Surgery for adolescent idiopathic scoliosis is very successful. There are two main goals of surgery:
- To correct the scoliosis as much as is safely possible
- To fuse that area of the spine so that the curve does not get worse after surgery
To accomplish the above 2 goals, spinal implants including screws and rods are attached to the vertebrae in the area of the curve. These implants give the surgeon the ability to straighten the spine. After the spine is straightened, bone graft is placed over the vertebrae to obtain a fusion. The goal is to get a solid block of bone (called a “fusion”) so that no further motion occurs in that area of the spine. The implants stay in the body forever unless there is a problem (such as infection). Once the spine is fused, the implants do not serve any function but removing them is unnecessary because it would involve another surgery.
Surgery is recommended in skeletally immature patients with curves greater than 50 degrees and in skeletally mature patients with progressive curves greater than 50 degrees. For more on treatment options for scoliosis, click here.
Some scoliosis curves are “flexible”. This means that the curve is not rigid and straightening the spine is much easier. Curve flexibility is determined before surgery with “bending X-rays”. If the curve improves significantly when the patient bends sideways, this means the curve is flexible and the surgery will be more straightforward.
Spines that are “rigid” are technically more difficult to straighten during surgery. In these cases, the surgeon has to “release” the spine by removing joints and ligaments in order to make the curve flexible. This procedure is called “osteotomy”, which means cutting or removing bones. Depending on the curve location, severity and rigidity, several osteotomies may need to be done to adequately straighten the spine.
The spine can be approached from either the front (anterior approach – through abdomen or chest)) or the back (posterior approach). While some curves are amenable to the anterior approach, the most common approach used is from the back of the spine, called a “Posterior Spinal Fusion”. With modern spine implants and techniques, almost all curves (even those that were previously treated through the front of the spine) can now be corrected from the back of the spine.
Details of Surgery
The first step of the surgery is to expose the bones in preparation for the work that will be done. The second step is to perform osteotomies (see above) to make the curve more flexible in preparation for the correction. This step is not necessary if the spine is already flexible to begin with (see above). The third step is the insertion of pedicle screws into the vertebrae. Depending on the size of the curve and location, anywhere between 12-30 pedicle screws may be placed. After the screws have been placed and confirmed to be in good position on x-rays, the two rods are placed and the spine is then straightened. There are several techniques used to straighten the spine. Once the spine has been straightened, bone graft is then placed between the vertebrae being fused. This is the fusion part of the surgery. The wound is then closed and the surgery is completed.
Patients and families understandably have anxiety about this type of surgery. Straightening the spine is a big operation and the surgery can take anywhere between 3-7 hours depending on the severity of the curve. Despite this, fusion for adolescent scoliosis is a very safe operation with very low complication rates. Adolescents typically recover very quickly and once healed, return to their previous activities without limitations.
Spinal cord monitoring is used to prevent and identify any injury to the spinal cord during the operation. Spinal cord monitoring gives the surgeon real-time information about the function of the spinal cord. If any changes occur in the monitoring signals, the surgeon can take steps to reverse the change and prevent further injury. Spinal cord monitoring has made the surgical treatment of scoliosis very safe.
Other risks include infection, failure of the fusion to heal and anesthetic-related risks that exist with any operation. The risk of these complications is very low in adolescents.
You should arrive at the hospital at least 2 hours before your scheduled surgery time. I will see you before you go back to the operating room to answer any additional questions you may have. You will then be taken back to the operating room where the anesthesiologist will give you a general anesthestic. After you are asleep under anesthesia, the spinal monitoring technicians will place the leads that will allow monitoring of your spinal cord function during surgery. You will then be positioned on the operating room table and the surgery will begin.
After the surgery, you will be taken to the recovery room where your blood pressure, temperature, pulse and respiration will be checked frequently. The nurses will also give you enough pain medication to make sure your pain is under control. You will stay in the recovery room for one to three hours. Meanwhile, I will speak with your family or friends in the waiting room regarding your condition and the details of the surgery. You will then be transferred to a regular hospital room. Your family and friends are welcome in your room at this time.
You will be given IV fluids until you are able to drink on your own. You will also be given IV pain medication initially, and then oral pain medication depending on your level of pain. Most patients will have a PCA (patient controlled anesthesia) pump after surgery. This machine is set up so you can get a prescribed amount of pain medication at intervals by pushing a button. You will also receive oral pain medications. This medication is on an as needed basis. Keep in mind that after back surgery, pain is expected but it should be under control and tolerable. If you feel your pain is excessive, please ask your nurse to call me or the pain specialists so we can adjust your pain medications.
Most patients are helped out of bed by the nursing staff or physical therapist on the day after surgery. After surgery, it is very important to get out of bed and start moving as soon as possible, ideally the day after surgery. You will have pain in your back from the surgery which we will control with pain medications. Lying in bed for a long period of time can lead to complications and will delay your recovery. So make every effort to get out of bed the day after your surgery. Physical therapists will provide instructions on the proper ways to move around after surgery. The therapists will also assess your needs for medical equipment to be used at home.
Your wound drainage will be monitored closely. The drainage tube is typically removed by the third day after surgery. When you return from surgery, you may have a drainage tube (Foley catheter) in your bladder that is connected to a collection bag. This is typically removed on the first or second day after surgery. Once you are able to drink, eat, and take your pain medication by mouth, your IV line will be removed. Most patients can go home 3-4 days after surgery. You will be discharged from the hospital when the following goals have been met:
- Your pain is reasonably controlled with oral pain medication
- You are able to eat a meal without nausea or vomiting
- You are able to walk safely on your own
- You are able to urinate on your own
- Your vital signs (temperature, blood pressure, heart rate, respiration) are normal
Depending on how soon the above 5 goals are met, some patients are able to go home three days after surgery, while others require up to 5 days.
At Home After Surgery
The post-operative instructions outlined below will give you the best possible chance of having a positive outcome from this surgery:
- Take short walks as your comfort allows. Gradually increase the amount of walking you do each day. Walk 15-30 minutes three times a day. Your goal is to walk 1 mile by end of the first month after surgery.
- Avoid bending over at the waist, twisting or bending motions for the first 6 weeks. Do not bend over to tie your shoe laces. Also avoid lifting anything heavier than 20 lbs for the first 6 weeks.
- Avoid all strenuous activities for 3 months. Do not lift heavy bags or luggage.
- Wound care:
- When you go home you can take a shower but keep your incision covered with gauze and Tegaderm dressing to keep the incision dry. After showering, pat the incision dry and cover it with a new dressing. Do not leave a wet dressing on the incision.
- Keep your incision covered with Tegaderm dressing for 2 weeks when you take a shower. After that, you can shower without anything covering your dressing as long as there is no drainage from the incision. Do not take baths or soak your incision (swimming, etc.) until your wound is fully healed, usually at around 3 weeks.
- Do not apply any lotions, ointments or creams to the incision.
- Reasons to contact us immediately:
- If there is any redness around the incision
- If there is any drainage from the incision after the second day.
- If you have a fever higher than 101 deg F.
- Return to school: most patients can return to school after 1 month. Some can return as early as 3 weeks and others need as long as 2 months. Every patient recovers at a different rate. You may go back to school half-days at first and gradually increase this to full days.
- If you are driving age, you may drive when you no longer require pain medications. Most patients cannot drive until at least one month after surgery.
- Three months after surgery, you will begin physical therapy. The therapist will help you strengthen your back muscles with back exercises. These exercises should be part of your lifelong fitness program. The therapist will also teach you about doing everyday tasks with proper body mechanics. This exercise program is a critical part of your recovery.
- Fusions heal slowly. It can take up to one year for a spinal fusion to fully heal. You will need to have X-rays taken of your back periodically during this period.