Why is there a difference of opinion among surgeons as to when patients require spinal fusion surgery?
The “book” answer is most generally agreed to be curves 45-50 degrees. There is some difference of opinion because the natural history of curves in this range is not fully understood. The evidence seems to show that almost all curves in this range or higher in children who are growing will progress but things are less clear in children as they end growth and enter young adulthood. To me, the decision needs to be a shared decision with patients and families incorporating their preferences around other issues besides curve size including cosmetic appearance, concerns about the possibility of surgery in the future, and concerns about the possibility of more involved surgeries if the curve progresses or extends further distally.
Q: Patients often ask, "Why is there a discrepancy among orthopedic spine surgeons regarding the number of hours for brace wear?"
Again the evidence base supporting these recommendations is not so strong and orthopaedic surgeons interpret this in different ways and have different feelings about the “costs” of bracing (psychosocial and activity modification during adolescence).
Q: Patients often ask, "The standard of care for scoliosis is observation, bracing and/or surgery. Do you believe the Schroth Method should be incorporated as part of the standardized treatment plan?"
Yes. We use Scoliosis Specific Physical Therapy routinely though ultimately the decision to do this in a compliant way is that of the patient and family.
Q: Patients often ask, "What is your treatment plan for newly diagnosed AIS patient?"
The degree of curvature determines the plan of care for a newly diagnosed AIS patient. Often if the curve is 10 -25 degrees, which is considered a mild scoliosis, the recommendation will be observation with follow up x-rays and supplemental Vitamin D and Calcium until full growth has been reached.
For a curve of 25–40 degrees in a skeletally immature patient, the recommendation would be for Bracing and close follow up to include x-rays to be done both in and out of the brace. We would also recommend scoliosis specific Physical Therapy such as Schroth Therapy and supplemental Vitamin D and Calcium.
Q: Patients often ask, "Is there a particular brace you find more effective than others? If yes, which one and why?"
We recommend the Rigo Cheneu brace. Both biomechanical and clinical research, including that of our group, suggests that 3 dimensional braces like the Rigo brace achieve better 3 dimensional in brace correction and result in lower rates of curve progression. We are working to achieve consensus on this point through a SRS/SOSORT sponsored best practice guideline.
Q: Patients often ask, "Can body weight affect fusion hardware long term? (Please address impact for both underweight and over, if any)"
We often recommend that our patients gain 5 lbs. before their scheduled spinal fusion. It is common for patients to lose a little weight during and after spinal surgery. Optimal nutrition is a vital component to the healing process after spinal surgery. In the very smallest children, hardware can be prominent and there are some “tricks” to help with this. The main issue with heavier kids is the increased risk of wound problems and infection. We often use a plastic surgeon for obese kids and use special types of dressings.
Q: Patients often ask, "What follow-up is recommended after surgery?"
We see our patients 7-10 days after surgery for a wound check. At this visit you are seen by one of our Nurse Practitioners or Physician Assistants, They will remove your dressing, review post-operative instructions and medications and go over any questions you may have. At that point they can bath without limits. At 6 weeks after surgery, we have them come in for another visit including X rays and allow the return to most activities at that point. We then continue to follow you for a couple of years after the surgery but usually only 1-2 times a year.
Q: Patients often ask, "What is the upper limit of curve size to use a brace to stop progression?"
This is controversial as natural history studies seem to show that curves greater than 45-50 degrees do not respond to bracing, especially in children with growth remaining. Moreover, the braces are often uncomfortable and not that well tolerated as the curves enter this range. At the same time, there are anecdotal stories of curves in this range treated with braces who do not progress and perhaps even get a bit smaller. Again, the SRS/SOSORT-sponsored best practice guideline is trying to develop an expert based consensus on this issue.
Q: Patients often ask, "What kind of follow-up is needed after bracing is over?"
We generally follow patients for at least one year after skeletal maturity with no curve progression.
Q: Patients often ask, "How long do you ask for your patient to be out of their brace with a follow up visit?"
At the brace follow up visits, we obtain x-rays out of the brace to assess for curve progression. At these follow up visits we ask that the patients be out of the brace for 24 hours prior to their appointment.
Q: Patients often ask, "How many hours do you recommend your patient to wear their brace daily?"
Our standard recommendation is that they wear the braces 18 hours/day but we often try to fine tune this recommendation based on the perceived risk of progression (related to skeletal maturity and curve size).
Q: Patients often ask, "Do you prefer an in-brace x-ray taken the same day the child receives their brace or do you wait several weeks for their body to adjust to the brace?"
Our preference is to take the in brace xrays 4-6 weeks after the brace was originally received.
Q: Patients often ask, "Can curves continue to progress after skeletal maturity? If yes, at what degree can this occur?"
Curve progression can be unpredictable in physically mature patients, but if the curve reaches >50 degrees, the chance of progression is rather high.
Q: Patients often ask, "If a child is initially diagnosed with a 50 degree curve, still has growth remaining, what would your treatment plan be?"
It really depends on the skeletal maturity of the child and the curve location. For children who are Sanders 2 or above with structural thoracic curves but non structural lumbar curves, surgery is generally recommended. In almost all cases, a selective thoracic fusion will stop progression and even result in spontaneous progression of the lumbar curve without lumbar fusion which is really ideal. On the other hand, if a patient already has a large lumbar curve and is well balanced, I’ll often attempt “aggressive conservative care” (Schroth, Vit D, RCB). In much younger kids, we sometime consider growing strategies including MAGEC, anterior tether or Shilla, though this is a complicated discussion and decision.
Q: Patients often ask, "Can you explain Sanders scoring system verses Risser staging?"
Both the SMS and the Risser correlate with menarche however, when looking at growth with AIS the SMS is a more precise indicator for correlating to the rapid phase of growth thus the greatest risk of curve progression. Use of Risser alone will result in “bad” decisions about bracing 1/5 times.
Q: Patients often ask, "What methods do you use to monitor growth remaining in your patients?"
Maturity Scale (SMS) which involves doing a series of hand x-rays to monitor patient’s growth. In our view, multiple studies including our own have shown this to be more accurate than other staging systems.
Q: Patients often ask, "Is it normal to have pain or numbness on the front of the thigh after surgery?"
This is caused by pressure on the lateral femoral cutaneous nerve during the surgery. This usually resolves within the first 6 weeks.
Q: Patients often ask, "What are the top three preventative health habits post-fusion patients should incorporate into their everyday lifestyle?"
Maintain a healthy lifestyle to include a healthy diet and regular exercise to maintain a strong core strength.
Q: Patients often ask, "May I get a massage after surgery?"
Because of discomfort it is probably better to wait until at least 6 weeks after surgery but then after that you can have a massage as tolerated.
Q: Patients often ask, "May I sleep on my stomach right after surgery?"
Yes you may sleep however is comfortable for you.
Q: Patients often ask, "Do I need antibiotics before dental work or a dental cleaning?"
You do not need antibiotics prior to dental work after spinal surgery.
Q: Patients often ask, "Is it normal to have pain around the shoulder blade after surgery?"
This is caused by the derotation of the spine during the surgery. This usually resolves within the first 6 weeks.
Q: Patients often ask, "Is numbness and tingling near the incision normal after a year+?"
Numbness and tingling can occur post-operatively for 6 months up to 1 year after surgery. Most numbness resolves within 6-9 months. In some cases it may take longer and in other cases the very line of the incision remains numb.
Q: Patients often ask, "May I get my ears pierced or belly button pierced right after surgery?"
You may from an orthopaedic standpoint at your parents’ discretion.