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Melanie Cole: Today, we’re talking about complex deformity correction, reconstructive spine surgery, but what does that even mean and for what conditions would be discussing this kind of correction and this kind of surgery? My guest is Dr. Kamran Parsa. He’s a neurosurgeon and a member of the medical staff at Palmdale Regional Medical Center. What are considered complex deformities? Are we talking things like scoliosis and kyphosis? Tell the listeners a little bit about what these are.

Dr. Kamran Parsa: First of all, very nice talking to you and talking about this topic, which is very close to my heart. This is what my advanced training was in, the complex deformity. There are two types. There's pediatric and adult deformity. Our focus today would be more on the adult population and what it involves, the different words that you hear is deformity, scoliosis, kyphosis, all these different words which can confuse individuals. All kyphosis means is that, for example, the natural curvature of the spine loses its normal curve and goes in the opposite direction. As an example, in the lumbar spine, they're supposed to have lordosis where you have a curve in your back that points where the inside of the curve is going behind you. What's happened during kyphosis is your disc, as you age, they start to degenerate, and as they degenerate, they start to lose their height and angulation. You start to lose that lordosis and go towards the opposite of lordosis, which is called kyphosis. That's a very common way to think of what these disease processes mean. What that leaves with the patient in mind is that as you lose your normal lordosis, your center of gravity moves forward. When that happens, your whole body starts to adjust to pushing your center of gravity back towards the middle.

Melanie: When you're talking about kyphosis and people sometimes see those very old people that are facing forward and their neck has that big hump, is that something similar that you're discussing because that gets pretty severe and some people can't stand up straight anymore because of that?

Dr. Parsa: Correct. You mentioned two keywords: old and the humps that you feel. Those are all abnormal and that’s because of the degeneration. That’s exactly what I'm talking about. The kyphosis can occur in your neck, can have an exaggerated kyphosis in your middle back or it can occur in your lower lumbar spine.

Melanie: Even something like scoliosis that can develop over time whether kyphosis develops as a result of osteoporosis and bone density issues, poor posture, whatever the reason is, but people have heard this term for years. Is this something that you are born with and that we only sort of see later on? Does it get worse as you get older?

Dr. Parsa: Yes and no. Scoliosis is just another term in my mind for deformity. Kyphosis that we're talking about a form of scoliosis. When I think of the term scoliosis, I think an abnormal curvature of the spine. Whether it's too much kyphosis, whether you're actually curved sideways when you look not from the side but when you're looking at a patient, that's what scoliosis means. In terms of when it develops, a lot of times, the curvature when you're not looking from the side, but at a patient, what people generally consider scoliosis, that is generally speaking you're born with it. Almost always, it is not surgical, never bothers you throughout your younger years or even middle ages, but as it degenerates, that curvature starts to worsen and then it starts to pinch in your nerves and you start to have back pain and leg pain and arm pain.

Melanie: What can you do for somebody whether they are starting to developing kyphosis, which you can see starting to develop, or if they’ve had scoliosis and then it’s getting worse and they're developing all this pain you're discussing, what can you do? Speak about first the nonsurgical defense what you tell people at the outset and when does this become a very complex surgery.

Dr. Parsa: My motto with everything I do is keep surgery the last resort. It is paramount that deformity correction surgery is absolutely the last resort. Complication rates from surgery, the national average is about 30% to 35%, so these are high complication rates at the best centers in the world. Needless to say, keep it as a last resort. What is conservative management? Preventive is number one. Preventive has you take the stress off your spine. The best thing to do for your thoracic and lumbar spine is to do core strengthening exercises. What I always advocate for, or try to educate my patients, is that if you're standing upright, there are two forces that are exerted on your spine and your ligaments and nerves and discs.

The first one is your weight. If you're larger set or heavier set, there's going to be more gravitational force on your lumbar spine and it increases its chances of degenerating and going into kyphosis. Number two is if you have a very poor core strength and therefore you don't have strong muscles in your psoas or your abdomen or your deep multifidus and other support muscles in your low back. If they are weak, then they're not adding any support and all the stress comes on your lumbar spine. What I always advocate for is first make sure your BMI range is within normal, these are the preventative measures, and number two is to strengthen that core so that the gravitational force dissipates not only on your disc but also your muscles and everything else. I also advocate for flexibility. The stiffer joints become, the faster it can degenerate. Range of motion, exercises, yoga, anything of that nature, keep those joints mobile. If you think about it, the elderly population, if you have a knee fracture or a shoulder injury or whatnot, the orthopedic surgeons always advocate for range of motions as soon as possible. If you don’t, you get a frozen shoulder or a frozen elbow or what not. The spine is exactly the same. It’s another joint. What you want to do is keep flexibility in your low back, mid back and neck, so that the fluid is not stagnant in your joints and it maintains integrity and strength.

Melanie: When does the point come when you say ‘we've done this, we've tried yoga, we’re tried physical therapy, we've even tried medications for pain relief, now we have to look to surgical reconstruction of this severe kyphosis or scoliosis and this is what's involved?’

Dr. Parsa: It’s really quality of life measures. I also advocate for temporary bracing as another form of conservative management or even chiropractic treatment as well. Debilitated patients that this is affecting that qualifies to a degree that they cannot function. A lot of these patients generally can't walk much. Some are wheelchair bound, some have severe radiating pain symptoms that they really are on multiple pain medications and their quality of life is so low. I send a lot of different questionnaires such as Oswestry Disability Index and multiple others that I have the patients fill out so I can gauge how back the quality of life is both subjectively and objectively.

I discuss with them, educate with them, as yes, we can always operate and we can always fix this, but we have to be realistic, we’re not turning back time, we’re improving current function status, talk about the complication rates and all of these things. Once both the patient and I are comfortable with each other, then it’s always a big fusion type of surgery with about a week hospital stay minimum. With the correct expectations, good surgical technique, clean hospital environment, and a good support staff, which we’ve created here at Palmdale, we’re able to have good outcomes and everyone is happy. It’s really a lot of education, a lot of getting ready to do such procedures that it’s not your run of the mill spine surgery; it’s a lot of education. That’s when I generally intervene in these cases.

Melanie: Wrap it up for us with your best information and advice for people that have been told they have scoliosis or are at risk of developing severe kyphosis and they don't want to be staring at the floor for the rest of their life, what you want them to know about the things that they can do that might help to strengthen up their core and their spine, and when they should consider coming to see you.

Dr. Parsa: I think if you're looking down at the floor, that’s a good time to come see me. That’s to me sounds severe. You also don’t want to wait for it to get to a point where you are looking at the floor because yes, we can fix it, but the surgery is larger. It's more traumatic and it's long recovery. I say scoliosis is a very complex nature. There are really very few surgeons in America, forget just California, that really do it well or are trained for it or even incorporated into their practice. In my opinion, I think if you're worried about scoliosis and you have a curvature, just come in for consultation and I'll give you all the information you need. As I said, I'm very conservative when it comes to it. My first answer would almost always be to send you to the appropriate authorities – physical therapy, chiropractic, bracing, all these things – to go get those and follow you. I will continue to follow you. I think I need to be the primary care taking care of scoliosis patients and directing their conservation management.

Melanie: Thank you so much. Always a pleasure to have you on with us. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, please visit palmdaleregional.com. That’s palmdaleregional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if these types of surgeries might be right for you. This is Melanie Cole. Thanks so much for listening.