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Getting it Straight

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Vol. 12 •Issue 21 • Page 29
Getting it Straight

New advances in endoscopic surgery offer hope for patients with severe scoliosis

By Jonathan Bassett

Its effects are rarely life threatening, but physical therapists know that the crippling results of scoliosis can range from an inferior body image to blinding pain and the eventual inability to walk.

Scoliosis, or curvature of the spine, remains relatively rare (2 percent of women and less than one half percent of men contract the condition), and the symptoms of most cases are mild. It is a condition generally associated with puberty: as one enters adulthood, the young spine begins to curve during its rapid growth. Once the growth stage is over, mild curves will rarely get worse, but severe curves almost always do.

Medically speaking, scoliosis is classified as mild or severe, depending on the curvature of the spine as one enters adulthood: curves measuring under 30 degrees are considered mild, those over 60 degrees severe.

Non-invasive Options

A diagnosis of scoliosis is often met with three options. The first is doing nothing at all. "The decision to do nothing may be a reasonable decision, depending on the age of the person and the predicted outcome," said Ronald Blackman, MD, of the Center for Minimally Invasive Scoliosis Surgery at Children's Hospital in Oakland. The determining factor in the decision to intervene is whether the condition is likely to worsen. "Increasing curves usually give an increase in the deformity," Dr. Blackman said. "That is, the chest twists, throwing the shoulder blade off in back, causing a rib hump. The chest in front rotates as well, and the hips at the waist become more uneven. Doing nothing in the teen years [for these patients] can be disastrous."

In these severe cases, the second option–wearing a brace–may be attempted. It's important to note, however, that braces will rarely correct curvature, Dr. Blackman said. At best, they will merely stop the condition from progressing. "Bracing has been shown to be an effective method to prevent mild curves from getting worse," he said. "From a practical aspect, though, this treatment is reserved for children and adolescents in whom the prediction of a rapid increase in the curve needs to be thwarted." Wearing braces is often not easy for teenagers entering their self-conscious years–they are hot, uncomfortable, cumbersome and must be worn for up to 23 hours per day.

Endoscopic Surgery

Most often, cases of severe scoliosis cannot be improved by noninvasive means, leaving surgery the only option. "Numerous studies have failed to show any benefit from exercise, manipulation, meditation or drugs," said Dr. Blackman. "While exercise is beneficial to maintaining good muscle tone and a healthier heart and lungs, there is no evidence that it affects, one way or the other, the curve progression. It may, however, help in reducing discomfort."

Thankfully, surgical treatment continues to improve. Surgery for scoliosis used to involve a large open incision through the patient's chest to allow spinal disks to be removed, then inserting hardware (rods and hooks) through large incisions in the back to hold the corrected spine in place. New endoscopic technology, however, has allowed surgeons to perform these delicate maneuvers through small holes through the patient's chest only, in effect skipping an entire step in the process and resulting in both less scarring and better patient comfort.

That was the case for Diana Hernandez, a 13-year-old from Ecuador who was told by her doctors that there was nothing they could do to correct her badly twisted spine. In fact, they were unable to even provide her with medication to help control the stabbing pain in her back. Diana suffered from non-idiopathic progressive scoliosis, a disorder that resulted in very large curves in her back that were steadily worsening. Left untreated, it could have resulted in permanent paralysis and perhaps even death from heart or lung injury.

Robert Pashman, MD, director of scoliosis and spinal deformity services at Cedars-Sinai Institute for Spinal Disorders in Los Angeles, learned of Diana's plight from a humanitarian organization. After reviewing her X-rays, Dr. Pashman agreed to perform endoscopic surgery pro-bono to permanently correct Diana's condition last June.

The painstaking procedure required three separate operations. The first two were designed to "loosen" her spine from the front and back, so it could be straightened. This was accomplished by first removing seven spinal disks through tiny endoscopic "punch holes" in Diana's chest, which would normally require a much larger incision.

The second procedure was a rib osteotomy, in which surgeons fractured ribs on both sides and removed joints from the back of her spine. A 10-day period of traction followed to slowly stretch and straighten her spine. Two weeks later, the third and final procedure had surgeons straighten Diana's spine and permanently stop the progression of the disease through the use of special titanium screws and rods and a bone graft. Diana now has a balanced spine and will not need to wear a corrective brace, Dr. Pashman said.

Following surgery, PTs at Cedars-Sinai built Diana's cardiovascular endurance and lower extremity strength through the use of an underwater treadmill, which minimized impact forces on her newly repaired spine. "If the upper region of the spine has been fused, it's important to strengthen the lower region," said Dr. Pashman, who recommends isometric strengthening as opposed to range of motion exercises.

Benefits

While accessing the spine from the front sounds like a more invasive procedure, in many cases it can allow surgeons to fuse fewer vertebrae and achieve a superior correction. "The spine is actually in the middle of the body, and the larger, weight-bearing part of the spine is in the front," Dr. Blackman said. The lessened invasiveness allows for improved recovery, he said.

"Our patients appear alert the day following surgery; most have been talkative, a few even smiling," said Dr. Blackman. "On their second postoperative day, they are usually out of bed and up in a chair. A number of patients have walked around the first day after surgery." Most are walking around by day three and discharged home by day five, he said. Once home, all patients Dr. Blackman has treated were ambulatory and able to return to light activities within a week.

"We definitely have shown that it is possible to correct curves from 60 to 65 degrees down to 15 to 20 degrees through this approach," Dr. Blackman said. "Just as gratifying is the postoperative recovery." Average correction is 62 percent initially, which drops to roughly 60 percent after one year and 58 percent at two years. These figures are in line with both the new anterior and conventional posterior methods, he noted.

Physical therapy can be useful in instructing patients how to raise themselves from a standing position, said Dr. Blackman. This is performed by having the patient lie on their side, drop the legs over the side of the bed, and be assisted into a sitting position while keeping the spine straight. Sitting in low chairs is best avoided, he added, and raised toilet seats are often prescribed. Because patients are often fearful of coughing or breathing deeply after scoliosis surgery, PTs and respiratory therapists can teach proper breathing exercises to help minimize pain and to clear mucous, which can accumulate and lead to a form of pneumonia.

Downsides

Despite the success of such patients, Dr. Blackman cautions that the findings are preliminary, and complications do exist.

"If one uses the endoscopic technique for releasing the ligaments and taking out the disks, the anterior fusion, then supplement it with a posterior fusion, then the endoscopic approach is excellent," said Dr. Blackman. "It has a smaller scar, less discomfort, one doesn't have to remove a rib to get to the spine, and generally, the surgeon can do a better job than in [an open surgery], because of the line of approach through many small incisions rather than one large one."

However, after following his patients for more than four years, he points out that the anterior endoscopic procedure is often associated with an unacceptably high rate of hardware complications, resulting in generally poorer results than originally thought. Most often, this is because vertebrae are not hard enough to hold the screws, as seen in children under 10, the elderly and patients with osteoporosis. Isolated incidents of pulled screws are disappointing, he stressed, but not considered calamitous.

As part of a poster exhibit at the September 2000 Scoliosis Research Society annual meeting held in Cairns, Australia, Dr. Blackman presented long-term results of the anterior endoscopic technique after following more than 60 patients after surgery. At 12 months postop, there were no hardware failures; however, at 24 months, seven broken rods required reoperation by a posterior fusion, and were regarded in Dr. Blackman's mind as failed procedures.

He feels that solid fusion during the operation can minimize this risk. Using the example of a paper clip, which will break if it is bent back and forth several times, he pointed out that a 3Ú16-inch screw will also fail if it is bent just slightly over long periods of time. "A solid fusion, or connection between the bones, will eliminate motion and the tendency for the rod to break," he said. He is also experimenting with calcium sulfate bone grafts, along with bone chips packed into the disk space, that he feels hold hardware in place more effectively and lead to better fusion results. Time will allow him to perfect such subtleties of the technique, and Dr. Blackman feels that the upside for certain population groups is notable.

"Children with neuromuscular scoliosis are not good candidates, since the stresses on the bones are tremendous and usually the vertebrae are not hard, due to inactivity," he continued. The best candidates appear to be healthy, active adolescents over the age of 9 or 10 with a single thoracic curve of more than 40 degrees; bracing is the intervention of choice if the curvature is between 20 and 40 degrees.

"As time and our experience increase, we are constantly changing the details of the procedure to make it more efficient and successful," he said. "This technique is new, and while it fires up the imagination, our results are preliminary."

• For more information on the anterior endoscopic surgical technique for scoliosis, visit Dr. Blackman's Website, www.scoliosisrx.com or Dr. Pashman's Website, www.espine.com

Jonathan Bassett is on staff at ADVANCE and can be reached at jbassett@merion.com.




     

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