What's Next for Scoliosis Surgery? Q&A With Dr. Behrooz Akbarnia of San Diego Center for Spinal Disorders

Behrooz A. Akbarnia, MD, is the medical director of the San Diego Center for Spinal Disorders and a clinical professor in the department of orthopedic surgery at the University of California San Diego. He is a past president of the Scoliosis Research Society and the founder of Growing Spine Foundation, an organization that supports research and educational activities in the field of pediatric spine. Dr. Akbarnia is board certified in orthopaedic surgery and completed the John H. Moe Scoliosis Fellowship Program at the University of Minnesota in Minneapolis. He specializes in spinal deformities in children and adults.

Here Dr. Akbarnia discusses how spinal deformity treatments have evolved since he started his spine practice more than 37 years ago and what the future holds for spinal deformity.

Question: How has the treatment of scoliosis surgery advanced since you first began practicing spine surgery?

Dr. Behrooz Akbarnia: There has obviously been amazing progress. When I started my fellowship in 1975, we treated scoliosis non-operatively, with braces and casts. Surgery-wise we only had one technique, which was spinal fusion with Harrington instrumentation — one hook at the top and one at the bottom and a rod. That was the gold standard for decades, and yet, represented a significant advancement from treating scoliosis with the cast. Harrington introduced that technology in the 1960s and reported his results. In most parts of the world, this technique is still being used.

In the past, we used to correct scoliosis with the preoperative cast before putting in the rods, and frequently patients developed skin sores and infection. After surgery, patients were put again in a cast to protect the correction and help with fusion. Initially, they were kept in bed, lying down, for several months. Then surgeons started experimenting walking the patients with the cast soon after surgery. It took so many years, until the mid-80s when segmental instrumentation was introduced by Cotrel and Dubousset and since then we have seen major changes in the treatment of scoliosis. Overall, I've seen significant improvement in surgical techniques since I started, but there's still a lot to be done to understand the etiology of scoliosis.

Q: Can scoliosis procedures become as minimally invasive as other spine treatments or do they present unique challenges?

BA: Deformity is behind as far as being performed less invasively, which is not surprising because there is more complexity to it. We first have to develop techniques to accomplish a good correction. It's not just introducing implants. Deformity correction has to be in three dimensions, which may requires some release of the tissues to get flexibility before correcting it.

Correction is one thing, but the other thing is to achieve solid fusion with less invasive techniques. It is a step-by-step road to achieve these goals. I think at this point there are some steps we can do less invasively and some things we can't. Achieving adequate correction and solid fusion at the same time for major deformities hasn't been yet proven to be possible with current MIS techniques. We need to have a longer follow-up to see if the results of current MIS techniques are the same as with standard open procedures.

In 2010 a group led by Gunnar Andersson, MD, deputy editor of Spine met in Chicago and devoted their time to discuss what the definition and goals of minimally invasive surgery was. Each person had his own view, but at the end the consensus was that to be successful, we have to achieve the same goals with MIS that we have with standard open surgery. We cannot compromise results because we want to do it through a small incision. We can use MIS techniques for milder curves and limited number of segments but not yet in very large structural curves that have been present for many years.

Anterior open surgery was popular for many years but most surgeons now are treating the deformities with posterior approach. However, there is increasing evidence that anterior surgery through a less invasive lateral approach is gaining popularity in certain adult deformity cases including sagittal deformity to make the procedure less invasive.

Same is true for progressive early onset scoliosis in a very young child, which has different challenges than we face in adult degenerative cases. We have now technology for lengthening of growing rods with remotely controlled devices using magnetic field to make the rod lengthening non-invasive and save open surgery and anesthesia. This technique is currently used outside of U.S., and we are waiting now for FDA approval for U.S. use.

Q: How much do you consider the financial cost when you are treating a patient?

BA: I don't think any of the economic issues should interfere with doing what's the best treatment for the patient. That should always be the focus of surgery. When we review cases in our pre-op conferences, we just think about what we can do to achieve the best possible outcome for that patient. Or if a patient is very high risk and not a candidate for surgery, then we will advise against surgery. We try to emphasize to our fellows the proper indications and principles of patient selection. Economics are something we have to work with but they are not influencing our decisions. If the outcomes of two different plans are comparable we then definitely consider the most cost effective method.

In adolescent scoliosis, we have reached the point where most of the techniques are very comparable through pedicle screws, correction maneuvers and osteotomies. Those techniques have been advanced to deal with more complex cases, and the research on the results is known as well.

The concern especially in adult patients is the increasing number of them we see because they live longer with spinal deformity and severe disabilities. Less invasive methods are useful for those adults who may also have co-morbidities and can't tolerate big surgeries. In order to justify putting them through these complex surgeries, we have to establish the value and long-term benefits for our treatment methods. It's not just the cost of surgery as much but also improving the quality of life for these patients. We have been slow in establishing the value of the procedures we do, but there are ongoing studies on that to try to get that information and data available.

Q: What are the biggest challenges for spine surgeons, particularly in the spinal deformity realm?

BA: The economy and increasing healthcare costs has become a big challenge. We know we have to be very mindful of the cost and perform procedures and methods that are most beneficial to the patients and cost effective at the same time. We will continue to do studies to compare the effectiveness of different methods that are beneficial for patients and at same time are cost effective. Both areas of adult deformity and early onset scoliosis are good examples of these challenges.

As far as specific techniques, the growing adult population is going to be a challenge as far as finding the best method of treatment. We are treating more adults with spine deformity than ever before. We need to do better in understanding the indications and best method of treatment for our aging population. Early onset deformities are not as frequently treated as adult cases, but they are life-threatening, unlike most adult degenerative deformity. If untreated or poorly managed, the patients may die from their pulmonary complications. It is also going to be a challenge to make scoliosis surgery less invasive and make the outcome good enough so they can go back to normal daily activities and work more quickly.

Q: Do you ever see scoliosis surgery fully moving to an outpatient setting?

BA: Although some deformity cases can be performed in an outpatient facility, the majority of deformity surgery is hospital-based. However, I foresee we'll be able to do more deformity cases in an outpatient facility in the future, as less invasive techniques improve. We are already doing surgery for one or two levels in outpatient settings or in the hospital discharging them the next day. As we move forward, we have to be careful to select the right patients so we don't put anyone at unnecessary risk. The outpatient facilities have to be able to handle emergencies. I don't see surgeries for patients with larger curves being moved to outpatient facilities for the near future.

I'm very much impressed with the progress we have made in this field and how much change I've seen in my 37 years of spine practice. I'm sure a lot more advances will take place in the future, and hopefully we will also have more knowledge of natural history and etiology of spinal deformities.

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