Problems After Spinal Surgery - Crankshaft

[rtremb]

Del:

I am so sorry to read about Elysia. She has already been through so much and so bravely too. It makes me very sad to read that this has happened to her.

Ruth

[FixScoliosis]

crankshaft

Kitty

crankshaft phenomenon occurs because the anterior parts of the spine keeps growing despite the rods in the back. Now the spine cant go on forever in a lordosis (as will happen if the anterior parts keep growing), the body will resist that and thereofre the spine begins to buckle sideways. (there is an exception, a rare condition called 'prune belly syndrome')

Now the rods are holding the posterior part in place and the front wants to keep growing. what happens? It has been shown in idiopathic scoliosis that the pedicles itself grow/develop different lenghts between the left and right side and we end up with deformed vertebrae.

The pedicle screws are a major breakthrough in scoliosis surgery as they don't allow the pedicles to grow to different lengths..

[Pooka1]

Yep that's right Sharon!! He Obviously had no idea!!! I want to ask him at our next appointment why pedicle size doesn't show up on x-rays - but what's the point now??? Or perhaps it DOES show up but he didn't think to check it - maybe he's never come across very tiny pedicles before!!!!

Del, after you wrote this I spent some time trying to find information on whether surgeons can accurately access pedicle size from appropriately scaled radiographs.

I haven't found anything definitive but I can tell you I came across a site that said if there is any doubt, use hooks. They added an exclamation after each time they said that. So there is a high caution factor when it's a close call between hooks and screws.

That, however, doesn't answer the question of whether he went in there KNOWING he would have to use hooks. Your daughter had a very low Risser and the curve was in the high 40s*, is that right? I don't know how fast the curve was moving.

I re-read your blog and note that Dr. Cree mentioned the possibility of crankshaft. What I would like to know are the actual numbers of crankshaft cases in the patient population with a Risser of zero who were fused with all hooks. It may still be a small percentage in which case other factors may have been used in decided to operate when he did. Let's hope that is the case. I'm having a hard time imagining that he would go in there even with the possibility of having to use all hooks if the likelihood of crankshaft was high.

[FixScoliosis]

regarding crankshaft phenomena I found this paper published in 1995.

Posterior arthrodesis and instrumentation in the immature (Risser-grade-0) spine in idiopathic scoliosis
says the following:

"Patients less than
ten years old, and older premenarchal patients who
have a Risser grade of 0 and open triradiate cartilages,
are likely to have progression of the curve after a posterior
arthrodesis; thus. we recommend an anterior
arthrodesis for these patients."

[Pooka1]

Hey FS,

Do you know if radiographs can have a scale factor to accurately size the pedicles? I think they can do this. I'm sure there are close calls but maybe some cases can be clearly shown ahead of time to be too small for screws.

When I asked about the possibility of crankshaft with my daughter (Risser = 0 at that time though 3 at surgery), the surgeon responded very quickly and positively that there was almost no chance. Now I don't know how he was so sure but I now suspect it's because he saw the size of her pedicles and knew he could use all screws if he wanted to. (He used two hooks on the top left I think for the kyphosis and to de-torque her rotation where screws might pull out).

We don't know the particulars in Elysia's case but it would be edifying for parents to figure out what the surgeon knew and how he made his decisions.

[Snoopy]

Del,

My heart goes out to your family. I would question your surgeon as to why he didn't know the size of Elysia's pedicles going into surgery and here's why:

Jamie had a CT scan before surgery for just this purpose--to check the size of her pedicles. The report reads in part: "COMMENT: As requested, pedicular diameter was assessed at T1 through T4 as well as at T12 through
L5. Measurements are as follows" and it goes on to say T1 Right-.6cm Left-.6cm. Hers ranged from .1 cm to .6 cm. Not that I know what that means.

The report from her surgery states: "We had recommended doing Smith-Peterson osteotomies to help correct posterior her kyphotic deformity unable to use pedicle screw fixation due to the narrowed pedicles."

Hang in there and know we are all here for you.

Mary Lou

[FixScoliosis]

Hi Pooka1

I could not find any really good papers on x-ray measurement and pedicle size.
there was some papers suggesting that a CT should be performed...
however, abstract for: Pedicle Morphology In Thoracic Adolescent Idiopathic Scoliosis: Is Pedicle Fixation an Anatomically Viable Technique? says
"Measured dimensions from the CT scans showed the actual pedicle width to be 1-2 mm larger than would have been predicted from the plain radiographs."

and these papers might provide more/better understanding.
Placement of pedicle screws in the thoracic spine. Part I
Placement of pedicle screws in the thoracic spine. Part II

[Aussiemum]

Hey thanks!!! That paper made very interesting reading. I guess I'm glad our surgeon didn't RISK IT by TRYING to use the screws and then perforating her pedicles or entered into the spinal canal! So I'm thankful for that.

I don't think he knew that her pedicles would be so tiny Sharon - but in hindsight I wished he had just closed her up and came back another day for an anterior release before the posterior fusion.

I guess this is informative for all those going into surgery, to ensure that the Dr has done everything in his power to ensure that he knows pedicle size - ESPECIALLY on the Risser 0 children.

Cheers
Del

[Karen E.]

Problems After Spinal Surgery - Crankshaft

Hi. I had posted a similar question in the section dealing with scoliosis due to other causes...neuromuscular in our sons case (Cerebral Palsy). I didn't think to check in the other section but was doing a search on line and this thread popped up. I guess I figured what our son was going thru was directly related to the severity of his cerebral palsy and that it wasn't as common in children dealing with scoliosis alone.

Our son went into puberty and developed sudden onset scoliosis. Within a years time he went from a good looking spine to an 82 degree curvature. He has spastic quad CP but his trunk area has always been very floppy...never sat up on his own and even when assisted he could not really sit up straight. At age 13 surgery was done. They were only able to do a posterior surgery in his case due to the high risk of doing anterior surgery...opening up the chest, collapsing a lung in order to put hardware in front of the spine. Based on his xrays they hoped that if he grew anymore it would be minimal. Unfortunately that wasn't the case. He continued to grow and the curvature increased. It has now leveled out at about 72 degrees...it's hard to tell...one measurement said 78 but that's xrays taken trying to sit him up with support so the most recent xray isn't all that great looking.

I did all sorts of research on line and was trying to understand what was happening. I didn't understand why the anterior wasn't done until it was explained that he was already high risk for the posterior surgery which also included going in from the side to do repair of the lower vertebrae...a couple were pretty messed up. The result has been that the vertebrae continued to rotate when he grew so now the front left side of his rib cage (standing behind him) protrudes pretty bad. The right rib cage is pushed back causing an elongated hump on the back right side.

I don't know how it works with children dealing with just scoliosis. I would think that corrective surgery would be easier? For our son two surgeons have said that further surgery would be risky respitory wise...and that's even with him not having any real issues at this point...that they can't do anterior and in the end even if they got some correction in the curvature they cannot repair the resulting ribcage deformity. For us it is now just monitoring....will see a pulmonologist to see if there is any impact at this point on the lungs and continue to check on the curvature. As long as it remains stable then we should be ok.

Like I said...I didn't check the section that dealt with just scoliosis but after reading the posts it added to my understanding of what happened with our son and his surgery. He looked so good after the surgery and like I told his surgeon...I think I thought it would just stay that way. I didn't really understand I guess that it was a gamble and due to the CP the odds weren't in his favor. Hope that for those of you dealing with it with your own kids that the outcome is much better.

Karen

[pmsmom]

Dear Del,

I'm just finding this thread now. Know that you and Elysia will be in my thoughts and prayers. Please do keep us posted as to how both she and you are doing!

Marian

[Aussiemum]

Quick update!

Big Sigh of relief!!! SIGH!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Went and had a second opinion with another surgeon and it appears that Elysia is not in "Full Crankshaft Phenomenom mode". It appears that what has happened (according to THIS surgeon) is her L1 Vertebrae (bottom of her fusion) has tilted and the thoracic has "sprung" back and rotation has occured! ??????? Mr Lumbar is now being naughty and will have to be put into chains and shackles to match Mr Thoracic! She was 46° going into surgery - 10° after surgery and is now back to 26° - that sounds all sooooooo odd to me!!!! We were told there is always SOME degree of springing back to the orginal shape - but wowwwww!!!!! That's some tough back this kid has got!

So we were told it's a "kind of crankshafting" - not the kind that happens in very very young children.

We were advised that it will be a piece of cake to open her up and extend her fusion down into her lumbar area!!! Wow!!!! It sounds like soo much fun - I can't wait and either can Elysia!!! WTF?? Piece of cake? Who the hell for??? LOL - oh a sense of humour must prevail or I'll go insane!!!

I guess what he REALLY meant was ..... piece of cake to kind of repair her than the nightmare of surgery if she was fully crankshafting!!!

So dear Scoli folks and folkettes - I guess we'll just sit tight and wait for the next installment in the fun and games of life and the next Photo and info session in June (aka x-ray and appointment) - Elysia always wanted to be a model, she never knew it would be of her insides!!!!!

And.... let me tell you right now peoples, for all those that followed the happy saga first time around...... she AINT getting another pet out of this surgery!!!!!!!

Alt3
Del

[Pooka1]

Great second opinion!!

Del,

I am glad and relieved to hear that the next surgery will be far more limited than the first.

These guys are amazing... they can fix anything it seems.

I would like to nominate your post for most humorous post in the face of further surgery. I especially liked the "not another pet" and the "folkettes"!

I won't tell you to hang in there because you obviously are already doing that!

Best regards,
sharon

[rtremb]

Del:

I have been wondering how Elysia was doing. I am sorry to read she will need another surgery. I sense a lot of pain behind your humourous post.

On the one hand it is reassuring the doctor thinks he can fix this - I hope he is right. I'd seek at least one other doctor's opinion if I were you just to be sure the right surgery is done this time.

Thinking of you often.

Ruth

[laurieg6]

I am so sorry that Elysia probably has to have another surgery. Is it definite or is the doctor waiting a few months to see if there's a chance her spine will settle down? Can you wait a while to do the surgery or do they think it should happen really soon?

I wish you all the best and hope that Elysia will soon be done with surgeries forever!

[Aussiemum]

Hi Laurie,

We are now waiting for her June x-rays and appointment to see what the prognosis is, but really her body shape looks to me just like it did now prior to her surgery!! Her Rib hump is no where near as bad as it was prior to her initial surgery but major problems with her breasts. Because of the rotation happening now (or is it the "springing back???"), she has 1 breast vastly different from the other.
At our appointment last week for our 2nd opinion, he suggested a Breast implant to balance her out when she's finished growing.

So we play the waiting game now until June and even then I guess we'll wait it out as long as we can. The good news was that we were told she's now Risser 2 or 3.

That's the funny thing about all this, our surgeon told us she had heaps of growing left to do - and then our 2nd opinion told us he thought she was almost done!!! WHAT EVER I say!!! I wish they would get together and have a coffee or something!!! I'd shout them!! LOL

Cheers
Del