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Pooka1
07-07-2011, 07:28 AM
http://drlloydhey.blogspot.com/2011/06/dr-heys-past-week-in-review.html

From Dr. Hey...


This also illustrates importance of screening for, and following scoliosis in younger people, especially during the adolescent and young adult years. If this woman would have had her scoliosis fixed years ago before the lowest levels of her spine became degenerative, we could have more likely fixed it with a shorter fusion, preserving the bottom 2-3 discs. As people get into their late 30's and 40's, often those lowest discs have degenerated so much that they must be included in the fusion -- not the end of the world, but it sure is nice to have "a stitch in time that saves nine!" - or that saves some mobile disc spaces.

I have often wondered why the older patients here seem to need longer fusions based on the testimonials. Most AIS curves are thoracic only yet the majority of adult testimonials seem to be about double major curves. Something isn't matching up. Maybe the double majors just progress more than T curves in adulthood. I have read that lumbar curves and certain TL curves tend to progress in adulthood but I don't know that it is more than T curves. I can't prove any of that statistically, it just seems so based on reading this forum. Here is an explanation for that if it is true. And it seems some with only originally a structural thoracic curve have such changes in the lumbar that they develop a structural curve there also if they don't get the T curve stabilized.

While I think screening of kids is questionable until they can demonstrate an effective conservative treatment, screening of adults with known scoliosis certainly is not.

jrnyc
07-07-2011, 01:17 PM
nothing new...physicians are always telling their over age 40 patients, in my experience, that the spine weakens with age......
also, the chance of activities that can cause herniated discs also seems to increase with age...

so Dr Hey is not telling us...me...anything i didn't hear years ago...

jess

mabeckoff
07-07-2011, 05:36 PM
Dr Hey is a wonderful Doctor and a great person as well

Melissa

titaniumed
07-08-2011, 10:08 AM
Sharon

I had a double major as a kid and would have had the same levels fused at that time. Still, my surgeon told me that I should have had surgery sooner....my general shape didn’t change much, the curves just increased along with degeneration. I was fortunate that my plumb from top to bottom remained centered.

I made it to 49, along with many others here. Since I never met any scolis through the years, it is amazing to see others that are my age, posting pretty much the exact same story. The silent readers should post and introduce themselves. Its ok, we are all in the same boat.

I cannot remember the stats exactly, but the curves are pretty much divided up and double majors are, I believe about 25% of all cases. I can look this up in Moe’s book if you wish.

I guess the question now should be, "Is there any advantage to delaying scoliosis surgery and what would those reasons be?" Other than young sports minded people, what would be the reasons?
Ed

titaniumed
07-08-2011, 10:12 AM
I’m thinking of adults. After maturity.
Ed

braceyourself
07-08-2011, 10:21 AM
I obviously don't know what it would have been like for me to wait to have my surgery, but I do know that I bounced back very quickly. I think having it at a young age makes the recovery somewhat easier and faster, which is nice. And there's the fact that progressing curves can cause a lot of problems. But you guys know all this already. : ) I just personally think that in time, most scoliosis cases that are bad enough will only get worse.

When I was diagnosed with scoliosis at 6 years old, I had one curve. Then several years later I had two. And actually, I'm glad I had two curves. Yes, it meant that the fusion would be longer, but they sort of balanced each other out, and I didn't lean to one side like most people with one curve do.

Pooka1
07-08-2011, 10:29 AM
(snip)
I cannot remember the stats exactly, but the curves are pretty much divided up and double majors are, I believe about 25% of all cases. I can look this up in Moe’s book if you wish.

Okay this is a good data point if correct. Someone correct me if I'm wrong but it seems like FAR more than 25% of the adult patients here are being fused long enough to be consistent with double major curves (or damage to the lumbar if not a frank structural curve) from a long-term untreated T curve. Either that or the 25% of double major curves just tend to progress far more than any other curve type. But I don't think that is correct. So it just seems that some of the single curves, expecially T curves, eventually necessitate long fusions as in orginal double majors for some reason. That reason appears to be eventual lumbar involvement even if originally not structural. And that is what Dr. Hey is saying as I understand it.

And that jives with what we were told about fixing a T curve and not expecting any more surgery. And it also jives with some testimonials about adults with T curves where the lumbar is affected by calcification and self-fusion. I am not clear on why these folks don't RUN to get the T curve fused if only to try to save the lumbar from self-fusion or needing surgical fusion. Forget about guessing about progresion of the T curve... that is not the only issue by far.

The take home I get from this is that if you have a T curve, get it fixed before the lumbar becomes involved. And now the question shifts to whether there are stable, smaller T curves that while not progressive in adulthood nevertheless damage the lumbar if not fixed. Pediatric orthopedic surgeons should be addressing this with parents if they have the data which they may not.


I guess the question now should be, "Is there any advantage to delaying scoliosis surgery and what would those reasons be?" Other than young sports minded people, what would be the reasons?
Ed

The advantage in delaying is only for fusions extending below about L3 as I understand it. I am not aware of any advantage to delay fusing a T curve. It seems like there are only downsides to delaying the fusion of a T curve. Anyone?

titaniumed
07-08-2011, 11:50 PM
Katie
We are opposite of one another as I have no idea how my spine progressed prior to age 16.
I did ok till age 27, then started Chiropractic for pain control. My problems started around age 42, with my first lower spasms after skiing in a competition. It was like a sword being pushed in my L3 area for 2 days. After Chiro and Accupressure, (from a Chinese girl)...smiley face, I could have gone skiing the next day. It was worth it, I made ESPN. Through my 40’s sciatica became an issue...that was brutal. I gave up when I was 49 and set my date.

Sharon
You made me look for my reading glasses!

Some info from Moe’s textbook. I was wrong. My memory has been affected since my surgeries and its bugging the hell out of me. I had to check.
------------------------------------------------------------------------------------------------------------------------
In general, the single lumbar curve is the least common pattern. Lonstein and Carlson reviewed 727 patients and found the following frequency of curve patterns; 31% single thoracic, 11% lumbar, 10% thorocolumbar, and 48% double curves. The latter group includes double major curves and structural thoracic and compensatory lumbar curves. Pg 222

Also, A double major curve is more likely to progress than a single curve. Pg. 221
-------------------------------------------------------------------------------------------------------------------------
Of course there are many parameters involved in types of curves, age, progression rates, etc. Some of the x-rays and pictures in this book are absolutely heartbreaking. I’m sure that there are Doctors that become Orthopedics, see this material, and decide that they cannot continue practicing medicine without doing something about it. I have tears in my eyes.
Ed

jrnyc
07-09-2011, 06:38 AM
needing surgery to the sacrum, with pelvic fixation, can be a BIG reason for an adult to delay surgery...especially an older adult...

jess

Pooka1
07-09-2011, 08:50 AM
needing surgery to the sacrum, with pelvic fixation, can be a BIG reason for an adult to delay surgery...especially an older adult...

jess

Yes I agree lumbar curves have reason to delay for sure, especially those extending to the sacrum. But thoracic curves? I don't see it. Only a downside if there is any possibility of lumbar involvement.

Pooka1
07-09-2011, 09:06 AM
Sharon
You made me look for my reading glasses!

Some info from Moe’s textbook. I was wrong. My memory has been affected since my surgeries and its bugging the hell out of me. I had to check.

Hey! That's happening to me now also but my surgeries were a while ago. :-)

From Dr. Moe's textbook...



In general, the single lumbar curve is the least common pattern. Lonstein and Carlson reviewed 727 patients and found the following frequency of curve patterns; 31% single thoracic, 11% lumbar, 10% thorocolumbar, and 48% double curves. The latter group includes double major curves and structural thoracic and compensatory lumbar curves. Pg 222

Also, A double major curve is more likely to progress than a single curve. Pg. 221


Okay that is good info if it has been garnered from a large population and has been replicated. I wonder why he lumped lumped structural T plus compensatory L in with structural double. Maybe that is an indication that they behave the same if left untreated. If so, that is IDENTICAL to what Dr. Hey is saying wherein if you don't get the T curve fixed, it will involve the L whether the L curve was originally structural or not. If data support this, if most patients with only T curves eventually develop double structural curves, then I think it would be unethical not to lower the surgical trigger for T curves. The issue with T curves is equally progression potential AND potential lumbar involvement down the road. Equally if not more so about hte lumbar involvement. Someone needs to get those data if parents are to make a rational decision.

What we need to know is what percentage of the double curves are really only T curves and what percentage are true double structural curves. If you assume half and half, then that brings the structural T curve total percentage to account for the majority of curves, maybe even 75% which is a number I have come across before. And then that would jive with the comment that T curves tend to progress more than other curves.

There is some reason Moe lumped some T curves with true double majors. It seems like apples and oranges... one structural curve versus two. If the reason to lump them isn't common behavior in the out years then I'd like to know what it is.

All these seemingly disparate data points can be fit together like a puzzle... slowly...


Of course there are many parameters involved in types of curves, age, progression rates, etc. Some of the x-rays and pictures in this book are absolutely heartbreaking. I’m sure that there are Doctors that become Orthopedics, see this material, and decide that they cannot continue practicing medicine without doing something about it. I have tears in my eyes.
Ed

I agree. And yet we have any number of folks here claiming these guys are nefarious. It's jaw dropping.

golfnut
07-09-2011, 09:11 AM
Jess,
My fusion from T4 to sacrum with pelvic fixation is not as horrible as one would think. I miss playing golf tournaments, but have recently started chipping and putting. If giving up golf for one season is the worst thing that happens to me in my life, I am lucky. My lumbar vertebrae had already started to degenerate, so I'm glad I didn't wait any longer ( even though I had very little pain). Did you read Jenee''s recent post? She is amazing!

Pooka1
07-09-2011, 10:07 PM
From Lenke et al. (2002)
(http://www.ncbi.nlm.nih.gov/pubmed/11884908)

Total = 606 cases

Type 1, main thoracic (n = 305, 51%)
Type 2, double thoracic (n = 118, 20%)
Type 3, double major (n = 69, 11%)
Type 4, triple major (n = 19, 3%)
Type 5, thoracolumbar/lumbar (n = 74, 12%)
Type 6, thoracolumbar/lumbar-main thoracic (n = 17, 3%)

So single thoracic accounts for half of all curve types. Now we need some data on potential for each type of curve to progress. My understanding is that T curves have the highest risk of progression but I'd like to see some data. But even if all the double majors progressed, they are only about one tenth of all cases. If I am correct in my observation that the majority of adults here have very long fusions that are inconsistent with a single curve (either T or L or TL) then there is some conversion going on between single curves to double majors if not treated. I think that result is inescapable given that double majors start out at only a small fraction of all AIS cases.

The other observation I have based on testimonials is that L and TL curves seem to progress more in adulthood than in kids. So maybe it is only during adolescence where T curves tend to progress more than other curve types. And this jives with what I have read.

In contrast, I would say among the kids, T curves mostly, followed by double majors, are the most prevalent curves being fused based on testimonials.

There is some reason why the fusions for kids and adults are not more similar. And parents need these data.

Susie*Bee
07-10-2011, 04:52 PM
I haven't read all this very thoroughly, Sharon... mine is long, but not a double major. I have 3 curves, but the main one is TL. Go in and look at my x-rays in my signature. The just-below-the-neck one in the digital x-rays is kind of interesting too. I did not have any x-rays taken before I was 54, am glad, even though I "knew" I had scoliosis, that I was ignorant of doing anything "about" it until I got all my family raised on their own. I just lived with it. My curves pretty much canceled each other out so I looked ok with my clothes on. The "AHA!" moments came with arthritis and menopause... much more pain, and the severe lumbar stenosis, lateral listhesis and other complications, not just the scoliosis itself.

My own opinion-- if you need surgery, take care of the problem before families begin if possible. I am sure the younger you are, the quicker and easier it all is. Even if you have started a family, you will bounce back much quicker than someone in their 50s or 60s. Having said that-- I do not regret for one second the fact that I had my freedom for those 56 years of not being fused. I am not one of the ones who can bend and twist and get down on the floor... and I'm supposed to protect my last two lumbar vertebrae by being careful. In August I'll be seeing a different doctor since mine is doing Shriner's only now--now I will see his former partner, Dr. Christopher DeWald.

Pooka1
07-10-2011, 05:28 PM
Hey Susie*Bee,

That's an interesting testimonial.

When they told you that you have three curves, did they mean all of them were structural? I take it they were or else they would have fused just the TL curve, perhaps with an anterior fusion, which would have been much fewer levels as I understand this than what you ended up having fused. Except for the other issues of course.

It would have been interesting to know if you only had the one structural TL curve to begin with and if you could have had a much shorter fusion and avoided all the other damage if it was fused. Now I realize that folks dealing with this before the pedicle screw era had less good choices available to them than folks today have. So my comments are towards those diagnosed now who could maybe avoid a longer fusion later due to ancillary damage or "structuralizing" a compensatory curve if they delay fusion.

Susie*Bee
07-10-2011, 07:21 PM
I was beginning to develop a dowager's hump... he felt it was just going to increase. The orthopedic specialist who referred me to Dr. H mentioned the 3 curves. Dr. H only talked about the one, so I assume there was only the one structural curve and the other two were compensatory (or whatever you call them!). They were each roughly 30º and the main one was 52º. Again, he's been in the business a long time and I trust his decision. I am down to 15º, have wonderful posture, and look great. Just have some limitations. Sometimes there are too many other facets that go into the decision making other than just the scoli-- DDD, stenosis, listhesis, etc. Again, possibly another reason to fuse earlier???

Pooka1
07-10-2011, 07:42 PM
Wow you got a top shelf correction! Hammerberg must be in that top eschelon.

I wish I knew more about this stuff. Did they tell you if all the damage to the lumbar could have been avoided if the TL curve as stabilized much sooner?

It's interesting that you are actively trying to protect the last two discs. I hope that works. It would be interesting to see some stats on how long fusions to L4 last before needing to be extended. Maybe you can extend it for the next several decades and never need more surgery. There have been a few testimonials where folks went about 30 years before needing an extension. And one parent was told there was only a 15% chance her teenage son would need an extension even though he was fused to L4 and was very young. So maybe things have been improved with the advent of pedicle screws.

Susie*Bee
07-10-2011, 07:57 PM
Sharon, I never asked any "what ifs" because there wasn't any point... I just dealt with what I had. Time will tell about the lower lumbars-- he said it was a gamble we could take, and we had about an 80% chance. It was my choice, but his recommendation as well.

titaniumed
07-10-2011, 09:20 PM
I think cases like my son's, where surgery is risky because of congenital factors and where he's not feeling pain or progressing, are pretty obvious cases for waiting. Our surgeon did everything but shoo us out of his office :)



I agree. I should have been more specific on age. I think these surgeons are leaning towards not waiting till age 50. Are they asking for 10 years? Not every 40-50 degree 20 year old scoli will submit to surgery. I think they are addressing the ones who wait, like me. I walked in there and I was whooped! I was begging Dr Menmuir at the end, it was only after he looked at my blood tests that he saw that I was in pretty good shape from skiing.

Years ago, scoliosis surgery was scary stuff, almost like putting a man on the moon. Its amazing that these things actually happened! Today, and tomorrow, these things are so much easier to accept.

After the shuttle comes home. That’s it. We have no space program.
I think shock is setting in.
Ed

Pooka1
07-10-2011, 09:28 PM
I think we have to necessarily limit this discussion to AIS, at least to start.

In congenital, the vertebra are misshapen and I think the risks are higher when trying to fix that. I think that article Linda posted a while back shows that... neuromuscular and congenital were associated with more complications than IS.

It would be truly unfortunate if these congenital cases also eventually involve formerly compensatory curves as AIS seems to do. It's a kick in the teeth balancing that with the higher risk of fixing congenital. It's less of a kick in the teeth doing that balancing with AIS apparently.

titaniumed
07-10-2011, 09:33 PM
needing surgery to the sacrum, with pelvic fixation, can be a BIG reason for an adult to delay surgery...especially an older adult...

jess

Yes and no. I think it depends on the pain. I had to do something.

I have had no issues at all with my pelvic anchors. They look a little large but I don’t feel them at all.

After driving a few golf balls, AND being complimented on my form, LOL (I’m not a golfer)
I realized that it could and would work. I did this for Karen about a month ago just to see and I must say it felt good. I could play golf and drive balls with a reasonable amount of success.

Ed

titaniumed
07-10-2011, 09:39 PM
I think we have to necessarily limit this discussion to AIS, at least to start.




Yes, I agree. Congenital and kyphosis are different animals.
Ed

Pooka1
07-10-2011, 09:50 PM
I have had no issues at all with my pelvic anchors. They look a little large [...snip]

That's not what the women say... most think they are VERY large. :)

titaniumed
07-10-2011, 10:28 PM
And there are 2 of them! (Pelvic anchors)

Now I have 3 of something else I just cannot say here!

A congenital benefit. LOL

Ed

Susie*Bee
07-11-2011, 09:26 AM
Well, I have a question-- I understand about correcting the structural curve the compensatory curves will then align on their own, in a younger body with no problems. But does that always happen with older bodies? It just seems like once you get to a certain age, you are really pretty rigid/fixed and may have developed other problems that lead to longer fusions anyway. My real question, though, is if compensatory curves will correct themselves in an older person (let's say over 55) the way they do in a younger person? (Although in my case that wouldn't have been the solution at either end...) If so, that would definitely be a reason to have surgery at a younger age... I think.

Pooka1
07-11-2011, 10:24 AM
Well, I have a question-- I understand about correcting the structural curve the compensatory curves will then align on their own, in a younger body with no problems. But does that always happen with older bodies? It just seems like once you get to a certain age, you are really pretty rigid/fixed and may have developed other problems that lead to longer fusions anyway. My real question, though, is if compensatory curves will correct themselves in an older person (let's say over 55) the way they do in a younger person? (Although in my case that wouldn't have been the solution at either end...) If so, that would definitely be a reason to have surgery at a younger age... I think.

That's a great question! For a surgeon!!

This is EXACTLY my point about a seemingly large difference in the length of fusions between kids and adults. If most adults need longer fusions, especially to include the lumbar) due to either structuralized originally compensatory curves or due to ancillary damage in other areas of the spine due to even a sub-surgical curve elsewhere, then surgeons need to be telling parents that.

I have been tossing the stats around in my head and I think the main issue might not be structuralizing compensatory curves (though there are testimonials to that effect here) but rather outright damage to other parts of the spine because a structural curve is present somewhere in the spine.

The game appears to be FAR more complicated than just guessing about progression, especially for thoracic and thoracolumbar curves. If the surgeons know there is a high likelihood of lumbar involvement in the out years in untreated T and TL curves then it might be unethical not to fuse even sub-surgical curves. I think this is exactly what Dr. Hey is saying in the OP. We need data on this.

Lumbar curves are a different story for obvious reasons.

titaniumed
07-11-2011, 11:47 PM
I agree. And yet we have any number of folks here claiming these guys are nefarious. It's jaw dropping.

I eventually had to comment on this.....It’s a shame that this happens.

After killing yourself for about 20 years in school, a specialist makes the big bucks ONLY to pay the loans off for years and years. In other words, it’s a 30 year plus minimum gamble...Fun and games are not part of the program.

It tells you something about specialists. It proves their dedication. They truly commit to a lifetime of learning both the art and science of medicine. Only after you have had your second chance at life, does one appreciate their efforts for perfection, in a realm of incredibly challenging odds....

After talking to Dr Hu at UCSF, I didn’t want to talk about scoliosis with her after the meeting was over. I felt that she, even though totally dedicated, needed some sort of break even on her day off at the last scoliosis conference....It was more about listening to the experts review current procedures and orthopedic difficulties and absorbing their ultimate wisdom. All I wanted to do was to give her a mental break, talk about lighter subjects which we did.

And after talks with my surgeon through the years, did I realize that he is a true genius who understands exactly what we go through, and will go through as scolis, a very understanding person, I just cannot accept anyone who would even think about posting or saying anything derogatory about scoliosis surgeons. These are people that just don’t understand......it makes no sense at all.

Ed

Pooka1
07-12-2011, 06:06 AM
I eventually had to comment on this.....It’s a shame that this happens.

After killing yourself for about 20 years in school, a specialist makes the big bucks ONLY to pay the loans off for years and years. In other words, it’s a 30 year plus minimum gamble...Fun and games are not part of the program.

It tells you something about specialists. It proves their dedication. They truly commit to a lifetime of learning both the art and science of medicine. Only after you have had your second chance at life, does one appreciate their efforts for perfection, in a realm of incredibly challenging odds....

After talking to Dr Hu at UCSF, I didn’t want to talk about scoliosis with her after the meeting was over. I felt that she, even though totally dedicated, needed some sort of break even on her day off at the last scoliosis conference....It was more about listening to the experts review current procedures and orthopedic difficulties and absorbing their ultimate wisdom. All I wanted to do was to give her a mental break, talk about lighter subjects which we did.

And after talks with my surgeon through the years, did I realize that he is a true genius who understands exactly what we go through, and will go through as scolis, a very understanding person, I just cannot accept anyone who would even think about posting or saying anything derogatory about scoliosis surgeons. These are people that just don’t understand......it makes no sense at all.

Ed

Ti Ed,

I completely agree with all you have wrote and quoted it in its entirety.

Parents are angry. They need an outlet for that anger. They want an answer yesterday.

Reading this forum has been eye-opening in terms of the completely ignorant and indefensible thought processes that occur out of stress and anger to folks who are likely very rational in every other area of their life. When the stakes are perceived to be high enough, some folks check their reason and ration at the door. These arguments they make simply make no sense.

While these are understandable sentiments, it is nevertheless inexcusable to throw the only people who can help them under the bus out of ignorance. Any noises implying surgeons are too dumb to realize alternative therapies work or too recalcitrant to give these alternative therapies a chance or too evil to want to search for a conservation treatment is to not be in the conversation at all. It's that bad in my opinion.

There is too much nonsense treatments in the scoliosis world for surgeons to individually and constantly knock down. Rather these alternative treatment purveyors need to pony up the evidence that it works so that surgeons can trial it. That never happens with alternative treatments. Folks can whinge about lack of money for fringe treatments but they never think about why there is no money from legitimate research sources funneling in. And the answer to that is very obviously NOT that they will lose revenue from fusions.

It strains credulity to suggest that surgeons can come up with a non-fusion treatment but fail to do so for non-scientific reasons. It's a failure by lay folks to understand the actual issues. And I suggest the reason they struggle is the abject poverty of science education in the US at least. When you have about half the public actively opposing scientific facts, how could it turn out worse?

It's cluelessness from a million different directions. On the wing.

Pooka1
07-13-2011, 10:16 PM
http://drlloydhey.blogspot.com/2007/09/29-yo-woman-with-progressive-scoliosis.html

(emphasis added)


Could earlier scoliosis have prevented this lumbar collapse? Probably yes. With modern current scoliosis techniques using pedicle screw fixation, and shorter constructs for thoracic curves (T5-L1 for example), 80-95% corrections are possible of the major curve, which results in nearly complete correction of the compensatory curves on either side, including the lumbar area. Although there can be an issue with adjacent level failure with lumbar fusions, it appears that the patients who have thoracic fusions down to L1 or L2, with most of the lumbar discs preserved actually wear their lower lumbar discs very well, especially when the top curve is well-corrected. Perhaps in the future we will have more longitudinal studies which will show that earlier short fusions can prevent the later collapse of the upper and / or lower curves that tend to affect quality of life a lot in the adult population. In this case, a “stitch in time may save nine”, in that a smaller operation can be performed on the adolescent or young adult which prevents the need for a longer instrumentation and fusion later in life to fuse across both the upper and lower curves. This younger age may also allow for a greater degree of correction, with subsequent improvement in load balance, and by fixing it at a younger age allow the discs to be subjected to more centered loads for the duration of the life of the person.

livingtwisted
07-13-2011, 11:00 PM
I know I'm late to the party on this, and I'm not really interested in getting involved in the debate. But I would like to respond to this question…


I guess the question now should be, "Is there any advantage to delaying scoliosis surgery and what would those reasons be?" Other than young sports minded people, what would be the reasons?

…since it doesn’t seem like very many have given their perspective on it.

I could have had surgery in my teens, but didn't, and still haven't. Currently I am happy that I've waited. Here are some reasons why:


I didn't have to miss out on any childhood activities due to hospital stays, doctors appointments, or activity restrictions.
I have progressed in adulthood in terms of cobb angle and pain, but not dramatically as apparently I was supposed to (hence the surgery recommendation)
While its performed successfully all the time, it is still an extremely risky and invasive surgery that I am happy to avoid if possible
Having surgery in my teens would not guarantee that I wouldn't need revisions later in life
If I end up getting surgery at least I will be dealing with it when I'm already old (relative to a teenager) and in pain -- it will be my choice and I'll appreciate the benefits more.
If I end up getting surgery I'll have the benefit of decades of medical advancements on my side


I realize that there are counterpoints to every one of these (and I'm sure somebody won't be able to resist writing them out). But just wanted to point out that there are reasons to wait. They just may not be for everyone.

titaniumed
07-14-2011, 12:36 AM
Mehera

We are not debating anything here, just acknowledging what some surgeons are saying.....
My question pertains to patients after 40.....Dr Hey is saying “young adult”.

I would have had a long fusion as a kid so I guess I might have benefitted by waiting. I did have my share of pain. It would be interesting to know if I could have avoided my anterior if I would have had my surgery 10 years sooner. I do know that I truly did run out of time and was slipped in just in time. I have met scolis that were not as fortunate, they waited too long. (osteoperosis)

My curves did hold for many years and I did monitor with x-rays. I had twin 50’s that held for about 20 years, it was in my 40’s that the signs, the pains, really started getting bad. When the 10 level spasms and sciatica set in, it’s a signal that something is seriously wrong.....

Its good that you posted, these decision making threads really are the hardest ones here. Every surgical candidate or parent needs to consider all this information. Complications from surgery, OR not having surgery, all need to be considered. The scales can be tipped in either direction.
Ed

Pooka1
07-14-2011, 07:36 AM
From Lenke et al. (2002)
(http://www.ncbi.nlm.nih.gov/pubmed/11884908)

Total = 606 cases

Type 1, main thoracic (n = 305, 51%)
Type 2, double thoracic (n = 118, 20%)
Type 3, double major (n = 69, 11%)
Type 4, triple major (n = 19, 3%)
Type 5, thoracolumbar/lumbar (n = 74, 12%)
Type 6, thoracolumbar/lumbar-main thoracic (n = 17, 3%)

So single thoracic accounts for half of all curve types. Now we need some data on potential for each type of curve to progress.


Okay here's some data on progression potential...

http://www.scoliosisjournal.com/content/1/1/2


Natural history/deformity

At an average of 40.5 years after skeletal maturity 68% of the 133 curves in 102 patients in the Iowa series progressed [23]. Curves initially 30°or less tended not to progress whereas curves more than 30° usually progressed. Single thoracic curves between 50° and 75° were the most likely to progress, an average of 29.4° or about 0.73°/year (29.4°/40.5 years). Others have noted that thoracic curves were the most likely to progress [34]. Additional risk factors for progression of single thoracic curves were those with apical vertebral rotation of more than 30 per-cent and Mehta-angle, a measure developed to differentiate resolving and progressing infantile idiopathic scoliosis [35], of more than 20° [23]. The lumbar components of double major curves were more likely to progress than the thoracic component. Right lumbar apex curves were twice as likely to progress as left apex lumbar curves. Lack of L5 deep seating and greater than 33% apex rotation were risk factors for progression [23].

Okay combining the data sets, thoracic curves are not only more prevalent but more likely to progress. So that means T curves continue to lead the league in progression potential even past maturity.

For now, I am simply noticing that although there are a few adults here who get a T fusion, the majority are not in that group. They get longer fusions.

More digging...

progress
07-28-2011, 02:29 PM
Wow you got a top shelf correction! Hammerberg must be in that top eschelon.

I wish I knew more about this stuff. Did they tell you if all the damage to the lumbar could have been avoided if the TL curve as stabilized much sooner?

It's interesting that you are actively trying to protect the last two discs. I hope that works. It would be interesting to see some stats on how long fusions to L4 last before needing to be extended. Maybe you can extend it for the next several decades and never need more surgery. There have been a few testimonials where folks went about 30 years before needing an extension. And one parent was told there was only a 15% chance her teenage son would need an extension even though he was fused to L4 and was very young. So maybe things have been improved with the advent of pedicle screws.
I'm hoping that's the case My well respected Dr in Sydney doesn't seem to think I will need further surgery (fused to either T3 or T4 in two weeks), is there any info on the pedicle screws saving the lower discs? My lower discs are good at the moment.
Kelly
55 deg thoroculumbar
49 yrs

Pooka1
07-28-2011, 02:45 PM
I'm hoping that's the case My well respected Dr in Sydney doesn't seem to think I will need further surgery (fused to either T3 or T4 in two weeks), is there any info on the pedicle screws saving the lower discs? My lower discs are good at the moment.
Kelly
55 deg thoroculumbar
49 yrs

I think there is some chance Linda might have a feel for that from her work.

I wonder what the data show? I have asked our surgeon this a few times but I am still not sure about the bottom. I think he doesn't have enough data to say one way or the other. That said, for what it is worth, my understanding and impression is that:

1. distal end of L1 or L2 is thought to avoid the need for extension further distally in a lifetime.

2. distal end of L3 and going down, chance of needing an extension goes up.

3. the further distal the fusion ends, the higher the chances go up of needing an extension.

That said, surgeons are telling patients and parents of kids fused down to L4 that they only have a small chance of needing an extension. That is why I think pedicle screws may be changing the landscape on this. Hopefully Linda will chime in.

Good luck.