Wednesday, April 29, 2020

New Publication to review...

117 patients were analyzed to assess if any of the preoperative labs could identify which patients were at a greater risk for a deep surgical site than other patients.

We are constantly striving to minimize, and ideally eliminate, surgical site infections after posterior spinal fusion.  There is a lot more work to be done!

To read the study, go to this Springer hyperlink:

Be safe, stay healthy!!


Thursday, April 16, 2020

Halo-Gravity Traction in Spinal Deformity Treatment (Part 2)
To provide a more complete answer from the last blog on “when” we use halo-gravity traction, the answer is: Before spine deformity surgery, at which time growing rods, Shilla Growth Guidance System or a definitive spinal fusion is performed. 

Case: 5 year old male with 101 degree curve. 

 Decreases to 72 degrees after 6 weeks of traction

Patient undergoes T2-L3 Shilla Growth Guidance Procedure after halo-gravity traction treatment.

When should halo-gravity traction not be used?
There are several situations in which we do not use halo-gravity traction:
1.       The halo is attached to the skull by pins.  This means there must be good bone where the pins are placed to provide safe, stable fixation.  Patients with soft bone or defects in their skull like Swiss cheese (such after brain surgery) may not be candidates for halo-gravity traction.

2.       Instability of the cervical spine or neck
3.       Patients with increased muscle tone, which includes most patients with cerebral palsy
4.       Behavioral issues
5.       Patients with spinal cord dysfunction (weakness, pain, sensation problems, bowel/bladder problems) may benefit from preoperative HGT, but each person must be evaluated individually.

Where is the halo placed?
The halo is applied under general anesthesia, which means the patient is completely asleep

Does it hurt?
When the halo is applied local anesthetic (numbing medicine) is injected at the pin sites to decrease the pain for up to 6 hours after halo application.  Pain medication is given through the IV or orally as needed.  Most patients report the pain is like having a headache and the pain usually subsides gradually and is mostly gone after 48 hours.

Why is the traction treatment typically around 6 weeks?
Studies from our hospitals, mainly Shriners Hospital, have demonstrated maximal correction takes up to 6 weeks.  The length of traction depends on many deformity factors which include location, magnitude and flexibility of the spine deformity.

How much weight is applied to the traction?
Typically traction weight starts at 5-10 pound right after surgery.  Weight is added daily until the goal weight is achieved.  Our studies have demonstrated maximal correction of the spine deformity occurs between 35% and 40% of the patient’s body weight.

Where is the halo-gravity traction used?  At home or in the hospital?
At our center we only use HGT while in the hospital.

1.       Bogunovic L, Lenke LG, Bridwell KH, Luhmann, SJ.  Preoperative Halo-Gravity Traction for Severe Pediatric Spinal Deformity: Complications, Radiographic Correction and Changes in Pulmonary Function.  Spine Deformity 2013;1:33-39
2.       Lenke LG, Sugrue PA, Bridwell KH, Kelly MP, Luhmann SJ, Sides BA, Bokshan S, Bumpass DB, Karikari IO, Gum JL:  The radiographic and clinical impact of preoperative halo-gravity traction in the treatment of early-onset spinal deformity.  Spine Deformity 3(6):617-618, 2015.

Sunday, April 5, 2020

Halo-Gravity Traction in Spinal Deformity Treatment (Part 1)

1. What is halo-gravity traction (HGT)?

Gravity pulls the body down, and causes the spine to bend and twist more, especially for those individuals with scoliosis or kyphosis or both.  Simply put, gravity makes spinal deformity worse.  Laying down in bed, or on the ground, negates the force of gravity making the spinal deformity better temporarily, and can decrease back and neck pain.  Unfortunately for spinal deformities we cannot lie down our entire life.  Traction on the spine is not a new concept, has been advocated for spinal problems since the age of Hippocrates (Vasiliadas ES, in Scoliosis 2009). 

HGT is aimed at correcting spinal deformity by reversing the impact of gravity on the spine.  Halo-gravity traction is the use of a halo, applied to the cranium or skull, through which a vertical traction force is applied to the head, neck and spine. 

2. Why is HGT used?

For treatment spinal deformity it can be used before surgery in order to improve the deformity before the individual undergoes their surgical treatment.  The bigger the deformity, the greater potential risks are for a problem with spinal cord function at surgery.  So by stretching the spinal deformity and spinal cord before surgery, while the individual is awake we can assess the function of the spinal cord.  Though there is no scientific proof HGT decreases the risk of a spinal cord problem in surgery, most surgeons who utilize this technique feel it may lessen the risk.

3. When is halo-gravity traction used?

Spinal deformity problems range from mild to severe, and it is for those problems on the severe end that HGT can be useful. 

Before and after HGT treatment:

Friday, April 3, 2020

“Doctor, what would you do?”….DWWYD…or more precisely:

“What would you do if this was your child?”

Fifteen years ago I rarely heard this question from parents and caregivers.  Now this is a commonly asked question.  The media (e.g. Parents Magazine) and advocacy groups have advocated this question as a good one to ask medical providers, when they are faced with having to make a decision about a diagnostic test or treatment.  Its quoted purpose is to simplify the issues, factors, cofounding variables of a medical problem or issue, which would then make it easier for non-medical people to understand.  The common thought is “well, if you would do “it” for your child then it must be the correct action for me to take for my child.  However, this is not that simple.

What is the right decision for my child, and everyone else’s children, is dependent on multiple issues: personal and family values, religion, culture, heritage, socioeconomic status, and many other personal perspectives.  So what is the right path for my child may be different than the one you may choose for your child.

This is a nice article from AAP about this topic:

My practice is focused on spine problems in children and adolescents.  I see the full spectrum of problem severity.  On one end some are very mild and need no treatment, and at the other end there are severe problems which need major spinal reconstructions.  So, from the parents/caregivers perspective the decision process may be an easy one or may be very complicated, convoluted and have significant potential risks to their child. 

So how do I, as the physician, present treatment decisions to parents and caregivers? 

First of all, I educate.  In order to make a good decision it is important to objectively educate parents/caregivers with the best, highest-level of scientific evidence and medical knowledge currently available about their child’s problem.  I always focus on what would I want to know if I was in their position, as if it were my child who needed a care decision.   

Secondly, it is important to detail how their child fits in the framework of medical knowledge.  By doing this it helps create a platform on which parents can better understand the issues treatment alternatives, benefits, complications and risks.  It empowers the parents, engaging them to be an active participant in their child’s medical care. 

Thirdly, my goal when presenting treatments, is to only present those which are reasonable and based on scientific information.  I never offer a treatment options if it will not provide similar or relatively equivalent long-term outcomes, with similar complication types and frequencies. A treatment option may be reasonable alternative even it requires more surgeries (actual or potential), more trips to the hospital or clinic, more radiographs, a longer postoperative recovery, with more activity restrictions and more pain temporarily.  Those are short-term and not long-term issues, though they may not be desirable.

Fourthly, I present the potential benefits and risks of the treatment and their likelihood of occurring.  Personally I don’t like to present actual numbers like 99%, 75%, 20% or 1%.  Rather I like to focus more on low, medium, high chances of an outcome or complication.  The reason I shy away from number is that it can be hard to understand a 75% chance of some problem happening, since this number is bases on population statistics.  A 75% chance means out of 100 people, 75 will have it happen to them, and 25 will not have it happen to them.  However, each person will (100%) or will not (0%) have it happen to them.  A person will not get 75% of the outcome, they either will or will not get it.

Lastly, I give the parents/caregivers plenty of time to ask questions, both in the office setting and after they go home with phone conversations as needed.  The nice aspect of pediatric spinal deformity problems, unlike severe medical problems, such as cancer, is that there need to make a rapid decision is infrequent.  There is usually time to think, discuss, and ask questions….and even get a second or third opinion from another physician.  I am never offended or disappointed if parents/caregivers want another opinion.  It is their right to do so for their child and I fully support it.