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Pooka1
12-28-2009, 05:04 PM
(from the other thread)

I don't know about adults nor about Anand's minimally invasive technique but I can say the literature that I was given for my kid stated the following:


Is it common for a child to have occasional back ache months after spinal fusion?

No, this infrequently happens.

Then it goes on to say which pain relievers should be taken and for how long.

I am guessing it is similar for adults but I certainly don't know that.

Pooka1
12-28-2009, 06:07 PM
My concern/question was a little different.

Will a patient who is now in pretty serious pain with scoliosis affecting the lumbar region (as JDM55 was, in the thread where the claim was made) have their pain completely eliminated by this or any other kind of scoliosis surgery.

My sense is that the answer to this question, by any conservative surgeon, would be "we would certainly hope to reduce the pain, although we can't guarantee that, but it's not likely that we would completely eliminate it."

I'd like to know the likelihood of eliminating pain completely in adult lumbar patients. It might be the majority of patients like with kids.

If that's the case then a conservative surgeon would necessarily say that.

Pooka1
12-28-2009, 06:18 PM
As an additional experiment, try googling on:

eliminate scoliosis pain

The only things that I see come up from practioners is people associated with Spinecor and Schroth. It's not a phrase that orthopedic surgeons generally use to describe the outcome of their surgery.

Yes I see that point but that is clearly an imperfect method to find the straight dope on this as it doesn't return the fact that most kids at least have zero pain after healing.

So if it missed that then it might miss that most adults have zero pain after surgery (if that is the case).

Anand is on the group now... maybe he will comment.

Pooka1
12-28-2009, 06:21 PM
I think the bit you posted form the pamphlet referred to children, who are seeking surgery to stop progression but who do not have pain from their scoliosis, and it's reassuring you that the surgery will not *cause* pain. That's a reasonable assurance - I imagine that the surgery mostly does not cause pain in patients who didn't originally present with pain.

Yes all that is true but I still want to know about the rate of pain elimination in adults.

I'd also like to see if adults who are pain free have similar outcomes to kids who largely don't have pain.

And by the way, my one kid with the rapid curvature rate did have pain pre-surgery that completely disappeared some months after surgery.

Pooka1
12-28-2009, 06:41 PM
I actually meant that to indicate a kind of "snake oil salesman" kind of language. It's the thing that I find off-putting about the Spinecor and Schroth, and I find it equally off-putting in a surgeon.

But it is clearly not strictly snake oil salesman lingo when a surgeon says it, at least w.r.t. kids and possibly w.r.t. adults.

It either is or isn't the case that most adult lumbar patients have all their pain eliminated after the healing period. If it is the case then a surgeon pointing that out is not a snake oil salesman.

I, too, find it off-putting when Spinecor and Schroth purveyors say it because it is brace- and PT-dependent as far as anyone knows and also they likely have no evidence to back it up like surgeons do if/when they make the statement. Surgeons saying that are just relaying the evidence.

mamamax
12-28-2009, 07:10 PM
The SRS surgeon Dr. Anand, may shed some light on this for us :-)

My two cents on this is: I've had several surgical consultations - the most recent with an SRS surgeon. I was not told that my pain would be eliminated. I was told we would hope that the pain would be reduced. No promises. My Spinecor provider made no promises either - but rather explained that many adults (in my age group) experience immediate pain relief - not all, but many. Do some people experience total elimination of pain with surgery - I believe so from what some members report in forum. Do all of them? Certainly not, again from what is reported in forum.

Does it all boil down to a combination of treatment and patient condition? I think so, in which case - it may be best for anyone advertising to say: the treatment may reduce or eliminate pain.

There just aren't any guarantees - with any treatment, and if someone tries to sell us one - I think we should run!

LindaRacine
12-28-2009, 07:49 PM
Improvement of back pain with operative and nonoperative treatment in adults with scoliosis.

Smith JS, Shaffrey CI, Berven S, Glassman S, Hamill C, Horton W, Ondra S, Schwab F, Shainline M, Fu KM, Bridwell K; Spinal Deformity Study Group.

Departments of Neurosurgery and Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia 22908, USA.

OBJECTIVE: The purpose of this study was to assess whether back pain is improved with surgical treatment compared with nonoperative management in adults with scoliosis. METHODS: This is a retrospective review of a prospective, multicentered database of adults with spinal deformity. At the time of enrollment and follow-up, patients completed standardized questionnaires, including the Oswestry Disability Index (ODI) and Scoliosis Research Society 22 questionnaire (SRS-22), and assessment of back pain using a numeric rating scale (NRS) score, with 0 and 10 corresponding to no and maximal pain, respectively. The initial plan for surgical or nonoperative treatment was made at the time of enrollment. RESULTS: Of 317 patients with back pain, 147 (46%) were managed surgically. Compared with patients managed nonoperatively, operative patients had higher baseline mean NRS scores for back pain (6.3 versus 4.8; P < 0.001), higher mean ODI scores (35 versus 26; P < 0.001), and lower mean SRS-22 scores (3.1 versus 3.4; P < 0.001). At the time of the 2-year follow-up evaluation, nonoperatively managed patients did not have significant change in the NRS score for back pain (P = 0.9), ODI (P = 0.7), or SRS-22 (P = 0.9). In contrast, at the 2-year follow-up evaluation, surgically treated patients had significant improvement in the mean NRS score for back pain (6.3 to 2.6; P < 0.001), ODI score (35 to 20; P < 0.001), and SRS-22 score (3.1 to 3.8; P < 0.001). Compared with nonoperatively treated patients, at the time of the 2-year follow-up evaluation, operatively treated patients had a lower NRS score for back pain (P < 0.001) and ODI (P = 0.001), and higher SRS-22 (P < 0.001). CONCLUSIONS: Despite having started with significantly greater back pain and disability and worse health status, surgically treated patients had significantly less back pain and disability and improved health status compared with nonoperatively treated patients at the time of the 2-year follow-up evaluation. Compared with nonoperative treatment, surgery can offer significant improvement of back pain for adults with scoliosis.

mamamax
12-28-2009, 08:03 PM
I would have some questions about that study - what are the results 20 years down the road, etc, etc.

LindaRacine
12-28-2009, 08:17 PM
I would have some questions about that study - what are the results 20 years down the road, etc, etc.

I agree. At least you know that the 20-year follow up is coming. I'd like to see even a 5 or 10 year follow up to Schroth, Clear, or any of the other alternative methods.

--Linda

Pooka1
12-28-2009, 08:25 PM
I will settle for no less than a 90 year follow up out of Schroth. :D

mamamax
12-28-2009, 08:35 PM
I agree. At least you know that the 20-year follow up is coming. I'd like to see even a 5 or 10 year follow up to Schroth, Clear, or any of the other alternative methods.

--Linda

Agreed - I would like a lot more long term studies than we are provided with. Schroth should have more than we see. I wonder if they exist but have not yet been translated? So far, Spinecor only has one 5 year follow up with adults I believe. And by the time we have a long term surgical follow up - techniques will have changed. In the non surgical world - Martha's 15 year study looks great - but how on earth do we duplicate it? Complicated :-)

Pooka1
12-28-2009, 08:39 PM
So far, Spinecor only has one 5 year follow up with adults I believe.

If you find that can you please post it?

'kay thanks. :)

Pooka1
12-28-2009, 08:45 PM
Thanks, Linda. That answered my question. So, taken as a whole, the surgical patients saw their pain reduced (roughly in half), but not eliminated. That's in line with what I'd expect, based on listening to adults after surgery on this forum.

Those are means. There could be plenty of patients who had their pain eliminated.


Again, if I went into a surgeon and he had a brochure stressing "eliminate pain," I would walk out of the office.

I doubt any surgeon stresses "eliminating pain" unless they have evidence for that. Anand didn't stress it. He mentioned it because surgery can eliminate pain. I think surgeons will give evidence for rates of reduction and elimination among their patients.


I have no argument that surgery can straighten a spine and reduce pain. Eliminating pain, though, in people who already have significant pain, would be an unusual outcome

Not sure we know that. And what of people with "some" pain? Maybe most of that is entirely eliminated.

Who knows.

mamamax
12-28-2009, 08:51 PM
If you find that can you please post it?

'kay thanks. :)


My mistake! Sorry - There is only a retrospective study (oral presentation) with 23 adults: http://www.scoliosisjournal.com/content/2/S1/S23

But at least we know there is one coming :D

LindaRacine
12-28-2009, 08:56 PM
So far, Spinecor only has one 5 year follow up with adults I believe.

I'd like to see that if it exists.


In the non surgical world - Martha's 15 year study looks great
Martha Hawe's does not have a 15-year study. She has an anecdotal case, which has never been reported in a peer reviewed journal.

mamamax
12-28-2009, 09:05 PM
I'd like to see that if it exists.


Martha Hawe's does not have a 15-year study. She has an anecdotal case, which has never been reported in a peer reviewed journal.

You missed my answer on the adult Spinecor study.

As for Martha Hawes - she is published in Scoliosis Journal - which is (as I understand it) a peer reviewed journal. From their website:


Scoliosis uses online peer review to speed up the publication process. The time taken to reach a final decision depends on whether reviewers request revisions, and how quickly authors are able to respond.

Scoliosis has an open peer-review process, aimed at improving the accountability of peer review and giving reviewers credit for the work they do.


http://www.scoliosisjournal.com/info/instructions/

LindaRacine
12-28-2009, 09:05 PM
Likewise, it's misleading to use the word "eliminate." I can live with reduce, or even, "often significantly reduce." But eliminate is a very strong word. I, personally, feel mistrustful when people throw around such charged words.

I actually totally agree with this. I currently volunteer with (and soon will work with) a surgeon who has amazing outcomes. I know of 2 or 3 of his patients who would consider themselves to have had bad outcomes. (Curiously, they both post to public forums.) The rest of his patients, when surveyed (and they all are), have said that their pain is either gone or vastly improved. He NEVER tells patients that they'll be out of pain. I think that's a relatively dangerous claim to make, as it seems to me that it might open the physician up to lawsuits.

--Linda

LindaRacine
12-28-2009, 09:08 PM
You missed my answer on the adult Spinecor study.

As for Martha Hawes - she is published in Scoliosis Journal - which is (as I understand it) a peer reviewed journal. From their website:


Scoliosis uses online peer review to speed up the publication process. The time taken to reach a final decision depends on whether reviewers request revisions, and how quickly authors are able to respond.

Scoliosis has an open peer-review process, aimed at improving the accountability of peer review and giving reviewers credit for the work they do.


http://www.scoliosisjournal.com/info/instructions/


Published 13 days ago. I missed it. Hardly time for any peer-review (which rarely happens in that journal anyway).

mamamax
12-28-2009, 09:10 PM
I think we're missing each other here. I'm not saying that it's not possible - I'm saying it's not the likely outcome that one would emphasize. For example, I know that it's possible for people to have their curves surgically reduced to equivalent to zero degrees. There are a few examples here. But, I would not expect a doctor who had seen that happen to post on a forum "We can reduce your curve to zero degrees." That still uses the "can" construction, but it's misleading, especially for an adult audience.

Likewise, it's misleading to use the word "eliminate." I can live with reduce, or even, "often significantly reduce." But eliminate is a very strong word. I, personally, feel mistrustful when people throw around such charged words.

OTOH, if Dr. Anand *mostly* sees pain *completely elminated* in adult patients with a painful lumbar curve, that would be more acceptable. I would still prefer more cautious language.

This is knowable. He'd just have to post his results.

I would agree. The can construction implies a sure thing. What concerns me most about surgery, more than pain factor, is the - revision factor. Something that again, cannot be definitively anticipated or dismissed.

LindaRacine
12-28-2009, 09:10 PM
You missed my answer on the adult Spinecor study.

As for Martha Hawes - she is published in Scoliosis Journal - which is (as I understand it) a peer reviewed journal. From their website:


Scoliosis uses online peer review to speed up the publication process. The time taken to reach a final decision depends on whether reviewers request revisions, and how quickly authors are able to respond.

Scoliosis has an open peer-review process, aimed at improving the accountability of peer review and giving reviewers credit for the work they do.


http://www.scoliosisjournal.com/info/instructions/



And, let us not confuse a single anecdotal case with a study.

mamamax
12-28-2009, 09:15 PM
And, let us not confuse a single anecdotal case with a study.

ok - nomenclature: The article type is: case report. But lots of folks sure are studying it :-) The case report is certainly important from the standpoint that it is the first scientifically documented case of its type. Is she the only person on this planet to experience such a thing. I don't think so.

LindaRacine
12-28-2009, 09:19 PM
It's interesting that you can clearly see the issue when it comes to surgery, but can't see it in terms of alternative therapies. You both (Mamamax and hdugger) have talked about reversal of curves in adults from alternative therapies. It seems to me that reversal could be construed as a complete reversal. That's nowhere near correct. From all of Martha Hawe's therapies put together, she was able to get approximately a 10 degree improvement. I've never heard of a complete reversal of curves in an adult, even in the short-term.

mamamax
12-28-2009, 09:23 PM
Published 13 days ago. I missed it. Hardly time for any peer-review (which rarely happens in that journal anyway).

It's my understanding that it was "in process" for some time before its announcement 13 days ago. With your connections, maybe you could make a few calls and find out for us?

mamamax
12-28-2009, 09:37 PM
It's interesting that you can clearly see the issue when it comes to surgery, but can't see it in terms of alternative therapies. You both (Mamamax and hdugger) have talked about reversal of curves in adults from alternative therapies. It seems to me that reversal could be construed as a complete reversal. That's nowhere near correct. From all of Martha Hawe's therapies put together, she was able to get approximately a 10 degree improvement. I've never heard of a complete reversal of curves in an adult, even in the short-term.

Actually I see all kinds of issues with some non surgical therapies but I don't know the need to go into that here.

I had not heard of reversal of any kind prior to Martha Hawes - probably most people haven't. I had always been told it was impossible with adults. There is a woman who posted here recently (in one of the Hawes threads) who had a similar experience without any therapy whatsoever. Based on the work of Hawes alone, I suspect there are other undocumented occurrences. I don't know - but it seems reasonable to suspect.

Martha has had more than a 10 degree reduction. Over a fifteen year period (1990 to 2005) she has reduced her thoracic curve by 20 degrees (or near 50%) and her lumbar curve by 16 degrees (near 40%).

LindaRacine
12-28-2009, 09:44 PM
Ah, I see what you were highlighting in the other post. I absolutely do not believe that exercise can completely or even mostly reduce a curve. That was just sloppy writing on my part. I really just meant reverse as in "the opposite of progress"

Sorry, I did not at all want to give the impression that I thought exercise was some miracle cure. I'm just interested to see that it can reverse/reduce a curve.

Whether it comes from a professional, or just a poster in a patient forum, there are plenty of people who read these claims and believe them to be true. We should all be very careful about talking in absolutes.

mamamax
12-28-2009, 09:50 PM
That there are no absolutes - is absolutely true :-) Surgical or non surgical. I do believe most adults here in this forum are perfectly capable of making adult judgments about what they read.

LindaRacine
12-28-2009, 10:08 PM
Martha has had more than a 10 degree reduction. Over a fifteen year period (1990 to 2005) she has reduced her thoracic curve by 20 degrees (or near 50%) and her lumbar curve by 16 degrees (near 40%).


According to the PDF, by 1 of 3 methods she reduced her curves by about 20 degrees. The other 2 methods, it was about 10 degrees. Nonetheless, it's not zero.

As I've said all along, it's possible for some people to potentially avoid surgery, at least in the short term, by means of an alternative program. If that's the case for you, great. If, on the other hand, one spends a lot of time or money on a program (as did Joy), and then eventually has to go on to surgery anyway, then the long-term outcome isn't so great.

LindaRacine
12-28-2009, 11:31 PM
I'm not talking in absolutes - I used a word that can mean both to de-progress as well as to completely cure. I meant the former, as I would hope would be obvious within the context of the discussion.

"Eliminate" OTOH, only has one meaning as far as I know.

And, the physician's statement of "A minimally invasive procedure can straighten out your spine and eliminate your pain." doesn't refer to an absolute either. Can is different than will.

mamamax
12-29-2009, 05:01 AM
According to the PDF, by 1 of 3 methods she reduced her curves by about 20 degrees. The other 2 methods, it was about 10 degrees. Nonetheless, it's not zero.

As I've said all along, it's possible for some people to potentially avoid surgery, at least in the short term, by means of an alternative program. If that's the case for you, great. If, on the other hand, one spends a lot of time or money on a program (as did Joy), and then eventually has to go on to surgery anyway, then the long-term outcome isn't so great.

I'm glad you address the subject of methodology (regarding cobb angle measurements) in this study (well, that's what Martha calls it on page 22). Maybe we can learn more about this. Method one (representing the 50/40% reduction), is from triplicate readings by three independent readers (the peer review processes?), and according to protocols defined by Goldberg et al (her reference #66).

Method #2 is taken from two independent institutions and carried out in non-blinded readings from film copies provided by the authors, and an explanation for each institution's findings is given on page 22 - where we find this information in table form.

So - what is the difference? And is there reason to accept one over the other?

Pooka1
12-29-2009, 07:25 AM
You missed my answer on the adult Spinecor study.

As for Martha Hawes - she is published in Scoliosis Journal - which is (as I understand it) a peer reviewed journal. From their website:


Scoliosis uses online peer review to speed up the publication process. The time taken to reach a final decision depends on whether reviewers request revisions, and how quickly authors are able to respond.

Scoliosis has an open peer-review process, aimed at improving the accountability of peer review and giving reviewers credit for the work they do.


http://www.scoliosisjournal.com/info/instructions/



I looked at the editorial board. Are they chiros? How many are qualified surgeons?

You know, not to beat a dead horse but the creationists also have "peer reviewed" journals but it is still stem to stern nonsense.

I'm just sayin'...

Pooka1
12-29-2009, 07:37 AM
I'm glad you address the subject of methodology (regarding cobb angle measurements) in this study (well, that's what Martha calls it on page 22). Maybe we can learn more about this. Method one (representing the 50/40% reduction), is from triplicate readings by three independent readers (the peer review processes?), and according to protocols defined by Goldberg et al (her reference #66).

Method #2 is taken from two independent institutions and carried out in non-blinded readings from film copies provided by the authors, and an explanation for each institution's findings is given on page 22 - where we find this information in table form.

So - what is the difference? And is there reason to accept one over the other?



I found that confusing. Those results should have been accompanied by more explanation. When you present two sets of results you say which is likely more reliable and why. The authors didn't do that here. There is a some reason for that. I have a guess - I think there is something going on with the non-blinded readers knew the curve improved in one plane and worsened in another and somehow accounted for that in the readings or choice of vertebra or something. In any case, it is a failure of review that that flew the way it did in my little opinion... I would have said in a review to pick one set of results and defend it against the other.

N.B. when you read the conclusions, they don't seem to be standing behind the larger reduction for some reason.

debbei
12-29-2009, 07:57 AM
As an adult surgical patient, my lumbar pain that I had prior to surgery is TOTALLY gone, and has been since the very beginning.

Where I get pain is in my upper back area, around my shoulder blade. For me, it's TOTALLY related to stress. When I am in a stressful situation (ex. at work on a horrible stressful project), I get muscle spasms. When the project is over and the stress is gone, those spasms go away like magic.

I wish I could control that. In the mean time, muscle relaxants and or tylenol or motrin help.

debbei
12-29-2009, 12:19 PM
That's great, Debbie. I'm always happy to hear that some method of treating scoliosis has completely worked for someone.

Did you have the upper back problem before the surgery? Or does it seem to have something to do with the way your back was realigned during surgery?

This upper back thing never happened prior to surgery. I think it is my muscles getting used to their new position post-surgery. It is getting slightly better over time, and doesn't happen as often. But when it happens--boy oh boy--I'm not a happy camper.

Pooka1
12-29-2009, 04:16 PM
Speaking of regular "middle-aged person" back stuff, that of course is the baseline for claims to "eliminate" pain. That is, they all necessarily refer to eliminating pain over and above the normal level and prevalence, not above zero. I don't know normal level but normal prevalence is ~85% of adults at some point in their life.

So it is not rational to expect fusion to decrease it below that seen in the general populace though it might be decreased below that if my wild thoughts on the matter pan out (i.e., fused sections can never experience pain due to DDD and such which is claimed to be as certain as death and taxes in unfused spines if you live long enough, etc.).

And from that one paper, we see surgical folks tend to have less pain than non-surgical folks even starting from a higher baseline of pain.

So while there are no guarantees ever, surgical fusion for scoliosis appears to be the best game in town for chance of pain relief.

jrnyc
12-29-2009, 05:19 PM
well, i have alot of pain...mostly lumbar..dont know if scoliosis can be separated as cause from herniated discs from spinal stenosis from arthritis...but...i will let you know what dr anand has to say when i see him end of january...

all other surgeons have told me i could expect to have reduced pain after surgery healed, & hopefully alot less pain, but they could not guarantee me no pain...it was always couched in those words..."hopefully"..."expected"..."less than before"....

jess

mamamax
12-29-2009, 08:01 PM
I looked at the editorial board. Are they chiros? How many are qualified surgeons?

You know, not to beat a dead horse but the creationists also have "peer reviewed" journals but it is still stem to stern nonsense.

I'm just sayin'...

Well, if you go to the web page that lists the editorial board members - you can click on their names and see who they are: http://www.scoliosisjournal.com/edboard/

Guess who's there? Lawrence Lenke, MD (SRS Vice President, Presidency set for 2010-2011) ?? :eek:
http://www.spinal-deformity-surgeon.com/

Pooka1
12-29-2009, 08:12 PM
Yes him, Weiss, Dubousset, and Boachie. Maybe a few more... I don't know.

I also note they have an orthotist on the Advisory board and a plant pathologist as a research editor. Very eclectic. :)

mamamax
12-29-2009, 08:19 PM
Definitely an impressive Editorial Board!

Ballet Mom
12-30-2009, 07:54 AM
My reaction was against someone using the term "eliminate." Not even that he thought he might be able to eliminate pain, but that that's the term he chose to summarize his surgery. It's just a word that puts me off. Researching a little more, my discomfort was increased by learning that Dr. Anand gets royalties on every use of the technology he developed.

This is nothing against surgeons in general. I very much liked the surgeon we went to see. But the (now) combination of absolutist language and great financial benefit puts my hackles up. My hackles might be wrong, but they are up.

I agree with you hdugger, my hackles went up immediately also. I think it's bizarre to have a surgeon (or one of his staff members) trying to drum up patients for a new surgical procedure on this forum. It would be one thing if he ever stopped to answer any questions, but he doesn't...he's merely advertising. Either this board allows advertising, or it doesn't.

And to state that he can eliminate pain is bizarre also. It is true that many patients are helped with pain, but many are not. And there is even a fairly new study showing that there are increasing pain levels at five years versus two years.

http://www.ncbi.nlm.nih.gov/pubmed/18449045

Spine (Phila Pa 1976). 2008 May 1;33(10):1107-12.

Adolescent idiopathic scoliosis patients report increased pain at five years compared with two years after surgical treatment.

Upasani VV, Caltoum C, Petcharaporn M, Bastrom TP, Pawelek JB, Betz RR, Clements DH, Lenke LG, Lowe TG, Newton PO.

Department of Orthopedic Surgery, University of California San Diego, San Diego, CA, USA.
/
/
CONCLUSION: There was a statistically significant increase in reported pain from 2 to 5 years after surgical treatment; however, the etiology of worsening pain scores could not be elucidated. Given continued patient satisfaction, the clinical relevance of this small reduction remains unknown. Nevertheless, this observation deserves further evaluation and must be considered in relation to the natural history of this disease


Also,

http://www.scoliosisjournal.com/content/3/1/9

Post-surgery pain

Pain is the primary indication for re-operation [64-66]. The mechanism for increased neck and back pain after surgery is not well understood [67]. Bridwell [10] suggests that late-developing pain could be a complication of surgery, or an effect of aging, or 'perhaps a focus on the disability associated with spinal deformity and surgical treatment.' But the answer for surgeons seems to be to re-operate [68]. Among 190 patients, 19% required re-operation within 2 to 8 years after surgery [67]. For 27 patients who sought treatment 59% felt their pain had been reduced, but 41% did not feel a reduction in their pain levels, and a further 26% were very unhappy with the outcome [68]. Among 34 patients with significant post surgical pain, 56% reported reduced pain after additional surgery, while 44% did not; in the same study, 2 patients who did not have pain before surgery reported pain in the follow up [69].

Pain at the iliac graft site, first noted in 1979, has now been formally published [70,71]; of 87 patients, 24% complained of pain at the graft site, with 15% reporting severity sufficient to interfere with daily activities. As reported by the authors such problems with iliac crest grafting have been severely neglected in literature, especially problems associated with rib-resection.

Pooka1
12-30-2009, 08:54 AM
but a very small group...

http://www.ncbi.nlm.nih.gov/pubmed/19752706?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=2


CONCLUSION: We evaluated long-term outcomes regarding LBP following scoliosis surgery. Regardless of residual back deformity, LBP was found to be no more frequent than in the normal population in Japan. Positive sagittal balance at the latest follow-up was a factor significantly contributing to LBP following scoliosis surgery.

These studies are all over the map for a lot of reasons. I suspect the people who achieved good sagittal balance have less or no pain compared to the people who don't. Maybe the majority of the revision cases happened because the original fusion did not achieve good balance for whatever reason. Maybe it isn't possible to achieve good balance with some patients. Maybe the reason pain in kids with AIS post surgery is rare is because it is easier to achieve good balance in a flexible spine with only a curve as opposed to a more rigid spine with a bunch of other conditions when AIS is left untreated. The jury is out on that equation but I think we will have an answer on when is best to fuse when some longer term results are in with the new instrumentation. But even then, I think the results are going to be constrained by the balance achieved or some true master variable and not just "fused" versus "untreated." This is complex.

So pain post surgery might be a proxy for the surgeon's ability to achieve balance in a given patient as opposed to anything intrinsic with the fusion. This is reason number 5 bazillion why the literature is likely always going to be flawed.

And the key point is to pick the appropriate baseline. Pain in surgical patients needs to always be compared to pain in untreated scoliosis, NOT the general public. That said, comparing to the general public, treated or untreated scoliosis is never going to look bad given the known incidence of back pain in the general public (~85%). The severity is likely to be different but that needs to be quantified in both populations if possible. For example, I am in the general population and I had debilitating pain, albeit for only a few months, associated with my natural fusion in my lumbar several years ago.

Perspective always.

Ballet Mom
12-30-2009, 09:17 AM
Perspective always.


I agree. That's why I posted those studies.

And unless Anand thinks that somehow his method of surgery has eliminated pain in the scoliotic patient, he should be very careful of what he is stating. His statement does mislead otherwise.

Perhaps he means to say that minimally invasive surgery has less post-operative pain than other methods due to less cutting of the skin, nerves and muscle. If so, he should certainly clarify it and be very careful with what he is stating. I believe he is, perhaps unintentionally, misleading people.

Pooka1
12-30-2009, 09:34 AM
Until someone shows that fusion versus not fusion is the master variable, all these pain studies that don't group people according to that master variable are hopelessly flawed.

Just because they divide people into "surgical" versus "untreated" versus "population" doesn't mean those are the key groupings. They can't just know it, they have to show it. At present they are just assuming it though there are a few studies that are pointing to sagittal balance as being a key grouping component. I would like to see a study where the separate good and less good balance post operatively and over time and correlate that with pain long term.

I did post the one study that showed that degree of correction did not correlate with low back pain. Other studies indicate lowest instrumented vertebra doesn't correlate. This is the way to proceed... knock out what isn't correlated and what is left standing might be what is the master variable. So far, sagittal balance is looking like a good candidate for pain long term. At least nobody as knocked it out to know knowledge and at least a few people hint that this is key.

If that is the case then someone is going to have to ask some hard questions now that the instrumentation is looking better about the wisdom of waiting to fuse if it is harder to achieve a good balance in a more rigid, more mature spine.

And perhaps the reason T curve fusions are much less problematic than L curve fusions is not necessarily the intrinsic function of the T versus L spine as is sometimes suggested but the ability to achieve a good sagittal balance with T versus L curves. Who knows. I'm just spitting in the wind. But we do know that nobody has isolated any master variable w.r.t. long term pain to date.

Pooka1
12-30-2009, 09:37 AM
And unless Anand thinks that somehow his method of surgery has eliminated pain in the scoliotic patient, he should be very careful of what he is stating. His statement does mislead otherwise.


If some of his patients have had their pain eliminated then he can say that. That is not a wacky statement as it is known to happen. The question is what percentage have achieved that in order to determine how misleading the statement is.

I agree with whomever said that Anand comes on here basically to advertise and he doesn't answer questions. He should start answering questions if he wants to avoid the charge of advertising.

Ballet Mom
12-30-2009, 09:49 AM
If some of his patients have had their pain eliminated then he can say that. That is not a wacky statement as it is known to happen. The question is what percentage have achieved that in order to determine how misleading the statement is.


Even if he has some patients that have had pain eliminated, at least temporarily, it is misleading for him to state that without some modifiers, such as hdugger has already explained. In addition, he certainly doesn't have long-term studies showing any pain elimination seeing as this is a new procedure.

It is funny (as in odd), as you would be all over anyone on this board who used this type of statement if it had anything to do with bracing or exercise or other non-surgical treatments and yet you allow the surgeon to mislead. You should at least be consistent.

Pooka1
12-30-2009, 09:50 AM
One more thing... I think they need to separate out anterior from posterior procedures as was not done in one of the posted studies. The issues with both are different and it isn't surprising per se that pain a few years out might be different with the two procedures. Lumping the two procedures is not likely to clear things up in my opinion.

As to iliac crest bone harvesting, enough was known when kid "A" had her surgery that I was going to mount a large push back on that if that was envisioned. I don't think they do that much any more, at least with kids. I spoke to one woman who said she has far more pain associated with the iliac bone harvest site than with her spine. She is several years out from surgery and she still have pain at the iliac crest. That was enough said for me.

Pooka1
12-30-2009, 09:52 AM
It is funny (as in odd), as you would be all over anyone on this board who used this type of statement if it had anything to do with bracing or exercise or other non-surgical treatments and yet you allow the surgeon to mislead. You should at least be consistent.

No is statement is factual. I don't know how many of his patients achieve pain elimination. Maybe many. Maybe it is similar to with kids in which case the statement is not misleading besides being factual.

Ballet Mom
12-30-2009, 09:53 AM
If that is the case then someone is going to have to ask some hard questions now that the instrumentation is looking better about the wisdom of waiting to fuse if it is harder to achieve a good balance in a more rigid, more mature spine.


That is a huge leap. Explain the increasing pain after two years of the AIS patients who were fused, seeing as they would have had these more flexible spines due to age, prior to fusion.

Pooka1
12-30-2009, 09:58 AM
That is a huge leap. Explain the increasing pain after two years of the AIS patients who were fused, seeing as they would have had these more flexible spines due to age, prior to fusion.

It was small and should be compared to the pain in the untreated cases as the authors state. Maybe it is far less of an increase compared to untreated kids. Who knows. The baseline matters.

And I'd like to see the cases broken out into good versus less good balance and anterior versus posterior.

The literature is very flawed. In a real sense, there is really nothing to explain because asking me to explain implies the result reported in the paper is real.

Ballet Mom
12-30-2009, 10:10 AM
the literature is very flawed. In a real sense, there is really nothing to explain because asking me to explain implies the result reported in the paper is real.

lol

...........

Pooka1
12-30-2009, 10:15 AM
Is there some special reason you think the results of the studies you posted are correct whereas the studies referred to in that paper showing most published research results are false?

What would that special reason be?

Basically, do you think this is straightforward or complex?

Ballet Mom
12-30-2009, 10:23 AM
Is there some special reason you think the results of the studies you posted are correct whereas the studies referred to in that paper showing most published research results are false?

What would that special reason be?

Basically, do you think this is straightforward or complex?

I give up. Science is obviously useless then, seeing as it can't produce any accurate studies. It's amazing we were able to crawl out of a cave.

Pooka1
12-30-2009, 10:26 AM
That isn't the conclusion I would reach starting from the same premises.

Pooka1
12-30-2009, 10:49 AM
I don't disagree with what you have said. And the more times Anand comes on here without more explanation and without answering questions, the more I don't disagree. If he does it one more time without addressing this statement then I'm going to outright agree with you. :)

Pooka1
12-30-2009, 12:41 PM
As with braces, we need to see unbiased published outcomes from as many groups as possible beyond the inventors.

Every medical publication has a financial interest disclosure section for a reason.

LindaRacine
12-30-2009, 10:11 PM
I agree with you hdugger, my hackles went up immediately also. I think it's bizarre to have a surgeon (or one of his staff members) trying to drum up patients for a new surgical procedure on this forum. It would be one thing if he ever stopped to answer any questions, but he doesn't...he's merely advertising. Either this board allows advertising, or it doesn't.
When I read Anand's first post, my first reaction was to delete the thread. But, there were already responses. If I had to do it over again, I'd probably delete the thread.


And to state that he can eliminate pain is bizarre also. It is true that many patients are helped with pain, but many are not.

We don't know that many of his patients are not helped.



Also,

http://www.scoliosisjournal.com/content/3/1/9

Post-surgery pain

Pain is the primary indication for re-operation [64-66]. The mechanism for increased neck and back pain after surgery is not well understood [67]. Bridwell [10] suggests that late-developing pain could be a complication of surgery, or an effect of aging, or 'perhaps a focus on the disability associated with spinal deformity and surgical treatment.' But the answer for surgeons seems to be to re-operate [68]. Among 190 patients, 19% required re-operation within 2 to 8 years after surgery [67]. For 27 patients who sought treatment 59% felt their pain had been reduced, but 41% did not feel a reduction in their pain levels, and a further 26% were very unhappy with the outcome [68]. Among 34 patients with significant post surgical pain, 56% reported reduced pain after additional surgery, while 44% did not; in the same study, 2 patients who did not have pain before surgery reported pain in the follow up [69].

Pain at the iliac graft site, first noted in 1979, has now been formally published [70,71]; of 87 patients, 24% complained of pain at the graft site, with 15% reporting severity sufficient to interfere with daily activities. As reported by the authors such problems with iliac crest grafting have been severely neglected in literature, especially problems associated with rib-resection.
That literature review is a joke. The vast majority of the papers they included were from the 90's and prior. And, they conveniently did not include any of the new, multicenter studies that have shown great outcomes. For example:

http://www.ncbi.nlm.nih.gov/pubmed/19752703?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=5


RESULTS: At 2 years, follow-up on the operative patients was 95% and for the nonoperative patients it was 45%. The demographics for the nonoperative patients who were followed up for 2 years versus those who were lost to follow-up were identical. The operative cohort significantly improved in all QOL measures. The nonoperative cohort did not improve and nonsignificant decline in QOL scores was common. At minimum 2-year follow-up, operative patients outperformed nonoperative patients by all measures. CONCLUSION: It would appear from this study that common nonoperative treatments do not change the QOL in patients with ASLS at 2-year follow-up. However, operative treatment does significantly improve the QOL for this group of patients. Our conclusions are limited by the fact that we were only able to follow-up 45% of the nonoperative group to 2-year follow-up, in spite of extensive efforts on our part to accomplish such.

And, http://www.ncbi.nlm.nih.gov/pubmed/19574829?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=11


CONCLUSIONS: Despite having started with significantly greater back pain and disability and worse health status, surgically treated patients had significantly less back pain and disability and improved health status compared with nonoperatively treated patients at the time of the 2-year follow-up evaluation. Compared with nonoperative treatment, surgery can offer significant improvement of back pain for adults with scoliosis.

With all that said, I think it's ridiculous that any doctor comes here trolling for patients. If a doctor in which I had an interest did that, I'd run the other way.

Pooka1
12-30-2009, 10:28 PM
(of yet another Weiss "review" article)

That literature review is a joke. The vast majority of the papers they included were from the 90's and prior. And, they conveniently did not include any of the new, multicenter studies that have shown great outcomes. For example:

(references deleted)

If you'll recall, Weiss also reached WAAAAAAAAYYY back in history for his 2008 "debate" paper on whether surgery is called for.

This seems to be his M.O..

And not to beat a dead horse but one of the obvious jobs of a peer reviewer is to make sure the latest papers are included if relevant. That's why people in the same subfield are often asked to review papers.

So again, I question the peer review. I should put this statement in my signature to save having to repeat it over and over again. But I have decided to only put quotes from hdugger in my signature so I just have to wait until she says it or something. :)

tonibunny
12-31-2009, 01:03 AM
Just a note on the three UK-based members of the editorial board.

Peter Dangerfield was an extremely well-respected scoliosis surgeon in the 1970s to early 1990s, but it looks like he teaches rather than practices today; he is definitely one of the older generation of consultants and he has retired from medical practice. He no longer appears on the list of registered Consultants for the UK. I would have great faith in his knowledge and experience but his age, combined with his teaching work at Liverpool University, make me wonder if he is able to devote much time to editing this journal or whether he delegates this work instead.

The other two members I have never heard of, which is perhaps surprising because I have been an active part of the scoliosis support scene in the UK for nearly ten years now.

Josette Bettany-Saltikov is a lecturer in Research Methods at Teeside University and her background is in physiotherapy. She appears to be very professional and I wouldn't doubt her skills in these areas, but she is not (as far as I am aware) a medically-qualified doctor. Maybe she concentrates on reviewing articles written by other physios.

Dr Nachiappan Chockalingam does not appear on the General Medical Council's register either. He is an academic, and is Professor of Clinical Biomechanics, Sport and Exercise at Staffordshire University. His research appears to encompass general biomechanics and does not seem to focus on the spine or on scoliosis.

Ballet Mom
12-31-2009, 05:37 AM
That literature review is a joke. The vast majority of the papers they included were from the 90's and prior. And, they conveniently did not include any of the new, multicenter studies that have shown great outcomes.


I thought everyone would like my using that paper :) . It is, however, the only recent paper that I see that actually tries to quantify the specific pain results with percentages, at least in the abstracts.

All the latest studies pretty much say something like "This long-term follow-up of Harrington rod fusion for adolescent idiopathic scoliosis showed no important impairment of health-related quality of life", which basically doesn't tell anybody about the significant disability of a portion of these cases. Perhaps now that they compare them to the general population, they can ignore them. The studies from about twenty years ago were actually much more forthright. (And yes, I'm using the Harrington rod studies for a reason).

And your other study is only for a two year time frame. There seems like there might be an issue with pain increasing after the two year mark after surgery, even a member of this board has recently had that happen, and it seems to be shown as statistically significant in the other study I mentioned. So hopefully, they'll be doing on a follow on study with these same people at a five year time frame and perhaps into the future.

Don't get me wrong, I truly hope that people are getting help with their pain through surgery, but it looks to me that lots don't. Perhaps Dr. Anand could post his own results to the board as he must have a significant number of cases and longer term results to be stating what he does.

Pooka1
12-31-2009, 10:59 AM
(Anand is a paid consultant for Medtronic and receives royalties for his contributions to the design of the screws used in the minimally invasive surgeries.)


The key test is if other surgeons are intrigued enough to train on the technique. That happened with pedicle screws which I assume are used by just about everyone these days and is happening now for VBS where the list of surgeons trained in the technique is growing.

We have also seen cases like Spinecor where surgeons did apparently try it on the strength of inventor reports and then abandoned it.

It's important to remember that pedicle screw usage in spinal fusion started with one guy who may or may not have held the equipment patent. Lenke invented the system that is in at least one of my daughters. So just because one guy is pushing something doesn't automatically mean it isn't going to pan out. Caution yes, scorched earth skepticism, no. Save that skepticism for much more deserving targets is my advice.

Pooka1
12-31-2009, 11:12 AM
Right I was agreeing and adding to your comments. I should have been clearer. Those comments are not directed at you because I was in agreement with you.

ETA: There is definitely misdirected scorched earth skepticism on this group in my opinion and I was addressing that issue with my comments. Your comments were on the money (no pun intended). :)

ScoliSkye2
12-31-2009, 11:36 AM
Hi,
You know Skye doesn't have any pain at all. Her curve issue for "her" is cosmetic, however the doctors believe that the curve will cause her difficulty in the future because it continues to progress - I hope the outcome for her is not a life of pain (because of the surgery) whew! back to my prayer closet.

Pooka1
12-31-2009, 11:44 AM
Hi,
You know Skye doesn't have any pain at all. Her curve issue for "her" is cosmetic, however the doctors believe that the curve will cause her difficulty in the future because it continues to progress - I hope the outcome for her is not a life of pain (because of the surgery) whew! back to my prayer closet.

Pain after the recovery period in kids is rare per the material I was given.

And you always have to compare that to the pain (and disability) associated with no treatment of the scoliosis. This point is routinely glossed over by some folks. Other people with scoliosis is the baseline, not the general population.

Surgery isn't really choice for many kids. I think it is always viewed as a co-equal choice with no surgery by some who don't really know what many parents are actually dealing with.

ScoliSkye2
12-31-2009, 12:14 PM
I agree Sharon,
As parents we have to try to know what is best for them and implement it. Thanks!
Docs and all I have read agree that it is best to have the surgery while they are still growing and young as they manage it better.

With anything we make our best choices and pray that they are the right ones. I got off on this pain thingy and felt for a minute ~ am I opening a can of worms. You know Pre-op gitters :-):o

Pooka1
12-31-2009, 12:28 PM
I agree Sharon,
As parents we have to try to know what is best for them and implement it. Thanks!
Docs and all I have read agree that it is best to have the surgery while they are still growing and young as they manage it better.

With anything we make our best choices and pray that they are the right ones. I got off on this pain thingy and felt for a minute ~ am I opening a can of worms. You know Pre-op gitters :-):o

Yes I know what you mean. :)

Steady. Forward. These guys know what they are doing. We are lucky to have the instrumentation available now. Kids with scoliosis years ago had many less optimal choices unfortunately. It was rational in my opinion to avoid surgery in many cases before the modern instrumentation.

At my one daughter's recent visit with the surgeon, the issue came up over choosing surgery. The surgeon said there was no choice in my daughter's case but other people do seem to have some choice either because the curve is smaller or not curving as fast or whatever.

In re pain, I am sure some kids have pain beyond the recovery period but per our surgeon's experience that is rare. He sees them until they are 18 so depending on the average age at surgery, that's likely several years.

And I'd like to see these studies on post operative pain compared against kids who are not treated. I don't see how it is publishable to compare against the general population. As with so many things, it's a number and you can measure it but it doesn't mean anything.

Good luck.

sharon

Pooka1
12-31-2009, 06:30 PM
Just a note on the three UK-based members of the editorial board.

Peter Dangerfield was an extremely well-respected scoliosis surgeon in the 1970s to early 1990s, but it looks like he teaches rather than practices today; he is definitely one of the older generation of consultants and he has retired from medical practice. He no longer appears on the list of registered Consultants for the UK. I would have great faith in his knowledge and experience but his age, combined with his teaching work at Liverpool University, make me wonder if he is able to devote much time to editing this journal or whether he delegates this work instead.

The other two members I have never heard of, which is perhaps surprising because I have been an active part of the scoliosis support scene in the UK for nearly ten years now.

Josette Bettany-Saltikov is a lecturer in Research Methods at Teeside University and her background is in physiotherapy. She appears to be very professional and I wouldn't doubt her skills in these areas, but she is not (as far as I am aware) a medically-qualified doctor. Maybe she concentrates on reviewing articles written by other physios.

Dr Nachiappan Chockalingam does not appear on the General Medical Council's register either. He is an academic, and is Professor of Clinical Biomechanics, Sport and Exercise at Staffordshire University. His research appears to encompass general biomechanics and does not seem to focus on the spine or on scoliosis.

Thanks for contributing that.

The editorial board are (is?) the people who decide where to send the papers out for review as far as I can tell. They may do some reviews themselves, I don't know.

That journal just gets curiouser and curiouser in my opinion. They have raised eclecticism of expertise to a zen art. They should concentrate on lining up appropriate reviewers as best they can, something that is often hard to do when the appropriate people are just too busy.

mamamax
12-31-2009, 06:47 PM
They have raised eclecticism of expertise to a zen art.

Nominating this for most colorful phrase of the week! Maybe year - Like it a lot! :D

Thanks Tonibunny for your input on the UK board members. I'm going to take a look at each one just because - well I don't have a hot date tonight :(

I think we are finding that we have a wide range of expertise here - from the upcoming president of SRS to ... well don't see the Dali Lama yet, but the line up is looking well rounded. This would make some sense as there as there is a wide range of treatment available for the condition.

Pondering music selection as I do this ... Rolling Stones?

Happy New Year Everyone!

mamamax
12-31-2009, 06:56 PM
We have also seen cases like Spinecor where surgeons did apparently try it on the strength of inventor reports and then abandoned it.


:eek:

but ... were they fully qualified/trained to treat - unsupervised??

Pooka1
12-31-2009, 06:59 PM
:eek:

but ... were they fully qualified/trained to treat - unsupervised??



Is it rocket surgery?

How about compared to spinal fusion?

mamamax
12-31-2009, 07:10 PM
Is it rocket surgery?

How about compared to spinal fusion?

Not a rocket scientist or a surgeon so I can't answer that adequately. But I can say this - one needs to know what they are doing, and if they don't .. they will not duplicate the results of those who do.

LindaRacine
12-31-2009, 10:37 PM
I thought everyone would like my using that paper :) . It is, however, the only recent paper that I see that actually tries to quantify the specific pain results with percentages, at least in the abstracts.

All the latest studies pretty much say something like "This long-term follow-up of Harrington rod fusion for adolescent idiopathic scoliosis showed no important impairment of health-related quality of life", which basically doesn't tell anybody about the significant disability of a portion of these cases. Perhaps now that they compare them to the general population, they can ignore them. The studies from about twenty years ago were actually much more forthright. (And yes, I'm using the Harrington rod studies for a reason).

And your other study is only for a two year time frame. There seems like there might be an issue with pain increasing after the two year mark after surgery, even a member of this board has recently had that happen, and it seems to be shown as statistically significant in the other study I mentioned. So hopefully, they'll be doing on a follow on study with these same people at a five year time frame and perhaps into the future.

Don't get me wrong, I truly hope that people are getting help with their pain through surgery, but it looks to me that lots don't. Perhaps Dr. Anand could post his own results to the board as he must have a significant number of cases and longer term results to be stating what he does.
Long term? You want long term?


http://www.ncbi.nlm.nih.gov/pubmed/19910755?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=3

CONCLUSION: When compared to a control group of equal sex, age, weight, and height, adolescent idiopathic scoliosis patients had a slightly higher incidence of back pain. When compared to the control group using short form-36 evaluation, the patients had statistically equal scores in all 8 domains. Most patients were able to perform most activities of daily living.

http://www.ncbi.nlm.nih.gov/pubmed/19713874?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=9

CONCLUSION: We evaluated long-term QOL in patients treated surgically for scoliosis, and found that it was not impaired, particularly in the case of patients with idiopathic or congenital scoliosis. Larger preoperative Cobb angle and positive sagittal balance at the most recent follow-up were related to poor outcome in QOL as assessed by the SRS-22.

http://www.ncbi.nlm.nih.gov/pubmed/17762812?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=88

CONCLUSION: Radiologic results, patient satisfaction, and mean scores for quality of life and back function were excellent after CD instrumentation for AIS, but a considerable number of patients had treatment for back problems.

http://www.ncbi.nlm.nih.gov/pubmed/16924553?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=122

Results of about 10 years of follow-up these patients treated with TSRH instrumentation suggest that the method is efficient for the correction of frontal and sagittal plane deformities and trunk balance. In addition, it results in a better life-quality.

As far as I'm concerned, quoting anything that Weiss does is a great way to lose credibility. As Weiss shows, there are plenty of studies showing the complication rate of scoliosis surgery. Those studies were published by the surgeons who had the complications. They're not hiding anything. Weiss apparently can't publish his own long-term followup studies. Instead, he attacks the surgeons who have helped thousands of people every year, in an effort to deflect criticism of his methods. By only using the negative papers in his literature review, he shows that he's either jealous or on some sort of vendetta.

--Linda

Pooka1
12-31-2009, 11:32 PM
As far as I'm concerned, quoting anything that Weiss does is a great way to lose credibility.

You said it. Several months ago, I said the same thing... if anyone quotes that Weiss "debate" paper then I will assume they are conceding the point.


As Weiss shows, there are plenty of studies showing the complication rate of scoliosis surgery. Those studies were published by the surgeons who had the complications. They're not hiding anything. Weiss apparently can't publish his own long-term followup studies. Instead, he attacks the surgeons who have helped thousands of people every year, in an effort to deflect criticism of his methods. By only using the negative papers in his literature review, he shows that he's either jealous or on some sort of vendetta.

--Linda

There is something up with Weiss it seems. He adopts the tactics of the nonsense purveyors though he is a surgeon.

Ballet Mom
01-01-2010, 11:24 AM
This is just silly.

Let's recall what started this thread. An orthopedic surgeon comes trawling through this site on two separate occasions advertising like any common chiropractor.

Here is his second advertisement, verbatim:


Addressing Your Concerns About Surgery

Hello, I can understand your concerns about having spine surgery and I'll be happy to address them.

I consider Minimally Invasive Spine Surgery techniques to be the answer. Smaller incisions, less blood loss, less risk, quick recovery, minimall discomfort - patients usually only taking Tylenol after the first week or so, No ICU - Intensive Care Unit post surgery, and you will be standing up straight.
I also do second opinions using phone, internet and reviewing x rays, there is a lot of information about minimally invasive techniques and information about second opinions.

A minimally invasive procedure can straighten out your spine and eliminate your pain.

hdugger and I question the doctor's proclamation that he can eliminate your pain. Fortunately for the doctor, he's a God in Pooka's eyes and therefore can do anything he wishes and she proceeds to debate the word "can" just like Bill Clinton debated what the meaning of the word "is" is.

And now we're back to the old standby comments of Pooka.


There is something up with Weiss it seems. He adopts the tactics of the nonsense purveyors though he is a surgeon.

It's hard for Pooka to allow anyone to have any thoughts different than her own party's programmed beliefs. It is a shame because there are people that don't wish to just be popped into surgery at forty degrees and would like an alternative to at least try before making a decision about a major surgery that will impact their life forever. I personally don't believe the Europeans are lying about their claims about bracing and exercise.

I think it's a shame we don't have a few doctors here in the U.S. where people with scoliosis could go to try out promising exercises, etc. to try and keep their curves from progressing and attempt to avoid surgery, and not have to resort to quacks in order to try. These patients would be under the guidance of a true medical doctor, doing actual research and reporting to the American academy their results. But apparently the "gatekeepers" must not allow that to happen as obviously nothing the Europeans do could possibly be valid.

I'm actually tempted to try and convince my sister the M.D. to start a practice in it, I think it's needed here in the U.S.

Pooka1
01-01-2010, 11:31 AM
It's hard for Pooka to allow anyone to have any thoughts different than her own party's programmed beliefs.

and


But apparently the "gatekeepers" must not allow that to happen as obviously nothing the Europeans do could possibly be valid.


There is no European bashing going on.

I don't have "beliefs." Rational people ACCEPT facts based on the evidence.

Pooka1
01-01-2010, 12:01 PM
I'm inclined to excuse some of what Weiss writes based on bad translation. But not the majority of it.

It is useful to document the performance of the old instrumentation because plenty of people are walking around loose with that and because that is an integral component to designing new instrumentation. But he continually elides the difference between the old and new instrumentation and outright says that the results for the old apply one to one to the new (with his use of verb tense in the "debate" article).

I can name the people who were fooled by this here and on other fora. It is misleading the bunnies in real time.

LindaRacine
01-01-2010, 12:23 PM
I think it's a shame we don't have a few doctors here in the U.S. where people with scoliosis could go to try out promising exercises, etc. to try and keep their curves from progressing and attempt to avoid surgery, and not have to resort to quacks in order to try. These patients would be under the guidance of a true medical doctor, doing actual research and reporting to the American academy their results. But apparently the "gatekeepers" must not allow that to happen as obviously nothing the Europeans do could possibly be valid.


http://www.ncbi.nlm.nih.gov/pubmed/18600146?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=20

CONCLUSIONS: Quantified trunk rotational strength training significantly increased strength. It was not effective for curves measuring 50 to 60 degrees. It appeared to help stabilize curves in the 20 to 40-degree ranges for 8 months, but not for 24 months. Periodic additional supervised strength training may help the technique to remain effective, although additional experimentation will be necessary to determine this.

http://www.ncbi.nlm.nih.gov/pubmed/15363104?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=79

CONCLUSIONS: The combined use of spinal manipulation and postural therapy appeared to significantly reduce the severity of the Cobb angle in all 19 subjects. These results warrant further testing of this protocol.

http://www.ncbi.nlm.nih.gov/pubmed/12597221?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=109

Sixteen of 20 patients demonstrated curve reduction, and no patient showed an increase in curve.

http://www.ncbi.nlm.nih.gov/pubmed/10780683?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=8

A 16-year-old girl with a 60 degree lumbar curve progressed and had surgery. None of the remaining patients progressed, and 4 of the 12 had decreases in their curvatures from 20 degrees to 28 degrees. None of the patients used braces during this study.

All we're asking for are a few follow-up studies.

mamamax
01-01-2010, 12:26 PM
Long term? You want long term?


http://www.ncbi.nlm.nih.gov/pubmed/19910755?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=3

CONCLUSION: When compared to a control group of equal sex, age, weight, and height, adolescent idiopathic scoliosis patients had a slightly higher incidence of back pain. When compared to the control group using short form-36 evaluation, the patients had statistically equal scores in all 8 domains. Most patients were able to perform most activities of daily living.

http://www.ncbi.nlm.nih.gov/pubmed/19713874?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=9

CONCLUSION: We evaluated long-term QOL in patients treated surgically for scoliosis, and found that it was not impaired, particularly in the case of patients with idiopathic or congenital scoliosis. Larger preoperative Cobb angle and positive sagittal balance at the most recent follow-up were related to poor outcome in QOL as assessed by the SRS-22.

http://www.ncbi.nlm.nih.gov/pubmed/17762812?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=88

CONCLUSION: Radiologic results, patient satisfaction, and mean scores for quality of life and back function were excellent after CD instrumentation for AIS, but a considerable number of patients had treatment for back problems.

http://www.ncbi.nlm.nih.gov/pubmed/16924553?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=122

Results of about 10 years of follow-up these patients treated with TSRH instrumentation suggest that the method is efficient for the correction of frontal and sagittal plane deformities and trunk balance. In addition, it results in a better life-quality.

As far as I'm concerned, quoting anything that Weiss does is a great way to lose credibility. As Weiss shows, there are plenty of studies showing the complication rate of scoliosis surgery. Those studies were published by the surgeons who had the complications. They're not hiding anything. Weiss apparently can't publish his own long-term followup studies. Instead, he attacks the surgeons who have helped thousands of people every year, in an effort to deflect criticism of his methods. By only using the negative papers in his literature review, he shows that he's either jealous or on some sort of vendetta.

--Linda

Linda - Might I suggest that you write Weiss directly with these concerns which have been echoed in forum. His response would be most interesting I should think. As forum moderator, with a great deal of experience in communicating with others in the medical profession, you would be a perfect choice for this - and to do so (I would think) would prove beneficial for all :-)

Pooka1
01-01-2010, 12:32 PM
I have a question about financial disclosure...

Weiss can (probably) honestly say he has no financial interest in surgical instrumentation (if he isn't doing surgeries any more). But would he have to disclose that that he is the director of a clinic pushing alternative treatments when writing articles about surgical outcomes? I would hope so but I seriously doubt it. If so, this is another failure of the publishing process.

Pooka1
01-01-2010, 12:40 PM
All we're asking for are a few follow-up studies.

You know, for a guy who is the director of a clinic pushing an alternative treatment that has been around for ~90 years, his "literature reviews" of surgical methods seem to be obvious "Look at the Wookie" moves.

Has a long term study on Schroth ever been published? I'd pay to hear Weiss address that.

mamamax
01-01-2010, 12:59 PM
I have a question about financial disclosure...

Weiss can (probably) honestly say he has no financial interest in surgical instrumentation (if he isn't doing surgeries any more). But would he have to disclose that that he is the director of a clinic pushing alternative treatments when writing articles about surgical outcomes? I would hope so but I seriously doubt it. If so, this is another failure of the publishing process.

He is no longer director of that Clinic and has gone into private practice. Let me take a look around and see if I can find the new director for us. I heard that the new one is heavily involved with several large medical facilities.

mamamax
01-01-2010, 01:05 PM
The current director:

Administrative Responsibility

Dipl.-Kfm. Peter Schmitz, Director
(Phone 00 49 67 51 / 8 74 – 161 / Fax - 170)

http://www.skoliose.com/Html/Englisch.htm

Pooka1
01-01-2010, 01:08 PM
I stand corrected.

It seems Weiss holds some patents on various braces...

http://www.koob-scolitech.com/Hans-Rudolf_Weiss.php


Patent application and trademarks: Chêneau Light brace, kyphologic brace, spondylogic brace, USO

One would hope he starts publishing short- and long-term results for those braces instead of using ancient papers to shoot down modern surgical techniques.

http://www.youtube.com/watch?v=18w6RLHiRMs&feature=related

LindaRacine
01-01-2010, 01:16 PM
I stand corrected.

It seems Weiss holds some patents on various braces...

http://www.koob-scolitech.com/Hans-Rudolf_Weiss.php




SpineCor vs. natural history - explanation of the results obtained using a simple biomechanical model.

Weiss HR.

Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Korczakstr. 2, 55566 Bad Sobernheim, Germany. hr.weiss@asklepios.com

In the recent peer reviewed literature the SpineCor is described as an effective method of treatment for patients with scoliosis. However until recently no prospective controlled end-result study is presented comparing the results obtained with this soft brace to natural history. The objective was to determine whether the results obtained by the use of the SpineCor are better than natural history during pubertal growth spurt. The method employed prospective comparison of the survival rates of SpineCor treatment vs. natural history with respect to curve progression during pubertal growth spurt. 12 Patients with Cobb angles between 16 and 32 degrees (at average 21 degrees) during pubertal growth spurt are presented as a case series treated with the SpineCor. Survival rate of this sample is described and compared to natural history (SRS brace study 1995). All girls treated in both studies were at risk for being progressive with the first clinical signs of maturation (Tanner 2-3). During the pubertal growth spurt most of the patients (11/12) with SpineCor progressed clinically and radiologically as well (at least 5 degrees). Progression could be stopped changing SpineCor to the Chêneau brace in most of the sample described (7/10). The avarage Cobb angle at the start of treatment with the SpineCor was 21.3 degrees, after an average observation time of 21.5 months 31 degrees. At 24 months of treatment time 33% of the patients with the SpineCor where still under treatment with their original bracing concept, at 72 months follow-up time 8 % of the patients with the SpineCor survived with respect to curvature progression. Survival proportion in the SpineCor sample, though was 0.08, while in the natural history cohort it was 0.34. The SpineCor treatment during pubertal growth spurt seems to lead to a worse outcome than observation only. The use of a simple biomechanical model explains that in the brace the compression forces exceed the lateral forces used for the corrective movement. Therefore SpineCor does not seem to be indicated as a treatment during pubertal growth spurt.
Does it surprise ANYONE that Weiss would find an issue with a competitive brace?

mamamax
01-01-2010, 01:20 PM
Let me be the first to say it ....

No!

And furthermore, he was not trained to the level of proficient, or to treat unsupervised in the application of the Spinecor brace.

I keep meaning to write someone a letter about that :-)

Hope the controversy (along with that of Wong) produced some changes in the peer review process of Scoliosis Journal! And in the process of who the manufacturer sells braces to.

Outside of this - I do have a great deal of respect for Drs. Weiss & Wong in their areas of expertise - Spinecor, simply is not one of those areas.

Ballet Mom
01-01-2010, 01:29 PM
The SpineCor treatment during pubertal growth spurt seems to lead to a worse outcome than observation only.[/U] The use of a simple biomechanical model explains that in the brace the compression forces exceed the lateral forces used for the corrective movement. Therefore SpineCor does not seem to be indicated as a treatment during pubertal growth spurt.[/INDENT]

Does it surprise ANYONE that Weiss would find an issue with a competitive brace?

It doesn't suprise me that he came to this result. I came to the same opinion, just from reading the results of the spinecor on the people on this board for the past few years and seeing the huge forces that were acting on my daughter's spine during her major growth spurt.

I really think that the Spinecor would best be used in the juvenile cases, switching to a more robust brace prior to the adolescent growth spurt, and hopefully to minimize pain in adult patients. It would be nice if there was an MD around who could tie this all together.

mamamax
01-01-2010, 01:41 PM
It doesn't suprise me that he came to this result. I came to the same opinion, just from reading the results of the spinecor on the people on this board for the past few years and seeing the huge forces that were acting on my daughter's spine during her major growth spurt.

I really think that the Spinecor would best be used in the juvenile cases, switching to a more robust brace prior to the adolescent growth spurt, and hopefully to minimize pain in adult patients. It would be nice if there was an MD around who could tie this all together.

There are many braces (even for adults I find as time goes on) and there are many cases. It would be nice if we could know without arduous trial and error, which would benefit who best. And yes, it would be nice to have an an MD around who could tie it all together!

RitaR
01-01-2010, 01:41 PM
Hey Pooka,
Have you already had surgery? I was wondering the reference of pain before surgery, which I have tons of horrible pain all day every day with lots of numbndess and tingling and lots of muscle spasms, versus pain postop immediately after surgery. I'm thinking it can't get much worse and besides that pain after surgery will go away - this just drags on day after day. Ugh! We become tired after a while.
Thanks for your insight.

Pooka1
01-01-2010, 01:51 PM
Hey Pooka,
Have you already had surgery? I was wondering the reference of pain before surgery, which I have tons of horrible pain all day every day with lots of numbndess and tingling and lots of muscle spasms, versus pain postop immediately after surgery. I'm thinking it can't get much worse and besides that pain after surgery will go away - this just drags on day after day. Ugh! We become tired after a while.
Thanks for your insight.

Hi Rita,

I am here as a parent of two kids with scoliosis who required fusion. I may soon be on here as a patient (no scoliosis) if my lumbar pain pushes me to the point of getting another radiograph.

I have no trained insight in this field other than general scientific method. That said, some things in this field stand out so much that anyone with scientific training can spot them a mile away.

As I understand it, many, if not most, adult scoliosis patients get surgery for pain. The rest get it I presume for progression and lung impairment.

You should get some opinions from surgeons about the likelihood of your pain being decreased or eliminated with surgery versus PT or Spinecor or something else.

My impression from the testimonials is that you can expect less and even much less pain but some here certainly did not get that result. Only a surgeon can advise you on that.

Good luck

mamamax
01-01-2010, 04:29 PM
The current director:

Administrative Responsibility

Dipl.-Kfm. Peter Schmitz, Director
(Phone 00 49 67 51 / 8 74 – 161 / Fax - 170)

http://www.skoliose.com/Html/Englisch.htm

Anyone coming up with anything on this guy? I can't find anything that isn't written in German! Would be nice to know something about the new Director and if his vision includes studies with long term follow up.

LindaRacine
01-03-2010, 11:25 AM
Long-term? We have long-term!

http://www.ncbi.nlm.nih.gov/pubmed/20038867?itool=Email.EmailReport.Pubmed_ReportSele ctor.Pubmed_RVDocSum&ordinalpos=11

Revision Rates Following Primary Adult Spinal Deformity Surgery: Six Hundred Forty-Three Consecutive Patients Followed-Up to Twenty-Two Years Postoperative.

Pichelmann MA, Lenke LG, Good CR, O'Leary PT, Sides BA, Bridwell KH.

From the Department of Orthopaedic Surgery, Investigation performed at Washington University School of Medicine, St. Louis, MO.

STUDY DESIGN.: Retrospective study. OBJECTIVE.: To analyze the prevalence of and reasons for unanticipated revision surgery in an adult spinal deformity population treated at one institution. SUMMARY OF BACKGROUND DATA.: No recent studies exist that analyze the rate or reason for unanticipated revision surgery for adult spinal deformity patients over a long period. METHODS.: All patients presenting for primary instrumented spinal fusion with a diagnosis of adult deformity at a single institution from 1985 to 2008 were reviewed using a prospectively acquired database. All surgical patients with instrumented fusion of >/=5 levels using hooks, hybrid, or screw-only constructs were identified. Patient charts and radiographs were reviewed to provide information as to the indication for initial and any subsequent reoperation. A total of 643 patients underwent primary instrumented fusion for a diagnosis of adult idiopathic scoliosis (n = 432), de novo degenerative scoliosis (n = 104), adult kyphotic disease (n = 63), or neuromuscular scoliosis (n = 45). The mean age was 37.9 years (range, 18-84). Mean follow-up for the entire cohort was 4.7 years, and 8.2 years for the subset of the cohort requiring reoperation (range, 1 month-22.3 years). RESULTS.: A total of 58 of 643 patients (9.0%) underwent at least one revision surgery and 15 of 643 (2.3%) had more than one revision (mean 1.3; range, 1-3). The mean time to the first revision was 4.0 years (range, 1 week-19.7 years). The most common reasons for revision were pseudarthrosis (24/643 = 3.7%; 24/58 = 41.4%), curve progression (13/643 = 2.0%; 13/58 = 20.7%), infection (9/643 = 1.4%; 9/58 = 15.5%), and painful/prominent implants (4/643 = 0.6%; 4/58 = 6.9%). Uncommon reasons consisted of adjacent segment degeneration (3), implant failure (3), neurologic deficit (1), and coronal imbalance (1). Revision rates over the follow-up period were: 0 to 2 years (26/58 = 44.8%), 2 to 5 years (17/58 = 29.3%), 5 to 10 years (7/58 = 12.1%), >10 years (8/58 = 13.8%). CONCLUSION.: Repeat surgical intervention following definitive spinal instrumented fusion for primary adult deformity performed at a single institution demonstrated a relatively low rate of 9.0%. The most common reasons for revision were predictable and included pseudarthrosis, proximal or distal curve progression, and infection.

Pooka1
01-03-2010, 12:13 PM
That second paper came out several months later though maybe not long enough for the authors to include the first paper in their review. If they did include the first paper, I'd like to see what they say about why the different revision rates.

It could be more smokers as they mention or it could be something else. I'd like to see revision rate plotted against average Cobb angle and also against average number of years the surgeon has been operating at the time of initial surgery.

Or it could be something simpler... the intrinsic variability of the underlying condition which controls the overall result is so high that you have to look at a few hundred patients to get a true picture. Or you might have to look at a few thousand. It seems like just another manifestation of the universal sampling problem. I mean it's not like the literature is air-tight or anything. ;)

------------

ETA: I was confused... the lower revision rate paper came out after the higher rate one. So it would be interesting to see if the second paper authors comment on the first paper.

LindaRacine
01-03-2010, 12:37 PM
Do you have a sense of why their results are so different from this study:

http://www.ncbi.nlm.nih.gov/pubmed/19365253?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed (http://www.ncbi.nlm.nih.gov/pubmed/19365253?ordinalpos=1&itool=EntrezSystem2.PEntrez. Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.P ubmed_Discovery_RA&linkpos=2&log$=relatedarticles& logdbfrom=pubmed)

The UCSF center has almost three times the number of reoperations (25% compared to 9% at the Washington University site.) Even odder considering that the UCSF study covers significantly fewer years.

Reoperation after primary fusion for adult spinal deformity: rate, reason, and timing.
Mok JM, Cloyd JM, Bradford DS, Hu SS, Deviren V, Smith JA, Tay B, Berven SH.

Department of Orthopedic Surgery, University of California, San Francisco, CA 94143-0728, USA.
STUDY DESIGN: Retrospective cohort study of consecutive patients undergoing primary fusion with segmental fixation for adult spinal deformity. OBEJCTIVE: We sought to determine the survivorship of primary fusion for adult spinal deformity and identify patient-specific predictors of complications requiring reoperation. SUMMARY OF BACKGROUND DATA: Compared with the adolescent population, surgery for adult deformity is often more complex and technically difficult, contributing to a high reported rate of complications that can result in the need for reoperation. Reported complication rates vary widely. METHODS: From 1999-2004 all patients who underwent primary instrumented fusion for nonparalytic adult spinal deformity at a single center were included. Inclusion criteria included minimum age at surgery of 20 years and minimum fusion length of 4 motion segments. Surgical, demographic, and comorbidity data were recorded. Reoperation was defined as any additional surgery involving levels of the spine operated on during the index procedure and/or adjacent levels. Comparisons were performed between patients who required reoperation and those who did not. RESULTS: Eighty-nine patients met inclusion criteria. Endpoint (minimum 2 years follow-up or reoperation) was reached for 91%. Mean follow-up was 3.8 years. Cumulative reoperation rate was 25.8%. Survival was 86.4% at 1 year, 77.2% at 2 years, and 75.2% at 3 years. Reasons for reoperation included infection (n = 8), pseudarthrosis (n = 3), adjacent segment problems (n = 5), implant failure (n = 4), and removal of painful implants (n = 3). Multivariate analysis showed smoking was significantly higher in the reoperation group. CONCLUSION: Using a strict definition of reoperation for a well-defined cohort, in the presence of relevant risk factors, many patients undergoing primary fusion for adult spinal deformity required reoperation. The results indicate that complex medical and surgical factors contribute to the treatment challenges posed by patients with adult spinal deformity. This represents the largest cohort reported to date of patients undergoing primary fusion using third-generation instrumentation techniques.
I don't know if the St. Louis paper was single center, or if they used the Spinal Deformity Study Group database (which includes the UCSF patients). It's difficult to know the exact details, but there's one obvious big difference. The SF study had a minimum age of 20, and the St. Louis study had a minimum age of 18. I suspect a lot of the St. Louis cohort was 18 or 19 years old (probably the most common age for AIS surgery).

--Linda

Pooka1
01-03-2010, 12:46 PM
I don't know if the St. Louis paper was single center, or if they used the Spinal Deformity Study Group database (which includes the UCSF patients). It's difficult to know the exact details, but there's one obvious big difference. The SF study had a minimum age of 20, and the St. Louis study had a minimum age of 18. I suspect a lot of the St. Louis cohort was 18 or 19 years old (probably the most common age for AIS surgery).

--Linda

Wow. If that pans out it will stand on the continuum with the kids having very low revision rates as far as anyone knows. It will also be a very good incentive to have this surgery as early as possible.

I'd like to see a graph of revision rate versus patient age. It might be a tighter correlation than even Cobb angle or sagittal balance. That would be very interesting indeed.

Pooka1
01-03-2010, 01:00 PM
The St. Louis paper was single center.

Do you have access to the entire papers? It would be interesting to look at the age distribution. Without that, I'd certainly like to know why UCSF is seeing so much worse results than Washington University.

The answer, if it has to do with surgeon experience, might be incendiary and create a problem for new surgeons trying to break into the field.

LindaRacine
01-03-2010, 01:05 PM
Wow. If that pans out it will stand on the continuum with the kids having very low revision rates as far as anyone knows. It will also be a very good incentive to have this surgery as early as possible.

I'd like to see a graph of revision rate versus patient age. It might be a tighter correlation than even Cobb angle or sagittal balance. That would be very interesting indeed.

Sharon...

I'm not nearly as gung ho about surgery as you are, but thought you'd like this:

Complications of spinal fusion for scheuermann kyphosis: a report of the scoliosis research society morbidity and mortality committee.

Coe JD, Smith JS, Berven S, Arlet V, Donaldson W, Hanson D, Mudiyam R, Perra J, Owen J, Marks MC, Shaffrey CI.

Silicon Valley Spine Institute, Campbell, CA 95008, USA. jcoe@svspine.com

STUDY DESIGN: Retrospective review of a prospectively collected, multicentered database from the Scoliosis Research Society. OBJECTIVES: To evaluate incidences of complications in a series of spinal fusions for Scheuermann kyphosis (SK) and to assess whether the incidence of complications is associated with patient age and surgical approach. SUMMARY OF BACKGROUND DATA: Although there is some evidence that adolescents have lower complication rates for spinal deformity surgery, this has not been well-documented for SK. Moreover, there is a lack of consensus on surgical approach for the management of SK. METHODS: The Scoliosis Research Society morbidity and mortality database was queried to identify cases of SK from 2001 to 2004. Complications rates were analyzed based on patient age and surgical approach. Pediatric and adult patients were defined as <or=19 and >19 year old, respectively. RESULTS: A total of 683 procedures involving spinal fusion for SK were identified. Mean patient age was 21 years (range: 5-75 years), with the majority (73%) of patients <or=19 years old. Procedures included 338 (49%) posterior spinal fusions (PSF), 73 (11%) anterior spinal fusions (ASF), and 272 (40%) same-day ASF and PSF. Ninety-nine complications were reported (14%). The most common complication was wound infection (3.8%). The acute neurologic complication rate was 1.9%, including 4 spinal cord injuries (0.6%). The mortality rate was 0.6%. Complications were more common among adult (22%) compared with pediatric patients (12%) (P = 0.002). The overall incidence of complications did not differ significantly between the PSF (14.8%) and same-day ASF/PSF (16.9%) procedures (P = 0.5). CONCLUSION: The incidence of complications associated with spinal fusion for SK in adults is significantly greater than in pediatric patients. There were no significant differences in complication rates between PSF and same-day ASF/PSF procedures. These data may be used to counsel patients regarding complications associated with spinal fusion for SK in the hands of experienced spinal deformity surgeons.

LindaRacine
01-03-2010, 01:06 PM
The St. Louis paper was single center.

Do you have access to the entire papers? It would be interesting to look at the age distribution. Without that, I'd certainly like to know why UCSF is seeing so much worse results than Washington University.

I've sent an email to Dr. Berven, so will hopefully have some insight soon. I don't have access from home (yet) for the full text.

Pooka1
01-03-2010, 01:10 PM
That may be, but I'd still like to know and I'd expect the surgeons at UCSF to want to know. There's an even more troubling alternate explanation, which is that the new instrumentation is requiring more reoperations. Intuitively, that doesn't make sense, but without the data we can't really say.

Yes but if you look at the reasons for revision, they are not associated with the new instrumentation over and above the old as far as I know.

ETA: WRT to pseudoarthrosis rate, I think it is known that that is much lower with the new instrumentation compared to the old, at least with kids. Infection rate is institution dependent as far as I know. And adjacent level failure is at least partially related to lowest instrumented vertebra with the older instrumentation... may not be related to that with the new.

Linda probably knows more about this type of data.

LindaRacine
01-03-2010, 06:21 PM
Do you have a sense of why their results are so different from this study:

http://www.ncbi.nlm.nih.gov/pubmed/19365253?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed (http://www.ncbi.nlm.nih.gov/pubmed/19365253?ordinalpos=1&itool=EntrezSystem2.PEntrez. Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.P ubmed_Discovery_RA&linkpos=2&log$=relatedarticles& logdbfrom=pubmed)

The UCSF center has almost three times the number of reoperations (25% compared to 9% at the Washington University site.) Even odder considering that the UCSF study covers significantly fewer years.

Reoperation after primary fusion for adult spinal deformity: rate, reason, and timing.
Mok JM, Cloyd JM, Bradford DS, Hu SS, Deviren V, Smith JA, Tay B, Berven SH.

Department of Orthopedic Surgery, University of California, San Francisco, CA 94143-0728, USA.
STUDY DESIGN: Retrospective cohort study of consecutive patients undergoing primary fusion with segmental fixation for adult spinal deformity. OBEJCTIVE: We sought to determine the survivorship of primary fusion for adult spinal deformity and identify patient-specific predictors of complications requiring reoperation. SUMMARY OF BACKGROUND DATA: Compared with the adolescent population, surgery for adult deformity is often more complex and technically difficult, contributing to a high reported rate of complications that can result in the need for reoperation. Reported complication rates vary widely. METHODS: From 1999-2004 all patients who underwent primary instrumented fusion for nonparalytic adult spinal deformity at a single center were included. Inclusion criteria included minimum age at surgery of 20 years and minimum fusion length of 4 motion segments. Surgical, demographic, and comorbidity data were recorded. Reoperation was defined as any additional surgery involving levels of the spine operated on during the index procedure and/or adjacent levels. Comparisons were performed between patients who required reoperation and those who did not. RESULTS: Eighty-nine patients met inclusion criteria. Endpoint (minimum 2 years follow-up or reoperation) was reached for 91%. Mean follow-up was 3.8 years. Cumulative reoperation rate was 25.8%. Survival was 86.4% at 1 year, 77.2% at 2 years, and 75.2% at 3 years. Reasons for reoperation included infection (n = 8), pseudarthrosis (n = 3), adjacent segment problems (n = 5), implant failure (n = 4), and removal of painful implants (n = 3). Multivariate analysis showed smoking was significantly higher in the reoperation group. CONCLUSION: Using a strict definition of reoperation for a well-defined cohort, in the presence of relevant risk factors, many patients undergoing primary fusion for adult spinal deformity required reoperation. The results indicate that complex medical and surgical factors contribute to the treatment challenges posed by patients with adult spinal deformity. This represents the largest cohort reported to date of patients undergoing primary fusion using third-generation instrumentation techniques.

From Dr. Berven:


I moderated this paper at the SRS and there were dramatic differences in the cohorts. The st Louis pts were MUCH younger and mostly AIS. Our pts were primarily degen scolis. The st Louis group had very few pts fused to the pelvis and most of ours were. Very different papers.

By the way, I believe that Dr. Berven was referring to moderating the St. Louis paper at the SRS (not his own paper).

Pooka1
01-03-2010, 06:29 PM
From Dr. Berven:

I moderated this paper at the SRS and there were dramatic differences in the cohorts. The st Louis pts were MUCH younger and mostly AIS. Our pts were primarily degen scolis. The st Louis group had very few pts fused to the pelvis and most of ours were. Very different papers.

Wow it is WAY beyond cool having Linda and her connections here. There is no way we bunnies would have known that absent Linda chasing that down though it might be obvious if we had the entire texts of both papers.

So it seems that having the surgery before the degenerative changes correlates with a far lower revision rate. And it further seems that it is disadvantageous to wait until the fusion involves the pelvis, if it is at all avoidable, though the revision rate is still pretty low.

This explanation from the surgeon is an object lesson on how you can't tell a damn thing from abstracts. :eek:

Pooka1
01-12-2010, 04:15 PM
And there is even a fairly new study showing that there are increasing pain levels at five years versus two years.

http://www.ncbi.nlm.nih.gov/pubmed/18449045

Spine (Phila Pa 1976). 2008 May 1;33(10):1107-12.

Adolescent idiopathic scoliosis patients report increased pain at five years compared with two years after surgical treatment.

Upasani VV, Caltoum C, Petcharaporn M, Bastrom TP, Pawelek JB, Betz RR, Clements DH, Lenke LG, Lowe TG, Newton PO.

Department of Orthopedic Surgery, University of California San Diego, San Diego, CA, USA.
/
/
CONCLUSION: There was a statistically significant increase in reported pain from 2 to 5 years after surgical treatment; however, the etiology of worsening pain scores could not be elucidated. Given continued patient satisfaction, the clinical relevance of this small reduction remains unknown. Nevertheless, this observation deserves further evaluation and must be considered in relation to the natural history of this disease


I think this talk from the 2009 IMAST conference in Vienna that dhugger posted recently addresses this earlier paper. Apparently, this earlier paper deals mostly with anterior surgeries. The newer paper deals with posterior where pain levels were NOT increased between 2 and 5 years. Still, 24 patients. How can that be significant?


142. Adolescent Idiopathic Scoliosis Patients Treated with Pedicle
Screw Constructs: Do the Favorable Two Year SRS-30 Outcomes
Hold Up at Five Year Follow-up?
Charles H. Crawford MD, Lawrence G. Lenke MD, Woojin Cho MD
PhD, Ronald A. Lehman MD, Kathryn A. Keeler MD, Timothy R.
Kuklo MD, Brian A. O’Shaughnessy MD, Michael S. Chang MD,
Josh D. Auerbach, Brenda Sides MA, Christine Baldus RN MHS,
Keith Bridwell MD
USA

Summary: In AIS patients treated with posterior pedicle screw
constructs, radiographic parameters and SRS-30 outcomes were
stable between the 2-year and 5-year follow-up period, except for
a significant decline in the mental health domain. The significant
improvements in self-image and function from preoperative to
2-years post-operative were maintained at 5-year follow-up. Patient
satisfaction remained high.

Introduction: Studies have shown improvements in SRS outcomes
from preop to 2yr postop in patients undergoing surgery for
adolescent idiopathic scoliosis (AIS). The first report on 5yr SRS-
24 outcomes in AIS showed increased pain subscores between 2yr
and 5yr in a multi-center group of 49 AIS patients, 76% of whom
underwent anterior procedures. (Upasani et al, Spine 2008) 5yr
SRS-30 outcomes in AIS patients have not been reported. We
hypothesized that posterior pedicle screw constructs (PPSC) would
provide stable outcomes between 2yr and 5yr postop.
Methods: 56 AIS pts from a single center treated with PPSC were
analyzed for changes in SRS-30 questionnaires between 2yr and 5yr
follow-up. Additionally, detailed radiographic measurements were
obtained and correlated with changes in SRS-30 outcomes.

Results: (Table 1) The avg age at surgery was 14+9. Female:male
was 44:12. An avg 10.2 levels were instrumented with an avg of
17.2 pedicle screws. The most frequent curve type was Lenke type
1A (30.4%), followed by type 2A (12.5%). 39% of patients had
a thoracoplasty procedure. Avg major Cobb measured 61° preop
with correction to 22° at 5yr (66% correction). There were no
significant radiographic or SRS outcome changes between 2yr
and 5yr, except for a decrease in the mental health subscore (4.28
vs 4.08,p=0.02). There was an insignificant trend towards more
pain (4.28 vs 4.13,p=0.18) including 7 patients who had pain
attributable to a recent injury (n=5) or a new job (n=2). Excluding
these 7 patients there was no change in the 2yr to 5yr pain (4.32
vs 4.30,p=0.85), while the decline in mental health remained
significant (4.34 vs 4.10,p=0.02). Significant improvements in
self-image and function from preop to 2yr were maintained at 5yr.
Changes in mental health and pain were not significantly correlated
with any demographic or radiographic variables.

Conclusion: At 5yrs, the 2yr improvements in SRS subscores for
function and self-image remained stable, although there was a
decline in mental health in this young adult population. Contrary
to a previous report of primarily anterior procedures, pain levels
were not increased between 2yrs and 5yrs in patients treated with
PPSC.

Significance: This is the first report on 5yr SRS-30 outcomes in
AIS patients.

LindaRacine
01-12-2010, 06:01 PM
I think this talk from the 2009 IMAST conference in Vienna that dhugger posted recently addresses this earlier paper. Apparently, this earlier paper deals mostly with anterior surgeries. The newer paper deals with posterior where pain levels were NOT increased between 2 and 5 years. Still, 24 patients. How can that be significant?


142. Adolescent Idiopathic Scoliosis Patients Treated with Pedicle
Screw Constructs: Do the Favorable Two Year SRS-30 Outcomes
Hold Up at Five Year Follow-up?
Charles H. Crawford MD, Lawrence G. Lenke MD, Woojin Cho MD
PhD, Ronald A. Lehman MD, Kathryn A. Keeler MD, Timothy R.
Kuklo MD, Brian A. O’Shaughnessy MD, Michael S. Chang MD,
Josh D. Auerbach, Brenda Sides MA, Christine Baldus RN MHS,
Keith Bridwell MD
USA

Summary: In AIS patients treated with posterior pedicle screw
constructs, radiographic parameters and SRS-30 outcomes were
stable between the 2-year and 5-year follow-up period, except for
a significant decline in the mental health domain. The significant
improvements in self-image and function from preoperative to
2-years post-operative were maintained at 5-year follow-up. Patient
satisfaction remained high.

Introduction: Studies have shown improvements in SRS outcomes
from preop to 2yr postop in patients undergoing surgery for
adolescent idiopathic scoliosis (AIS). The first report on 5yr SRS-
24 outcomes in AIS showed increased pain subscores between 2yr
and 5yr in a multi-center group of 49 AIS patients, 76% of whom
underwent anterior procedures. (Upasani et al, Spine 2008) 5yr
SRS-30 outcomes in AIS patients have not been reported. We
hypothesized that posterior pedicle screw constructs (PPSC) would
provide stable outcomes between 2yr and 5yr postop.
Methods: 56 AIS pts from a single center treated with PPSC were
analyzed for changes in SRS-30 questionnaires between 2yr and 5yr
follow-up. Additionally, detailed radiographic measurements were
obtained and correlated with changes in SRS-30 outcomes.

Results: (Table 1) The avg age at surgery was 14+9. Female:male
was 44:12. An avg 10.2 levels were instrumented with an avg of
17.2 pedicle screws. The most frequent curve type was Lenke type
1A (30.4%), followed by type 2A (12.5%). 39% of patients had
a thoracoplasty procedure. Avg major Cobb measured 61° preop
with correction to 22° at 5yr (66% correction). There were no
significant radiographic or SRS outcome changes between 2yr
and 5yr, except for a decrease in the mental health subscore (4.28
vs 4.08,p=0.02). There was an insignificant trend towards more
pain (4.28 vs 4.13,p=0.18) including 7 patients who had pain
attributable to a recent injury (n=5) or a new job (n=2). Excluding
these 7 patients there was no change in the 2yr to 5yr pain (4.32
vs 4.30,p=0.85), while the decline in mental health remained
significant (4.34 vs 4.10,p=0.02). Significant improvements in
self-image and function from preop to 2yr were maintained at 5yr.
Changes in mental health and pain were not significantly correlated
with any demographic or radiographic variables.

Conclusion: At 5yrs, the 2yr improvements in SRS subscores for
function and self-image remained stable, although there was a
decline in mental health in this young adult population. Contrary
to a previous report of primarily anterior procedures, pain levels
were not increased between 2yrs and 5yrs in patients treated with
PPSC.

Significance: This is the first report on 5yr SRS-30 outcomes in
AIS patients.
The fact that there was a significant difference in the mental health domain is a little odd.

Pooka1
01-12-2010, 07:27 PM
I hope it isn't ledge walking...

LindaRacine
01-12-2010, 07:33 PM
Do you know what things the mental health domain measures?

Depression, I think.