Sunday, June 19, 2005
Copyright © Las Vegas Review-Journal

SCOLIOSIS SURGERY: LEARNING TO STAND TALL

Revolutionary technique offers hope to 13-year-old with painful spinal deformity

Andrew Sheridan comforts his son, Nicholas, after surgery to correct a severe curvature of the spine. "I cried for him and worried that the physical pain was too much for him," Andrew Sheridan says. Photos by Clint Karlsen. About a week before his back operation, Nicholas enjoys pizza that his stepmother, Janice, serves him and her 85-year-old mother, Lenora Bales, who was paralyzed by her own back surgery. "It's hard not to think about what happened to her," he says. By using linked levers that he designed, Dr. Mark Barry rotates Nicholas Sheridan's vertebrae into straight alignment. Nicholas has second thoughts about having an operation as he walks into Sunrise Hospital and Medical Center with his father. Using X-rays, Barry plans every step of Nicholas' procedure. Diana Sheridan, Nicholas' mother, hugs her son before surgery. Click image for enlargement. Graphic by Mike Johnson. In less than a minute, Dr. Mark Barry's surgical team rotates the third dimension of Nicholas Sheridan's spinal deformity into alignment. Before surgery After surgery After his operation, Nicholas Sheridan rests at home. A couple weeks after surgery, Nicholas and Dr. Mark Barry discuss a timetable for recovery. Less than five months after the procedure, Nicholas trains at Desert Sun Taekwondo. After his operation, Nicholas no longer has a hump on his back.

In less than a week, 13-year-old Nicholas Sheridan will undergo surgery to try to correct his scoliosis, a twisting curvature of the spine that keeps getting worse. Sitting near him at the dinner table is 85-year-old Lenora Bales, confined to a wheelchair since her 1997 back surgery went wrong.

The sun streams in the windows of the one-story home and forces the squinting, white-haired woman to roll out of the sunlight and away from Nicholas. A grimace replaces her smile as she twists to turn her chair.

Between bites of pepperoni pizza, the seventh-grader at Saville Middle School in northwest Las Vegas watches the elderly lady he has come to love. And he admits it is difficult with his Jan. 18 operation coming up to keep his mind off what happened to her.

The mother of Nicholas' stepmother -- she refers to herself as "still a young chick" -- had a couple of troublesome discs in her back before what she thought would be a simple surgery. She had relatively little pain or trouble getting around until complications from her procedure left her with nerve damage in her legs and feet.

"Now she says she feels like she has thousands of needles sticking in her feet all the time so she can't walk," Nicholas says, running his hands through an unruly shock of brown hair as he watches her wheel herself to her bedroom. "I see her every day, and what she had done was supposed to be easier than what I'm having done on my back. So I think it's natural for me to be nervous."

Nicholas, who loves video games, karate and the violin, actually started to get a little nervous nearly a year earlier. It was then that his stepmother, Janice Sheridan, thought she saw "something strange with Nicholas' waist and shoulder. One side would curve in. I think I probably knew a little more of what to look for because my own daughter had scoliosis."

X-rays revealed a severe curvature of Nicholas' spine. The family's doctor referred the youngster to a Las Vegas pediatric orthopedist, 46-year-old Dr. Mark Barry. A Canadian transplant, he has been instrumental in developing a system of three-dimensional correction of scoliosis that is drawing attention from physicians across North America.

Embarrassing deformity

About 2 to 3 percent of the population, or an estimated 6 million people in the United States, are affected by scoliosis. According to the National Scoliosis Foundation, scoliosis patients make more than 600,000 visits to private physician offices each year. An estimated 30,000 children are put into a brace for the condition, and nearly 40,000 patients undergo spinal fusion surgery that can cost up to $150,000.

Research shows the primary age of onset for scoliosis is 10 to 16 years old, and the condition occurs equally among both genders. However, females are eight times more likely to progress to a curve that requires treatment.

At its worst, scoliosis causes constant pain, compromises lung and heart function, and leaves an individual looking like Quasimodo, the stooped and hump-backed hero of Victor Hugo's classic novel "The Hunchback of Notre Dame."

It is a deformity, say some with the condition, that can cause so much shame and embarrassment that an individual becomes relegated to a lifetime role of embittered observer and loner. For some with the disability, the term "hunchback" has the emotional power of a racial slur.

When Hugo's novel was being made into a Disney movie in 1996, thousands of scoliosis sufferers objected to the marketing of the Quasimodo image that they said dehumanized them. The National Scoliosis Foundation asked Disney to refrain from using the word in its production and to forgo toys, posters and television ads featuring the spinal deformity, to no avail.

An undetected ailment

Nicholas worries about taunts as his scoliosis progresses in severity, the curvature increasing more than 20 degrees in just four months.

"I haven't been able to concentrate at school. All I could think about was the hump I had on my back and how kids looked at me and what they thought of me. It was very weird, and I felt very self-conscious. Every time I turned the corner I thought that people were talking about me, `the scoliosis boy,' and how they were making fun of me. I felt like there was no one else who felt or looked like me. It made me feel very alone and sometimes isolated.

"I think that all made me really want the surgery."

That Nicholas' scoliosis wasn't noticed sooner is not uncommon. The condition usually progresses at an age when children become more self-conscious and avoid exposing their bodies to parents and others.

Often, nurses in state-mandated school screening programs are the first to detect the uneven shoulders, prominent shoulder blade or shoulder blades, uneven waists, elevated hips or leaning to one side that are warning signs of the condition. (In Nevada, children are screened in the fifth and eighth grades.)

Because it is rarely particularly painful in a child's formative years, scoliosis can go undetected by someone with the condition until it progresses well beyond any chance of a brace stopping it in its tracks.

"Sometimes I've been short of breath, but I didn't know it could be from a crooked spine," Nicholas says as he plays a video game in the family room of his home. "I always just figured sore muscles I had came from doing too much."

Physicians have dealt with the spinal deformity with varying degrees of success for centuries, yet 85 percent of the cases are classified as idiopathic, or having no known cause.

The likelihood of having scoliosis increases from 2 percent to about 20 percent when someone in the family has the condition.

Nicholas' grandmother on his father's side has it. So did his late great-aunt, who had to stay in a body cast for a year when spinal surgical techniques were more primitive.

Researchers have been unable to find a genetic component for the condition that would allow physicians to reverse the abnormal growth nonsurgically.

Unnatural curvature

Natural curves are part of everyone's spine, creating slightly round shoulders and lower backs that curve slightly inward.

Viewed from behind, a normal spine appears straight from the neck to the buttocks. But on an X-ray, the spine of an individual with scoliosis also curves side to side, looking more like an "S" or "C" than a straight line. And the spine rotates or twists at the same time, making it a three-dimensional deformity.

Nicholas has the "S" twisting variety of scoliosis. Unlike poor posture, his curves can't be corrected by learning to stand up straight.

A spinal curvature of greater than 10 degrees defines scoliosis.

Viewed straight on, a normal spine is at 0 degrees. A curve that is horizontal, or parallel to the floor, would be 90 degrees.

When Nicholas first saw Barry in late summer of 2004, his "S" curve was more than 45 degrees in his upper back and 36 degrees in his lower back. By December, the curves had jumped to 66 degrees and more than 50 degrees, respectively.

"When a child is in a growth spurt, that often happens," Barry says.

Doctors typically recommend surgical treatment for people whose curves are greater than 40 to 50 degrees, aware that the deformity will only continue to worsen.

Fortunately, four out of five patients with scoliosis require no treatment other than periodic observation.

Observation usually is appropriate for curves up to 25 degrees. If a curve measures more than 25 degrees, but less than 40 degrees, and the child still is growing, a brace usually is prescribed.

Studies have shown bracing to be effective in preventing scoliosis from progressing to the point of needing surgery in about 70 percent of cases. So while bracing does not cure scoliosis, or even improve the curve, it can be a critical key to avoiding the scalpel.

"I can't emphasize just how important early detection is," says Joseph O'Brien, president of the National Scoliosis Foundation. "Parents and doctors and schools can save a lot of wear and tear on many young people if they discover the problem early."

A revolutionary technique

Nicholas was devastated when Barry told him he needed surgery.

"I almost cried," he says.

"He turned white as a sheet," his stepmother recalls.

Nicholas' father, Andrew Sheridan, a 41-year-old schoolteacher and son of a retired surgeon, didn't immediately settle on Barry, a Canadian-trained physician, to perform his son's surgery.

"We contacted several orthopedic groups, but only a few seemed to emphasize pediatric cases," he recalls.

"Dr. Barry's group offered a solution that, while still a developing treatment, appeared safe and effective. We were assured that the curvature would be corrected, with few side effects, and that Nick would return to a normal life within several months. We contacted several parents of patients who had undergone the surgery and heard only good news."

What the Sheridans learned from parents and Barry was stunning.

Since 2002, in the more than 30 scoliosis cases where he used a surgical technique that he had largely developed, he saw an average correction in excess of 93 percent, without complications.

Many surgeons consider correction of 50 percent to 70 percent a success. Eighty percent corrections are considered major accomplishments.

"Dr. Barry's surgical technique for scoliosis correction is a very real advancement," says Dr. Isadore Lieberman, head of minimally invasive surgery at the renowned Cleveland Clinic, which is recognized as the country's top medical center.

"He's taken a technically challenging procedure, simplified it and made it much more efficient and safer for the patient."

Lieberman invited Barry to present his technique at the Cleveland Clinic in June. Surgeons from across the country listened intently and asked a lot of questions.

"People are starting to look at his (Barry's) technique," Lieberman says. "He's raised a lot of eyebrows. I don't quite use his techniques, but I am using his ideas."

Barry, who has done more than 500 spinal surgeries, also was called upon to give his "Three Dimensional Scoliosis Correction" presentation at the prestigious Pediatric Orthopedic Society of North America annual meeting held earlier this year in Ottawa, Canada.

Lieberman says Barry is using real time X-rays and other advancements to ensure the screws are placed correctly. And he described his method of torquing the spine into alignment as an advancement.

A fellow of the Royal College of Surgeons of Canada and diplomate of the American Board of Orthopaedic Surgery, Barry received his medical degree from the University of Ottawa in 1984 and received fellowship training in pediatric orthopaedics and scoliosis at the Hospital for Sick Children in Toronto.

He would go on to complete a musculoskeletal tumor fellowship in 1991 at Mount Sinai Hospital.

Barry left Canada in 1993. He found the socialized system of medicine there often made his patients wait months for treatment.

"I'll never forget how he came home one night and said he had a little boy who had been without a foot for months just because of the bureaucracy," says his wife, Yvonne, who also is a physician. "He had designed a procedure for the prosthesis and the boy was having to wait, and it was killing my husband."

When Desert Orthopedics offered to streamline the immigration process, Barry came to Las Vegas, where he is now an assistant clinical professor for the departments of pediatrics and surgery at the University of Nevada School of Medicine.

He initially planned on staying just four or five years. But the avid skier fell in love with the city, particularly enjoying its access to the mountains.

And he immediately found young people who could use his help.

Overcoming cold feet

Twice Barry had to cancel surgeries for Nicholas. First, in October, Nicholas was sick. Then in December, Nicholas' father was ill.

One teenager, Breanna Ogle, called Nicholas in January. She told him that Dr. Barry had done her work just eight months before and now she was able to ski.

"I couldn't believe it," Nicholas says, shaking his head a few hours before his surgery. "She was calling me from the top of a mountain where she was skiing. It meant a lot to hear from another kid. She told me to keep asking questions of Dr. Barry. That he would answer them. And he did."

But at 5:30 a.m. Jan. 18, Nicholas is questioning whether he should even have the procedure.

With his father and stepmother accompanying him in the darkness, he walks across the Sunrise Hospital and Medical Center parking lot in his pajamas, robe and slippers, and appears to be talking to himself. He is shivering in the 40-degree weather.

"I just want everything to go all right today," he says to no one in particular. "I'm not sure we should do this today."

When Nicholas arrives at the hospital, his mother, Diana Sheridan, is there. She is reading the Bible.

"I'll be praying hard for my son today," she says as they hug.

Well before the surgery begins at 8:45 a.m., a smiling Barry strolls into the operating room with his red toolbox. Inside are the tools of the orthopedist: drills and saws and hammers and screwdrivers of different shapes and sizes.

"I helped build four houses as summer jobs and fixed many cars," he says. "This definitely helped my familiarity and comfort with tools and techniques I use in surgery today."

Walking up to Barry to give him a glass of orange juice, which she refers to as a "magical elixir," is Dr. Yvonne Barry. The mother of their three children and a family physician, she assists her husband on major cases.

She is a master at utilization of time, having had all three children while either in medical school or in her residency. She says she has gotten used to her husband awakening in the night to write down a new surgical technique.

Visit Barry's office and you see evidence of his sketches and designs everywhere.

"The ideas and inventions keep coming at all times," he says. "I come up with some of my best ideas during periods of insomnia, when I have a racing mind. I've always been the type of person who looks at something and wonders how it can be done better. I talk with colleagues, engineers, nonmedical idea people, and keep in touch with technologic innovations to see how I can apply ideas to what I'm doing."

The periods of insomnia seem to have no effect on Barry's energy. "He'll never have to drink Red Bull," his wife says, laughing. "He's always going. Of course, he loves the operating room more than any place. It's his sanctuary."

When Barry isn't working, he's running, lifting weights, skiing on both snow and water, playing tennis or mountain biking. His 6-foot-1 inch frame remains at an athletic 170 pounds.

The registered nurse who assists Barry on scoliosis cases, Jan Monroe, says Yvonne Barry has the energy to keep up with her husband in the operating room.

"She always seems to know what her husband needs in the operating room," Monroe says. "She anticipates very well."

Monroe jokingly calls the surgeon's wife, who also holds a doctorate in cardiac physiology, "Dr.-Mrs.-Dr. Barry."

Also on the team are certified surgical technician Rick Boohr, certified orthopedic technician Randy Wells, anesthesiologist Dr. Roland Miyada, and Glenn Livezey, a neurophysiologist who monitors the spinal cord during the procedure.

"We don't want any neurological damage," Livezey says.

Joining the team is Brian Diefenbacher, a spine technical product specialist for EBI, a New Jersey firm that often supplies Barry and other surgeons with the instruments and tools they need. Diefenbacher has visited operating rooms around the world.

He says his company often custom makes instruments from Barry's designs. Often in the operating room, Barry suggests a new tool or instrument he would like.

"What he is doing is really cutting-edge stuff," Diefenbacher says. "I'm having other surgeons look at what he does. I can't tell you how incredible his results are. He's getting results like no one else in the world."

Each operation is carefully planned, with Barry using quiet time early in the morning to mentally picture how he expects the procedure to go. Marked up X-rays of Nicholas can be seen throughout the operating room.

"At every point of the operation I continually evaluate how I can do each step optimally and what potential hazards I need to avoid. That's what keeps me out of trouble."

As the Barry team prepares the room for surgery amid the hum, buzz and beeps of modern medical apparatus, their discussion, sprinkled with a good bit of laughter, centers on falls on the ski slopes. And on families.

"The closer we get to one another, the better we do," says Barry, who might be the least talkative of the team. "You need a good team to get a good result."

Teamwork, he says, is probably more important in surgery than on the athletic field. Who does what when in a procedure isn't something learned overnight.

"One thing I've never understood," Barry says, "is that people in managed care insurance companies seem to appreciate in discussions that athletes have to be together as a team to win. But too often they want surgeons to go into the most difficult of procedures with different members on a team. You can't get the best result that way. You just can't. I want the same good people around me."

When Nicholas is wheeled into the operating room, Miyada, who'll be monitoring the patient's anesthesia, asks him if he's allergic to anything. "Cats," Nicholas says.

"We don't allow cats in the operating room," Miyada replies.

After Nicholas is placed facedown on the operating room table as the anesthesia takes hold, the first cuts of the 3 1/2 hour procedure, and of the music, begin. To the accompaniment of the Moody Blues, Peter Frampton and the Beatles, Barry attacks the deformity.

A painstaking process

Peeling muscles back, Barry exposes the spine.

The sounds of hammering and drilling occasionally drown out the CDs as he strategically and oh-so-carefully places 19 2-inch-long screws in select vertebrae. He uses real-time X-rays to know exactly where to insert the screws, none of which are placed at quite the same angle.

The work must be precise. A wrong move can harm the spinal cord and mean paralysis, or worse. It takes about an hour for Barry to anchor the screws from the top of the curve to the bottom.

For the next 45 minutes, Barry works to attach two thin 8-inch-long titanium rods to the screws. This process begins with Barry bending the rods to the curvature of the spine with an instrument that looks much like a pair of pliers.

The rods then are inserted into the screws and secured. Barry rotates the rods using instruments similar to wrenches until the spine is straight from a posterior view, or looking down on the spine.

Nicholas' scoliosis now has been corrected in two dimensions.

Traditionally, scoliosis has been regarded as a two-dimensional deformity, a simple "S" shaped curve, for example.

Traditional treatment has been a partial straightening of the "S" curve with two rods and multiple attached bone hooks. The "S" curve is stretched out along the rods and anchored using the hooks.

The previously uncorrected third dimension of scoliosis, however, involves the kind of twisting of the vertebrae that Nicholas and most others with the condition suffer. Barry uses specially designed torque tubes, or levers, to rotate the vertebrae into alignment.

The tubes/levers are placed onto the the heads of the screws, and Barry and his team grasp them, providing rotation and counterrotation force for correction throughout the spine where needed.

The pressure applied on the levers is not unlike loosening a lug nut while changing a flat tire.

The rotation and counterrotation takes less than a minute, and Nicholas' third dimension of scoliosis is corrected.

"It's so exciting when our team uses those levers to correct the curve," nurse Monroe says. "With all those levers there, it looks like an erector set. It's really like the climax of a movie when they turn those levers and the spine straightens. That's when you know the child is going to be so much better off."

Barry peers at new X-rays and seems satisfied. "Looks good," he says, nodding at his wife next to him. He sprinkles donor bone graft along the rods.

In three months, the grafts will be so hard that the rods won't even be needed for the fusion. But because they do no harm, and opening up the body is always risky business, they will be left in the body.

The length of the stiff, fused segment in Nicholas' back has been minimized by the three-dimensional technique.

Since most spinal motion in the trunk comes from the low back, fusing as high in the spine as possible saves more mobile discs in the low back. That might mean a future of less lower back pain and less chance of future painful spinal degenerative arthritis.

A painful recovery

When Nicholas wakes up in the recovery room, he doesn't want to hear about less pain in the future. He has pain like he never has had before, and he pushes a patient-administered morphine drip to blot it out.

Again and again and again.

For three days.

His mother, father and stepmother, who took turns at his bedside right after the surgery, then help him take his first few halting steps the day after his procedure.

Each day Barry wants him to walk a little longer. Sometimes there are tears in the youngster's eyes. "Oh, it hurts," he moans.

A few weeks later the memory of the pain is still with him.

"I hurt all over after surgery," he says. "Especially in my back. It was like someone had put thousands of needles in me."

As Nicholas lay in the hospital, his father's heart ached.

"I cried for him and worried that the physical pain was too much for him," Andrew Sheridan says, recalling his son's five-day hospital stay. "But then I saw how well the hospital staff took care of him and tended to his every need. At first, he was immobile and helpless. His mobility improved a bit toward the end of his hospital stay. ...

"Upon arriving home, he remained bedridden for the better part of two weeks, though his eating improved."

Every day at home, Nicholas follows doctor's orders and walks a little further.

"It really does hurt," he tells a visitor, grimacing as he walks stiffly across the room.

When Nicholas is in bed, his Chihuahua, Gidget, as if sensing his pain, often jumps on his bed and licks his face.

After seven days at home, however, Nicholas is able to wean himself from all pain medication but still needs assistance.

"He had a bell in his room (for) when he wanted something," Janice Sheridan recalls. "Mother's chair for the bath really came in handy. Not to mention the hand-held shower head. Without that, Nick could not have taken showers. He was way too weak to stand and to close his eyes made him dizzy."

Resilience on display

Four weeks after the operation, Nicholas feels well enough to go to school.

His classmates are incredulous when they see him. One after another they say, "You've grown."

In fact, the operation made him gain 2 inches. He literally stretched from 5 feet 1 inch tall to 5 feet 3 inches tall in less than four hours.

Aware that Nicholas still is a tad shaky on his feet, school administrators give him a hall pass so he can walk to his next class before or after the other students and avoid getting bumped.

The school bus driver gives him the first seat on the bus so he will have an easier time getting on and off.

The teachers allow him to stand or move in class when he needs to.

"Everyone was so nice and patient to me," he says.

Less than eight weeks after the operation, Nicholas has to be told repeatedly to take it easy by his father and stepmother.

"Just because you feel good doesn't mean you can be carrying big water bottles," Janice Sheridan tells him.

Before getting his full release to resume activity -- with Barry's technique that usually comes three months after the operation -- Nicholas and his dad hike at Red Rock.

"I took it easy, but Nick just needed to get out and do something," Andrew Sheridan says a few days later. "He's feeling great. It's amazing. A few weeks ago he was hurting so bad, and now he feels ready to do anything. Kids really are resilient."

During one of Nicholas' visits to Barry after the operation, the doctor is ecstatic as he looks at X-rays. So is Nicholas.

"You're as straight as you're going to get," Barry says, indicating there is more than a 95 percent correction of the curve. Barry seems to feed off the boy's enthusiasm.

"I love working with children," he says. "They have so much desire to be healthy, active and happy. I do my part to give them the best body for the rest of their lives, and they do the rest. I tell everyone that I have the best job in the world."

The Sheridans arrive at the wrong time for a three-month checkup, which delays Nicholas' full release for a couple weeks until they can reschedule. Finally, the day comes. Barry says all is well.

Dad and son celebrate by taking a karate class.

"I can't feel the rods in my back, but I still know something is there," Nicholas says. "I'm told pretty soon I won't even know they're there. I'm still kind of weak and really have to get in condition again."

Janice Sheridan is tickled by the change she sees in Nicholas.

"He's so much more confident now," she says. "His whole attitude has changed.

"What's given him so much pain in recovery is that his muscles were out of whack from the scoliosis, and they're learning how to work differently now. Everything was being cramped or stretched in ways they shouldn't have been. And now he's walking differently.

"He can even breathe better. He's not worried about how people are seeing him. He's not holding back when he's around people. It's good seeing him smile so much."

Nicholas is effusive in his praise for Barry, but he doesn't think anyone should take the surgery lightly.

"Dr. Barry developed a great technique," he says. "You have to give him all the credit. It's good for you, and you should have it if you really need it. But the immediate issue is that it sucks. You can't do too much immediately.

"I'm really looking forward to just being a regular kid again."