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Scoliosis correction surgery (Causes (Idiopathic 70% (early onset / late…
Scoliosis correction surgery
Scoliosis
Lateral curvature of the thoracolumbar vertebrae with a resulting rib cage deformity
Girls > boys
Curvature may resolve, remain small or prog increase
Surgery indicated once curvature >40 degrees (Cobb angle - lateral curvature, once > 65 deg - reduction in lung volumes and V/Q mismatch, if > 100 deg - risk PHT + RV hypertrophy)
Cardioresp dysfunction may prevent surgery
Causes
Idiopathic 70% (early onset / late onset)
Neuromuscular (CP, Myopathy, Polio, Syringomyelia, Freidrich's ataxia)
Congenital (vertebral anomalies, rib anomalies, spinal dyraphism)
Traumatic (vertebral fractures, radiation, surgery)
Syndromes (Marfans, RA, Osteogenesis imperfecta, Mucopolysaccharide disorders, neurofibromatosis)
Neoplastic (primary or secondary tumours)
Infection (TB, Osteomyelitis)
Sequelae
Cosmetic deformity
Back pain
Chest cavity narrowing
restrictive lung defect
dyspnoea on exertion
respiratory failure
pulmonary hypertension
right heart failure
Surgical
Aims
Correct curve and fuse spine
Improve posture
Halt progression of pulmonary dysfunction
Approach may be anterior, posterior or combined depending on cause and severity
Technique
Vertebral laminae decorticated, facet joints destroyed and spinous processes removed
Bone graft packed over raw decorticated surfaces and rods used to correct deformity, provide stability
May require one lung ventilation to improve surgical access (mostly in high thoracic curves)
May be staged or combined anterior and posterior approaches
Anaesthetic
Preop
History and Exam
Scoliosis (aetiology, location, degree)
Comorbid conditions (if non-idiopathic then increased suspicion for Cardiomyopathy - Muscular dystrophies, ability to cope with fluid shifts intraop)
Cardio-resp function (restrictive deficitm PHT, cor-pulmonale, chest wall expansion, peripheral oedema)
Exercise tolerance
Ix
Bloods (FBE, G+H, UEC, electrolytes)
CXR
PFTs (FEV1, FVR expect restrictive deficit (ART blood gas if spirometry not available)
ECG +/- echo (esp if non idiopathic scoliosis, RV hypertrophy, mitral valve prolapse)
Liaison and optimisation
Discussion of wake up test if it is possible
Post op pain plan
Nutrition
Hb optimisation: Iron, EPO, autologous blood donation
Optimize comorbidities (epilepsy, cardiac function)
Consider stress dose of steroids e.g. Duchenne musc dystrophy
Intra op
Planning and preparation
Consider premed
Standard and invasive monitoring (ART, CVC)
Warming and blood tx prep (2 large IVC, cell saver)
IDC once asleep
X Ray compatible table
Induction
Avoid Sux in muscular dystrophies
Maintenance
Stable depth of anaesthesia allowing for neurophys monitoring (Remi + propofol/volatile)
Positioning (Secure ETT, avoid kinks, free mvmt of abdomen (avoid venous congestion), meticulous eye care, neutral neck, brachial plexus, pressure points
Blood conservation techniques (minimise losses, controlled hypotension, TXA, prevent coagulopathy, autologous blood)
Prolonged anaesthesia (fatigue, pressure areas, repeat Abx, temp control, TEDS)
Post op
Extubation timing
Most extubated immediately post op for early neurological assessment
Ongoing invasive monitoring may be required in HDU
If volume, temp or metabolic abnorm, may need a period of post op ventilation
Analgesia
Allow physiotherapy and early mobilization
Multimodal - consider epidural/PVB during anterior correction (neuro assessment prior to insertion), NASAID controversial
Correct fluid losses
Likely ongoing blood losses
Paralytic ileus possible
Assess volume status regularly