Episode 13 - Adult Spinal Deformity with Dr. Matt McGirt
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Episode Summary
It’s a pretty common to have your posture be significantly affected by a spine condition. Whether you’ve had congenital scoliosis as a child or went through an accident that caused the deformity, it’s important to have an understanding of these so you know your options are towards recovery.
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia speaks with Dr. Matt McGirt, a partner doctor at the Carolina Neurosurgery and Spine Associates. Dr. McGirt dives deep into spinal deformities that occur in adults, including complex spines and scoliosis. He discusses the types of scoliosis that develops in children, and once it stabilizes, as they grow older. The main thing to check for as an adult is the pelvic-spine-shoulder alignment, making sure that any malalignment does not progress over time.
He also lists down the various symptoms that signal a worsening spinal deformity, including more muscle strain and stress around the spine area. Conservative care is always the first option, where your quality of life is improved first, including doing minor outpatient procedures. It’s only when there’s a severe loss of quality of life such as reduced lung capacity that spinal surgery becomes an option, which Dr. McGirt gives a brief overview on.
Before things take a turn for the worse, you can help yourself by doing activities such as building core strength and flexibility, stretching, and losing weight.
Dr. McGirt suggests adopting healthy habits like cultivating relationships, developing hobbies and doing breathwork, to improve your overall health and well-being.
Key moments in the episode
Links mentioned in the episode
Dr. Mark McGirt on the Ellen show with Dean Otto
Schroth method
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
It’s a pretty common to have your posture be significantly affected by a spine condition. Whether you’ve had congenital scoliosis as a child or went through an accident that caused the deformity, it’s important to have an understanding of these so you know your options are towards recovery.
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia speaks with Dr. Matt McGirt, a partner doctor at the Carolina Neurosurgery and Spine Associates. Dr. McGirt dives deep into spinal deformities that occur in adults, including complex spines and scoliosis. He discusses the types of scoliosis that develops in children, and once it stabilizes, as they grow older. The main thing to check for as an adult is the pelvic-spine-shoulder alignment, making sure that any malalignment does not progress over time.
He also lists down the various symptoms that signal a worsening spinal deformity, including more muscle strain and stress around the spine area. Conservative care is always the first option, where your quality of life is improved first, including doing minor outpatient procedures. It’s only when there’s a severe loss of quality of life such as reduced lung capacity that spinal surgery becomes an option, which Dr. McGirt gives a brief overview on.
Before things take a turn for the worse, you can help yourself by doing activities such as building core strength and flexibility, stretching, and losing weight.
Dr. McGirt suggests adopting healthy habits like cultivating relationships, developing hobbies and doing breathwork, to improve your overall health and well-being.
Key moments in the episode
- What is a complex spine - 06:14
- Definition of spinal deformities - 08:53
- Types of scoliosis developed in kids and adults - 11:04
- Routine imaging for an individual with mild scoliosis - 14:05
- Symptoms that signal worse spinal deformity - 15:16
- Schroth method - 17:20
- Symptoms to determine if surgery should be considered - 18:17
- Non-musculoskeletal symptoms - 19:40
- Surgeries to address adult spinal deformity - 21:47
- Big scoliosis surgery - 24:13
- Going to work after spinal surgery - 27:38
- Surgical approaches - 29:16
- Dr. McGirt’s personal health habits - 31:50
Links mentioned in the episode
Dr. Mark McGirt on the Ellen show with Dean Otto
Schroth method
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Intro: 00:01
Welcome. You're listening to Back Talk Doc where you'll find answers to some of the most common questions about back pain and spine health brought to you by Carolina Neurosurgery and Spine Associates where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 00:32
In the wellness spine care over the course of my career, most of the things I see are fairly common and can be attributed to issues like back arthritis or disk herniations, but there certainly are patients that come into my office that make me pause, in particular, and we've all seen them, uncles, aunts, friends and family, individuals whose postures significantly affected by their spine. And you might hear terms like scoliosis or spinal deformity, and that is a condition that we sometimes struggle with.
Sanjiv Lakhia: 01:12
And I'm very excited today to bring to you an interview with my guest, Dr. Matt McGirt, a partner of mine at Carolina Neurosurgery and Spine Associates. He's one of our go-to guys. We're blessed in our group to have several physicians who understand adult spinal deformity and scoliosis quite well and can lead patients down a path to recovery. So I wanted to grab an hour of his time and really pick his brain today and share with you his insights. Matt, welcome to the show.
Matt McGirt: 01:42
Thank you, Sanjiv. I'm excited to be here with you today. This is an important topic.
Sanjiv Lakhia: 01:46
Yeah, absolutely. Now, folks, I want to go over his background and looking at his bio, it would take the entire interview to review it, so let me just give me some highlights. He's been with Carolina Surgery and Spine since 2014, and he did his medical school at Duke University, and did residency through the Johns Hopkins Hospital and also a spine fellowship.
Sanjiv Lakhia: 02:14
Scrolling through his achievements, there's just too many to count. He's an author or a coauthor on over 300 peer-reviewed publications. He's done hundreds of presentations locally and nationally. And really, Matt, if you were to end your career today, and I know you won't because you're just getting started, we could say you've had a great career already [inaudible 00:00:02:37]. It's unbelievable and your contributions to the field of neurosurgery and spine. And I'm going to put you on the spot, this is not on our list of interview questions, but you are perhaps best known for your appearance on The Ellen DeGeneres Show. Would you like to share with our listeners a little bit about how that came to fruition?
Matt McGirt: 02:58
Well, that was a great highlight of my career about 10 years in, and I was blessed to get to know a patient of mine, Dean Otto. It was under unfortunate circumstances. He was hit by a car, broke his spine, his back, was pinching his spinal cord and he could not move. He was paralyzed.
Matt McGirt: 03:16
And we'll make a long story short, surgery went great, but Dean was an incredibly unique individual. He demonstrated how belief, faith, hope, incredible hard work and determination, and a little bit of luck allowed him to beat the odds. And that story sort of found itself in mainstream media as a story of forgiveness, faith and determination. As Dean challenged me to run a half marathon with him on the one year anniversary of his paralysis, and he did this the day after the accident, something that I thought would be impossible.
Matt McGirt: 03:48
Just to tell you how great of a human he is, he forgave the young man who hit him, invited him to join us and then, we celebrated this triumph of those two gentlemen, one year in Napa Valley, ran a half marathon together. And quite frankly, just blessed to have been a part of that story. The two gentlemen that I mentioned did all the heavy lifting there and I appreciate them taking me along for the ride.
Sanjiv Lakhia: 04:12
Absolutely. What an uplifting story, just reminds me of why we're in this. And if you want to know more, we'll put a link on the show notes to the actual video clip when they appeared on The Ellen DeGeneres Show. Matt's been very humble. He played a big part in it as well, but that's just a fantastic story that I thought you should share. Let's rewind a little bit as individuals get to know you better, what kind of put you into the path of neurosurgery?
Matt McGirt: 04:37
Oh, I knew I wanted to be a physician, a doctor, gosh, since I was in elementary school. I loved going to the doctor, liked watching my friends get stitches when they got banged up. I was always a little different that way and quite frankly, did not have a physician or anyone in medicine in my family. It was new and exciting.
Matt McGirt: 04:55
I was fortunate enough to find myself at Duke medical school as a 22-year-old and went in with an open mind. The first thing in medical school you realize are that the medical specialties and the surgery specialties are quite different, and I just fit in with the fast-paced, immediate fix it of the surgical world and I knew I wanted to do surgery.
Matt McGirt: 05:15
And the organ system that just fascinated me that I loved studying in our classroom work and even on rotations was the nervous system. And for me, it was the perfect mix of the two, central nervous system, the peripheral nervous system and surgery. And I'm so thankful I made that decision. It's been, I think, the perfect fit and I love it. I love what I do.
Sanjiv Lakhia: 05:35
Yeah. I can tell you've never looked back. It's just great to hear how you kind of found your way into the field for a benefit for sure. Matt, when I have patients in the office and they're very complicated, I feel blessed that I can turn to you for your help. We have, I think between you and Dr. John Ziewacz and Dr. Paul Kim and others, we have several guys that we would consider as "complex spine specialists." To the average listener out there, can you explain to them a little bit about some of your training that allows you to do some of these type of cases and what exactly defines complex spine?
Matt McGirt: 06:14
Certainly, yeah. I mean I think in our practice and here locally, complex spine typically refers to larger, more challenging spine surgeries that involve instrumentation, screws and rods, revision surgery, surgeries that expand five, six, seven levels, and surgeries that really have come to the forefront over the last 15 years.
Matt McGirt: 06:42
Common spine surgery, we would call perhaps not complex, are your more common things, a disc herniation, a one- or two-level laminectomy, a one-level fusion, an anterior cervical fusion for arm pain or weakness in arms or hands. And that is the basic armamentarium of anyone who trains in neurosurgery, but larger spine surgery like we're talking about today, scoliosis or adult deformity, going in and having to revise or redo large fusion procedures, large spine tumors and some complicated spine fractures that we see from car accidents would fall under a more complicated spine.
Matt McGirt: 07:21
And to answer your last part of that question, most folks who go into that area of spinal reconstruction, complex spine, tend to spend an extra year or two after neurosurgery or orthopedic basic residency training, and I did that with Ziya Gokaslan at Johns Hopkins. He was world renowned for his cancer surgeries where we did some of the largest and innovative reconstructions, and I'm forever grateful for Ziya, Dr. Gokaslan for his mentorship over the years.
Matt McGirt: 07:48
And then, I would say the most important step actually is what happens after fellowship, when you get into the real world and you start cutting your teeth so to speak, that is, getting in under early supervision, beginning to increase your autonomy and taking on bigger and bigger cases. So that's certainly what I've done since I started out of fellowship in 2010, ten years ago.
Matt McGirt: 08:10
And I'm fortunate at CNSA that we're such a large practice that we can each have specialty positions so I can do and see a large volume of it. And the more of these you get to do, the better of them, the better you are at doing them.
Sanjiv Lakhia: 08:24
That's terrific. As a physiatrist, some of these cases, I have patients that come in and they can barely even look up at me because they have such a curvature and it's nice to have expertise in the group so I can hand the baton off and give the patient some hope.
Sanjiv Lakhia: 08:40
Let's go back a little bit. Can you define for our listeners spinal deformities, scoliosis? These are the different terms that are discussed. And can you give us some insight into what they actually mean?
Matt McGirt: 08:53
Certainly. Scoliosis is a type of spinal deformity. Simply put is an incorrect spine curvature. It affects your posture. It will allow your shoulders perhaps to be offset from your pelvis. And that can be in all different types of shapes, right? We come and think of scoliosis as an S-like curve, whereas you normally look at someone straight on and it should be straight up and down the spine. It'll look like a side-bending S.
Matt McGirt: 09:25
Other times, we will see if you look at someone from the side, normally someone would stand up straight. We've all seen folks whose spine is just sort of bent forward where their chest is actually leaning a good foot in front of their hips. That is another type of global alignment problem.
Matt McGirt: 09:44
So in its simplest form, spinal deformity is when the spine is malshapen so that your shoulders are no longer over your hips. And the reason that's important, particularly in the adult population, is imagine a tree leaning and trying to fall over, your spine muscles do everything they can because the brain tells them to, to help hold that tree up. So it's going out and it is firing muscles just like you would put rope around a tree on the back end to try to keep it from falling. You could imagine if those muscles have to strain all day long, to try to straighten that crooked spine, they're going to hurt a lot. And that's the essence of why folks with these spinal malalignments have so much pain in the adult population.
Sanjiv Lakhia: 10:34
That's a great point, and we'll talk a little more about that when we get into treatment, but that's the reason why when I have individuals with those postural deformities and they come in asking for trigger point injections and I basically tell them the relief will likely be short-lived because we're not getting to the root of the problem, which is your overall posture. You touched on this a little bit here, but do you consider any significant differences between adults and kids in terms of the types of scoliosis that can be developed?
Matt McGirt: 11:04
Yes. Thank you for asking that question. They're really separate diseases. You think of scoliosis and deformity, childhood and adolescence, it's really a different disease process. There are congenital types of scoliosis, whether it be malformed parts of the spine or the anatomy, whether it be that it secondarily forms in childhood because of a neuromuscular problem, whether it be from a tumor in the spinal cord. There are all kinds of primary congenital problems. And that typically is obvious early in childhood and many times, those need to be treated surgically to fix them. There's not a good medical or physical therapy way to do that, and that's congenital scoliosis of children.
Matt McGirt: 11:49
The most common childhood scoliosis, right, and we can all probably remember, we knew someone growing up who had a little bit of a scoliosis. In adolescents, we call that idiopathic, meaning unknown cause, idiopathic adolescent scoliosis, and that often and most commonly is a cosmetic issue. It will start to develop in a young person in late elementary school. Oftentimes, a school nurse may notice it and send to the pediatrician. It can be subtle S shape curves.
Matt McGirt: 12:18
I mentioned looking at someone's face forward and you may notice that there's a little S shape. Their shoulders and hips may be aligned, but if someone were to be in a bathing suit or you could see them from the back, maybe in fifth grade recess, it might be a little bit of a curve.
Matt McGirt: 12:33
And that's something that in most cases does not need surgery. The idea is that that mild scoliosis curve stays the same and does not progress. And as long as it doesn't progress or become too severe, nothing really surgical needs to be done. And the goal there is often bracing and bracing can be used up until puberty to help make sure that that curve does not worsen.
Matt McGirt: 13:00
Interestingly enough, Sanjiv, that once you are through puberty and kids are on the other side of that, the curve really sort of settles in and fixes there. So you could kind of the general terms, the goal of adolescent idiopathic scoliosis is to brace them, do stretching, physical therapy so that the progression of the severity of the curves does not progress and you can get them through puberty and then stabilized at that level. So those are sort of a brief summary and overview of the pediatric and adolescent scoliosis.
Sanjiv Lakhia: 13:33
That's terrific. And I know you deal mostly with adult spinal deformity, but certainly, I have some parents that are out there listening and have concerns for their teenage kids and I think that's a really nice summary of how to approach the problem. Another question that I'll often get, I'd like your thoughts on, is if you evaluate an individual, let's say in their early 20s and they come into your office and they had a slight S shape curve, does that patient require routine imaging the rest of their life to monitor for progression?
Matt McGirt: 14:05
Yeah, great question. Typically, once some ... So that individual almost always had developed that mild scoliosis in adolescence, almost always and it stabilized, right, in maybe age 13, 14, 15. And then typically, if a curve has stabilized, say age 14 through 23 like you mentioned, it is rare that at age 23 that it will pick up steam and start worsening all of a sudden. The greatest predictor of what will happen from age 23 to 33 is really what happened in the 10 years before. So if you can obtain or a family can obtain an X-ray if they have it, or even if they don't, sort of think back over the five years prior to what that spine of the child looked like, if it's been stable for five or six years before age 22, it's almost always stabilized up through adulthood.
Sanjiv Lakhia: 15:00
So that patient returns to your office, let's say now they're in there 40s and they're having some increased pain, what are some symptoms that you're looking out for that make you concerned about the scoliosis and their spinal deformity?
Matt McGirt: 15:16
Absolutely. Well, first of all, when folks carry that teenage year idiopathic scoliosis that stabilized, it might look a little bit different at the swimming pool, but never needed anything surgically done into adulthood, I always remind my adult patients at age 40 that look, in the aging spine, we all have reasons to have some back pain, some arthritis, some wear and tear. Somebody who has a little bit of a malalignment is just prone to see a little bit more strain and degeneration and wear on the tires, if you will, than someone who has a straight spine.
Matt McGirt: 15:54
So when I get the middle aged adult patient who carried high school scoliosis forward, I really try to get them thinking about core strength building, right, to take pressure off the spine, flexibility, stretching, losing weight, and really just remind them that they've just got a little bit of headwind, a little bit more stress on their spine than someone that doesn't have that lifelong mild scoliosis. Because the goal with scoliosis, as long as your shoulder, your global alignment, that your shoulders, when you look from the side and the front, line up over the hips when you stand up straight, right, meaning you're not off to the side or you're standing not leaning forward, you can tolerate forever a mild S shape curve as long as you're globally aligned and you're not hanging off to one side or the other.
Sanjiv Lakhia: 16:44
Well, that makes a lot of sense. Now, you touched a little bit on the treatment and the therapy approaches. I want to elaborate on that for our patients. We have an extensive physical therapy department and this is kind of their approach and you tell me what you think. In general, what I'll advise patients is the goal of PT when you're looking at scoliosis and spinal curvature issues is you want to strengthen the weak muscles, loosen some of the tighter muscles and really work from the ground up to reestablish that pelvic-spine-shoulder alignment. Now there is a method called the Schroth method. That's S-C-H-R-O-T-H if you're taking notes and we'll put a link to that in the show notes. That is out there and has been recommended for several decades for scoliosis. Do you have much familiarity with that?
Matt McGirt: 17:35
I do know about it because our therapy [inaudible 00:17:38] patients go to it and return from it oftentimes with successful results, but I'm not a part of administering it.
Sanjiv Lakhia: 17:46
Yeah, and I think that's where I tend to recommend individuals start out. But the question I'd have for you is let's say an adult comes in now with back pain and scoliosis. What are the things you're looking out for that would kind of flash a light bulb and say, "You know what, this individual, PT may not be the right initial approach. Surgery may be on the table for consideration," so what are some of the more concerning signs and symptoms that you're looking out for in your patient?
Matt McGirt: 18:17
Absolutely. Situations where that curvature and degeneration that might be a little bit more advanced in the aging spine because of that malalignment takes hold, it can begin to encroach on nerves. And if folks began to have spinal stenosis or shooting sciatica from nerve root impingement, that's going to be a red flag that things are a little bit more advanced.
Matt McGirt: 18:41
We like to take x-rays of the entire spine standing upright so we can then ... We have metrics and measurements, and I mentioned global alignment. In folks whose global alignment is off, meaning it might bend one way and back the other way, but the end result is the head and shoulders just don't come back into alignment over the hips in any plane, that right there is a red flag that physical therapies, stretching, medications may have a little bit harder time to work. So when global alignment x-rays look off, when we start seeing signs of nerve impingement, those are some red flags that say, "Okay, we may need to think about being more aggressive on treatments."
Sanjiv Lakhia: 19:29
Are there any symptoms from a non-musculoskeletal side that are of concern? For example, ability to breathe, digestive, do you look at any of those more globally?
Matt McGirt: 19:40
Yeah, absolutely. So you'll see that one in some of the congenital pediatric cases and the idea with the idiopathic adolescent teenage years is that when you're bracing and you are following these curves almost every six months with x-rays, the goal is never to let it get so severe that it begins to threaten your ability to breathe or the ribcage or you have ribs rubbing on your hips.
Matt McGirt: 20:05
Now the adult population's a little bit different, right? Adult folks can oftentimes with curves that have progressed quite severely, in those situations, we've seen ... You can see all kinds of things, reduced lung capacity, right? You can only take maybe a quarter or a half amount of breath in so it's really hard to breathe and that's because you are so crunched over one direction that the chest cannot expand. Cervical deformities, which is a little bit different of an entire category can affect your ability to chew and eat and breathe well. And then, you can also have rib pain. Oftentimes, the ribs can rub against the iliac crest, the hip bone. They can cause a lot of pain as well. And the ability to balance, to use the legs when spinal stenosis gets progressive can also be obvious so ...
Matt McGirt: 20:57
And it's more severe forms of scoliosis can actually be life threat, something that occurred a lot in the '50s through '70s, 1950s through 1970s. Something that we tend in modern healthcare to be able to identify a little earlier than that, but not always. We do see some folks who were with pretty severe advanced disease that are in dire straits.
Sanjiv Lakhia: 21:20
Yeah, that's exactly true and I'm very thankful that we have the ability to potentially help them out. Now, moving forward, let's say you've seen this patient and you've determined that they have a significant enough spinal deformity that they need corrective surgery. So Matt, what can a patient expect as they go through the process? And since you do adult scoliosis and deformity surgery, let's focus on what adults can expect in particular.
Matt McGirt: 21:47
Certainly. Certainly. First of all, surgery to address adult deformity is a really big surgery. It's a big deal that has risks of a long time in the hospital, a long time out of work or out of activities of daily living. And so because it's such a big investment for patients, their caregivers and families, we really do everything we can to optimize the patient's quality of life before signing up for surgery.
Matt McGirt: 22:17
So, for example, I have many patients who will have a scoliosis, who will have a spinal malalignment that perhaps may require a 12-level fusion and three months of their life to recover from, but their biggest concern might be a pinched nerve at L5. In those situations, we'll go and do a small incision and decompress that nerve rather than do a big surgery. Why? Because it takes 45 minutes. You don't even need to spend the night in the hospital in many cases. And we can quite frankly begin to shift the overall quality of life enough that it meets the satisfaction of the patient.
Matt McGirt: 22:55
And that's a critical point, Sanjiv is that, look, if I'm a hammer, I don't want everything to look like a nail, right? And so sometimes, we have to pump the brake, we listen to patients and we say, "Look, this is largely a quality of life discussion." And I tell all my patients, "Look, you define what is acceptable or not to you, and I respond to that." In many cases, going in and doing a huge surgery to correct posture and all of these other things can be overkill if the patient is mostly trying to get to a point that's important to them in quality of life.
Matt McGirt: 23:32
So long story short is we really personalize the treatment to meet the shared goals of myself and the patient. So that might be injections on the nerve. That might just be a small discectomy or a couple of levels of discectomy. But when patients, Sanjiv, begin to not do well, have severe loss of quality of life and we've proven that some of the lower risk, less invasive treatments just aren't going to change the overall sum total of symptoms to a point that is satisfactory to the patient or their family, and we've proven that, right, that is when it makes sense to do something like a big scoliosis surgery.
Sanjiv Lakhia: 24:13
So someone's out there listening right now and they're wandering what do you mean by big?
Matt McGirt: 24:18
So big, yeah, yeah. So scoliosis surgery is one of the most invasive and most involved surgeries that we do in spine surgery. Doesn't matter if you're a neurosurgeon, you're an orthopedist, whether you're at Johns Hopkins or at CNSA in Charlotte, it is a big surgery. So what does that mean? On average, adult scoliosis surgery is 13 spinal levels, right? That means we are talking about a two-foot or a foot and a half incision on your back. In its smallest sense, oftentimes, it's five- or six-hour surgery. And in some situations, it can be the entire thoracolumbar-sacral-pelvic spine, which could be a three-foot long incision and 17 levels of fusion so that screws and rods throughout the spine.
Matt McGirt: 25:08
We often have to remove bone or quite frankly, fracture and break the spine in order to get it to move in the way we need it to, to straighten out. We're moving bone and ligament around a very sensitive spinal cord. Sometimes it gets angry or it doesn't work as well when we have to manipulate it or the spine around it. Wound healing can be a challenge. So there's a lot of ... Blood loss is not insignificant. Patients often have to have blood transfusions.
Matt McGirt: 25:36
So it's a large invasive surgery that takes a lot of time, loses blood, that puts in a lot of hardware and requires actually breaking the spine and putting it back together, and it hurts a lot. So folks are in the hospital usually a week, sometimes a little bit longer. They usually will spend a couple of weeks after surgery at a dedicated rehab facility rather than going home. And then, most patients will find themselves back a few weeks after surgery. And most all of my patients will tell you that the incisional pain, it takes about four weeks for that to really get better, but they're tired. They're fatigued. They're having to recondition for a few months after surgery. And Sanjiv, that's when there are no problems. That's when there are no road bumps and that's the story when there are no adverse events or complications.
Sanjiv Lakhia: 26:26
So if you're listening to Matt and I talk, please don't listen to what he's just said and just stop the podcast because ... As he said prior, there's extensive conservative care that's typically offered. And then, even before an individual can be scheduled for surgery, Dr. McGirt and colleagues will have you go through extensive medical clearance through your primary medical team. There's a lot of preparation and risk-benefit assessment that's done before an individual hits the table for a procedure like this.
Sanjiv Lakhia: 26:59
But the flip-side of that coin is that it's almost miraculous where you have individuals, Matt, that you'll treat who come to you with their eyes looking at their toes and then in their followup, they can look you in the eye because their postural change has been so significant and it's life altering. So it's both sides of the coin certainly with that. And I think you did a really good job there, just kind of breaking down in an honest way for individuals who are suffering from spinal deformity what the surgical process would look like.
Sanjiv Lakhia: 27:29
So on average, would you say, depending on the surgery, do you think individuals can go back to work or is it more dependent upon what type of work they're involved with?
Matt McGirt: 27:38
Yeah, there are many research studies that have come out in the last decade, right? This last decade, innovations in spinal deformity surgery skyrocketed. And the focus on true patient-reported outcomes data have really validated the effectiveness of these large spinal deformity surgeries when done right, the right way in the right patient.
Matt McGirt: 28:00
And to answer your question is absolutely. Some of my happiest patients, believe it or not, went through this four-week long surgical and recovery period to find themselves for the next many years feeling like they got their life back. And usually, this is a combination of severe spine pain or leg pain in addition to, just inability to get out and walk and stand up straight.
Matt McGirt: 28:26
And you mentioned it, your words of getting their life back are quotes that I have heard over and over again. When you can stand up, you can go outside to a park and walk around like everyone else, not for just a few steps, but for a mile, it is amazing the emotional and mental improvement these patients have and they're very grateful. So yes, it's a big surgery. It takes a lot of work from both the medical care team, patients and their families, but it can be well worth it on the other side of the journey.
Sanjiv Lakhia: 28:59 Now one more question about the surgical side that I get often asked by patients that I'd love for you to elaborate on is the surgical approaches. Individuals want to know is he going to go through my back? Is he going to go through my side? Is he going to go through my front? Can you give us kind of a simple breakdown of how you make those determinations?
Matt McGirt: 29:16
Yeah. It really depends on how much realignment is needed and how stiff the spine is. Just in the past probably six or seven years as minimally invasive advancements have begun to blossom, it has become less problematic to go through the side in order to create mobility through that anterior approach. So when surgeons say, "Look, I want to go through the side or through the front," that's to remove disks and to free up these spinal segments so that they're more mobile.
Matt McGirt: 29:52
And then typically, we then flip to the back and then it allows the posterior part of the surgery where we put the pedicle screws and rods in to be a little quicker, a little bit less blood loss and sometimes, you have to break the spine as I called it, and remove bone where a lot of risk can lie on nerves and spinal cord less.
Matt McGirt: 30:11
It really depends on a lot of details and nuances of what your X-rays and CAT scans show, but oftentimes, if you get two opinions and one opinion is to go only from the back and then, you get a second opinion, say, "Oh, wow, there's a thought that I need two surgeries, it must be twice as much," that's actually not true. There are data now showing that if you do a minimally invasive approach from the front, it can actually make that posterior part a lot less involved and quicker and safer.
Sanjiv Lakhia: 30:39
Oh, thanks for that clarification. That's been very helpful and in fact, of all interview, Matt, I've actually learned a ton myself so I really appreciate taking the time to do this. Just to recap for our listeners, we've gone over definitions with regards to scoliosis. We discussed some nonsurgical options. And then, you just kind of broke it down for us in a real nice way what to expect if you have to have surgery to correct your deformity.
Sanjiv Lakhia: 31:04
So I want to close with asking you a question I ask all my interviewees, look, those types of surgeries you just described, folks, he's standing on his feet for hours at a time doing these operations. It's a fairly stressful event for the surgeon to kind of go through. So you are not able to do that without some degree of health habits and healthy living. And I'd love for you to share your daily routine health habits that you adopt to stay physically and mentally strong and really function at such a high level, operating, committee work, research, scholar, leadership. Matt, what's your secret to success?
Matt McGirt: 31:50
Gosh. I try, I really work to have balance. I love medicine, science, my patients so much and I have a lot of energy. When I first started doing this, I was 120% into neurosurgery and spinal surgery. As I've gotten older, I'm happily married. My wife is a practicing physician. I have four children and a fifth one on the way. And I've learned over the years that I'm better at work and better at home, better father, better friend, better husband and better doctor when I'm balanced. So I now make sure that I set aside time to develop hobbies, to cultivate relationships with people and just take time to take a breath. So really balance for me is really helped me with staying power and not burn out.
Sanjiv Lakhia: 32:45
What do you do kind of for fun and recreation and to let go some of the stress?
Matt McGirt: 32:51
Yeah, absolutely. I've become just absolutely in love with golf. [Inaudible 00:33:00] started playing at 40 and it is something that I do with my sons. It's like a social game so it's something that's done in foursomes. It's cerebral. It's athletic and that is the best way for me to go out and blow off steam. Sometimes, I will on a Saturday morning get an early morning tee time and walk the seven-mile track here in Charlotte by myself, pray, think, practice gratitude and work on a hobby of mine. And so, that really has been something that I picked up about six years ago and spend a lot of time doing now.
Sanjiv Lakhia: 33:33
That's great. And I know a lot of golfers feel the same way. I myself, if I took up more golf, would likely find myself on your OR table with some sort of back injury. So I share a lot that I'm into meditation and just enjoy reading, spending time with family, but it's great to hear. And I always ask this question so our listeners can understand that there's other sides to the physicians and we take our preparation seriously, and when we show up to work and show up to perform.
Sanjiv Lakhia: 34:02
So Matt, I really appreciate you taking the time today. I know you're super busy. We covered a very important complex and at times confusing topic in a way that's simplistic, which really has been my goal with the Back Talk Doc podcast is to provide patients with information that they can understand and really educate them as they go into conversations with their health providers. So Matt, thank you for your time.
Matt McGirt: 34:26
Sanjiv, thank you so much for having me.
Outro: 34:29
Thank you for listening to this episode of Back Talk Doc brought to you by Carolina neurosurgery and spine associates with offices in North and South Carolina. If you'd like to learn more about Dr Lakhia and treatment options for back issues, go to backtalkdoc.com we look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
Welcome. You're listening to Back Talk Doc where you'll find answers to some of the most common questions about back pain and spine health brought to you by Carolina Neurosurgery and Spine Associates where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 00:32
In the wellness spine care over the course of my career, most of the things I see are fairly common and can be attributed to issues like back arthritis or disk herniations, but there certainly are patients that come into my office that make me pause, in particular, and we've all seen them, uncles, aunts, friends and family, individuals whose postures significantly affected by their spine. And you might hear terms like scoliosis or spinal deformity, and that is a condition that we sometimes struggle with.
Sanjiv Lakhia: 01:12
And I'm very excited today to bring to you an interview with my guest, Dr. Matt McGirt, a partner of mine at Carolina Neurosurgery and Spine Associates. He's one of our go-to guys. We're blessed in our group to have several physicians who understand adult spinal deformity and scoliosis quite well and can lead patients down a path to recovery. So I wanted to grab an hour of his time and really pick his brain today and share with you his insights. Matt, welcome to the show.
Matt McGirt: 01:42
Thank you, Sanjiv. I'm excited to be here with you today. This is an important topic.
Sanjiv Lakhia: 01:46
Yeah, absolutely. Now, folks, I want to go over his background and looking at his bio, it would take the entire interview to review it, so let me just give me some highlights. He's been with Carolina Surgery and Spine since 2014, and he did his medical school at Duke University, and did residency through the Johns Hopkins Hospital and also a spine fellowship.
Sanjiv Lakhia: 02:14
Scrolling through his achievements, there's just too many to count. He's an author or a coauthor on over 300 peer-reviewed publications. He's done hundreds of presentations locally and nationally. And really, Matt, if you were to end your career today, and I know you won't because you're just getting started, we could say you've had a great career already [inaudible 00:00:02:37]. It's unbelievable and your contributions to the field of neurosurgery and spine. And I'm going to put you on the spot, this is not on our list of interview questions, but you are perhaps best known for your appearance on The Ellen DeGeneres Show. Would you like to share with our listeners a little bit about how that came to fruition?
Matt McGirt: 02:58
Well, that was a great highlight of my career about 10 years in, and I was blessed to get to know a patient of mine, Dean Otto. It was under unfortunate circumstances. He was hit by a car, broke his spine, his back, was pinching his spinal cord and he could not move. He was paralyzed.
Matt McGirt: 03:16
And we'll make a long story short, surgery went great, but Dean was an incredibly unique individual. He demonstrated how belief, faith, hope, incredible hard work and determination, and a little bit of luck allowed him to beat the odds. And that story sort of found itself in mainstream media as a story of forgiveness, faith and determination. As Dean challenged me to run a half marathon with him on the one year anniversary of his paralysis, and he did this the day after the accident, something that I thought would be impossible.
Matt McGirt: 03:48
Just to tell you how great of a human he is, he forgave the young man who hit him, invited him to join us and then, we celebrated this triumph of those two gentlemen, one year in Napa Valley, ran a half marathon together. And quite frankly, just blessed to have been a part of that story. The two gentlemen that I mentioned did all the heavy lifting there and I appreciate them taking me along for the ride.
Sanjiv Lakhia: 04:12
Absolutely. What an uplifting story, just reminds me of why we're in this. And if you want to know more, we'll put a link on the show notes to the actual video clip when they appeared on The Ellen DeGeneres Show. Matt's been very humble. He played a big part in it as well, but that's just a fantastic story that I thought you should share. Let's rewind a little bit as individuals get to know you better, what kind of put you into the path of neurosurgery?
Matt McGirt: 04:37
Oh, I knew I wanted to be a physician, a doctor, gosh, since I was in elementary school. I loved going to the doctor, liked watching my friends get stitches when they got banged up. I was always a little different that way and quite frankly, did not have a physician or anyone in medicine in my family. It was new and exciting.
Matt McGirt: 04:55
I was fortunate enough to find myself at Duke medical school as a 22-year-old and went in with an open mind. The first thing in medical school you realize are that the medical specialties and the surgery specialties are quite different, and I just fit in with the fast-paced, immediate fix it of the surgical world and I knew I wanted to do surgery.
Matt McGirt: 05:15
And the organ system that just fascinated me that I loved studying in our classroom work and even on rotations was the nervous system. And for me, it was the perfect mix of the two, central nervous system, the peripheral nervous system and surgery. And I'm so thankful I made that decision. It's been, I think, the perfect fit and I love it. I love what I do.
Sanjiv Lakhia: 05:35
Yeah. I can tell you've never looked back. It's just great to hear how you kind of found your way into the field for a benefit for sure. Matt, when I have patients in the office and they're very complicated, I feel blessed that I can turn to you for your help. We have, I think between you and Dr. John Ziewacz and Dr. Paul Kim and others, we have several guys that we would consider as "complex spine specialists." To the average listener out there, can you explain to them a little bit about some of your training that allows you to do some of these type of cases and what exactly defines complex spine?
Matt McGirt: 06:14
Certainly, yeah. I mean I think in our practice and here locally, complex spine typically refers to larger, more challenging spine surgeries that involve instrumentation, screws and rods, revision surgery, surgeries that expand five, six, seven levels, and surgeries that really have come to the forefront over the last 15 years.
Matt McGirt: 06:42
Common spine surgery, we would call perhaps not complex, are your more common things, a disc herniation, a one- or two-level laminectomy, a one-level fusion, an anterior cervical fusion for arm pain or weakness in arms or hands. And that is the basic armamentarium of anyone who trains in neurosurgery, but larger spine surgery like we're talking about today, scoliosis or adult deformity, going in and having to revise or redo large fusion procedures, large spine tumors and some complicated spine fractures that we see from car accidents would fall under a more complicated spine.
Matt McGirt: 07:21
And to answer your last part of that question, most folks who go into that area of spinal reconstruction, complex spine, tend to spend an extra year or two after neurosurgery or orthopedic basic residency training, and I did that with Ziya Gokaslan at Johns Hopkins. He was world renowned for his cancer surgeries where we did some of the largest and innovative reconstructions, and I'm forever grateful for Ziya, Dr. Gokaslan for his mentorship over the years.
Matt McGirt: 07:48
And then, I would say the most important step actually is what happens after fellowship, when you get into the real world and you start cutting your teeth so to speak, that is, getting in under early supervision, beginning to increase your autonomy and taking on bigger and bigger cases. So that's certainly what I've done since I started out of fellowship in 2010, ten years ago.
Matt McGirt: 08:10
And I'm fortunate at CNSA that we're such a large practice that we can each have specialty positions so I can do and see a large volume of it. And the more of these you get to do, the better of them, the better you are at doing them.
Sanjiv Lakhia: 08:24
That's terrific. As a physiatrist, some of these cases, I have patients that come in and they can barely even look up at me because they have such a curvature and it's nice to have expertise in the group so I can hand the baton off and give the patient some hope.
Sanjiv Lakhia: 08:40
Let's go back a little bit. Can you define for our listeners spinal deformities, scoliosis? These are the different terms that are discussed. And can you give us some insight into what they actually mean?
Matt McGirt: 08:53
Certainly. Scoliosis is a type of spinal deformity. Simply put is an incorrect spine curvature. It affects your posture. It will allow your shoulders perhaps to be offset from your pelvis. And that can be in all different types of shapes, right? We come and think of scoliosis as an S-like curve, whereas you normally look at someone straight on and it should be straight up and down the spine. It'll look like a side-bending S.
Matt McGirt: 09:25
Other times, we will see if you look at someone from the side, normally someone would stand up straight. We've all seen folks whose spine is just sort of bent forward where their chest is actually leaning a good foot in front of their hips. That is another type of global alignment problem.
Matt McGirt: 09:44
So in its simplest form, spinal deformity is when the spine is malshapen so that your shoulders are no longer over your hips. And the reason that's important, particularly in the adult population, is imagine a tree leaning and trying to fall over, your spine muscles do everything they can because the brain tells them to, to help hold that tree up. So it's going out and it is firing muscles just like you would put rope around a tree on the back end to try to keep it from falling. You could imagine if those muscles have to strain all day long, to try to straighten that crooked spine, they're going to hurt a lot. And that's the essence of why folks with these spinal malalignments have so much pain in the adult population.
Sanjiv Lakhia: 10:34
That's a great point, and we'll talk a little more about that when we get into treatment, but that's the reason why when I have individuals with those postural deformities and they come in asking for trigger point injections and I basically tell them the relief will likely be short-lived because we're not getting to the root of the problem, which is your overall posture. You touched on this a little bit here, but do you consider any significant differences between adults and kids in terms of the types of scoliosis that can be developed?
Matt McGirt: 11:04
Yes. Thank you for asking that question. They're really separate diseases. You think of scoliosis and deformity, childhood and adolescence, it's really a different disease process. There are congenital types of scoliosis, whether it be malformed parts of the spine or the anatomy, whether it be that it secondarily forms in childhood because of a neuromuscular problem, whether it be from a tumor in the spinal cord. There are all kinds of primary congenital problems. And that typically is obvious early in childhood and many times, those need to be treated surgically to fix them. There's not a good medical or physical therapy way to do that, and that's congenital scoliosis of children.
Matt McGirt: 11:49
The most common childhood scoliosis, right, and we can all probably remember, we knew someone growing up who had a little bit of a scoliosis. In adolescents, we call that idiopathic, meaning unknown cause, idiopathic adolescent scoliosis, and that often and most commonly is a cosmetic issue. It will start to develop in a young person in late elementary school. Oftentimes, a school nurse may notice it and send to the pediatrician. It can be subtle S shape curves.
Matt McGirt: 12:18
I mentioned looking at someone's face forward and you may notice that there's a little S shape. Their shoulders and hips may be aligned, but if someone were to be in a bathing suit or you could see them from the back, maybe in fifth grade recess, it might be a little bit of a curve.
Matt McGirt: 12:33
And that's something that in most cases does not need surgery. The idea is that that mild scoliosis curve stays the same and does not progress. And as long as it doesn't progress or become too severe, nothing really surgical needs to be done. And the goal there is often bracing and bracing can be used up until puberty to help make sure that that curve does not worsen.
Matt McGirt: 13:00
Interestingly enough, Sanjiv, that once you are through puberty and kids are on the other side of that, the curve really sort of settles in and fixes there. So you could kind of the general terms, the goal of adolescent idiopathic scoliosis is to brace them, do stretching, physical therapy so that the progression of the severity of the curves does not progress and you can get them through puberty and then stabilized at that level. So those are sort of a brief summary and overview of the pediatric and adolescent scoliosis.
Sanjiv Lakhia: 13:33
That's terrific. And I know you deal mostly with adult spinal deformity, but certainly, I have some parents that are out there listening and have concerns for their teenage kids and I think that's a really nice summary of how to approach the problem. Another question that I'll often get, I'd like your thoughts on, is if you evaluate an individual, let's say in their early 20s and they come into your office and they had a slight S shape curve, does that patient require routine imaging the rest of their life to monitor for progression?
Matt McGirt: 14:05
Yeah, great question. Typically, once some ... So that individual almost always had developed that mild scoliosis in adolescence, almost always and it stabilized, right, in maybe age 13, 14, 15. And then typically, if a curve has stabilized, say age 14 through 23 like you mentioned, it is rare that at age 23 that it will pick up steam and start worsening all of a sudden. The greatest predictor of what will happen from age 23 to 33 is really what happened in the 10 years before. So if you can obtain or a family can obtain an X-ray if they have it, or even if they don't, sort of think back over the five years prior to what that spine of the child looked like, if it's been stable for five or six years before age 22, it's almost always stabilized up through adulthood.
Sanjiv Lakhia: 15:00
So that patient returns to your office, let's say now they're in there 40s and they're having some increased pain, what are some symptoms that you're looking out for that make you concerned about the scoliosis and their spinal deformity?
Matt McGirt: 15:16
Absolutely. Well, first of all, when folks carry that teenage year idiopathic scoliosis that stabilized, it might look a little bit different at the swimming pool, but never needed anything surgically done into adulthood, I always remind my adult patients at age 40 that look, in the aging spine, we all have reasons to have some back pain, some arthritis, some wear and tear. Somebody who has a little bit of a malalignment is just prone to see a little bit more strain and degeneration and wear on the tires, if you will, than someone who has a straight spine.
Matt McGirt: 15:54
So when I get the middle aged adult patient who carried high school scoliosis forward, I really try to get them thinking about core strength building, right, to take pressure off the spine, flexibility, stretching, losing weight, and really just remind them that they've just got a little bit of headwind, a little bit more stress on their spine than someone that doesn't have that lifelong mild scoliosis. Because the goal with scoliosis, as long as your shoulder, your global alignment, that your shoulders, when you look from the side and the front, line up over the hips when you stand up straight, right, meaning you're not off to the side or you're standing not leaning forward, you can tolerate forever a mild S shape curve as long as you're globally aligned and you're not hanging off to one side or the other.
Sanjiv Lakhia: 16:44
Well, that makes a lot of sense. Now, you touched a little bit on the treatment and the therapy approaches. I want to elaborate on that for our patients. We have an extensive physical therapy department and this is kind of their approach and you tell me what you think. In general, what I'll advise patients is the goal of PT when you're looking at scoliosis and spinal curvature issues is you want to strengthen the weak muscles, loosen some of the tighter muscles and really work from the ground up to reestablish that pelvic-spine-shoulder alignment. Now there is a method called the Schroth method. That's S-C-H-R-O-T-H if you're taking notes and we'll put a link to that in the show notes. That is out there and has been recommended for several decades for scoliosis. Do you have much familiarity with that?
Matt McGirt: 17:35
I do know about it because our therapy [inaudible 00:17:38] patients go to it and return from it oftentimes with successful results, but I'm not a part of administering it.
Sanjiv Lakhia: 17:46
Yeah, and I think that's where I tend to recommend individuals start out. But the question I'd have for you is let's say an adult comes in now with back pain and scoliosis. What are the things you're looking out for that would kind of flash a light bulb and say, "You know what, this individual, PT may not be the right initial approach. Surgery may be on the table for consideration," so what are some of the more concerning signs and symptoms that you're looking out for in your patient?
Matt McGirt: 18:17
Absolutely. Situations where that curvature and degeneration that might be a little bit more advanced in the aging spine because of that malalignment takes hold, it can begin to encroach on nerves. And if folks began to have spinal stenosis or shooting sciatica from nerve root impingement, that's going to be a red flag that things are a little bit more advanced.
Matt McGirt: 18:41
We like to take x-rays of the entire spine standing upright so we can then ... We have metrics and measurements, and I mentioned global alignment. In folks whose global alignment is off, meaning it might bend one way and back the other way, but the end result is the head and shoulders just don't come back into alignment over the hips in any plane, that right there is a red flag that physical therapies, stretching, medications may have a little bit harder time to work. So when global alignment x-rays look off, when we start seeing signs of nerve impingement, those are some red flags that say, "Okay, we may need to think about being more aggressive on treatments."
Sanjiv Lakhia: 19:29
Are there any symptoms from a non-musculoskeletal side that are of concern? For example, ability to breathe, digestive, do you look at any of those more globally?
Matt McGirt: 19:40
Yeah, absolutely. So you'll see that one in some of the congenital pediatric cases and the idea with the idiopathic adolescent teenage years is that when you're bracing and you are following these curves almost every six months with x-rays, the goal is never to let it get so severe that it begins to threaten your ability to breathe or the ribcage or you have ribs rubbing on your hips.
Matt McGirt: 20:05
Now the adult population's a little bit different, right? Adult folks can oftentimes with curves that have progressed quite severely, in those situations, we've seen ... You can see all kinds of things, reduced lung capacity, right? You can only take maybe a quarter or a half amount of breath in so it's really hard to breathe and that's because you are so crunched over one direction that the chest cannot expand. Cervical deformities, which is a little bit different of an entire category can affect your ability to chew and eat and breathe well. And then, you can also have rib pain. Oftentimes, the ribs can rub against the iliac crest, the hip bone. They can cause a lot of pain as well. And the ability to balance, to use the legs when spinal stenosis gets progressive can also be obvious so ...
Matt McGirt: 20:57
And it's more severe forms of scoliosis can actually be life threat, something that occurred a lot in the '50s through '70s, 1950s through 1970s. Something that we tend in modern healthcare to be able to identify a little earlier than that, but not always. We do see some folks who were with pretty severe advanced disease that are in dire straits.
Sanjiv Lakhia: 21:20
Yeah, that's exactly true and I'm very thankful that we have the ability to potentially help them out. Now, moving forward, let's say you've seen this patient and you've determined that they have a significant enough spinal deformity that they need corrective surgery. So Matt, what can a patient expect as they go through the process? And since you do adult scoliosis and deformity surgery, let's focus on what adults can expect in particular.
Matt McGirt: 21:47
Certainly. Certainly. First of all, surgery to address adult deformity is a really big surgery. It's a big deal that has risks of a long time in the hospital, a long time out of work or out of activities of daily living. And so because it's such a big investment for patients, their caregivers and families, we really do everything we can to optimize the patient's quality of life before signing up for surgery.
Matt McGirt: 22:17
So, for example, I have many patients who will have a scoliosis, who will have a spinal malalignment that perhaps may require a 12-level fusion and three months of their life to recover from, but their biggest concern might be a pinched nerve at L5. In those situations, we'll go and do a small incision and decompress that nerve rather than do a big surgery. Why? Because it takes 45 minutes. You don't even need to spend the night in the hospital in many cases. And we can quite frankly begin to shift the overall quality of life enough that it meets the satisfaction of the patient.
Matt McGirt: 22:55
And that's a critical point, Sanjiv is that, look, if I'm a hammer, I don't want everything to look like a nail, right? And so sometimes, we have to pump the brake, we listen to patients and we say, "Look, this is largely a quality of life discussion." And I tell all my patients, "Look, you define what is acceptable or not to you, and I respond to that." In many cases, going in and doing a huge surgery to correct posture and all of these other things can be overkill if the patient is mostly trying to get to a point that's important to them in quality of life.
Matt McGirt: 23:32
So long story short is we really personalize the treatment to meet the shared goals of myself and the patient. So that might be injections on the nerve. That might just be a small discectomy or a couple of levels of discectomy. But when patients, Sanjiv, begin to not do well, have severe loss of quality of life and we've proven that some of the lower risk, less invasive treatments just aren't going to change the overall sum total of symptoms to a point that is satisfactory to the patient or their family, and we've proven that, right, that is when it makes sense to do something like a big scoliosis surgery.
Sanjiv Lakhia: 24:13
So someone's out there listening right now and they're wandering what do you mean by big?
Matt McGirt: 24:18
So big, yeah, yeah. So scoliosis surgery is one of the most invasive and most involved surgeries that we do in spine surgery. Doesn't matter if you're a neurosurgeon, you're an orthopedist, whether you're at Johns Hopkins or at CNSA in Charlotte, it is a big surgery. So what does that mean? On average, adult scoliosis surgery is 13 spinal levels, right? That means we are talking about a two-foot or a foot and a half incision on your back. In its smallest sense, oftentimes, it's five- or six-hour surgery. And in some situations, it can be the entire thoracolumbar-sacral-pelvic spine, which could be a three-foot long incision and 17 levels of fusion so that screws and rods throughout the spine.
Matt McGirt: 25:08
We often have to remove bone or quite frankly, fracture and break the spine in order to get it to move in the way we need it to, to straighten out. We're moving bone and ligament around a very sensitive spinal cord. Sometimes it gets angry or it doesn't work as well when we have to manipulate it or the spine around it. Wound healing can be a challenge. So there's a lot of ... Blood loss is not insignificant. Patients often have to have blood transfusions.
Matt McGirt: 25:36
So it's a large invasive surgery that takes a lot of time, loses blood, that puts in a lot of hardware and requires actually breaking the spine and putting it back together, and it hurts a lot. So folks are in the hospital usually a week, sometimes a little bit longer. They usually will spend a couple of weeks after surgery at a dedicated rehab facility rather than going home. And then, most patients will find themselves back a few weeks after surgery. And most all of my patients will tell you that the incisional pain, it takes about four weeks for that to really get better, but they're tired. They're fatigued. They're having to recondition for a few months after surgery. And Sanjiv, that's when there are no problems. That's when there are no road bumps and that's the story when there are no adverse events or complications.
Sanjiv Lakhia: 26:26
So if you're listening to Matt and I talk, please don't listen to what he's just said and just stop the podcast because ... As he said prior, there's extensive conservative care that's typically offered. And then, even before an individual can be scheduled for surgery, Dr. McGirt and colleagues will have you go through extensive medical clearance through your primary medical team. There's a lot of preparation and risk-benefit assessment that's done before an individual hits the table for a procedure like this.
Sanjiv Lakhia: 26:59
But the flip-side of that coin is that it's almost miraculous where you have individuals, Matt, that you'll treat who come to you with their eyes looking at their toes and then in their followup, they can look you in the eye because their postural change has been so significant and it's life altering. So it's both sides of the coin certainly with that. And I think you did a really good job there, just kind of breaking down in an honest way for individuals who are suffering from spinal deformity what the surgical process would look like.
Sanjiv Lakhia: 27:29
So on average, would you say, depending on the surgery, do you think individuals can go back to work or is it more dependent upon what type of work they're involved with?
Matt McGirt: 27:38
Yeah, there are many research studies that have come out in the last decade, right? This last decade, innovations in spinal deformity surgery skyrocketed. And the focus on true patient-reported outcomes data have really validated the effectiveness of these large spinal deformity surgeries when done right, the right way in the right patient.
Matt McGirt: 28:00
And to answer your question is absolutely. Some of my happiest patients, believe it or not, went through this four-week long surgical and recovery period to find themselves for the next many years feeling like they got their life back. And usually, this is a combination of severe spine pain or leg pain in addition to, just inability to get out and walk and stand up straight.
Matt McGirt: 28:26
And you mentioned it, your words of getting their life back are quotes that I have heard over and over again. When you can stand up, you can go outside to a park and walk around like everyone else, not for just a few steps, but for a mile, it is amazing the emotional and mental improvement these patients have and they're very grateful. So yes, it's a big surgery. It takes a lot of work from both the medical care team, patients and their families, but it can be well worth it on the other side of the journey.
Sanjiv Lakhia: 28:59 Now one more question about the surgical side that I get often asked by patients that I'd love for you to elaborate on is the surgical approaches. Individuals want to know is he going to go through my back? Is he going to go through my side? Is he going to go through my front? Can you give us kind of a simple breakdown of how you make those determinations?
Matt McGirt: 29:16
Yeah. It really depends on how much realignment is needed and how stiff the spine is. Just in the past probably six or seven years as minimally invasive advancements have begun to blossom, it has become less problematic to go through the side in order to create mobility through that anterior approach. So when surgeons say, "Look, I want to go through the side or through the front," that's to remove disks and to free up these spinal segments so that they're more mobile.
Matt McGirt: 29:52
And then typically, we then flip to the back and then it allows the posterior part of the surgery where we put the pedicle screws and rods in to be a little quicker, a little bit less blood loss and sometimes, you have to break the spine as I called it, and remove bone where a lot of risk can lie on nerves and spinal cord less.
Matt McGirt: 30:11
It really depends on a lot of details and nuances of what your X-rays and CAT scans show, but oftentimes, if you get two opinions and one opinion is to go only from the back and then, you get a second opinion, say, "Oh, wow, there's a thought that I need two surgeries, it must be twice as much," that's actually not true. There are data now showing that if you do a minimally invasive approach from the front, it can actually make that posterior part a lot less involved and quicker and safer.
Sanjiv Lakhia: 30:39
Oh, thanks for that clarification. That's been very helpful and in fact, of all interview, Matt, I've actually learned a ton myself so I really appreciate taking the time to do this. Just to recap for our listeners, we've gone over definitions with regards to scoliosis. We discussed some nonsurgical options. And then, you just kind of broke it down for us in a real nice way what to expect if you have to have surgery to correct your deformity.
Sanjiv Lakhia: 31:04
So I want to close with asking you a question I ask all my interviewees, look, those types of surgeries you just described, folks, he's standing on his feet for hours at a time doing these operations. It's a fairly stressful event for the surgeon to kind of go through. So you are not able to do that without some degree of health habits and healthy living. And I'd love for you to share your daily routine health habits that you adopt to stay physically and mentally strong and really function at such a high level, operating, committee work, research, scholar, leadership. Matt, what's your secret to success?
Matt McGirt: 31:50
Gosh. I try, I really work to have balance. I love medicine, science, my patients so much and I have a lot of energy. When I first started doing this, I was 120% into neurosurgery and spinal surgery. As I've gotten older, I'm happily married. My wife is a practicing physician. I have four children and a fifth one on the way. And I've learned over the years that I'm better at work and better at home, better father, better friend, better husband and better doctor when I'm balanced. So I now make sure that I set aside time to develop hobbies, to cultivate relationships with people and just take time to take a breath. So really balance for me is really helped me with staying power and not burn out.
Sanjiv Lakhia: 32:45
What do you do kind of for fun and recreation and to let go some of the stress?
Matt McGirt: 32:51
Yeah, absolutely. I've become just absolutely in love with golf. [Inaudible 00:33:00] started playing at 40 and it is something that I do with my sons. It's like a social game so it's something that's done in foursomes. It's cerebral. It's athletic and that is the best way for me to go out and blow off steam. Sometimes, I will on a Saturday morning get an early morning tee time and walk the seven-mile track here in Charlotte by myself, pray, think, practice gratitude and work on a hobby of mine. And so, that really has been something that I picked up about six years ago and spend a lot of time doing now.
Sanjiv Lakhia: 33:33
That's great. And I know a lot of golfers feel the same way. I myself, if I took up more golf, would likely find myself on your OR table with some sort of back injury. So I share a lot that I'm into meditation and just enjoy reading, spending time with family, but it's great to hear. And I always ask this question so our listeners can understand that there's other sides to the physicians and we take our preparation seriously, and when we show up to work and show up to perform.
Sanjiv Lakhia: 34:02
So Matt, I really appreciate you taking the time today. I know you're super busy. We covered a very important complex and at times confusing topic in a way that's simplistic, which really has been my goal with the Back Talk Doc podcast is to provide patients with information that they can understand and really educate them as they go into conversations with their health providers. So Matt, thank you for your time.
Matt McGirt: 34:26
Sanjiv, thank you so much for having me.
Outro: 34:29
Thank you for listening to this episode of Back Talk Doc brought to you by Carolina neurosurgery and spine associates with offices in North and South Carolina. If you'd like to learn more about Dr Lakhia and treatment options for back issues, go to backtalkdoc.com we look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.