An Emily Litella moment on FixScoliosis's Blog

[Pooka1]

http://www.fixscoliosis.com/forum/showthread.php?t=36

Some folks there are wowing themselves over the results in this oral presentation (i.e., not peer-reviewed) given at a conference...

endoscopic scoliosis surgical rod breakage

It's crystal clear nobody there realizes several important points:

1. endoscopic fusions are a minuscule fraction of the total fraction of fusions
2. our surgeon told me two years ago that these procedures were in decline then
3. the incidence of rod breakage for this one study on endoscopic fusion is much higher than for the much more commonly used posterior and anterior approaches.

and the corker...

4. once the back is fused, you can take the rods out and it wouldn't matter. At that point, the rods are doing N-O-T-H-I-N-G.

And indeed, the conclusions from that oral presentation include:

Discussion Rod breakage can occur following endoscopic scoliosis surgery. Our study shows that this is not associated with any significant loss of curve correction and has no effect on clinical outcome. Since changing to femoral allograft and by increasing the rod diameter no further rod breakages have occurred.

And even if endoscopic surgery wasn't in decline, clearly they had completely resolved the rod breakage problem by 2006. So we have folks trotting out old data like it matters now. Not honest.

FixScolisis is a chiro who knows what he knows. With this thread, we now have some idea of how much he doesn't know about surgical techniques which I find shocking since he does put in the time to slog through the literature. If folks insist on staying in "blind leading the blind" situations, they will never get the straight dope.

Do the reading. Get the facts. Ask experts.

[LindaRacine]

It's also an old, Australian study. If they wanted to use an Australian study, why didn't they use the newer one from May 2009? Probably because it showed better results.

Or, better yet, why didn't they quote a 5-year followup study published in the US?

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

J Bone Joint Surg Am. 2008 Oct;90(10):2077-89. Links
Surgical treatment of main thoracic scoliosis with thoracoscopic anterior instrumentation. a five-year follow-up study.

Newton PO, Upasani VV, Lhamby J, Ugrinow VL, Pawelek JB, Bastrom TP.
Department of Orthopedic Surgery, Rady Children's Hospital and Health Center, San Diego, CA 92123, USA. pnewton@rchsd.org
BACKGROUND: The surgical outcomes in patients with scoliosis at two years following anterior thoracoscopic spinal instrumentation and fusion have been reported. The purpose of this study was to evaluate the results at five years. METHODS: A consecutive series of forty-one patients with major thoracic scoliosis treated with anterior thoracoscopic spinal instrumentation was evaluated at regular intervals. Prospectively collected data included patient demographics, radiographic measurements, clinical deformity measures, pulmonary function, an assessment of intervertebral fusion, and the scores on the Scoliosis Research Society (SRS-24) outcomes instrument. Perioperative and postoperative complications were recorded. Patient data for the preoperative, two-year, and five-year postoperative time points were compared. In addition, a univariate analysis compared selected two-year radiographic, pulmonary function, and SRS-24 data of the study cohort and those of the patients lost to follow-up. RESULTS: Twenty-five (61%) of the original forty-one patients had five-year follow-up data and were included in the analysis. Between the two-year and five-year follow-up visits, no significant changes were observed with regard to the average percent correction of the major Cobb angle (56% +/- 11% and 52% +/- 14%, respectively), average total lung capacity as a percent of the predicted value (95% +/- 14% and 91% +/- 10%), and the average total SRS-24 score (4.2 +/- 0.4 and 4.1 +/- 0.7). Radiographic evaluation of intervertebral fusion at five years revealed convincing evidence of a fusion with remodeling and trabeculae present at 151 (97%) of the 155 instrumented motion segments. No postoperative infections or clinically relevant neurovascular complications were observed. Rod failure occurred in three patients, and three patients required a surgical revision with posterior spinal instrumentation and fusion. CONCLUSIONS: Thoracoscopic anterior instrumentation for main thoracic idiopathic scoliosis results in five-year outcomes comparable with those reported previously for open anterior and posterior techniques. The radiographic findings, pulmonary function, and clinical measures remain stable between the two and five-year follow-up time points. Thoracoscopic instrumentation provides a viable alternative to treat spinal deformity; however, the risks of pseudarthrosis, hardware failure, and surgical revision should be considered along with the advantages of limited muscular dissection and improved scar appearance. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

It has been widely reported that there is a steep learning curve in this type of surgery. The earliest pioneer, Ron Blackman, gave up doing this type of surgery after seeing a lot of rod breakage in his early cases.

Sharon, contrary to what your daughter's surgeon said, there are still some surgeons performing these surgeries, and getting good results.

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

: J Bone Joint Surg Am. 2009 Feb;91(2):398-408. Links
Video-assisted thoracoscopic spinal fusion compared with posterior spinal fusion with thoracic pedicle screws for thoracic adolescent idiopathic scoliosis.

Lonner BS, Auerbach JD, Estreicher M, Milby AH, Kean KE.
Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 212 East 69th Street, New York, NY 10021, USA. BLonner@nyc.rr.com
BACKGROUND: Although the gold standard for the surgical treatment of thoracic adolescent idiopathic scoliosis has been posterior spinal fusion, video-assisted thoracoscopic surgery recently has become a viable alternative. In the treatment of structural thoracic curves, video-assisted thoracoscopic surgery has demonstrated outcomes equivalent to those of posterior spinal fusion with use of an all-hook or hybrid pedicle screw-hook construct. No study to date, however, has compared this technique with posterior spinal fusion with thoracic pedicle screws, which has become the current standard of care. METHODS: A matched-pair analysis of thirty-four consecutive patients (seventeen pairs) undergoing either video-assisted thoracoscopic surgery or posterior spinal fusion with thoracic pedicle screws for the treatment of structural scoliosis was performed; the study included eight male and twenty-six female patients with an average age of 15.0 years. Pairs were matched according to curve type and magnitude, patient age, and sex. Clinical data, the results of the Scoliosis Research Society questionnaire, and radiographic data were collected preoperatively and at a minimum of two years postoperatively and were compared between the groups. RESULTS: Video-assisted thoracoscopic surgery was associated with significantly increased operative times (mean, 326 compared with 246 minutes; p = 0.033) and reduced blood loss (mean, 371 compared with 1018 mL; p = 0.001), but there were no differences between the groups in terms of the transfusion rate (18% compared with 29%; p = 0.69) or the length of stay. The percentage correction of the major curve was 57.3% for the video-assisted thoracoscopic surgery group and 63.8% for the posterior spinal fusion group (p = 0.08). With the numbers available, no differences were detected in terms of the cephalad thoracic curve, caudad compensatory lumbar curve, coronal balance, thoracic kyphosis, lumbar lordosis, sagittal balance, end vertebra tilt angle, or angle of trunk rotation measurements preoperatively or at the time of the latest follow-up. The average number of fused levels was 5.9 in the video-assisted thoracoscopic surgery group and 8.9 in the posterior spinal fusion group (p < 0.001). Relative to the Cobb end vertebra, the most caudad instrumented vertebra was 0.81 level more cephalad in the video-assisted thoracoscopic surgery group as compared with the posterior spinal fusion group (p = 0.004). No significant differences were detected in any of the questionnaire outcomes at any time point. Although both groups experienced similar improvement from baseline in terms of pulmonary function at two years, the posterior spinal fusion group had significantly improved peak flow measurements (p = 0.04) in comparison with the video-assisted thoracoscopic surgery group. CONCLUSIONS: For single thoracic curves of <70 degrees in patients with a normal or hypokyphotic thoracic spine, video-assisted thoracoscopic surgery can produce equivalent radiographic results, patient-based clinical outcomes, and complication rates in comparison with posterior spinal fusion with thoracic pedicle screws, with the exception that posterior spinal fusion with thoracic pedicle screws may result in better major curve correction. The potential advantages of video-assisted thoracoscopic surgery over posterior spinal fusion with thoracic pedicle screws include reduced blood loss, fewer total levels fused, and the preservation of nearly one caudad fusion level, whereas the disadvantages include increased operative times and slightly less improvement in pulmonary function.

I think that there are relatively few surgeons doing this procedure, because of the long learning curve.

[Pooka1]

It has been widely reported that there is a steep learning curve in this type of surgery. The earliest pioneer, Ron Blackman, gave up doing this type of surgery after seeing a lot of rod breakage in his early cases.

Sharon, contrary to what your daughter's surgeon said, there are still some surgeons performing these surgeries, and getting good results.

I think that there are relatively few surgeons doing this procedure, because of the long learning curve.

Okay maybe I'm misremembering this but I did ask about it and I thought he said it was not being done as much as previously.

The reason I asked him is because of the advantages it has over posterior fusion but of course there are disadvantages. And if I had to ferret out one of the few people skilled in it, it would be harder to get through it because it wouldn't be done locally.

Thanks for posting the citations and edifying me.

[LindaRacine]

Maxene...

Since I can't answer you on the FixScoliosis forum, I'd like to answer here. Here's your post:

Dr Kalla - Post 4
Study #1
Australia 2006
83 Patients were included in the analysis
13 w/rod breakage = 15.6%
http://proceedings.jbjs.org.uk/cgi/c...SUPP_III/446-a

lindaracine - Post 9
Study #2
USA 2008
25 Patients were included in the analysis
6 w/rod breakage or requiring revision = 24%
http://www.ncbi.nlm.nih.gov/sites/entrez

In General: Rod breakage is not seen to not have any significant effect on clinical outcome?

I wonder if patients feel differently.

The study I quoted (see post #2 above) had rod breakage in 3 out of 25 (12%). I would imagine that for anyone who has a major surgical complication, there would be some impact. (Not great, but there are no guarantees in scoliosis surgery. The industry has been very open about that.) Did you notice that the surgeons got between 52%-56% curve improvement? The SRS score of 4.1-4.2 would indicate that the patients felt very good about their outcomes.

You should remember that this is for one type of scoliosis surgery, that is well in the minority. The vast majority of scoliosis surgeries are done with open incisions, where the overall complication rate is about 5%.

You'll never justify alternative treatments by attacking surgical treatment, as there's just far too much evidence that it works.

[Pooka1]

You should remember that this is for one type of scoliosis surgery, that is well in the minority. The vast majority of scoliosis surgeries are done with open incisions, where the overall complication rate is about 5%.

How can mamamax remember that when she doesn't realize that is a tiny minority of all fusions because she is being actively mislead?

Mamamax thought that number applied to all types of fusion approaches NOW. In other words, not even a little bit correct on any point. It's hard to reach that level of GLOBAL confusion but they are achieving that routinely over on Fix/Kalla's site. "Awesome."

You'll never justify alternative treatments by attacking surgical treatment, as there's just far too much evidence that it works.

The fact that they feel the need to ignorantly attack surgery says something about the evidence level of all alternatives. Now what other group with no positive evidence for their case does that remind you of? Hmmmmm.......

[Pooka1]

Finally someone (Goldfinch) administers a much needed edification on Fix's blog but five will get you ten the majority of people over there will go on thinking all fusion today has a 15% rod breakage rate and that that even matters.

Hello everyone! I'm a spinal liaison nurse in the UK and I work with kids who have scoliosis, both those who are facing surgery and those who try alternative treatments.

As I understand it, thoracoscopic surgeries never really took off. Most surgeries these days involve two rods at the posterior of the spine which I suppose are a lot more stable. Certainly, we never see rod breakages happen at the rate described above. We get maybe a four or five a year in the largest scoliosis centre in the UK.

Hardware used in spinal fusions is redundant after the fusion process is completed, so it can be removed at any time after that, and doesn't need to last fifty years. I do know many people who have had rods for 30-40 years with no problems though - the old style Harrington rods, at that. It's not all doom and gloom.

[S4Sarah]

Rod breakage rates depend on the type, each type has their own pros and cons. Some are hevaier, some are lighter, some are sturdier, some are weaker, some are cheaper, some are more expensive.
Each type though has their own breakage rate though.
Like Spinecor we haven't had much long term research with rods, as they have been jsut recently developed in the 1950's I believe and that was the Harrington rod. Now we have other rods we use too but most of the people being treated are in their teens and we haven't been able to seem much long term results. We haven't seen the patients with newer rods grow up with them and see how they do over the years and throughout life.
I'm concerned rods will cause long term issues, yet I'm not a doctor so I don't really know for sure. I'm just concerned they may cause problems later on down the road.

[Pooka1]

I'm concerned rods will cause long term issues, yet I'm not a doctor so I don't really know for sure. I'm just concerned they may cause problems later on down the road.

I win the bet with myself.

Sarah, the point is after you get a fusion (think within a year for most people), the rods are irrelevant.

The long term of rods is NOT RELEVANT.

It is impossible to get facts across.

[mamamax]

Maxene...

Since I can't answer you on the FixScoliosis forum, I'd like to answer here. Here's your post:

Dr Kalla - Post 4
Study #1
Australia 2006
83 Patients were included in the analysis
13 w/rod breakage = 15.6%
http://proceedings.jbjs.org.uk/cgi/c...SUPP_III/446-a

lindaracine - Post 9
Study #2
USA 2008
25 Patients were included in the analysis
6 w/rod breakage or requiring revision = 24%
http://www.ncbi.nlm.nih.gov/sites/entrez

In General: Rod breakage is not seen to not have any significant effect on clinical outcome?

I wonder if patients feel differently.

The study I quoted (see post #2 above) had rod breakage in 3 out of 25 (12%). I would imagine that for anyone who has a major surgical complication, there would be some impact. (Not great, but there are no guarantees in scoliosis surgery. The industry has been very open about that.) Did you notice that the surgeons got between 52%-56% curve improvement? The SRS score of 4.1-4.2 would indicate that the patients felt very good about their outcomes.

You should remember that this is for one type of scoliosis surgery, that is well in the minority. The vast majority of scoliosis surgeries are done with open incisions, where the overall complication rate is about 5%.

You'll never justify alternative treatments by attacking surgical treatment, as there's just far too much evidence that it works.

Hi Linda ~ sorry for not answering earlier, just now saw your post.

Thank you for the information.

As for your comment that I will never justify alternative treatments by attacking surgical treatments ...

I can only say, such is not my intention. If by participating in conversations I appear to be attacking surgical methods, then I apologize - for the truth is: I believe surgical/non-surgical methods of treatment is entirely an individual (case by case) decision to be made between patient and health care provider - and it is certainly not for me to decide (or suggest) which is best for another.

If pressed for a personal opinion, at this time, I guess we would find me in the Weiss camp. In other words: surgery yes - for severe cases - for all else, non-surgical if at all possible.

The merit in both - well justified, or not ... depending upon many things.