Tuesday, August 23, 2022

 

Blog Topic: Talking Points for Early-Onset Scoliosis Patients: Magnetically-Controlled Growing Rods vs. Shilla Growth-Guidance

8-23-2022

 

In the surgical treatment of Early-Onset Scoliosis (EOS) the options boil down to two main constructs:

 

Distraction-Based: this encompasses both Traditional Growing Rods (TGR) and Magnetically-Controlled Growing Rods (MCGR)

            Growth-Guidance: this is also called the “Shilla Procedure”

 

We will not go into detail about these two spine constructs, but ask you go back in this blog to older posts to get the information you are interested in obtaining for you or your child.

The below table is a breakdown of the similarities and differences between Shilla Growth Guidance and Magnetically-Controlled Growing Rods.  This table can be used to stimulate and augment discussions with pediatric spine surgeons about the two constructs, and which is more appropriate for their child.



Monday, August 22, 2022

 

Blog Topic: Blood Management During Spine Deformity Surgery

8-22-2022

 

In 2022, spine deformity surgery usually requires a long incision and temporary retraction of muscles from the spine.  This extensive exposure of the spine helps to loosen up the spine (to get better correction), insert pedicle screws to grip the spine and place the long rods, which moves the spine in space and maintains the correction in its new position (while the spine fusion develops).

 


 

This type of exposure, and the amount of time required for these surgeries (4-6 hours), creates the opportunity to have significant blood loss. Does the amount of blood loss in surgery matter? The answer is “yes”. There is a convincing amount of published research which documents lower complications and better patient outcomes when the blood loss from surgery is low.

 

 

 

During surgical procedures in the operating rooms there are various methods to minimize or stop bleeding, from intravenous medications to topical materials to surgical technique.  In spine deformity surgery, some of these are effective and easy to do, while others are not as effective or require changes in the execution of surgery.   

So how do we minimize blood loss during pediatric spinal deformity surgery? Here are a few of methods we utilize on a daily basis:

Meticulous surgical technique: During surgery it is important to identify any and all bleeding.  Electrocautery is used to stop the bleeding.

Use of tranexamic acid: This medication is given by vein, through an IV, during surgery and has been demonstrated to decrease bleeding.

Topical hemostatic agents: These materials are applied on the surfaces of muscle and bone which coagulates bleeding.

Use of red blood cell scavenging: During surgery we suction blood out of the wound and this type machine collects, filters and spins down to concentrate the blood.  We can then give this concentrated back to the patient.







Sunday, August 7, 2022

 

Blog Topic: The Use of Internal Distraction in Severe Scoliosis

8-7-2022


In severe scoliosis, the use of traction has demonstrated an ability to improve the spinal deformity before surgery was actually performed.  There are three main methods:

1.    1. Preoperative halo-gravity traction

2.    2.   Intraoperative halo-femoral traction

3.    3. Intraoperative Internal Dis-Traction


This post will focus on #3: Intraoperative Internal Dis-Traction


To demonstrate this treatment we will use the case of a 13 year old female who has severe scoliosis measuring 105 degrees.  Treatment thus far has been observation.  She had been having daily back pain which prevented her from playing athletics. 

Due to the severe scoliosis a total spine MRI was ordered and a thoracic syrinx was diagnosed (treated nonoperatively).

I call her type of scoliosis: neurogenic.  Many surgeons will call this neuromuscular but I don’t think it is correct to included this type of patient into the same group as cerebral palsy, spina bifida, spinal muscle atrophy, etc….diagnoses.

The image, below far right, is a push prone.  This image demonstrates that when a force is exerted on the spine the scoliosis improves from 105 degrees to 77 degrees.

On the below right sidebender (right side radiograph) the deformity decreases to 82 degrees.

Next are a picture and radiograph taken in surgery, which both demonstrate Intraoperative Internal Dis-Traction.  After exposure of the spine multiple osteotomies (posterior column osteotomies or PCOs) are done to make the spine more flexible, and allow more correction of the scoliosis.

Then a few screws are placed in the lower part of the spine (red circle), then hooks are placed on 4 ribs on the concave side of the scoliosis (yellow circle).  These two foundations are then connected by a rod and then distraction can be done to improve the scoliosis, which you can see it is much better than it was before surgery.

After this rod is placed the remainder of all the pedicle screws are inserted.  Distraction is done multiple times to gradually improve the scoliosis.  It is important to have spinal cord monitoring as the Dis-Traction can make the spinal cord not work normally.

In surgery the right rod is placed, then the Dis-Traction rod is removed, and a new left rod is placed.  During the rod placements more and more and more correction is safely obtained.

The below radiographs demonstrated the postoperative correction, improved from 105 degrees to 38 degrees.

Overall a nice correction in both the front and side views of the spine.






Wednesday, July 20, 2022

 

Blog Topic: Spinal Deformity in Neurofibromatosis Type 1

Surgical Case #2

7-20-2022


The next case is a 14 year old male with NF-1.  There are dystrophic changes to the spine around the thoracolumbar junction, specifically penciling of the ribs and scalloping of the vertebral bodies (red arrows).  This has induced a painful kyphoscoliosis.

The next pictures demonstrate there is some, but not much flexibility of the spine deformity.  The second picture from the left is a supine (laying on one’s back) radiograph.  The third from the left is a push-prone (laying on one’e stomach and radiology technicians pushing to try to improve the spine deformity. Neither of these two do much to change the spine deformity position.

The below two radiographs are performed with the patient actively bending to the left and right.

The below pictures are made from a CT scan, which is then rendered into a 3-dimensional picture which one can rotate around to better understand the deformity.  These particular images were made just prior to the creation of a 3-d model.

The below MRI images demonstrates dural ectasias (red arrows), vertebral scalloping (yellow arrows), and wedging of the vertebra (orange arrow).    The spinal cord (green arrow) is bent around the backside of the L1 vertebra.

The next pictures are intraoperative radiographs (x-rays).  Fixation of the spine can be very difficult (due to dural ectasias and vertebral scalloping) and the quality of the bone to be softer than normal (osteopenia).  Spinal deformity surgery of NF-1 patients requires preoperative CT and MRI evaluations to understand spines and where fixation could be placed and how to correct the spine deformity.  Surgery typically requires use of screws, hooks and sublaminar bands to successfully treat NF-1 spines.

After the L1 vertebra was completely (100%) removed a titanium cage (red arrow) was placed between the vertebra above (T12) and below (L2).  This cage increases the strength of the spine construct.

Below are the before and after surgery pictures.  The surgery nicely improves the spinal alignment on both views.  There was no weakness or sensory changes after surgery.  The patient’s preoperative pain resolved.

Multiple rods across the area where L1 was resected, and the cage was placed, to add more rigidity and durability.

Wednesday, July 13, 2022

 

Blog Topic: Spinal Deformity in Neurofibromatosis Type 1

Surgical Case

7-12-2022


The case presented is a 13 year old male with NF-1 who has a severe, progressive, painful kyphoscoliosis.

There is some inherent spinal flexibility as the thoracic kyphosis of 91 degrees improves when he lays on his back and hyperextends. 

The below selected MRI cuts demonstrates he does not have significant dural ectasias which could complicated surgery.  The axial MRI cut shows the spinal cord very eccentric in the canal, resting against the pedicle.  The spinal cord is slightly out-of-round, which elevates the risk of neurologic issues during surgery.

The below coronal CT scan cuts nicely shows the apex of the scoliosis having very abnormal vertebra.  Instead of being rectangular they are trapezoidal or triangular, which makes the scoliosis have a very tight turn.

The below axial CT scan cuts demonstrates the very abnormal pedicles.  Several of these pedicles (R T7, R T8 and R T9) are very difficult to place straight pedicle screws.  The reason these can be cannulated safely is due to the bone being malleable or bendable, and the pedicles can be bent straight (within reason).

The patients underwent 4 weeks of in-patient halo-gravity traction, with a maximum traction weight of 28 lbs. Despite the spine improving above and below the apex of the scoliosis, and the kyphosis improving, there still was a stiff apex.

Surgical treatment was a T3-L3 posterior spinal fusion and a T10 vertebral column resection, which means the entire T10 vertebra was removed.  This technique disconnects the spine and dramatically increases the flexibility of the spinal deformity.  After the spine was straightened a metal cage was placed in the front to help attain and maintain correction.

The patient is one year out from surgery and his doing well without pain.

 

Sunday, July 10, 2022

 

Blog Topic: Spinal Deformity in Neurofibromatosis Type 1

7-10-2022

 

For details on Neurofibromatosis Type 1 (NF-1), I will refer you to Wikipedia:  https://en.wikipedia.org/wiki/Neurofibromatosis_type_I

As this blog focuses on spinal deformity in children and adolescents following is a brief summary as it relates to the musculoskeletal system (spine and extremities):

1.    1.  NF-1 causes tumors along nervous system which can grow anywhere on the body.

2.     2. Musculoskeletal abnormalities:

a.      Spine: Meningocoeles, dural ectasia, scoliosis, kyphosis

b.      Skeletal muscle weakness

c.      Long bones: pseudarthrosis (most commonly tibia), limb hypertrophy

3.      3. Approximately 20% of NF-1 patients will have spinal deformity.

4.     4. There are two types of spinal deformity in NF-1

a.      Idiopathic-like: looks and behaves more like idiopathic scoliosis

b.      Dystrophic

                                                    i.     Sharp, angulated spine deformity (kyphosis, scoliosis and kyphoscoliosis)

                                                   ii.     More common in the thoracic spine

                                                  iii.     Spines can start out having a more idiopathic-like deformity, which can change into a dystrophic type.

                                                  iv.     Causes penciling or thinning of the rib heads which can migrate into the spinal canal

 

 9 year old female

 

 

5.      5. Dural Ectasia: Circumferential enlargement or ballooning of the thecal sac, nerve root sleeves and spinal canal.


a.      More common in lumbar spine


b.      Causes vertebral body scalloping


c.      Also thins the pedicles

 


 

6.      6. Treatment

a.      For the idiopathic-like deformities, lower magnitude deformities are amenable to bracing. Surgical treatment mirrors guidelines for idiopathic scoliosis.

b.      For the dystrophic deformities:

                                                    i.     Bracing is limited in effectiveness

                                                   ii.     Surgery is performed for lower magnitude deformities due to the sharper-angulated deformities, increasing difficulty in achieving necessary spinal fixation and the risk of neurologic changes (such as weakness, sensory changes, bowel/bladder dysfunction).

Next several blog posts actual surgical cases of NF-1 will be presented.

Tuesday, June 14, 2022

Wednesday, June 8, 2022

 



Blog Topic: Congenital Spine Dislocation with 8 Years of Postoperative Follow-up

6-8-2022

 

Congenital dislocation of the spine (CDS) is a rare congenital malformation due to failure of the spine and the spinal cord to develop at a single spinal level.

The patient may be completely neurologically intact or, in severe cases, may not have any muscle function or sensation below the level of the dislocation.

It is potentially the most serious form of congenital kyphosis or scoliosis with an abrupt single-level displacement of the spinal canal.  See the below x-rays of an 18 month old female, who was noticed to have a “bump” on her back, at the red arrow. 

 

She was moving her legs normally and was felt to have normal sensation in her legs.  The red arrow points to the T12 vertebra which does not sit under the T11 vertebra (orange arrow).

The right side X-ray shows how the upper spine (thick green line) does not line up with the lower spine (thick red line)

 


When lying down the T12 vertebra does not move under the T11 vertebra…..it is dislocated.

 

On the below CT scan cuts the red arrows point to the dislocation, with T12 sitting too far back.


The below MRI cut nicely shows how the spinal cord is draped over the posterior T12 vertebra.  It is easy to see if the dislocation gets worse the spinal cord will get more compressed and deformed, which would then cause problems with muscle function and sensation in the legs and cause bowel and bladder incontinence (inability to control).


 

To correct the dislocation, the T12 vertebra needed to be completely removed, and once it was the spine was very mobile and allows T11 get appropriately lined up with the L1 vertebra.  Because there was a space between T11 and L1 a cage (yellow arrows) was put between them to add to stability and put the spinal cord at the correct length. 

Four pedicle screws were placed above and below the removed T12 vertebra and were locked down.  To make sure this area heals solidly, and permanently a bone graft was placed in the cage in the front and also in the back of the spine.


 

In the below slide the patient is now 6 weeks after surgery.  It is easy to see the improvement of the spine alignment back to normal.  Because the bone is soft at this age we kept her in a brace for 6 months to protect the surgery.


Here she is now 8 year out after surgery.  She has normal spinal alignment and normal function of her spinal cord.  Her long-term prognosis is for a normal life.


 

 

Tuesday, May 3, 2022

 Blog Topic: Disc herniation/Bulges in adolescents and how to treat

5-3-2022

 

So, the symptoms of lumbar disc problems and the cause symptoms (pressure against nerve roots) are similar between adults and adolescents. 

What is different?

In adults the pressure is created by a dehydrated (lack of water) or a bad disc herniates through the posterior ligament in adults

In adolescents the growth plate on the vertebral body (called ring apophysis) fractures and pushes backwards.


So what are the available treatments for adolescents? There are two main groups:

·        Nonoperative

o   Rest (short-term only)

o   Analgesics (pain medications)

o   Physiotherapy: Paraspinal and Core strengthening, aerobic conditioning

o   Spinal injections: epidural and selective nerve root

o   What do I not recommend:

§  Chiropractic manipulation

§  Bracing (weakens back and core muscles)

·        Operative/Surgical: Microdiscectomy

 

Some important facts:

+ Nonoperative treatment listed above is almost ALWAYS the first step in care.  This is because most ring apophyseal injuries are minor, heal and don’t cause long-term problems.

+ Persistent numbness and weakness require more urgent treatment and more frequently need early surgery.

+ There is no hurry to do surgery (from a surgeon standpoint) when there is only pain down the leg +/- back pain.  Surgery appears to be helpful in relieving leg pain even if done late.

+ Selective nerve root injections can be diagnostic and therapeutic.  Even temporary symptom improvement is important as it can help identify the cause of the back/leg pain.

+ Microdiscectomies do a good job of improving leg pain, but not a good job of alleviating back pain.

 

When should I consider an Operative/Surgical Microdiscectomy?

If nonoperative treatments have failed to adequately alleviate leg pain

There is a ring apophseal fracture or disc herniation on MRI

Selective Nerve Root Injections confirm pain generator, even if only temporary relief

Discussions with your surgeon determine the pain generator is the disc and no other nonoperative options remain which could help.



Thursday, April 7, 2022

 

Blog Topic: Disc herniation/Bulges in adolescents, and how they differ than those in adults.

4-7-2022

 

When talking about a new topic, I have tended to go into significant detail about the basics of the problem to be discussed.  However, after review of the below webpage from the American Academy of Orthopaedic Surgeons (AAOS) I don’t think I can do a better, more thorough explanation of the anatomy, pathology, diagnosis and treatment of disc herniations in adults.  Therefore, I will encourage you to use this hyperlink:

https://orthoinfo.aaos.org/en/diseases--conditions/herniated-disk-in-the-lower-back/

Alternatively, try this link to OrthoBullets:

https://www.orthobullets.com/spine/2035/lumbar-disc-herniation

 

Like many problems in the musculoskeletal system, there can be significant differences between adolescents and adults, from presentation, to diagnosis, treatment and the short- and long-term outcomes.  Therefore, before we discuss the differences let us present some of the commonalities between adolescents and adults:

  • ·        Symptoms of low back pain, leg/hip numbness and pain and leg muscle weakness are similar. 
  • ·        Nerve root pain is caused by the disc material compressing the nerve root.
  • ·        Both typically have a more acute onset of back and leg pain symptoms, often related to a twisting/bending motion.

 

So what are the differences between adolescents and adults?

  • ·        “Arthritis” is common in adults and uncommon in adolescents. 
  • ·        Disc degeneration is required for a disc herniation in adults and often there are multiple levels which have degenerative discs.  “Only bad discs herniate”.
  • ·        In adolescents, disc degeneration sometimes is seen on MRI. 
  • ·        In adults, a piece of the degenerated disc is extruded backwards against the nerve roots (see below diagram).  In adolescents the small growth plate on the vertebra separates and this piece of bone and the attached soft tissues move backwards against the nerve roots (see below diagram).

In Adolescents: In the below diagram of the spine the normal ring apophysis (at green arrow) is a growth center in the developing spine and is a weak link when twisting and bending forces are placed onto the spine.  If overloaded, the ring fracture is pulled off the vertebra (black arrow) and moves toward the spinal canal (the area in blue).


 

In Adults: When the nerve root exits the spinal canal (green arrow) there is plenty of room without any areas of compression.  When the disc degenerates it will push a piece of the disc into the spinal canal and against the nerve root (red arrows) which can cause leg pain and numbness and muscle weakness in the leg.

 

 

 


 




Saturday, March 12, 2022

 

Blog Topic:  Bone Grafting in Spine Surgery

3-12-2022


In the previous blog post, we presented “what is a spine fusion”?

In most pediatric spine surgeries metal implants correct and stabilize the spine in a new position (see below), then a spine fusion is performed.


 

What I tell families/patients: “The metal allows us to attain and maintain the spine in a new position while the spine then creates a bony fusion” 

How do you get a spine to fuse? During surgery, after the implants are placed and the spine is corrected (see above), the fusion part of the surgery is then done. This involves decorticating, or roughening up, the bone in the back of the spine.  This stimulates the bone to heal, and the bone graft then is laid over this roughened bone.  The body breaks down, or digests this new bone graft and then creates a solid bony connection.

In the past, we used to always use the patients’ own bone, usually taken from the iliac crests above the hip joints. This type of bone is call “Auto-graft” = the patient’s own bone, whether it be from the spine, pelvis or both.


Harvesting the iliac crest bone takes additional time in the OR and it really hurts after surgery.  Since we have switched to allograft the amount of postoperative narcotics needed and the length of time patients’ were having significant pain has declined.

The standard of care now in pediatric spine surgery is to use allograft bone.  “Allo-graft” = another person’s bone. 




Bone is not rejected from the person receiving it, unlike in other type of tissue transfers between people.  There are no antigens on bone, unlike other transplanted tissue such as hearts or livers.

At present, during spine surgery there is some small amount of the autograft, or the patient’s own bone, which is collected during surgery, but the majority of the bone used is allograft.  So both types are used in deformity surgery, but most of the volume is because of allograft.

 








Wednesday, January 26, 2022

 

  Appointments: 314-514-3500                      Appointments: 314-432-3600

 


Blog Topic:  Latest Publication on Intraoperative Halo-femoral Traction

1-26-2022

 This study was just published in the Journal of Spine Deformity


 

For those interested to read more please use this hyperlink supplied by the publisher:

https://rdcu.be/cFHmd