Age Effect on Surgical Outcomes

[hdugger]

Actually, I was wondering if the implication of this study was just the opposite, i.e. you might as well wait until you are older and more disabled because older people are likely to get a disproportionate improvement in pain & disability and be happier with the results.

I *think* the reason the younger people aren't responding more positively to the results is because they're not in that much pain to begin with. So, the surgery doesn't improve their ability to do things, because they're not really experiencing any problem in doing things. The older people, OTOH, seem to have been limiting their lives almost unknowingly because of the disability and are shocked to find out how much they're been missing.

But, this is really all reading the tea leaves. Linda, who actually sees patients, might have a truer take on it.

Are we still at the point where they can't say definitively on a scientific (non-anecdotal) basis that there are benefits from this surgery?

I would argue that we're not. The *only* thing that science can really measure is the Cobb angle. That's a real thing - something everyone can see and agree on (more or less). But, the Cobb angle isn't a precise measurement of disease. There are people on this forum with small curves and a good deal of disability and people with large curves and very little disability.

This study tries to get to those real measures of the disease burden by using surveys to measure pain and quality of life, but we have no way of knowing how these surveys actually measure those things. Are they accurate? Are they reliable? Unless we can put a dipstick in people and read their quality of life measure, there's no way of calibrating these surveys to how people actually feel.

I *think* what all this means is that anecdote *is* the real measure. I think the accumulation of people's stories on this forum have more to say about the expected results of surgery then any study I've seen.

[loves to skate]

This should help some. If you get past the stuff about kids, you'll find some interesting stuff quoting one of my bosses, Sigurd Berven.

http://www.nytimes.com/2010/08/10/health/10brod.html

Hi Linda,
You know this and I know this, but how do we get the Primary Care Docs to know this?
Sally

[Susie*Bee]

Sally-- the "elderly" neurologist I'm seeing for my migraines was super surprised about my scoli surgery at this ripe old age-- that my scoli could have progressed to the point of needing it... and just this past week, the person doing my mammogram couldn't believe I would have had scoliosis surgery at my age. Sometimes I wonder if the whole medical profession, barring the scoliosis specialists and a few others, are living in a bygone era... it's like reading textbooks on computers from 25 years ago.

[Pooka1]

Sally-- the "elderly" neurologist I'm seeing for my migraines was super surprised about my scoli surgery at this ripe old age-- that my scoli could have progressed to the point of needing it... and just this past week, the person doing my mammogram couldn't believe I would have had scoliosis surgery at my age. Sometimes I wonder if the whole medical profession, barring the scoliosis specialists and a few others, are living in a bygone era... it's like reading textbooks on computers from 25 years ago.

They seem to be operating under the paradigm that being sub-surgical at skeletal maturity is sufficent to avoid the need for fusion ever.

The sheer number of adult sugeries seems to suggest that that paradigm is wrong but of course some of those adult cases were probably in surgical range before maturity.

I would like to see a pub on the surgical rates for people who were sub surgical at maturity. Maybe it's a very small crowd and maybe it isn't.

Maybe even just knowing how many people younger or older than ~18 are fused each year would be a good first step at figuring that out.

[Back-out]

Sally-- the "elderly" neurologist I'm seeing for my migraines was super surprised about my scoli surgery at this ripe old age-- that my scoli could have progressed to the point of needing it... and just this past week, the person doing my mammogram couldn't believe I would have had scoliosis surgery at my age. Sometimes I wonder if the whole medical profession, barring the scoliosis specialists and a few others, are living in a bygone era... it's like reading textbooks on computers from 25 years ago.

Yeah, and yet what's peculiar is that according to a figure I ran into recently, there are at least 12K scoli ops performed annually in the US alone.

I don't know how that compares to say thirty-forty years ago, when the "vogue" of Harrington rod surgeries among adolescents began. (FWIW that's the generation now facing revisions, almost to the last "man"! I used to see that as a failure but now I see it as a success - "success" redefined to mean not solution but reprieve!)

My guess is that all told, there are far more scoli ops performed now than in the past, if only because of population expansion and the inclusion of older patients. Not to mention revisions!

You'd think that would have registered on the surgical radar screen - even for non-orthopods. Seemingly, not even a blip, though!

[Pooka1]

Yeah, and yet what's peculiar is that according to a figure I ran into recently, there are at least 12K scoli ops performed annually in the US alone.

Is that all fusions or just scoli fusions?

I don't know how that compares to say thirty-forty years ago, when the "vogue" of Harrington rod surgeries among adolescents began. (FWIW that's the generation now facing revisions, almost to the last "man"! I used to see that as a failure but now I see it as a success - "success" redefined to mean not solution but reprieve!)

No, according to Linda, mainly (if not only) the L fusions were problematic. The H rod T fusions are not doing too badly even all these years out as I understand it.

My guess is that all told, there are far more scoli ops performed now than in the past, if only because of population expansion and the inclusion of older patients. Not to mention revisions!

And pedicle screws.

[Susie*Bee]

If you read the 4th paragraph up from the bottom in the article Linda posted the link to, it talks about how a mild case of scoli in adolescence can progress with aging. That is what so many in the medical profession don't understand. They were taught it was something that occurred during adolescence and then it was over with. As with many fields, not just medicine, education often doesn't continue unless it's your specialty, once you are out of school.

[Pooka1]

If you read the 4th paragraph up from the bottom in the article Linda posted the link to, it talks about how a mild case of scoli in adolescence can progress with aging. That is what so many in the medical profession don't understand. They were taught it was something that occurred during adolescence and then it was over with. As with many fields, not just medicine, education often doesn't continue unless it's your specialty, once you are out of school.

Yes but apparenty even specialists are getting this wrong.

[rohrer01]

Scoliosis is a progressive disease. Period. What is so hard to understand about that? Curve size doesn't always have anything to do with the amount of pain one suffers. Curve location does. What is so hard to understand about that? One doesn't have to be a "rocket scientists" or in this case a scoliosis specialist to realize that "Joe" down the hall with a 30* cobb in severe pain as compared to "Bill" down the other hall with a 90* cobb and no pain, that maybe it's not the SIZE of the curve but something else that matters? What makes ANYONE think that a progressive disease stops at skeletal maturity? Anyone here take a general biology class? What is one of the main characteristics that qualify something as being alive? GROWTH, duh! Skeletal maturity doesn't mean that growth stops. It means it slows down to a maintenance level. Well, whatever systems are awry don't just magically get fixed just because growth slows down. Does juvenile arthiritis stop when they get them all grown up? Maybe not a fair comparison, but all this gibberish just makes me angry. Think, people! (referring to scoli docs)

Sorry ahead of time if I offended anyone. I'm just sick and tired of fighting this disease and sick and tired of not being able to find anyone who can THINK and understand what is going on. A little compassion would be in order, too.

[Pooka1]

Scoliosis is a progressive disease. Period. What is so hard to understand about that?

Except it isn't always progressive. In fact I suggest 99.99999% of parents here, if not 100% of them have been told or have read that it is NOT progressive if you are sub-surgical at skeletal maturity. Or rather it won't progress to fusion range in one's lifetime. This notion came from somewhere so it is probably largely true but I don't think this notion includes the out years.

Curve size doesn't always have anything to do with the amount of pain one suffers. Curve location does. What is so hard to understand about that?

Yes even if the curve doesn't progress in most sub-surgical cases, how is the pain level from the ancillary damage from the uneven loading affecting folks over time?

What makes ANYONE think that a progressive disease stops at skeletal maturity?

Well, plenty of orthopedic surgeons do make that claim. It comes from somewhere whether or not it is true of the out years.

Anyone here take a general biology class? What is one of the main characteristics that qualify something as being alive? GROWTH, duh! Skeletal maturity doesn't mean that growth stops. It means it slows down to a maintenance level. Well, whatever systems are awry don't just magically get fixed just because growth slows down. Does juvenile arthiritis stop when they get them all grown up? Maybe not a fair comparison, but all this gibberish just makes me angry. Think, people! (referring to scoli docs)

I see what you are saying but that is not the case with most scoli cases if we are to believe what most (not all) surgeons are saying.

Sorry ahead of time if I offended anyone. I'm just sick and tired of fighting this disease and sick and tired of not being able to find anyone who can THINK and understand what is going on. A little compassion would be in order, too.

I think you are one of the many testimonials here that seem to buck the paradigm. This group is not randomly selected so it is hard to say if the paradigm needs changing or not.

I hope you find help for your pain. It's very unfair.

[Pooka1]

Some clues from that NY Times article on long term of untreated, presumably subsurgical, scoliosis

http://www.nytimes.com/2010/08/10/he...=me&ref=health

While scoliosis in children rarely causes symptoms other than cosmetic ones, the situation is quite different in adults, who are 10 times as likely as adolescents to require corrective surgery, Dr. Berven said.

Well if adults are 10 times as likely to need corrective surgery as kids then that doesn't seem to square with the paradigm of avoiding surgery if you are sub-surgical at skeletal maturity (since most cases by far are sub-surgical at maturity). Am I missing something?

“The impact of the deformity on adults — pain and functional disability — can be quite severe,” he said. “It can have as much of an impact on quality of life as chronic obstructive lung disease, peripheral vascular disease, coronary artery disease and advanced arthritis of the hip and knee.”

As people age, degenerative changes occur in the upper and lower spine that can cause a minor case of adolescent scoliosis to progress. One result can be spinal stenosis — a narrowing of the spaces between vertebrae — and pressure on spinal nerves that causes back and leg pain.

Yes but at what rate does this occur? Few? Some? Most?

But surgery is by no means the only option in such cases. When the condition is identified early, its severity can often be reduced by exercises that improve overall fitness, increase spinal flexibility and strengthen the body’s core muscles, Dr. Berven said.

I think he is saying PT has been shown to be effective at halting or slowing progression and relieve symptoms in adults but I think he means life-long exercise. I think we knew the part about pain but I didn't realize that PT has been shown to halt (or slow) progression on a permanent basis. Maybe he means during the PT.

“Adults with scoliosis and back pain can improve symptomatically by increasing their level of fitness and mobility, enabling some to avoid surgery,” he said.

Yes PT is effective for pain in adults.

However, he added, once patients develop nerve symptoms like weakness and numbness, exercise is unlikely to be of much benefit and surgery may be the only effective treatment.

[LindaRacine]

Hi Linda,
You know this and I know this, but how do we get the Primary Care Docs to know this?
Sally

They can't know it all.

[LindaRacine]

Is that all fusions or just scoli fusions?



No, according to Linda, mainly (if not only) the L fusions were problematic. The H rod T fusions are not doing too badly even all these years out as I understand it.



And pedicle screws.

While the issues of the Harrington rod being straight usually only cause problems when attached to the lumbar spine, Harrington rod patients can experience proximal junctional kyphosis problems at least as much as other implants. They may cause more PJK than newer implants systems, but I don't think I've ever seen anything published on that.

--Linda

[LindaRacine]

It's important to understand that the vast majority of scoliosis curves do not reach 25 degrees at skeletal maturity. Those folks very rarely require treatment, at least as far as we know (If your experience differs, consider yourself one of the unlucky ones.) Please remember that study conclusions talk about what happens to the majority, not what happens to everyone.

As far as I know, we don't know if people who had those small curves when they were young end up with degenerative problems at a higher rate than the general public when they're older. I can tell you that I talk to patients with degenerative scoliosis all the time who tell me that they either didn't have scoliosis as a child, or didn't know they had it.

--Linda

[Pooka1]

It's important to understand that the vast majority of scoliosis curves do not reach 25 degrees at skeletal maturity. Those folks very rarely require treatment, at least as far as we know

Yes.

I think the open question is what happens in the out years for people in the range where treatment is initiated and where surgery is suggested. That is generally between ~25* and ~50*.