what is the chance of developing abnormal kyphosis after surgery?

[Susie*Bee]

Well, I'm definitely not Ed, but I'll write a little anyway -- or a lot-- sorry! I did a lot of reading after my surgery... you have to pick easy reading; no deep stuff. Since I'm "into" children's literature (elementary librarian) and I believe the last Harry Potter was coming out (or the next one???) I re-read all the ones leading up to it, read a bunch of other similarly longish books that I could put down if I didn't want to continue, etc. I remember Pam /TXmarinemom) saying she was going to load up on vampire books-- before I knew about the twilight saga and wondered about her...!)

After my surgery, when I was feeling a little more up to it, we went shopping and I picked out a cross stitch kit that kept me occupied for hundreds of hours, I'm sure. It's easy to bring that up towards you, and not have to look down. NO, I never finished it, but it's a beaut. Maybe some day I'll finish working on it. I would have loved to do some scrap booking, but I couldn't lean forward over a table. Try to think of some things you can do short term... A teacher friend broke her hip this past year and was out for a little while. I stopped by B&N and picked up a book of word type puzzles that looked like fun for an adult lady. Try to find a variety of things that you can do. I like reading recipes every once in a while. (Yes, I'm probably strange... or maybe there's no probably to it.) Make yourself a box (that you can reach) of this and that sort of things-- easy to watch chick flicks, short books, deck of cards for old fashioned solitaire, thank you notes for all that food people will bring in (hopefully), etc. You'll be able to manicure your fingernails, if you're into that. Buy what you need. Catch up on some snail mail correspondence. Look through your old yearbooks. Just try to have things ready and waiting for you. I'm sure you can fill your time up if you think about it and have some of it ready to go. Most of these ideas may be pretty dumb, but I'm trying to help you brainstorm. I KNOW it's a long time... but you can get through it.

As far as not being able to look down to read, I often place a pillow or two on my lap and bring the book up to me, to a comfortable level. That could probably work with a laptop too, as long as it doesn't slip off. There's often more than one way to skin a cat.

PS-- my husband bought me this little table thing that is sort of like a tv tray, at the drug store, after my surgery. My lap top has been on it ever since, right here in a comfy spot at my couch. It's at a perfect height for me. I do not have to look down. The table's height is adjustable and you can also slant it for writing if you wish. I think the cost was about $20-$25. One nice thing about it is that it has a U shaped base, so my feet don't get tangled in it. I often used it also to rest my books on... In fact, if you click on the "and pics of me" in my signature and look at my "3 months post op" pic, you will see me doing my good ol' cross stitch and there's my trusty ol' lap top table. I've also got my brace on, but that was in a different thread today, I think... (you can see a little smidge of it peeking out the top of my shirt.) Good luck!

[Back-out]

Well, I'm definitely not Ed, but I'll write a little anyway -- or a lot-- sorry! I did a lot of reading after my surgery... you have to pick easy reading; no deep stuff. Since I'm "into" children's literature (elementary librarian) and I believe the last Harry Potter was coming out (or the next one???) I re-read all the ones leading up to it, read a bunch of other similarly longish books

Well, I've got things bass ackwards as so often, having recently finished the Harry Potter series and just put down Swiss Family Robinson (and other kiddie classics - but there are always more, especially since I'm sleeping in my son's old bedroom with the wall to wall bookshelves full).

James Herriot too (love them!). Escapist, relatively mindless literature takes my mind off things, especially if they're upbeat. Have a bunch of Pearl Buck in my Amazon "basket" to check out along with Scoliosis books! And tomorrow I'm sending some Travis McGee to an old boyfriend about to have major surgery for cancer. That's HIS thing!

Just one problem. I found myself REALLY getting my hackles up at all the H.P. references to "hunch-backed witches". Guess I have my politically-correct fixations too. (What should she say? "Spinally challenged cougars"?)

[LindaRacine]

Spine (Phila Pa 1976). 2010 Aug 26. [Epub ahead of print]
Changes in Radiographic and Clinical Outcomes With Primary Treatment Adult Spinal Deformity Surgeries From Two Years to Three- to Five-Years Follow-up.

Bridwell KH, Baldus C, Berven S, Edwards C 2nd, Glassman S, Hamill C, Horton W, Lenke LG, Ondra S, Schwab F, Shaffrey C, Wootten D.

From *Washington University School of Medicine, St. Louis, MO; daggerUniversity California-San Francisco, San Francisco, CA; double daggerThe Maryland Spine Center, Baltimore, MD; section signSpine Institute, Louisville, KY; paragraph signState University of New York at Buffalo, Amherst, NY parallelEmory Orthopaedics & Spine Center, Atlanta, GA; **Northwestern University Medical School, Chicago, IL; daggerdaggerNYU-Hospital for Joint Diseases, New York, NY; double daggerdouble daggerUniversity of Virginia Medical Center, Charlottesville, VA; and section sign section signMedtronic Spinal & Biologics, Memphis, TN.
Abstract

STUDY DESIGN.: Retrospective analysis of data entered prospectively into a multicenter database-clinical and radiographic outcomes assessment. OBJECTIVE.: Our hypothesis is that between the 2-year and the 3- to 5-year points surgically treated adult spinal deformity patients will show significant reduction in outcomes by Scoliosis Research Society (SRS), Oswestry Disability Index (ODI), and numerical rating scale back and leg pain scores and will show increasing thoracic kyphosis, loss of lumbar lordosis, and loss of coronal and sagittal balance. SUMMARY OF BACKGROUND DATA.: Most analyses of primary presentation adult spinal deformity surgery assess 2-year follow-up. However, it is established that in some patients unfavorable events occur between the 2-year and 5-year points. METHODS.: The cohort of 113 patients entered into a multicenter database with complete preoperative, 2-year, and 3- to 5-year data. All patients who had adult spinal deformity and surgical treatment represented their first reconstruction. Diagnoses were scoliosis (82.5%), kyphosis (10%), and scoliosis and kyphosis combined (7.5%). Outcome measures and basic radiographic parameters (curve size, thoracic and lumbar sagittal plane, coronal and sagittal balance) were assessed at those 3 time intervals. Complications (pseudarthrosis/implant failure, infection, and junctional deformities) were assessed at the 2-year and the 3- to 5-year (mean, 3.76 years) points. RESULTS.: The mean major curve Cobb angle (preoperative, 57 degrees ; 2-year, 29 degrees ; 3-5 year, 26 degrees ); thoracic kyphosis T5 to T12 (30 degrees , 31 degrees , 32 degrees ) and lumbar lordosis T12 to sacrum (48 degrees , 49 degrees , 51 degrees ) did not change from the 2-year to ultimate follow-up. Likewise, coronal and sagittal balance parameters were the same at 2-year and ultimate follow-up. SRS total scores and modified ODI were similar at the 2 year and final follow-up (SRS: 3.89-3.88; ODI: 19-18). Preoperative SRS total score was 3.17. Six patients demonstrated complications at the 2-year point and additional 9 patients demonstrated complications at the 3- to 5-year point. Those 9 patients with complications at ultimate follow-up demonstrated significant deterioration in their ODI and SRS scores when compared with the patients who did not have complications at ultimate follow-up. CONCLUSION.: Contrary to our hypothesis, we could not establish deterioration in mean radiographic or clinical outcomes between the 2-year and 3- to 5-year follow-up points when analyzing the group as a whole. However, for the 9 patients who experienced complications between 3- and 5-year follow-up, their outcomes were significantly worse than for the other 104 patients.One should not anticipate an overall radiographic and clinical deterioration of the outcomes of surgically treated primary presentation adult spinal deformity patients in this studied time interval. However, close to 10% of patients will experience a new complication at the 3- to 5-year point, most commonly implant failure/nonunion and/or junctional kyphosis, which will negatively effect the patient-reported outcome.

PMID: 20802383 [PubMed - as supplied by publisher]

[mgs]

I am surprised that a non-union could go for 3 - 5 years without any symptom that would cause suspicion. I am 1 year post-op, and (as of my appt Thurs) there is a question of non-union. Sometime in Jan, I had a hunch that something wasn't right.

[JenniferG]

I am sorry to hear that mgs. Please let us know how it turns out.

I, too, am surprised it could take 3-5 years to notice a non fusion problem. Just when I thought I was outta the woods!

[Ryy]

I'm really worried that i'm developing pjk. I'm 3 wk out of surgery, fused T3-L3 for kyphosis. My curve was pretty high up. My neck seems to stick out forward more than normal. If i relax all my muscles, my neck faces down instead of straight ahead. Is there anything that anyone can recommend for me to do now that might help stop pjk this early on? I try and tuck my chin in as much as possible. My post op appt is in a week. Any input? Hopefully i'm just being paranoid. Thanks

[LindaRacine]

I've been waiting for the paper below to be published for a long time. We're going into a trial with Transition implants next week.

Spine (Phila Pa 1976). 2011 Dec 28. [Epub ahead of print]
The Use of a Transition Rod May Prevent Proximal Junctional Kyphosis in the Thoracic Spine Following Scoliosis Surgery: A Finite Element Analysis.
Cahill PJ, Wang W, Asghar J, Booker R, Betz RR, Ramsey C, Baran G.
Source
1Shriners Hospitals for Children, Philadelphia, 3551 North Broad Street, Philadelphia, PA 19140 2Temple University College of Engineering, Philadelphia, PA 3Albert Einstein Medical Center, Department of Orthopaedic Surgery, Philadelphia, PA.
Abstract
Study Design. Finite element analysisObjective. Via finite element analysis: 1) to demonstrate the abnormal forces present at the top of a scoliosis construct, 2) to demonstrate the importance of an intact interspinous and supraspinous ligament (ISL/SSL) complex, and 3) to evaluate a transition rod (a rod that has a short taper to a smaller diameter at one end) as an implant solution to diminish these pathomechanics, regardless of the integrity of the ISL/SSL complex.Summary of Background Data. The pathophysiology of increased nucleus pressure and increased angular displacement may contribute to proximal junctional kyphosis. Furthermore, high implant stress can be demonstrated at the upper end of the construct, possibly leading to risk of implant failure.Methods. A finite element model was constructed to simulate a thoracic spinal fusion. The model was altered to remove the ISL/SSL complex at the level above the construct. Lastly, the model was altered again by extending the construct one level superior with a transition rod. The angular displacement, the maximum pressure in the nucleus, and stress within the implant were extracted from computational results under two conditions: load control and displacement control. The testing was performed with both titanium and stainless steel implants.Results. Pressure in the nucleus and angular displacement are all increased when the ISL/SSL complex is removed immediately above the instrumented levels, while the screw pull-out force and maximum stress within the screw is decreased. The nucleus pressure increases by over 50%. The angular displacement increases 19-26%. This absence of the ISL/SSL complex simulates the clinical scenario that occurs when these structures are iatrogenically detached. Abnormal mechanics can be restored to normal level by extending the construct rostral one level with a transition rod. Furthermore, the elevated nucleus pressure and angular displacement noted even when the ISL/SSL complex is intact can be avoided with the use of a transition rod. Under the same bending moment (3 Nm), the nucleus pressure at the level immediately cephalad is up to 23% lower than the pressure in a standard construct. The angular displacement is 18-19% less than the standard construct. The maximum implant stress is also decreased by as much as 60%.Conclusions. Finite element modeling suggests that the pathomechanics at the proximal end of a scoliosis construct may be diminished by preserving the ISL/SSL complex and possibly completely eliminated with the use of rods with a diameter transition at the most proximal level.

[Pooka1]

Hey Linda, I saw that abstract but didn't post it because it is still in the mathematical modeling stage.

That said, I thought Dr. Hey blogged about a case of actually using a tapered rod for this situation but I can't find it. I must be confusing it with the u-rod technique for the same problem...

http://drlloydhey.blogspot.com/2011/...nique-for.html

[Pooka1]

Oh hey I was right... he talks about using tapered rods before developing the u-rod. I'm thinking, though, that it must be different than what those guys are modeling.

Often the way we fix this is by using a tapered rod, which goes from a standard 5.5 or 6 mm in diameter down to a smaller diameter to allow for fixation to the cervical spine. These rods, however, can appear a bit too weak when you are trying to lever the spine into a better non-kyphotic posture, even though we also do a bone wedge or osteotomy to help free up the spine so it will be able to move.

[LindaRacine]

Oh hey I was right... he talks about using tapered rods before developing the u-rod. I'm thinking, though, that it must be different than what those guys are modeling.

Yes, I think this is different, but not sure how. I'm going to try to find the time to watch one of the first surgeries that are done.

--Linda

[golfnut]

The transitional rod sure makes sense. How long would it be before surgeons would use it? I am worried about the pressure of a golf swing on the top vertebrae of my fusion.

[LindaRacine]

It's already approved for use. The manufacturer (Globus) needs some of the big centers to get trained on it, and publish some post market results. I think it typically takes at least a few years from the start of the trial, to start seeing new implants in more general use.