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Spine Surgery Guide

Common Scoliosis Questions?

How do I know if I have scoliosis?

Scoliosis or curvature of the spine commonly produces a cosmetic deformity. Visible asymmetries in the contour of the back and the observation that one shoulder or hip is higher than the other are the most common signs that someone has scoliosis. These asymmetries are more pronounced in adolescence during rapid growth spurts and may be detected by parents or friends.

Adults, who have not suspected that they have a curvature of the spine, may realize that they are rapidly losing height which could be an indication of a progressive curvature of the spine. Direct examination by a qualified orthopedic spine surgeon and confirmation by x-ray will confirm the presence of scoliosis in an adolescent or an adult.

Is there someone I can talk to who has scoliosis?

Discovering that you have scoliosis may be frightening. Once patients understand that curvature of the spine is not rare (approximately 3% of the population has a curve of 10° or more), they accept being followed by a qualified physician to monitor the curvature for progression. Information about scoliosis and its many variants is readily found in bound reference material and on the Internet The primary source of information on scoliosis and curvatures of the spine should be obtained by a qualified orthopedic spine surgeon. Many patients find that speaking to a similar aged individual who is also dealing with scoliosis can be comforting.

In my experience, patients especially appreciate speaking to other patients about their postoperative experiences and the timeline for their recovery. Routine activities of daily living in the postoperative period are best communicated between patients. In my practice, if the patient is scheduled for surgery, arrangements are made for other patients that I have treated to speak to the patient about many issues. All over the country and in every community there are scoliosis organizations that have meetings to discuss common experiences and issues related to scoliosis. The National Scoliosis Foundation, Inc. and the Scoliosis Association, Inc are two of the largest associations.

Is scoliosis caused by not drinking enough milk or eating too much junk food?

In extremely rare cases, scoliosis can be caused by dietary issues. Scoliosis may be an infrequent finding in diseases where calcium is lacking which causes softening of the bone. What one eats and how much one eats does not produce curvature of the spine. To my knowledge, junk food by itself has never caused curvature of the spine.

Does scoliosis hurt?

Children and adolescents who have scoliosis rarely complain of pain. If pain is the major complaint in a young patient with scoliosis, further analysis is needed beyond plain x-rays to establish an underlying cause of the curvature. For example, in rare instances a benign inflammatory focus of tissue (osteoid osteoma) can produce curvature of the spine.

The adult population diagnosed with scoliosis often seeks treatment because of pain. As one ages, the spine becomes less flexible and undergoes changes which reduce water content in the disks and produce inflammation in the joints.

Why do kids get scoliosis?

To answer this question it must be understood that scoliosis falls into two major categories: idiopathic and non-idiopathic scoliosis. Idiopathic is the more common type of scoliosis and the one that is most commonly identified at the beginning of accelerated growth in adolescence. Unfortunately, at this time we have not established a single identifiable cause for production of curvature of the spine in idiopathic scoliosis. I have the honor of being a member of an international group of physicians who have received grants from the Cotrel Foundation of France to investigate the causes of idiopathic scoliosis. To date, research has focused on genetics (based on the observation that scoliosis can run in families), nerve and muscle abnormalities (based on the observation that scoliosis can occur in patients who have abnormalities of the nerves and muscles), central mechanisms and abnormalities of the inner ear. My research focuses on the finding that the fluid around the spinal cord (CSF) flows asymmetrically in patients that have curvature of the spine. That research is being carried on here at the Cedars-Sinai Institute for Spinal Disorders in Los Angeles. To read more about this research project, please click here.

If surgery is not an option, is wearing a hard brace the only other choice to preserving the spine?

Although there is little controversy as to whether patients who meet certain criteria should be braced, the exact choice of the brace type and duration of brace wear generates some debate.

Who qualifies for spinal surgery (and who makes that decision)? How bad does the curve have to be?

For a patient diagnosed with Adolescent Idiopathic Scoliosis, who has never had spine surgery, the main indicator for surgery is a progressive curvature measuring 40° or more. The physician will recommend surgery based on medical necessity (not cosmetic reasons), and then surgical options are discussed with the patient, and the parents of any patient less than 18 yrs. The decision to proceed with surgery is in the hands of the patient. (And the parents of any patient less than 18 years of age)

Is there an age requirement? (If so, is this a common age that many spinal surgeons tend to go by)?

The decision for surgery is based on medical criteria, including the degree of curvature, the skeletal maturity of the patient, and the progression of the curvature. Through surgical intervention, the spinal curvature can routinely be corrected to 40% of the original size, but the surgical goal should more importantly be producing a fused spine that leaves the patient balanced.

What are the goals and expectations of scoliosis surgery?

The goal of surgery for children and adolescents is to stop the progression of a curve and leave the patient with a balanced spine in the front and side view plane. Patients and families are always interested in the amount a curve was reduced from its preoperative status. I am frequently asked whether the spine will be straight after surgery. With the use of new instrumentation techniques, our ability to straighten the spine is improved. On the other hand, I always tell the patient that the primary goal of surgery is to stabilize the curve.

The goals of scoliosis surgery for the adult patient are to stop progression of the curvature and to improve one's quality of life. Although surgery can significantly reduce pain in adults with scoliosis, I counsel patients to recognize that their improvement is viewed as increased function in managing their daily activities with less pain.

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How much correction do you expect to achieve?

The spine maintains its flexibility and higher percentages of correction can be achieved with children, adolescents and young adults. As was stated in the previous question, newer instrumentation provides greater corrective forces than older techniques (Harrington Rods) to straighten the spine. In these younger patients, corrections up to 60, 70 and 80% are commonly achieved.

How long will the incision be, and what can I expect in terms of scarring?

Any time an incision is made in the skin, a scar is produced. With careful attention to the technique of closing the incision the scarring can be minimized and be cosmetically acceptable. In the standard posterior spinal fusion, the length of the incision will correlate with the number of vertebrae that need to be fused. In endoscopic procedures, multiple one to two inch incisions will be produced at the point that the camera and instruments are introduced into the body.

Which vertebrae will be fused in the "average" scoliosis correction?

The choice of vertebrae that are fused in scoliosis surgery is determined by the primary curve. Many times the primary curve has a secondary, flexible curve which allows the spine to be balanced as the primary curve gets larger. In most cases only the rigid primary curve needs to be corrected, and the secondary flexible curve will decrease by itself without surgery. The determination of which vertebrae need to be fused takes skill and experience. Incorrect choices of fusion levels can sometimes lead to unbalanced spines and further surgery if an unoperated curve progresses. In rare instances most of the thoracic and lumbar spine needs to be fused. More often only a minority of the spine needs to be fused. Correction can be achieved by fusing three or four vertebrae together in certain types of curves.

Do you normally show the patient the hardware that you will use in the surgery?

I show patients and their families x-rays of similar types of operations that the patients are about to undergo. I do keep a small inventory of metallic implants in my office for patients to examine, however, I find that most patients understand the instrumentation by viewing x-rays.

Can you see or feel the hardware under the skin?

It is uncommon to be able to see instrumentation under the skin. Depending on the size of the patient and the thickness of her skin or fat layer, the instrumentation may or may not be noticeable to the touch. Even in the thinnest and youngest patient rarely does instrumentation need to be removed because it can be felt or seen.

How much growth would you expect the fused portion of my spine to have grown had it been left unfused?

Lost growth potential of fused vertebrae after scoliosis surgery is dependent on the age of the patient at the time of surgery. If a patient is extremely young (less than 7 years old), significant loss of height can occur after spinal fusion. When these young fusion patients are adults, there will usually be a significant discrepancy between the size of their torso and the length of their legs. The actual decrease in their overall height will depend on what their potential growth could have been based on other factors such as genetics. In patients with significant scoliosis, height loss also occurs because it is taken up in the curvature. If it is possible, surgeons will elect to delay operations in young patients in an attempt for them to gain maximum growth potential. Sometimes braces can be used to hold the curve until this maximum growth potential is achieved. Unfortunately, if a large curve is rapidly progressing, it is prudent to surgically control the curve despite the potential for loss of height.

What is a "crankshaft phenomenon," and when does it occur?

Crankshaft phenomenon occurs in a very young patient who undergoes a posterior spinal fusion for scoliosis. Although the back of the spine is fused, the front of the spine continues to grow causing the characteristic twisting of the fusion mass in crankshaft phenomenon. New more rigid instrumentation techniques using stronger screws and rods can sometimes overcome continued of the spine. If this is not possible, the front and back of the spine may need to be fused by performing an anterior and posterior spinal fusion.

Would instrumentation without a fusion be a better alternative than a fusion when growth potential is remaining?

The technique of a "growing Rod" is used in very young patients to maximize growth potential. In this procedure instrumentation is placed without a fusion. In multiple intervals, the Rod is lengthened until a time when growth potential can be maximized. There are clinical investigations that use partial fusing of growth centers in the spine (epiphosyodesis) in an attempt to minimally impair growth potential and induce correction of the curve. At some centers in very young patients, temporary staples can be placed across the spine to maximize growth potential.

What will I be given for pain after surgery?

Both children and adults are given patient controlled analgesia for 24-48 hours after surgery. The patient has control of a button which provides incremental doses of narcotic medication to effectively control their pain. After that time period, interval injections of narcotics and oral pain pills are usually sufficient. The patients are discharged with a prescription for oral narcotic pain pills which they may need to take for a few weeks after surgery.

How often will I be awakened and checked by a nurse after my surgery?

The nurses check on the patients every four to six hours for the first 24 or 48 hours and then every six to eight hours after that. The nurses monitor vital signs, and are looking for any changes in neurologic functions such as weakness or numbness.

When will I be able to get up and walk for the first time after surgery?

With rare exception, patients are either walking or getting out of bed and sitting in a chair within 24 hours after surgery.

How soon will I be able to eat and drink after surgery?

Most patients can take sips of water or liquid within three to four hours after surgery. Broth, Jello, and soft foods are offered, and if they are tolerated, solid food is introduced.

What will be done to make my back incision safe after surgery?

I rarely use staples to close the skin. A dressing is kept over the patient's incision for 48 hours after surgery while the incision seals. Significant protection is usually unnecessary after the wound has sealed.

Will I need physical therapy after surgery?

Adults are more likely to require physical therapy than children or adolescents. A prescription for physical therapy after surgery will depend on the type of surgery performed. If the instrumentation is holding the spine rigidly, physical therapy can usually be prescribed within four to six weeks following surgery. Many surgeons will not institute physical therapy until three months after surgery or at a time when the fusion starts to consolidate.

What are some types of therapy that I might have to undergo?

Most children and adolescents do not require any physical therapy. A careful description of usual post operative activities will usually suffice with these individuals. In adults, physical therapy can range from exercises in a swimming pool to land-based strengthening and cardiovascular instruction.

Will I need a special type of mattress on my bed?

No. The mattress which was comfortable for you before surgery is usually the one that will be comfortable for you after surgery.

How much experience will the person who is monitoring my spinal cord function have?

At Cedars-Sinai Medical Center, the technician who performs neurological monitoring is extremely experienced, and specializes in this type of anesthesia. The operating room equipment is connected by high speed wiring to a central command center. A specially trained medical doctor monitors the operation with the technician. Any observed changes in the monitoring are quickly relayed from the control room to the operating room for confirmation.

What is a "wake up" test and when is it performed?

During the correction of the spine the spinal cord can become irritated. A wake-up test is a sensitive technique to detect any malfunction in the spinal cord during correction of the spine. It is performed by waking the patient up during the surgery and asking the patient to move their feet as a test for spinal cord function. Sedation is provided to the patient during the wake-up test so that they have no recollection of being awake during surgery.

Motor evoked potentials are used during surgery. Motor and sensory evoked potentials are highly sensitive in detecting slight changes in spinal cord function during surgery. If the patient is able to undergo both motor and sensory evoked potential's effectively, a wake-up test during surgery is not necessary. If there is any question about the results of the motor or sensory evoked potentials during surgery, a wake-up test will be performed.

I want my rib hump corrected. How is this done?

The rib hump is produced by rotation of the chest wall as the spine curves. In many cases correction of the curvature of the spine may induce the rotation of the spine to produce a cosmetically acceptable decrease in the rib hump. If this cosmetic deformity cannot be adequately controlled by the instrumentation alone, the ribs are removed and are used as graft material. This procedure is called they thoracoplasty and produces excellent cosmetic results.

When can I take a shower?

72 hours after surgery or after the wound seals.

Do I have to get my stitches taken out?

I do not use external sutures. The sutures usually dissolve underneath the skin.

When can I go back to school?

Ideally, surgeries are done over a school break, either in late spring or early summer enabling the patient to return to school in late summer or early fall. If children meet this surgery schedule, they usually never miss any school time.

How much can I do after surgery?

For the first year after surgery, activities are decreased. Normal activities such as walking and traveling are allowed. If the fusion heels after 12 months all restrictions are usually lifted.

How long will I have to take pain medicine?

Most young patients remain on pain medicines for two to four weeks after surgery. Adults may require pain medicines for a longer period of time, but are discouraged from taking them beyond three months.

Do my rods have to be taken out?

In my practice it is rare that rods need to be removed. The most common cause of rod removal is failure of fusion or disassociation of the rods from the spine. This is uncommon in young patients.

Can I have children if I have had scoliosis surgery?

Yes. It is advisable that you meet with the anesthesiologist performing your epidural prior to giving birth. He may request the latest x-rays of your fusion for reference.

Do I need to eat a special diet and drink extra milk to help my spine to heal?

No. In most individuals normal diet will suffice for healing.

What will my activity restrictions be after scoliosis surgery?

In most instances, restrictions are lifted after 12 months post-op. Each patient is different and restrictions may depend on the type of surgery performed and the age of the patient.

What are the differences between an open and an endoscopic procedure?

Endoscopic surgery utilizes cameras and instruments which are manipulated through small portals in multiple places on the body to correct and stabilize the scoliosis. The incisions for endoscopic surgery are narrow. This technique is best applied to single thoracic curves in young patients with extremely flexible spines. Failures have occurred because of the technical difficulties in placing strong enough instrumentation and applying enough corrective force through small incisions to induce adequate correction.

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