Journal article focusing on surgical complications

[jrnyc]

i think folks are making much ado about little...

revision surgery is not a given...those who have first surgeries to sacrum seem less likely to need revision at all......and alarming predictions that are unlikely to come true are not useful...the sky is not falling!

jess

[Back-out]

To Pooka, re thoughts abt practitioner/industry interest in cost:benefit and other outcomes research on complex spinal surgery.

This is a summary of a recent story and lead editorial in the AMA Journal on the subject (here it is specifically abt surgery with instrumentation for spinal stenosis, but being much cheaper, the points hold even more strongly abt scoliosis surgery):

What, you might ask, is positive* about that story? What is positive is that it is the lead article in the JAMA and that there is an editorial by Jay Lemery which neither apologizes for or rationalizes the findings. The conclusions, in fact, of the editorial are that patients and surgeons and payors need to carefully assess the value and risks of new technologies, and that market forces, such as they are, do not favor careful assessment

http://whyisamericanhealthcaresoexpe...ve-change.html

* Note, "positive" is from the POV of the site making the comment - dedicated to cost-containment in medicine. It's NOT "positive" by me!

[LindaRacine]

To Pooka, re thoughts abt practitioner/industry interest in cost:benefit and other outcomes research on complex spinal surgery.

This is a summary of a recent story and lead editorial in the AMA Journal on the subject (here it is specifically abt surgery with instrumentation for spinal stenosis, but being much cheaper, the points hold even more strongly abt scoliosis surgery):

What, you might ask, is positive about that story? What is positive is that it is the lead article in the JAMA and that there is an editorial by Jay Lemery which neither apologizes for or rationalizes the findings. The conclusions, in fact, of the editorial are that patients and surgeons and payors need to carefully assess the value and risks of new technologies, and that market forces, such as they are, do not favor careful assessment

http://whyisamericanhealthcaresoexpe...ve-change.html

The issue of decompression vs. fusion has been hot for at least the last year. I don't know which side is right, but I can tell you that a large percentage of the revision surgeries done at UCSF have had previous decompressions. I'm sure that decompressions work for many situations, but unfortunately not every surgeon is capable of knowing when it's better to do a fusion.

--Linda

[Confusedmom]

revision surgery is not a given...those who have first surgeries to sacrum seem less likely to need revision at all......

Jess,

I'm curious about this issue of fusion to the sacrum. I am getting told by my docs that fusion to the sacrum actually carries a higher risk of need for revision for me (age 38). They would expect the fusion to fracture at some point in my life. They are saying it's better to go to L5 and hope that I don't ever have to fuse below that (although it's a real possibility that I might). Have you been told differently?

Evelyn

[LindaRacine]

revision surgery is not a given...those who have first surgeries to sacrum seem less likely to need revision at all......

Jess,

I'm curious about this issue of fusion to the sacrum. I am getting told by my docs that fusion to the sacrum actually carries a higher risk of need for revision for me (age 38). They would expect the fusion to fracture at some point in my life. They are saying it's better to go to L5 and hope that I don't ever have to fuse below that (although it's a real possibility that I might). Have you been told differently?

Evelyn

Hi Evelyn....

I don't think I've heard that. There's no shortage of research on the subject. Here are some of the references:

Spine (Phila Pa 1976). 2010 Apr 9. [Epub ahead of print]
Risk Factors of Sagittal Decompensation After Long Posterior Instrumentation and Fusion for Degenerative Lumbar Scoliosis.

Cho KJ, Suk SI, Park SR, Kim JH, Kang SB, Kim HS, Oh SJ.

From the *Department of Orthopaedic Surgery, Inha University Hospital, Incheon, Republic of Korea; and daggerSeoul Spine Institute, Inje University Sanggye-Paik Hospital, Seoul, Republic of Korea.
Abstract

CONCLUSION.: Sagittal decompensation is common after long posterior instrumentation and fusion for degenerative lumbar scoliosis. It is mostly associated with complications at the distal segments, including pseudarthrosis and implant failure at the lumbosacral junction. Restoration of optimal lumbar lordosis and secure lumbosacral fixation is necessary especially in patients with preoperative sagittal imbalance and high pelvic incidence in order to prevent sagittal decompensation after surgery.

PMID: 20386505 [PubMed - as supplied by publisher]

Eur Spine J. 2009 Apr;18(4):531-7. Epub 2009 Jan 23.
Arthrodesis to L5 versus S1 in long instrumentation and fusion for degenerative lumbar scoliosis.

Cho KJ, Suk SI, Park SR, Kim JH, Choi SW, Yoon YH, Won MH.

Department of Orthopaedic Surgery, Inha University Hospital, Inha University, 7-206, 3-Ga, Sinheung-Dong, Jung-Gu, Incheon 400-130, Korea.
Abstract

For the patients with sagittal imbalance and lumbar hypolordosis, L5-S1 should be included in the fusion even if L5-S1 disc was minimal degeneration.

PMID: 19165507 [PubMed - indexed for MEDLINE]

Spine (Phila Pa 1976). 2007 Nov 15;32(24):2771-6.
Thoracolumbar deformity arthrodesis stopping at L5: fate of the L5-S1 disc, minimum 5-year follow-up.

Kuhns CA, Bridwell KH, Lenke LG, Amor C, Lehman RA, Buchowski JM, Edwards C 2nd, Christine B.

Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.
Abstract

CONCLUSION: Advanced L5-S1 DDD developed in 69% of deformity patients after long fusions to L5 with 5 to 15 year follow-up. SAD frequently results in significant positive sagittal balance at a minimum 5-year follow-up. Long fusions to the upper thoracic spine down to L5 and circumferential fusion may further promote subsequent L5-S1 disc degeneration.

PMID: 18007259 [PubMed - indexed for MEDLINE]

Neurosurg Clin N Am. 2007 Apr;18(2):281-8.
The selection of L5 versus S1 in long fusions for adult idiopathic scoliosis.

Swamy G, Berven SH, Bradford DS.

Department of Orthopaedic Surgery, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada. gswamy@ucalgary.ca <gswamy@ucalgary.ca>
Abstract

Complications with fusion to L5 include possible loss of fixation and subsequent disc degeneration at L5-S1, however, leading to possible pain and loss of sagittal balance and the need for revision surgery. To date, the functional consequences of an open disc space beneath long constructs remain poorly defined, and there is no firm evidence in the literature guiding the surgeon's choice. The issues and evidence guiding the decision to fuse to L5 or S1 are examined in this article.

PMID: 17556129 [PubMed - indexed for MEDLINE]

[jrnyc]

ummmmm...hey Ev...was told by several surgeons that i need fusion to pelvis...that fusion to sacrum wouldnt even be solid enough for me..

also...have seen on forum and was told by surgeons as well that when in doubt about going to L5 or sacrum, they weigh
several factors, including disc problems, etc...but if there is doubt, often the fusion to sacrum is chosen as safer for the future of the individual's spine...

jess

[diane2628]

I will just add a few points, from my humble perspective as someone who a) had fusion surgery 10 years ago and am fine, and b) works as my state's director of patient safety and has done a fair amount of research on available data related to clinical outcomes:

1) any article in a non-peer reviewed journal is immediately slightly suspect (or at least not to be as highly regarded as that in a peer-reviewed publication)
2) any article by someone who advocates for and is employed by a company that specializes in a different treatment for a condition, then writes about why the competing treatment modality is bad, is immediately much more suspect. Just a little conflict of interest there!
3) many of the complications they cite (UTI, blood loss, infection, death) are complications/risks for ALL surgeries. In addition, in many cases they mention a type of complication as though it is common, without discussing rates or sample sizes in the studies they reference, nor do they provide any reference to complication rates for other types of surgery as a benchmark.
4) Given that many people don't seek surgery until their scoli is pretty far advanced and they are already having lots of pain, post-op pain is an unsurprising complication.
5) These complications are exactly what my surgeon told me about 10 years ago, before my surgery. He even said that 20% of patients need some sort of follow-up procedure within 10 years. Given that and the wealth of research (of varying quality), I don't think anyone is trying to hide any of this information.
6) Their recommendation is that people only try surgery after trying other, non-surgical methods first. But are there many of us who have NOT done exactly that?

[LindaRacine]

I will just add a few points, from my humble perspective as someone who a) had fusion surgery 10 years ago and am fine, and b) works as my state's director of patient safety and has done a fair amount of research on available data related to clinical outcomes:

1) any article in a non-peer reviewed journal is immediately slightly suspect (or at least not to be as highly regarded as that in a peer-reviewed publication)
2) any article by someone who advocates for and is employed by a company that specializes in a different treatment for a condition, then writes about why the competing treatment modality is bad, is immediately much more suspect. Just a little conflict of interest there!
3) many of the complications they cite (UTI, blood loss, infection, death) are complications/risks for ALL surgeries. In addition, in many cases they mention a type of complication as though it is common, without discussing rates or sample sizes in the studies they reference, nor do they provide any reference to complication rates for other types of surgery as a benchmark.
4) Given that many people don't seek surgery until their scoli is pretty far advanced and they are already having lots of pain, post-op pain is an unsurprising complication.
5) These complications are exactly what my surgeon told me about 10 years ago, before my surgery. He even said that 20% of patients need some sort of follow-up procedure within 10 years. Given that and the wealth of research (of varying quality), I don't think anyone is trying to hide any of this information.
6) Their recommendation is that people only try surgery after trying other, non-surgical methods first. But are there many of us who have NOT done exactly that?

Well done Diane.

[Confusedmom]

Linda, Jess,

Thank you. This is excellent info. that I will definitely transform into some kind of question(s) for Dr. Bridwell later this month.

Dr. Pernendu Gupta in Chicago definitely told me last week that the biggest point of debate in my surgery would be fusion to L5 vs. sacrum. He said in the case of younger(ish!) age and healthy L5 disk, he would highly recommend fusion to L5 because of likelihood of breaking the fusion to sacrum throughout the course of my life. "You're still young; you're active." He did say there's a reasonable likelihood of disk degeneration at L5 that would necessitate extending the fusion later in life. My Indy doc also recommended stopping at L5 because of concern of fracture as well as greater tendency toward pseudoarthrosis if it was extended to sacrum. That seems to be contradicted by the studies Linda cites, so I will definitely get more opinions on this.

Thanks again for the info.; I'll let you know what I find.

Evelyn

[jrnyc]

hi Ev
do you have disc problems that would necessitate going to sacrum?

jess

[Confusedmom]

Jess,

L5 disk is healthy; L3 & L4 not so much. So apparently, no, disk problems don't necessitate going to sacrum.

Is a bad L5 disk typically the determining factor as to whether you fuse to the sacrum?

Evelyn

[jrnyc]

several surgeons have told me that...said my spine would not be stable without going all the way down...my L's are bad 1-5...just a mess back there...listhesis, rotation, but worst is stenosis, arthritis, and degenerative discs...all in lower lumbar!


jess

[CHRIS WBS]

Dr. Pernendu Gupta in Chicago definitely told me last week that the biggest point of debate in my surgery would be fusion to L5 vs. sacrum. He said in the case of younger(ish!) age and healthy L5 disk, he would highly recommend fusion to L5 because of likelihood of breaking the fusion to sacrum throughout the course of my life. "You're still young; you're active." He did say there's a reasonable likelihood of disk degeneration at L5 that would necessitate extending the fusion later in life. My Indy doc also recommended stopping at L5 because of concern of fracture as well as greater tendency toward pseudoarthrosis if it was extended to sacrum. That seems to be contradicted by the studies Linda cites, so I will definitely get more opinions on this.

This surprises me. Before my surgery, through a co-worker I was put in touch with a woman a few years younger than me who had surgery back in the early 70s by Dr. Ronald DeWald (the big Chicago scoli doc at that time; Dr. Neuwirth acknowledges him in his book). I spoke to this woman and was astonished to hear that despite an older surgery with Harrington rod instrumentation and a long fusion to the sacrum, she led a very active lifestyle including roller-blading and long-distance cycling. She’s had a few bad falls over the years but nothing that disturbed her fusion until recently. About the time of my surgery, she was hit by a car while cycling and thrown from her bike. She suffered a broken knee cap and 9 fractures to her fusion. Her spine was re-instrumented and last I heard, after a long rehab, she’s ready to resume cycling against her doctor’s orders. It took quite a whammy to crack her old fusion with older instrumentation. If anything, I would think it would be us older broads with thinning bones that are at higher risk for cracks to our sacrum fusions.

[Confusedmom]

The only explanation I can think of for the discrepancy is just the number of decades that would wear on that fusion to sacrum. Maybe this is why they keep telling me they might do it later.

Plus the (perhaps incorrect) assumption that at 38 I will be more active than someone a couple of decades older. (What's up with all you 50 and 60 somethings that dance, rollerskate, skydive, etc., anyway? I'm so impressed--I consider it a good day if I can get myself on an exercise bike!!)

What an awful accident that happened to your acquaintance, Chris. I'm glad she made it through okay!!

Evelyn

[Lorraine 1966]

Well, hey I am patting myself on the back here.I am 60 next year, am now 44 years post op, someone should do a study on me. (Joking) I think most of my pain is DDD from below fusion and a touch of osteoarthritis thrown in probably a bit of compression too. But I have a had such a full life, you would not believe it. Moved house by myself 22 times, packed it all the lot. Have worked for 30 years, blah blah blah. Count myself one of the lucky ones.

Lorraine.