Dr. Rick Hodes on the Approach to Spinal Disease

Dr. Rick Hodes, a friend and colleague of Abraham Verghese, is an internist who had dedicated much of his life’s work towards treating spine disease in Ghana. In this Stanford Medicine 25 blog post, we welcome Dr. Hodes discusses one of his cases in Ghana and shares with us his approach and method to diagnosing and treating his patients.

More on Dr. Hodes:
Rick Hodes, a native of Long Island, graduated from Middlebury College and University of Rochester Medical School. He trained in internal medicine in Baltimore. He taught at Addis Ababa University from 1985-88 as a Fulbright scholar, and has worked as the medical director of the American Jewish Joint Distribution Committee in Ethiopia since 1990. His practice concentrates on spinal deformities and rheumatic and congenital heart disease. He partners with FOCOS Hospital in Ghana for spine surgery, and AIMS Amrita Hospital in Cochin for cardiac patients. He lives in Addis Ababa with his family and patients.
You can visit his website at www.Rickhodes.org

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The Case:
Mubarak is a 12 year old Ethiopian who came to me with a longstanding
spinal deformity. I’d like to point out how I examine patients like this.

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I start from the front, with the patient standing comfortably, arms to the
side. ​I try to come up with a spinal diagnosis, simply by observing the
front of the patient. ​

Observations from the front: ​

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General – comfortable, no distress, no obvious pain. Shape is symmetrical. (1)
Color – pink, no cyanosis (2)
Head – seems normal.
Neck – seems normal, no deformity (3)
Chest – expands well, symmetrical (4)
Abdomen – has abdominal breathing. Symmetrical line across the abdomen. (5)
Skin – no lesions (6)
Hand – normal (7)
Knees – hands touch the top of patella (8)
Feet – no deformity (9)

​Observations from behind:

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Chest: tremendous, symmetrical, V-shaped deformity of the thoracic spine.
Spine appears quite straight from the AP view, so I do not see any signs of
scoliosis. Rather, this is a symmetrical kyphosis, and an exaggerated
lumbar lordosis. ​When bending, the apex of the deformity is not pointed,
but rather flat (10).

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Skin: normal (11).

1) I look at the shape from the front, looking at the “plumb line” from the
chin to the umbilicus for abnormalities. Severe scoliosis patients can
develop arc-shape deformities of the torso, putting the umbilicus several
cm away from the midline.

I also look at lines on the abdomen, as a hint of the deformity of the
spine. In this case, the symmetrical line across the front on on expiration
belies the symmetrical deformity behind.

If he seems in pain, or mentions pain, or I find pain, I evaluate using the
PQRST acronym: Provocative/Palliative factors, Quality, Radiation, Severity, Timing.

2) I do see cyanosis due to the common restrictive lung disease in my spine patients.

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3) Spine patients can easily have C-spine deformities, including Klippel-Feil and Turner syndromes.

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4) Must always be looking for neuromuscular defects which affect both the musculature and breathing.

5) Abdominal breathing is not uncommon in my patients with severe spine disorders.

6) Skin exam is very important. I especially look for signs of neurofibromatosis, including cafe-au-lait spots, and freckling in the axilla. About 5% of my patients have NF. Signs of traditional healing, including cupping, scarification, and bloodletting may be found. And drainage from old TB lesions may be seen on the back.

7) W​eak hand grip or loss of thenar eminence may indicate neuromuscular disease. I commonly see old polio, muscular dystrophies, and spinal muscular atrophy. ​

8) I pay a lot of attention to the relationship between the hands and
the knees, as a proxy-indicator of lung function. I’ve found that when
the hands touch the top of the patella, the
patient has lost about half of their forced vital capacity (FVC). It can be
worse in scoliosis patients, who have asymmetrical lung compression.
Scoliosis patients such have hands which may be at far different
distances from the knees respectively.

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9) Congenital scoliosis patients may have other congenital bony defects,
including foot and arch.

​10) Symmetrical lesions like this can either be caused by congenital
defects, or tuberculosis. It is common see destruction of vertebrae on
imaging to diagnose TB. This patient does not have scoliosis.

11) I am looking for signs of traditional healers including
scarification and cupping, neurofibromatosis, as well as a hairy patch
(seen in congenital scoliosis, possibly indicative of underlying
spinal cord issues) or drainage tracts from old or active TB.

My assessment:

This boy has a severe, symmetrical deformity involving multiple thoracic
vertebrae, with apex about T9. He has significant respiratory compromise –
as predicted by physical exam, he has lost exactly 50% of his FVC. His
reflexes were normal, and toes down going. MRI scan was read
“post-inflammatory fusion of lower thoracic vertebral bodies with
thoracolumbar kyphosis and compression of the spinal cord causing
compressive myelopathy.” Note that on his CT scan, as well as his plain AP
X-ray, you are looking directly into the spinal canal.

Plain Film
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CT Spine
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MRI Spine
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I believe this boy has severe spine deformity from old TB. When I pick him
up by the neck, he is not flexible. Likely, he will benefit from
several months of ambulatory traction (shown here with other
patients), followed by surgery. Surgery will likely involve posterior
spinal fusion and vertebral column resection. He has the possibility
of a good outcome.

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Note: I have hundreds of patients like this fellow.

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