Lawrence Lenke, the man behind the Lenke system of classification, tells Spinal News International about how fortunate he feels to be able to limit his practice exclusively to treating patients of any age with spinal deformity. He is looking seriously into the prospect of an electronic Journal of Spinal Deformity and getting ready to take up the post of president of the Scoliosis Research Society, later this year.
How did you become interested in orthopaedic surgery?
I always wanted to become a doctor since my childhood. My mother was secretary to a famous orthopaedic surgeon in the Chicagoland area – Dr Howard Schneider, who invented the Schneider nail, an intramedullary nail for long bone trauma. He was my first mentor in orthopaedic surgery. I vacillated between entering either orthopaedic surgery or cardiothoracic surgery and ultimately chose orthopaedic surgery, somewhat because I thought the general surgery training required to obtain advanced training in cardiac surgery was overly burdensome.
What is it that interests you about spinal deformities?
I am fascinated by how the spinal column can become so severely deformed over time. I believe that correction of spinal deformity requires many different types of surgical expertise, including both orthopaedic and neurosurgical techniques. It is certainly one of the most challenging forms of surgical disciplines. It also requires one to be a complete physician in the pre-operative as well as post-operative care of the patient.
I do spend a fair amount of time in my practice treating severe spinal deformities usually referred by other surgeons throughout North America and beyond. Interestingly, many other patients with severe deformities also find me through the Internet as well. I feel very fortunate to have been able to limit my practice, for the last eight years, exclusively to the treatment of patients of any age with a spinal deformity. For the first 10 years of my surgical career, I took care of any operative spinal problem in children/adults, but have been able to slowly specialise in deformities after that. Like anything in medicine/surgery, the more you concentrate in one area, especially when one practices at a major medical centre like we have at the Washington University medical centre in St Louis, the more one is referred more challenging patients having that particular problem. I am very fortunate to be able to operate at three outstanding hospitals each week (Barnes-Jewish hospital for adults, St Louis Children’s hospital and the Shriners hospital for Children for paediatric deformities), each with extremely dedicated nursing/ancillary staff and administration which has supported my treatment of these most challenging patients. It certainly requires a team effort and my teams are top-notch and have allowed us to consistently provide good care to these patients. I guess at this point, it has become my calling and mission to have such a practice–everything has just slowly fallen in place over the past 18 years to do so.
You are pioneering a new surgical technique, the posterior vertebral column resection technique. Could you describe it?
The posterior verterbral column resection (VCR) technique has revolutionised the treatment of the most severe and stiff spinal deformities. It is really a procedure of last resort, when other more conventional techniques will not allow adequate deformity correction. The VCR has been around for several decades, but traditionally was done through separate anterior and posterior approaches to the spine, usually done on separate days. Now, we are able to perform the entire procedure through a single posterior incision, usually all in one day. To explain the procedure, and the reason for its usefulness in severe, stiff deformities, one can imagine a very deformed and stiff spinal column where the apical vertebra(e) of the scoliosis or kyposis is/are removed. This essentially separates the proximal and distal limbs of the deformity, which we then slowly bring back into a more normal alingment with segmental pedicle screw instrumentation. The large degree of instability produced by the separation is quite advantageous for correction, but also carries a fair degree of risk to the spinal cord at the same time. So the use of sophisticated spinal cord monitoring techniques are essential to minimise major neurologic deficits during the surgery. The radiographic and clinical results are quite dramatic and the patients and their families have been quite pleased with the outcomes. It has actually become one of the most common procedures that I perform, reflecting the type of patients that my practice now treats.
Could you describe some memorable cases you have treated, and the outcomes?
My first VCR was performed on a very severe 149 degree thoracic scoliosis teenager from Moscow, Russia. She was in florid cor pulmonale when she came to us. Following three months of halo-gravity traction and two surgical procedures, her spinal column was corrected to 49 degrees, she had gained seven inches in height and stood up (taller than I at that point) and gave me the biggest hug a patient has ever given me! I think she realised that not only had we corrected her curve/given her a large height gain, we had also saved her life as she would have not done well for very long with the severe curvature that she had had.
What are the major challenges facing scoliosis today?
There are many challenges facing spinal deformity surgery today. One of the most pressing ones is the cost associated with modern scoliosis care. Although throughout the world, research has shown that the use of posterior segmental pedicle screws has provided optimal radiographic and clinical results with very low complication and revision rates, these are very expensive surgeries. Also, spinal deformity care at the opposite ends of the age spectrum remains especially challenging: early onset and elderly patients. For the early onset (<age 8), correcting deformity without fusion and still allowing for spinal and chest wall/pulmonary growth remains challenging.
Any type of implant that we place across the spine/ribs tends to stiffen the segments alongside the device, thereby making continued growth difficult. Also, many revisions are often needed for device-related complications such as broken rods/implant migration that occurs due to lack of fusion across the instrumented vertebral segments. In the elderly population, dealing with the medical comorbidites and varying degrees of osteoporosis often found in long-term spinal deformities makes surgical intervention difficult and the rate of complications high.
Could you tell us about the journey that led to your creating the Lenke classification system?
Early in my career, I was always a bit frustrated by the King-Moe scoliosis classification system. Although it was the gold standard for many years, it had several shortcomings including: 1) It only classified thoracic curves, so it was not complete; 2) It only looked at the coronal plane;
3) It was not very reliable.
In 1991, during my spinal fellowship with Keith Bridwell, MD, I was invited to a small meeting organised by Randy Betz, MD, to review a newer treatment of thoracic
scoliosis, via the anterior approach, being pioneered in Europe by Jurgen Harms. Harry Shufflebarger, probably the most respected scoliosis surgeon in North America at the time, also came as he was a strong proponent of the traditional poserior approach. My job at this meeting of Professors Betz, Harms and Shuffelbarger (all of whom have made a tremendous impact on my career starting then and continuing until today) was to press the slide projector button to advance the slides of cases being shown by the three senior surgeons. While debating the various treatments being presented, I noticed right away that the three experts could not agree on the correct King Classification for the majority of the cases being presented. So I wondered how we could ever compare different treatments of scoliosis to select out the best one, if we could not agree on the type/classification of curve it was in the first place! So I knew right then that a new classification would be needed to allow for grouping of similar curves by a reliable system.
The first step was to show that the King system’s inter and intraobserver reliability was suboptimal, and then begin work on a new system. This was all done in combination with the Harms Study Group, led by Dr Betz, Harms and Shufflebarger and also included Drs Peter Newton, David Clements, Tom Lowe (deceased) along with my partner Keith Bridwell, MD, and long time clinical and research nurse Kathy Blanke. By 1998, our new system was in place and being presented at spinal meetings. It was published in 2001. I am very fortunate to have worked with such great people who allowed my name to represent this multi-surgeon effort and will always be indebted to that group, and especially Dr Betz and Professor Harms for the opportunity and guidance they provided.
What is the focus of your current research?
My current research interest mirrors my clinical practice. Thus, prospectively collecting data on all of our paediatric and adult deformity surgeries is ongoing. Almost all patients are being treated with posterior-only surgeries, so we need to continue to show the benefits of this approach vs. the traditional combined anterior and posterior approaches with respect to radiographic, functional (eg: pulmonary function), patient specific questionnaire outcomes with the SRS, Oswestry, and SF instruments, and overall satisfaction. Clinical research on all aspects of the VCR patients is an especially important topic as well.
What do you hope to achieve as the incoming president of the Scoliosis Research Society?
I am extremely honoured to become the president of the Scoliosis Research Society in September this year. This organisation, dedicated to the eduation, research and treatment of all patients with spinal deformity, is the greatest spinal society in the world, with the most dedicated members and staff of any organisation I have been associated with. During my presidential term, I would like to continue the globalisation efforts of past presidents to maximise the international presence of the SRS and international members. One small reflection of that is our next annual meeting where I will take over from Richard McCarthy, MD, as president, which will take place in Kyoto, Japan.
I also want to focus on becoming less dependent on industry funding for our educational activities. As is the trend in North America, society members and meeting attendees will be required to fund a larger portion of meeting costs. This will provide for a more independent and stronger future with increased fiscal independence. Lastly, I would like to improve our Internet-based educational media through optimisation of our website (www.srs.org), our electronic text on spinal deformity which is going live right now on our website, and to explore the possibility of an electronic Journal of Spinal Deformity, an idea I have been promoting for the past decade.
What are your interests outside of medicine?
My interests include long-distance running, skiing, golf and enjoying time with my wife of 20 years, Beth, and three great children, Lauren, age 18, Bradley, age 15 and Erin, age 13. Our favourite destination is the mountains of Colorado where we spend vacation time in both the summer and winter.
Place of Birth Harvey, Illinois, USA
Education Medical School, Northwestern University Medical School,Chicago, USA
MD, 1986, Alpha Omega Alpha
1994 American Board of Orthopaedic Surgery
1995 American Academy of Orthopaedic Surgeons – Fellow
1998 Scoliosis Research Society – Fellow
2005 Recertified – American Board of Orthopaedic Surgery
Academic appointments – Washington University School of Medicine, St. Louis, Missouri
08/93 Chief, Spinal Surgery, Shriners Hospital for Children– St Louis Unit
03/98–01/01 Associate Professor (tenure), Orthopaedic Surgery
09/99–08/05 Director, Orthopaedic Surgery Residency Program
08/05–08/06 Co-Director, Orthopaedic Surgery Residency Program
01/01–08/01 Professor, Orthopaedic Surgery
08/01 Jerome J Gilden Endowed Professor of Orthopaedic Surgery
2004 Co-Chief Adult/Pediatric Scoliosis & Reconstructive Spinal Surgery
2006 Professor, Neurological Surgery
2000-2009 Best Doctors in America – St Louis Magazine
2003 1st Place, Outstanding Resident/Fellow Paper Award Eastern Orthopaedic Association/Southern Orthopaedic Association, Dublin
2005 Louis A Goldstein Award, Best Clinical Poster, Scoliosis Research Society 40th Annual Meeting, Miami
2005-2009 America’s Top Doctors, Castle Connolly Medical Ltd
2007 Russell A Hibbs Award Best Clinical Science Paper. Scoliosis Research Society 42nd Annual Meeting, Edinburgh
2008 Louis A Goldstein Award Best Clinical Presentation Scoliosis Research Society 43rd Annual Meeting, Salt Lake City
2008-2009 Guide to America’s Top Orthopedists – Consumer Guide e-book, Consumer’s Research Council of America, Washington, DC