Michael Chang, MD, a spine surgeon at Sonoran Spine Center in Mesa, Ariz., is specially trained to perform complex spine surgery on patients with spinal deformity. He discusses one of these procedures, the three-column osteotomy.
Q: What causes people to develop a deformity condition?
Dr. Michael Chang: It's usually a result of a failed past spine surgery. The patient might have undergone a fusion which didn't heal properly or the spine may have healed in an improper shape. In either case, this can lead to substantial back pain and other problems and so the goal of deformity surgery is to fix these problems by restoring the natural contours of the spine. Patients can also develop deformities from tumors or spinal fractures. All of these problems may be fixed by three-column osteotomies. However, part of the reason why a lot of other surgeons don't do this procedure is that it's pretty high risk and requires a great deal of technical training. It's not uncommon for surgeries to last eight to 14 hours to fix a patient's problem.
Q: Why are you able to have success with spinal deformity cases that most spine surgeons won't touch?
MC: Many of the techniques we used to fix the most complex spinal problems today weren't developed until the past ten years, and now these techniques are slowly being introduced into the healthcare system. Up until recently, we didn't have equipment and instrumentation to perform procedures like the three-column osteotomy of the spine. Furthermore, only a few fellowships exist around the country that provides such specialized deformity training.
A lot of deformity deals with patients who have spinal imbalance, which means they are leaning far forward or off to the side. These patients can't walk straight and the condition is very painful for them. At the minimum, treating spinal imbalance requires a lot of screws and rods, such as what is used for teenagers with scoliosis. The three-column osteotomy additionally requires the surgeon to break the spine in half while preserving the spinal cord, and then realign the spine to allow it to heal properly.
Q: How does the three-column osteotomy work?
MC: "Osteotomy" literally means "to cut bone." A "column" is roughly 1/3 of the width of the spine. Thus, the goal of three-column osteotomies is to break the spine in half without damaging the spinal cord. First, the back portion of the spine covering the spinal cord, known as the lamina, is removed. Then, once the spinal cord is exposed, the surgeon must go around the spinal cord from the back and take out the vertebral body in front of the spinal cord. Once the entire vertebra is removed from around the spinal cord, the spine is effectively cut in half. Once the spine is cut, you can bend it to any shape you want and then hold it in its new shape with screws and rods.
Q: Is this procedure covered by insurance carriers?
MC: This is a high-risk spine surgery where the patient must be under anesthesia for a long time because there's no other way the correction can be done. Despite the risks, it's almost always covered because it has a high success rate and provides a very high degree of patient satisfaction, while the alternative of not doing surgery is so debilitating to patients. While not a lot of physicians perform this surgery, it is not considered experimental because it is clinically proven with great results. Thus, despite the risk and high cost, insurance companies will pay for it and this includes Medicare, Medicaid and all private insurance companies. The nature of the problem means you often have a very big incision in order to fix it and the hospital stay might be one to two weeks. This adds up, but for many patients it is invaluable because of the pain relief it provides.
Q: Where do you see deformity procedures trending in the future?
MC: The general trend nowadays is that instrumentation systems are constantly evolving and as a result, deformity correction is consistently better with time. Twenty years ago, we could fuse a deformed spine in place in order to prevent it from getting worse, but not improve upon the deformity itself. Nowadays, we can put instrumentation in the spine, straighten it out and hold it in place. We can affect a pretty substantial correction — often 60 percent or more.
As another example, it is no longer necessary to cut the ribs of girls with scoliosis who have protruding ribs when they bend forward. We used to take these ribs out and it would weaken lung capacity. Now we have newer technologies that allow us to grab a hold of the spine directly and rotate the ribs, allowing us to take care of protruding ribs without causing any future breathing difficulties. I imagine medical technology will only continue to get better and better as time goes on.
Learn more about Dr. Michael Chang.
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Dr. Michael Chang: It's usually a result of a failed past spine surgery. The patient might have undergone a fusion which didn't heal properly or the spine may have healed in an improper shape. In either case, this can lead to substantial back pain and other problems and so the goal of deformity surgery is to fix these problems by restoring the natural contours of the spine. Patients can also develop deformities from tumors or spinal fractures. All of these problems may be fixed by three-column osteotomies. However, part of the reason why a lot of other surgeons don't do this procedure is that it's pretty high risk and requires a great deal of technical training. It's not uncommon for surgeries to last eight to 14 hours to fix a patient's problem.
Q: Why are you able to have success with spinal deformity cases that most spine surgeons won't touch?
MC: Many of the techniques we used to fix the most complex spinal problems today weren't developed until the past ten years, and now these techniques are slowly being introduced into the healthcare system. Up until recently, we didn't have equipment and instrumentation to perform procedures like the three-column osteotomy of the spine. Furthermore, only a few fellowships exist around the country that provides such specialized deformity training.
A lot of deformity deals with patients who have spinal imbalance, which means they are leaning far forward or off to the side. These patients can't walk straight and the condition is very painful for them. At the minimum, treating spinal imbalance requires a lot of screws and rods, such as what is used for teenagers with scoliosis. The three-column osteotomy additionally requires the surgeon to break the spine in half while preserving the spinal cord, and then realign the spine to allow it to heal properly.
Q: How does the three-column osteotomy work?
MC: "Osteotomy" literally means "to cut bone." A "column" is roughly 1/3 of the width of the spine. Thus, the goal of three-column osteotomies is to break the spine in half without damaging the spinal cord. First, the back portion of the spine covering the spinal cord, known as the lamina, is removed. Then, once the spinal cord is exposed, the surgeon must go around the spinal cord from the back and take out the vertebral body in front of the spinal cord. Once the entire vertebra is removed from around the spinal cord, the spine is effectively cut in half. Once the spine is cut, you can bend it to any shape you want and then hold it in its new shape with screws and rods.
Q: Is this procedure covered by insurance carriers?
MC: This is a high-risk spine surgery where the patient must be under anesthesia for a long time because there's no other way the correction can be done. Despite the risks, it's almost always covered because it has a high success rate and provides a very high degree of patient satisfaction, while the alternative of not doing surgery is so debilitating to patients. While not a lot of physicians perform this surgery, it is not considered experimental because it is clinically proven with great results. Thus, despite the risk and high cost, insurance companies will pay for it and this includes Medicare, Medicaid and all private insurance companies. The nature of the problem means you often have a very big incision in order to fix it and the hospital stay might be one to two weeks. This adds up, but for many patients it is invaluable because of the pain relief it provides.
Q: Where do you see deformity procedures trending in the future?
MC: The general trend nowadays is that instrumentation systems are constantly evolving and as a result, deformity correction is consistently better with time. Twenty years ago, we could fuse a deformed spine in place in order to prevent it from getting worse, but not improve upon the deformity itself. Nowadays, we can put instrumentation in the spine, straighten it out and hold it in place. We can affect a pretty substantial correction — often 60 percent or more.
As another example, it is no longer necessary to cut the ribs of girls with scoliosis who have protruding ribs when they bend forward. We used to take these ribs out and it would weaken lung capacity. Now we have newer technologies that allow us to grab a hold of the spine directly and rotate the ribs, allowing us to take care of protruding ribs without causing any future breathing difficulties. I imagine medical technology will only continue to get better and better as time goes on.
Learn more about Dr. Michael Chang.
Related Articles on Spine Surgery:
Scoliosis as a Neurologic Condition: 4 Points on Two Genes Making the Connection
What Happened With Infuse: 6 Points From Dr. Eugene Carragee
Dr. Robert Rovner: 3 Points on a New Technique for Better Outcomes in Scoliosis Surgery