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.