A GUIDE TO YOUR CHILD’S SURGERY

The diagnosis of a spinal deformity, such as scoliosis or kyphosis, can be overwhelming. These conditions often require surgical treatment and may raise many questions. This guide will explain the surgical management of scoliosis, including what to expect before and after surgery.

For specific details regarding your child’s surgery, please contact your orthopedic surgeon or nurse practitioner.

Spinal Fusion Surgery

Spinal fusion surgery will partially straighten the curve, usually 50 percent, keep the curve from progressing with a fusion and improve physical appearance of the body. It permanently connects the individual vertebrae together as a single piece of bone over the curved part of the spine. After the rods are in the back, pieces of the bone graft or bone chips are placed next to the rods. For the anterior surgery these bone chips replace the disc. Fusion occurs when the spine and bone graft heal together.

The bone chips may come from the hip (iliac crest), requiring a separate incision, or rib during the anterior surgery. If these sites are not suitable, bone is available from the Children’s Hospital of Michigan bone bank.

Sometimes a brace or cast helps to hold the spine in place until the fusion heals. Once bone healing has occurred the rods are no longer needed. However to avoid another major surgery, the hardware is usually left in place without any complications.

Following surgery, the fused area of the spine will no longer grow. Growth will continue above and below the fusion. In fact, immediately following surgery, your child may appear taller because the spine has been straightened.

Types of Surgical Techniques

POSTERIOR SPINAL INSTRUMENTATION

This is the most common operation for idiopathic scoliosis. An incision or cut is made down the middle of the back and will vary in length depending on how much of the spine needs to be fused. Two metal rods are shaped to match the normal shape of the back and then secured to the spine with screws, hooks and wires. The rods are made of stainless steel and about as wide as a pencil. The rods act as a brace to hold the spine in the straightened position until the bones heal solidly. Several types of instruments are available for use, which are named after the surgeon or hospital who designed them, including Harrington, Luque, Cotrel-Dubousset (CD), Texas Scottish Rite Hospital (TRSH) and Isola. The orthopedic surgeon will decide which instrument is best for your child.

ANTERIOR SPINAL INSTRUMENTATION

This may be used in children with congenital scoliosis, kyphosis or myelomeningocele and in some special instances of idiopathic scoliosis. When the operation is only on the thoracic spine, an incision is made on one side of your rib cage from back to front. When the surgery is on both the thoracic and lumbar spine, an incision is made across the lower rib cage and down the front of the abdomen. The discs between the vertebrae are removed and replaced with bone chips. Then a rod is secured to the spine with screws, hooks and wires.

ANTERIOR AND POSTERIOR INSTRUMENTATION

Some special cases of scoliosis require both anterior (front) and posterior (back) surgeries. These procedures can be done on the same day or spaced a week apart.

STAYING HEALTHY

It is important that your child eat a balanced diet, be active and get plenty of rest to stay healthy. Continue with normal activities before surgery. Keep your child away from people who are sick with a cold or flu.

MEDICATIONS AND SUPPLEMENTS

Aspirin, Bufferin and non-steroidal anti-inflammatory medications such as Advil, Ibuprofen, Motrin, Nuprin or Naprosyn may cause extra bleeding during surgery. Stop using these medications at least two weeks before surgery. If you are unsure whether your child should discontinue using any of the medications, talk with your doctor or nurse. Tylenol or Acetaminophen may be used, if needed.

PRE-OPERATIVE APPOINTMENT

An appointment will be scheduled several weeks before surgery to speak to a nurse practitioner, get X-rays and a blood test. You and your child will also meet with an anesthesiologist who will explain the medication that will be used during and after surgery. Depending on your child’s type of curve or medical history, he or she may also need to see a cardiologist or pulmonologist before surgery.

BLOOD FOR SURGERY

Blood transfusions are often needed during spinal surgery. There are three options to arrange for blood to be available:

1. AUTOLOGOUS DONATION

Your child can donate his or her own blood for surgery. This is a perfect match. Your child needs to be healthy, 14 years- old and weigh at least 110 lbs to donate. They can donate from 4 to 42 days prior to surgery. Since the body replaces blood very quickly, they can donate it and still be ready for surgery. if your child’s blood is not used, it is discarded

2. DIRECTED DONATION

Parents, relatives or friends can donate blood for your child’s surgery. The donations can be made from 5 to 21 days prior to surgery. Each person can only donate one unit. Blood not matched or a unit matched but not used goes to the general pool.

3. CHILDREN’S HOSPITAL OF MICHIGAN BLOOD BANK

The American Red Cross supplies each type of blood to the hospital. Each unit is tested at the National Testing Laboratory to determine the blood type, detect infectious agents and ensure the safest possible blood. Autologous and directed donations are arranged with the surgeon’s office and the Red Cross. The order form and the results of the blood test are sent to the Red Cross to start the process. Once the Red Cross receives the order from the hospital they will call the donor coordinator to arrange the appointments. When blood is used from the hospital blood bank it will be arranged by the surgeon’s office. Please give the office four weeks notice to begin the process.

COMPATIBLE BLOOD TYPES

This will help you identify which blood type your child can receive.

Your Child’s Blood Type Compatible Blood Types

O Positive	O Positive; O Negative
O Negative	O Negative
A Positive	A Positive; A Negative; O Positive; O Negative
A Negative	A Negative; O Negative
B Positive	B Positive; B Negative; O Positive; O Negative
B Negative	B Negative; O Negative
AB Positive	Any Blood Type
AB Negative	A Negative; B Negative;

SCHOOL

Please inform your child’s school of the surgery, their teachers can plan homework assignments or homebound teaching. Your child will miss approximately four to six weeks of school.

FAMILY SUPPORT

Plan ahead with your family and friends. An adult should always be at home to help during the first few weeks of recovery.

WHAT TO BRING TO THE HOSPITAL

You should bring underwear, slippers, snug cotton T-shirts that your child can wear under a brace, if needed, and loose comfortable clothing. You can also bring a radio with a headset. Please do not bring large or valuable items.

THE NIGHT BEFORE SURGERY

Your child cannot eat or drink anything after midnight (12 a.m.) the night before surgery. This includes water, candy, mints and gum. This is for your child’s safety. It is important to have an empty stomach before anesthesia and surgery to prevent vomiting.

The Day of Surgery

Once in the operating room, a number of things will happen to monitor your child’s body during the procedure.

• Electroencephalogram (EEG) leads, are placed on the scalp to watch your child’s neurological function.
• A few IV’s will be placed to provide fluids, medicine or blood as needed.
• A urinary catheter will be inserted to measure the amount of urine your child’s kidney produces.
• If the chest cavity is opened during an anterior fusion, a chest tube will be used to drain the fluid that collects outside the lungs, so that they continue to expand properly.
• Remember: only one IV is placed while your child is awake, all other tubes are inserted after your child is asleep.

When surgery is completed, a bulky, soft bandage is placed over the incision. This bandage usually remains in place for three to five days.

Your Child’s Hospital Stay

After your child has gone into the operating room, a parent or legal guardian should remain in the waiting room until the surgery is completed. Following surgery, parents are welcome to visit anytime and one parent may spend the night. Your child will spend time in three different areas of the hospital. First, the Post Anesthesia Care Unit (PACU) for two hours, then the Intensive Care Unit (ICU) for one to two days, and finally the postoperative unit until discharge.

PAIN MANAGEMENT

Please tell the doctor of nurse if your child feels pain or discomfort. Your child will be asked to rate their pain with a number or picture.

To minimize discomfort, your child may continuously receive medicine through the IV or the patient controlled analgesia (PCA) system. Pain medicine is located in the PCA’s small pump, which connected to the IV lines. PCA allows your child to get pain medicine as needed, by simply pressing a button attached to the pump. For added safety, there are limits or lockouts to the amount of medication your child can receive. Pain medicine helps them to move freely and breathe more deeply, thus promoting healing and recovery.

Getting out of bed for the first time can be uncomfortable, but it will get easier each day. They will gradually increase the amount of time sitting up, and will then begin walking.

Your child’s diet will begin with ice chips and water. Remember that their stomach has been empty, so they must slowly begin to eat. It may take several weeks for the appetite to return to normal.

He or she may be given a laxative or suppository to help a bowel movement

Other drainage tubes will be removed as you recover.

It is not uncommon for girls to start their menstrual cycle during the hospital stay, even if they have just finished one. This is due to the stress of surgery on the body. Periods will return to normal within a couple of months.

The surgeon will decide if your child needs a brace after the spinal fusion. The orthotic company will measure him or her in the hospital and design the brace. If necessary the postoperative brace is used for approximately three months.

Going Home

When your child is eating normal food, feeling less pain in their back, receiving oral pain medicine, and able to get up with some assistance to walk around, they should start to think about going home. The surgeon will tell you when they can expect to go home approximately one day ahead of time. An X-ray of the spine will be done prior to going home to check the hardware placement. A nurse will give you and your family important instructions on how to manage your child’s diet and medications, how to care for the incision, what problems to watch for and when to call the doctor. If your child has a brace, the orthotic company will explain how to care for it. Generally, no special equipment is needed at home. Your child can sleep on any mattress that is comfortable.

AT HOME

Your child’s strength will gradually return to normal. You will be instructed whether you can take a shower. Your child should walk every day, increasing the distance as they feel stronger. Recovery time following spine surgery takes a total of 6-12 months. This allows bone to grow and become strong. Check with the surgeon before participating in any activities.

Please plan to schedule a follow-up visit with the orthopedic surgeon as soon as you are home. If you have any questions when you return home, call the surgeon’s office or orthopedic nurse practitioner.

Family Support

A diagnosis of scoliosis can be overwhelming and may raise questions. Families with children who have the same or similar diagnosis, and have gone through scoliosis care are willing to talk with you. If you are interested, please contact the nurse practitioner for a name and telephone number of a family.

Preparing for Surgery

BEFORE SURGERY CHECKLIST

• Eat a well-balanced diet.
• Inform your school.
• Arrange for blood donations.
• If you are donating your own blood, take iron supplements two weeks prior to the donation until the day before surgery.
• Stop taking aspirin and ibuprofen two weeks before surgery.
• Stop smoking.
• If you develop a cold, flu or illness one-week prior to surgery contact the orthopedic office.
• Do not eat or drink after midnight the night before surgery.

ONLINE RESOURCES

• www.childrensdmc.org/kidshealth/ (keyword search: scoliosis)
• www.iscoliosis.com
• www.spineuniverse.com
• www.orthoinfo.aaos.org
• www.orthoknow.com/support/groups.htm
• www.srs.org
• www.scoliosis.org

Glossary of Terms

Anterior Fusion: fusion performed on the front of the spine, usually replacing inter vertebral discs with bone chips.

Autologous Blood: a person who donates their own blood for their future operation. This can be used for an elective surgery when a blood loss is expected.

Bone Graft: the transplantation of bone. Bone for grafting can be taken from two sources; one site to another in the same individual; or from a bone bank who uses screened human donors.

Brace: a semi rigid plastic device which pushes on the muscles and ribs adjacent to the spinal column. The brace, also called an orthosis, is designed to lessen the abnormal spinal curvature when used prior to surgery and to stabilize the spine after surgery. Individual braces are customized to fit a particular patient’s body shape and spinal curvature. Two common braces that are used are Boston and TLSO (Thoraco-Lumbar-Sacral-Orhtosis).

Directed Blood: family or friends donate blood for a specific person’s future surgery.

Endotracheal Tube: a tube which passes through the mouth into the trachea and is used to provide anesthesia and air during an operation.

Foley or Urinary Catheter: a thin flexible rubber tube which is placed in the urethra to the bladder to allow drainage for urine.

Fusion: a spinal fusion permanently connects the individual vertebrae together as a single piece of bone at the curved part of the spine. After bone graft is added to the spine the fusion occurs when the spine and bone graft heals together.

Iliac Crest: the iliac crest is the large flat portion of the pelvis bone from which bone graft is taken.

Intravenous Line (IV): a small tube is inserted into a vein to deliver fluid and medicines to the body.

Nasogastric Tube (NG): the nasogastric tube passes through the nose down the back of the throat and into the stomach to drain fluid from the stomach.

Posterior Fusion: a fusion on the posterior or back surface of the spine.

Segmental Spinal Instrumentation: consists of multiple types of fixation systems for the spine.