Week Eleven Day Two: Bracing

As the project is coming to a close, my last day being tomorrow, I wanted to make sure I addressed the other form of treatment for scoliosis: bracing.

Bracing is usually done when a child's curve is not yet high enough to be operated on, but still at risk for progressing, which is dependent on age, the degree of the curve, and physical maturity.

The brace is a full back brace that must be worn 16+ hours a day. It does not reduce the curve by any means, however it does slow the progression of the curve, and hopefully prevent children from having to go through the surgery.

Most braces can be worn under clothes, and Doctor Shindell recommends that it's worn all day and night except for school. It's formatted personally to each kid's body, by a professional.

Generally this brace is called a Boston brace, and does not necessarily look like the one above, but similar, with straps to hold it in place.

Although it does not reduce the curve, it is a much less invasive option that can slow the road to surgery, or even stop it completely.

Week Eleven Day One: Risser Sign

As my project is coming to a close this week, and tonight I'm finalizing my presentation and nearing the end of my research paper, I wanted to talk about one more thing that I'm not sure I've addressed so far on this blog: risser signs.

A risser sign is a cap that forms over the pelvis in teenagers. For girls, it forms during their last year or two of growth, informing doctors that she's reaching her full maturity and height. However it's different in boys, as it isn't as reliable and they still grow following the caps formation.

Doctors use this cap by labeling it risser sign 0, 1, 2, 3, 4 or 5, based off how far the cap has developed over the pelvis.

By using this as an indicator in female patients, doctors can figure out how they want to treat a patient. For example, if a patient has risser sign 5, and only has 16 degrees of curvature, it is very unlikely that the curve will progress due to the fact that she's done growing, and that scoliosis in children is not degenerative and instead genetic.

Above is a picture showing what the cap would overall entail and what each risser sign means.
Below is a picture of a risser sign on an x-ray.

If you look at the pelvis you can see a little cap forming over it, that is the risser sign.

Week Ten Day One: A Slow Week/Familial Influence

Coming back from my break was a bit harder than I expected in terms of sleeping, but I'm now back in the hang of things.

So far I've seen some pretty interesting patients this week, however it has been slow when it comes to patients who have had the spinal fusion.

Of course this project is not solely based on studying my research question, or else I'd be bored out of my mind, but also learning about other things related to the medical field and seeing what it's like being inside a patient room not as a patient.

One thing I noticed a lot of this week was how the family truly affects the level of care, even with the same doctor.

If Dr.Shindell puts a cast on two kids in the same spot at the same time, but one kid's parents let them run around and not wear a sling, the affects will not be the same as the kid who doesn't. Although many people assume your level of care is based on your doctor and that alone, it's not true. The family plays a huge role in the kids level of success after care, and their ability to get the correct care in the first place (such as families forgetting what happened to cause an injury).

It's a simple thing to keep in mind when you think of doctor's and how their patients are, but it's a very important topic to also be discussed.

Week Nine Day Two: Spinal Fusion Vs. MAGEC Rods

So as this week's coming to a close, I will not be here next week and posting as I am going to Hawaii! I'm very excited.

Now looking at my data, I thought I had a set number but apparently I was wrong. It's very late in the project, so I cannot try and change anything about it, but there are some things I realized:

For scoliosis, there two surgeries, the spinal fusion for kids that are fully grown, and the MAGEC rod system for kids that are still growing. If I shaped my question to "scoliosis surgeries" I would have 13 data points rather than the 9 I have now, and they would include more complications and a better way of analysis.

I'm trying to find a way to get more data if I can, but the project is so near over it seems very difficult.

I made a post early about the MAGEC rods so you can go check it out.

I hope everyone has a great week!

Week Nine Day One: Understanding the Mental Health As Not Being a Complication.

Well seniors! The project is almost coming to a close, and I hope everyone is getting excited about college and their future. With my project ending soon, I'm trying to nail down and get a full grasp on some of the definitions I'm using for my presentation, the main one being complication, which I'm defining as an unexpected and unwanted consequence of the surgery.

Most of the time this means physical complications such as the progression of the curve of the spine following the insertion of the rods, lose screws, breaking of the rods, etc. But today, after seeing a patient who's gone through multiple surgeries and is suffering from unhappiness (I cannot define it as depression since I do not know) it made me think about whether or not there can be mental complications following the surgery.

Before the spinal fusion surgery, some people may have to quit sports or activities that they enjoy, which can cause a depressive state. In most cases, from what I believe, doctors are on the look out for the patient's mental state, before, during, and after the surgical process, as it can be "expected" for their to be some sort of unhappiness given the discomfort patients must endure.

In that case, it wouldn't be a complication, as most doctors can expect/must look out for this, however depression wouldn't be the only possible mental side affect.

Through reading Scoliosis: Ascending the Curve I found that some people began to have anxiety following their surgery surrounding crowds, or sports even after their doctor has given them permission to continue doing said sport. Some people are fearful of being bumped into, and therefore can suffer social or crowd anxiety.

In cases like these, it can also be considered understandable reaction, and though unwanted, it isn't necessarily unexpected.

So for the sake of this project, and me gathering up the small amount of data that I have, mental side affects are not considered a complication.

Week 8 Day Two: Why This is Important To Me.

Before research projects are funded, the real question people ask is why is this important? Why could this research be a benefit to us and our society? In this post, I'm going to take this question and change it a bit, and answer why this is important to me.

This post will conclude my mini 3 part endeavor into my personal journey with scoliosis spinal fusion surgery and its complications.

In my last post I talked about how I had a complication involving my adrenal gland and my blood pressure. Following everything with the ICU and going home, and seeing the endocrinologist to get some sort of confirmation on what exactly happened to me, I realized that I am not the only kid who's had to go through this following this surgery, and I certainly didn't have it the worst.

Carrying around the needle with an emergency dose of hydrocortisone and having to teach my friends how to use it made me feel fearful, even if this wasn't the biggest thing that's ever happened to me.

Through experiencing this, it made me wonder what about the kids whose surgery didn't work all together, or the kids who's rods break? How hard was this on them?

Maybe this research isn't the most pressing issue in our modern society, but I wanted a project that felt close to me, and this fit the bill exactly.

Most of the people I know who had the surgery didn't have any complications, and I'm grateful for that, but that doesn't eliminate those who did.

I read in an article that this surgery has a large rate of complications and have talked about rates in a previous post. It's hard to determine exactly why, but as someone who was given no answer as to why my blood pressure dropped so severely, I want to be able to seek it out (although I expect not much as I'm only a high school senior).

Week Eight Day One: In the Eyes of a Patient (pt. 2).

Before I describe what it was like after surgery, here are my x-rays before the operation.

My three curves were measured 34 degrees, 54 degrees, and 28 degrees, from top to bottom. Because that 54 is clearly above the 45-50 degree operative level, that meant I needed surgery. However, because I also had a chiari malformation (when the brain tissue extends into the spinal canal) I needed another surgery. I talked about this in an earlier post, how the brain tissue can cause syrinx (pockets of spinal fluid) to build up in the spine, and that can be dangerous for spinal fusion patients.

In my last post I talked about before the surgery, but now I'll talk about what happens after.

Most people stay in the ICU for one day, although Dr.Shindell is working to find a way to make that not necessary, where they're under high surveillance. Within the first day following the surgery, the doctors have the patient start walking, though with some assistance. I, on the other hand, had to stay in the ICU for two days, as I had a severe drop in blood pressure, causing me to go blue, and causing my parents to have to wait to see me for a few extra hours after.

I wish I could say that I remembered the hospital visit, but I don't, not one bit of it, so here's what my dad said about what I was like,

"You were very antsy, and wanted to be moved around every five minutes, most likely because your body was getting used to being at a different angle. You kept asking to be adjusted. We didn't know if your body was producing cortisol (the hormone they thought was causing your drop in blood pressure). You were very emotional, you wanted to make sure you weren't being a burden. You walked as fast as possible when they asked you to walk because you hated it."

Following about 6 days in the hospital, I was sent home, with a walker, and pain medication (which I didn't take much of after a little while).

For about three weeks, I was in bed, and occasionally following that time, I would leave my bedroom and start walking with the walker, only to sit in the living room chair instead, just for meals.

I didn't eat much, and lost about 11 pounds following the surgery.

Because they thought my body wasn't producing cortisol, they put me on a medication to try and boost the levels of that hormone, and even sent me around with a needle and liquid medication just in case I passed out.

I wasn't allowed to carry anything over 10lbs, and I very often got tired. My muscles ached more than anything, as they cut through a lot of muscle to get down to your spine. Even to this day, over 3 months since the surgery, I still get severe muscle pain in my shoulders when I do too much.

There's so much more that I experienced after the surgery that I either don't remember, or don't want to overwhelm you with, but I feel that these past two blog posts have been pretty informative.

Here is my spine now.

The curve is 28 degrees, which is very good, as very few surgeries actually get full fusion.

The reason I'm trying to study the complications now, is because I had a preoperative condition, and I had postoperative complications (the very low blood pressure) and I wanted to know if they are connected.

I still struggle with data, but with the small amount that I have plus some readings I found, I should be able to get some understanding, but of course this is just a high school project and not an actual government funded research.

Week Seven Day Two: In the Eyes of a Patient (pt 1).

Because my project is very personal to me, and something I've dealt with, I thought I'd go ahead and share how this surgery works from the patient's perspective, starting from the night before/morning of the surgery. This might get long, considering I have a lot to say, but that's why I'm splitting it into two parts.

Two days before the surgery, I went to the hospital to do blood work. While I was there, a pediatric child life specialist came in and gave me a small run down of what would happen the morning of the surgery, such as that I will meet with my surgeon, and my anesthesiologist, as well as showing me pictures of the OR. They put it in very child like terms, as I was staying in a children's hospital to get this done. They also gave me these wipes (which I had used before my other surgery) that you're supposed to put on the night before surgery, after you've showered and dried, and the morning of surgery, where you're not supposed to shower.

I had to stop eating at midnight, so because I am very dramatic and told myself I would starve the next morning, I literally made mac and cheese around 11:30 so I could eat right until the end.

Sleeping was hard, as I was stressed and nervous. I had to leave the house at 5:30am to get there, as my surgery was scheduled for 7am and I had to get there an hour early for checkin and getting an IV placed in my arm so they could put me under.

I got dressed in the worst clothes I had, grabbed my blanket, and sat in the back of my mom's car as she drove me there. They gave me permission to bring a comfort item back to surgery, as well as a camera, so I brought my blanket.

In the pre-op room, they gave me a gown to put on, and they told me to get completely undressed, then get onto the bed. There's a whole room to yourself, and my parents and I watched Zootopia, and talked about my nephew.

I was freezing, even under the few blankets they gave me, and I was shaking, out of fear as well as the cold. A nurse came in and put my IV in my arm, but made sure to give me a numbing medication beforehand so I wouldn't feel the needle go in. We waited for a while, and met with the anesthesiologist, and made sure to explain to them that I get sick after anesthetics, so they would add a medication in it to make sure I didn't. Then I met with my surgeon, and he told me what was going to happen, even though we've already gone over it plenty of times.

After all that, a few more minutes passed before a nurse came in and told my parents it was time to take me back. I kissed them both goodbye, and my nurse wheeled me down the hall into the OR. I know we talked about something, possibly school, but I can't quite remember. When we got to the OR I saw everything, the table, the bright lights, literally everything.

The nurse told me she was going to give me the first part of the anesthetics, and then told me to count down from ten. After that, I can't remember much.

I'll explain in the next post, the second half of the surgery, aka recovery, but I thought it'd be interesting to put in my own perspective of the two days beforehand, and the morning of.

Week Seven Day One: The Issue with Genetics.

After talking to Doctor Shindell yesterday, and knowing that he has said, not only to me, but to all his patients that scoliosis is a genetic issue, I now know that the main question is: how? There is no certain answer as to what gene directly causes scoliosis, although plenty of research has been done on the subject.

When parents or grandparents have a known history of scoliosis, it's common for them to watch out for their children to see if/when the scoliosis takes an obvious form.

According to this website (The National Library of Medicine) there are different genetic and environmental factors that contribute to a child having scoliosis, however, when a "close relative" has idiopathic scoliosis, it increases a child's risk at having the disorder as well.

Although I didn't have access to the full text, in an abstract for an article called "Genetics of Scoliosis" by Robert F Henry ,M.D., and Karthik Madhavan, M.D., it is proposed that the gene for scoliosis is either autosomal dominant, X-linked, multigene, or multifactoral. None of these have actually been proven true and are still just theories.

Although knowing the gene isn't a pressing issue that needs to be figured out, it is still largely important as some theorize that the genetics of the disorder can also call for how severe the curve is and can be the difference between 20 degrees (top) and 60 degrees (bottom) which is also the difference between bracing and operation.

Of course, if (hypothetically) science gets to the point where doctors can calculate the projected amount of curvature, the doctor would and should still brace as the "projected amount" could be avoidable.

However this begs the question, is putting money into this research really a large need? But that's another issue on its own.

Week Six Day Two: Collecting Data and Fun Facts.

So, yesterday at the office, it was a busy and hectic day. The doctor was on call, and definitely got a lot of calls, for emergencies at Phoenix Children's Hospital. At least for me it was enlightening on what it was like to be a surgeon on call. Hectic, the only word I can really think of to describe it. Dr.Shindell even apologized to me for it being so hectic.

Anyways, moving on from that story to the stuff I know you're all dying to know. How am I going to collect enough data to support an argument. Well... at first I didn't know. I was convinced I could do some data mining at the office, but that didn't prove true, so I contacted a scoliosis association called "Curvy Girls" that one of the parents recommended to me when they found out that I had scoliosis surgery myself. They have an online board for people to talk about their scoliosis and everything related to it, so I decided to reach out to them and see if there was anyway I could send out a survey for people who had the spinal fusion surgery. Currently it's waiting review, but I'm going to try and contact them again tomorrow about it. The only thing that concerns me is that this might come together at the last minute, but I'm doing my best to try and get as much data as possible.

I know that talking about data may be boring so I decided to spice up this post with some celebrities that have scoliosis.

Sarah Michelle Gellar - You probably know her as Buffy from Buffy the Vampire Slayer TV show.
Shailene Woodley- Known for her role as Tris Prior in the Divergent Series Movies.
Laura Dern- I know her for her role in Jurassic Park but she's been in much more.

Many more celebrities have scoliosis, considering 2-3% of the population has scoliosis, this isn't really shocking. I hope this has been fun and informative, and please expect more in detail posts next week.

Week Six Day One: The Older Days.

Cast after cast after cast in the first thirty minutes today, apparently children get hurt often on the playground, who ever would've guessed? Anyways, that's besides the point. Today was a shorter day for patient visits, but I was able to read some interesting things in the book, Scoliosis: Ascending The Curve, about how scoliosis surgery was about fifty years ago.

First of all, I read that instrumentation wasn't even used, it didn't go in depth on how this surgery would've worked without instrumentation, but this is all for my own pleasure in trying to understand how lucky other recent patients and I have been with the evolution of treatment that has happened over this time period with shortened hospital stays, better/more available instrumentation, and not having the large preoperative examination that used to be standard.

In this examination, patients had to stand in a swimsuit in front of 20 or so doctors for them to look at the patient and see them visually before taken back for surgery.

They also had to go through a series of full body casts for six weeks, to prepare her for the traction she would have to go through for those six weeks before the surgery. People used to call it the "torture chamber" according to this book.

Because there instrumentation was new and rarely used, when it wasn't used, the spine was straightened by force and a bone graft.

We've come a long way from there and now make it easier on patients to recover, with most of them able to walk the day after surgery rather than the two months after that most people used to have to do because of full body casts.

Week Five Day Two: A Misunderstanding and Change in Data

Well, this project is meant to be educational, and a learning experience, which therefore means there will be some mistakes and misunderstandings. This post may be short, but this was kind of the focus of today (other than my internship site getting me dairy queen, which was a nice end to my week).

A few blog posts ago, maybe the second to last one, I talked about MAGEC rods and how they related to spinal fusion, however due to a small misunderstanding on my behalf, the surgery those children have who are still in the process of growing is not considered spinal fusion.

In the regular spinal fusion surgery, whether done anteriorly or posteriorly the spine is legitimately fused together, however,  and this should make sense by using any sort of common sense children who are still growing should not have their spine fused, as it could lead to issues with their height and health, and back pain, and so on.

This to me really just shows one thing, that I'm going to struggle more than I thought I would with collecting data. I can try to data mine, or possibly ask for some data points from Dr. Shindell himself, or even use data collected through other studies, to put together a well rounded set of data to answer my question, but I still fear a significant lack in this data.

From the beginning of the project, I knew the amount of data would be my number one problem with this project (that, as well as my emotional connection to the project, which I will explain in another post), but at the end of the day, this is a great learning and personal experience that I'm very grateful for, and I will try my best to try and collect enough data to have some sort of analysis. Some people say 6 is a minimum, while others say 10, which is what I'm hoping for. I'll keep everyone updated with how the data collection is going throughout my other blog posts during this project.

Week Five Day One: What Defines a Complication?

Today in the office, we sadly had no patients who had the spinal fusion surgery that I have been studying, but that didn't stop me from trying to think of ways to improve my project and my data collection. The term complication is very broad, and (when using google) is described as:

A circumstance that complicates something; a difficulty

This by no means isn't true, but does not fit my project or give me any basis of trying to decided whether or not something that happened following spinal fusion is a complication or not. So, for my project, I describe it as:

An unexpected result of spinal fusion surgery

This has worked for the patients I have seen so far, but through data mining from reliable medical publications, I have realized that there can be some "unexpected results" that actually are not harmful (which was what I originally had in mind for this project) such as the degree of curvature decreasing past the expected amount, or a patient growing more than the doctor had expected. 

This has led me to have to try and mold the definition around to try and make my project and research more clear. Now I have formed the definition to be:

An unexpected and unwanted result of spinal fusion surgery.

This rules out the sort of "positive" and unexpected results of the surgery. 

That data I have collected so far says that out of the kids who had preoperative conditions, 2/4 of them had complications. The data so far is small, but I plan to talk to Dr. Shindell about some patients with complications that he knows, as well as using some data mining from outside resources.

Week Four Day Two: MAGEC Rods

A few days ago, I was able to learn about scoliosis in infants and pre pubescent children. Normally, pre pubescent children who have scoliosis can be treated with a brace if the degree of curvature passes 20 degrees. This brace would try to restrict the curve from increasing at the child grew and developed. However, there are some cases where kids have the 45+ degrees and are still growing. In this case, surgery is the best option to try and reduce the curve.

Once a child has reached puberty, and is fully grown, the curve is less likely to increase. Take these two cases for example.

1 ) A 16 year old female, who is fully grown, with a 30 degree curve.
2 ) A 9 year old female, who still has lots to grow, with a 30 degree curve.

In case one, it'd be most likely that the orthopedic specialist wouldn't do anything for the curve, other than checking it out again six months to a year later, to ensure it isn't growing. There would be no bracing, and no surgery.

In case two, the girl would most likely be put in a brace to stop the increase of the curve. If there is no brace, she would be at high risk for the curve to increase into what I like to call the red zone, which is 45+ degrees, implying possible or guaranteed surgery.

So, picture a 6 year old with a 50 degree curve (below is a picture of a 50 degree curve in an adult for reference).

This child would be at extremely dangerous chance of increasing their curve as they grew, and since the curve is 50 degrees, it would be in the surgical point of development.

However, it is impossible and highly dangerous to put rods and screws in a child who is growing and developing (that should be quite obvious). Because of that, there are rods called MAGEC Rods.

The rods can be placed in growing children for their surgery, and can actually be lengthened while still in the child's body. It's an extremely strange concept, especially when you see in person how the rods are lengthened.

In this picture, if you look closely on the rods, there is one location on each rod that seems a bit darker grey, with a white line in the middle. That is where the rods are lengthened. I was able to see three lengthenings while doing my shadowing experience. It is done by placing a magnetic tool on the child's back to stretch the metal rods out while in the child. No extra incision is needed, and it can be done simply at a specialist's office with the correct tools.

The three instances I saw all helped with the data I was collecting, as all of the instances included pre-existing conditions before the operation, and gave me three more data points in that one day. As someone who had scoliosis, and the surgery, this was a very humbling experience, as I saw kids younger than me having to go through what was the roughest period of my life so far. I'm overall grateful for what I saw, as it gave me a lot of perspective. I cannot wait to continue this experience and hope to learn more about my own condition through observation.

Week Four Day One: A Precautionary Tale

Today was a very emotional day, and it put a lot of things into perspective. At my internship, I see a lot of patients every day, maybe somewhere around fifteen but it's hard to actually count and remember; but what I do remember is how I felt like my world was collapsing around me when I heard that I needed this spinal fusion surgery. Yet patient after patient I start to think that some of my issues pale in comparison. You see patients with disorders that can affect their quality of life, patients with not the greatest family lives, and so on, and it just puts everything into perspective.

Now on from that emotional moment of personal insight, to what I really wanted to focus on in this post: taking precaution due to chiari malformations.

Out of the many patient's we have seen with scoliosis, and from my own personal experience, I know that when a patient with scoliosis has an x-ray of the back from the side, it's normally slightly curved as well, but patient's that have a straight back when viewed from the side can be at risk of having spinal fluid build up in their spine, aka the spinal fluid is not actually flowing throughout the spinal chord. This is due to a chiari malformation (yes, I know this may not seem related to my topic, but trust me, it is, just hold on with me for a second here), in which the brain grows into the spinal canal.

This build up of fluid is called a syrinx, as seen above. It is possible to reduce the syrinx through a surgery called decompression surgery (again, it may not seem related to spinal fusion, but bear with me just a little bit longer). In this surgery, pieces of the skull are removed to allow for the tonsils to move and the cerebral spinal fluid to move throughout the spinal cord.

Now here is where it begins to relate to spinal fusion and its complications.

By having a patient who has both a chiari malformation and scoliosis, proceeding with a spinal fusion without having the decompression surgery can make the spinal fusion surgery much more complicated, and can result in complications such as loss of function following the surgery.

As my project is focused on studying two things:

1. Whether or not complications following spinal fusion are related to pre-operative conditions
2. If there are precautions doctors can take to limit complications

This falls into the second category. 

Some doctors do not require their patients to have the decompression surgery, however other doctors do. In doing so, the latter of the two types of doctors, take a precaution to try and limit the complications following the surgery, as well as give parents and children a peace of mind when it comes to knowing that this shouldn't be a problem.

However, there can be a sort of downside to this. In doing so, this would mean one more large operation for the child to endure, which can be an emotional and physical strain. Decompression surgery also doesn't always get rid of the syrinx, but may instead reduce it, which could leave parents weary, or make them question whether it was worth it in the first place. Overall, taking this step is one way doctor's can take their precautions.

I've seen a few patients (and myself included) in which the doctor I am shadowing requested an MRI to see the extent of the syrinx, and recommend seeing a neurosurgeon to get this done. 

Week Three Day Two: Collecting Data

So far, this internship has given me a lot of light into scoliosis. Both the kind that is treated by surgery and the kind that isn't. It's been a very personal experience because of how I've been through the surgery, and I've even seen into the life of a doctor who does not only these surgeries, but other things like pins for fractures, and even hip dysplasia. It's been such an enlightening experience and I cannot wait to continue this internship.

Now onto the focus of my own project: complications.

I talked last post about types of complications, and I'm even considering analyzing my own complications and how the doctor did everything he could to prevent other issues.

The way I plan to take data is through my patient observations but also data mining through studies done before me, to collect an overall comprehensive set of data. Below is the table that I've been using so far.

Currently, my main issue is the amount of data I'm trying to collect, and also HIPAA regulations. But as you can see, since my question analyzes if postoperative complications have a correlation to preoperative conditions, my table answers the questions I need to try and understand.

Things that the doctor can do to limit complications is working with other doctors who have a better understanding of the patient's preoperative conditions to try and set up a basis for the surgery and an understanding between doctors so they know who needs to be in the OR and if there's any specific techniques that need to be used. For example, if the patient knows they have an allergy to nickel, the doctor could make a decision to use a type of rod and screw that doesn't contain this, before they even enter the operating room.

Not very many people have an understanding of how important and possibly dangerous this surgery can be. As well as how much of an impact it can have on the family. This is why studying complications and ways to limit them is very important to make this process easier for families. Especially as someone who knows how much this can affect children emotionally, limiting complications can prove to be a very important study.

Week Three Day One : Understanding Possible Complications

To understand the rest of my project, I want to explain what complications can occur in spinal fusion surgery, and just go over some examples. On Friday, I plan to talk about the data I am/will be collecting throughout the project to analyze if complications following spinal fusion surgery do have a relation to pre-operative conditions, however, before I can do that, I want to explain what complications can arise, and how they are important to this project.

Firstly, I define a complication as an unexpected consequence of the spinal fusion surgery, thus eliminating subsequent and expected pain as a complication. There are plenty of complications, but the ones below are the ones I've heard about through one of my readings, Scoliosis: Ascending the Curve. 

Allergic Reactions

Many people do not know that they have an allergy to nickel, which is found in some stainless steel rods that are surgically implanted. This can lead to lesions and an unnatural sort of pain in the back. If the doctor knows the patient has this sort of allergy, titanium rods are also useful for spinal fusion surgery, and can work just as well. The only way to counteract this is by removing the rods in patients' backs.

Decompensation

This is when the spine continues to grow and curve above and below where the spine is initially fused. If seen in pediatric patients, the usual treatment can be bracing the patient's back, which is much different than in adults who may need more surgery to correct this. Below is a picture of decompensation. 

Pseudarthrosis and Broken Rods

This is when following spinal fusion, the spine does not completely fuse together, and therefore the spinal fusion has failed. Another issue would be if the rod was broken, however this can be dealt with, and does not necessarily needed to be treated surgically (but by using my definition of a complication, it still is defined as such, even if it doesn't need surgical correction).

Loss of Spinal Function

This is actually common in all spinal fusion patients, with one article saying that there is a reduced range of movement, which is understandable because of the instrumentation in the patient's back, however any abnormal loss of function would be considered a complication. 

Some other complications that I have found through other articles that analyze the rate of complications following this operation are death, infection, curvature progression, or increased torso deformity. This is just a general overview of some different types of complications which will set up an easier understanding of the rest of my project, however these are not the only complications, as other, more random complications, can also happen following the surgery. 

Week Two Day Two: The Basics of Spinal Fusion

Today has yet again been another entertaining day at the office. What's great about this experience is that not only do I get to see examples of scoliosis, and kyphosis (which may also require spinal fusion surgery), but I get to see plenty of other orthopedic cases as well, such as fractures, and limb length discrepancies.

Below is a picture of a patient with a 60 degree thoracic curve, and a 47 degree lumbar curve. They underwent spinal fusion, and the picture beside it shows the x-ray following the surgery.

As you can see, the surgery limited the curve to only 15 degrees all together.

The main point of the spinal fusion surgery is to fuse the vertebrae together to limit the degree of curvature within the spine. When it comes to juvenile idiopathic scoliosis, currently instrumentation such as rods, screws, hooks or wires are a successful way at lowering the amount curvature in the spine and keeping it in the same place.

Following spinal fusion surgery, patients are not allowed to twist their back, and recovery can take up to a year. They're also not allowed to bend over at the waist, such as reaching for their toes.

Today I got to see a patient recovering from spinal fusion surgery, a little less than two months out of their surgery. It was interesting to see a patient beginning their recovery, as the only recovery I had been able to see in such depth beforehand was myself.

The following image is a side view of what instrumentation such as screws look like in an x-ray of a patient.

Although the screws may look painful, they usually do not cause any sort of pain in the patient, such as poking, which many people may imagine due to how the screws look.

When it comes to pediatric scoliosis spinal fusion, the threshold to require spinal fusion is 50 degrees or above, however curves between 45 and 50 degrees may also have surgery if justified by the surgeon, such as for aesthetic reasons.

The other main treatment for scoliosis is a back brace, but this is only affective and useful in patients who are not done growing, as normally the curve stops increasing when the patient stops growing. The brace is used to limit the growth of the curve, not lessen the curve.

I'm very excited to see more examples of this surgery and start my research about the complications that may follow such a surgery, as all of this is very close to me personally.

Week Two Day One: Learning More About Scoliosis

Today was an overall comprehensive day. Out of the four days that I've done this internship, it was our busiest day and had the most amount of patient visits. I even got the chance to see four scoliosis patients, each with differing levels of scoliosis.

To be able to really have a comprehensive grasp on spinal fusion surgery, as well as the complications that happen following the surgery (which is my main focus on this project) I had to get a decent understanding of how scoliosis works, the categories it presents itself in, and other such things, meaning today was an overall learning day, filled with questions and quite a bit of reading.

The main categorization of scoliosis that I will be studying is called idiopathic, and specifically juvenile scoliosis. Idiopathic separates scoliosis by the time in which it appears by age. However, I learned that there are many other categories of scoliosis such as secondary, congenital, neuromuscular and constitutional.

I also learned how to measure a spinal curve.

This way of measuring the curve is called the Cobb method. It works by marking the endplate of the most deviated vertebrae and making a right angle on both. The resulting angle from the intersection is the degree of curvature. However, in Dr. Shindell's office, as I assume for most other orthopedic offices, the computer measures the curve for you, by drawing two lines at the most deviated vertebrae.

When it comes to juvenile scoliosis, in some cases it is caused by other underlying pathology such as a chiari malformation in the brain or Marfan syndrome, but over all it seems to be a genetic inheritance; although most scientists know that not every child of a parent who has scoliosis actually expresses the genes to the same extent, meaning they are currently researching more genetic background for the causes of this disorder.

One more final thing that I knew, however studied more today, is how most people notice scoliosis in their children or in others. When patients who have scoliosis bend down towards the ground, most of the time, there is something called a "rib hump" in which one rib is visibly higher than the other.

This is because when a child has scoliosis, the spine doesn't just curve to the side, it also twists to an extent and affect the ribs. When parents/friends see this in a child, it is a key indicator for scoliosis, as well as a visible curve in the spine when standing up with their bare back visible.

Overall I would say today was a very informational day, and I think this information will help me towards my overall goal for this project.

Day Two: The Basics

As of today, I've finished my first two days of my internship under Dr. Shindell. So far I've seen lots of patient visits, and even gotten the chance today to sit in during a meeting about new surgical tools for scoliosis surgery. All of the different patients and their conditions have my considering changing my project a bit. Currently I'm studying recovery following different types of surgeries, but I may change it to focus on sports related injuries and how they can be prevented, or something about the physical and psychological aspect of scoliosis.

As both of these seem important to me in society and personally, as I've suffered both. Considering that under my internship, I have already seen a lot of scoliosis patients, ranging from children to young adults, I think this is how I want to focus my project from now on, but after my day on Friday, I'll try and make a final decision.

Scoliosis can be treated with a brace or with spinal fusion surgery, for which right now there are different instrumentations that can be used. Many are trying to study which form of instrumentation works the best, however not a lot of people take into fact the emotional side of the process, which I think would be interesting.

Throughout my two days shadowing at the office already, I've seen how scoliosis can impact people's lives. Many people throughout the country have a curve under 10 degrees, but anything above is considered abnormal. There are even different types of scoliosis such as infantile or juvenile, that can be caused by different deformities, such as something genetic or a chiari malformation which causes syrinx in the spinal cord.

Hopefully by Friday I'll have a clear grasp on what I want to focus on for my project.

Introduction to the Project

Tomorrow marks the beginning of my senior research project under supervision of Dr. Richard Shindell. He's a pediatric orthopedic surgeon who owns his own private practice while working through Phoenix Children's Hospital.

In this project I'll be researching what precautions can be taken in order to make recovery after different types of orthopedic surgeries, especially scoliosis, shorter and easier for the patient and their family.

Dr. Shindell was my own personal doctor when I went through scoliosis surgery, also known as spinal fusion surgery. This process includes inserting screws into the patient's back to try and reduced the spinal curve, however he also helps treat other conditions such as cerebral palsy, growth deformities, and hip dysplasia.

Tomorrow I'll be going to observe his practice, including watching patient visits when granted permission by the parents. In doing this, I will be able to see physically how patients are following their operations, as well as figure out more from my readings which I will be checking out from the Emily Center Library in Phoenix Children's Hospital.

Many surgeries can be a large burden on patients and their parents, not only emotionally but also physically. As someone who's gone through similar processes, I want to focus on the recovery, as it is close to my heart and a personal issue I've had to deal with too.