Tuesday, January 20, 2015

TREATING IN THE FOURTH DIMENSION

At lunch the other day, a friend asked me about surgical indications.  The discussion turned to how treatment of kids differed from that in adults with similar problems.  I discussed the obvious things, like the relative size of the child, the anesthesia and other medical concerns, the relative strength of bones and soft tissues and the presence of growth plates.  But as I talked, it occurred to me that the biggest difference in operating on children vs. adults is the effects of time.

We teach our students to learn anatomy and surgery in all three dimensions.  It is not just the flat shape of a structure that is important, it is also its alignment in space and its relationship to the structures next to it on all sides.  But it seems to me that pediatric specialists bring a unique perspective to the operating table.  We also have to look at things in the fourth dimension – time.

All structures change with time.  Human anatomy and physiology is by no means immune to the effects of the passing years.  But once adulthood is reached, the changes in the body are less dramatic.  A thirty year old is almost the same anatomically as her forty year old self, barring disastrous pathology.  The opposite is true with children.  Small increments of even a few months during the growth spurt can change the length, the breadth and even the shape of an anatomic structure in a child.


Consequently, when we as pediatric providers make a decision on treatment, we are not only looking at the child in the clinic on that given day.  We are also calculating the passage of time, reading the tea leaves and consulting the crystal ball to determine what that child will be like – with and without treatment – in a month, in six months, in six years and in sixty years.  Our decision is not only based on the two dimensions of an x-ray or even the three dimensions of the alignment on the clinical examination.  That fourth dimension, the effect of time, is also of paramount importance.


Tuesday, October 21, 2014

Out Of the Garden: When Scoliosis Is Not Just Scoliosis



Earlier this month, I had the privilege of presenting a talk at the Chiari and Syringomyelia Foundation regarding scoliosis other than the adolescent idiopathic variety.  It was fun and liberating to talk about all the unusual causes of the disorder, something that I rarely get to do since the idiopathic variety accounts for 90% or so of scoliosis cases.  Researching and considering the topic was also eye-opening, because it reminded me of the fact that complex causes of spinal curvature may not be as uncommon as we suppose and so-called Garden variety scoliosis may be far more complex than we imagine.

The talk is archived at this address: : http://csfinfo.org/videos/physician-lecture-videos/carolinas-chapter-physician-lectures/

Please enjoy, and as always, I welcome your comments.

Thursday, September 4, 2014

CLUBFOOT AND GLOBAL MOTOR DEVELOPMENT: SOME PRACTICAL CONSIDERATIONS

Along the lines of my Tummy Time essay comes this reflection on the treatment of clubfoot.  As I note, our understanding of clubfoot is very much under evolution.  I have tried to discuss the larger picture of childhood development with clubfoot rather than specifics of clubfoot treatment.  Please let me know your take on this and all of my posts.  ~KPM


The foot is undeniably the pedestal for human balance and ambulation.  Humans depend on the complex interaction of the many joints and ligament structures in the foot to hold up their weight, propel them forward, stop their momentum and cushion their landings.  The emphasis on proper foot function is so strong that it has fostered a billion dollar footwear and orthotics industry that governs what we wear (and don’t wear) and how we play and live.

Because of this overarching significance, great care is placed in early childhood in getting the foot to grow as “normal” as possible.  This care is especially seen in the congenital deformities of the foot, such as talipes equinovarus, also known as clubfoot.

The understanding of clubfoot continues to evolve.  Most experts no longer think that clubfoot is simply a positional abnormality from months of in utero molding.  Although a small subset may be due to extrinsic issues like multiparous conditions, breech positioning and fibroid uterus, the vast majority of clubfeet are now recognized to be a true disruption of the neural axis into the foot, probably arising from the brainstem or even the brain itself.  In other words, clubfoot is a true neuromuscular condition.

The treatment of clubfoot is evolving as well.  Not so many decades ago, the emphasis of early treatment was on loosening the ligaments up so that a child could be more easily repositioned during surgery.  Mixed long-term functional results from surgery as well as the need for non-surgical options in developing countries led to the advent of rigorous casting and bracing protocols, sometimes lasting for many months or longer.  Although there is no clear consensus that the casting techniques are the final word in treatment, nevertheless most children with clubfoot now have an extended course of casting and/or bracing.
 
The issue at hand is that clubfoot itself may pose challenges to a child’s development, even after the foot is realigned.  The treatments themselves are time-consuming and by definition happen during the period of utmost importance in the early motor development of a child.  The casts may span the first six to nine months of life, when a child is typically starting to grapple with crawling and other forms of locomotion and beginning to assay the challenge of upright stance and walking.

It is important to give special attention the motor development in these children throughout the treatment process.  There is a tendency to keep the children lying on their back throughout the treatment to “protect the casts”, but this is both unnecessary and potentially harmful. Parents need to understand not only that milestones may be somewhat delayed by the treatment, but also that they should not be passive about the child’s positioning and function during the treatment.  It is essential, despite casting to allow as much of the child’s general function to develop as possible.

There are a number of strategies which I have incorporated into my treatment protocols which hopefully will minimize the developmental effect of the casting.  First and foremost, I have tried to engage the parents in the child’s positioning as much as possible.  A lot of the early postural development need not be lost to the casting regimen.  Since the casts are typically placed with the knees bent, the all-important curving forward of the body and limbs into what is termed the flexor position need not be disturbed.  Also, the child will still be able to explore side positioning and rolling, although the parents may have to be more active in helping the child position and in clearing the casts over the other leg during rolling.

Since positioning on the baby’s stomach (prone-lying) is so important for the development of arm and hip/ pelvis position and function, I try to place the casts so that there is some active movement available in the knees.  The child should be able to bring the legs under while in the prone position and push off with the arms and hips to get the full benefit of the ground reactive force.   

Another important point is to make full use of whatever time out of the casts might be available.  In point of fact, since it is not the casting, but the interval stretching before casting that is the actual treatment, I find that these timeouts are actually very important in the regimen.  I try to encourage the parents to take full advantage of the time away from immobilization to have the child rolling and prone and to do as much facilitating as possible in the brief respites.  In the early stages of the casting, I will use a material that the parents can remove the day before the next stretching/ casting treatment.  This not only allows the parents to bathe the child thoroughly but also give an extended period of attention to motor stimulation.  I have also talked to parents about specific techniques like brushing to stimulate the child’s awareness of the feet during the periods out of the casts.  These same techniques can also be done while the child is the cast since the toes and forefoot are exposed.

An interesting technique I have incorporated recently has been cast application in a bouncy seat.  Not only does this help the child to relax during the cast application.  It also allows the child to maintain a flexor posture better than placement of the cast in the fully flat position typically used.  My hope is that the child will accommodate to the cast as part of the more natural flexor positioning.  Early results in terms of acceptance of the cast by the child and maintenance of leg function have been encouraging.

In summary, the most important point is to not allow the casting regimen to dominate the child’s function.  The parents can and should be instructed to be as active in the child’s development as they would be if the child were not casted.  And special exercises and activities should be used to take advantage of every moment that the child is freely mobile.

Monday, July 28, 2014

The Hip and Tummy Time

(Although this blog has long been devoted to pediatric spine topics, I feel like I reserve the right to branch out a little and touch on some general pediatric orthopaedic areas and maybe even on some issues in society pertaining to medicine and the care of kids.

Along these lines, I offer this essay which I wrote in regards to an early motor development program that I am helping develop.  Please let me know if the topic is of interest.  There a many more essays like this one in this feverish brain of mine. -  KPM)




There is an ancient Greek fable about a dreaded creature called the Sphinx who used to waylay travelers with a riddle.  Answer the riddle (as none did) and you could pass safely on your path.  Fail to answer and you were torn apart by the ravenous beast.  The riddle, made simple by the repetition of the years, was “What walks on four legs in the morning, two at midday and three at night?”  The answer or course is a human – crawling in infancy, walking tall in midlife and using a cane in dotage.

What makes this riddle true is the remarkable changes that occur in the structure of the child to go from a fetal ball to a walking youth and nowhere are they more evident than at the hip joint.  The hip is the only joint in the body to actually change its whole structure, positon and anatomy as it develops, and it is these changes that allow humans to eventually stand and walk on two feet in a way that no other creature can.

One of the major changes that the hip undergoes between birth and walking is the alignment and rotation.  When first born, a child has hips that are very flat with respect to the pelvis (the technical term is retroverted).  This allows the hip and legs to retract out of the way without undue stress as the child is delivered through the maternal pelvis and the birth canal.  But it means that, at first, the child cannot bring the hips in front.  We see that in the newborn alignment of the hips with the legs splayed out in what we call the frog position, bent up and rolled out.  A newborn cannot (and should not) be able to bring the hips in to the midline and care should be made in the very early days of life not to pull the legs together to swaddle since it drives the hips into an unnatural position.

Over the course of the first few months of life, the hips begin to roll forward into what is called anteversion.  Ultimately, this lets the child bring the hips straight in front and gives them the stability to start bearing weight and even to push the body forward into crawling.  Ultimately the anteversion provides the child with a secure, forward directed center of balance that will allow upright stance and walking.  Finally, as the child gets more secure and the balance and ambulation muscles develop fully, the posture becomes more upright and the hips assume their adult position.

As with all bone development, the hip realignment cannot happen in a vacuum.  Bone shape follows function, so the bone will shape and position according how it is used.  In children with neuromuscular disease who never walk or crawl, the hips stay retroverted.  If the muscle forces don’t balance during early walking (as in some types of cerebral palsy) then the hips end up too anteverted by late childhood and adulthood.

Which brings us to Tummy Time.  There was a trend through the 1980’s and early 90’s to avoid stomach lying as much as possible.  Genuine fears about protecting the child’s airway led to this well-meaning but ultimately misguided conservatism.  The prevailing feeling was that children ultimately roll over and crawl, so we will protect them until they figure out how to do those actions safely on their own.  Added to the advent of car-seats and other important safety measures, we saw a generation of kids who were essentially told to figure it out on their own.

Many did, but we did see an increase in delayed walking and in some cases the loss of important milestones, like rolling, arm push up and other actions which help develop normal patterns of gait and balance.  Although it is still early to tell, we seem to be seeing an increase in early joint problems in this protected generation.

We seem to have finally figured out that prone lying, or Tummy Time, is safe and vitally important to the development of upright function.  It promotes the awareness of weight bearing and transfer.  It leads directly to experimentation with arm and leg movements which facilitate crawl.  And ultimately, it is from the prone position that humans learn to lift up and become upright walkers.

As for the all-important hip joint, which seems to govern all of propulsion, Tummy Time provides the ground and reactive forces necessary to start the process of realignment of the joint.  The baby feels the ground below the pelvis and reacts with muscular contraction.  The muscle function starts to reshape the hips.  As the hips reshape, pulled inward and forward by the muscle function, they become stronger and better positioned to lift the body and to start forward propulsion.  And ultimately, these functional changes lead to increased strength and balance which lift the child upward into stance and walking.

The Sphinx would be so proud!

Monday, May 5, 2014

"VALUE" IN HOLLYWOOD - Notes from the Pediatric Orthopaedic Society 2014 (part 1)


I recently traveled to Hollywood for the annual meeting of the Pediatric Orthopaedic Society of North America (POSNA).  I am always bemused by LA and especially Hollywood, packed as it is with an odd mix of tourists and denizens, the former trying to snap photos of Marilyn Monroe’s footprints, the latter trying to shill lurid stories about the stars’ dwellings and demises.


The meeting was held in the same facility that hosts the Oscars, and as expected, they did their best to schmaltz it up, complete with a Red Carpet Banquet, which I missed.  It would have been fun to see what some of my colleagues came up with as Hollywood formal.

On the serious side, amidst the usual presentations about hip reconstruction and clubfoot (to operate or not, that is always the question), there were some curious trends that I noticed in the overall thought process of the group, mostly change for the better although some of it remains to be seen.  The watch cry for the whole meeting was “Value”, which is the newest in a long line of buzzwords in the medical community.  In past the issue has always been to define the word in a practical manner so that it can be measured, duplicated (and I guess hopefully rewarded).  The working definition that interlaced a lot of the conversation was the quasi-mathematical expression [Value=Outcome/Cost].  So simple – plug in the numbers and you will have the secret value score.  The problem remains as always: what are the numbers to plug in?

Cost, one would think, is an easy variable to define.  All things have a finite price after all, and there must be some way to find and report that price.  But as we all know, medical economics defies even the simplest logic.  In fact any medical occurrence has multiple prices.  There is the price for the actual treatment (brace or implant or what have you), the price for the treating doctor’s visit, the price for any hospital service, the price for anesthesia, and so on.  About the only one of those that is easy to obtain is the charge of the treating physician, and even that is complicated by the fact that the actual number may have little or nothing to do with the actual fee that a patient or an insurer pays.  Don’t even try looking for hospital or implant costs – that way lies madness.

What about outcome?  By definition, this is a non-numerical factor which wiser heads than mine have been trying to arithmetize for decades.  As such, there are complex surveys and instruments which are supposed to come up with a useable score to plug into this kind of formula.  Although some of these may work in some settings (the Harris Hip Score is elegant for simple arthritis of the hip but not so good for hip impingement), these tools are bulky and hard to implement.

The emphasis at POSNA was on bolstering awareness of the need to understand cost and outcome, so that a value can be derived.  The insurers and the government conflate value with cost alone, but the mere cutting of costs may not enhance the value of anything.  Ultimately, the goal is to bolster the value to such a degree that it overrides any effect that the cost may have.

An excellent point made was that value must be determined in communication with the patient and family, not just by some measurements on an x-ray.  Even if a hip implant lasts for 25 years, it is still not valuable if the patient is in constant pain for every day of that span.

So, finally and at long last, surgeons (and I presume all doctors) will be forced to speak to their patients before, during and after their care.  They will need to go beyond the superficial questions (“Any pain?”) and delve into complex interactions like “How has this affected your life?”, “Did the surgery match your expectations?” or the all-important “Are you satisfied with your care?”  Although these factors will be hard to quantify, they are the true measurements of value.

Monday, March 31, 2014

THOUGHTS FROM THE EAST - My visit to Korea

Last week, I had the estimable pleasure of being one of the invited speakers at a symposium on Patient Care in Spinal Surgery at SoonChunHyang University Medical Center in Seoul, Korea.  The faculty, led by Dr. B-J Shin, was made up of some of the leading orthopaedic spine experts in that country.  Despite the obvious language barrier (the talks, besides mine, were exclusively in Korean), I was able to learn a tremendous amount, not only about the art of treating spine patients but also about the nature and the character of my colleagues in this delightful and mysterious country.

This was my first visit to Asia and from first to last I found my hosts charming and welcoming.  They all seemed delighted to try out their English speaking skills, which to my great fortune were uniformly excellent.  The curious nature of the medical field is that many of the words used in talks are not translated into the native tongue, so despite the balance of the talks being in Korean, many of the words and phrases were understandable.  Combined with the tone of voice, the frequent laughter and the body language, I was able to understand the gist of almost all the lectures, although there were some in which I wish I could have gleaned the details.



The symposium ran from preoperative evaluation to postoperative and chronic pain management.  There were a number of talks on blood loss and transfusion, which is one of my special areas of interest.  I presented my work on Blood Conservation In Scoliosis Surgery which fit in very well with the overall scope of the conference.  The audience asked me a number of insightful questions and the whole interchange made it clear that my message had been delivered.  In fact, the talk was well enough appreciated that I was 'hi-jacked' by Dr. K-Y Ha, another prominent spine professor, to give Grand Rounds the next morning at another University Hospital, Seoul St. Mary's for the orthopaedic residents.  Despite being Saturday morning and my talk again being in the non-native language, I only put two of the residents to sleep, which is an excellent ratio.




After a whirlwind city tour of the magnificent and exotic city - think New York skyscrapers mixed with Buddhist shrines and ancient palaces - I spent the final day in the city observing the surgery of Korea's preeminent deformity specialist, Dr. C-S Lee.  I was impressed by his flair and elegance as well as the fascinating process that had gone into the development of his technique.  As with all my other hosts, he was friendly and welcoming and genuinely interested in my thoughts on everything from his screw placement and curve reduction to the skating of Yu Na Kim (I agree with him and his whole country that she was cheated out of Olympic Gold, but that is a conversation for another time).

Dr. C-S Lee and me

I was thoroughly enchanted by my visit to Korea.  I was treated with fantastic courtesy and amazing hospitality.  But more importantly, I was impressed by the dedication and the skill of the spine community in that country.  I hope that I can continue to interchange ideas and to learn from them and I certainly hope that my future includes another visit.

Friday, March 14, 2014

BRACING FOR SCOLIOSIS: PROBLEM SOLVED?


For years, one of the great controversies in the treatment of scoliosis has been the use of bracing.  Despite almost a hundred years of (mixed) experience, the scoliosis world divided itself into three camps.  On one side, were the Ardent Bracers – “Give me enough Plastazote and I will conquer any curve!”  The rival camp, the Nihilists, would rejoin, “It’ll never work!” like the character in the child’s cartoon.  Somewhere in the middle was a pragmatic group which would use the braces with modest expectations, sometimes because they knew that a brace must work in some settings or no one would have invented in the first place and sometimes because they had nothing better to do.

In October 2013, a landmark article was published in the prestigious New England Journal of Medicine titled “Effects of Bracing in Adolescents with Idiopathic Scoliosis” with the lead author Dr. Stuart Weinstein from University of Iowa.  The article reported on the findings of a multicenter trial (the BrAIST trial) involving both randomized and preference groups of braced vs. observed patients.  72% of the braced group did not progress to surgical curves by maturity vs. 42% in the observed cohort.  The trial was in fact so successful that the group applied the research equivalent of the Mercy Rule – they stopped the trial well before its scheduled time because the numbers were so one-sided.

This is a landmark for several reasons.  For generations, the holy grail of bracing literature was how to do a suitably ‘controlled’ study with the devices.  After all, you can’t fool a patient into thinking they are wearing a brace when they are not (and vice versa).  And you can’t hide the brace from the doctor.  Combining the randomizing with a preference group would seem to balance out some of the inherent bias in any brace study.  Although I believe that there is still an ‘apples vs. oranges’ effect inherent in the fact that every curve has its own personality, the relatively large groups involved would tend to even this out (although I am surprised that the authors could only come up with 242 patients for this study – why not add another few centers and get up to four- or five hundred?).  So here at last is the first recognizably scientific paper on bracing, and it is in favor of the devices.

 
The favorable outcome for bracing is in itself landmark in a surprising way.  Dr. Weinstein, while not a true Nihilist has been known in the community to be skeptical to say the least about braces.  I was involved in discussions with him and Lori Dolan, PhD at a national meeting not long ago, and they seemed convinced that the study would go quite the opposite way, citing the difficulties in getting kids to wear the braces and the somewhat suspect effectiveness as a reason why bracing is not cost effective.  The numbers in this study must be truly convincing if Dr. W has come around to the pro-brace side.

The third and most astonishing thing about this study is that it was published in NEJM.  The Journal as a rule is the bastion of Internal Medicine and Public health studies.  It is unusual to say the least for them to publish a surgical paper at all.  The last time they even acknowledged the existence of orthopaedics was to publish a very negative article concerning the use of a specific knee arthroscopic technique.  I’m not sure they even know how to spell ‘pediatric orthopaedics.’  For them to feature a work on a mechanical treatment in Pedi Ortho is as remarkable as when the Red Sox first won the World Series.  But there it is, in proverbial black and white.  Which means that the paper must be remarkably rigorous from a statistical point of view (and it seems to be) and it must be of really significant clinical importance.

So does Dr. W’s paper solve the question?  Are the Nihilists now going to throw down their standards and take up Boston braces with a hearty “Huzzah?”  Probably not.  There are still important questions about which curves do best with bracing, when to start (age and magnitude of curve) and when to stop. The paper rather tantalizing brings up the amount of time in the brace as an important variable but falls short of any clear recommendation.  What is the effect of genetics of the curve? Will the ‘successful outcomes’ in this study hold onto their success or will they progress even after maturity?
Most importantly, what kind of brace is best?  I will discuss the types of bracing a future post, but there are rigid and flexible, daytime and nighttime types.  Until the community can come to a real consensus as to who to brace, how long to brace and what brace to use, the controversy will rage on and on.

Friday, December 13, 2013

SPINAL FUSION - A Brief But Loving Overview PART I

I had a comment to this blog (which I always welcome) requesting that I review the history of spinal fusion for deformity.  What follows is a vastly oversimplified yet still long review of the history of fusions and an overview of where the art has come from and where I think it is heading.  Please enjoy:

Scoliosis is an ancient problem and it is only in the last fifty or so years that we have started to engage in treatments beyond punishing braces and witchcraft.  Modalities ranging from bracing to electrical stimulation have been tried in an effort to reduce the curvature and stop its progression.  New vistas such as gene therapy are arising as we learn more about the genetic basis.  But for the last fifty plus years, the only tried and true method of actual correction of a curve was through surgical spinal fusion.

This does not mean to imply that spinal fusion is (or has ever been) a single monolithic procedure.  From the early onset of treatment, there has been controversy and change, some subtle, some drastic, in an effort to make the procedure safer and more reliable.  Even at our current sophisticated state, all surgeons recognize (or should) that we are just passing through this age with the “next great innovation” just over the horizon.  Ultimately, the key fact is that fusion surgery is a non-anatomic salvage.  It is a procedure that provides great benefit, but it is still a response to a process that we do not fully understand.  Until we understand the genetic or even the molecular level of the process, our efforts will be by necessity crude, regardless of how elegant they may be.

I marvel at the first few surgeons who undertook opening a spine for fusion.  Organized and scientific study of spinal fusion began in the late 1940’s, a time when antibiotics were just coming into their own and surgical infection rates were alarming by modern standards.  The exposure of a large portion of the spinal column must have seemed unbelievably daunting, but the truth of the matter is that younger   humans have incredibly robust immune systems.  As a result, infection in these cases was surprisingly low.  Early fusions did not have the benefit of internal fixation (the screws and rods that are commonly in use today).  Frequently, the child was corrected either by serial casting – a technique which is regaining some favor – or by a progressive brace hinged at the curve apex.  When the desired flexibility and correction had been obtained, the brace or cast was locked into position.  The child was taken to the operating room and the posterior bones of the spine were exposed and “shingled” – strips were cut and folded on themselves to provide a local graft material.  Later, graft from the hip/ pelvis area was use to supplement the local bone.  The incision was closed and then the child was left in the brace or cast in a corrected position until the bone had healed, for the most part a matter of months.  My father recalls rounding on pediatric floors during his early Orthopaedic years in Pittsburgh and following fifteen children wallowing in beds in large ward rooms over the course of entire summer.
The dreaded Turnbuckle Cast.  A child would live in this for months during healing of early fusions.

As has been often the case, it took the vision of one man to change the face of surgical treatment for scoliosis.  Paul Harrington from Baylor developed a fairly simple rod and hood complex which could act as an internal support for those children undergoing treatment.  The steel rod complex was threaded either with a fixed hook and a moving hook or two moving hooks.  By separating the fixed hooks in site, the convex side could be lengthened to allow what we term distraction of the curve.  The same type of local fusion was performed and patients still needed bracing for an extended course.  But casting was able to be put by the wayside and the children could be more mobile and released from hospital at a much earlier date after surgery.  Harrington rods rapidly became the gold standard and were used regularly as late as the late ‘70s.  Many operating room inventories still include Harrington sets on a shelf somewhere, although they are almost never used these days.

Harrington Rods - a distraction (lengthening) rod on the left and a compression (shortening) one on the right. 



As good as Harrington’s system was – and it had the benefits of ease of use and a simple elegance – there were several flaws in the design which needed to be overcome as fusion and instrumentation went forward.  The first and most obvious is in the mechanical design.  The Harrington device is ultimately a long rod with a hook at either end.  Each hook is secured into a bony bridge in the spine called the lamina.  Laminar hooks provide excellent fixation and were the basis of fixation for years to come until the advent of screws.  But a single lamina is a relatively thin strip of bone.  A single fixation at each end of a device which sees a tremendous amount of force over the course of a lifetime is bound to be prone to disruption, either by movement of the hook off the lamina or by breaking of the bone itself.   Another issue is that the linkage between the barrel and the screw of the rod proved to be a weak point, particularly if the bone fusion does not fully heal.  Breakage of Harrington rods was not an uncommon occurrence, usually at that transition point.

Various techniques were used to try to bolster the security of Harrington constructs.  Multiple rod constructs were attempted – necessary if the child had more than one curve.  I have seen constructs of two Harrington rods side-by-side along the spine.  Unfortunately rods continued to break and hooks to subside.

Around the same time that Dr. Harrington was developing his system, Dr. Eduardo Luque in Mexico City was working with a device that would stabilize if not fully correct a curve.  His device was predicated on a stainless steel rod placed alongside the spine and held in place with a series of wires wrapped around the lamina.  These Luque wires were individually flexible, but by wiring at each level the entire construct was made more rigid.  The inability to distract the device to allow curve correction ultimkately limited its use to patients with neuromuscular disease (such as Cerebral Palsy).  But the entire device could be placed safely and quickly and the concept and benefits of segmental fixation began to be evident.

Luque wiring and Galveston rods in the lower spine and pelvis of a child with cerebral palsy

The Luque wires were sometimes applied in hybrid to the Harrington Rod devices – creating a construct that was fondly called a Harri-Luque.  The application of this type of segmental fixation did seem to improve the strength of the constructs and disruption was diminished.  Added refinements, such as wires which went into the posterior elements of the bone rather than around the lamina (Drummond wires) helped as well.  But they could not overcome one of the main flaws of the Harrington design.

The human spine is mechanically based on the front to back curvatures, what is termed the sagittal alignment.  This allows the balancing of the centers of gravity in the body and facilitates all upright and most sitting posture in a normal person.  What the Harrington distraction did not take into account was the sagittal malalignment that makes up scoliosis.  Think about your high school geometry.  Simple lengthening of the convex side of a two-dimensional semicircle may straighten into a line, but in the third dimension it will decrease the necessary backward bend of the lower back, called the lordosis.  Patients who had Harrington fusion often developed severe pain and fatigue in their lower backs and an inability to sit unsupported for a long period of time.  This so-called Flat Back Syndrome was the long-term curse of the otherwise promising corrective ability of Harrington fusions.


As the science entered the late ‘70’s and early ‘80’s, it would take the French approach to the segmental fixation problem and the developing concept of a rotational model to advance the surgical art of scoliosis treatment.

To be continued...

Sunday, October 27, 2013

HOW I SPENT MY SABBATICAL

With the crisp air of fall settling in and the State Fair roaring to a close, it is time to review the long Spring and Summer and harvest whatever lessons life has offered me during my much needed break.  As my Sabbatical draws to a close, I can reflect on some of the ways my time off has changed me, as well as what about me has remained the same.

The constant is, and will always be, my interest in working with and I hope helping the children in my community.  I confess that I looked at other opportunities in other areas of the country.  But it was too difficult to leave the kids I already know and I could not escape the feeling of having unfinished business.  I have always felt loyalty is the strongest of virtues.

What has changed is my understanding of the need for full and clear communication, not only between myself and the children who are my patients, but also and especially with the parents and families of these kids.  I realize in retrospect that the pressures of being involved with such a busy practice did not allow me to spend as much time as I should have explaining my thinking and trying to understand the concerns and expectations of all involved.  I was able, during my break, to talk to a number of practitioners about how they maximize communication, and although I can tell you that no one has it down to a science, I came away with a number of new ideas that I think will help.  I also hope I never lose sight of the all-important trust factor that makes a successful doctor-patient relationship.

I, like many Americans, spent the summer trying to grapple with changes in policy as the Affordable Care Act begins to take effect.  I promise not to get overly political, but I find the ACA to be a tremendous opportunity to improve health care delivery, especially in the pediatric specialties.  For one thing, more children will have insurance and access to quality care.  For another, the law promotes communication and cooperation between specialty doctors and referrers and between doctors and hospitals.  And although it does not seem so right now, I think it will ultimately empower patients in the management of their own care.  Obviously, there is much more to see before anyone can make the final determination about the law.

Most importantly, my Sabbatical gave me an extended opportunity to spend time with my family and to relearn the importance of family ties.  This time enabled me to work with my son, a Second Year student at University of Virginia, on a number of creative outlets.  Through his encouragement, I sketched and wrote.  He even got me to start running regularly, which I would have bet could never happen.  I took voice lessons, which I had promised myself for a long time now.  I accompanied my wife on travel that I would never have been able to do had I been working – and so, I saw Brazil for the first time and attended the Gala Opening of the American Ballet Theater in New York City, among other adventures.  Throughout it all my family was a source of comfort and inspiration.

Perhaps most satisfying, I had the time to work with my father, Henry, an esteemed orthopaedist living in semi-retirement in Boston, on a book on Genetic Conditions in Orthopaedics, which has been published and is available to anyone who has absolutely nothing better to do.  We even included my son in the project as he designed the cover art (see below).



Overall the strength and support  of my family has reinforced the importance of engaging the families in my clinical endeavors.  And although I have enjoyed my time away, it is definitely time to return to work and try to put my new-found ideas into practice.

Thursday, June 27, 2013

185 Orthopaedists Walk Into a Bar...


I have a friend who does improv in New York City, and she told me about the traditional “walk into the bar…” joke or as they call them “185 jokes”.  The jokes are always along the lines of 185 something or other walking into a bar and being refused service.  The punchline, fast and furious, is generally groan-inducing.  A recent contribution from her goes like this:

185 Scoliscore tests (gene test for scoliosis) walk into a bar.  The bartender says “We don’t serve your kind here.”

              The Scoliscore tests respond, “Well, that sure threw us a curve!”

This month, June, has been Scoliosis Awareness month as always.  I have had the experience of giving four talks, writing three papers and two articles and being interviewed twice on media, always about scoliosis and mostly about Scoliscore, which I am championing.  Earlier articles in my blog have discussed the test which can determine the prognosis of a mild to moderate scoliosis with up to 99% accuracy, making it one of the most effective prognostic markers currently available in clinical medicine.

One of the reasons I have had this luxury is my self-imposed (and hopefully temporary) sabbatical from clinical care.  In three months, I have not seen a single patient (which has been unquestionably painful) and have not done a single surgical operation, which has been surprisingly refreshing.  Being out of the OR has allowed me to reflect on medical care from an entirely different perspective than my previous busy surgical practice allowed.

Doctors are an interesting lot.  We tend to define ourselves very strongly in terms of the composition of our practice.  We place ourselves by geography (“urban” vs. “rural”), by referral pattern (“primary” vs. “tertiary”), by complexity of the patient we see.  Surgeons, that most superstitious of groups, tend to define ourselves by surgical parameters – how busy are we, what is our caseload, what types of surgery are we comfortable with and what will we refer out?

The old adage from residency days is “a chance to cut is a chance to cure.”  But being outside of the surgical sphere made me realize that surgeries actually define a failure of a kind; the failure of non-operative treatment.  And in the bustle of being a busy surgeon, we run the risk of losing sight of the patient attached to the surgery.  No surgeon defines him or herself by the number of clinic patients seen, or the number of times that operative care was not invoked.

Humans also tend to define themselves in broad categories.  When it comes to medical care, they will often group themselves by their diagnosis, and will often carry the stigmata that go along with that diagnosis.  In adolescents and children, that is a particular issue, since placing yourself in a “diseased” category makes you somehow “other” or “different”.  Scoliosis is particularly pernicious in this regards.

Thinking, writing and speaking about Scoliscore through the eyes of a non-surgeon as much as I have over the past several months has led me to see the strengths of the test differently.  To be sure, a high score is very helpful.  It can define referrals and govern treatment plans.  It can give the doctor and patient a chance to explore more aggressive treatment options up to and including surgical intervention.  There is that surgical angle again (no scoliosis pun intended).

But the low score is inarguably most important to the patient.  With a 99% negative predictive value (only 1% or less of kids with the low scores will progress to need treatment) it will remove the fear and the stigma of having the diagnosis.  A child with a low score does not need to define herself as having “scoliosis” at all, since it so unlikely that there will be any consequence.  She can go on to other more congenial definitions like “preppy” vs. “Goth” or “athlete” vs. “artist”, and fit in more readily into the difficult vagaries of adolescent society.

 So, 185 low-risk Scoliscore tests walk into a bar.  The bartender says, “We don’t serve your kind here.”

The tests say, proudly, “We are not a kind.  We are as individual as anyone else in this bar. Serve up the drinks!”
That little effort would surely get me booed off the improv stage, but for a child with the diagnosis of scoliosis, it is surely a punchline to be cheered!