View Full Version : "How much correction is enough?" by Winter, Lonstein, and Denis

12-06-2008, 10:03 AM
Here's the HTML version. I couldn't figure out how to post the pdf location. rrection+Is+Enough%3F%22+scoliosis&hl=en&ct=clnk&cd=2&gl=us

Alternately, if you search on google for:

"How Much Correction Is Enough?" scoliosis

the pdf is the second item.


12-06-2008, 02:32 PM

Interesting article. I wondering why my surgeon used only screws on me. I will be sure to ask him next month when I see him, at my 1 year appointment. I think that he probably thought that I would be participating in some pretty extreme activites that would result in some pretty extreme crashes. I think that showing up for my A/P surgeries with a smashed up shoulder might have influenced his decision.

Tripping over rocks, high speed ski crashes, waterskiing with martini in one hand, you know , that kind of stuff LOL

My spine is quite balanced after surgery, and my Doc has said it was about a 50% correction. 34 screws were used.

I feel good enough to do anything right now. My surgery was 100% sucess.

Im ready to waterski with 2 martinis. (I have good teeth)


12-06-2008, 10:31 PM
Like I said earlier Ed, you certainly sound like an interesting cat.

I like your attitude. :)

12-07-2008, 01:22 PM
Really interesting paper. I suspect that surgeons go for the better correction because it makes them more competitive. We all need to be more socially conscious when making healthcare decisions. If we had to pay for these surgeries out of our pockets, most of us would probably give up 10 degrees of correction for say a $5,000 difference between a screw and a hook. (I don't actually know the magnitude of difference.)


12-07-2008, 04:29 PM
My surgeon told me that he would make more decisions after he was inside, and that if I was too stiff that he would fuse me "as is". In other words, do not expect to be straight as an arrow and most likely you can expect a 50% correction.

here is a video

Hooks are stronger in kyphotic situations and screws will strip. The artwork of scoli surgery sure is multifactoral.

Its nice to be competitive with straightness, but at what cost? paralysis? One paralysis is a big negative! A good surgeon should not be concerned with the cost of the hardware since that cost is minimal compared to the total cost of the procedure and hospital costs. From an economic standpoint with these surgeries, its more cost effective to achieve a good outcome on one surgery, than to have to do another revision surgery due to cutting costs on hardware!

Insurance companies should not dictate medical procedures for cost savings with these surgeries. All I have to say is, if one is contemplating a scoli surgery, and that person has trouble with getting invoices paid for a smaller procedure, its time to make a judgment call. The quality of your insurance is more important than your salary going into one of these surgeries.

If insurance companies are dictating costs and medical procedures then I would say that having quality insurance should be the first step in the whole process. If you do not have quality insurance, then obtaining that quality surgeon is problematic. If you have a good insurance company, selecting the Doctor of your choice becomes quite a bit easier.


12-08-2008, 10:51 AM
I would like to make a case for why we chose a doctor who does try to achieve near perfect correction. After literally months of internet research and 5 consultations with scoliosis surgeons, I made the decision to fly out of state for my daughter's surgery based on the following criteria:

1. We had the choice, I could go anywhere in the US with our insurance.

2. Dr. Lenke, who we ultimately chose, has a huge amount of work in the literature which leads me to believe he has a genuine interest in research and furthering our knowledge of scoliosis surgery.

3. Dr. L also travels around the globe training other surgeons in pedicle screw placement, he also leads a fellowship program.

4. He performs >250 surgeries/year (experience was a huge must for us)

5. He does achieve near perfect correction in many idiopathic scoliosis cases, but if you go to his website, you'll see that he does many complex cases where perfect correction isn't even possible or probably desirable.

Personally, I desired the best correction if it was safe. Besides the aesthetics, logically, I felt that the better alignment may help with disc issues in the future. Because there's no conclusive evidence one way or the other, I had to make the best judgement call that I could.

6. He places screws at every level of fusion. This does create greater loss of blood and higher risk of penetration, but again, skill has a lot to do with that. Also, I compared it to a piece of wood that's curved, if you want to hold it in a straight line, you increase the number of points of contact so the overall stress on each point is decreased.

As we all know, choosing the right surgeon and putting your trust in him is a very difficult decision and shouldn't be rushed. I'm very happy with my daughter's outcome and can only hope her future is as bright as it is now.

12-08-2008, 11:53 AM
A good surgeon should not be concerned with the cost of the hardware since that cost is minimal compared to the total cost of the procedure and hospital costs. From an economic standpoint with these surgeries, its more cost effective to achieve a good outcome on one surgery, than to have to do another revision surgery due to cutting costs on hardware!


12-08-2008, 01:56 PM

One of the things that I had to think about in the selection of my surgeon was, do you go with the older more experienced surgeon with thousands of surgeries under his belt? or do you go with the younger freshly trained in new techniques surgeon? Its a tough one to weigh out. Good communication is essential. I chose the latter. Its our ultimate gamble.
I do highly recommend Dr Menmuir and team at Reno Orthopedic. My appointments usually take such a long time since I have to hug everyone for at least 60 seconds, and with 60 people, its takes about an hour before anything gets accomplished! LOL

Your right on with note 6. They have done studies on pullouts of screws and yes having screws placed at each level will help guarantee the integrity of the construct. Like a bridge over water with multiple pilings. Once again, surgeons use hooks for a reason.

If you look at my first thread, you will see a saggittal view of my construct, with a nice stack of screws,very similar to you daughters. One screw was not inserted around my T6 level due to a lack of clear trajectory. BMP-2 was used on me. I fused at 6 months.

I wish that everyone can have as great an outcome as I have had. After all the pain I was in over the last 25 years, being out of pain now is such a blessing.

As far as "how much correction is enough?" goes, that is determined on each individual case and sometimes it is not feasible and dangerous with older and with severe cases. The main goal should be pain reduction. I think that one should be satisfied with their post op curves as long as the pain is reduced and quality of life is improved. I feel that the cosmetic and mobility issues should not a determining factor for this dangerous of a surgery.

Pamela will have valuable input on this subject. I know I'm missing things here.


12-08-2008, 02:44 PM
I fused at 6 months.

Hey Ed, how was it determined that you fused at 6 months?


12-08-2008, 05:38 PM
By x-ray analysis. Look at my x-ray down low, just above the hoo-haa, and you will see vertical white lines where the discs used to be. This pic was shot at about 6 weeks post. Click and zoom in.

Also the added bonus, my coronal x-ray, check out how close the pelvic anchors are to my hips.

Nice rack huh?

12-08-2008, 05:57 PM
The vertical white lines are the evidence of fusion? Hoo-haa? :D

Per my reading and what the surgeon said, it's hard to find evidence on radiographs of fusion or at least you can't rule out pseudoarthrosis on radiographs or some combination/permutation of those terms.

One site I came across mentioned that halos around the screws was consistent with non-fusion or pre-fusion if I'm remembering that correctly.

At my daughter's 7.5 month visit with the surgeon, I mentioned that I had read that it can't be determined if there is a pseudoarthrosis on radiograph and he agreed with that per my recollection.

12-08-2008, 09:30 PM
Wow, those are some big screws, Ed! Who says size doesn't matter. It's amazing they could embbed those completely in bone. I'm glad to hear you're so happy with your results. That's the most you can ask for from this surgery.

All the doctor's we consulted with were very competent, but it wasn't until I met Lenke that I felt right about it, I felt very reassured that it was going to be ok. This was the most difficult and imporant decision I've ever had to make and it absolutely had to be the best one. Sounds a little dramatic, but making this decision for your child is so hard. If something had gone wrong, I could never forgive myself. We're fortunate that the technology is so good in this day and age.

Lenke used BMP on Sheena too. I'm not convinced that she needed that but on the other hand, there's no doubt that she's fused.

How is your mobility? Sheena can't even bend 45 deg. at her hips but she was never very flexible. At her one year, Dr. Lenke said that she must start stretching more. He said that since the discs don't have a blood supply, the only way they get nutrients is through flexing and movement.

take care

12-08-2008, 11:09 PM
Oh yes, parents have it the hardest. And twice as hard with twins! Id rather be the patient.

Mobility? When I bend foward, I can get my fingers about 3 inches from the floor. One of the things that stands out is if I am sitting in a chair and someone says "look behind you" I cannot do it without getting up. If you do it right now, you can rotate your shoulders 90 degrees to the left or right, and the rest from your neck. I cant do that. Other than that, its not that much of a problem. You get used to it.

Apparently, screws strip, or he wouldnt have buried those anchors as deep as he did. Now that the bone growth has occured around the threads, those screws are in there solid.

In January, we will shoot more x-rays and my whole spine should be one solid mass.

My main worrys are my belly button expolding after Susie Bees next post after watching Benny Hill in the library at 8AM !

12-09-2008, 06:37 AM
Oh yes, parents have it the hardest. And twice as hard with twins! Id rather be the patient.

There are others here with more than one kid, though not twins, with scoliosis, unfortunately. That's the same boat I'm in.

And there is an economy of scale (if you can believe it) with twins because they are usually doing the same thing at the same time, at least when young. So it's not usually double the work. For example, I only had to pick a surgeon once.

It's really fascinating how they are different in many/most things even though they are identical. And no matter how mad they get at each other, they always think the other girl is VERY good looking. :D