Scoliosis surgery - child

Definition

Scoliosis surgery repairs abnormal curving of the spine (scoliosis). The goal is to safely straighten the spine, align your child’s shoulders and hips, and give you long-term correction for your child’s back problem.

Alternative Names

Spinal curvature surgery - child; Kyphoscoliosis surgery - child; Video-assisted thoracoscopic surgery - child; VATS - child

Description

Before surgery, your child will receive general anesthesia. This will make your child unconscious and unable to feel pain during the operation.

During surgery, your child's surgeon will use steel rods, hooks, screws, or other metal devices to straighten your child's spine and support the bones of the spine. Then the surgeon will often use bone grafts to hold the spine in the correct position and keep it from curving again.

Your child's surgeon will make at least one surgical cut to get to your child's spine. This cut may be in your child's back, chest, or both places. The surgeon may also do the procedure using a special video camera.

• A surgical cut in the back is called the posterior approach. This surgery usually takes several hours.
• A cut through the chest wall is called a thoracotomy. The surgeon makes a cut in your child's chest, deflates a lung, and usually removes a rib. Recovery after this surgery is often faster.
• Some surgeons do both of these approaches together. This is a much longer and more difficult operation.
• Video-assisted thoracoscopic surgery (VATS) is a newer technique. It is used for certain kinds of spinal curves. It takes a lot of skill, and not all surgeons are trained to do it. The child must wear a brace for around 3 months after this procedure.

During the surgery:

• The surgeon will move muscles aside after making the cut.
• The joints between the different vertebrae (the bones of the spine) will be taken out.
• Bone grafts will often be put in to replace them.
• Metal instruments, such as rods, screws, hooks, or wires will also be placed to help hold the spine together until the bone grafts attach and heal completely.

The surgeon may get bone for the grafts in these ways:

• The surgeon may take bone from another part of your child's body. This is called an autograft. Bone taken from a person's own body is probably the best.
• Bone can also be taken from a bone bank, much like a blood bank. This is called an allograft. These grafts are not always as successful as autografts.
• Scientists are developing a man-made (synthetic) bone substitute, but it is not commonly used yet.

Different surgeries use different types of metal instruments. These are usually left in the body after the bone fuses together. Three of the more common procedures are:

• In the Harrington procedure, a steel rod that runs from the bottom of the curve to the top is put in place. Your child must wear a full body cast and lie in bed for 3 to 6 months after this procedure.
• In the Cotrel-Dubousset instrumentation (CDI), instruments are placed in each part of the spine that needs straightening. Your child may go home in about 5 days and may return to school in about 3 weeks.
• The Texas Scottish-Rite Hospital (TSRH) operation is similar to the Cotrel-Dubousset procedure.

During surgery, the nerves that come from the spine will be watched using special equipment to make sure no damage is done to any of the nerve roots.

Scoliosis surgery usually takes 4 to 6 hours. It may be longer or shorter for some children.

Why the Procedure Is Performed

There are several reasons to treat scoliosis:

• Appearance is usually a major concern for anyone with scoliosis.
• Scoliosis often causes back pain.
• If the curve is severe enough, scoliosis may affect your child's breathing.

Braces are often tried first to slow the curve from getting worse.

The choice of when to have surgery will vary.

• After the bones of the skeleton stop growing, the curve should not get much worse. Because of this, the surgeon may want to wait until your child's bones stop growing.
• However, your child may need surgery before this if the curve in the spine is severe or is getting worse quickly.

Surgery is usually recommended for the following children and adolescents with scoliosis of unknown cause (idiopathic scoliosis):

• All young people whose skeletons have matured, and who have a curve greater than 45 degrees.
• Growing children whose curve has gone beyond 40 degrees. (There is still some debate, however, about whether all children with curves of 40 degrees should have surgery.)

References

Hedequist DJ. Surgical treatment of congenital scoliosis. Orthop Clin North Am. 2007;38(4):497-509.

Lonner, B. S. Emerging minimally invasive technologies for the management of scoliosis. Orthop Clin North Am. 2007;38(3): 431-440.

Patil CG, Santarelli J, Lad SP, et al. Inpatient complications, mortality, and discharge disposition after surgical correction of idiopathic scoliosis: a national perspective. Spine J. 2008 Mar 19 [Epub ahead of print]

Alternative Names

Spinal curvature surgery - child; Kyphoscoliosis surgery - child; Video-assisted thoracoscopic surgery - child; VATS - child

Before the Procedure

Always tell your doctor or nurse what drugs your child is taking, even drugs, supplements, or herbs you bought without a prescription.

Before the operation:

• Your child will have a complete physical exam by the doctor.
• Your child will learn about the surgery and what to expect.
• Your child will learn how to do special breathing exercises to help the lungs recover after surgery.
• Your child will be taught special ways to do everyday things after surgery to protect the spine. He or she will learn how to move properly, change from one position to another, and sit, stand, and walk. Your child will be told to use a "log-rolling" technique when getting out of bed. This means moving the entire body at once to avoid twisting the spine.
• Your child's doctor or nurse will talk with you about having your child store some of his or her blood about a month before the surgery. This is so that your child's own blood can be used if a transfusion is needed during surgery.

During the 2 weeks before the surgery:

• If your child smokes, he or she needs to stop. People who have spine fusion and keep smoking do not heal as well. Ask the doctor for help.
• Two weeks before surgery, the doctor may ask you to stop giving your child drugs that make it harder for the blood to clot. These include aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), and other drugs.
• Ask your child's doctor which drugs you should still give your child on the day of the surgery.
• Always let your doctor know if your child has any cold, flu, fever, herpes breakout, or other illness before the surgery.

On the day of the surgery:

• You will usually be asked not to give your child anything to eat or drink 6 to 12 hours before the procedure.
• Give your child any drugs the doctor told you to give with a small sip of water.

The doctor or nurse will tell you when to arrive at the hospital.

After the Procedure

Your child will need to stay in the hospital for about 3 to 4 days after surgery. The repaired spine should be kept in its proper position to keep it aligned. If the surgery involved a surgical cut in the chest, your child may have a tube in the chest to drain fluid buildup. This tube is usually removed after 24 to 72 hours.

A catheter (tube) may be placed in the bladder the first few days to help your child urinate.

Your child’s stomach and bowels may not work for a few days after surgery. Your child may need to receive fluids and nutrition through an intravenous (IV) line.

Your child will receive pain medicine in the hospital. At first, pain medicine may be delivered through a special catheter inserted into your child's back. After that, a pump may be used to control how much pain medicine your child gets. Your child may also get shots or take pain pills.

Your child may have a cast or a brace.

Outlook (Prognosis)

Your child’s spine should look much straighter after surgery. But there will still be some curve. It takes at least 3 months for the spinal bones to fuse together well. It will take 1 to 2 years for them to fuse completely.

Fusion stops growth in the spine. This is not usually a concern because most growth occurs in the long bones of the body, such as the leg bones. People who have this surgery will probably gain height from both growth in the legs and from having a straighter spine.

References

Hedequist DJ. Surgical treatment of congenital scoliosis. Orthop Clin North Am. 2007;38(4):497-509.

Lonner, B. S. Emerging minimally invasive technologies for the management of scoliosis. Orthop Clin North Am. 2007;38(3): 431-440.

Patil CG, Santarelli J, Lad SP, et al. Inpatient complications, mortality, and discharge disposition after surgical correction of idiopathic scoliosis: a national perspective. Spine J. 2008 Mar 19 [Epub ahead of print]

Alternative Names

Spinal curvature surgery - child; Kyphoscoliosis surgery - child; Video-assisted thoracoscopic surgery - child; VATS - child

Risks

There may be complications with any of the procedures for scoliosis repair.

Risks for any anesthesia are:

• Allergic reactions to medicines
• Breathing problems

Risks for any surgery are:

• Bleeding
• Blood clots in the legs that may travel to the lungs
• Heart attack or stroke during surgery
• Infection, including in the lungs (pneumonia), bladder, or kidney

Possible complications from any scoliosis repair surgery are:

• Blood loss that requires a transfusion.
• Gallstones or pancreatitis (inflammation of the pancreas) may occur.
• Infection.
• Intestinal obstruction (blockage) may occur.
• Nerve injury. This occurs in fewer than 1% (1 out of 100) of patients and may cause muscle weakness. Paralysis is very rare.
• Some people may have lung problems up to 1 week after surgery. Breathing may not be completely normal until 1 to 2 months after surgery.

Problems that may develop in the future include:

• The fusion does not heal. This can lead to a painful condition in which a false joint grows at the site. It is called pseudarthrosis.
• The parts of the spine that are fused can no longer move. This puts stress on other parts of the back. The extra stress can cause back pain and make the disks break down (disk degeneration).
• One of the metal hooks placed in the spine may move a little. One of the metal rods may rub on a sensitive spot. Both of these things can cause some pain.
• New spinal problems may develop, especially in children who have surgery before their spine has stopped growing.

References

Hedequist DJ. Surgical treatment of congenital scoliosis. Orthop Clin North Am. 2007;38(4):497-509.

Lonner, B. S. Emerging minimally invasive technologies for the management of scoliosis. Orthop Clin North Am. 2007;38(3): 431-440.

Patil CG, Santarelli J, Lad SP, et al. Inpatient complications, mortality, and discharge disposition after surgical correction of idiopathic scoliosis: a national perspective. Spine J. 2008 Mar 19 [Epub ahead of print]