Q: My 14-year-old daughter has scoliosis and her pediatrician thinks she might need to have surgery. What does that entail?
A: The surgical repair for scoliosis is Posterior Spinal Fusion, and it is a surgery performed often in my hospital. It is a long surgery, often taking between 6 to 8 hours. The children usually, but not always, come to the Pediatric Intensive Care Unit (PICU) afterwards for postoperative care. They might stay in the PICU for 1 to 4 days, depending on how they recover. After that, they go to our inpatient Carrie Tingley Rehabilitation Unit, where they receive physical and occupational therapy. These therapies facilitate their ability to resume their activities of daily living, and also enhance their recovery. The therapists will give you exercises to continue at home. The entire hospital stay is typically 5 to 7 days.
There are 3 different kinds of pediatric scoliosis, all of which may require surgical treatment. They are idiopathic scoliosis, neuromuscular scoliosis and congenital scoliosis. Idiopathic scoliosis is by far the most common type. This affects otherwise healthy children, who have a sideways curve in their spine, which measures greater than 10 degrees. Your pediatrician may have done the Adams Forward Bend test to assess this, followed by some X-rays.
The American Academy of Orthopedic Surgeons (AAOS) provides the following information: If the spinal curve is between 25 degrees and 45 degrees and your child is still growing, your doctor may recommend bracing. Although bracing will not straighten an existing curve, it may prevent it from getting worse to the point of requiring surgery. Your doctor may recommend surgery if your child’s curve is greater than 45-50 degrees or if bracing did not stop the curve from reaching this point. Severe curves that are not treated could eventually worsen to the point where they affect lung and heart function. That is the main medical reason for intervening.
Now, here’s some good news. I have personally noticed that the patients I get from the operating room after this procedure are in much better condition than in years past. They are more stable in terms of their breathing and blood pressure, they start eating and drinking sooner after surgery, they start sitting up and getting out of bed sooner and their pain is better controlled. It is frankly amazing to me that some of these children don’t have to come to the PICU after surgery. This surgery takes a long time and involves blood loss and many hours of anesthesia. All of those factors are stressful to the body, and these children used to come out of surgery somewhat unstable. They would require active management of their fluid balance, blood pressure, pain and breathing. We would check labs and replace electrolytes and clotting factors. Nowadays, we barely do anything except watch them closely. They typically come out of the operating room breathing on their own, with stable blood pressure and good pain control. These changes are striking improvements, and prompted me to ask my colleague Dr. Antony Kallur, “What has changed?” Here’s his answer:
Well, things definitely have changed for the better in a lot of ways.
First of all we understand the importance of three dimensional correction and restoration of spinal alignment. Anesthetic techniques have changed very much and are safer with newer medications and ability to keep children unconscious but maintaining baseline nerve and brain function so that we can monitor the child’s spinal cord.
Neuro-monitoring; which is now used all the time for any scoliosis surgery has made the surgery very safe reducing the incidence of neurological injury.
The surgical techniques and our understanding of how to correct the spine and the alignment that needs to be restored has made the children able to return to all activities after healing up from surgery without any restriction. The implants used are advanced to help us correct the spine and maintain alignment to healing and can be placed safely. Titanium implants used now are also biocompatible and incidence of infection is negligible in healthy children. Our incidence at Carrie Tingley hospital is ‘zero’ in healthy children.
These days, the child does not need to stay in bed or use a brace after surgery. The newer instrumentation techniques mean that need to harvest child’s own bone (from the pelvic bone) as graft for achieving fusion/healing is not needed.
The recovery from scoliosis surgery has become so much easier to the child and family compared to how it was 10 to 15 years ago. So, we achieve better correction and alignment with safer surgery with a quicker recovery and return to activities. I hope things go very smoothly for your daughter!
Anjali Subbaswamy is a Pediatric Intensive Care Physician at UNM. Please send your questions to her at firstname.lastname@example.org