Tuesday, July 28, 2020

Closure of Spinal Deformity Wounds

The long-term appearance of a planned surgical scar is a common concern before surgery.  Sometimes this question is asked to us, other times it is not, likely because people do not want to appear overly concerned or vain about appearance or aesthetics of their skin.  Either way, the concern exists and is valid. Why would anyone want a wide, unattractive scar?

So how do you close the below surgical wound safely and so that it has the narrowest scar long-term?

Our method of wound closure in pediatric spine is influenced by several factors:
1. Location of the wound: Back incisions, though easy to hide under shirts and tops, can easily be seen when the child/adolescent is not wearing a covering (e.g. swimming).
2. Desire to minimize the visibility of the surgical scar.
3. Patient intolerance, anxiety and/or distress when non-absorbable sutures or staples need removal. 
4. We want to avoid the need for additional outpatient visit for surgical wound suture or staple removal

In the operating room, at the end of the surgical procedure, the surgical wound is closed in two layers, the deep spine fascia (black arrow) and the skin (red arrow).  The fascia is a strong covering over the muscle, and this is the first layer to close.  It is important to close this tightly to get the appropriate healing after surgery.

The second layer is the skin (small red arrow in above picture).  This layer is actually closed with two separate suture layers

The first layer is deep dermal layer (red suture in below picture) which closely re-approximates the skin edges.  This takes the tension off the edges of the skin.

The second layer is the subcuticular or epidermal suture (blue suture in picture above).  This uses a small suture woven back and forth just barely underneath the surface of the skin.  It is this layer which gently puts the edges of the skin against each other to minimize the amount of scar tissue which develops.  A gap will require scar to heal the area, and this never leaves an attractive scar.

Lastly the skin in sealed with a glue.  This glue also helps the skin edges to be very close together and minimize motion.  It also nicely seals the skin watertight.  This glue usually starts to fall off about 3 weeks after surgery.

We don’t use sutures, steri-strips or staples in our skin closures.

They don’t leave as nice a wound as we want
We want to avoid our wounds looking like this

Instead this is the way we want our skin closures to look. This is only 4 weeks after surgery!

Next blog post we will show pictures of surgical wounds, after surgery, to demonstrate the nice progression of healing with our technique.

Friday, June 26, 2020

Spine Rotation in Scoliosis (part 3): How we correct spine malrotation and rib prominence during spine fusions

In the last 2 posts I showed how scoliosis is a 3-dimensional problem, with the spine rotating around itself as it bends to the side.  The way to visualize this is to imagine a water slide, as it turns to the side, it also rotates…just like the spine in scoliosis and how the spine twists the ribs around.

This post will show how we can improve the spine and rib position during a spine fusion surgery.
The case example is a 14 year old young lady with a 58 degree right thoracic idiopathic curve, and 35 degree proximal thoracic and 24 degree lumbar curves.

The supine side bending radiographs demonstrate the flexibility of the spine.  So only the main thoracic curve of 58 degrees is what we call “structural” and the other two curves, due to the fact they bend out to be below 25 degrees, we call “nonstructural” or “compensatory”.

In order to maximize 3-dimensional correction and long-term outcome, while minimizing need for any additional surgeries the plan was to do a T3 to L1 posterior spinal fusion.  T7-T8 and T8-T9 PCOs, or posterior column osteotomies were also performed.  These osteotomies (PCOs) are done at the time of surgery to increase spine flexibility in all 3 planes, to maximize spinal deformity correction to as close to “normal” as we can safely achieve.

Pedicle screw are the optimal method of spine fixation.  They allow rigid fixation to the spine, and permits the spine to be moved 3-dimensionally.  Not every vertebra needs to have 2 screws.  Strategically placing screws to optimize immediate correction and assure long-term outcome is preferred, so about 1.5 screws per level is common.
By placing the screws at certain locations, specifically at the apex, the spine can be derotated back more toward normal.

The silver towers or rods are attached to the screws (picture on left), and then these towers are connected together to improve strength of the spine fixation (middle picture).  This connection process, for this patient, make 3 groups, one for each curve.  These 3 groups of towers/screws are then rotated back toward normal (picture on right).  You can see the different position of the middle group, relative to the other two groups, between the middle and right-sided pictures.  Once rotated to the improved position (right picture) the screws are then tightened down, and much more work is done in surgery to 3-dimensionally improve and balance the spine.

These postoperative radiographs are one year after surgery.  The patient is nicely balanced 3-dimensionally and has nicely improved.

Tuesday, June 16, 2020

Spine Rotation in Scoliosis (part 2)

In the last post I showed how scoliosis is a 3-dimensional problem, with the spine rotating around itself as it bends to the side.  The way to visualize this is to imagine a water slide, as it turns to the side, it also rotates…just like the spine in scoliosis.

What is interesting is that each patient is unique in the amount of rotation of scoliosis, some have more rotation, and some have less for the exact same amount of scoliosis.  While the rotation of the spine has not yet been shown to impact the long-term functional outcome of the spine, it DOES impact the physical shape of the body.  The rib prominence in the back causes the shoulder blade to be prominent.  The rotation of the ribs also impacts the body in the front, by making the ribs stick out more on one side and can cause breast asymmetry.  So the greater the rotation of the spine, the more physical deformity of the body.

When the scoliosis is smaller, somewhere between 20 and 45 degrees, bracing is typically a treatment option.  When a scoliosis brace is applied to the body it is molded to push against the rib prominence, to try to prevent the scoliosis to continue to progress and rotate more.


When the scoliosis gets to more than 45 degrees, bracing is not very effective because it cannot exert enough force on the ribs to prevent the spine from progressing.  Surgery can be an option for curves >/= 45 degrees.  If surgery is an option, the amount of rotation in the scoliosis is important to determine, and is usually done using a scoliometer (see below).

This is a measurement from horizontal; similar to an inclinometer. 

As mentioned in a previous post on vertebral body tethering, rotation of more than 20 degrees is a relative contra-indication to a tether procedure.  This is because a tether does not significantly alter the rotation of the spine, so if the spine is corrected with a tether, there still may be permanent physical deformity due to the residual rotation of the spine.  In these circumstances, specifically a curve 45+ degrees with more than 20 degrees of rotation, a spine fusion may be a better option.

A successful surgery depends on quantifying the spinal deformity, identifying what are the major (and lesser) cosmetic/aesthetic/physical body concerns, and then developing a strategy to maximize correction safely.

In the next post the surgical correction of pediatric scoliosis will be demonstrated, mainly focusing on correction of the rotation.  So if you don’t like surgical photos, and a little blood, then don’t view the next post!

Saturday, June 6, 2020

Spine Rotation in Scoliosis

I have scoliosis….
So why do I have a rib hump?
Why does my shoulder blade sticks out more on one side?
Why are my ribs in the front different?

These are common questions I hear from patients with scoliosis and their parents and caregivers.  So why do these changes to the chest happen? Well it’s the ribs which are causing the rib hump, shoulder blades to stick out on one side and the ribs in the front to be uneven.  Why?  Well, first we need to understand what happens to the spine in scoliosis.  If you look at the radiographs (x-rays) below,

from the top to the bottom, the spine moves to the right, then the left and back to the right.  In this sense it looks like a lazy river ride at your local water park.

The lazy river moves right, then left, then right…..just like the scoliosis.  However, we are only looking in two planes…and scoliosis is actually a 3-d spine problem.  So when the spine curves, it also rotates.  So this makes scoliosis more like a water slide than a lazy river. As it curves, it also banks

So if the spine is banking as the spine curves left and right….why does that impact the ribs?  Well the ribs are attached to the spine with strong ligaments

Which means if the spine banks or twists, it will also bank or twist the ribs, both in the back and in the front of the chest. 

On the convex, or outside part of the curve, the ribs will be pulled backwards, and on the concave side (inside) of the curve, the ribs are pushed forward.  Since most scoliosis has a curve to the right on the upper curve, the ribs on the right side stick out more, and makes the shoulder blade wing out more, as in the above two pictures.

Also, if the right ribs are pulled back and the left ribs are pushed forward (pictures above) then the patients will see the ribs on the left side, just below the breast be more prominent (stick out more).

In the next blog post I will show how we improve the rib prominence or deformity during surgery.

Be Safe…

Friday, May 29, 2020

Scoliosis Surgery Frequently-Asked Questions

1. How do I know if I have scoliosis?
            Uneven shoulders or hips, or asymmetry of the contour of the back (which is more obvious with forward bending) can be visual tip-offs that scoliosis is present.  Also, individuals with a family history of scoliosis are more likely to have scoliosis.  Assessment by primary care physicians can typically identify an individual with these types of body asymmetry and, if any is detected, a single radiograph (x-ray) from the front/back of the thoracic and lumbar spine (from collar bones to hips) is indicated to definitively diagnose scoliosis.

2. Is there someone I can talk to who has scoliosis?
            Yes, we can connect you with other individuals (patients, parents, caregivers) who would be willing to discuss the issues and problems of scoliosis on a first-hand basis.

3. Is scoliosis caused by not drinking enough milk or eating too much junk food?
            No, though both of these may impact the long-term health of the spine by decreasing the overall bone mass of the body.  Low spinal bone mass as an adolescent can become magnified in one’s 60’s, 70’s and 80’s and can increase the risk of osteoporotic spinal fractures.

4. Does scoliosis hurt?
            Mild scoliosis does not cause pain.  Moderate to severe scoliosis can increase the likelihood of activity-related musculoskeletal pain.

5. Why do kids get scoliosis?
            The cause of “garden-variety” scoliosis is unknown.  Some researchers have found an association between scoliosis and a very subtle form of neurological abnormality which has no outward manifestations besides the scoliosis.  Current research is ongoing to identify the specific genes responsible for scoliosis.

6. What are the goals and expectations of scoliosis surgery?
            The classic type of scoliosis surgery is a spinal fusion.  In this surgery a segment of the spine is corrected to the optimal 3-d alignment and then fused to eliminate motion between the vertebral body segments.  At the time of surgery the malalignment of the spine is corrected as much as possible toward normal alignment.  The use of spinal implants (metal screws, hooks and rods) permits straightening of the spine and also maintains the correction as the spine fusion heals after surgery.  Newer techniques for correction of scoliosis which do not “fuse” the spine are in the development (vertebral body tether and Apifix) and early adoption phase and hopefully will decrease the need for spinal fusions.

7. How much correction do you expect to achieve at the time of spine fusion?
            The amount of correction depends on multiple patient factors: patient age, curve size, location and flexibility, presence of other curves, concomitant medical problems, previous surgery, etc....  Judicious correction of the scoliosis is always indicated as overcorrection of the spine can lead to temporary or permanent neurological injury, such as nerve root deficits or paralysis.

8. How long will the incision be, and what can I expect in terms of scarring?
            For “open” procedures, the incision will be made directly down the middle of the back.  A “plastic surgery-style” closure is performed with all of the sutures being under the skin, so no sutures have to be removed after surgery.  The sutures gradually dissolve under the skin and are absorbed by the body.  There is only “glue” on the skin, which falls off about 3 weeks after surgery.

9. Which vertebrae will be fused in the "average" scoliosis correction?
            In the “average” scoliosis correction in the thoracic spine the fusion starts at T3 or T4 and ends at T12 or L1.  If there are thoracic and lumbar curves which need to be fused then the distal levels typically are at L3 or L4.
10. Do you normally show the patient the hardware that you will use in the surgery?
            Yes, we have plastic spine models with a typical scoliosis spinal construct which nicely demonstrates the implants utilized during surgery.

11. Can you see or feel the hardware under the skin?
            You cannot see the spinal implants under the skin.  Occasionally a thin individual may feel a prominent implant under the skin due to the decreased muscle mass or subcutaneous tissue to “pad” the implants.  Prominent implants are more common when the fusion is continued to the pelvis with screws into the iliac wings.

12. How much growth would you expect the fused portion of my spine to have grown had it been left unfused?
            The amount of growth lost due to a spine fusion is typically 0.07 cm cm per level per years of growth remaining.  Females typically complete growth by 14 years of age and males by 16 years of age.  For example an average 12 year old female with a spine fusion from T3-L1 would lose approximately 1.8 cm (2/3 of an inch) of overall height.

13. What is a "crankshaft phenomenon," and when does it occur?
            This phenomena can develop when a posterior spinal fusion is performed in an individual who is less than 10 years of age.  The “crankshafting” occurs due to the arrest of posterior spinal growth, due to spinal fusion, while anterior spinal growth continues causing the previously fused segment of the spine to slowly twist into a more deformed position with growth.  Prior to the development of thoracic pedicle screws, surgery was performed on the front and back of the spine in younger patients to prevent “crankshafting”.  With the use of thoracic pedicle screws, this phenomena does not appear to occur due to the improved spinal fixation.

14. Would instrumentation without fusion be a better alternative than fusion when growth potential is remaining?  Ideally the answer is “yes”.  Currently several U.S. medical centers specializing in pediatric spinal deformity are researching various types of “fusionless” scoliosis surgery, such as vertebral body tethering and Apifix.  Early, preliminary reports from these centers are encouraging but these are still in the developmental phase and indicated only for very specific curve types.

15. What will I be given for pain after surgery? Immediately after surgery, pain is managed with a PCA, which stands for “patient-controlled analgesia”.  By pushing a button you can administer your own intravenous pain medication without the need of the nursing staff.  As intake of fluids and food improves after surgery oral pain medications will be started and the PCA will be gradually weaned off in preparation for hospital discharge.  No injections are used for pain medication in our hospitals after surgery.  Opioid use is minimized by using other medications to help decrease pain.

16. How often will I be awakened and checked by a nurse after my surgery?  The first night the hospital staff will closely monitor vital signs.  This means every several hours you may be awakened, however all attempts are made to minimize intrusions.

17. When will I be able to get up and walk for the first time after surgery?  The first day after surgery you will sit on the side of the bed to dangle of the feet, then stand, transfer to a chair and then take a few steps.  Longer walking (in the hallway) is normal at 2 days after surgery with the assistance of a physical therapist or nurse.  Thereafter, walking is expected to be done a minimum of 2 times per day.

18. How soon will I be able to eat and drink after surgery?  Usually drinking of clear liquids (such as water, sodas, etc…) can be started immediately after surgery.  Since the stomach does not function normally initially after surgery oral intake is limited, but is started the day after surgery.  Any type of food you want to eat is perfectly fine, though salty, fatty, spicy foods are not usually preferred by postoperative patients.  The day after surgery the intravenous pain medications are converted to oral pain medication and since these medications can cause some nausea and vomiting, eating some food can help significantly.

19. What will be done to make my back incision safe after surgery?  The initial postoperative dressing which is applied in the operating room is removed, on average, at 3 days after surgery along with the surgical drains.  After this time the incision is typically left open to air without any dressing covering the wound.  The incision should be kept clean and dry for 1 week after surgery.

20. Will I need physical therapy after surgery? Formal physical therapy is started in the hospital for transfers and ambulation.  However, after discharge from the hospital physical therapy is not usually continued for the typical scoliosis surgery.  In addition, bracing is not typically used after surgery.

21. What are some types of therapy that I might have to undergo?  In the hospital the physical therapist will assist and teach the appropriate methods for transferring from bed to chair and to standing position.  Your ability to ambulate will be assessed and the therapist may temporarily have you use a walker to help with balance.  The great majority of patients walk fine at discharge from the hospital and do not need a walker to go home.

22. Will I need a special type of mattress on my bed? No.  Most individuals have an adequate mattress on their bed.  Occasionally a hospital bed may be helpful if the physical environment at home makes use of the regular bedroom and bed temporarily difficult.

23. How much experience will the person who is monitoring my spinal cord function have?  The spinal cord monitoring team at our 3 hospitals consists of 8 full-time highly skilled individuals who as a group monitor over 1200 surgeries per year. 

24. What is a "wake up" test and when is it performed?  Essential to a successful spine surgery is the absence of any adverse neurological outcome during or after surgery.  Spinal cord monitoring is extremely accurate in identifying neurological deficits (>99%) during surgery, but there are some individuals in whom spinal cord monitoring is suboptimal or unobtainable.  In these cases, a “wake up” test is used in which the patient’s anesthesia is temporarily lightened during surgery so that, while following verbal commands, the arms and legs can be actively moved by the patient.  After neurological function has been assessed the patient’s anesthesia is deepened back to the routine level of anesthesia.  Due to the type of anesthetic agents used, patients typically have no recall of the wake-up test after surgery.

25. I want my rib hump corrected. How is this done?  The correction of the scoliosis is achieved by several inter-related techniques during the surgery which can also secondarily decrease the rib hump.  If the rib hump is perceived as a significant part of the overall deformity a “derotation maneuver” can be additionally performed which directly corrects the abnormal scoliotic spinal rotation and thereby decrease the rib hump significantly.