Scoliosis Overview

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Phase I: Diagnosis

Phase II: Non-Operative

Phase IV: Life After Surgery

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Scoliosis Treatment

What are the goals of surgery?

The goals of surgery are to prevent further progression of scoliosis and to correct the spine as much as can be done safely. Stopping progression will prevent the significant health issues later in life that are associated with severe scoliosis (>70 – 80 degrees). Some of the problems of large curves include breathing, heart and muscle weakness as well as pain.

 

What is the Surgery?

The surgery is a spinal fusion with instrumentation. During surgery the curve is corrected as much as is safely possible. To do that, implants (generally rods, screws, wires and/or hooks) are attached to the vertebrae at the section of the spine that is curved. After correction is achieved, bone graft is placed over the implants. With time, this bone graft fuses (or grows together) with the existing bone and forms a solid column of bone in that area. The implants act as an internal brace to hold the spine in the corrected position while the bones are fusing. This generally takes 6 – 12 months to become solid.

The fusion of the bones takes away the growth potential in that part of the spine, which is what has caused the scoliosis to worsen. Individual vertebrae grow approximately 1 mm per year and potential height lost is generally balanced by the amount of height gained with correcting the curve(s). The fusion also permanently stops the motion of the spine in the segments that are fused. The loss of flexibility is modest and limits function of the trunk very little.

 

Why Now?

“My child isn’t having any problems.”
“Shouldn’t we wait until my child is done growing?”
“Why not wait until it is causing pain?”


With moderate scoliosis, you wouldn’t expect your child to be having any health problems. Surgery is often recommended before pain and other symptoms develop for a variety of reasons. The ease of addressing the smaller, more flexible curves present in a child vs. the larger, rigid curves in adults involves less risk, less complicated surgery and potentially fewer vertebrae may need to be fused.

In addition, the recovery is easier and life less complicated (school, family, career) at this stage of life.

 

How do we decide if surgery is the right decision?

Educate yourself and ask questions. We suggest that the most important questions to ask are:

“ What are the risks and benefits of having surgery at this time?”
“ What are the risks and benefits of not going ahead with surgery at this time?”
“ What are the risks and benefits of the suggested surgical procedure?”

Everyone will interpret the answers and weigh the risks and benefits a little differently, but these questions are an excellent place to start as you analyze information that will allow you to make an informed decision.

Your specialist may be able to connect you with other patients that would be willing to talk with you about their experience.

 

What about getting a 2nd opinion?

Good idea. Recommendations on who to see can come from the current specialist, pediatrician, family doctor or from the internet. Some patients and families may know people who have been in this situation--asking them about their experiences with their surgeon can be helpful, but we do recommend getting a second opinion from a board-certified spine surgeon.

 

We don’t want surgery...what’s next?

Choosing not to proceed with surgery is choosing observation and your doctor will recommend how frequently you should follow up for x-rays and exam. Bracing curves in the surgical range is of little or no benefit.

 

We want to proceed with surgery... what’s next?

Choosing a surgeon, then formulating a surgical plan (deciding on the procedure to be done) together and choosing a date for surgery are the next steps.

 

How do we decide on a surgeon?

It is recommended that you choose a surgeon that:

• is Board Certified

• specializes in the treatment of pediatric and teenage spinal deformities

• is affiliated with a pediatric hospital facility

• has successful experience treating pediatric spinal deformities

 

What is a surgical plan?

There is more than one way to surgically treat scoliosis. One needs to decide which levels of the spine are going to be fused and by which approach/procedure. Surgeons can approach the spine through either an incision on the back or on the side of the chest or flank. The approach(es) recommended will depend primarily on the curve pattern, physical deformity and skeletal maturity.

 

What are the possible procedures?

There are two general surgical approaches.

The most common approach is through the back, a Posterior Spinal Fusion with Instrumentation. With this procedure, an incision is made along the spine, screws and/or hooks are then attached to the vertebrae and the rods are then attached to the screws or hooks. These act as anchor points to secure the rods. Bone graft is then placed over the implants so that the spine can fuse in the corrected position. All curve patterns can be treated with this approach.

An Anterior Spinal Fusion with Instrumentation is done through an incision either on the flank or chest and is an option when there is a single curve to be treated. One or two screws are placed from the side through the front (anterior) part of each vertebra that is going to be fused. Rods are then attached to the screws lengthwise along the spine.

The discs between the vertebrae are removed and replaced with bone graft, allowing the spine to fuse in the corrected position. This open approach is an option for single curves in the thoracic region of the spine and is also well suited for single lumbar curves.

In special circumstances, both anterior and posterior approaches may be accomplished with less invasive incisions. A Thoracoscopic Anterior Spinal Fusion with Instrumentation is done through 4 or 5 small incisions on the chest. This approach is best suited for single right thoracic curves.

Some curve patterns may be best treated with a Combined Anterior and Posterior approach. The combined approaches are reserved for very young patients and those with more rigid curves.

 

What do the implants look like?

 

What are the implants made of?

Implants are made of metal, either Stainless Steel, Titanium or Cobalt Chromium. There are a wide variety of implants available and most surgeons have individual preferences and will discuss this with you.

 

How long will the implants stay in?

Except in uncommon circumstances such as infection or discomfort, the implants will stay in the body indefinitely. The rods maintain the spine in its corrected position, acting as an internal brace while the vertebrae grow together and fuse, creating a column of solid bone. After the bones fuse together, the implants don’t really have a job, as the fusion is what maintains the correction. However, the surgery to remove the implants (rods, hooks, screws) is major and not needed in most cases.

How do the bones fuse together?

Bone grafting is used to fuse the spine in its corrected position and can come from a variety of sources. These sources will depend on the surgical approach and will likely include a combination of bone harvested from the child during surgery and supplemental bone products.

 

What are the effects of a fusion?

Besides maintaining the spine in its corrected position and preventing further progression of scoliosis, a fusion also stops growth in that section of the spine. This is of little consequence in most teens as some height is gained with straightening the spine.

In addition, the section of the spine that is fused is no longer flexible. This is of little consequence in the thoracic spine because this region of the spine has relatively little motion naturally. However, the lumbar spine is more flexible, and a fusion in this area limits more motion. Concentrating motion on just a few lumbar discs may cause them to wear out sooner, so every effort is made to fuse as few of the lumbar vertebrae as possible.

 

Which procedure will be best?

The “best” procedure will depend on the curve pattern, skeletal maturity, amount of physical deformity and your surgeon. There are risks and benefits associated with every surgery. A discussion of options will be part of the surgical planning that you do with your surgeon.

 

How to choose a hospital facility?

• Board Certified Pediatric Anesthesiologist available

• specialized pediatric staff

• availability of a pediatric Intensive Care Unit (ICU)

• intraoperative spinal cord monitoring

• other features such as availability of Pain Management and other pediatric specialists

 

What is spinal cord monitoring?

A little more anatomy first: the spinal cord and nerves control voluntary and involuntary activities of the body--movement, sensation, bladder and bowel function, to name a few. The brain processes all of the messages transmitted to it via sensory nerve pathways to the spinal cord then directs activity by sending messages back via the spinal cord to the muscles.

Throughout surgery, the message-sending and receiving ability of the spinal cord and nerves are monitored, as well as the brains response to these messages, looking for any changes in spinal cord and nerve signals that might indicate a problem.

This testing is done by a trained professional using a sophisticated computer system. This monitoring significantly lowers the risk of spinal cord dysfunction following surgery.

 

How do we decide on a date for surgery?

There are a variety of factors--for example, the surgeon’s schedule and your own (working around school, sport season, other activities, planned vacation, etc). Discuss with your surgeon the risks of waiting greater than 6 – 12 months as there are some cases where there may be enough progression during that time that additional levels of the spine may need to be fused. Your surgeon can help you decide how long it is safe to wait.

 

Okay, we’ve got a plan and a date… what’s next?

In the time just before surgery, you will meet with the surgeon for additional discussion of the planned surgery. This is an excellent opportunity to ask questions, but do not hesitate to contact your surgeon at any time during this process with questions or concerns. At this visit, additional x-rays may be needed.

Your surgeon’s staff will assist with obtaining authorization from your insurance provider, arrange for blood products to be available for the procedure, as well as additional diagnostic tests that may be recommended by the surgeon.

You may also have the opportunity to tour the hospital and speak with other families that have had this experience.

 

It is the day of surgery... what can we expect?

• Lots of paperwork

• Meet with anesthesiologist (the doctor that puts you to sleep)

• Meet with surgeon’s assistants

• Repetition! Many people asking the same questions

• An opportunity to ask questions prior to surgery

• A long day with minutes passing like hours for parents and the day passing like seconds for patients

• Support and patience from staff

• To feel great relief when you meet with your surgeon after surgery, and even greater relief when you are reunited with your child/parent

 

Surgery is done...what’s next?

After surgery, most patients will go to the Recovery Room so that they may be closely monitored while waking from anesthesia. After time spent in the Recovery Room, they will be transferred to their hospital room.


The patient will likely be in the hospital for less than a week. During that time, the focus will be on pain management, sitting, walking, eating, bowel and bladder routine, and education-- the multitude of things that will allow the patient to meet the necessary milestones before going home.


Individuals recover at different rates, and surgeons’ post-surgery regimens vary. Patients are generally in the hospital three to seven days, depending upon the extent of the procedure.


Pain Management, diet and bowel/bladder routine will depend on how quickly the stomach and intestines return to normal function, or “wake up,” and bowel sounds can be heard.


Once bowel sounds return, the patient can begin to eat and drink. This usually starts with liquids and then progresses to solid food. They will then be transitioned to oral pain medicine. Typically, a bladder catheter remains in place until this transition. Constipation is not uncommon as it is a side effect of anesthesia, narcotic pain medicine and decreased activity levels. The medical staff will assist in managing this.


 

When can we leave the hospital?

While there will be differences among surgeons, in general parents will see their child going from:

• In bed all of the time to taking walks in the halls

• Transitioning from Intravenous pain medication to oral (swallowed) pain medicine

• Not eating or drinking to eating and drinking again

• Urination managed with a bladder catheter to urinating normally

Parents will also see themselves going from being nervous and wanting the nurses to do everything involved in your child’s care to becoming confident that you can do it. They can!

When these milestones are achieved, the patient is ready to go home.

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