How to maximize the function of your back and minimize back pain:

After a lot of recent office visits on back pain, I think it’s a good idea for me to post some information on how to avoid back pain…at any age.

Three things you can do to optimize the function of your back, and not get back pain:

1.      Maintain your ideal body weight.  The more weight you carry, the higher your body mass index (BMI), the more stress is on your back, its muscles, vertebra and soft tissues.

2.      Be physically fit.  This does not mean running a marathon, riding a century (100 miles on a bike), or swimming the English Channel.  Instead, we recommend participating in aerobic activity in which you raise your heart rate and break a sweat for 20-30 minutes every other day.  This does not have to a competitive or a team sport.  Noncompetitive, individual activities (such as swimming, jogging, etc…) are ideal, as they can be done whenever and wherever you want.  By working on your fitness, you will likely drop unhealthy body weight, strengthen your core musculature, have improved energy and mental outlook.  It is a simple fact: people who are more aerobically fit have less back pain.  There is plenty of scientific data supporting the need for people to be more active and sit less.

3.      Don’t smoke cigarettes or vape.  Both of these activities permit the toxic substance nicotine to enter the body.  The impact of nicotine on the human body is well-documented, and I will not go into it in this blog.  For our topic the impact of nicotine on your back is its effect: severe small blood vessels constriction and inhibition of new blood vessel growth.  This strangulates the tissues, which need continuous supply of oxygen and nutrients, and this especially impacts the intervertebral discs.  These discs are the shock absorbers in the back, and their health is important for the long-term function of the back.  Nicotine accelerates the damage to the discs, causing them to become dehydrated, or lose their water content, which causes secondary collapse and back and possibly leg pain (sciatica).  Once the discs are damaged they can never return to normal…they will only continue to become more worn out.

Just a reminder…..these are two links to access solid, physician-accepted information about early-onset scoliosis

https://www.srs.org/patients-and-families/conditions-and-treatments/parents

https://www.growingspine.org/family-resources

Hot off the presses....this study helps us identify which patients will need the highest level of respiratory therapy care and to discuss this with parents and caregivers before surgery

The Risks of Spinal Deformity Surgery

In order to minimize the risks of spinal deformity surgery for scoliosis, kyphosis, spondylolisthesis, spondylolysis, etc….. Obtaining a thorough medical history is necessary, along with a physical examination, blood work and imaging studies.  Shared decision-making is important during discussion about surgery, along with the alternatives to surgery, the benefits of surgery, potential complications and risks.  Below is the first part of the routine preoperative discussions on spinal deformity surgery in children and adolescents.

Overall there are two layers of risks in spinal deformity surgery: 1) Those common to any surgical procedure, and 2) those unique to spinal deformity surgery.  The below information are those risks common to all surgical procedures which require general anesthesia.

1.      Risks common to any surgical procedure: general anesthesia and the need to incise the skin for the surgery

a.      General Anesthesia = being asleep for the entire procedure

                                                    i.     Statistically there is a greater risk of a fatal car crash over a year (1 in  4,000 to 8,000) than there is of a catastrophic event due to general anesthesia in a healthy adolescent or child (1 in 100,000 surgeries).  The riskiest part of the day may be the drive to the hospital, so drive safely and buckle up.

                                                   ii.     Nausea and vomiting are common after general anesthesia, in up to 30% of surgical case.  The Anesthesiology team give medications during surgery to minimize nausea and vomiting after surgery

                                                  iii.     Being under general anesthesia is like taking a nap, only medication-produced.  You won’t know how much time you have been asleep until you wake up and see a clock or someone tells you….it is just like taking a nap.

b.      Surgery requires creating an incision on the skin, which means the area of surgery can develop a bacterial infection. 

                                                    i.     In medical terms this is call a SSI or Surgical Site Infection

                                                   ii.     There are many things the surgical team will do to minimize the chance of an infection. 

1.      The use of antibiotics is very important.  They are given before incision is made, during the surgical procedure and after surgery to minimize the risk of a SSI.  It is also important the correct antibiotic is give, at the correct dose and at the optimal time.

2.      Before surgery, usually at the preoperative visit, a nasal swab will be performed.  This is to try to identify people with MRSA on their bodies, specifically their noses.  MRSA = Methicillin-Resistant Staphylococcus Aureus, which is a very bad infection to get due to its being resistant to most antibiotics which can be given to prevent infection.  It is important to know who carries MRSA before surgery to make sure the correct antibiotic is given before an incision is being made.

3.      And there are many things you will not see the surgical team doing, such as the sterile skin preparation, surgical draping, sterile surgical technique, etc…. which also help minimize surgical infections.

                                                  iii.     Due to the large amount of metal used in spine deformity surgery a deep infection of SSI (an infection which is on the spinal metal) is a major problem.  It can be difficult to get rid of a deep infection around the metal since many bacteria strongly adhere to the metal.  In addition bacteria can put up a protective wall around itself which prevents antibiotics from reaching the bacteria and killing it.  If a SSI occurs it usually requires several surgical procedures (called irrigation and débridement) to wash out the wound in order to remove the bacterial load.  The use of antibiotics is essential, with the initial treatments given intravenous (through tubing) and then switched over to oral.

                                                  iv.     The surgical site infection rate for patients with idiopathic scoliosis (which means no known cause) is at Washington University is much lower than the average for pediatric hospitals in the U.S.  However we will not be satisfied until ALL infections are prevented.

The next post will be on risks unique to spinal deformity surgery…..such as neurologic deficit, failure of fusion, implant breakage or dislodgement, need for repeat surgery, etc…..

International Congress of Early-Onset Scoliosis

Novemer 15, 2018

Lisbon, Portugal

Shilla Growth Guidance Procedure

1.      What is the Shilla procedure? The Shilla technique is one which passively guides spine growth, rather than actively distracting across like a growing rod system.  I refer to it as a "track and trolley" system.

 

2.      Who is a candidate for the Shilla technique?  Many patients who are candidates for traditional growing rods (GR) are also candidates for the Shilla technique.  The decision between GR and Shilla technique will be made between the surgeon and parents/caregivers focusing on what is best for the child. 

3.      How is it different that traditional growing rods or MAGEC?  The Shilla fixes the worst part of the deformity, that part of the spine which is growing more sideways than vertically.  By straightening out the severely curved part and then fusing the apex of the deformity the apex will be permanently improved. A traditional growing rod or MAGEC system fixates above and below the worst part of the spine deformity and creates small fusions in the part of the spine which is growing more normally.  The growing rods are then forcefully distracted to put the spine under tension.  See reference #1 below for more details.

 

4.      Is Shilla better than traditional growing rods or MAGEC?  To this surgeon, if a Shilla can be used over a traditional growing rod or MAGEC then it is my first choice.  The question is why?  The initial surgery is similar between all three surgeries in terms of recovery.  The benefit of the Shilla is there is no need for repetitive surgeries, unlike traditional growing rods, or frequent clinic visits, as is necessary for MAGEC.  Overall, when Shilla is compared to growing rods the overall outcome on x-rays is nearly identical.  Another benefit is Shilla patients undergo 1/3 the number of surgeries/anesthesia when compared to traditional growing rods.  See reference #2 below.

5.      Is the spine fused in a Shilla procedure?  A spine fusion is performed typically over 2-4 vertebra where the scoliosis is at its worst.  These vertebra were not growing normally anyways.  Even if the patient had received a traditional growing rod or MAGEC that very curved part of the spine would not grow normally.

6.      How long will the Shilla procedure last? In the 2^nd paper listed below it was demonstrated that they average patient underwent 3 surgeries: initial, one revision and then one final surgery.  The average patient underwent a revision surgery at 3-3.5 years after the first surgery and then final surgery at 6-7 years after the first surgery.  Every patient is different.

7.      When growth is completed what happens with the Shilla construct?  At or near the end of spine growth a decision is made to either convert the Shilla to a definitive spine fusion or removal all the implants with the idea to restore spine motion and not need a fusion surgery. 

8.      Whose decision is it to remove the implants or convert to a spine fusion?  It is a decision made by the patient, family and surgeon.  Most patients are undergoing definitive fusion surgery thus far because they wanted to improve their body position permanently.

9.      How many patients have had their implants removed? Thus far between our center and Little Rock there are less than 10 patients.

10.   If the implants are removed can a fusion surgery be done in the future?  Yes.

References:

1.            Luhmann SJ, McCarthy RE.  A Comparison of SHILLA™ GROWTH GUIDANCE SYSTEM and Growing Rods in the Treatment of Spinal Deformity in Children Less than 10 Years of Age.  J Pediatr Orthop 37(8):e567-e574, 2017.

2.            Luhmann SJ, Smith JC, McClung A, et al.  Radiographic outcomes of Shilla Growth Guidance System and traditional growing rods through definitive treatment.  Spine Deformity, 5:277-282, 2017.

3.            Luhmann SJ, McAughey EM, Ackerman SJ, Bumpass DB, McCarthy R: Cost analysis of a growth guidance system compared with traditional and magnetically controlled growing rods for early-onset scoliosis: a US-based integrated health care delivery system perspective. ClinicoEconomics & Outcomes Research 1:179-187, 2018.

Vertebral Body Stapling (VBS)      Part 2

1.  What is the success rate for VBS?  Two centers have reported their outcomes of VBS in patients (Washington University in St. Louis, and the Philadelphia Shriner’s).  Overall success rates for lumbar and thoracic curves are around 70%, which means the curve improved, did not change or changed less than 6 degrees.

2.  What is the success rate of bracing?  The highest level of evidence on bracing for idiopathic scoliosis is from the BRIAST study, which was a prospective study of scoliosis patients who wore a scoliosis brace and those who did not.  48% of non-braced patients did not have progression of their scoliosis and 72% of braced patients did not progress.

3.  So to conclude: the success rates for VBS and bracing appear to be equivalent.

4.  Why would a VBS be offered or performed if the results are similar to bracing?  Bracing is not an easy treatment for anyone.  VBS provides an option for those patients who cannot or will not wear a brace to control their scoliosis.  It is important to note VBS is not better than bracing, it is just a different treatment option.

5. Do the staples have to be removed in the future?  The answer is no.  The staples do not have to be removed.  The body will cover over the staple with scar tissue and the staple will gradually loosen in the vertebral body.  Due to the tines of the staple curving in the staples will not back out.

6.  What happens if the VBS does not control the scoliosis and a posterior spinal fusion is needed? Do the staples have to be removed at that time?  Again, no.  Since the staples are placed in the front of the spine they will not interfere with the instrumentation placed in the posterior (back) part of the spine.  Also the staples do not interfere with the ability to correct the scoliosis at the time of fusion.

7.  Who is a candidate for Vertebral Body Stapling?

     a.  Skeletally immature: since scoliosis mainly progresses due to growth, the use of VBS only is indicated during the growth.  There is no benefit of VBS in skeletally mature individuals

     b.   Scoliosis who Cobb measure is:

                                                    i.     </= 35 degrees in the thoracic spine

                                                   ii.     </= 40 degrees in the lumbar spine

     c.  Patients who cannot or will not wear a brace to halt the progression of scoliosis.

     d.  Diagnosis of idiopathic scoliosis or patients who have idiopathic-like scoliosis    

Who is not a candidate for VBS?

a.      Skeletally mature patients: Risser >/=3

b.      Diagnoses with poor bone quality, increased muscular tone, neurogenic scoliosis (patients with Chiari or syrinx), etc…

c.      Cobb measures >35 in the thoracic spine and >40 in the lumbar spine.

d.      Increased kyphosis of the thoracic spine >40 degrees (since the staples induce kyphosis)

e.      Those patients whose spine is excessively malrotated due to the scoliosis.  VBS will not significantly change this for the better.