Short Segment Bone on Bone

[Cheryl M]

Just wondering if anyone has heard of this technique. It was the front page article in the spring/summer edition of The Spinal Connection. Dr. Robert W. Gaines performs this surgery in Missouri.

Cheryl

[flowerpower]

I read the article and researched a little on the internet. It sounds promising, but I was somewhat confused if this approach can be used on a double, as well as single curve. It seems like the surgeries they have done so far using this technique have been successful, but long term post-op?? Have you done any research, and what have you found? I would be interested in hearing others opinions. Has anyone consulted with Dr. Gaines or another dr. regarding this approach?

Renee

[Cheryl M]

We saw Dr. Gaines today. He does sound very promising. He is a great dr. We have a lot of thinking to do over the next few weeks. He does do a double major. He just does two segments instead of one. We are from NC so the decision to go to Missouri for surgery is a hard one.

Cheryl M

[flowerpower]

Good luck with your decision. What do your daughters curves measure & which vertebrae does Dr. Gaines propose fusing? How did that compare with your other dr.?

Renee

[Cheryl M]

Renee,

I need to go back over my notes and then I can be a little more certain of what we talked about yesterday. I think the bone on bone would be 8 vertebrae, 5 in the thoracic and 3 in the lumbar region from t12 to L2. He would make two incisions which would not be straight down the spine.
They would be lateral incisions across the ribs. Posterior surgery would be from t3 or t4 to L2 or L3. If my daughter only had a thoracic curive we would no doubt go to Missouri for the surgery. Ours is a little more complicated. I'll give you more info once I've had time to digest this.

Cheryl

[DaveWolpert]

I wanted to offer my two cents here. I met Dr. Gaines at a spine conference a few months ago. We discussed his bone-on-bone surgical technique for two hours and I reviewed his success rates and pre- and post-op patient x-rays. (Disclaimer: I am not a doctor, but I'd rate my medical knowledge of scoliosis surgery as well above average.)

Based on the material he showed me, I was blown away. His results are generally so outstanding I truly believe that one day his technique (or a variant of it) will become the de facto standard surgical correction procedure for scoliosis in most cases. Let me stress that it isn't appropriate for everyone, but if Dr. Gaines were to say you are a good candidate for his technique, I would be hard pressed not to go with him.

I can explain his technique in another post if there's interest, but the key benefits of his procedure are (1) Fewer fused vertebrae, which means more mobility post-op, (2) Faster recovery times, with less pain, and (3) A level of correction that frequently approaches -- and in some cases reaches -- zero degrees; i.e., a perfectly straight spine. He has strong documentation and patient testimonials to support these benefits.

It's worth noting that the more traditional surgical approach has come a long way in recent years, too. I like to compare the surgical technique my surgeon used on me in 2002 with what Dr. Gaines would have done, since I consider my surgical outcome to have been excellent. My surgery involved fusing 8 of my vertebrae and used pedicle screws exclusively. This reduced my curve from 49 to 11 degrees. It's impossible to predict this accurately, but my same case in Dr. Gaines' hands probably would have involved fusing between 4 and 6 vertebrae and would have reduced my curve to 5 or fewer degrees. While this would clearly be better, would I really have noticed the difference? Probably not. Then again, why NOT reduce the number of fused vertebrae and get better correction if it's possible with little additional risk?

You're probably wondering why more surgeons don't use b-on-b technique. I think the honest answer is that it takes time to learn how to do it, and when you're getting great results using commonly-accepted practices, it's natural to want to stick with what you know and trust. Still, interest among surgeons is growing, more so in Asia and Europe, where it IS being used. Some U.S. surgeons are now studying his technique and I predict many will be using it within a year.

A couple of other points are worth making. First, this is not a radical, experimental, untried procedure. Dr. Gaines has performed hundreds of these procedures. His complication rate is no higher (and in fact may be lower) than traditional techniques. One caveat is that there is no long-term outcome study of his patients, as the technique is fairly new. Then again, there aren't any long-term studies of the more common approaches used today, either, as these weren't performed prior to the mid-1990s.

Second, Dr. Gaines is by no means a quack. He is a highly experienced, highly regarded scoliosis surgeon, and a wonderful guy, too. I applaud him for trying to advance scoliosis surgery to the next level.

I am not suggesting that Dr. Gaines' technique is right for everyone. You should pick the surgeon you trust, and of course insurance or travel/distance issues may prevent you from seeing him. But I would say that it's worth a consultation with him, even if it means you must pay for it, just to get an assessment if you're a candidate for the surgery and what kind of result he thinks he could achieve.

Dave Wolpert

[LindaRacine]

As with ANY treatment, there's no way of knowing what the long term results will be. Also, until Dr. Gaines results can be reproduced elsewhere, they should be considered a little risky. I don't mean to cast doubt on Dr. Gaines procedure. It really could be the best thing available. There's no real way for any of us to judge yet. If this is something you want to pursue, be sure you understand that any new procedure is risky, and be willing to accept the potential complications.

--Linda

[Gail]

What is the bone on bone procedure?

Thanks,
Gail

[Nicky's Mom]

I would love to have this procedure explained in "laymans" terms. If anyone can do this, I would be extemely grateful!
Cathy :)

[flowerpower]

DaveWolpert,

Perhaps you could explain more on this procedure in "laymans" terms as NickysMom said. I also want to compliment & thank you for your book on scoliosis surgery. I read the 2nd ed. & found it so informative & helpful. It answered so many of my questions & is really helping to prepare me for my son's upcoming surgery.

To the others,

I have sent an e-mail to Dr. Gaines & also to my sons surgeon for opinions & info regarding this procedure. I will share what they have to say when I get a response.

Regards,

Renee

[Cheryl M]

Dave, I too, would like to thank you for your book. Along with my Bible, it has been my constant companion over the last few months.

I agree with you. Dr. Gaines is a highly experienced Dr and a wonderful human being. He was wonderful with both me and my daughter. My daugher has two major curves which would require two separate operations. If she required only one surgery I would be booking a flight and hotel back to Columbia today.

There is an excellent article in the Spring/Summer 2005 edition of The Spinal Connection put out by the National Scoliosis Foundation that explains this technique in a way that most familiar with scoliosis can understand. Also, Dr. Gaines very kindly answered my e-mails to him over the last couple of weeks before our decision to go to Missouri. We booked a flight on Friday and he saw us on Monday (thanks to whoever cancelled their appointment on Monday).

We are still wieghing our options and praying that God will give us wisdom.

Cheryl M

[flowerpower]

Well, as of this morning I have not received a response from Dr. Gaines. Our dr.'s nurse responded that he (our dr.) does not do this type of surgery and does not recommend it. There was no reason given so I will put in another e-mail and ask for specifics on why not. Will post again when I get an answer.

Renee

[flowerpower]

Ok, just received a response from our dr. Here is what he said, "Bone on Bone... Joseph has 2 really big curves that need attention and the b-on-b is only for very short curves", he also stated that he isn't really convinced that it works well on those either from the results that he has seen. As he is the Director of Pediatric Orthopedic Research and Surgery at Children's Hosp. San Diego, I trust his opinion and feel very safe with him.

I still have yet to hear from Dr. Gaines office, but who knows? this might work for someone. I would love to hear from someone personally who has had this procedure done.

Renee

[flowerpower]

I received an e-mail from Dr. Gaines earlier today. He gave me the name of a San Diego surgeon, Dr. Behrooz Akbarnia (for anyone interested) who does surgeries at Childrens Hospital. He said....."Dr. Akbarnia has done over 20 bone-on-bone cases with terrific results."

Dr. Gaines also said that he was just here in San Diego 2 weeks ago as a guest speaker to all the San Diego surgeons.

He said that my son sounds like a good candidate for the b-on-b surgery (in my e-mail I gave him Joe's curves measurements, Risser, desc. of rotation and vertebrae our current dr. is planning on fusing. He is going to send a copy of my e-mail to Dr. Akbarnia to let him know that I may be calling for an "opinion".

The last thing he said was..."for the "right patient", nothing is better than "bone-on-bone.

It sounds promising, but I am not very comfortable with the fact that Dr. Akbarnia has only done a little over 20 surgeries of this type. Yes, even with terrific results right now, it didn't seem there was much info on long-term success. The surgeon I have right now has done about 120 surgeries so far this year, and I have spoken with one of his patients who is doing great 10 years post op. If this was for me, I might be more willing to go with the more "advanced" approach, but this is my son and the mother in me is leaning toward the more "tried and true" approach.

I wouldn't discourage anyone from at least looking into it. Dr. Gaines said that for the "right patient", nothing is better. I'm not sure that this would be right for my son's situation. If I talk to Dr. Akbarnia, I will post again.....

Good Night All,

Renee

[KRIS ATKINSON]

Cheryl, good luck with your decisions. God will find ways to help you decide! God bless you all and hang in there! Kris

[DaveWolpert]

Thank you to those who commented on my book. I always appreciate the feedback!

Regarding Renee’s last post, I completely understand your hesitation to want anything other than a tried-and-true procedure performed on your son. If I were in your situation, I may do the same. Dr. Akbarnia, by the way, is very well regarded.

To reiterate a point in my previous post, though, this procedure really isn’t “new.” Dr. Gaines and several other surgeons have been performing it for at least three years, in hundreds of cases, and more importantly the bone-on-bone procedure involves smaller surgical procedures that have been performed thousands of times over. What’s really new is the application of some of these techniques to treating scoliosis, specifically.

For those unfamiliar with Dr. Gaines’ technique, let me outline the basics:

1. The anterior approach (from the side) is used. The advantage here is better access to the vertebral discs, and a less noticeable scar after surgery (because it is partially masked by your arm). The disadvantage is that a rib may need to be removed and a lung deflated – this is generally more risky than a standard posterior (from the back) approach.

2. The surgeon will only operate on a small number of vertebrae around the apex (peak) of your curve. On your x-ray, you will see 1 or 2 vertebrae that appear to be the most out of alignment. This is the apex. Several vertebrae above and below this level will also be out of alignment, by decreasing amounts the farther away you move from the apex. Most surgeons operate on (fuse and instrument) all or most of these misaligned vertebrae. In b-o-b, only the apex and 1-3 vertebrae each above and below the apex will be addressed. The other vertebrae will fall into alignment.

3. The discs in this small group of vertebrae will be completely removed. In traditional posterior surgeries, the discs are usually left in-place and fused over with bone grafts. In this technique, there are no bone grafts. With the discs removed, the vertebrae will be squeezed together so that they sit on top of each other. This is what “bone on bone” refers to. Without the discs in the way, a generally higher level of correction is achievable because the vertebrae can be brought into tighter alignment. Your body will grow new bone over the small gaps and fuse on its own.

4. Instruments (rods or cages) are placed above the vertebrae to stabilize them while healing. Very strong pedicle screws with two screws per unit are generally used to affix the rods to the vertebrae.

5. After surgery, an epidural catheter is placed directly into the spine for pain control. The catheter provides a steady flow of a narcotic. Dr. Gaines claims this is far more effective than an IV or oral narcotics. Time in the hospital is 5-14 days, which is higher than the more typical 5-8 days for more traditional surgeries.

6. A brace is usually prescribed for 6-8 weeks. Most surgeons do not prescribe a brace for their patients after more traditional surgeries.

I hope this helps!

Dave Wolpert

[flowerpower]

Dave,

Thanks for explaining the procedure in simpler terms. The decision on the when, where and by whom to have surgery done is such a highly personal one. I wish everyone the best in their decision making. I do like the fact that Dr. Akbarnia does surgeries at Children's Hosp. & I have run across his name a few times in my "research". I probably will call him for a consultation as it certainly won't hurt to look into a new approach, and I will be researching up until the day my son has surgery anyway....

Cheryl, in your case I would probably feel more at ease being that Dr. Gaines developed this technique and HE has performed many surgeries of this type already. He seemed very nice in his e-mail to me. Let us know how things progress in your situation.

Take Care,

Renee

[ProudParents]

Unless I am missing something, isn’t this short segment bone-on-bone technique just another name for anterior surgery? The only differences being the addition of staples to the standard two segmented rods and the fact that no grafting material is added between the vertebrae if the surgeon deems unnecessary. Although there are many advantages and disadvantages to be considered regarding anterior surgery, the main advantage is that fewer vertebras need to be fused. The surgeon will know best, but be aware that the amount of kyphosis will be greatly increased in the fused area. Our daughter was not a candidate for this type of surgery because her thoracic kyphosis was near the upper end of the normal range.

Mark

[DaveWolpert]

A few issues here.

The number of vertebrae fused in the SSBOB procedure is typically much less than in a standard anterior approach. A few short years ago, the relatively new anterior approach was believed to be superior over the more time-tested posterior approach because fewer vertebrae needed to be fused. But, with time, advances in posterior techniques and better instrumentation closed the gap. Today, anterior approach surgeries usually involve fusing only 1 or 2 fewer vertebrae than a posterior approach. The SSBOB procedure usually involves fusing only HALF as many vertebrae as in a posterior approach, and probably 1/2 - 2/3 as many as a typical anterior approach--that's a big difference.

The other big difference is that the level of correction achieved through a typical anterior approach isn't significantly better than that achieved through posterior approaches (in most cases). I don't know the exact stats, but in general SSBOB will get a better correction than a standard anterior approach.

I can't comment on your point about kyphosis, as I simply don't know.

Dave Wolpert

[ProudParents]

I agree that the introduction of pedicle screws has somewhat closed the gap in the number of vertebrae fused between anterior and posterior approaches, but most doctors are now fusing selectively regardless of technique so there still is a significant difference. For adolescents, many surgeons will only fuse five vertebrae to correct substantial curves using standard anterior approaches. If better correction could be achieved by fusing only three vertebrae using the bone-on-bone method, that would be great. As was described in the earlier post, the discs between the vertebrae are removed entirely in any type of anterior procedure, hence the increased flexibility and correction. Perhaps the additional increased flexibility claimed in the bone-on-bone technique is derived from the fact that there is no bone graft taking up space between the vertebrae. I would seek opinions for both types of anterior procedures before proceeding.

Mark

[Nicky's Mom]

Dave.
Thank you so much for your description of the bone-on-bone procedure. Although fusion won't be an issue for us for quite some time (my son is only 4 years old, and has the VEPTR or titanium rib), I am always interested in hearing about new spinal corrective procedures. I appreciate you taking the time to explain it, in a way that I can understand.
Regards,
Cathy

[LindaRacine]

Hi...

There was quite a bit of discussion about this technique at last week's Scoliosis Research Society annual meeting. What I got from the comments is that many physicians feel that this technique will lead to an increased kyphosis. Obviously, no one will know for some years, but it's something to consider if you're thinking of undergoing this technique.

Regards,
Linda

[flowerpower]

Hi Linda,

Thanks for sharing the info. Can you give specifics as to why the physicians felt b-on-b might lead to increased kyphosis? While I am no longer considering this as an option for my child currently facing surgery, I want to educate myself as much as possible as I have 2 other children who may someday need treatment, and I hope I can also one day be of some help to others who are going through this process.

Renee

[LindaRacine]

Hi Renee...

Since discs are removed, the front part of the spine is shortened, but the back of the spine is not. If you look at the drawing here:

http://www.spineuniversity.com/images/illustrations/scheuermanns_normal.gif

Hopefully you can see what would happen to the spine if the 4 discs were to be removed.

Regards,
Linda

[flowerpower]

Thanks Linda,

You are helpful, as always...!

Renee