the answer is known. Maybe the reason they don't fuse smaller curves is not just the likelihood they won't progress but also because early fusion doesn't often stop progression. Also crankshaft is an issue. It doesn't seem like as much an issue in T curves as in L curves where you really want to limit the number of vertebrae.
There have been studies on this, although I couldn't easily find them. Sine it has been studied, and has not been adopted by the masses, I'm guessing that it wasn't all that successful in the long term. What immediately came to mind is the Robert Gaines bone-on-bone technique (as mentioned in Dave Wolpert's book).

--Linda

jrnyc
07-04-2010, 04:46 PM
hi Linda
thanks for the reply concerning early scoli..and all the information you gave us in this thread!

i'd be willing to bet that there are lots of folks out there who had undiagnosed scoli when teens and went on to develop degeneration later on, as you said...though i didnt notice the skirt/dress thing til i was in my 30's (mostly wore jeans as a teenager)...and it wasn't til my 40's that i noticed my pants needed hemming differently for each leg!

also, when i went to school, there was NO screening for scoli...that easy test when kids bend over and the school nurse can spot problems...i realize i am dating myself...:rolleyes: but that is how it used to be...

i was also not diagnosed until age 31, when my back bothered me...i remember telling the doctor that it felt like a gorilla was on my back...though nothing close to as bad as it bothers me now!!!

jess

LindaRacine
07-04-2010, 05:00 PM
hi Linda
thanks for the reply concerning early scoli..and all the information you gave us in this thread!

i'd be willing to bet that there are lots of folks out there who had undiagnosed scoli when teens and went on to develop degeneration later on, as you said...though i didnt notice the skirt/dress thing til i was in my 30's (mostly wore jeans as a teenager)...and it wasn't til my 40's that i noticed my pants needed hemming differently for each leg!

also, when i went to school, there was NO screening for scoli...that easy test when kids bend over and the school nurse can spot problems...i realize i am dating myself...:rolleyes: but that is how it used to be...

i was also not diagnosed until age 31, when my back bothered me...i remember telling the doctor that it felt like a gorilla was on my back...though nothing close to as bad as it bothers me now!!!

jess

I also did not have school screening.

rohrer01
07-04-2010, 07:40 PM
That's a good one for mortality. I wonder what the deal is w.r.t. morbidity. That is, maybe there would be less mincing around with adult cases if it was known that even moderate cases at relatively young ages would all be destined for degenerative scoliosis on top of idiopathic absent fusion surgery. So maybe a case can be made to do fusion earlier on smaller curves if it is known that most/all of these people will need it later for degeneration when they are older and the surgery is dicier.

And on this general subject of when to fuse due to morbidity if not mortality, I wish there was some way to determine if earlier fusion on less vertebrae will avoid later fusion on more vertebrae. I am haunted by the thought that maybe my kids could have had 4-6 vertebrae around the apex fused instead of 10 vertebrae each. Has anyone ever tried to study this? Maybe they have and maybe the answer is known. Maybe the reason they don't fuse smaller curves is not just the likelihood they won't progress but also because early fusion doesn't often stop progression. Also crankshaft is an issue.


(edited for clarity)

These are some very good points. I have often wondered if they would have done my fusion at 39* as a teen when my lower curve was in the teens if the lower curve would have progressed anyway. It would have only been a few vertebrae back then. Now I'm looking at maybe 12 or so. Also, I never understood the mentality of wait until you are 50 or 60 degrees when the curves are progressing and painful. It seems like asking for other health problems to develop which would inevitably lead to complications, especially in those of us that are middle aged or older. It is very frustrating.

Pooka1
07-04-2010, 07:58 PM
These are some very good points. I have often wondered if they would have done my fusion at 39* as a teen when my lower curve was in the teens if the lower curve would have progressed anyway. It would have only been a few vertebrae back then. Now I'm looking at maybe 12 or so. Also, I never understood the mentality of wait until you are 50 or 60 degrees when the curves are progressing and painful. It seems like asking for other health problems to develop which would inevitably lead to complications, especially in those of us that are middle aged or older. It is very frustrating.

I think it is a balancing act.

They have to balance earlier surgical issues on the one hand:

1. inherent surgical risk
2. failure of fusion to stop progression
3. crankshaft (young kids)

with issues associated with not doing surgery:

1. risk of progression
2. pain which may not be resolvable with fusion
3. bone density which may make fusion problematic
4. longer recovery time
5. degenerative scoliosis on top of idiopathic scoliosis.

I think as surgical risk comes down with real-time nerve signal monitoring and such, and more data is collected about maybe the inevitability of earlier and worse degenerative changes due to an idiopathic curve over time, that earlier fusion may occur.

That one testimonial about that doctor clearing his calendar to fusion a TL curve in the 40s in the hope of sparing some lumbar vertebrae might be indicative of where the thinking might be heading. I wonder if my kids could have been fused when they were diagnosed like that. Until someone ponies up evidence that a conservative modality avoids surgery, this will remain a live question.

It might be the case than many cases of scoliosis require surgery if not when the patient is younger then when they are older. The surgical rates for each curve magnitude we hear about are due to progression I think. When you count in surgical rates for degenerative changers, I wonder just how much of the scoliosis population is included.

LynetteG
07-05-2010, 07:52 AM
I had no scoli screening at school in Ireland either. I only found out about my scoli when I was 32.

Pooka1
07-05-2010, 12:22 PM
Okay idiopathic and degenerative are clearly two different things...

http://drlloydhey.blogspot.com/2010/04/idiopathic-and-degenerative-scoliosis-w.html

LindaRacine
07-05-2010, 01:04 PM
Okay idiopathic and degenerative are clearly two different things...

http://drlloydhey.blogspot.com/2010/04/idiopathic-and-degenerative-scoliosis-w.html

It's possible that she knew that she had scoliosis when she was younger. We see a lot of older patients with scoliosis who don't know if they had scoliosis when they were younger, and as far as I can tell, it's not always easy to know which it is.

Back-out
07-05-2010, 05:56 PM
Here's a basic question I've been grappling with, reminded of by the discussion here. Somehow, it calls to mind my struggle to figure out what is politically "Left" versus "Right" in Communist or former Communist countries. :p (Well, it WAS my original college major!)
What is the meaning of "CONSERVATIVE" in scoliosis surgery (other than avoiding surgery altogether)?

Two of my consulting surgeons so far want to start my fusion at T10 (to the sacrum - with pelvic fixation) and two want to start at T4 with the same endpoint.

Clearly, the ones who advocate starting lower want to avoid, if possible, more loss of mobility and greater surgical time, the latter leading to a a more difficult recovery and a greater likelihood of complications. I guess all are figuring roughly that difficulty and risk are increased linearly (though not exponentially) with the number of segments fused.

Likewise, the ones who want to fuse from a higher level, believe they are sparing me what they regard as the certainty of more surgery later (to extend the fusion).

Interestingly, though, both these "T4" surgeons spontaneously warned me to expect more surgery down the road - type non explicit. Got the impression from one that it was just the nature of the Beast, the Beast being such complex surgery.

Maybe, maybe not, the warning was a function of my demographic.

OR was it a function of their OWN DEMOGRAPHIC? The two "T10" surgeons are fortiesh, and seem to know each other well. Likewise, both "T4" are contemporaries, about my age - i.e., early to mid 60s.

Is it more "conservative" to start with a longer fusion to avoid the greater risk of an extended fusion - maybe also "lordosis failure" - i.e., flatback?

Or is it more "conservative" to fuse less and subject me to less surgery - NOW? Again, in their minds, they're sparing me the consequent risks. Maybe the younger surgeons think I might die of other causes before needing the fusion extension (I think in their hearts, they expect it to be needed if I live long enough).

Back-out
07-05-2010, 06:04 PM
I've simplified, above. There seems to be a carry-over of planning whereby the pair who want to start the fusion higher, also are planning to do more anterior strengthening to reinforce the re-created lordosis. This too corresponds to more surgical time/risk etc., in return for more assuredly avoiding later failure of the correction.

FWIW I suppose the degree of correction expected/sought ought by rights to figure in with the nomenclature question. Answer: I was left with the impression that all four expected correction to be "about half" - at least, that's what they SAID. I felt this was a politic answer, though - designed to lower my expectations and avoid commitment. Then they could pleasantly surprise me, if it turned out to be possible. I don't know what they REALLY thought or intend to shoot for, given the same presentation once I'm open on the table.

I'm still waiting for the results of my bending X-rays to get a more informed reply. I'm sure all four will welcome the imaging to set their surgical bar, whether or not they tell me what they really hope for!

I'm very curious about what this grouping means in terms of training, their personal expectations of themselves, what warnings or shared experience they are responding to apparently in a generational fashion. Basically, I see the surgeons themselves as two cohorts and want to understand them.

I sort of see Lenke/Bridwell as representing a similar breakdown and in that pairing, I definitely regard Dr. Lenke (trained by Bridwell) as reflecting greater self-confidence in his more radical corrections. But here I ask a broader question. Not merely, which is the more "conservative" of those two :confused: but is this term really defined by the intended fusion length? If the surgeon is choosing that length according to his own well-founded self confidence about what he can achieve, is he less conservative or is he simply realistic given his skills?

Confusedmom
07-05-2010, 07:16 PM
I think "conservative" = less surgery now and a willingness to possibly forego some correction to obtain an acceptable result with a shorter and less traumatic surgery (i.e. Dr. Gupta who wants to fuse me T8-L5 all posterior).

The opposite, which I'm labeling "aggressive" = more surgery now with the aim of a better correction and possibly avoiding additional future surgeries (i.e. Dr. Dietz who wants to do a 12-hour A/P fusion on me from T4-L4).

So, in your case, Amanda, I think the T-10 group would be the ones considered more "conservative."

Evelyn

Back-out
07-05-2010, 07:57 PM
I think "conservative" = less surgery now and a willingness to possibly forego some correction to obtain an acceptable result with a shorter and less traumatic surgery (i.e. Dr. Gupta who wants to fuse me T8-L5 all posterior).

The opposite, which I'm labeling "aggressive" = more surgery now with the aim of a better correction and possibly avoiding additional future surgeries (i.e. Dr. Dietz who wants to do a 12-hour A/P fusion on me from T4-L4).

So, in your case, Amanda, I think the T-10 group would be the ones considered more "conservative."

Evelyn
Thanks, Evelyn. I'd kind of answered my own question once I realized anew that NO surgery is the most conservative of all (in Pooka context). I got both "surgical cohorts" mislabeled above (since corrected) but it doesn't matter.

Still wonder in a general way how to label the Lenke/Bridwell duo in this conservative-aggressive continuum, though I suppose the definitions are pretty cut and dried in a professional sense; i.e. here, anyhow - more surgery = more aggressive. That's so even if taken over time. it might be considered more conservative to avoid a second surgery.

Again, I regard the "T10s" as actually staging the surgery over the long haul. It's just that they're delaying the second stage figuring it may never be reached, and meanwhile the patient is more comfortable.

This is ala Baron Lonner, who in a way represents the mid-point in age and rationale. Funny, that by now I can pretty much predict what he will recommend for me based on what we've heard of him on this forum, c/o Jess especially. Also her curves are much the same as mine, as is our demographic and DDD.

One " T4" particularly pointed out that even with a longer fusion, there are "no guarantees". Thanks to Linda Racine's links on the subject (PJK and kyphosis) I knew just what he was referring to.

jrnyc
07-05-2010, 08:43 PM
no one's back is identical to another's...so i would not predict what ANY surgeon will advise one patient based on what that surgeon advises another patient...no patient's overall health is the same as another's...nor their weight, nutritional profile, number of discs degenerated, degree of rotation, amount of stenosis, degree of arthritis, or anything else...nor is a prediction of how the patient will tolerate the surgery, the liklihood that patient will need revision in the future, their lifestyles, or anything else!

jess

Back-out
07-05-2010, 10:13 PM
no one's back is identical to another's...so i would not predict what ANY surgeon will advise one patient based on what that surgeon advises another patient...no patient's overall health is the same as another's...nor their weight, nutritional profile, number of discs degenerated, degree of rotation, amount of stenosis, degree of arthritis, or anything else...nor is a prediction of how the patient will tolerate the surgery, the liklihood that patient will need revision in the future, their lifestyles, or anything else!

jess

Of course, it's not a real prediction. It's just a probability assessment based on increasing understanding of what different surgeons appear to recommend on the conservative-aggressive continuum, as defined in context.

Funny that among the top East Coast surgeons, it is seeming a bit generational. Small personal sample, and the rest by hearsay. We'll see. Nothing I'd base a decision on. Just means I'm starting to understand where they're coming from. Some of it is empirical. I can't really understand all the research behind it, of course, but I don't think it's my imagination that there are groupings based on surgical philosophies - maybe even fellowship programs or exposure to a certain body of research.

CHRIS WBS
07-06-2010, 11:57 AM
Amanda,

I considered the surgeon I saw at Rush and the one I saw at Northwestern conservative in their thinking. Both are older surgeons who perform a lot of surgeries. They recommended a traditionally more invasive surgery for me based on the severity of my scoliosis…a thoracoabdominal surgery and a posterior surgery from T2 to the pelvis staged a week apart. I believe their recommendation was based on years of experience and proven long term results; and I don’t think either of these surgeons would be open to change. They will stick with what has proven to be most successful for their patients long term. And that’s why I view them as conservative. When I saw Dr. Bridwell, he told me that he has pretty much backed away from performing thoracoabdominal surgeries. I viewed Dr. Bridwell and my surgeon as more progressive and cutting edge. On his website the following is stated, “Dr. Bridwell formulates the least invasive and least risky procedure for each patient, taking into account their surgical goals and what their body can handle.” And I believe this is true of my surgeon as well. I’m not sure cutting edge is necessarily better though. It’s tough trying to assimilate it all and make a decision that you feel is best for you.

FYI, Dr. Fessler is with Northwestern and not U. of Chicago.

Back-out
07-06-2010, 12:18 PM
Chris,

I had pretty much the same approach as you are describing semantically, viewing "tried and true" as meaning conservative. "Conservative" as in politics - meaning resistant to change.

It seems that surgically, though, "conservative" refers to less surgery. ...even if it's a breakthrough technique or riskier per se.

But what risk is one trying to mitigate? :confused:

BTW I was curious abt Dr Fessler re your comments and looked him up, finding this

http://nmhphysicians.photobooks.com/profile.asp?pict_id=11077&LastnameSearch=Y&Lastname=fessler

He was recruited relatively recently from the U Chicago to Northwestern. Not sure just what this means in terms of his geographic availability. (He sure is a lot better looking without surgical scrubs obscuring his handsome face! Kind of like removing hijab!)

CHRIS WBS
07-06-2010, 12:29 PM
Maybe you should select your surgeon based on how good-looking he is.:D You seem to have a thing about hunky surgeons.;) I recall Karen Ocker mentioning that there was a surgeon who ended up marrying his patient.

Back-out
07-06-2010, 12:44 PM
Maybe you should select your surgeon based on how good-looking he is.:D You seem to have a thing about hunky surgeons.;) I recall Karen Ocker mentioning that there was a surgeon who ended up marrying his patient.
haha. I'm afraid surgeons have a greater array to select from than an almost Medicare age broad! Unless he wants a practice dummy, that is.

I used to think it would be cool to marry a plastic surgeon, but now I admit I'd find it handier to marry a great scoli surgeon. I doubt they'd ever operate on a spouse, though, even if a bottle genie brought me such a loon!

(Actually, anyone with good insurance would suit me just fine :p )

Confusedmom
07-06-2010, 08:25 PM
When I saw Dr. Bridwell, he told me that he has pretty much backed away from performing thoracoabdominal surgeries.

Chris,

This is interesting. Do Dr. Bridwell say if that is simply because the surgeries are harder to recover from, or is there new evidence that posterior-only is just as successful? Maybe it has something to do with BMP? Just wondering if you knew any more about this change.

Thanks,
Evelyn

LindaRacine
07-06-2010, 08:46 PM
Chris,

This is interesting. Do Dr. Bridwell say if that is simply because the surgeries are harder to recover from, or is there new evidence that posterior-only is just as successful? Maybe it has something to do with BMP? Just wondering if you knew any more about this change.

Thanks,
Evelyn

Hi Evelyn...

When they say they're no longer doing the thoracolumbar approach, they're referring to the big slash openings that many of us had. Now, they simply do multiple ALIFs, TLIFs, and/or XLIFs.

--Linda

Susie*Bee
07-06-2010, 08:57 PM
I considered the surgeon I saw at Rush and the one I saw at Northwestern conservative in their thinking. Both are older surgeons who perform a lot of surgeries. They recommended a traditionally more invasive surgery for me based on the severity of my scoliosis…a thoracoabdominal surgery and a posterior surgery from T2 to the pelvis staged a week apart. I believe their recommendation was based on years of experience and proven long term results; and I don’t think either of these surgeons would be open to change. They will stick with what has proven to be most successful for their patients long term. And that’s why I view them as conservative.
Chris- Dr. H (for the rest of you--the one at Rush) was going to do A/P a week apart with me too. We had it all scheduled. Then about a month beforehand, he decided he could do it with just the posterior. Sometimes they change their minds...

Back-out
07-06-2010, 11:21 PM
Hi Evelyn...

When they say they're no longer doing the thoracolumbar approach, they're referring to the big slash openings that many of us had. Now, they simply do multiple ALIFs, TLIFs, and/or XLIFs.

--Linda
Feeling very out of the loop but nevertheless hoping the old rule of thumb still holds ("the only stupid question is one you know the answer to") -

what do these (to me) new acronyms mean?

Thinking not for the first time, that this specialty website (like others in various fields) needs its own glossary...

LindaRacine
07-06-2010, 11:51 PM
Feeling very out of the loop but nevertheless hoping the old rule of thumb still holds ("the only stupid question is one you know the answer to") -

what do these (to me) new acronyms mean?

Thinking not for the first time, that this specialty website (like others in various fields) needs its own glossary...

They're all types of interbody fusion. All done with different, minimally invasive techniques (anterior, transforaminal, and lateral).

Pooka1
07-07-2010, 07:11 AM
It's possible that she knew that she had scoliosis when she was younger. We see a lot of older patients with scoliosis who don't know if they had scoliosis when they were younger, and as far as I can tell, it's not always easy to know which it is.

I'd like to know if a single patient with long-term untreated scoliosis ever escapes degenerative scoliosis. It may be that virtually everyone with untreated scoliosis will also develop degenerative scoliosis, including most subsurgical folks. That would be important to know I think.

leahdragonfly
07-07-2010, 08:21 AM
Hi Sharon,

I'm totally guessing here, but I think a plausible reason my lumbar curve increased from 35 to 47 in the last year is due to severe degeneration. I have severe spinal arthritis, facet joints are massively enlarged, spinal instability, spondylolisthesis and stenosis. I was diagnosed with a double curve at 13, with 32 and 33 degrees. Withstood "successful" bracing, with curves both reduced to around 20 at 3 months out of brace. A few years ago, when my back started giving me trouble at age 40, my curves were 35 lumbar and 21 thoracic. A few months ago they were measured at 47 and 28 degrees. I just turned 43. I am scheduled for fusion T10-pelvis on October. I am told by my surgeon that I will be at risk for having continued degeneration above the fusion, with eventual fusion extension maybe needed of the thoracic curve too.

Interesting thread...

LindaRacine
07-07-2010, 03:03 PM
I'd like to know if a single patient with long-term untreated scoliosis ever escapes degenerative scoliosis. It may be that virtually everyone with untreated scoliosis will also develop degenerative scoliosis, including most subsurgical folks. That would be important to know I think.

http://jama.ama-assn.org/cgi/content/full/289/5/559

JAMA. 2003 Feb 5;289(5):559-67.

Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study.
Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV.

Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA. stuart-weinstein@uiowa.edu

Comment in:

J Fam Pract. 2003 Jun;52(6):451-2.
JAMA. 2003 May 28;289(20):2644; author reply 2644-5.
JAMA. 2003 Feb 5;289(5):608-9.

Abstract
CONTEXT: Previous long-term studies of idiopathic scoliosis have included patients with other etiologies, leading to the erroneous conclusion that all types of idiopathic scoliosis inevitably end in disability. Late-onset idiopathic scoliosis (LIS) is a distinct entity with a unique natural history. OBJECTIVE: To present the outcomes related to health and function in untreated patients with LIS. DESIGN, SETTING, AND PATIENTS: Prospective natural history study performed at a midwestern university with outpatient evaluation of patients who presented between 1932 and 1948. At 50-year follow-up, which began in 1992, 117 untreated patients were compared with 62 age- and sex-matched volunteers. The patients' mean age was 66 years (range, 54-80 years). MAIN OUTCOME MEASURES: Mortality, back pain, pulmonary symptoms, general function, depression, and body image. RESULTS: The estimated probability of survival was approximately 0.55 (95% confidence interval [CI], 0.47-0.63) compared with 0.57 expected for the general population. There was no significant difference in the demographic characteristics of the 2 groups. Twenty-two (22%) of 98 patients complained of shortness of breath during everyday activities compared with 8 (15%) of 53 controls. An increased risk of shortness of breath was also associated with the combination of a Cobb angle greater than 80 degrees and a thoracic apex (adjusted odds ratio, 9.75; 95% CI, 1.15-82.98). Sixty-six (61%) of 109 patients reported chronic back pain compared with 22 (35%) of 62 controls (P =.003). However, of those with pain, 48 (68%) of 71 patients and 12 (71%) of 17 controls reported only little or moderate back pain. CONCLUSIONS: Untreated adults with LIS are productive and functional at a high level at 50-year follow-up. Untreated LIS causes little physical impairment other than back pain and cosmetic concerns.

PMID: 12578488 [PubMed - indexed for MEDLINE]Free Article

LindaRacine
07-07-2010, 03:09 PM
Hi Sharon,

I'm totally guessing here, but I think a plausible reason my lumbar curve increased from 35 to 47 in the last year is due to severe degeneration. I have severe spinal arthritis, facet joints are massively enlarged, spinal instability, spondylolisthesis and stenosis. I was diagnosed with a double curve at 13, with 32 and 33 degrees. Withstood "successful" bracing, with curves both reduced to around 20 at 3 months out of brace. A few years ago, when my back started giving me trouble at age 40, my curves were 35 lumbar and 21 thoracic. A few months ago they were measured at 47 and 28 degrees. I just turned 43. I am scheduled for fusion T10-pelvis on October. I am told by my surgeon that I will be at risk for having continued degeneration above the fusion, with eventual fusion extension maybe needed of the thoracic curve too.

Interesting thread...

There's a huge difference between the average spine of a 40 year old and the average spine of a 60 year old. Since I started seeing so many xrays on a daily basis, I became aware of that difference. I was shocked, recently, to see my latest xrays, which made me look and feel very old. I don't think anyone knows if people with curved spines see more general degeneration (that is, degeneration unrelated to assymetrical loading). I suspect it's more a function of bone density and other factors.

--Linda

jrnyc
07-07-2010, 11:56 PM
hi Linda
i was doing fine with my scoli until i herniated discs....then all went downhill and more and more problems came out! am wondering how much discs contribute to acceleration of degeneration of the spine in general...

jess

theizzard
07-08-2010, 07:45 AM
I was not screened as a child in England and did not know I had scoli until in my 40's. I had a laminectomy when I was 37 and the surgeon said nothing about having scoli. Perhaps it grew after age 37!! I must have had it as a child because my mother would yell at me to stand straight when she was hemming my clothes. She assumed that one hip was higher than the other because I wasn't standing correctly. I still have scoli because my kyphosis was the main concern when I had my surgery. When I saw my xrays and saw the curve was still there I was very upset. Dr. Rand did not feel that my scoli had anything to do with my pain since I had pronounced kyphosis, stenosis and who knows what else. I mentioned it to him at a follow up and my impression of that conversation was that it would be very problematic to fix. I seem to think that because I have 2 artificial hips it would have thrown them off. I have the unfortunate problem of sometimes not remembering what is said to me. Next time I am taking my mp3 voice recorder with me instead of my husband who remembered even less than I did.
avis:D

Confusedmom
07-08-2010, 07:55 AM
CONCLUSIONS: Untreated adults with LIS are productive and functional at a high level at 50-year follow-up. Untreated LIS causes little physical impairment other than back pain and cosmetic concerns.

PMID: 12578488 [PubMed - indexed for MEDLINE]Free Article

Linda,

Thanks for this. Do you know how "late-onset idiopathic scoliosis" is defined? What is the age of first diagnosis? It seems like this study uses "LIS" the same way "AIS" is commonly used now (which I think is defined as scoliosis first diagnosed at age 11 or later).

If I'm reading this correctly, this article suggests that most untreated AIS causes no more problems than more frequent back pain and cosmetic deformity for most people (except for those with very large or severely rotated thoracic curves).

Evelyn

LindaRacine
07-08-2010, 07:29 PM
Linda,

Thanks for this. Do you know how "late-onset idiopathic scoliosis" is defined? What is the age of first diagnosis? It seems like this study uses "LIS" the same way "AIS" is commonly used now (which I think is defined as scoliosis first diagnosed at age 11 or later).

If I'm reading this correctly, this article suggests that most untreated AIS causes no more problems than more frequent back pain and cosmetic deformity for most people (except for those with very large or severely rotated thoracic curves).

Evelyn
Hi Evelyn...

I've heard it used on and off, but only know what I've found on the internet. For example?


The term infantile scoliosis is used specifically to describe scoliosis that occurs in children younger than 3 years. Other terms for scoliosis also depend on the age of onset, such as juvenile scoliosis, which occurs in children aged 4-9 years, and adolescent scoliosis, which occurs in those aged 10-18 years. These terms, however, are now being replaced by the broader terms early-onset scoliosis and late-onset scoliosis, depending on whether the scoliosis occurs before or after 5 years of age.


From another site:
Scoliosis diagnosed in patients aged between 10 and 18 years is termed late onset scoliosis. By far the most common type of scoliosis in the adolescent period is one in which the cause is not known and is called idiopathic or adolescent idiopathic scoliosis (AIS). Although important research continues in this area, including into the genetic basis for AIS, there are no identifiable causes for this condition. Nevertheless, there are accurate methods to determine the risk of curve progression and good methods of treatment.


But, what about this?
Adolescent idiopathic scoliosis (AIS) is defined by the Scoliosis Research Society as scoliosis whose onset occurs after ten years of age and whose cause is essentially unknown. It is a relatively common condition among adolescents.
Not that it really makes much difference, but I'll see if I can find any MD who will go on record on the subject.

Back-out
07-08-2010, 07:59 PM
Being 64, I belong to a generation that wasn't screened in school for scoliosis - not that it would necessarily have been caught.

The last consult I had (Weds.), the surgeon kept questioning me about when I was diagnosed with scoliosis. I guess he was trying to figure out same as me, when it started and when it got worse. Since I'd said I was told in my early 20s I had scoliosis he wanted to know what my curve was then - what had the doctor said, the one who had made the diagnosis?

I had to admit that it was only an exercise instructor at the local Y who had told me I had scoliosis. Actually, she told me at the same time she told the class, using me as an example ("if Amanda can do these exercises so well, with her scoliosis, why can't the rest of you?")

Great! Except no one attended to it - most importantly, I guess, not my parents who could have sent me to a specialist. My mother was keen on having my bunions corrected even then (they were unsightly), but nothing about this problem with all its future functional ramifications.

So hard to track my history! I guess I would have been nagged if the scoliosis had been severe since it would have affected my ability to wear nice clothes. Unlike me, she cared a lot about this. Don't remember the dress-maker doing anything special to make adjustments, but then would she have said anything? Doubtful.

I only went to spinal specialists when my back started to hurt and that came and went depending on whether I was stressing it - traveling a lot, carrying many heavy bags...I am guessing since my height remained stable at 5'6 1/2" until about a decade ago, that the curve itself was also steady. But then again, I can't remember whether or not my GPs ever actually measured me, or whether they just took my word for it. Only my weight and blood pressure were definitely checked.

As I shrunk (now I measure 5' 2 1/2" - 3"), I GUESS my back was twisting more and more. I'm struggling now to figure out what happened, when. The local hospital isn't much help. They've been reporting my scoliosis as "mild to moderate" ever since my first spinal Xrays are documented - starting only around 2000. Recently, with no degree changed noted, they suddenly called it "severe"! (They still have me down as Cobb 44 deg!) It's as if I went abruptly from adolescence to senior-hood with nothing in-between - from being a Senior in HS to being a Senior in a different demographic!

I wasn't even told there was such a thing as a "scoliosis series" or "study" until then, so all prior Xrays are piecemeal - patched together, from thoracic and lumbar views. Not a single one imaged my total spine. But then, this geographical area is "special" - not in a good way. :(

Most of all, I wonder what difference it makes now for surgery. Why does the surgeon care? Usually diagnosis determines treatment and prognosis; dx -> rx. But did/does it with me? Was there ever a missed intervention that could have spared me this radical solution? And does treatment now differ in any way depending on the origins of my condition? :confused:

Confusedmom
07-10-2010, 12:04 AM
Hi Amanda,

Since I am getting the same questions from the docs, I can relate to the drill you are going through (except it sounds like I have more documentation). Basically, I think they are trying to establish beyond a doubt that your curve is still progressing. That is how they justify surgery. If your curve is not progressing, they might just want to treat you will pain management and PT.

Evelyn

Tall Paul
09-13-2010, 11:58 PM
Also I watched referenced and discussed a video of a M. I. lumbar fusion (done by Dr Fessler of U Chicago). He specifically said that:

a) lumbar fusion surgery could be done very successfully using a M.I approach as long as the surgeon was extremely experienced in the technique - someone like him. The difference the surgeon makes in outcomes with ALL radical spinal surgery is hardly news, though it cannot be overstated for those of us still in the arranging/deciding end of things!

Dr. Fessler said that
b) current state of the Art does NOT permit doing a longer fusion using a M I. approach (This is what I especially took from the interview, regretfully. One always remembers what is personally relevant, I guess).

Incidentally, Dr Fessler was actually interviewed while he was performing a M.I lumbar fusion! I've tried several times since to retrieve the video-interview. Unfortunately, though, it seems to have been deleted from the U. Chicago's online reference library. Shame, as the contents don't appear available in text form.



Here is the video:
http://www.spineuniverse.com/professional/surgical-video/scoliosis-surgery-a-minimally-invasive-approach