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.