Building a Foundation for Scoliosis Treatment: 3 Important StudiesWritten by Laura Miller | November 15, 2011
Scoliosis affects more than six million people in the United States and approximately 38,000 patients undergo spinal fusion for scoliosis correction each year, according to the National Scoliosis Foundation. Surgical scoliosis correction has traditionally been a large, open procedure, but technological advancement allows surgeons to perform better surgery with improved outcomes.
"The pedicle screw systems are wonderful in giving us the ability to treat scoliosis in the three-dimensional plane, thus treating both the coronal and sagittal planes," says Purnendu Gupta, MD, medical director of the Chicago Spine Center at Weiss Memorial Hospital and associate professor of surgery in orthopedics and rehabilitation at the University of Chicago. "The technology we have now allows us to better treat the lower back in terms of the sagittal plane, which has a big impact on function. As a result, we are doing a better job of performing surgery for our patients now."
Dr. Gupta discusses three important papers on scoliosis deformity correction presented at the North American Spine Society annual meeting in Chicago and how they will influence spine care in the future.
1. Progress in osteotomy treatment for scoliosis. Initially, spine surgeons did more anterior and posterior combined treatment for severe scoliosis, but they are now able to do more from a posterior-only approach, says Dr. Gupta. "We have better fixation now than we did in the past," he says. "The Ponte osteotomies, Smith-Peterson osteotomies and pedicle subtraction osteotomies are all techniques we use routinely."
One of the papers, based on a multi-center study, examined the benefit of coronal deformity correction as it relates to patient-reported and clinical outcomes. For the 60 adult spinal deformity patients participating in the study, a correction of less than 25 degrees resulted in a significant improvement of health-related quality of life scores. However, a correction between 25 degrees and 35 degrees didn't show a significant improvement in clinical outcomes. The authors of the study suggested that the findings show the importance of preoperative planning and patient counseling on surgical correction of coronal deformity.
"The nice thing about this paper was it helped us understand why we are doing these corrections and how much is correction is necessary for a good functional outcome," says Dr. Gupta. "We have tools to correct the spine, but we always ask ourselves: How much correction is clinically relevant? We are beginning to pay more attention to outcomes data, and thoughtful papers like this one are going to help us going forward."
2. Traditional techniques still serve a purpose. In some cases, there is a reason certain techniques and procedures are still around today. As advancements in technology come along, Dr. Gupta says it's important to have a sturdy foundation of traditional technique available to pull from as well. There are certain situations where traditional fixation constructs can be advantageous over pedicle screw constructs, and new studies are suggesting little clinical difference between combination hybrid constructs and pedicle screw constructs for spinal fixation for treatment of routine curve patterns. The use of pedicle screws can make the procedure more costly.
"We can potentially do more correction with pedicle screws, but we can still do well with the combination of hybrid constructs," says Dr. Gupta. "We have different types of fixation methods: pedicle screws, hooks and sublaminar wires. We find that the pedicle screws may give us greater correction, but the other fixation methods still may give us good, clinically relevant results possible at less of a cost. All of these fixation methods are important and we should keep them in our armamentarium."
Dr. Gupta learned the traditional fixation techniques during his initial medical training and has since become proficient at using the pedicle screw fixation. He still uses all of them in his practice. "I make my decision on which fixation method to use based on the location of the spine I'm working in," he says. "I'm more likely to use pedicle screws in the lumbar spine, but the decisions also depend on the curve rigidity, types of releases and anatomy. Sometimes the anatomy dictates that you need to use a different fixation; it might not be practical to use pedicle screws at some levels due to the anatomy. In other cases, you might need to do direct vertebral rotation with the pedicle screws."
Beyond the regular practice, spine surgeons might want to consider using the less-expensive, clinically beneficial fixation when performing humanitarian spine surgery for underserved populations. In a study led by Oheneba Boachi-Adjei, MD, a spine surgeon at Hospital for Special Surgery in New York City, surgeons performed idiopathic scoliosis surgical correction on 82 patients in West Africa through a global outreach program using the posterior approach for spinal fusions. Forty-nine patients were treated with hybrid constructs while 33 patients were treated with all pedicle screw constructs. The surgeons noted no significant differences in sagittal alignment between the two techniques.
3. Whether to use autologous blood donations. When Dr. Gupta began his practice, he regularly took autologous blood donations from patients to promote fusion at the surgical site, and he noticed those patients often needed postoperative blood transfusions because they were more anemic during surgery. There are additional problems associated with autologous blood donation: Surgeons are opening their patients a second time to extract the blood, which creates extra exposure to infections and other complications.
An alternative is erythropoietin to stimulate blood production at the surgical site, but the cost is prohibitive. A study conducted at Washington University and presented at the NASS annual meeting examined the preoperative autologous blood donation overuse in adolescent idiopathic scoliosis patients and how it impacts morbidity and healthcare costs. In the prospective study, 86 patients underwent AIS fusion receiving either preoperative autologous blood donation or non-donation.
Approximately 81 percent of the PABD patients received perioperative transfusions, compared to 41 percent of NPABD patients.
Much of the focus in spine surgery today is on the functional outcomes of treatment, which will lead to better patient care, says Dr. Gupta. "I think because of our better understanding of how much correction we need to make and whether we need a sagittal or coronal correction will lead to better patient outcomes," he says. "Addressing clinical relevance of the procedures we perform will have the biggest impact on patients' lives."
As for technology, Dr. Gupta says new innovation is great but he cautions spine surgeons to pay attention to the foundation and principles of scoliosis treatment. "Remember what our goal is: better patient care," he says. "We may be able to do a more complicated surgery for the patient, but if it has more morbidity, it may not help in terms of patient outcome. With time, we are going to learn where that balance is, and that's where our attention to outcomes research is going to help us."
More surgeons are pooling their data now than in the past, which will make a bigger impact on nationally relevant clinical data. Evidence-based medicine is the focus of healthcare professionals across the spectrum of care, and spine surgeons are working hard to prove the success of their treatment.
"I think the importance of all this is for us to make a greater impact on healthcare so we can protect the welfare of our patients," says Dr. Gupta. "If we can better prove what is working with outcomes data, it will help us at the governmental level to impact healthcare with our studies and outcome data. Professional organizations such as NASS and SRS are essential to support surgeons and researchers in this endeavor."
Frank Schwab, MD, et. al. "The Limited Benefit of Coronal Cobb Angle Correction in the Setting of Adult Spinal Deformity: A Health Related Quality of Life Assessment on Two-Year Outcomes," The Spine Journal: vol. 11, #10, Oct. 2011 (p. 28S).
Oheneba Boachi-Adjei, MD, et. al. "Radiographic and Clinical Outcomes of Posterior Spinal Fusion for Idiopathic Scoliosis in African Patients: A Comparison of All Pedicle Screw Versus Hybrid Instrumentation," The Spine Journal: vol. 11, #10, Oct. 2011 (p. 28S).
Lukas Zebala, MD, et. al. "Preoperative Autologous Blood Donation Results in More Transfusions in the Surgical Treatment of Adolescent idiopathic Scoliosis," The Spine Journal: vol. 11, #10, Oct. 2011 (p. 29S).
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