In this review of the comprehensive adult spinal deformity program at the Penn Spine Center, Drs. Vincent Arlet and Ali Ozturk discuss the management of scoliosis and kyphosis, a consideration that includes nonoperative treatment, pain management, and surgery.
Welcome to this podcast series from the experts at Penn Medicine. I'm Melanie Call, and today we're talking about spinal deformities and treatment options at Penn Medicine. Joining me in this panel are Dr Ali Osterc. He's an assistant professor of neurosurgery at the Pennsylvania Hospital, and Dr Vincent are Lay. He serves as chief of adults spinal deformity surgery within the Department of Orthopedic surgery at Penn Medicine and he's co director of the Spine Surgery Fellowship at the Hospital of the University of Pennsylvania. Gentlemen, I'm so glad to have you join us today. Dr. Osterc, I'd like to start with you. Please help us understand the spectrum of spinal deformity that you see in practice so that our audience convert a better sense of this condition. What are the types of spinal deformity you see it? Penn Medicine most commonly weaken divide spinal deformities that we see in adults in the two groups, one of which is scoliosis. That's an abnormal curve of the spine. Many of these air a symptomatic on. They don't necessarily require intervention. However, if they progress, it can be very painful. In addition, the pain can radiate to the legs. If nerves are compromised or manifest a severe back pain. Second major category is a sort of a khilafah tick deformity where patients start leaning forward. This could be just due to aging. But most commonly we see that deformity following surgery. Yes, and I would like to add as well we see a number off patient who had previous surgeries Onda. After some years, the, uh, degenerate process ads on the develop deformity, uh, above the previous surgery started common to see a patient who had a previous surgery with developed scoliosis que forces on or flat back Dr R. Lay. Do we know what the causes so most commonly at the scoliosis associated with the degenerative process of the spine? What happens is the disk is going to collapse on one side in a symmetric fashion, and it's going to induce local okay, forces on the patient's going to develop, uh, significant deformities. So one thing that waas minimal initially with this a symmetric disc degeneration can become in a bigger problem as the years go by with further degeneration of the spine. So that is one of the accepted mechanism of the a dark scoliosis. Dr. Osterc, tell us about some of the recommended imaging studies for patients with spinal deformity and about the advanced diagnostics available at Penn Medicine that you use. We like to be very thorough in our work up with these patients. Um, this is a one surgical treatment is to be considered. It's a very complex decision, since many of these patients, our old in the surgeries, are usually fairly involved, both in terms of the length of the operation and in terms of blood loss. Um, and it's a long recovery. So, uh, pre operatively. We typically get a nem R I of the lumbar spine. Possibly the you're a sick as well. We like to have a cat scan of the same areas. This shows us the bone better. In addition, it shows us any of the prior screws or fusion constructs if they are solid, or if there's, for example, been a non union. We always get what's called standing films with our Eos machine. We have the only one to my knowledge in Pennsylvania, um, at Pennsylvania Hospital. This is a very low dose radiation that takes an X ray of the entire body from head to toe, and we can appreciate if patients are compensating for their forward posture, say, by flexing their knees on their hips. Eso it gives us really a complete assessment of the of the body and the skeletal alignment. And lastly, we have a very low threshold to get Dexia scans, uh, to appreciate the bone quality again, we like to make sure that, um, the bone quality is good. Should we use a lot of screws for our correction? And so the screws, like any screw, is about as good as the wood we put it into. So that's sort of the last piece of the puzzle. If a patient has a pacemaker or, um, you know, can't get an m r I for a good reason or if they have too much hardware from a prior surgery, sometimes we'll get a C T mile a gram, which can substitute for the M. R I and show us the nerves. Yes, I would like to add that we had had this US machine doctor on stock was talking about for the last four or five years, and I think thanks to ah, this machine, we have a much better understanding half the problem the patient has and how to achieve the goal toe get a better surgical outcome. I think this differently. A big advance in the quality of a surgery. I thanks to this machine. So it's a big plus. We have a pen medicine at treating this patient with a spinal deformities. Dr. R Lay Nure Oh, and Ortho Oh, do they work together right from the get go? Or is there a point at which there is a handoff? Tell us how that works. I think it's the case is a very, um, specific just to, uh, the symptoms of the patient. But definitely we work as a team. We have, ah combined conference. We have once a week where we discuss our cases. Onda, uh, we have some cases where we want the surgery to ah go faster to be expedited in a timely manner. And we, uh, both teams North Surgical team and athletic team work together. Dr As Turk, as we're talking about surgical procedures now, before we do, are there any non operative nonsurgical help for these issues? And then if you would please let us know some of the approaches that you might use surgically our principal in spine. It's always start with non operative treatment. There certain red flags, of course, for example, of profound weakness, unbearable pain, bowel and bladder symptoms or things that merit urgent surgery. In the absence of these things are approach would always be to try a course of physical therapy and then followed subsequently to try pain management. If patient fails, conservative therapy is when we would consider surgical options. It's extremely important that we get an accurate assessment of the patient's symptoms. Someone might have a severe scoliosis, but they're only problem. Might be a single nerve root that's being pinched off. That patient might just benefit from a simple decompression. In other cases, the patient needs a complex reconstruction. This is usually done with multiple levels of political screw instrumentation, the levels of which very, very significantly based on the imaging and the patient's needs and several levels of ost IAT amis. That's when we remove certain elements of the bone so as to loosen it up. In addition, in terms of scoliosis, we don't worry quite as much about correcting the curve necessarily as at the end of our treatment toe, have what we call for the spine spine to be in harmony, meaning the head resting over the patient's pelvis, both in the Corona Land sagittal plane. These are priorities, and I think Dr Lee would agree. It's very patient specific, based on the surgery they've had before, where the deformity is the severity on and so forth. Yeah, I think we we always start with the conservative treatment. We have our pain management team on all off them. Help us to treat the patient conservatively. Now, when it comes to ah, surgery, we use the the skills off our general surgeon to access to the spine and most of the central surgery nowadays, down in minimally invasive fashion. Or, I think, with the team we have of neurosurgeons, access surgeon and orthopedic surgeons were very well versed into attacking the most complex smile deformities in the adult population. So, Dr Orly, you just brought up second opinions and referral and your expertise tell us about the expertise off the specialists at Penn Medicine in the Spine Center. And what would you like? Other referring physicians to know about referral and the specialists available their way? Have the large river specialist I was talking about the physical medicine, the pain medicine doctors We have, uh, Georges, who help us read some complex and Ryan Miro Citi scan when it's, uh, a difficult we have our physiotherapist that take care of our patients s Oh, there's no question we have a larger group of specialists toe help us, uh, Thio decide by the surgery, although I think to we should look into is, uh, uh, some of these patients have a TV or still poses on their required tohave treatment of the Austro pauses. Before we can think of doing the spine surgery eso rheumatologists on the chronology start their toe. Help us, uh, maximize the, uh, bone strength off our patients in the same manner. This thing Surgery are quite invasive. One of the medical treatment conservative treatment has failed. We need to optimize the the patient to the surgery and that z done with what we call pre habit. That means we won the patient to get to the surgery in the best physiologic state doing exercises, physiotherapy and, uh, ana maximizes nutrition status. Uh, stopping smoking tried to cut down on this opioid medication. All this require a team approach, which is going to, uh, maximized the outcome of the surgery. So I think it's very important to work as a team and that I think as a surgeon, we have to listen to everybody. Everybody's input. It's important when we decide to ah, uh, to treat the patient's buying the funny Dr Oz Turk, Would you like to add anything else in the area of technical considerations you'd like to share with other providers? The main technical considerations when we think about the spine is that first, how to get to it is Doctor Arlie mentioned, We can access the spine from an anterior posterior or lateral Um, approach. Um, there several, uh, considerations. When considering which is the best approach very frequently and deformity patients, it needs to be a combination of an anterior or lateral and posterior. Other times, we can address it all post eerily. Obviously, that's the most direct access to the approach. The other thing we need to decide is how much to fuse and if so, how many levels. Um, sometimes if the patient's principal problems air in the legs indicating nerve compression. If we can identify that clearly we can offer just a decompression which case we don't necessarily put in screws. We're not doing a fusion, uh, recovery from those operations tend to be a little quicker. Um, and they can be very rewarding again if the principal complaint is chiefly in the legs when there starts to be more of a structural issue, meaning the patients sort of lost their posture. And the back pain of severe is when we need to consider do infusions again, in which case we can go from multiple, uh, roots toe access. The spine coming from ah, front approach, an anterior approach has the advantages of were much more able to straighten the spine out. Eso We do like to do that because many of these patients tend to be leading forward, and that leads to quite a bit of back pain. And then, lastly, where to stop our fusion while we try, Always try to do the least amount possible. We, at the same time want every one of our surgeries to be the last one and spine. It's very possible to kind of address a the patient's issue right at that instant, but the patient might be back six months later. That's not what we want. We want to reach a point where we don't think the patient's gonna have any more surgery. That's our ideal goal in terms of our outcomes. These are very complex cases. And, you know, as Dr Lee mentioned, we have an excellent team here. We have to be very calculated and who we offer surgery too. So we do an extensive work of pre operatively. We discuss as a team which patients were gonna operate on, and we make sure that they're in, You know, the best shape that they could be before we offer the surgery and that following the operation we have an excellent I see you with complex. With complex surgeries like this, it's always it's extremely important to be done at the hospital on a team that has extensive experience, and that's what we're so happy to be able to offer here. This isn't just routine back pain and we're not operating on routine back pain here. This is absolutely life altering. A lot of these patients aren't ableto leave the house due to their pain, and so when we get them straightened and their leg and back pain improved, it can be a 3 to 6 month process, but with life expectancy Uh, constantly, Um uh, lengthening in this country, you know, someone who comes to you at 70 75 might have 10, 15 years, life expectancy. And that's who we try to pick. They're absolutely some of our happiest patients, and we're just so happy to restore them toe a functional lifestyle for that long Dr R Lay before we wrap up. What research avenues are you currently exploring to advance treatment for spinal deformity? I think this we have, ah, lots of exciting avenues. Just, uh, one is the, uh, robotic surgery, which not sure applies yet toe complex spinal deformities. But definitely, uh, some of the ah robotic or advanced imaging techniques may help in the in the future to treat this spot a phony. We've made a good advance in terms of biologic in terms to achieve a fusion. Uh, then, uh, the artificial intelligence is going to be probably the next step to being born toe. Tell us what we have to do on with your patients. So I think the official intelligence is going to be, uh, the next step forward would be ableto have a much better understanding of what represent the best outcome, how to get to the best outcome and have, ah, much better understanding how to optimize the patient outcome. Thank you, gentlemen, so much for joining us and sharing your incredible expertise on this comprehensive and complex topic. Thank you again. That concludes this episode from the experts at Penn Medicine To refer your patient to a specialist at the Penn Medicine Spine Center, please visit our website at penn medicine dot org's slash Refer or you can call 877937 pen for more information and to get connected with one of our providers. Please remember to subscribe rate and review this podcast and all the other pen medicine podcasts. I'm Melanie Coal Mhm.