Pediatric Spinal Surgery Options
The orthopedic surgeons of the Spine Center use the most advanced anterior and posterior surgical methods for the correction of spinal deformities. The surgical approaches, whether with fusion or a non-fusion growth-sparing technique, are designed with the individual patient and their deformity in mind.
One of these procedures for scoliosis is vertebral body tethering (VBT), also called spinal growth tethering surgery, a procedure that partially restrains one side of the spine to allow growth on the other side. Patients from across the country come to Rady Children’s for this cutting-edge procedure. Learn more about our surgical options below.
Recovery Period
The recovery after scoliosis surgery is variable, depending on the nature of the surgery performed. In general, after having 2–8 or more hours of surgery, time is spent initially in the Recovery Room. In this area the patient is allowed to wake up from the anesthesia and regain voluntary breathing. There are times when it is necessary to maintain respiratory support on a ventilator for one or more days following this surgery. If this is required or there are other indications to do so, the initial postoperative period may be spent in an Intensive Care Unit. This allows for ventilatory support of the respiratory system, as well as close monitoring of the cardiovascular system.
There are several options for managing pain in the initial postoperative period. These include intravenous narcotic medicines, such as morphine or Demerol. Once the patient is drinking/eating, the transition from IV to oral pain medication will be initiated. The intravenous route is convenient and can be delivered either by the nurse or with a patient-controlled anesthesia (PCA) system. This allows the patient some control over the timing of administration of pain medication.
Immediately After Surgery
In the initial postoperative period, there may be several tubes in place. The tubes will be placed while the patient is under anesthesia. These may include:
- A nasogastric tube to drain the stomach contents, the tube will be in place while the intestines “wake up” or recover from the effects of anesthesia usually 2-3 days. After the intestines start to work again (bowel sounds and flatus present), the patient may then start to drink and eat again. Generally the diet is advanced gradually, starting with liquids and progressing to solid food.
- There will be a bladder (urinary) catheter inserted during surgery.
- Surgical drains may be placed in the back to allow for drainage of fluids.
- If surgery in the chest area is performed, a chest tube will be required to drain fluid from the chest (thoracic cavity).
- Intravenous lines will be in place to administer both medications and fluids. There may also be an arterial line for the same purpose, as well as to assist with blood pressure monitoring.
These monitoring lines and drainage tubes will be removed sequentially in the days following surgery when they are no longer necessary.
First Day or Two After Surgery
In the first day or two following surgery, there is little physical activity required of the patient, though the nurses will be repositioning the patient in bed every 1–4 hours. There will then be a gradual increase in activity/mobilization, generally starting with sitting, then standing, then resuming walking. The timing and rate of the increase in activity will vary, depending on the type of surgery done. Depending on the patient and/or the type of surgery performed, some patients may need to wear a brace for 3-4 months after surgery. The brace provides external support to the trunk while the fusion is healing. This brace comes in various forms and the form will depend on the patient and type of surgery performed. This brace is to be worn at all times except when in bed. This brace will be fit and provided to you prior to discharge from the hospital.
In general, requirements for being discharged from the hospital following surgery include:
- Tolerating oral liquids and food
- Comfortable on oral pain medications
- No fevers
- Ability to ambulate (if ambulating prior to surgery)
- Able to urinate and have bowel movements
Recovery at Home
After discharge from the hospital to home it usually takes several weeks for pain to completely resolve and in general, a gradual weaning from narcotics to Tylenol takes place naturally. It is not uncommon for patients to be comfortable on Tylenol during the day and need narcotics at night for comfort during this weaning process.
In general, school age children/teens are ready to return to school 3–4 weeks after surgery, depending on the child and the type of surgery. Some children tolerate a return to school for just half days initially, but we encourage returning as soon as possible to a “normal” schedule.
Physical activity and sports are restricted after surgery for 6–12 months, depending on the type of surgery. We encourage children to begin walking for exercise (if child is ambulating prior to surgery) at the time of discharge. Bending, twisting, and lifting activities are to be avoided. At each follow-up visit, x-rays will be done to assess the healing of the fusion. This will allow your surgeon to make decisions regarding easing off on both bracing and activity restrictions. As healing occurs, brace wear will be discontinued, and permitted activities may be increased. Generally, at 1 year following surgery, children may participate in all activities without restriction.
Risks of Surgery
With any surgical procedure, the risks and benefits of the procedure must be carefully assessed for each individual patient. The risk to the patient of not having surgery must also be addressed.
In the case of progressive scoliosis, the risks of not having surgery if brace treatment has failed or is not indicated involve progressive deformity of the trunk with potential imbalance and offset between the trunk and pelvis when in an upright position. In addition, with thoracic curves, risk to the heart and lung function develops when curves reach 80-90°. This results from compression of the lung within the deformed chest cavity, which makes it difficult for the heart to pump blood through the compressed lung. Most cases of scoliosis are treated at the spine surgery center prior to curves reaching such a magnitude.
During Surgery
The specific surgical risks are dependent on multiple factors, including the general health of the patient, any underlying medical disorders, as well as the type of surgery that is required. In general, with all operations around the spine, there are potential complications relating to the anesthesia, as well as risks of bleeding and wound infection. With anticipation preoperatively, blood loss can be managed by one of several means, depending on the anticipated magnitude of the blood loss. These include pre-donation of the patient’s blood (autologous) or of blood from family members or friends (donor-specific). An additional option involves the use of banked blood components. Intraoperative blood conservation techniques can be utilized with either use of hemodilution or blood salvage with recirculation methods to minimize need for other forms of blood replacement.
Additional potential intraoperative complications relate to neurologic injury. Surgery involving the spine places the neural elements of the spinal cord and nerve roots at some risk for injury. Injury to these structures may result in a spectrum of disability that spans from mild numbness to loss of bowel or bladder function to complete paralysis below the area of injury. The risk of spinal cord injury can be minimized, although not completely eliminated, by the use of sophisticated spinal cord monitoring systems. This spinal cord monitoring is performed during the exposure and correction of the spinal deformity and monitors the electrical function of the spinal cord throughout the surgical procedure. When indicated a “wake-up” test may be utilized to ensure normal neurologic function. This involves decreasing the level of anesthesia, after completion of the deformity correction, to the point that the patient is able to hear and follow commands. The patient is instructed to move the lower extremities to confirm that voluntary motor function remains present. If normal function is observed, the procedure is completed with wound closure. If spinal cord functional problems are noted with spinal cord monitoring and confirmed by abnormality appreciated on a wake-up test, removal or adjustment of the instrumentation may be required. This decreases the stress applied to the spinal cord by the instrumentation system, improving the likelihood of neurological recovery.
After Surgery
Postoperatively, complications may also arise. These include development of a wound infection, pulmonary difficulties, as well as problems associated with the hardware system and fusion. Postoperative wound infections occur in roughly 1 percent of patients. Measures taken to minimize this risk include the use of antibiotics before, during, and after the operation. There are risk factors that increase the likelihood of wound infection, which include poor nutritional status, history of urinary tract infections and revision surgery. In most cases wound infection can be managed by a return to the operating room with cleaning of the wound and closure of the wound over drains, along with prolonged antibiotic use. In rare cases there is a delayed presentation of infection, which may come as late as 1–2 years postoperatively. In these cases, generally the treatment is cleaning of the wound and removal of the hardware. These delayed infections can be successfully managed with hardware removal and antibiotics.
Complications related to the instrumentation system and fusion are possible. In occasional instances, there is loss of fixation of the rod system to the spine, resulting in some loss of correction. This may require revision of the instrumentation system with replacement of hardware and reattachment to the spine. Additionally, there may be difficulties in obtaining fusion at each of the involved levels of the spine. If an area of nonunion (lack of fusion) or pseudarthrosis develops, there may eventually be breakage of the rod system. In many circumstances this does not cause further problems. However, in some cases it may require revision of the instrumentation system if there is pain or evidence of curve progression.