Seven spine surgeons discuss trends in spinal deformity.
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Question: What are the key trends in spinal deformity care today?
Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: Spinal deformity continues to be top of mind among most new graduates and current symposiums. The key things to look out for are the concepts of global spine balance and using ALL release to correct flat back deformities. I am keen on learning more about both of these concepts this year. Our goal as surgeons is to heal, and hopefully we can decrease the number of advance level sufferers and repeat surgeries.
Medhat Mikhael, MD. Medical Director of the Non-operative Program at Center for Spine Health at Orange Coast Memorial Medical Center (Fountain Valley, Calif.): The key trend for the treatment of spinal deformities is to use conservative approaches like physical therapy, special braces, acupuncture, spine interventions and medications like NSAIDs and muscle relaxants, however surgical interventions sometimes are warranted if pain is out of control and conservative approaches failed, or more importantly, the deformity has caused progressive neurological symptoms, spine instability or visceral compromise, like a restrictive lung condition, that can lead to major respiratory distress.
David Feldman, MD. Director of Center for Scoliosis and Spinal Deformity at the Paley Orthopedic & Spine Institute at St. Mary's Medical Center (West Palm Beach, Fla.): The therapeutic and surgical management of spinal deformity in children and adults has expanded and grown over the past decade. Spinal deformity encompasses scoliosis, kyphosis and spondylolisthesis. All aspects of spinal deformity may occur from infancy to the geriatric population and may cause pain and dysfunction.
While training 20 years ago at New York University in New York City and the Hospital for Sick Children in Toronto, there were few non-surgical options to offer patients and the surgery was maximally invasive. Physical therapy was thought to have little impact for the patients. Today at the Paley Institute, we have children and adults alike undergoing Schroth Therapy and other modalities to specifically treat spinal deformity. Schroth Therapy is a Pilates-like exercise therapeutic program that is showing great promise in correcting and stemming the progression of childhood and adolescent scoliosis. In adults, this can often aid in pain relief and reduced disability.
Surgical intervention has advanced logarithmically in recent years. Spinal deformity is being treated in children with non-fusion techniques such as growing rods and vertebral body tethering as well as fusion surgery that allows for very accurate placement of spinal hardware with various CAT scan and 3-D modeling techniques. These new techniques allow patients to be corrected to a normal state, resume all activities very soon after surgery and reduce complications of spinal surgery.
Minimally invasive spinal surgery in the correction of spinal deformity has become the norm. Adults and children may have surgery that has one-half inch incisions and allow for placement of hardware and correction of the spinal deformity. New instrumentation and imaging possibilities has allowed for this to become the definitive treatment of the deformity.
Understanding the normal alignment of each individual spine and how to correct the curve, so that other spinal deformities do not develop, is critical. Our understanding of the spine has grown and our ability to use imaging that has little radiation exposure to the patient is the standard of care. The EOS system, a low-dose total body X-ray machine, exposes children and adults alike to a fraction of the radiation seen in standard X-rays and demonstrates the alignment from the head to the feet.
In conclusion, spinal deformity is a problem that requires extensive expertise to treat. Finding solutions with a billboard-commercial quick-fix is unfortunately doomed to failure making it more complicated and often harder to correct. However, in 2018, assessed correctly and with the utilization of all the modern non-surgical and surgical tools available, an outcome that leaves the individual functioning fully and pain-free should be expected.
Payam Farjoodi, MD. Orthopedic Spine Surgeon at Spine Health Center at MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): There is an increasing focus on sagittal alignment as this has been found to correlate with patient outcomes. I think an emphasis on improving biologics and minimally invasive techniques to achieve these results are important to minimize the risk of complications in these complex patients.
Ram Mudiyam, MD, Orthopedic Spine Surgeon at the Spine Health Center at MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): Spinal deformity surgeons involved in the management of early onset scoliosis have a better understanding of the classification and available treatment options. There is an increased interest in derorational casting on the one hand and magnetic growing rods on the other, both attempting to minimize the morbidity associated with traditional growing rods in this very challenging group of children. The prosthetic titanium rib is reserved for severe cases of thoracic insufficiency syndromes.
Adolescent skeletally immature children with progressive idiopathic scoliosis are ideal candidates for surgical correction. The key trends include a better understanding of fusion levels based on 2-D and 3-D classification of idiopathic curves aided by low-dose imaging techniques that allow imaging from the cranium to the feet. Other advances include the use of anti-fibrinolytic agents such as tranexemic acid to significantly reduce intraoperative blood loss and the use of multimodal neuromonitoring to decrease risk of neurological injury during surgery. Fusionless surgery via growth modulation techniques and minimally invasive techniques are gaining traction among pediatric and adult spinal deformity surgeons.
The management of complex adult spinal deformity continues to be a daunting challenge for spinal deformity surgeons. Understanding global sagittal and coronal alignment is an evolving field. The key trends include a better understanding of the patients's comorbidities, which allows for better risk stratification prior to surgery, presurgical optimization of the patient's nutritional and metabolic status including aggressive treatment of severe osteopenia/osteoporosis with anabolic agents such as teriparatide/abaloparatide, age-adjusted understanding of spinal parameters to avoid overcorrection, understanding junctional complications, such as proximal junctional kyphosis and proximal junctional failure and most importantly, engaging the patient in the informed consent process through shared decision making.
David Roberts, MD. Pediatric Orthopedic Surgeon at NorthShore Orthopaedic Institute, NorthShore University HealthSystem (Evanston, Ill.): As a pediatric orthopedic surgeon specializing in scoliosis and spinal deformity surgery, I see several exciting trends in this area of medical care.
First, the ultra low-dose 3-D imaging system known as EOS is minimizing radiation risk during scoliosis monitoring. This radiation exposure is up to nine times less than a standard X-ray, which is particularly important to young scoliosis patients who are watched closely throughout their lifetimes. Also, computer navigation for pedicle screw insertion is helping with more accurate placement and fixation in correcting spinal deformity as well as reducing time in the operation room and postsurgical complications.
In addition, optimizing implant density is saving surgical time and cost by reducing unneeded screws. Studies have shown these benefits using low-density constructs. Finally, postoperation care pathways through best practices such as better multimodal pain management are leading to faster discharge. All these trends are leading to a better future and care for children and adolescents with spinal deformity.
Theodore Belanger, MD. Orthopedic Surgeon at Texas Back Institute (Plano): Some trends include less invasive surgery, more use of surgical navigation and robotic surgery as well as programs directed at reducing hospital length of stay and associated cost.
Additionally, we are seeing a transition toward more anterior and lateral techniques, with deformity correction achieved through interbody techniques, and performing fewer "destabilizing" osteotomies.