Surgeries About

When is scoliosis surgery necessary?

Surgical decision is typically based on the degree of the curvature. The main consideration is whether the curve will progress. Curve progression in skeletally immature patients necessitates surgery to correct the curve and prevent further progression. ­

The treatment scheme for the skeletally immature patients are as follows;

·         0-20 degrees is observation with follow-up controls

·         20-40 degrees is bracing

·         And >40 degrees is surgical treatment

Skeletally mature patients and adults do not have the same risk of curve progression between 0-40 degrees. Hence, the surgical decision for adults is given when the thoracic curves are >45-50 degrees and lumbar curves are >40 degrees.

What are the other factors for scoliosis surgery desicion?

·         The affected part of the spine

·         The presence of increased or decreased kyphosis

·         Residual potantial for growing

·         Patient’s alignment and balance

·         The HQRoL scores of the patients

·         Pain (Rare in adolescents, more common in adults)

·         Personal factors

What hapens if surgery is not performed for scoliosis?

Children or adolescents having a curve degree >40 degrees tend to progress with growth, and may reach to a severity that can cause lung and heart problems, decrease the quality of life, and shorten the lifespan.

Even in skeletally mature individuals, thoracic curves of >50 degrees and lumbar curves of >40 degrees tend to progress with time. This progression rate is not as fast as in the skeletally immature. Spinal degenerative changes will be absent or few in young adults. Likewise, comorbidities such as diabetes, hypertension, cardiovascular diseases, etc., will be less frequent. Therefore, surgical deformity correction for young adults may be more beneficial and easier than later adulthood and for the elderly.

Surgical Treatment of Scoliosis

The type of surgery for scoliosis depends on many factors such as age, magnitude and type of curvature. The objective is to correct the deformity and maintain the correction by operating on a minimum number of vertebra.

If the patient is skeletally mature or close to maturity, the most common operation is posterior spinal fusion to achieve bony union. This is done using metallic instrumentation such as hooks, screws, wires and bands.

In skeletally immature patients (i.e. under age 10) fusion is avoided since it halts the growth of the spine and the chest cage. Therefore, so-called “growing rods” is more appropriate at this age. These instruments allow and further stimulate growth. The lengthening of growing rods are traditionally done via additional surgical operations. Recently, magnetically controlled growing rods are used and lengthening is easily done at the clinic without pain. When skeletal maturity is reached, then posterior spinal fusion is applied to maintain the correction.

A more recent method is minimally invasive thoracoscopic anterior tethering. A polyester band is used and the surgery is done via endoscopic methods. This technique allows for correction without the need for fusion. The curve is partly corrected in the surgery; with the help of the tether it keeps correcting with time as the child grows.

Another method that aims to save motion segments is selective fusion. It’s also a fusion method, but only one curve is operated in a patient that has two or three curves. The major curve is operated, corrected and fused. The other curve or curves are spontaneously corrected and not fused. There are several criteria to judge whether the patient is appropriate for selective fusion.

Surgical Considerations:

The goal of both scoliosis and kyphosis surgery is to attain the maximum correction that can be done safely, and fuse the spine in this position. Every surgery carries risks. These must be discussed with your orthopedic surgeon. Some topics to consider when you plan surgery are:

·         A comprehensive interview prior to surgery

·         A good diet before and after surgery

·         An exercise program before and after surgery

·         Positive attitude

Instrumented Posterior Spinal Fusion

What is Spinal Fusion?

The spine consists of bones named "vertebra". Strong connective tissues connect one vertebral bone to the other, and discs act as cushions in-between.

The discs allow movement of the vertebrae, enabling people to bend and rotate their necks and backs. The magnitude and type of movement differs between the regions of the spine: cervical (neck), thoracic (chest), and lumbar (lower back). The cervical spine is a very mobile area that allows movement in all directions. The thoracic spine is much more rigid due to the presence of ribs, and is constructed to protect the heart and lungs. The lumbar spine allows relatively more movement in bending toward the front or back (flexion and extension).

The attachment of one or more vertebral bones to each other with total elimination of movement is called fusion. The concept of fusion resembles welding. However, the vertebrae are not welded to each other during fusion. Rather, bone grafts taken from the patient or cadavers are placed around the spine. The body heals those grafts within a few months—like bone healing—and this attaches, or fuses, the vertebrae to each other. 

Spinal fusion surgery can also be applied for conditions other than scoliosis. Please follow the link for details.

What’s the Recovery Time?

Pain and discomfort after spinal fusion surgery is generally more severe than other spinal operations. However, there are excellent methods for controlling postoperative pain, such as oral or intravenous painkillers. Another option is a pain pump, also known as Patient Controlled Anesthesia (PCA). In this technique, the patient presses a button that releases a predetermined amount of narcotic painkiller to the blood stream. This device is frequently used in the first few days after surgery.

Recovery following fusion surgery is longer compared to other spinal surgery operations. After surgery, the patients often stay for three or four days in the hospital, yet longer stays are not uncommon after more comprehensive surgery.

Similarly, returning back to an active lifestyle takes longer after fusion compared to other spinal operations because your surgeon must observe evidence of bone healing. The process of fusion has a different course in each patient. The body incorporates bone grafts into itself to achieve a durable bone union. Healing after fusion surgery closely resembles bone healing. Usually, the first signs of bone healing are not visible on the X-ray before the sixth week.

During this period, activities should be limited. In most cases, a strong bone healing does not occur before six months after the operation. Although evidence shows that bone healing continues to progress beyond one year, patients are allowed to increase their activities after three to four months following the operation.

Time off from work depends both on the type of surgery and also your occupation. Sick leave typically ranges from four to six weeks after a single-level fusion in a young individual working behind a desk, to four to six months in a patient who is older or working in a more physically demanding job.

What Should I Expect Long-Term?

In addition to limiting activities, a brace (corset) may be used in the early postoperative period. There are different types of braces. Some significantly limit activities and others offer comfort and some support. Whether or what type of brace will be used depends on your surgeon’s choice and surgery type.

Your surgeon may recommend a postoperative rehabilitation program after spinal fusion surgery. Exercises for strengthening the back muscles, a program that strengthens the cardiovascular system (aerobic program), or a custom program that focuses on early return to work may be used. The decision to continue with a postoperative rehabilitation program is related to a number of factors: type and extent of the surgery, ­or the patient’s age, health status, expected levels of activity. For a young patient undergoing fusion of a single level, rehabilitation may be initiated as early as four weeks.

Although fusion is a very good treatment for selected spinal diseases, it does not return your spine to "normal". In a normal spine, there is a certain degree of motion between the vertebrae. Fusion eliminates the movement between fused vertebrae. This in turn may cause greater loads being transferred to the vertebra located above and below the fusion. Fortunately, fracture of a fusion is very rare once it has healed. However, because fusion results in greater loads impacted on vertebral bones adjacent to the fusion, it has the potential to accelerate degeneration in these segments. This risk ranges among individuals. As a result, to minimize the load around the fusion site, most surgeons advise their patients to refrain from activities that will require repetitive lifting of heavy objects or rotational movements.

The decision whether to perform or avoid spinal fusion is very complex, and depends on factors related to the treated disease, age and health status of the patient—and the patient's expectations regarding activities after surgery.