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  • Mobility of levels To fuse or not to fuse?

    I received a copy of Moe’s "Textbook of scoliosis and other spinal deformities” the other day and have been reading until I basically go blind. My eyes hurt.

    One of my questions is “How much mobility does each level have”. In the book it explains about the 6 degrees of freedom, X,Y, and Z which would be, flexion-extension, lateral bending, and axial rotation. Flexion-extension values in degrees are greatest in the cervical and lumbar areas of the spine. Cervical values average about 12degrees for each level. Lumbar flexion-extension values,L3-L4 (15degrees) L4-L5 (17degrees) and L5-Sacrum (20degrees). Lateral bending in these lumbar areas,3-7 degrees, and axial rotation 2-5 degrees.

    Not only do we have discs, but we also have something called “facet joints” There are 2 on each level on the backside, and play a major role in determining the range of motion for that joint. Orientation of the facet joints plays a big part in range of motion and pathogenesis of lower back pain.

    There are many many parameters involved in scoliosis, its mindboggling. 20 degrees on the lowest joint seems like a large number, its probably a best case scenario, with a normal spine......For those who’s surgeons choose to fuse and leave the lowest levels untouched, this is probably the reason.

    Not only are there many different examples of scoliotic spines, some are unbelievable, but one thing I didn’t know was that disc space wedging and vertebral wedging affect cobb measurements. You can have a spine that looks like a 50 degree curve, but it’s really a 90.

    Ed
    49 yr old male, now 63, the new 64...
    Pre surgery curves T70,L70
    ALIF/PSA T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
    Dr Brett Menmuir St Marys Hospital Reno,Nevada

    Bending and twisting pics after full fusion
    http://www.scoliosis.org/forum/showt...on.&highlight=

    My x-rays
    http://www.scoliosis.org/forum/attac...2&d=1228779214

    http://www.scoliosis.org/forum/attac...3&d=1228779258

  • #2
    I didn't realize how much we're like airplanes ... X Y and Z are just like roll, pitch and yaw, the 3 dimensions of flying! Spines are intricate constructions, and if I didn't have a degenerated disc at L4-5 I'd definitely my lumbar spine alone in order to hang on to that important bit of flexibility.
    Juliet, age 57
    37˚ lumbar and 35˚ thoracic with rotation
    Diagnosed at age 11 and untreated.
    Total degeneration of disc at L4-5, spondylolisthesis at L4, L5 sacralized.
    Surgery on 10/26/10
    Dr. Matthew Geck, Seton Spine & Scoliosis, Center, Austin, TX.
    University Medical Center @ Brackenridge Hospital.
    Posterior fusion of T11-S1, part minimally invasive; TLIF at L4-5.

    Comment


    • #3
      Yet it's amazing just how much we can live without.
      Surgery March 3, 2009 at almost 58, now 63.
      Dr. Askin, Brisbane, Australia
      T4-Pelvis, Posterior only
      Osteotomies and Laminectomies
      Was 68 degrees, now 22 and pain free

      Comment


      • #4
        That is extremely interesting, Ti Ed. Extremely.

        I know that vertebral range of motion has been studied in horses and they can predict the smallest circle a horse can bend through for example from those results.

        Amazing how the flex-exten range is so relatively large at L5-S1.
        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."

        Comment


        • #5
          Yes indeed, those 'facet joints' are the ones I kept getting injected for pain relief, from L2/3 - L5/S1.

          Ti-Ed, sounds like this textbook is a good read.
          Vali
          44 years young! now 45
          Surgery - June 1st, 2009
          Dr David Hall - Adelaide Spine Clinic
          St. Andrews Hospital, Adelaide, South Australia
          Pre-op curve - 58 degree lumbar
          Post -op - 5 degrees
          T11 - S1 Posterior
          L4/5 - L5/S1 Anterior Fusion

          Comment


          • #6
            Great reporting, Ed!

            I hope you'll keep letting us know your findings. I'll think about this all day.
            Amy
            58 yrs old, diagnosed at 31, never braced
            Measured T-64, L-65 in 2009
            Measured T-57, L-56 in 2010, different doc
            2 lumbar levels spondylolisthesis
            Exercising to correct

            Comment


            • #7
              Jennifer

              It is amazing what we can live without. I hardly notice anymore. We are lucky in a way, we wont have to worry about all sorts of issues in the future. Spondy’s, disc issues, nerve impingement. This should go in my benefits thread.


              The lumbar lordosis plays a big part on facet joints. If too large or too flat, those facets will account for the majority of lower pain. There are posterior column ligamentous structures which include the facet capsule, ligamentum flavum, interspinous ligament, supraspinous ligament,and the intertransverse ligament. These all play a role on each level, and if impinged, or altered before or after surgery, can present difficulties. Surgery on the lowest level is challenging.... especially in males.

              There is high value in fusing a joint from the front. Balancing by fusing front and back is needed if the low levels are in bad shape.

              Ed
              49 yr old male, now 63, the new 64...
              Pre surgery curves T70,L70
              ALIF/PSA T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
              Dr Brett Menmuir St Marys Hospital Reno,Nevada

              Bending and twisting pics after full fusion
              http://www.scoliosis.org/forum/showt...on.&highlight=

              My x-rays
              http://www.scoliosis.org/forum/attac...2&d=1228779214

              http://www.scoliosis.org/forum/attac...3&d=1228779258

              Comment


              • #8
                Thanks for posting that! I always wonder what flexibility in those few joints translates into when it comes to daily living and activities. Those are the three joints that would not be fused in my case.
                Cristi
                30 year old female, 50-55 deg lumbar curve
                Diagnosed with 30deg lumbar curve at 18
                Scheduled for T10-L3 fusion with Dr. P. Gupta Jan. 3rd
                Considering physical therapy options to slow progression.

                Comment


                • #9
                  It's important to remember, though, that hip joint flexibility, including flexibility of hamstrings and hip flexor muscles, can make a huge difference in functioning with a fused spine. I am glad that my hips are loose, largely because of all the years spent in a Milwaukee brace in childhood, adolescence and teen years (I was braced for NINE years). I'm hoping this will make a huge difference in functioning after my fusion.
                  Stephanie, age 56
                  Diagnosed age 8
                  Milwaukee brace 9 years, no further treatment, symptom free and clueless until my 40s that curves could progress.
                  Thoracolumbar curve 39 degrees at age 17
                  Now somewhere around 58 degrees thoracic, 70 degrees thoracolumbar
                  Surgeon Dr. Michael S. O'Brien, Baylor's Southwest Scoliosis Center, Dallas TX
                  Bilateral laminectomies at L3 to L4, L4 to L5 and L5 to S1 on April 4, 2012
                  Foramenotomies L3 through S1 in August 2014

                  Comment


                  • #10
                    Originally posted by titaniumed View Post
                    The lumbar lordosis plays a big part on facet joints. If too large or too flat, those facets will account for the majority of lower pain. There are posterior column ligamentous structures which include the facet capsule, ligamentum flavum, interspinous ligament, supraspinous ligament,and the intertransverse ligament. These all play a role on each level, and if impinged, or altered before or after surgery, can present difficulties. Surgery on the lowest level is challenging.... especially in males.
                    Ed
                    Hi Ed

                    I've always wondered how does the surgeon determine the degree of lordosis for the lumbar area when shaping the rods? Is that addressed in your book? If you look at Sheena's side profiles, she has a very pronounced lordosis after surgery, it "looks" good to me, but I wonder if there's a standard that they work by? I would assume stature would play a part.

                    Comment


                    • #11
                      Sherie

                      Good question.

                      First, I have to say that Sheena’s construct looks great! I hope she is doing well.

                      The first thing to consider is the preexisting shape. There is quite a variation in lordotic and kyphotic cobbs. In the book, one study of French and Italian adults has thoracic kyphosis averaging 37 degrees, whereas lumbar lordosis averaged 50 degrees, with “considerable” variation in each range. Another study was within 2 degrees average.

                      With considerable variation thrown into the mix, and trying to correct coronal curves, and rotation while achieving the best possible sagittal balance, I’m sure that trying to achieve something that might be a “textbook” lordosis value is not feasible. They must take the angular values of the pre-existing x-ray, and work from there as far as bending and shaping rods is concerned. Radical coronal corrections happen, we see 140 degrees curves corrected to 70 degrees, but kyphotic and lordotic corrections are not as easy.... especially in a posterior only surgery.

                      My goddaughter is in medical school. When she enters a class, there might be one textbook, but she buys about 4-6 books on each subject matter and they brainstorm. They will be tested on material that will not be in the required textbook. Fun, fun, fun. This book I have is only one book, and just the tip of the iceberg you might say.

                      There are other orthopedic textbooks I want, but wow are they expensive!!!!!!!!!!!!!!!! I need new reading glasses first! LOL I go back and forth, book, glasses,book, glasses.
                      Ed
                      49 yr old male, now 63, the new 64...
                      Pre surgery curves T70,L70
                      ALIF/PSA T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
                      Dr Brett Menmuir St Marys Hospital Reno,Nevada

                      Bending and twisting pics after full fusion
                      http://www.scoliosis.org/forum/showt...on.&highlight=

                      My x-rays
                      http://www.scoliosis.org/forum/attac...2&d=1228779214

                      http://www.scoliosis.org/forum/attac...3&d=1228779258

                      Comment


                      • #12
                        Thanks Ed, Sheena is doing great! (knock on wood) She started college this fall and I am shocked at the price of the textbooks, they cost more than the tuition! I'm taking a french class for the heck of it and found the textbook on Amazon for $13 (almost new), some of my classmates purchased used books for >$100 from the campus bookstore and online. You might have to wait a week or so for the book but was well worth it. I guess you better get your glasses first though or you won't be able to read the books!

                        I think Dr. Lenke did a fantastic job on her back. I know he's a very skilled surgeon but wasn't sure if there's a magic formula they use. It doesn't sound that simple, especially when you have to take into account all the different variations and degrees of scoliosis. Plus, the age of the patient and amount of feasible correction. Something I've been wondering about after all was said and done.

                        Thanks for all your informative threads, I was especially impressed with your bending photos, Sheena's not even that flexible. You're doing fantastic and you give me much hope that my daughter can lead a full and normal life.

                        Comment


                        • #13
                          infantile stats, boys vs girls

                          Hdugger

                          I didn’t forget your question about boys stats vs girls stats in the book...Here it is.

                          I finally stumbled upon it on page 224. They mention that “Infantile idiopathic scoliosis” is rare in the United States, most cases of infantile scoliosis happen in Europe.

                          The first description of infantile scoliosis was made by James in 1951. He presented 33 cases of idiopathic scoliosis with an onset before age 3 years, noting that, as opposed to adolescent idiopathic scoliosis, boys outnumbered girls, with the curves being primarily thoracic, and convex to the left........

                          In 1955, Scott and Morgan analyzed 28 cases of progressive and seven cases of resolving infantile scoliosis, their results confirmed the findings of James. Boys were affected more frequently than girls, and the majority of curves occurred in the thoracic spine and were convex to the left......

                          This must be what the past poster referred to.
                          Ed
                          49 yr old male, now 63, the new 64...
                          Pre surgery curves T70,L70
                          ALIF/PSA T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
                          Dr Brett Menmuir St Marys Hospital Reno,Nevada

                          Bending and twisting pics after full fusion
                          http://www.scoliosis.org/forum/showt...on.&highlight=

                          My x-rays
                          http://www.scoliosis.org/forum/attac...2&d=1228779214

                          http://www.scoliosis.org/forum/attac...3&d=1228779258

                          Comment


                          • #14
                            Thanks so much, Ed. Odd that infantile scoliosis occurs disproportionally in boys. I can't imagine what would account for that.

                            Comment


                            • #15
                              Ed,

                              That was very interesting finding.
                              62/75 (T4-T9 68 degree & T11 - L4 80 degree) 10/19/2010
                              45/50 year 2000
                              36 yrs old
                              Considering, researching surgery for the first time
                              S. California
                              http://s1210.photobucket.com/albums/...ashionista889/

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