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  • Complications in Degenerative Scoliosis Surgery

    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.
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

  • #2
    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.
    Last edited by Back-out; 07-04-2010, 11:21 AM.
    Not all diagnosed (still having tests and consults) but so far:
    Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
    main curve L Cobb 60, compensating T curve ~ 30
    Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

    Comment


    • #3
      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.
      Last edited by Back-out; 07-03-2010, 07:21 PM.
      Not all diagnosed (still having tests and consults) but so far:
      Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
      main curve L Cobb 60, compensating T curve ~ 30
      Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

      Comment


      • #4
        Originally posted by Back-out View Post
        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.
        Sharon, mother of identical twin girls with scoliosis

        No island of sanity.

        Question: What do you call alternative medicine that works?
        Answer: Medicine


        "We are all African."

        Comment


        • #5
          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

          Comment


          • #6
            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...
            Be happy!
            We don't know what tomorrow brings,
            but we are alive today!

            Comment


            • #7
              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

              Comment


              • #8
                Here's a short piece on degenerative scoliosis...

                http://www.spine-health.com/conditio...tive-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.
                Sharon, mother of identical twin girls with scoliosis

                No island of sanity.

                Question: What do you call alternative medicine that works?
                Answer: Medicine


                "We are all African."

                Comment


                • #9
                  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,
                  Not all diagnosed (still having tests and consults) but so far:
                  Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
                  main curve L Cobb 60, compensating T curve ~ 30
                  Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

                  Comment


                  • #10
                    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...

                    jess

                    Comment


                    • #11
                      Originally posted by Back-out View Post
                      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."
                      Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                      ---------------------------------------------------------------------------------------------------------------------------------------------------
                      Surgery 2/10/93 A/P fusion T4-L3
                      Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                      Comment


                      • #12
                        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
                        Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                        ---------------------------------------------------------------------------------------------------------------------------------------------------
                        Surgery 2/10/93 A/P fusion T4-L3
                        Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                        Comment


                        • #13
                          Originally posted by jrnyc View Post
                          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...

                          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
                          Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                          ---------------------------------------------------------------------------------------------------------------------------------------------------
                          Surgery 2/10/93 A/P fusion T4-L3
                          Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                          Comment


                          • #14
                            Originally posted by LindaRacine View Post
                            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.
                            Sharon, mother of identical twin girls with scoliosis

                            No island of sanity.

                            Question: What do you call alternative medicine that works?
                            Answer: Medicine


                            "We are all African."

                            Comment


                            • #15
                              Originally posted by Back-out View Post

                              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.
                              Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                              ---------------------------------------------------------------------------------------------------------------------------------------------------
                              Surgery 2/10/93 A/P fusion T4-L3
                              Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                              Comment

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