Surgery on just 1 of 2 curves...?

[mebo]

Hello people. Since I last wrote I had a second opinion and was seen by Dr. Ted Wagner at UW Bone and Joint in Seattle. His evaluation says that my lumbar curve is 60 plus and my thoracic is approx. 45 degrees. He proposes a "posterior" intrumentation from T11 to L3. The letter says that he would then (during surgery I think) x-ray to see if L4 had become "horizontal" or not, it if it still tilted he would "extend" to L4. He says he would like to "ignore" the upper curve and that it might "go below 25 degrees" (after surgery I guess, on its own). Most of my pain and visible deformity is definity connected with the lower curve, although that hump on the left side of my back is nearly smack in the middle. I am told the hump is partly so visible because of the rotation of my vertebrae so that the little wings that protrude out are sticking outwards more than they should. The doc said that he would basically be twisting those vertebrae to reduce the rotation.

So these are my concerns and questions: Won't my thoracic curve sort of go bonkers when it's buddy is gone -- it is there to "compensate" or balance out the bigger curve, so what typically happens next...? And when I am having to sit around like a veggie, recovering and not moving much, how can I be doing the exercises and stretches I should, to help the thoracic spine..?

My second concern is, is the rest of my lumbar/sacral spine now going to take on a huge load due to the fusion above it, and my discs degenerate faster/ more pain? and will the rest of me, my hips shoulders, knees, be all out of kilter and in pain, since their lifelong balance is gone?

I don't really know how big or long this proposed fusion is, but i guess the shorter, the less your range of motion is compromised is good, since I love to be athletic -- I do ultimate frisbee, I lift weights, I bike, I swim, I stretch, and i am so sick of pain but I am so scared of losing my athletic abilty.

I am forty, single, two kids, in the middle of a career change. THis surgery would happen in December, when each of my parents can take about a month to come help me..

ideas folks?

[LindaRacine]

Hi Mebo....

Those are all excellent questions for your specialist. Unfortunately, there is no way of absolutely knowing what will happen, but your specialist can certainly talk to you about the possibilities.

Regards,
Linda

[Suzy]

Hi Mebo,

I didn't have 2 curves just lumbar. I am fused T10 to L4 (5 1/2 months ago.) I too was very active and was told all I will need to give up is waterskiing (Due to the unexpected and hard crashes.) I was concerned about the discs below my fusion but have learned since I started P.T. that you learn to how to move and how to strengthen your core to protect those last couple of discs. You won't need to work on those muscles till you have recovered a couple of months or so. I started at 4 months. The balance issue you asked about is one I remember my Dr. stressing to me. He wanted to get me balanced and that didn't necessarily mean complete correction of my curve. I can't see your Dr. leaving your thoratic curve if it was going to throw off your balance. I wonder if he expects to get your lumbar curve to around the same degree of curve as your thoratic. Thus balancing you that way? I think I have read that some with the regular S curve are balanced out due to the top and bottom curves. I was really off due to the C shaped curve I had. The fact that you are active and I assume you are in shape will help in your recovery tremendously! I too was a weight lifter (Hate cardio.) Scubadiver, rollerblader, swimmer and snowskiier. Sometimes I would waterski too but it wasn't as much a part of my life as the other things, it doesn't bother me that I have to quit it. My P.T. was amased at the amount of muscle tone I still had after not lifting for 4 months. It has helped me so much, it will you too. I don't think you will loose your athletic ability. I also don't have my hump anymore. That is from spine rotation. I am 43 and don't even worry about that at all (Loosing athletic ability) now that I have been through this. Another thing as one Mom to another. I was able to drive my kids around and do grocery shopping at 4 WEEKS! You will have lifting restrictions but thats what the baggers are for at the store then kids to unload at home. I hope this has helped. Sorry it was so long........

[mebo]

Thanks Suzy. I know, as Linda says, there will be variations in what happens, but I really want to hear from as many people as possible who have actually experienced this, since the professionals are all maddeningly vague in resoponse to these sorts of questions and haven't actually lived it. I want to know what real people have really experienced firsthand. Your description is helpful, since it sounds like our circumstances are similar in several respects. I do have great faith in my sheer physical strength, and like you I can retain a surprising amount of muscle and rebuild it quickly. I think that when we work out and build muscle it also keeps our hormones up, which keeps our skin and energy level and bone density (and maybe mood) up, too. I think the concept that scares me most is that the area of fusion will not be flexible; it's hard for me to imagine what that will be like, and what movements I won't be able to execute anymore.

Meanwhile, I seem to have ripped my medial collateral ligament (on the interior of my left knee) playing ultimate frisbee friday night! So now I am limping around with crutches, will have an MRI on tuesday. Argh!

mary

[LindaRacine]

Selective anterior fusion of thoracolumbar/lumbar curves in adolescents: when can the associated thoracic curve be left unfused?

* Sanders AE,
* Baumann R,
* Brown H,
* Johnston CE 2nd,
* Lenke LG,
* Sink E.

Christus Santa Rosa Children's Hospital, San Antonio, Texas, USA. asanders09@msn.com

STUDY DESIGN: A retrospective multicenter study was conducted to investigate patients with a major thoracolumbar/lumbar adolescent idiopathic scoliosis and an associated minor thoracic curve treated with an anterior instrumentation and fusion of the lower curve. OBJECTIVE: To establish criteria for determining when such curves can be successfully treated by an anterior only procedure of the lower curve with acceptable spinal balance and residual thoracic curve. SUMMARY OF BACKGROUND DATA: Anterior spinal instrumentation techniques have been proved effective for the management of isolated thoracolumbar/lumbar scoliosis with small compensatory thoracic curves. The success of a selective anterior fusion when the associated thoracic curve had some structural changes in a small preliminary study was variable and was the stimulus for this study. METHODS: A multicenter study involved 49 adolescent patients with a major thoracolumbar/lumbar curve in which the associated minor thoracic curve measured between 30 degrees and 55 degrees. In all the patients, the apical vertebra of the lower curve lay outside the midsacral line, and the thoracic apical vertebra fell outside a line dropped from the center of C7. Multiple radiographic parameters were evaluated. The Risser sign, height, weight, onset of menses, and closure of the triradiate cartilages were studied to access the patients' maturity. All the patients were observed at least 2 years. Patients were considered to have a satisfactory result if the thoracic curve at the final follow-up assessment measured 40 degrees or less, if balance and sagittal alignment were reasonable, and if additional procedures were not required. RESULTS: At final follow-up assessment, two groups emerged. Group 1 (n = 43) had satisfactory results. The preoperative thoracic curve in this group averaged 40 degrees and 26 degrees after surgery. The lumbar curve averaged 56 degrees before surgery and 22 degrees after surgery. Group 2 (n = 6) had unsatisfactory results. The average thoracic curve was 49 degrees before surgery 54 degrees after surgery, whereas the lumbar curve averaged 59 degrees before surgery and 27 degrees after surgery. Three of these patients underwent posterior thoracic instrumentation and fusion. CONCLUSIONS: Statistical analysis showed that a successful surgical outcome was dependent on both the structural changes in the thoracic curve and the patient's maturity. The thoracolumbar/lumbar-thoracic (TL/L:T) Cobb ratio in combination with the degree of the thoracic curve on lateral bending was the best predictor among the structural indexes. Of 44 patients with a TL/L:T Cobb ratio of 1.25 or greater and/or a thoracic curve, which bent out to 20 degrees or less, 42 had a satisfactory result. The best predictor among the maturity indexes was closure of the triradiate cartilages. Of 43 patients in whom the triradiate cartilages were closed, 42 had satisfactory results. When this data is combined, the outcome for the thoracic curve can be reasonably predicted.

[Suzy]

Correction

MARY! Like you don't have enough pain from your back now your knee? Yikes. Sorry to hear about that. Just wanted to let you know I was experimenting and really don't have much movement limitations except for side bends and back bends. (Of coarse.) I can still do side bends but instead of being able to reach to my knee I can only go to my mid thigh. Also, I corrected something in my inital post. I was back driving at 4 weeks, not months. Hope I didn't scare you! Best wishes on your MRI. Hopefully you only pulled something and it won't be a big issue after all.

[CHRIS WBS]

Hi Mebo,

The description of your spine sounds almost identical to mine, except my lumbar curve is bigger at roughly 75°. You are still relatively young at age 40, and I believe age is a determinant when a surgeon decides on how many levels to fuse. In an effort to stave off inflexibility of the entire spine for as long as possible, I believe the surgeon will recommend fusing fewer vertebrae realizing that perhaps in 20 years the fusion may have to be extended. In my case, I've had two surgeons recommend fusing from just below my neck to the pelvis. But then I am 57. Nevertheless, I am seeking a third opinion.

Chris

[lindabar]

I had only one curve fused...

I'm aged fifty and had a cervical fusion (C4-C7) and a lumbar fusion (T8 to sacrum). I had a lumbar curve that was 68 degrees and a thoracic curve that was 50 degrees. The surgeon was going to fuse to T3, but did not finish because I lost too much blood. After the surgery, he suggested that I have no more surgery to correct the thoracic curve, but to leave it.
I can tell you my perceptions regarding the uncorrected curve and feeling "balanced".
The cervical fusion corrected a slight right curve in my neck, which (my perceptions, the doctor didn't have any opionion) pushed my left shoulder up.
The lumbar correction did nothing to alleviate the shoulder problem and may have aggravated it, causing it to be pushed even higher. I feel as if my left shoulder is very high and is pushed forward, causing strain on my shoulder and neck muscles. My shoulders look pretty even from the front, from the back they look bad, the left shoulder blade is pushed out and my back is rounded on that side.
I did get a 10 degree correction of the thoracic curve after the lumbar fusion.
I know from reading other posts here and from my doctor that a thoracic fusion does not necessarily create even shoulders. It also may not alleviate shoulder pain. My doctor said that he would operate on me to correct the thoracic curve and it would lower my shoulder, but perhaps not as much as I would like.
The thoracic curve is sometimes painful and it does feel like it is being "pulled"
(I have a fusion above and below it) and other times it feels like someone has a fist in my back and is pushing in on the vertebrae at the curve apex.
I have this fear, probably irrational, that leaving the thoracic curve uncorrected will cause the corrected curves to worsen although my doctor says that won't happen.
My balance seems to be pretty good, but I do lean forward at times and have to make an effort not too. I can't really determine if that is caused by the uncorrected curve, but I suspect that it is causing it. The uncorrectd curve feels like a weight in my back, causing me to lean forward.
So now I have to decide if I want the thoracic curve corrected. If I do, I will have only 3 unfused vertebrae, T1 to T3, and my doctor says there is a pretty good chance that I will have to have them fused too, in the next five years. I shudder when I think of going through yet another spinal operation and the possiblity of another one after that. My doctor assures me that the future ones will not be as bad as the first.
Another thing that I think about-what flexibility do I have now will be lost with the T3 to T8 fusion? Most people would think not much. I think that the fact that I don't have to "log roll" out of bed and have no trouble getting up out of the tub, or tying my shoes, may be because I still have some flexibility there. I can stretch those vertebrae and I have feeling in them, unlike the fused ones.
I'm going to see some more surgeons and ask them their opinion about what is causing me to lean forward and whether the remaining curve should be fused. but in the end it is still going to be my call. I'm thinking right that I'll just leave it alone, until I feel I have to get it fused. I may have another opinon after I speak to these other surgeons. I hope this helps you. I suggest you get as many opinions as you can and ask all of the surgeons their opinion regarding leaving the thoracic curve unfused.

[Pips]

My surgeon decided at the last minute to try correcting my lumbar curve only (it was 75 degrees). I was due to have 2 stage surgery but he got such good correction from the anterior lumbar part - especially with regards to de-rotation and in getting my head over my middle (it hadn't been there for years) that he decided to call a halt. My thoracic curve 'natuarally' corrected down to 30 degrees and sorting that out may still be on the cards if the curve changes at all - they are keeping a close eye on it and we will see how it goes. They are concerned that it may get worse, or that it will 'lever' against my top screw, but only time will tell.

I am 43 years old, and am now 6 months post op and doing well. For me, only sorting the lumbar curve has maintained much better flexibilty through my shoulder area. This means that I can still easily use my wheelchair and do sport. Extending the fusion would have limited some of the activities that I wanted to do.

Of course all surgeons are different in their approach, but I think mine has made the right choice. The fusion can always be extended in the future if necessary, but in the meantime he has given me the best correction for the fewest fused levels.

[mebo]

thank you everyone

Linda, thanks for putting text from that article up. My dad is a doc so I'll have him take a look at it, too. From my read it sounds like they said the outcome was often good, leaving the thoracic alone and only correcting the lumbar/ larger curve, given other variables and within certain parameters, which pretty much fit me except I'm not adolescent.... I wish I HAD done surgery much younger. I am pretty upset nobody ever recommended it. It has just gotten worse, more pain, more deformity... and it was "severe" as of age 16. Why, I wonder, and what would things have been like for me if it had been corrected much earlier... Oh well, at least there is the option available now.

The other weird thing about my curve is that I was assaulted at age 13 - somebody threw a large unripe pumpkin at me from a speeding truck and it hit my lower back; I was temporarily paralyzed, I don't remember the impact. I could not see or feel anything, or breathe at first. I was just body-less, floating in black space. I never did get medical care for it beyond ice and asprin... so my curve might have been exacerbated by this incident..

It amazes me that a secondary curve does naturally reduce for some people once a larger lumbar or thoracolumbar curve is corrected -- why would this happen, when we try so hard with execise/ stretch/ etc. to straighten our curves with so little success!! I'm glad of it, but surprised, I guess. I understand that the lesser curve compensates, and is no longer "needed" by the body maybe, but... our curves seem so stubborn to change!

Thank you Suzy, Pips, Lindabar & Chris. I am somewhat cheered by what i hear about what I will be able to do, eventually.