One long surgery can realign an extremely misshapen spine — boosting stature, restoring self-image and healing the pain.
It's important to stabilize the spine as much as possible before removing vertebrae. The spine is then separated into two sections, allowing for correction of the deformity.
Jessie Morgan was born with a spinal deformity. Three hours post-birth, an X-ray revealed kyphoscoliosis, a curvature of the spine that would cause him to have a hump and a spine that twisted and corkscrewed, putting pressure on his ribcage and eventually making it difficult to breathe.
"It was like the loops on a roller coaster, except it was my spine," says Morgan.
An operation followed by months of traction at age four hadn't solved the problem, and although he did pretty much everything the other kids did, it often was difficult to explain his condition to other children.
"I always taught him not to lie or tell stories, but one time when we were at the swimming pool, the other kids were asking him what was wrong with his back," recalls Jessie's mom, Dottie Apperson. "And he asked me, 'Mom, can I lie just one time?' And I asked him what he was going to say, and he said, 'I'm gonna tell them I got attacked by an alligator.'"
"That worked for the longest time," Jessie recalls with a laugh. "I remember kids seeing me and saying to each other, 'There's that boy who got bit by an alligator!'"
But his problem didn't impress everybody. He was suspended in junior high after fighting with a boy who put a Quasimodo figure on his desk and repeatedly called him a hunchback.
Most doctors weren't able to offer much help, but that changed when Jessie was referred to Lawrence G. Lenke, MD.
In recent years, Lenke, the Jerome J. Gilden Professor of Orthopaedic Surgery, has concentrated his entire practice on correcting difficult-to-treat spinal deformities. A few spine surgeons will perform complicated vertebral column resections (VCRs) to realign and stabilize severely deformed spines like Jesse Morgan's. But Lenke employs a novel technique.
Traditional VCR operations are just that, operations — as in more than one. One procedure involves the surgeon working through an incision made in the patient's side (chest and/or abdomen) to get to the front of the spine. In a second operation on a second day, the surgeon works through an incision in the back and finishes the job. Lenke no longer uses that two-stage technique. He is pioneering a different approach, working through a single incision in the back of the spine to perform the entire correction, usually in a single operation.
"These are big surgeries," Lenke says. "My average surgical time is almost 10 hours, but that's a lot less time than two operations."
Lenke has performed more than 70 posterior VCR surgeries. Because he's one of only a handful of surgeons using the posterior approach, he now treats patients from all over the United States and other countries. He also teaches the procedure to surgeons from all over the world.
At a recent meeting for spinal deformity surgeons, he asked 50 of his colleagues from around the country how many were using the posterior VCR approach.
"Only one raised his hand," Lenke says. "And these are pretty advanced surgeons who attend this meeting. I would guess that maybe 50 surgeons in the United States do this procedure once or twice a year. There might be 5 or 10 who do it monthly. I've been doing two or three of these procedures each month."
Lenke is renowned for his skills as a surgeon, according to Richard H. Gelberman, MD, the Fred C. Reynolds Professor and head of the Department of Orthopaedic Surgery.
"A posterior vertebral column resection is technically very demanding surgery," says Gelberman. "The many referrals Dr. Lenke receives from spine surgeons across the country stand as a testament to the respect he garners from his peers."
Lenke received international notoriety last fall when he received the Russell Hibbs Award for the best clinical presentation at the 42nd Annual Meeting of the Scoliosis Research Society in Edinburgh, Scotland. The award recognizes a paper in which he reported on his series of 43 consecutive cases of posterior-only VCR spinal deformity corrections.
"In our experience, this has been a very safe procedure," Lenke says. "One thing we insist upon is monitoring the spinal cord during surgery to avoid neurologic deficit. In theory, paralysis is one of the biggest risks of this approach, but that hasn't happened to any of our patients. In fact, all but two of my first 70 patients left the operating room with the same or better function following surgery than before it. In those two cases, there was severe preoperative spinal cord dysfunction, but both patients are slowly recovering following their reconstructions.
Lenke says these surgeries are used to treat very advanced problems, like Jessie Morgan's curving, corkscrewing spine. Although much of the benefit is cosmetic, the surgery did more than improve Jessie's posture; it also may have saved his life.
"As it advanced, everything was caving in on his heart and lungs," explains his mother, Dottie Apperson. "One lung was pretty far gone."
In fact, Morgan needed two months of traction at Shriners Hospital to take pressure off his lungs and get him healthy enough for his surgery at Barnes-Jewish Hospital in December 2005.
"As a youth, he played soccer and baseball and rode motorcycles," Apperson says. "But just before the surgery, we saw a change. He couldn't go as far when he walked. He was slowing down."
Ten years earlier, Jessie might have been out of luck; at that time, most spine surgeons couldn't treat very severe problems like his.
In the past few years, Lenke and other surgeons have learned to stabilize the spine with screws inserted above and below the site where one or more vertebrae will be removed. Temporary rods also are used to stabilize the patient. It's important to get things as stable as possible before removing vertebrae because after Lenke removes bone from the back of the spine, he works underneath the spinal cord to extract bone and discs from the front of the spine, and the patient's spinal column on the operating table is left in two pieces.
"The patient's spine is basically separated into two halves," Lenke says. "It's held together by temporary rods and the spinal cord running down the middle. The spine is completely disconnected, but that is what allows correction of these stiff deformities."
"It gives us a lot of freedom," Lenke explains. "Obviously, we move very slowly and carefully, but we can correct very severe deformities into a more normal alignment because the top and bottom of the spine are completely disconnected. That instability allows us to create better alignment. Then we restabilize the spine with rods and metal cages before finishing the procedure with a spinal fusion to make everything more secure."
But when the incision is closed, the repair is complete. The patient needs no cast, though a few small children will require a brace for a few months. Total recovery can take several months, but most patients are out of bed the next day and home from the hospital in a week.
Lenke says many patients like Jessie, who have experience with an earlier spine surgery, are surprised when they aren't immobilized in a body cast and confined to bed for weeks or months. Still, the procedure does leave patients with some significant pain, requiring the use of postoperative pain medication for weeks to months.
"Most people are pretty sore for eight, 10, 12 weeks, and it's a good six months to a year before a person is fully recovered," Lenke says.
Jessie's mom knew that her son was recovering when she noticed him taking less pain medication in the weeks following surgery. Then, he really proved that he was feeling better. "The first thing he did when he got on his feet was he moved out," Apperson says. "He's also driving now and has his own car. He became very independent."
"Dr. Lenke gave me a new lease on life," Jessie says. "I feel like I can do anything. If I think I can do it, I don't hold back."
And he's not the only one.
"It's not uncommon to hear a patient say, 'I'd rather die than continue to live like this,'" Lenke says. "People often are miserable before surgery, and they're willing to take the chance. Luckily, our experience has been that although it's very challenging, the operation has produced dramatic radiographic and clinical results for these severely deformed and often desperate patients."