Results of New Surgery for Adults with Scoliosis
Any good writer knows the reader wants to know who, what, when, where, and why to help make sense of any story or news item. The authors of this article use these guide posts and present a very clear picture right from the start. This is a study of older adults (40 years old and older) with scoliosis (curvature of the spine). That takes care of the who and what.
The 'where' is easy: Johns Hopkins University Hospital, a well-known medical facility. The 'why' is the most important feature. There are lots of studies done on children and adolescents treated surgically for scoliosis. Reported results among adults are harder to come by. And this is a prospective study (the 'when') meaning they gathered information and observed results as they treated and followed these patients.
To give you a little bit more information about the 'who' on both the patients and the surgeon -- one orthopedic spine surgeon performed all the procedures on patients who had never had spinal surgery done before. The patients ranged in age from 40 to 66 years old. Most were in good health but everyone had at least one other health problem such as high blood pressure, heart burn, osteoporosis, depression, anxiety, asthma, and so on.
The surgery consisted of fusing the spine at multiple levels (at least 10 levels up to as many as 20 segments). Some fusions went to the bottom of the lumbar spine (just above the sacrum) while others fused the last lumbar vertebrae to the sacrum. Everyone in the study agreed to stay in the study for at least two years.
Information gathered from the patients during that time included questions about general health and the presence of comorbidities (other problems). They also measured outcomes using patient level of satisfaction, function, need for additional (revision) surgery, and development of complications. Complications were divided into two groups: major (e.g., death, blood clots, fractures, deep wound infection) and minor (urinary tract infection, nerve palsy, lung or spleen puncture).
The fusion procedures were done with today's new technology and improved techniques and fixation devices. Devices used to fix (fuse) the bones in place included transsacral bars, alar screws, and iliac screws. This is the third-generation of instrumentation techniques -- meaning the third round of improvements in these devices.
Analysis of the results showed successful fusion rates but with a high rate of complications. Almost half (49 per cent) of the patients had at least one problem following surgery. Most of the complications were minor and occurred later after the patient went home. The more major complications presented early and required additional hospitalization. There were no deaths and no cases of permanent paralysis.
But most of the patients were very satisfied with their improved results and said they would have the surgery again if they had to do it over. In fact, patient satisfaction was equal among all patients regardless of whether or not they had complications. Both mental and physical health improved. Many of the patients were able to return to work after recovering.
There was one important factor to note: fusion to the sacrum comes with some additional limitations and restrictions. Patients should be prepared for that before surgery. The sacrum is included in the fusion process when the lumbar spine is just too unstable or too fragile to allow for movement at the last lumbar/first sacral (L5-S1) level.
The authors make suggestions for reducing complications. They advise staging the surgery in two-separate procedures. The first part of the fusion is done posteriorly (from the back of the spine). The second stage is done about a month later from the front (anteriorly). The double fusion isn't always needed -- just when there is a need for structural support at the L5-S1 (lumbosacral) junction.
In summary, today's third-generation fixation devices and improved surgical techniques make spinal fusion for scoliosis in older adults not only possible but very beneficial. The improvements in symptoms despite the loss of motion and possibility for post-operative complications is enough to satisfy the majority of patients.
Ryan M. Zimmerman, MD, et al. Functional Outcomes and Complications After Primary Spinal Surgery for Scoliosis in Adults Aged Forty Years of Older. In Spine. September 15, 2010. Vol. 35. No. 20. Pp. 1861-1866.