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Thread: Average Progression rates

  1. #46
    Join Date
    Sep 2003
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    Northern California
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    6,797
    Adjacent level disease can be caused by many things, but I think the one thing the best surgeons will tell you is true is that if the wrong level is selected, leaving the vertebrae below the lowest instrumented vertebrae or the vertebrae above the highest instrumented vertebrae, in a non-horizontal position, leaves the patient more vulnerable to ALD. I think it also can be caused by choosing a top vertebrae that is at a level vulnerable to the forces in the sagittal plane. For example, I think that patients who need to be fused starting at around L1 are usually actually started at T10 or T11 to avoid this problem.

    I'm far from being an expert on the subject, and have actually read relatively little of the literature, so as always, I suggest that patients (or parents) follow the advice of qualified professionals.

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
    I'm sarcastic... what's your super power? --Unknown
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation
    ---------------------------------------------------------------------------------------------------------------------------------------------------
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  2. #47
    Join Date
    Jan 2008
    Location
    NC
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    8,901
    Thanks, Linda.

    So in both cases you mention, leaving a tilted vertebra and not stabilizing an area that is not structural but vulnerable to sagittal forces, isn't that the trade-off I spoke off? Isn't that trading a risk of ALD for increased flexibility?

    All of these decisions seem to reduce to reducing risk of further problems by going longer versus taking a risk to preserve flexibility. I can imagine some folks who have a high risk of developing ALD below a fusion to just go ahead and fuse a final 2 or 3 vertebrae to reduce the risk to exactly zero. Or maybe the difference in flexibility is so large with leaving L4, L5 and S1 unfused such that many patients will opt to take a risk of ALD and not fuse them.

    In reading testimonials, it seems some pediatric guys will only go to L3 on some double major curves in kids whereas an adult surgeon might go lower on an adult patient with similar curves. So maybe there is a big difference in flexibility fusing to L3 versus L5 or S1. In kids, some times this risk pays off and sometimes it doesn't. There were three cases I can think of where only fusing the top curve and stopping at T12 or L1 did not seem to work (at least in the short term) but I have to believe it works sometimes or else surgeons would never chance it. That seems to clearly be a case of accepting large risk for the big reward of a flexible lumbar.

    Hopefully the surgeon can accurately convey the risk of various issues when deciding to go shorter versus longer so hte patient can make an informed decision.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  3. #48
    Join Date
    May 2009
    Posts
    3,745
    hi Sharon
    i think there is a very big difference in flexibility between fusing to L3 vs/sacrum or lower!! i would LOVE to only need fusion to L3 or even L5!! but i need fusion to pelvis! Dr Lonner told me there is little difference between fusing to sacrum vs/pelvis...but fusing to L3 is much better for flexibility than fusing lower!! thus, most surgeons try to fuse children only to L levels so they have the flexibility when young...

    have a great wkend...

    jess

  4. #49
    Join Date
    Sep 2003
    Location
    Northern California
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    6,797
    Quote Originally Posted by Pooka1 View Post
    Thanks, Linda.

    So in both cases you mention, leaving a tilted vertebra and not stabilizing an area that is not structural but vulnerable to sagittal forces, isn't that the trade-off I spoke off? Isn't that trading a risk of ALD for increased flexibility?
    Yes, I guess that's correct. In adults, at least with the surgeons I work with the most, there's very little talk about preserving motion segments. I'm sure it comes up occasionally, probably mostly when a patient has the concern. I'm sure it's more of an issue with kids.

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
    I'm sarcastic... what's your super power? --Unknown
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    If you've signed up and are having trouble posting, please check your spam folder. An email was sent to the email address which you subscribed. You have to follow the instructions in that email. Done that and still having trouble posting? Contact Joe O'Brien at jpobrien@scoliosis.org.

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