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Thread: Real or for argument sake range of opinion?

  1. #1
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    Real or for argument sake range of opinion?

    This is a session from the upcoming IMAST conference in Istanbul this year...

    http://www.srs.org/UserFiles/file/IM...elim-Final.pdf

    If this is the actual range of opinion then I think there is no clear best solution unfortunately. I didn't realize that if true.

    My main question to these guys would be what is the best chance of saving the lumbar which I am guessing is structural given the size in relation to the T curve.

    Boy I would love to hear this session. For Newton to immediately fuse both curves, he must have a boatload of data showing selective fusion does not work in this case. Or maybe he only intends to fuse to L3 in any case. Certainly the gods hate this child, hypothetical or otherwise.

    Debate #3: Optimal Treatment for a 13-Year-Old, 6-Month Post-Menarchal
    Elite Soccer Player with a 45-Degree Thoracic, 40-Degree Lumbar Lenke
    3C Scoliosis

    Moderator: Azmi Hamzaoglu, MD

    8:15 Optimal Treatment is Observation
    Paul D. Sponseller, MD

    8:25 Optimal Treatment is Selective (Thoracic Only) Posterior
    Instrumentation
    B. Stephens Richards, III, MD

    8:35 Optimal Treatment is Fusion of Both Curves
    Peter O. Newton, MD
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

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


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  2. #2
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    It's too bad that they don't televise these things. I would LOVE to hear the whole program. Makes me wish I was a doctor sometimes.

    I forgot how large your girl's lumbar curves were, but I remember that they didn't fuse them. IF I have surgery, Tribus is planning on fusing both curves and I've never had a bending x-ray. Albeit, I'm not a 13 y/o anymore, but the curve magnitudes are scarily similar to mine. It would be interesting to hear how this debate turns out. Dr. Tribus said he would "watch" a 12 y/o with a 46* curve the last time I saw him. So, yes, there really IS a wide range of thought out there. That's what makes it so confusing. Someone could go to three different doctors and get three different opinions. OR, in my case, go to ONE doctor and get three different opinions. LOL ...Not that it's really funny. It's frustrating.

    No, the "god's" don't hate this child. Life is just unfair, as you told your girls. =)
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  3. #3
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    Quote Originally Posted by rohrer01 View Post
    I forgot how large your girl's lumbar curves were, but I remember that they didn't fuse them.
    Kid 1 (T4-L1 fusion): preop L34*; postop L~0*

    Kid 2 (T4-L1 fusion): preop L39*; postop L19* - L26* (bounced around)

    The issue is my kids had only one structural curve and I think the hypo child has a double major. But still, I think they should stand on their head to save the lumbar by staying above L3.
    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."

  4. #4
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    Quote Originally Posted by Pooka1 View Post
    Kid 1 (T4-L1 fusion): preop L34*; postop L~0*

    Kid 2 (T4-L1 fusion): preop L39*; postop L19* - L26* (bounced around)

    The issue is my kids had only one structural curve and I think the hypo child has a double major. But still, I think they should stand on their head to save the lumbar by staying above L3.
    Are you sure Kid 2 doesn't have a structural lumbar? Bouncing around between 19* - 26* sounds like she's not out of the woods with her lumbar just because of what we are seeing with people progressing to surgical levels with reletively small curves at maturity. Isn't she the one who wore the brace? I'm curious to know how similar their curves were prior to bracing Kid 2. I know you said that one had more rotation than the other.

    I agree about staying above L3 if possible. But extending a fusion for some of these kids later on in life may be an unavoidable eventuality. I will tell you that the wearing out process of developing DDD is very painful even in the "early" stages. It just makes me wonder sometimes if fusing the whole spine would save pain later on in life or create more. I had a doc tell me that they have artificial discs that they are actually using at our hospital. I've only seen them in a cadaver spine on the internet. It's really quite interesting. When I think about how they work (they pivot on a ball bearing or at least it appeared that way to me), I wonder if they could tweak these discs to have a range of motion that could actually correct a curve by individually adjusting each artificial disc to have only a limited range at each level specific toward the tendency of the curve. That way some motion would be lost, but not all motion and fusion would be avoided. I'm just thinking out loud.
    Be happy!
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    Quote Originally Posted by rohrer01 View Post
    Are you sure Kid 2 doesn't have a structural lumbar?
    There is no doubt the lumbar is not structural. It bent out to to L4*. The goal with the false double that she has seems to be to leave a balanced smaller double curve as far as I can tell. And that is what the surgeon did. Overcorrecting the T would have been wrong and would not have driven more correction in the lumbar as I understand these surgical papers and I may not.

    Bouncing around between 19* - 26* sounds like she's not out of the woods with her lumbar just because of what we are seeing with people progressing to surgical levels with relatively small curves at maturity.
    No it is not the same. The curves under fused spines don't behave in the same way as untreated curves. She will likely be stable for at least 20 years...

    http://www.ncbi.nlm.nih.gov/pubmed/21971127

    Spine (Phila Pa 1976). 2012 May 1;37(10):833-9.
    Lumbar Curve Is Stable After Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: A 20-Year Follow-up.
    Larson AN, Fletcher ND, Daniel C, Richards BS.
    Source

    *Department of Orthopedic Surgery, Mayo Clinic, MN †Division of Pediatric Orthopaedics, Emory Orthopaedics and Spine Center, Atlanta, GA; and ‡Texas Scottish Rite Hospital for Children, Dallas, TX.
    Abstract

    STUDY DESIGN.: A retrospective cohort study comparing long-term clinical and radiographical outcomes using selective thoracic instrumented fusion versus long instrumented fusion for the treatment of adolescent idiopathic scoliosis (AIS). OBJECTIVE.: To evaluate long-term behavior of the lumbar curve in patients with AIS treated with selective thoracic fusion and to assess clinical outcome measures in this patient population compared with those patients treated with fusion in the lumbar spine. SUMMARY OF BACKGROUND DATA.: Selective thoracic fusion for the treatment of AIS preserves motion segments, but leaves residual lumbar deformity. Long-term results of selective fusion using segmental fixation are limited. METHODS.: Nineteen patients with AIS treated with selective thoracic fusion and 9 patients treated with a long fusion returned at a mean 20 years (range, 14-24 years) postoperatively for radiographs, clinical evaluation, and outcome surveys (Short Form-12, Scoliosis Research Society-24, Spinal Appearance Questionnaire, Oswestry Disability Index, and visual analogue scale for pain and stiffness). Curve types were Lenke 1B, 1C, or 3C. All patients underwent posterior fusion with Texas Scottish Rite Hospital or Cotrel-Dubousset hook-rod instrumentation. RESULTS.: The selective thoracic fusion group had no significant progression in the lumbar curve magnitude and no worsening of L4 obliquity to the pelvis between initial postoperative and 20-year follow-up. Mean preoperative lumbar curve magnitude (mean, 44°; range, 32-64) corrected 43% on initial postoperative films versus 38% at latest follow-up. Mean L4 obliquity to the pelvis, trunk shift, sagittal balance, and coronal balance were stable over time. Outcome scores between the 2 groups were similar. Scores in long fusion group, when compared with the selective group, were higher for 2 Scoliosis Research Society domains: self-image after surgery (P = 0.005) and function after surgery (P = 0.0006). CONCLUSION.: Spinal balance and correction of the lumbar curve remain stable over time in selective thoracic fusion. Those with selective fusions have outcome measures comparable with those with long fusions.
    Isn't she the one who wore the brace?
    Yes.

    I'm curious to know how similar their curves were prior to bracing Kid 2. I know you said that one had more rotation than the other.
    They both had single T curves but that is where the similar ends. The T curve types were different types and the rotation amount could not have been more different although they were very close in angle on the table (high 50s*).

    I agree about staying above L3 if possible. But extending a fusion for some of these kids later on in life may be an unavoidable eventuality. I will tell you that the wearing out process of developing DDD is very painful even in the "early" stages. It just makes me wonder sometimes if fusing the whole spine would save pain later on in life or create more. I had a doc tell me that they have artificial discs that they are actually using at our hospital. I've only seen them in a cadaver spine on the internet. It's really quite interesting. When I think about how they work (they pivot on a ball bearing or at least it appeared that way to me), I wonder if they could tweak these discs to have a range of motion that could actually correct a curve by individually adjusting each artificial disc to have only a limited range at each level specific toward the tendency of the curve. That way some motion would be lost, but not all motion and fusion would be avoided. I'm just thinking out loud.
    Surgeons seem very reluctant to put kids in countdown mode. They want them to have as much flexibility as possible for the longest time possible as far as I can tell. That seems to be what drives Dr. Hey from what I can tell.
    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."

  6. #6
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    Kid 2:

    L26* (10/10/09)
    L19* (10/29/09)
    L25* (6/14/10)

    All are under the magic 30* any road.
    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."

  7. #7
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    I don't think the cases are necessarily real, and I'm fairly certain that the treatment options are assigned rather than being a surgeon's actual preference.
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
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    Quote Originally Posted by LindaRacine View Post
    I don't think the cases are necessarily real, and I'm fairly certain that the treatment options are assigned rather than being a surgeon's actual preference.
    I would have assumed that these would have been based on "real" cases with doctors debating on how they would preferably treat the case. I guess I'm wrong???
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    I wrote:

    The goal with the false double that she has seems to be to leave a balanced smaller double curve as far as I can tell. And that is what the surgeon did. Overcorrecting the T would have been wrong and would not have driven more correction in the lumbar as I understand these surgical papers and I may not.
    I read some papers and I think the issue is decompensation to the left if you overcorrect the structural T curve of the false double. There is also the issue of adding on if you pick the wrong lowest instrumented vertebrae which also limits how much correction you can get in the T curve and therefore how much correction is driven in the L curve. These may be two sides of the same coin... I don't really know.

    I think the surgeon went as far as he could because Kid 2 was decompensated to the left after surgery and then slowly came more towards vertical over time. She still has a slight list which may or may not be apparent to anyone but someone who knows to look for it. But her curves are stable and expected to remain so with her treatment.

    In contrast, Kid 1 had a pure T curve and the surgeon was able to hypercorrect that to "no residual scoliosis in the T spine" which then drove the L spine straight without touching it. She had almost the same Cobb on the table as Kid 2 yet had a completely different outcome.

    Kid 2's curve was dicey in my opinion because of the decompensation and adding on issues but the surgeon said that was straightfoward but Kid 1's case, who ended up with a straight spine, was not. That comment must have been referring to the extreme rotation but it could also be referring to adding on that can happen in that type of T curve if the wrong lowest instrumented vertebra is selected. These surgical papers are very dense in my opinion and that is what I think they are saying. It would be good to have a surgeon here to dope slap me if I am off base.
    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."

  10. #10
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    Sharon,

    Are you going to keep following up with Kid 2, or encourage her to do so after age 18? It only concerns me for her because she was left with a fairly significant L curve even though she's fused up top. I guess I'm thinking perhaps she might have more rapid degeneration on down the road when she reaches middle age. I realize that not everyone gets a "straight" spine after fusion and that the goal is to stop progression in its tracks and hope for improvement. I just hate to see anyone suffer with back pain. It's so debilitating. But as long as she's pain free now, she'll at least get to enjoy a significant part of her life without pain.

    My daughter has smallish curves and has pretty severe back pain at times. I'm just kicking myself for not having her seen by a scoli doctor. BUT, in my own defense, I needed a referral to anyone besides a GP with the insurance that I had at the time. She was only referred to a regular ortho. :-( Now I can't convince the girl to even get a follow up and it's been TEN years since she's been measured.
    Be happy!
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  11. #11
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    Quote Originally Posted by rohrer01 View Post
    Sharon,

    Are you going to keep following up with Kid 2, or encourage her to do so after age 18?
    Probably not past college unless it goes above 30*. But even then I am guessing there were plenty of cases in the 20 years study of lumbars starting out >30* and still there was no sign of instability after decades. It probably isn't necessary to follow it but we'll see if they follow that group out to 30 or 40 or 50 years if anything happens. It seems like with the T curve treated and locked in so to speak, maybe the L can't collapse. Don't know. Even though that paper only had a relatively few patients, they all were stable at least 20 years out. In that case, you get to put your conclusion in the title I guess. :-)

    Kid 1 with the straight spine was told explicitly she was done with scoliosis surgery for life. I did not ask about Kid 2 and he didn't volunteer it nor did he tell me to follow up with other surgeons. He knew that he told me about the issue of their fusions ending at L1 and that, given all else with the case, was protective against the need for future surgery for scoliosis. That's my understanding and that one paper seems to back it up somewhat even for the unfused part of the spine.
    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."

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