Spinal surgery: Joining neurologic and orthopedic expertise
Over the past decade, significant advances have occurred in surgery to correct scoliosis and spinal deformity. Improvements in spinal implants and biologics that promote bone fusion have led to better outcomes and easier recovery for adolescents with idiopathic scoliosis and adults with degenerative scoliosis, for whom scoliosis surgery poses particular challenges.
"More surgeries are being offered because we're getting better at doing these procedures," says Jeremy L. Fogelson, M.D., a neurologic surgery consultant at Mayo Clinic in Rochester, Minnesota. "These surgeries are complex but have been very beneficial in terms of quality of life. We are helping patients become active again."
Dr. Fogelson treats pediatric and adult patients, and has training in both neurosurgery and orthopedic spinal deformity surgery. "It is very helpful to learn from both fields — one with a more neurologic viewpoint, and the other with a musculoskeletal focus," he says. "That allows me to see issues and to manage complications from the perspective of both specialties."
At Mayo Clinic, the treatment team for spinal deformity surgery includes anesthesiologists and nurses with experience in complex spine surgery. Intraoperative image guidance facilitates safe placement of implants; sensory and motor function of the spinal cord is monitored in real time, to minimize the chances of neurological deficits. "In some of the more challenging cases, we assemble surgical teams from several departments, including pediatric orthopedic surgery," Dr. Fogelson says. "This facilitates better outcomes and lower complication rates."
Dr. Fogelson frequently collaborates with Anthony A. Stans, M.D., and A. Noelle Larson, M.D., consultants in Orthopedic Surgery and at the Children's Center at Mayo Clinic in Rochester, Minnesota. In the case of a 16-year-old girl with congenital kyphosis that progressed over time, Dr. Stans and Dr. Fogelson worked together to remove the malformed vertebrae via a vertebral column resection to restore normal alignment. Post-surgery, the patient has improved posture and was able to return to most sports.
Idiopathic scoliosis trial
Dr. Larson is one of the principal investigators for the Minimize Implants Maximize Outcomes (MIMO) Study Group, a randomized multicenter study at 12 sites. The randomized trial will compare clinical and radiographic outcomes in two cohorts: one with low-implant density, the other with high-implant density. Participants must be ages 10 to 17, and have a diagnosis of idiopathic scoliosis for which surgery is recommended and a Cobb angle of 45 to 65 degrees.
"Every time we implant a pedicle screw, there is a risk it might be inserted incorrectly and cause complications. We're trying to find the right balance between number of screws and best outcome," Dr. Larson says.
Multispecialty treatment for adults
Adults can develop scoliosis related to arthritis in the spine, leading to back and leg pain and difficulty walking. "We try to avoid surgery if possible, but in selected patients it can improve quality of life substantially," Dr. Fogelson notes. Surgery typically involves laminectomies to remove pressure on nerves, and fusion to stabilize the scoliosis. One of the main challenges is preventing the spine from failing above the fusion. This condition, known as proximal junctional kyphosis, is usually related to osteoporosis and is one reason why patient selection is key.
Dr. Fogelson cites the case of a 64-year-old woman who had noticed progressive collapse of her spine over several years. She had back pain and also leg pain from a pinched nerve. Comorbidities included multiple sclerosis, osteoporosis and gastrointestinal disorders.
Mayo Clinic consultants in neurology, endocrinology and gastroenterology all confirmed the patient was an acceptable candidate for surgery. The procedure involved a fusion of the upper thoracic spine down to the sacrum, completed in one day with one posterior incision. The patient reports overall improvement in pain, posture and appearance, and marked improvement in quality of life.
"After surgery, these patients are generally able to walk much longer distances and stand up straighter," Dr. Fogelson says. "They typically experience relief from back and leg pain and stop taking narcotic medications."
For more information
University of Minnesota. Minimize Implants Maximize Outcomes (MIMO) clinical trial. ClinicalTrials.gov.