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Thread: Dr in New York, LA and other region.

  1. #46
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    I posted this is September 2012. The first bullet is the conclusion from one of the talks BY A SURGEON. It is actually better NOT to fuse the lumbar on these false doubles. Now Neustadt clearly has plenty of experience so I am at a loss about why he did what he did given the material quoted below. The only potential saving grace is that as of 2010, not fusing the lumbar on a false double is apparently still considered controversial but that may be due to the inability of surgeons to balance the fusion. I am simply saying with what I (a lay person) can find in the literature (not to be confused with "truth"), I cannot even begin to imagine allowing a surgeon to fuse my child's lumbar in these situations.

    - if you only want the T curve fused in a false double, you better get someone who has mucho experience - they tend to do selective T fusions much more than less experienced surgeons who fuse well into the lumbar. (I am extremely relieved that our surgeon did a selective fusion on my one kid with a false double. He is non SRS but we were referred to him by an SRS surgeon.)

    It is important to point out that selective thoracic fusion is considered the optimal treatment. So apparently, only the experienced guys are comfortable doing the optimal treatment. This situation sounds completely unacceptable because apparently it is better to NOT fuse into the lumbar on these false doubles and indeed there is a study showing the lumbars under selectively fused T curves in false doubles are stable for at least a few decades (the length of study) in all patients in the study (I don't remember how they were selected). Wait a minute... here it is:

    http://journals.lww.com/spinejournal...ive_Thoracic.5. aspx


    Lumbar Curve Is Stable After Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: A 20-Year Follow-up

    Larson, A. Noelle MD*; Fletcher, Nicholas D. MD†; Daniel, Cindy‡; Richards, B. Stephens MD‡
    Collapse Box
    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.



    And another...

    http://www.ncbi.nlm.nih.gov/pubmed/21030900


    Spine (Phila Pa 1976). 2010 Nov 15;35(24):2128-33.
    Predicting the outcome of selective thoracic fusion in false double major lumbar "C" cases with five- to twenty-four-year follow-up.
    Chang MS, Bridwell KH, Lenke LG, Cho W, Baldus C, Auerbach JD, Crawford CH 3rd, O'Shaughnessy BA.
    Source

    Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
    Abstract
    STUDY DESIGN:

    Retrospective radiographic and clinical study.
    OBJECTIVE:

    To examine the long-term outcome of selective thoracic fusion (STF) performed for lumbar "C" modifier curves in adolescent idiopathic scoliosis.
    SUMMARY OF BACKGROUND DATA:

    The efficacy of STF in lumbar "C" false double major curves is controversial. We examined the 5- to 24-year outcomes of patients with "C" lumbar curves who underwent STF at a single institution to determine which factors help predict successful outcome.
    METHODS:

    Thirty-two patients (age, 14.8 ± 2.0 years) with a lumbar "C" modifier underwent primary STF and had minimum 5-year follow-up (mean, 6.8 years). All patients were fused distally to either T12 or L1. At latest follow-up, 18 were considered successful (group S), 2 required reoperation to accommodate worsening deformity (group R), and 12 were considered marginal outcomes (group M), as defined by >3 cm coronal imbalance (n = 5), >5 mm worsening of lumbar apical vertebra translation compared with preoperative (n = 4), >1 Nash-Moe grade worsening of lumbar apical vertebra rotation (n = 1), >10° thoracolumbar junction kyphosis which was at least 5° worse than preoperative (n = 5), and lumbar Cobb angle >5° worse than preoperative (n = 2). Clinical outcomes were determined by Scoliosis Research Society (SRS)-30 at final follow-up.
    RESULTS:

    Of the multiple factors considered, 2-month postoperative standing lumbar sagittal alignment was most predictive for long-term outcome (P < 0.019 by Kruskal-Wallis ANOVA). Satisfactory outcomes had statistically significantly greater T12-S1 lordosis than those that were marginal (64.8° (group S) vs. 52.0° (group M); P = 0.014) or required reoperation (64.8° [group S] vs. 38.0° [group R]; P < 0.001). Traditionally considered variables such as apical vertebra rotation, apical vertebra translation, Cobb angle magnitudes, coronal and sagittal balance, and their respective thoracic-to-lumbar ratios were not independently significant.
    CONCLUSION:

    Selective thoracic fusions performed for lumbar "C" modifier scoliotic deformities generally have excellent long-term radiographic and SRS-30 outcomes at 5- to 24-year follow-up. Care should be taken to ensure that overcorrection of the thoracic curve is not performed beyond the ability of the lumbar curve to compensate. Furthermore, consideration of selective thoracic fusion should not be ruled out simply because the patient may have a somewhat stiff lumbar curve based on side-bending radiographs.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
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  2. #47
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    Quote Originally Posted by Pooka1 View Post
    Thank you for calling and checking. That was important to do.

    Telling patients he intends to go to L4 on a kid, and NOT telling them this translates to a pretty good chance of eventual fusion to pelvis (per Boachie), and letting the patient and parents stew about that until possibly the day before surgery, is not the kind of surgeon I would ever employ FULL STOP. We don't even know if he wouldn't still go to L4 even if he determined the lumbar was compensatory. This is a textbook example of why more than one opinion is vital. It is also a potential example of someone who CAN'T hit the balance reliably and so has to go to L4 on a false double. Just my opinion.
    I have to agree with pooka. Same thing happens to me, but just because of my flexibility I am used from t4-l1

  3. #48
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    Quote Originally Posted by Kat3573 View Post
    I have to agree with pooka. Same thing happens to me, but just because of my flexibility I am used from t4-l1
    Actually, per that second article I posted, stiff lumbars are not a reason to fuse a compensatory lumbar. So flexibility is not a determining factor.
    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. #49
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    Quote Originally Posted by Pooka1 View Post
    Actually, per that second article I posted, stiff lumbars are not a reason to fuse a compensatory lumbar. So flexibility is not a determining factor.
    Whoops! Well for some reason I was not fused to L3

  5. #50
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    Quote Originally Posted by Kat3573 View Post
    Whoops! Well for some reason I was not fused to L3
    What kind of curve you you have? Do you have more than one?
    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. #51
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    I am so glad you reposted the two articles on Selective Thoracis Fusion (STF) levels. It is certainly on my mind all them time. So correct me if I am misunderstanding the articles but it sounds like:

    A false double is fine not to fused into the Lumbar. The key is to stay balanced. So how does a surgeon do that? During surgery do they sort of feel their way in correcting the T curve leaving room for some L curve to coexist for balance reasons?

    How much effect does rotation play in the end results? Should my son's doctor notes have rotation degrees on the curves?

    Lastly, I am confused about how the last article concluded that stiff lumbar is not a reason to do a long fusion, does that mean flexibility does not play a role?

    How exactly is a false double determined, bending Xrays and size of curve?
    Mom to son with new straight spine 8/15/2013 T16, L16
    Pre op T65, L?
    diagnosed 2/21/13 T55, L42

  7. #52
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    Pooka1 you have some interesting data on your two girls and I can only imagine how happy you are that it all worked out. Just curious if you've given some analysis as to why kid#2 T Curve did not straighten out as much? Same surgeon right? Could it be a difference a year makes in living with a curve even if it is not progressing?

    I have'n't really heard of hyper correction and am now curious about it. Now that you mention it, Dr. Hey does ask patients "how straight to do you want me to get it?" So is there a benefit to leaving a small T curve?

    I guess everyone's body is different and we'll just have to trust our surgeon's judgement....

    So just to confirm both your girls are post-op 3 & 4+ years and they've stabilized in the lumbar, with no progression?

    Do you think boys might be more at risk for Lumbar issues when stopping at L1 and having a false double, given they tend to continue to grown more in high school and college? Does growth also cause just rotation?

    It seems pretty consistent that girls growth hormones slow down after their menstrual cycle.

    And thanks for all your input!
    Mom to son with new straight spine 8/15/2013 T16, L16
    Pre op T65, L?
    diagnosed 2/21/13 T55, L42

  8. #53
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    I had one big curve in the middle of my spine, so the lumbar vertebras were tilted because of the curve

  9. #54
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    Quote Originally Posted by tampamom View Post
    A false double is fine not to fused into the Lumbar. The key is to stay balanced. So how does a surgeon do that? During surgery do they sort of feel their way in correcting the T curve leaving room for some L curve to coexist for balance reasons?
    That is a question for the surgeon! From my reading, as far as I can tell which might be totally wrong, with false doubles, you cannot do a hyper-correction because they will decompensate (lean) left. So I assume the aim to correct the T curve as much as is "safe" and then hope the lumbar matches it. That happened in my kid and apparently usually happens. Still, my kid had some decompensation left that slowly came almost vertical. Now, 3.5 years out, she is pretty much vertical but it took most of that time.

    How much effect does rotation play in the end results? Should my son's doctor notes have rotation degrees on the curves?
    No idea! The surgeon can tell you this. All I can tell you is that he surgeon said Thing One with the pure thoracic was the difficult case of the two so the false double was not the most difficult between them. The false double had no obvious rotation but the pure thoracic was extremely torqued around. Maybe correcting the rotation is what the surgeon meant by being the "difficult" case.

    Lastly, I am confused about how the last article concluded that stiff lumbar is not a reason to do a long fusion, does that mean flexibility does not play a role?
    Apparently. It's the last line of the conclusions, "Furthermore, consideration of selective thoracic fusion should not be ruled out simply because the patient may have a somewhat stiff lumbar curve based on side-bending radiographs."

    How exactly is a false double determined, bending Xrays and size of curve?
    That's my understanding. If it looks like a double major but the lumbar (or thorax) bends out then it is a false double.
    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. #55
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    Quote Originally Posted by tampamom View Post
    Pooka1 you have some interesting data on your two girls and I can only imagine how happy you are that it all worked out. Just curious if you've given some analysis as to why kid#2 T Curve did not straighten out as much? Same surgeon right? Could it be a difference a year makes in living with a curve even if it is not progressing?
    Same surgeon. The reason Thing Two was not hyper-corrected is (at least) that you can't hyper-correct false doubles because they will decompensate left. Even straightening her thorax to 20* caused a left lean for a long time. It slowly came vertical over a few years. Had she been corrected more, maybe she never would have come vertical and it would have strained the lower discs to the point of needing an extension. I have no idea. I do think that the way to avoid extension into the lumbar is to balance the fusion in all three planes so the unfused discs are carrying equal weight at all points.

    Thing One had a different curve that could be hyper-corrected. Her lumbar is not measurable which is why I think the surgeon said she is not expected to ever need more back surgery for scoliosis. Those lower discs are perfectly aligned like in a normal person.

    I have'n't really heard of hyper correction and am now curious about it. Now that you mention it, Dr. Hey does ask patients "how straight to do you want me to get it?" So is there a benefit to leaving a small T curve?
    Well you have to ask more about this to get the straight dope. I have an opinion about this issue, though. Dr. Hey asking people how straight they want to be is just small talk. I am sure they all say "perfectly straight". Every patient wants to be perfectly straight. He does nothing per the patient but only does anything according to his professional experience. He will straighten a patient as much as is safe and not more so as to avoid decompensation and adding on and whatever that would trigger an extension.

    There is a benefit to leaving a small T curve when the curve cannot be hyper-corrected. False doubles apparently cannot be hyper-corrected because they will decompensate left. Pure thoracic curves clearly can be hyper-corrected... Thing One was fused in March of 2008 and has ZERO issues. She has forgotten about scoliosis.

    I guess everyone's body is different and we'll just have to trust our surgeon's judgement....
    That's really the only option. I would not use a surgeon who took their cues from their patients rather than their experience base. That would be incompetent because lay people are incompetent.

    So just to confirm both your girls are post-op 3 & 4+ years and they've stabilized in the lumbar, with no progression?
    Actually we just passed the five year mark on Thing One (pure T) and we are at ~3.5 years on Thing Two (false double). Thing one had no change in either curve from 4 days out until she was released about two years later. Thing Two's lumbar did bounce around a bit between ~19* and ~25* and I think she was 25* when released. It stayed near the T curve mark and I assume it always will. The curve tries to balance itself it seems. That's why decades out they are not seeing problems with selective T fusion I assume.

    Do you think boys might be more at risk for Lumbar issues when stopping at L1 and having a false double, given they tend to continue to grown more in high school and college? Does growth also cause just rotation?
    I have no idea! The surgeon will have a feel for that. It could be an issue in boys but I tend to doubt it because the rotation is due to anterior overgrowth. That's what makes structural curves rotate and what makes them, well structural. The lumbar, not being structural, has no anterior overgrowth. The only reason compensatory curves exist is to balance structural curves. Once you correct the structural curve, the compensatory curve bounces back to match to maintain the balance. The fused spine will not grow longer but the lumbar will. Still, I don't think there is any mechanism for the lumbar to rotate or curve once the T curve is fixed. I think it will grow normally.

    It seems pretty consistent that girls growth hormones slow down after their menstrual cycle.

    And thanks for all your input!
    Please run these questions by the surgeon. I am a lay person.
    Last edited by Pooka1; 03-31-2013 at 09:35 AM.
    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."

  11. #56
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    Quote Originally Posted by tampamom View Post
    She put me on hold to double check his notes, then said they don't do bending Xrays until just before surgery and that L42 was a big curve, we'd want to fusion it, could't leave it alone!
    Like Sharon stated, I too would be very uncomfortable with this approach. To wait until "just before surgery" to have this vital information (and the time to digest, discuss, research options, etc.) doesn't make sense to me.
    mariaf305@yahoo.com
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    Vertebral Body Stapling 3/10/04 for 40 degree curve (currently mid 20's)

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  12. #57
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    hmmmm...i had no surgery scheduled with Dr Lonner in NYC...but
    he wanted bending X rays, which he did in his office...
    it was a shock to me to discover that gravity was deluding me into
    thinking i have any flexibility left...without gravity, laying down on
    table, i had little to no flexibility....

    i do not see any reason for any surgeon to delay bending Xrays....
    doesn't make sense....

    jess

  13. #58
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    Right, Jess - how could it possibly hurt to have this information sooner? There's no downside to doing a bending x-ray sooner rather than later. Makes no sense.
    mariaf305@yahoo.com
    Mom to David, age 17, braced June 2000 to March 2004
    Vertebral Body Stapling 3/10/04 for 40 degree curve (currently mid 20's)

    https://www.facebook.com/groups/ScoliosisTethering/

    http://pediatricspinefoundation.org/

  14. #59
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    Quote Originally Posted by mariaf View Post
    Right, Jess - how could it possibly hurt to have this information sooner? There's no downside to doing a bending x-ray sooner rather than later. Makes no sense.
    There's something funny here. I am not convinced he usually waits for the bending films until right before surgery on all patients. The fact that the nurse couldn't answer the question right away may mean it was strange and she needed some sort of explanation. I suspect Neustadt just assumed the lumbar was structural because of the size and because the ratio of the T to the L is not greater than 1.2. I have seen that "rule" somewhere, I think among Lenke's writings. But given that Lenke himself backed off that rule with this patient (if it was his writing), then others should damn well back off too! I'm just speculating wildly here! But something is funny.

    There are some surgeons out there who will never be my surgeon FULL STOP.
    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."

  15. #60
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    Had fusion from T9-S1 with Dr. Boachie 10 months ago. Today, no more low back pain. He is surely a gifted surgeon.

    Best of Luck to you!

    Quote Originally Posted by titaniumed View Post
    Tampamom,

    More info

    Here is a Dr Boachie interview..... Its mainly about adults but mentions what Sharon had been talking about in fusing to L4.


    http://www.hss.edu/professional-cond...l-stenosis.asp

    If you fuse a 13-year-old to L4, 20 to 25 years later, at the most, he or she is going to have problems at L4-5 and L5-S1 levels. So I tell them to take it easy a little bit, and avoid excessive high impact, rotational sports and activities, no other things that will cause early degeneration. But if you fuse them to L1 or T12, they can do very well for the rest of their lives, provided the remaining lumbar spine is properly aligned and has not shifted.

    Ed

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