Regarding likely outcome on pain

[Pooka1]

I'm glad you address the subject of methodology (regarding cobb angle measurements) in this study (well, that's what Martha calls it on page 22). Maybe we can learn more about this. Method one (representing the 50/40% reduction), is from triplicate readings by three independent readers (the peer review processes?), and according to protocols defined by Goldberg et al (her reference #66).

Method #2 is taken from two independent institutions and carried out in non-blinded readings from film copies provided by the authors, and an explanation for each institution's findings is given on page 22 - where we find this information in table form.

So - what is the difference? And is there reason to accept one over the other?

I found that confusing. Those results should have been accompanied by more explanation. When you present two sets of results you say which is likely more reliable and why. The authors didn't do that here. There is a some reason for that. I have a guess - I think there is something going on with the non-blinded readers knew the curve improved in one plane and worsened in another and somehow accounted for that in the readings or choice of vertebra or something. In any case, it is a failure of review that that flew the way it did in my little opinion... I would have said in a review to pick one set of results and defend it against the other.

N.B. when you read the conclusions, they don't seem to be standing behind the larger reduction for some reason.

[debbei]

As an adult surgical patient, my lumbar pain that I had prior to surgery is TOTALLY gone, and has been since the very beginning.

Where I get pain is in my upper back area, around my shoulder blade. For me, it's TOTALLY related to stress. When I am in a stressful situation (ex. at work on a horrible stressful project), I get muscle spasms. When the project is over and the stress is gone, those spasms go away like magic.

I wish I could control that. In the mean time, muscle relaxants and or tylenol or motrin help.

[debbei]

That's great, Debbie. I'm always happy to hear that some method of treating scoliosis has completely worked for someone.

Did you have the upper back problem before the surgery? Or does it seem to have something to do with the way your back was realigned during surgery?

This upper back thing never happened prior to surgery. I think it is my muscles getting used to their new position post-surgery. It is getting slightly better over time, and doesn't happen as often. But when it happens--boy oh boy--I'm not a happy camper.

[Pooka1]

Speaking of regular "middle-aged person" back stuff, that of course is the baseline for claims to "eliminate" pain. That is, they all necessarily refer to eliminating pain over and above the normal level and prevalence, not above zero. I don't know normal level but normal prevalence is ~85% of adults at some point in their life.

So it is not rational to expect fusion to decrease it below that seen in the general populace though it might be decreased below that if my wild thoughts on the matter pan out (i.e., fused sections can never experience pain due to DDD and such which is claimed to be as certain as death and taxes in unfused spines if you live long enough, etc.).

And from that one paper, we see surgical folks tend to have less pain than non-surgical folks even starting from a higher baseline of pain.

So while there are no guarantees ever, surgical fusion for scoliosis appears to be the best game in town for chance of pain relief.

[jrnyc]

well, i have alot of pain...mostly lumbar..dont know if scoliosis can be separated as cause from herniated discs from spinal stenosis from arthritis...but...i will let you know what dr anand has to say when i see him end of january...

all other surgeons have told me i could expect to have reduced pain after surgery healed, & hopefully alot less pain, but they could not guarantee me no pain...it was always couched in those words..."hopefully"..."expected"..."less than before"....

jess

[mamamax]

I looked at the editorial board. Are they chiros? How many are qualified surgeons?

You know, not to beat a dead horse but the creationists also have "peer reviewed" journals but it is still stem to stern nonsense.

I'm just sayin'...

Well, if you go to the web page that lists the editorial board members - you can click on their names and see who they are: http://www.scoliosisjournal.com/edboard/

Guess who's there? Lawrence Lenke, MD (SRS Vice President, Presidency set for 2010-2011) ??
http://www.spinal-deformity-surgeon.com/

[Pooka1]

Yes him, Weiss, Dubousset, and Boachie. Maybe a few more... I don't know.

I also note they have an orthotist on the Advisory board and a plant pathologist as a research editor. Very eclectic.

[mamamax]

Definitely an impressive Editorial Board!

[Ballet Mom]

My reaction was against someone using the term "eliminate." Not even that he thought he might be able to eliminate pain, but that that's the term he chose to summarize his surgery. It's just a word that puts me off. Researching a little more, my discomfort was increased by learning that Dr. Anand gets royalties on every use of the technology he developed.

This is nothing against surgeons in general. I very much liked the surgeon we went to see. But the (now) combination of absolutist language and great financial benefit puts my hackles up. My hackles might be wrong, but they are up.

I agree with you hdugger, my hackles went up immediately also. I think it's bizarre to have a surgeon (or one of his staff members) trying to drum up patients for a new surgical procedure on this forum. It would be one thing if he ever stopped to answer any questions, but he doesn't...he's merely advertising. Either this board allows advertising, or it doesn't.

And to state that he can eliminate pain is bizarre also. It is true that many patients are helped with pain, but many are not. And there is even a fairly new study showing that there are increasing pain levels at five years versus two years.

http://www.ncbi.nlm.nih.gov/pubmed/18449045

Spine (Phila Pa 1976). 2008 May 1;33(10):1107-12.

Adolescent idiopathic scoliosis patients report increased pain at five years compared with two years after surgical treatment.

Upasani VV, Caltoum C, Petcharaporn M, Bastrom TP, Pawelek JB, Betz RR, Clements DH, Lenke LG, Lowe TG, Newton PO.

Department of Orthopedic Surgery, University of California San Diego, San Diego, CA, USA.
/
/
CONCLUSION: There was a statistically significant increase in reported pain from 2 to 5 years after surgical treatment; however, the etiology of worsening pain scores could not be elucidated. Given continued patient satisfaction, the clinical relevance of this small reduction remains unknown. Nevertheless, this observation deserves further evaluation and must be considered in relation to the natural history of this disease


Also,

http://www.scoliosisjournal.com/content/3/1/9

Post-surgery pain

Pain is the primary indication for re-operation [64-66]. The mechanism for increased neck and back pain after surgery is not well understood [67]. Bridwell [10] suggests that late-developing pain could be a complication of surgery, or an effect of aging, or 'perhaps a focus on the disability associated with spinal deformity and surgical treatment.' But the answer for surgeons seems to be to re-operate [68]. Among 190 patients, 19% required re-operation within 2 to 8 years after surgery [67]. For 27 patients who sought treatment 59% felt their pain had been reduced, but 41% did not feel a reduction in their pain levels, and a further 26% were very unhappy with the outcome [68]. Among 34 patients with significant post surgical pain, 56% reported reduced pain after additional surgery, while 44% did not; in the same study, 2 patients who did not have pain before surgery reported pain in the follow up [69].

Pain at the iliac graft site, first noted in 1979, has now been formally published [70,71]; of 87 patients, 24% complained of pain at the graft site, with 15% reporting severity sufficient to interfere with daily activities. As reported by the authors such problems with iliac crest grafting have been severely neglected in literature, especially problems associated with rib-resection.

[Pooka1]

16 year followup on low back pain with old instrumentation

but a very small group...

http://www.ncbi.nlm.nih.gov/pubmed/1...m&ordinalpos=2

CONCLUSION: We evaluated long-term outcomes regarding LBP following scoliosis surgery. Regardless of residual back deformity, LBP was found to be no more frequent than in the normal population in Japan. Positive sagittal balance at the latest follow-up was a factor significantly contributing to LBP following scoliosis surgery.

These studies are all over the map for a lot of reasons. I suspect the people who achieved good sagittal balance have less or no pain compared to the people who don't. Maybe the majority of the revision cases happened because the original fusion did not achieve good balance for whatever reason. Maybe it isn't possible to achieve good balance with some patients. Maybe the reason pain in kids with AIS post surgery is rare is because it is easier to achieve good balance in a flexible spine with only a curve as opposed to a more rigid spine with a bunch of other conditions when AIS is left untreated. The jury is out on that equation but I think we will have an answer on when is best to fuse when some longer term results are in with the new instrumentation. But even then, I think the results are going to be constrained by the balance achieved or some true master variable and not just "fused" versus "untreated." This is complex.

So pain post surgery might be a proxy for the surgeon's ability to achieve balance in a given patient as opposed to anything intrinsic with the fusion. This is reason number 5 bazillion why the literature is likely always going to be flawed.

And the key point is to pick the appropriate baseline. Pain in surgical patients needs to always be compared to pain in untreated scoliosis, NOT the general public. That said, comparing to the general public, treated or untreated scoliosis is never going to look bad given the known incidence of back pain in the general public (~85%). The severity is likely to be different but that needs to be quantified in both populations if possible. For example, I am in the general population and I had debilitating pain, albeit for only a few months, associated with my natural fusion in my lumbar several years ago.

Perspective always.

[Ballet Mom]

Perspective always.

I agree. That's why I posted those studies.

And unless Anand thinks that somehow his method of surgery has eliminated pain in the scoliotic patient, he should be very careful of what he is stating. His statement does mislead otherwise.

Perhaps he means to say that minimally invasive surgery has less post-operative pain than other methods due to less cutting of the skin, nerves and muscle. If so, he should certainly clarify it and be very careful with what he is stating. I believe he is, perhaps unintentionally, misleading people.

[Pooka1]

Until someone shows that fusion versus not fusion is the master variable, all these pain studies that don't group people according to that master variable are hopelessly flawed.

Just because they divide people into "surgical" versus "untreated" versus "population" doesn't mean those are the key groupings. They can't just know it, they have to show it. At present they are just assuming it though there are a few studies that are pointing to sagittal balance as being a key grouping component. I would like to see a study where the separate good and less good balance post operatively and over time and correlate that with pain long term.

I did post the one study that showed that degree of correction did not correlate with low back pain. Other studies indicate lowest instrumented vertebra doesn't correlate. This is the way to proceed... knock out what isn't correlated and what is left standing might be what is the master variable. So far, sagittal balance is looking like a good candidate for pain long term. At least nobody as knocked it out to know knowledge and at least a few people hint that this is key.

If that is the case then someone is going to have to ask some hard questions now that the instrumentation is looking better about the wisdom of waiting to fuse if it is harder to achieve a good balance in a more rigid, more mature spine.

And perhaps the reason T curve fusions are much less problematic than L curve fusions is not necessarily the intrinsic function of the T versus L spine as is sometimes suggested but the ability to achieve a good sagittal balance with T versus L curves. Who knows. I'm just spitting in the wind. But we do know that nobody has isolated any master variable w.r.t. long term pain to date.

[Pooka1]

And unless Anand thinks that somehow his method of surgery has eliminated pain in the scoliotic patient, he should be very careful of what he is stating. His statement does mislead otherwise.

If some of his patients have had their pain eliminated then he can say that. That is not a wacky statement as it is known to happen. The question is what percentage have achieved that in order to determine how misleading the statement is.

I agree with whomever said that Anand comes on here basically to advertise and he doesn't answer questions. He should start answering questions if he wants to avoid the charge of advertising.

[Ballet Mom]

If some of his patients have had their pain eliminated then he can say that. That is not a wacky statement as it is known to happen. The question is what percentage have achieved that in order to determine how misleading the statement is.

Even if he has some patients that have had pain eliminated, at least temporarily, it is misleading for him to state that without some modifiers, such as hdugger has already explained. In addition, he certainly doesn't have long-term studies showing any pain elimination seeing as this is a new procedure.

It is funny (as in odd), as you would be all over anyone on this board who used this type of statement if it had anything to do with bracing or exercise or other non-surgical treatments and yet you allow the surgeon to mislead. You should at least be consistent.

[Pooka1]

One more thing... I think they need to separate out anterior from posterior procedures as was not done in one of the posted studies. The issues with both are different and it isn't surprising per se that pain a few years out might be different with the two procedures. Lumping the two procedures is not likely to clear things up in my opinion.

As to iliac crest bone harvesting, enough was known when kid "A" had her surgery that I was going to mount a large push back on that if that was envisioned. I don't think they do that much any more, at least with kids. I spoke to one woman who said she has far more pain associated with the iliac bone harvest site than with her spine. She is several years out from surgery and she still have pain at the iliac crest. That was enough said for me.