Was Kathy fused? -- fusions, casts, & hardware

[Guest guest]

Hi, Kathy --

Once again, could you please confirm that you received my email reply to you?

Otherwise, I'd better try to resend it. My gmail has been a little glitchy

lately. (My " estranged spouse " finally received an email on September 20th which

I had sent him on the 10th!)

In response to your most recent post: It can be very hard to determine whether

someone's spine has fused from radiographic evidence alone. Let me qualify that,

however: In general it seems to me that spontaneous " natural " fusion (e.g., in

the lower spine, after years of undue stress on unfused vertebrae coupled with

the usual severe joint degeneration) may be diagnosable from an x-ray alone.

When it comes to successful surgical fusion higher up, however, the only sure

way to tell might be for the diagnostician to open the patient up once more and

take a look through the " naked eye. " At that point failed fusion or

pseudarthrosis should be uniquivocally clear and readily diagnosable.

Of course if the original surgeon insists he merely implanted the hardware

without any attempt to fuse -- which is so off-the-wall, I am surprised any

surgeon would admit to such an inappropriate intervention! -- and if you find

him credible, then you have reason to be certain that there was no attempted

surgical fusion.

This might be a good time to do a mini-review of spinal hardware -- anyone who

is interested can read on, and anyone starting to glaze over :-) can go do

something else.

As you undoubtedly know, the hardware alone serves no essential long-term

purpose. It is implanted to protect and support a healing surgical fusion during

the first post-op year or two. In providing internal fixation, it replaces the

external fixation once provided by cumbersome orthotic devices such as the

old-time casts some of us lived in for months or years. To contrast those

plaster casts with internal hardware such as the H. rod: The external orthosis,

generally a Risser jacket, was a 20-to-30-pound body cast worn externally,

extending from the back of the patient's head to her hips or to one or both

knees, with a kind of shelf under her chin. The cast had built-in traction,

forcibly pulling and holding the spine in a straighter position.

With the transition from Risser jackets to Harrington rods, we moved from

traction to " dis-traction. " Distraction, the H. rod's major claim to fame, was

the earliest, crudest approach to internal fixation of a corrected scoliotic

curvature. (For now I'll skip any detailed discussion of the later, more

sophisticated segmental systems and their additional abilities such as deroation

of vertebrae and apical translation. In brief, these more advanced systems also

included rods, but the rods were flexible so that the surgeon could contour them

to the specific curves of an individual spine --performing whatever action was

appropriate to each individual spinal segment. Most crucially, when implanted by

surgeons with exceptional skill and precision, the segmental systems could be

used in such a way as to preserve rather than destroy sagittal mechanics, thus

averting the development of flatback sydrome -- this after some forty years of

exclusive Harrington rod use and the one million patients who were crippled as a

result.)

" Distraction, " the ,major function of the H. rod, refers to the action of

pulling the ends of a spinal curvature further apart. The H. rod, which featured

a series of notches, was positioned on the curve's convex side. It passed

through two hooks, one to be fastened under the topmost vertebra of the

curvature (superior hook) and the other over the bottommost vertebra (inferior

hook). The surgeon would move the superior hook up the rod, little by little,

until he was satisfied that he had obtained optimal straightening of the

curvature. This has often been likened to the procedure for jacking up a car.

Both external fixation (casts) and internal fixation (hardware) played

essentially temporary roles. Of course the hardware, unlike the casts, was

normally left in place indefinitely. While casts could easily be sawed off once

they had served their purpose, removing the hardware would have entailed

additional invasive surgery. Unless the hardware broke or became problematic in

some way, most surgeons would not have felt that the benefits of such surgery

would have outweighed the risks.

These days many surgeons do opt to remove and replace antiquated hardware in the

course of revision surgery. Dr. Rand, in a surgical approach which may be unique

to his practice, untethered my rod and " hung the new hardware off it, " as he put

it. A few years later when I needed additional revision, Dr. Ondra decided to

" rip out all your implants and get things more streamlined. " On my x-rays you

can still see the cages Rand installed to hold the graft material he used (my

own autologous cancellous bone, cadaver graft, and morphogenic bone protein),

but the old H. rod has been taken out (along with some big pelvic bolts that had

begun causing me untenable pain).

While it is rather common to find an occasional older patient like Ann or me who

had one of the early spinal fusions with no hardware whatsoever, it is

essentially unheard of to meet someone who got hardware with no fusion. In fact,

Kathy, I believe you are the first person I have ever known to report such an

experience. I continue to puzzle over what that surgeon could have been

thinking.

I probably should add one caveat: Occasionally a member of this group has

expressed the hope that hardware removal alone would heal all her problems. In

fact, we even had one member urging this on others some years ago, after having

her own hardware removed. At least initially, she was under the impression that

this had fixed her. But the hardware, at least in the vast majority of cases, is

there to preserve and protect whatever the surgeon may have done to the spine.

If the surgeon has jacked up a person's spine with an H. rod, ignored sagittal

mechanics entirely, and induced another case of florid flatback syndrome, that

flatback deformity is here to stay pending major spinal revision surgery. The

rod, now superfluous, can be left or removed, but generally speaking there will

be no effect on the flatback deformity either way.

Best,

ScolioFlatbackers , " KATHYINBK " <kathyinbk@...> wrote:

>

> Hi - I am absolutely sure. I even argued with my surgeon, prior to

surgery. He just " knew " I had fused...either from my previous surgery or " self

fused " . He admitted I was right after my surgery. He said it looked like a

solid mass in the x-rays...but actually wasn't. You are right with your theory

about me not being fused having something to do with my original rod breaking.

I could never figure out why it never progressed...even during and after my

first pregnancy. Once again...I am the 1% =) Anyway...have a great

weekend..........Kathy

>

>

> > > >

> > > > Hi, Kathy --

> > > >

> > > > Thanks so much for sharing your spinal films. I had lots of trouble

posting my own x-rays. I just found out yesterday (from reading through an

endless blog about the changes being made to -- we are in the midst

of an overhaul that began in August) that many other people besides us were

having problems uploading photos to groups. The people updating say

the glitch is now corrected. So it wasn't you -- it was (in case you were

taking it personally, as I was).

> > > >

> > > > You have very clear films. I am not a doctor and am not qualified to

evaluate any radiological images, so let me just comment as a layperson that you

still seem to have a pretty good scoliosis correction. I'm afraid that second

film from the side confirms everything you have been telling us about your

condition. No wonder you have had such horrible pain. It " took me back " just

seeing the visual evidence of your flatback syndrome -- what a lousy, rotten

condition to have (I speak from experience, as you know).

> > > >

> > > > The good news is that Dr. Hu should be able to do a great correction on

your back. (Again, I'm being recklessly opinionated without a medical license!)

I am so glad you have resolved to have the revision when you can. I think your

life is going to be much better in so many ways once you get over that hurdle.

You are one feisty, gutsy, determined woman -- bravo -- you go, girl!

> > > >

> > > > Best,

> > > >

> > > >

> > >

> >

>