Ask the Expert: Scoliosis, Part II

by Dr. Matthew Cunningham
8.4 Blog

Hospital for Special Surgery partnered with Curvy Girls Scoliosis to host our first-ever scoliosis Facebook chat, titled “Life with Scoliosis: Diagnosis and Treatment.” Thank you to all who participated! Dr. Matthew Cunningham, Orthopedic Spine Surgeon, answers the remaining questions from the chat.

Q1. Do you have plans for studies 15 to 20 years after surgery? This seems to be the commonality of many degenerative issues after long spinal fusion. Are there any treatments available then? My daughter had epidurals, radio frequency ablation and other temporary ways to block the pain. Short of more fusion and worse disability in limitations…we are out of options to address her degenerative discs due to scoliosis fusion surgery.

Dr. Cunningham: Yes, long term follow-up is critical to determining if what we do is durable. Unfortunately, because technology changes so rapidly and 15-20 year follow up takes so long, these long term follow-up studies are not very common. There are treatments: at first non-operative with PT, activity mods, meds by mouth, and meds being injected to name a few. If all that happens to fail, then surgery to “add on” the degenerated segments to the index fusion will take place. The discs degenerate below and above the fusion zone. It is more a matter of the mechanics of a fused portion of the spine, and less due to the specifics of the surgery or the implants used.

Q2. Why don’t more surgeons prescribe PT before and after surgery? Core strength is so important and after muscles become atrophied from non-use in healing. PT should be offered to every scoliosis patient facing surgery.

Dr. Cunningham: I routinely try PT as a first try to treat just about anything. I’d have to assume that the physicians don’t try conservative measures first don’t think that the non-operative means to treat work as well as the surgical interventions do.

Q3. What about the causes of scoliosis? We read there are environmental factors. What would those be?

Dr. Cunningham: Causes of scoliosis include genetic predispositions (scoliosis is more common in healthy family members of affected individuals, more common in identical twins, and genes have been identified that correlate with increased risk), associated neuromuscular conditions (cerebral palsy, neurofibromatosis, muscular dystrophy to name a few), and environmental (mostly shown in animal research, but there is suggestion that exposure to carbon monoxide can cause devastating abnormalities in fetal rat pups- it would follow that other exposures, such as heavy metals, could possibly have a similar role, albeit data is lacking).

Q4. As a 55 year old person who was told at 13 no brace and no surgery, what kind of health issues can I expect at this age?

Dr. Cunningham: You don’t have to have symptoms at all. You don’t have to have scoliosis that gets any worse than it is right now. However, for adults with scoliosis over 50 degrees, there is an increased risk for progression (at a slow rate of 1 degree per year), and a risk that you might get arthritis changes in the spine that could cause back pain or leg symptoms (sciatica, or stenosis). It would be very unlikely for you to get lung function problems (curves tend to need to be 80-100 degrees for this), or issues related to the heart (right heart failure, an end-stage problem in severe scoliosis). For prevention, I’d recommend PT and keeping the “core” trunk muscles strong and well-conditioned.

Q5. I have a friend whose daughter had surgery last year. Her top rods have broken loose. 3 screws are backing out. Her doctor wants to watch it. She is in extreme pain. Is it dangerous to have rods that have broken loose inside her?

Dr. Cunningham: It might be safer to have the spine re-instrumented, as the bones are less likely to fuse/heal correctly if they are not held still. If the screws and rods are “pulling out,” then they sound like they are not doing their job. I might recommend that she’d have better pain control, and ultimately a better chance at getting the fusion desired if the implants and fusion was revised. I will have to add that the above opinion is rendered only with the information provided and I do not know any other specifics of the case that would allow me to render a more credible professional opinion, such as her possibly having very fragile health status and her treating physician respecting the fact that they would rather have the patient be uncomfortable for a while and perhaps heal eventually, rather than being physiologically stressed in a second surgery to the point where she has a heart attack or stroke, and ends up with a worse situation.

Q6. I know flat back is associated with Harrington Rods. Are girls that are fused into the lower lumbar or sacrum at risk? Even with pedicle screws and newer materials?

Dr. Cunningham: H-rods normally get a bad rap. It isn’t the rod as much as it is the fact that the spine was fused at all, which predisposes to flatback. Patients typically fuse and then go about their lives. Every day brings hundreds or thousands of loading events to the spine, and when a fusion is present, all of those forces are transmitted and dissipated in the disc segments that were not fused. Hence, the discs below the fusion tend to wear out at an accelerated rate- independent of the H-rod, newer Clotrel-Dubosset, or newest all-pedicle screw construct used. Having no discs below the end of the fusion (i.e. being fused to the sacrum/sacropelvis does not allow the lumbar disc degeneration to occur. Hence, there is no flatback for these patients.

Q7. Are there any studies on the number of patients that the surgery doesn’t take, fusions that failed, rods that came loose, or chronic pain that resulted in rod removal? How many years after surgery?

Dr. Cunningham: Yes, there are dozens of studies to document failure of fusion & implant failure. I would direct you to www.pubmed.gov, where you can type in keywords and the search engine can identify specific papers to read. Far fewer reporters focus on patients following implant removal, but there are a few. Implants can be removed once the bones have healed together: as early as 2 years, and as late as 30 years or longer after surgery.

Click here to learn more facts about scoliosis through an infographic on Adolescent Idiopathic Scoliosis, presented by the HSS Lerner Children’s Pavilion.

Matthew E Cunningham MD PhD is an orthopedic surgeon at HSS, specializing in Pediatric and Adult, Spine and Scoliosis surgery. Dr. Cunningham’s interests include minimally invasive and open surgery for spine deformity and degenerative conditions. He currently is the Interim Chief of the Scoliosis Service, Director of the John Cobb Scoliosis Fellowship, Principal Investigator of the Molecular and Cellular Spine Research Laboratory at HSS, and acts as a reviewer for Clinical Orthopedics & Related Research, Hospital for Special Surgery Journal, Journal of Orthopedic Research, Arthritis Research & Therapy Journal, Scoliosis Journal, Biochemistry Journal, American Academy for Laboratory Animal Science Journal, and Journal of Biomechanics.

Topics: Ask the Expert, Featured, Orthopedics
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The information provided in this blog by HSS and our affiliated physicians is for general informational and educational purposes, and should not be considered medical advice for any individual problem you may have. This information is not a substitute for the professional judgment of a qualified health care provider who is familiar with the unique facts about your condition and medical history. You should always consult your health care provider prior to starting any new treatment, or terminating or changing any ongoing treatment. Every post on this blog is the opinion of the author and may not reflect the official position of HSS. Please contact us if we can be helpful in answering any questions or to arrange for a visit or consult.

Comments

Natasha Cooper says:

I am 22 and had a scoliosis spinal fusion done 3 months ago due to Marfan Syndrome. I had instrumentation from T2 to L1. Is there any known differences in the duration of healing for those with Marfan Syndrome?or side effects that might be prone to those with Marfan Syndrome?

HSS on the Move says:

Hi Natasha, thank you for reaching out. Dr. Matthew Cunningham, Orthopedic Spine Surgeon, says: “People with Marfan’s have an association with dural ectasia. This can lead to eventual thinning and failure of the fusion mass in at least some cases. There are no good statistics on how many fail, but it is a good idea to maintain good follow ups with your surgeon to be monitored.” If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Maureen says:

Hi Dr. Cunningham and everyone,

I have been a scoliosis patient at HSS since I was nine years old! I am turning thirty- nine in three weeks, anyway, ughhh! I started off with the pretty normal S female curve, however, it was not that severe. I was an active child, ballet, tap, jazz, etc. When I hit twelve years old, almost thirteen, it went haywire. I remember walking home from school with my friends and I was complaining about pain in my side. Luckily, my parents knew about HSS and were smart enough, even back in the eighties to take me there. The Peds dept. was so drab, dull, and nothing like I heard it is today back then but it was great medical care and even though I’ve had many surgeries since I was thirteen, I wouldn’t go anywhere but HSS for any of them. Dr. Stephen Burke performed my first spinal fusion back in 1989 and he has of course since retired, but, I now go to Dr.Girardi. He is wonderful. I recently had to get both of my knees replaced and I went to Dr. Russell Windsor. I am eight weeks out and swimming two hours a day and walking up and down stairs daily. I have to say, the knees were the most painful than any eleven hour spinal fusion I’ve ever had to endure.
I went on to obtain my Master’s from Columbia University and I am a K-12 Certified Special Ed Kindergarten Teacher for NYC…..currently on medical leave unfortunately…..but going out of my mind already!!!! After all of my babbling, my question is, I would love to obtain a position at the hospital, one in which you are sort of an advocate for a young child who is about to have surgery for scoliosis? Even for the parents of the child as well? They didn’t have anything like that at all when I had my very first surgery and I wish they had……Thanks!

HSS on the Move says:

Hi Maureen, thank you for reaching out. For career opportunities at HSS, please visit http://www.hss.edu/careers.asp.

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