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.