Preparing for Spinal Surgery

If you or your child requires surgical correction of scoliosis or kyphosis, there are probably many questions and concerns. This guide is designed to help answer many of these common questions and concerns. We will explain some of the common surgical procedures used in the treatment of scoliosis, how to prepare for the surgery, and what to expect during the initial post-operative period. It is important to understand, however, that every patient and every spinal deformity is different. If you have questions specific to your scoliosis or spinal surgery, please feel free to contact the Pediatric Orthopaedic office at 617-726-8523. The doctors and nurses at Mass General for Children are here to care for you and your family.

About Scoliosis & Spinal Surgery

Scoliosis is defined as a lateral curvature of the spine measuring >10 degrees on x-ray. Scoliosis can occur in either the upper back (thoracic), lower back (lumbar), or rarely, in the neck (cervical). Scoliosis is the most common spinal deformity seen in adolescents 10-16 years of age. Most cases (about 85%) of scoliosis are idiopathic, or have no known cause. Idiopathic scoliosis is much more common in females, and is usually noticed at the onset of puberty coinciding with the pre-adolescent “growth spurt.” Scoliosis is usually discovered during regular check-ups with the pediatrician, or during school screening programs. The most common signs are asymmetry of the spine, uneven shoulders or hips, waist and ribcage asymmetry. These changes are especially noticeable when the child is bending over.

What Is a Spinal Fusion?

If the spinal curvature progresses despite the use of conservative measures (bracing), it may be necessary to proceed with surgical intervention. If the scoliosis progresses to measure greater than 45-50 degrees on x-ray, surgery is often recommended to prevent further progression of the curve. The surgery that is most often performed for progressive scoliosis is called a “posterior spinal fusion with instrumentation.” It is also known simply as a spinal arthrodesis or fusion. The goal of this surgery is to create a solid “fusion” of the curved part of the spine. The fusion is created by operating on the bones of the spine (vertebrae), manipulating and correcting some of the curve/rotation of the spine, adding bone graft, and allowing the vertebral bones and bone chips to slowly heal together to form a solid mass of bone. The hardware that is placed (rods, hooks, and screws) serves as an internal “cast” while the fusion is allowed to heal and become solid. The bone graft may come from your hip (autologous iliac crest bone graft) or more likely from the hospital’s bone bank (allograft). This spinal instrumentation is left in your back and should not cause any problems.

Before Surgery

Aspirin and Other Medications: Aspirin, bufferin, and non-steroidal anti-inflammatory medications (NSAIDS) such as Advil, Motrin, or Naprosyn may cause extra bleeding at the time of surgery. These medications should be stopped two-three weeks prior to surgery. You should also avoid NSAIDS (non-steroidal anti-inflammatory medications) such as Advil or Motrin the first 6 months after a spinal fusion. Tylenol (Acetaminophen) can safely be used for pain relief prior to surgery. If you are unsure whether you should stop a certain medication, consult with your physician or nurse practitioner.

The Night Before Surgery: The night before surgery, do not eat or drink anything after 10:00pm. This includes water, chewing gum, and candy. Your stomach needs to be empty when you go to sleep. This will help avoid aspiration during or after general anesthesia. It will also keep your stomach from getting upset and vomiting after surgery.

Pre-Surgical Area: When you get to the hospital on the morning of your surgery, you will need to check in at the pre-surgical area in the Ellison Building, 3rd Floor. The nurses will record your vital signs (height/weight, temperature, pulse, and blood pressure), and you will change into a hospital gown. An IV line (intravenous) will often be started while in the pre-surgical area. The IV is started using a needle that is removed once the line is in place. This leaves a small plastic tube inside your vein through which you will be receiving medicine and IV fluids. In the pre-surgical area, you and your family will meet with the anesthesiologist, and your surgeon/nurse practitioner. The anesthesiologist will review the pain medication you will be receiving after surgery. This may include a patient-controlled analgesia (PCA) or more rarely an epidural catheter (delivers pain medication directly to the spine). The PCA is a computerized pump that has a tube of pain medication inside. This tube is attached to your IV line and gives you a small amount of pain medication when you press the button. There are lockouts (limits) to the amount of medication to make sure that you receive the right amount. Your parents will meet the surgical liaison nurse either in the Pre-Surgical waiting area. During surgery, the liaison nurse checks with the operating room about every hour and a half for progress reports and then shares this information with your parents. When you are ready to be taken to the operating room, you will be transported to White 3 (Main OR).

Child Life Specialists: Child life specialists have advanced training in child development, and are a vital member of the hospital team on the floor. If you have questions or concerns, please contact the Child Life Department at (617) 724-5727. A quick tour can often be done on the same day as pre-admission testing.

During Surgery

The Operating Room (OR): A nurse will greet you as you arrive in the operating room. One parent can stay with you in the OR until you are asleep. Soon after arriving, the anesthesiologist will often give you medicine through the IV line to help you fall asleep. You may also be asked to breathe through a mask, which is also used to help you fall asleep. After you are asleep, the anesthesiologist will put a small tube in the back of your mouth and throat and into your airway. The tube delivers oxygen to your lungs during surgery, and is usually removed before you wake up after surgery. Sometimes you will have a mild sore throat after surgery, but usually patients never know that the tube was there. Because your stomach is also asleep from the anesthesia, you will usually need to have a nasogastric tube (NG tube) to prevent nausea and vomiting. This tube goes in through the nose and down into the stomach. The NG tube is usually left in until the 2nd or 3rd postoperative day (when your stomach starts to “wake up”). The nurse will also place a Foley catheter into your bladder when you are asleep. The Foley drains urine from your bladder so that it can be measured and monitored post-operatively. The catheter is usually removed on post-operative day 2 or 3.

Posterior Instrumented Spinal Fusion

If you are having a posterior spinal fusion, the incision will run straight down the middle of your back. The incision length will depend on how much of your spine needs to be fused. The spinal hardware placed in the spine consists of rods, hooks, and screws. Bone graft, either donor bone or from the iliac crest (hip), is placed along the spine. The goal of surgery is not only to gain some correction of the scoliosis (curve), but also to gain a solid fusion of the vertebrae to prevent further progression.

Anterior Instrumented Spinal Fusion

If you are having an anterior instrumented spinal fusion, you will have one of two possible incisions. If the curve involves only the thoracic spine, the incision will be on one side of your rib cage from the back to front (thoracotomy incision). If the curve involves either the lower thoracic and/or lumbar vertebrae, the incision will usually be across your lower rib cage and down the front of your abdomen.

Occasionally, it is possible for the anterior spinal fusion to be completed through thoracoscopic surgery. Thoracoscopic surgery of the spine utilizes microscopic cameras which magnify images for the surgeon. There are three to four tiny incisions (about 1 inch each) where the camera is inserted and where the surgeon releases/corrects the spine using tiny instruments. Thoracoscopic surgery is usually usually less painful with a shorter recovery period when compared to traditional open techniques. In addition, the scars are much smaller as well as more cosmetically appealing.

You will usually need to have a "chest tube" after anterior spinal surgery. This tube is placed to drain the fluid that collects outside your lungs and to keep your lungs expanding properly after surgery. The chest tube is covered with a large dressing, and is attached to a plastic container that collects the drainage. The tube is usually left in place until postoperative day 3-4, and will then be removed by the surgeon.

Combined Anterior/Posterior Fusions

Sometimes, it is necessary for the surgeon to complete a two-stage operation for scoliosis. This will involve both anterior and posterior surgeries. The combined anterior/posterior spinal surgery is often necessary for severe scoliosis and/or stiff curves. Usually, they will be done on separate days spaced about one week apart. However, in some cases, it is possible to complete both procedures on the same day.

After Surgery

The Recovery Room (PACU): When you wake up from anesthesia, you will be lying on your back in the recovery room or post-anesthesia care unit (PACU). You may feel stiff from being in one position for a long time. You may not even remember the PACU, because you will still feel sleepy and groggy from the surgery. Your nurse and anesthesiologist will be checking your vital signs frequently, and they will also make sure that you are comfortable. If you are having any pain, the PACU nurse will give you pain medicine through the IV. You will be receiving oxygen through your nose or mouth, and you will be encouraged to cough and deep breath to help clear your lungs. You will still have the IV and Foley catheter (and sometimes chest tube) in place.

A large dressing will be placed over your incision. Occasionally, you will have an X-ray in the PACU to check the rods and hooks in your back. Usually, patients will stay in the recovery room for 2-3 hours while they wake up and recover from the surgery and anesthesia. It is possible to have a parent visit in the PACU after they have met with the spine surgeon. The PACU is located on White 3 next to the Main OR.

Ellison 18: You will usually be transferred up to the floor after the PACU. The adolescent floor is located in the Ellison building on the 18th floor. This is a twenty-four bed pediatric unit with children between the ages of five and twenty years. All the rooms are decorated especially for children and adolescents, and each bedside has a sleep chair/bed for a parent. Parents are welcome and encouraged to spend the night with their child. Child Life Specialists are dedicated to making the hospitalization as positive as possible. They help you in coping with illness/surgery, hospitalization, as well as separation from home, routine, and friends. A new pediatric/adolescent play-room has recently been added to the floor. Television, video games, movies, and other activities are also available on Ellison 18.

Pain Medication: Your nurse will check your vital signs and assess your pain frequently on the floor. You will usually need to have pain medication through your IV for one to two days. Once you begin to drink and eat small amounts of food, you will be able to take pain medications by mouth. You will often be given a stool softener or laxative to prevent constipation which is a common side effect of pain medications.

Activity: It is common to feel quite tired following spinal surgery, and you may need help turning from side to side initially. You will meet with a physical therapist usually on the second post-operative day. The physical therapist will assist with deep breathing, coughing, mobility, and endurance. After your surgeon says it is okay, you may get out of bed and sit in a chair (usually on P.O.D #1) The physical therapist will work with you to teach you the correct way to get out of bed and walk without twisting your spine. You will then progress to walking short distances on the floor. Some patients get up the day after surgery, and others have to wait a few days. Your individual pace of recovery is unique, and depends on the type and extent of spinal surgery. You will be given additional information about specific activity restrictions at your six-week follow up visit. As a general rule, however, no contact sports are allowed for six months after a spinal fusion surgery and three months after anterior vertebral teething.

Eating: Your IV will remain in place so that your body receives enough fluids while you are unable to eat or drink very much. The IV will be removed when you no longer require IV pain medications or transfusions, and you are drinking enough fluids.

It is important to advance your diet VERY slowly to prevent nausea and vomiting! It may actually take two or three weeks for your appetite to return back to normal.

Showering: You will have a dressing on your incision. Usually, the stitches used to close your incision are under your skin. They are absorbable sutures, so they will not have to be removed. It is important to keep your incision clean and dry after surgery to avoid infection. There are different restrictions based on the types of spinal surgery. Your care team will let you know when you can shower and/or bathe.

Going Home: Most patients will remain in the hospital for about 2-3 days after surgery. When your pain is well controlled, you are able to eat and drink without nausea, and you are able to walk around on the floor, you will start to think about going home. Usually your surgeon will tell you when you can expect to go home about a day in advance. During your hospital stay, your parents will be taught how to take care of you. You and your family will be instructed on what problems to look for, as well as how to manage your diet and medications prior to discharge. Generally, no special equipment is needed at home following a spinal fusion.

You will be given prescriptions for pain medication before you go home. Plan to take a dose of pain medication prior to leaving the hospital, as the ride home can sometimes be uncomfortable. If you still have pain after taking the medication, please call the orthopaedic office and let us know. It is possible to make an adjustment to your pain medications to make you more comfortable. Also, if any of the following problems occur after surgery, please let your spine surgeon know right away:

• fever, chills, redness, warmth, or foul smell from the surgical site
• increase in pain that is not controlled with medications
• numbness, tingling, or weakness in your arms or legs
• change in bowel or bladder control

You will not be able to return to school or work right for the first few weeks after surgery. Please arrange for a home tutor through your school system if possible and provide our office with the necessary documentation prior to surgery.

Before you leave the hospital, please schedule a follow-up visit with your spine surgeon (617) 726-8523. Usually, the first post-operative visit is scheduled six weeks after surgery. If any questions or concerns arise before your scheduled follow-up visit, please feel free to call us at any time.