By Robert Bohinski, MD, PhD
When patients come to me with a complex spinal deformity, pain is not always their major complaint. More often they agonize over everyday matters that most of us take for granted. They can’t stand up straight. They can’t socialize the way they used to. They can’t travel, can’t walk on the beach with their loved one, can’t make it to the store even if they use the handicapped parking spot. Without a doubt, these patients are struggling.
When your parents told you to “stand up straight” when you were a child, you thought it was hard work. But standing up straight for us is nothing compared to the energy required to stand while compensating for a complex spinal deformity. Patients may need to summon all their muscular strength in order to interact with others. They may need to extend their hips, flex their knees, and extend their neck. Some will put their hands on their thighs to help them get around. Not surprisingly, few people can hold these postures for very long.
Thankfully, we are able to help many of these patients at Mayfield Brain & Spine. The results can be life-changing, the “before and after” pictures breathtaking.
There are many causes of complex spinal deformity. They include:
• Unlucky genetics;
• a degenerative process called ankylosing spondylitis, a type of arthritis characterized by long-term inflammation and stiffness;
• spinal fractures that leave a portion of the spine unstable;
• progression of a prior, underlying problem after successful spine surgery;
• progression of a prior, underlying problem after an imperfect spine surgery, resulting in a flat back, or lack of normal curvature;
• failure of a spinal implant, which occurs when the implant pulls out of the bone.
When these patients come to Mayfield, a thorough investigation begins. Our goal is to discover the least invasive way to help. We also ask whether the problem truly involves the spine, or whether a hip or pelvic issue is to blame.
Sometimes x-rays don’t tell the whole story. What appears to be a major problem on an x-ray – an abnormally curved spine, for example – may not be the source of trouble for a patient complaining of sciatica. Looking closely, we may find that we can alleviate the sciatica by performing a limited surgery in one small area. This scenario is good news for the patient, as we can take pressure off a compressed nerve with a safe, straightforward surgery. We may wish to check this patient annually, however, to make sure the spine doesn’t change.
In other situations, we may find that a patient with a bad limp and bent posture doesn’t have a back problem at all. More than once an x-ray has revealed a bad hip. The patient undergoes a hip replacement and is spared having a really difficult spine operation.
If a patient does need surgery involving a major correction, significant planning begins. As the carpenter’s proverb advises, we “measure twice and cut once.” Using high-quality x-rays, we take careful measurements. We want to ensure that the pelvis is straight, the hips are balanced, the shoulders are square. We know that small angular measurements at the base of the spine can impact where the shoulders fall. We measure for lordosis, as the curvature of the lower spine should arch backwards. One of my Mayfield colleagues, the late Charles Kuntz IV, MD, created a spinal deformity classification system and led the way for people to respect these measurements, here in the United States and around the world.
With a patient’s exact measurements in hand, we determine the correction necessary. In complex cases, this will involve an osteotomy, the surgical fracturing and removal of a wedge of bone. We will implant shims (interbody grafts) and anchor our work with rods and screws. The surgical process likely will be staged over two or three days.
The result is a dramatic realignment.
Deformity spine surgeries are not risk-free, especially in the cervical spine. But they are life-changing. They enable patients to stand tall and look their friends and colleagues in the eye. They change the way patients see themselves and in the way they interact with their world.
Robert Bohinski, MD, PhD, is a neurosurgeon and complex spine specialist for Mayfield Brain & Spine.