Surgery

Help you to prepare for your consent clinic appointment by explaining key details about the surgery to give you time to review before your appointment.

Why? Your treating surgeon will go through all the information in clinic during the consent process. It can be a lot of information to take in if you’re hearing it for the first time. We recommend you look at the information below to prepare and write down any questions to ask at the appointment.

It will cover:

• Information on surgery and the benefits and risks

• Spinal cord monitoring during surgery

• Surgery performed from the front: Anterior approach

Surgery is typically offered to patients who have a scoliosis that has a Cobb angle of 50 degrees or more to prevent it getting bigger throughout adult life. This is to prevent a much larger curve causing pain, heart or lung problems in later life.

If you are still growing, the size of your scoliosis will get worse. Even after you have finished growing, the curve can still get bigger, but at a much slower pace. It is important to note that not all curves get bigger. However, apart from the Cobb angle measurement, we have no other way of trying to predict who will develop very large curves in later life.

Although the operation does improve the shape of your back (by making the Cobb angle smaller), the way you look is not the main reason for operating because we do not achieve a straight back after surgery. This means that some people are still unhappy with their shape after an operation. Back pain may or may not improve, and in some people can be worse after surgery for scoliosis.

All scoliosis surgeries involve a general anaesthetic and spinal cord monitoring. When the anaesthetists are happy that you are fast asleep and all monitoring is in place, you are turned onto your tummy so that the surgery can be performed. At this stage we ensure you are in the correct position so your head, arms and legs are placed comfortably.

In most cases the surgery involves a long cut down the middle of your back. If your surgery is going to be performed using an approach from the front (anterior), please see the separate section on this.

The muscles are moved off the spine to allow placement of screws in the pedicles and vertebra of the spine. Hooks or bands are also often used where necessary and attached to slightly different parts of the spine. Segments of your spine are then made more flexible by removing the joints or making cuts to the back of the spine. The spine is then straightened by connecting the screws that are attached to the spine to rods.

At times during the procedure, tools are used to remove the joints at the back of the spine, and to remove the outer surface of the bone, to allow fusion. This is where the bone grows across the spine where the rods and screws have been placed and prevents further change in the shape of the spine.

From 2am

• You won’t be allowed to eat anything but will be allowed to sip clear fluids (water) until your operation. 

7:30am–8:15am

• The anaesthetic and / or surgical teams will normally come and see you to check you still want to go ahead and answer any final questions.

• The nurses will also go through some final checks with you.

8:15am–9am

• Once the theatre team is ready, a member of the team will come and collect you from the ward.

• You will either walk to theatre, or come on a trolley, depending on how you are feeling and what medicines you have been given.

• You will meet your anaesthetist in an anaesthetic room like the one pictured below, this is connected through the double doors to the operating theatre.

9am–11am

• Your anaesthetist who will talk you through what will happen and then you will be given your anaesthetic and go to sleep and the anaesthetist will set up the drips for your pain relief.

• All necessary monitoring will be attached to your body, this will include the spinal cord monitoring.

• When you wake-up you will find spots of blood and pinpricks on your arms and legs, and in your hair, from the tiny needles used.

• A catheter (a tube to allow you to wee) will also be passed into your bladder while you are asleep. 

10:30am–11:30am

• Once all the monitoring is placed, you will be positioned on the operating table and the surgery will start.

• It will normally take between 4 and 6 hours to perform your surgery, but unexpected events can make it last longer.

• You will be lying on your front during the procedure so when you wake up you may notice some red marks on the front of your body for a little while. These appear because you’ve been lying in the same position for a long time.

Early evening

• You will wake-up in theatre or in recovery and stay there whilst the nurses check on you.

• You will have your first neurological checks and be made comfortable with any additional painkillers you may need.

• A member of your family will be allowed down once the whole team is happy it is safe for them to do so.

• A member of the surgical team will talk to you and your parents once you are awake and inform you and them of how the surgery went and if there were any difficulties or complications during the operation.

Later evening

• Once it is safe for you to leave recovery, and your pain is under control, you will return to the ward. 
• Once there you can move around in bed as much as you want to get comfortable, and you will be allowed to eat and drink. You should start with something light like toast, ice cream, or yoghurt.

Overnight

• You will have a nurse checking everything is well with yourself at least every hour. This means you may not get much sleep but it is important we make sure you are ok all throughout the night. 
  
  
• One of the medical team will check everything is going well later that evening.

You will find  information and videos about general anaesthetic on the website of the Royal College of Anaesthetists including the 2 leaflets:

• General Anaesthetic a brief guide for young people from 12 years old
• Rees Bear has an anaesthetic. A story for younger children about having an anaesthetic

During the operation, signals in your body are monitored to ensure everything is working as it should be, to help keep you safe and healthy. Examples include heart rate, blood pressure and lung function. In some spinal operations, as well as these routine checks, surgeons request intraoperative spinal cord monitoring. 

This information is designed to give you and your family information about the role of spinal cord monitoring during your operation.

What is Intra Operative NeuroMonitoring (IONM)?

During surgery, screws are placed in the pedicles and in the vertebra of the spine around the spinal cord. As the spine is then corrected, the shape of the spinal cord also changes. By monitoring we aim to identify significant changes at a point where the surgeon is able to intervene to reverse these changes. 

IONM is a method of checking how the spinal cord is working during surgery.

The reason for using IONM is to identify any potential problems with the spinal cord early and therefore to implement changes with the aim of preventing the development of new neurological symptoms, including paralysis. Your monitoring will be performed by Clinical Physiologists / Clinical Scientists with specialist neurophysiological training.

Top tip: Is there anything I need to do before my operation?

Yes, please:

·         have clean, dry hair free from hair products

·         avoid using moisturiser on the day of your operation

·         If you have long hair, it would be helpful to put this in two loose plaits starting low at the hairline to enable us to attach electrodes to your scalp, and in addition prevents your hair from getting too tangled.

Additional information about spinal monitoring during surgery

If you attend a pre-operative Somatosensory Evoked Potentials (SSEP) study with us, you will be asked some questions to help us better plan our monitoring of your operation. Alternatively, these may be asked over the telephone.

What happens on the day of my operation?

After your anaesthetist has helped you go to sleep, electrodes in the form of stickers and thin, short needles will be attached to various places on your limbs, shoulders, neck and head. Since you will already be asleep, you won’t feel these electrodes being attached and they will be removed before you wake again. In some instances, skin electrodes will need to be held in place with special skin glue which will also be removed before you wake up.

For the vast majority of your operation, a mixture of SSEPs and MEPs are performed. If there are any significant changes to your responses, the Physiologists / Scientists will inform your surgeon.

 

 

What are SSEPs and MEPs?

During your operation electrical signals will be sent up your spinal cord by stimulating nerves at your ankles and / or your wrists. The resulting electrical activity will be recorded from electrodes on your legs, shoulders, neck and head. These are called Somatosensory Evoked Potentials (SSEPs). You may have had these studied as part of a pre-operative investigation in the months or weeks leading up to your surgery.

Electrical signals are also sent down your spinal cord by stimulating a specific part of your brain through electrodes on your head and then recording the electrical activity produced by some of the muscles (mostly) in your legs. These are called Motor Evoked Potentials (MEPs). The ongoing activity on your muscles at rest may also be recorded.

In brief, SSEPs monitor the feeling parts of your limbs whilst MEPs monitor the moving of your limbs.

 

What are the risks and benefits of IONM? 

Benefit 

The aim of intraoperative spinal cord monitoring is to reduce the likelihood of neurological complications resulting from spinal surgery. These can include but are not limited to: paralysis, weakness and changes in sensation. 

Risks 

·         MEP stimulation causes your muscles to tense briefly. As a result, there is a small risk of biting the inside of your mouth or tongue. Most anaesthetists place some soft material in between your teeth to reduce this risk. 

·         MEP stimulation may elicit a seizure or changes in heart rhythm in patients with pre-existing medical conditions. This is a very small risk. As part of our pre-operative checks, we will ask you some brief questions about your previous medical history to help determine whether MEP monitoring is possible (or contraindicated) and if necessary, consult with your surgeon to determine the most appropriate monitoring for your operation. 

·         There are a few isolated reports in the UK of small patches of hair loss associated with use of the head needle electrodes. 

·         The needles used to record the electrical activity from your muscles may lead to infection, or cause injury to a nerve. However, the sites where the needles are used are prepared with alcohol and carefully selected to reduce this risk. The likelihood of either of these events happening is very small and there are no known reported cases of nerve injuries occurring due to IONM needle electrode use. 

 

For more information on neurophysiology please contact:

Clinical Neurophysiology Department, QMC Campus, B Floor, West Block

Telephone: 01159709146

Some scoliosis surgery is performed through a front (anterior) approach. This approach is sometimes used as a first stage surgery if you have a large curve to make your spine more flexible. In other circumstances it is used as a single procedure to correct the spine from the front. The main advantage to this is that it means we need to fuse fewer spinal bones together, which we believe will benefit you in the long-term.

The surgical cut (incision) is normally on your left-hand side, running along a rib and then curving into your tummy towards the belly button. You will therefore be laid on your side during the procedure. Some patients will have shoulder pain when they wake up from lying on their side all day.

To get to the spine, we have to go past your ribs. The discs between the vertebra are removed and bone graft is placed in these to allow fusion between them. The screws are also placed through the sides of the vertebra, rather than down the pedicle, but are still joined together with a rod.

When you wake up you will have a chest drain for 1 to 2 days. A chest drain is a tube that goes into your chest to help fluid or air leave your body to improve your breathing. The rest of the postoperative pathway is similar whether surgery is performed from the front or back of the spine.

There is no doubt that the majority of people who undergo scoliosis surgery are happy and feel the hard work is worthwhile. However, sometimes things don’t go as well as expected. For this reason, we have to tell you about things that could possibly go wrong. Some complications happen more often than others, and often these are treatable. Life-changing complications are thankfully rare.

The risk of any complication, no matter how big or small, is between 1 and 5 in 100 surgeries (1 to 5%), with a risk of re-operation for any reason in up to 1 in 20 (5%) at 10 years after the first operation.

To put any figures in context, we perform approximately 80 to 100 surgeries a year for adolescent idiopathic scoliosis at Nottingham Queens Medical Centre.

Medical complications

Having a general anaesthetic and an operation is a big event for your body. You can develop urine (wee) infections and chest infections which will be treated with antibiotics. It is also a strain on your heart and kidneys, particularly if you lose a lot of blood. Although rare in children, damage to the kidneys and heart muscle or heart attacks can occur, and these will be treated by the anaesthetic and medical teams. 

Ileus

This is when the bowel slows down and food and wind is not moved from the stomach through your bowels at normal speed. This can lead to bloating and being sick. Once you have been told you can start eating and drinking, start with simple light food before returning to a full meal. For the first few days, if your bowel is working normally, you will find you pass wind (fart), but no stools (poo). This is entirely normal.

Ileus can last several days and is uncomfortable. There are no specific treatments, and we must wait for the bowels to start working again. If you are vomiting a lot, a tube can be passed through your nose into the stomach so that you do not need to vomit. It is taken out when the ileus settles.

Blood clots (deep vein thrombosis and pulmonary embolus)

Blood clots are rare in young people undergoing surgery for scoliosis. Your main defence is movement and so we will encourage you to start moving as soon as the first night of your operation. You must tell us if you are taking any hormone treatment or any contraceptives because we may need to stop them before your surgery.

If blood clots occur only in the leg, (deep vein thrombosis or DVT), then you may have leg pain or swelling. Treatment is aimed at preventing you from having another one. DVTs happen after around <0.01% (less than 1 in 10,000) of surgeries.

Rarely (0.03% of the time) these blood clots can move and travel to the lung. This can lead to chest pain, breathing problems and, in severe cases, death. Treatment is aimed at supporting your breathing and preventing you from developing further blood clots.

Infection

Infection occurs in 0.4% to 1% of surgeries. It can occur early in the first few days or weeks after the operation but can sometimes take months or years to become apparent.

A superficial infection in the wound, will often be treated with antibiotics and nothing more is needed.

However, a deep infection around the metalwork and spine is much harder to treat. You are likely to need antibiotics given through a drip in the arm, and an operation to ‘clean’ the metalwork. Sometimes we need to do this more than once. If this doesn’t get rid of the infection, then you may need to have all, or part, of the screws and rods removed. Depending on how long it is from your surgery, we may need to put the metalwork back in. If this is necessary, we may have to keep you in bed in hospital for a period of time before replacing them to minimise the chance of the new metalwork becoming infected.

We will keep you informed of our treatment and decision making at all times.

Bleeding

All surgeries cause some bleeding, but more complex operations can lead to a large amount of blood loss. Bone contains many blood vessels, and so because we are placing screws in the bone and peeling off the surface of the bone to achieve fusion, scoliosis surgery can lead to significant blood loss.

During the surgery we use cell salvage where we collect the blood from the surgical site. We then filter it to ensure it is clean and give it back to you. We sometimes use blood transfusions, where you receive blood from someone else. This happens infrequently in this surgery and we will only use this if absolutely necessary.

Bleeding can also occur next to and around the spinal cord, this is called an epidural haematoma. If this happens, then pressure will build up on the spinal cord and you may become paralysed. You will have regular checks on the movement in your arms and legs after the operation. If there are any concerns, then you will undergo further imaging of your spine. If there is something obvious pressing on the spinal cord, then an emergency operation may be needed to remove this and give the spinal cord chance to recover. This is thought to occur in less than 0.01% of surgeries.

Nerve injury

We can damage nerves and vessels during the time it takes to expose the spine, but also when we are putting the screws in the pedicles and vertebra. If we are unhappy with the position of a screw during the procedure, we will replace it, however some nerve injuries are not apparent until after the surgery.

If this happens in the thoracic spine you may have pain coming around your chest wall or patchy numbness. In the lumbar spine you may have pain shooting down the leg, areas of numbness or even weakness in some muscles.

Depending on the severity of the symptoms, we will check the position of the screws with X-rays, CT, or MRI scans. In discussion with you, we may decide to leave the screws alone and see if the symptoms settle, or we may decide to take you back to theatre and change the position of the screws that are in the wrong position.

Nerve injury happens in 0.3% or 3 in 1000 procedures.

CSF Leak and dural tear

The nerves and spinal cord are surrounded by a thin layer called the dura. This helps protect them and maintain the flow of cerebrospinal fluid (CSF) around them. This thin layer may be injured by our instruments or the screw. Most dural tears will heal with repair in theatre, or with a period of bed rest after the operation.

If, however, they do not heal, you may have a watery fluid leaking through your wound and develop headaches. We may need to do another operation to find the location of the leaking fluid and try and repair it. Please do contact the spinal nursing team if you are ever concerned about a wound healing problem.

Once the wound is healed, most dural tears will not give you any side effects in the long-term. 

CSF leak and dural tear happens in 0.2% or 1 in 500 procedures.

Lateral cutaneous femoral nerve injury

This is a small nerve that runs across the prominent bone at the front of your pelvis. When we position you face down during the operation you may be lying on this nerve and be squashing it for the whole of the procedure. We place you on soft cushions to try and make sure you are comfortable, but this can still happen despite our best efforts.

The nerve supplies sensation to the outside of your thighs. If it is damaged from lying on it, you may notice numbness or tingling in these areas (it can occur on only one side). It can affect 1 in 4 procedures, with data showing it resolves after 1 day in 40% of cases. It normally gets better over days and weeks and can cause tingling (paraesthesia) whilst it recovers. If it doesn’t return to normal, you will be left with numbness on the outside of your thighs which most people get used to. If the tingling persists and is very uncomfortable, you may need painkillers to decrease how much it bothers you.

Metalwork mal-placement and failure

As mentioned earlier, screws, hooks or bands are placed in the bones of the spine around the spinal cord. There are lots of precautions that are taken to ensure that these anchors are placed safely and correctly. However, despite our best efforts, some of the metalwork may not be in the ideal position.

The risk of metalwork malposition is between 5 and 12% for scoliosis surgery but not all cause symptoms. Most of these go unnoticed. If problems do arise with metalwork malposition, the majority can be treated without further surgery resulting in full recovery of symptoms. 1 in 285 (0.35%) of cases required revision surgery in one published case series.

Sometimes rods and screws move or detach from each other after the operation. You may not have any symptoms, but you may develop pain or be able to feel the screws and rods through your skin. If this occurs, we may need to take you back for another operation to repair the problem.

If the bone doesn’t fuse together, then the rods may break. This can lead to increased pain in the back, but sometimes it is simply seen on a routine X-ray. Depending on where it occurs, how many rods break and how long it is from surgery, we may not need to replace it. We will usually perform a CT scan to help with this decision.

If you develop an infection, the screws and rods can become loose. The main aim of the treatment will be to get rid of the infection, and more details about this are discussed in the infection section.

Damage to adjacent structures

Although surgery focusses on the spine, there is a risk of damaging structures next to the spine. Although there is a greater risk with the anterior approach, the posterior approach also carries with it the chance of damage to the bowel, the lung, the kidney or the large vessels running in front of the spine. Any injury will be treated dependent on the nature of it.

Injuring a large vessel can cause major bleeding which can be life threatening and will mean you require a blood transfusion. You may also need emergency surgery to repair the damaged vessel and stop the bleeding.

Injury to the lung may mean you wake up with a chest drain that you were not expecting.

Information: We will only perform repair to structures without telling you if it is an absolute emergency that needs treating immediately. Where possible, we will talk to you and your family to explain what has happened and decide what further treatments are necessary.

Non-union

One of the aims of surgery is to create a fused spine. This is where the bone grows around the screws and rods. If the spine does not fuse, then this is called a non-union.

Non-union will normally occur in a small area rather than across the whole spine. If this happens, then you may experience increasing back pain or prominent metalwork. It may also be only picked up incidentally on a routine X-ray showing a broken rod.

This will normally be investigated further with a CT scan and depending on your symptoms you may need further surgery to try and get the area of non-union to fuse. 

Information: The rate of non-union in adolescent idiopathic scoliosis surgery is approximately 1%. 

Add-on phenomenon 

If you have the surgery whist you are still growing, there is a chance that curves that are not included in the original fusion get bigger as you grow. In approximately 1 in 8 to 1 in 10 selective thoracic fusions, a patient will need to go back to theatre to have the second curve included in the fusion. This may be several years later.

However, the reason we don’t include the second curve, is because up to 9 in 10 children will have a smaller operation, and therefore more movement, than if we had included the whole scoliosis in the first operation.

In operations other than selective thoracic fusion, there is still a chance of add-on phenomenon, but this occurs less frequently. Overall revision rates for surgery for any type of complications in patients with AIS are around 5% of all operations.

Back pain

There is no guarantee that your back pain will improve, and some people are left with more back pain than they started with. The majority of back pain will improve over weeks and months, and you will be encouraged to increase your activities over this period because this has been shown to improve symptoms in the majority of people.

If your back pain does not improve you may be offered physiotherapy after your first follow-up appointment.

Shoulder imbalance

Depending on the type of scoliosis you have, you may notice that your shoulders aren’t level before your operation. During the surgery, attempts will be made to try and level your shoulders or make them look symmetrical. However, it is not always possible to get this absolutely right.

People who notice their shoulders aren’t level after the operation will be given some physiotherapy exercises to perform to try and help level them. Research has shown that your shoulder balance can improve over the first year after your surgery.

Proximal junctional kyphosis (PJK)

This is when the spine suddenly bends forward over the top of the fixed spine, that is, where the last screws are at the top of the back. It can occur as early as straight after the operation.

In severe circumstances this can cause paralysis at this level of the spine. If there are any concerns after the operation with the function in your arms, legs or both, then you will undergo further investigations immediately. Rarely, a patient may need an emergency operation to correct the kyphosis.

Blindness

Surgery in the prone position (lying on your tummy) is associated with blindness. This is very rare, found in less than 0.02% (less than 2 in 10,000) of surgeries.

During the operation your face is placed in a special cushion which is cut out to allow space for the eyes. The weight of your head is supported by your jaw, cheeks and forehead. During your operation the eyes are checked regularly to ensure the cushion has not moved and the eyes are not under pressure.

You must tell us if you are being investigated or being treated for any eye conditions.

Risk to life

There is always a small chance that a patient dies during their operation, or during their recovery. This is rare in adolescent idiopathic scoliosis surgery, occurring in approximately 0.01% to 0.18% of surgeries (1 to 18 in 10,000). If you have a lot of other medical conditions requiring treatment, then your risk is higher.

Possible causes of death are major bleeding that the surgeon is not able to control, severe infections leading to sepsis, or other medical complications. The team looking after you will do everything they can to treat the cause, but sometimes they are not effective.

Paralysis

This is thought to occur in approximately 1 in 850 to 1 in 1000 (0.1 to 0.11%) of surgeries for adolescent idiopathic scoliosis. It can occur if screws are put in the wrong part of the spine, or if instruments we use during the procedure hit the spinal cord.

The critical part of the operation is when the curve is straightened as the rods are attached to the spine and this may affect the blood flow to the spinal cord. The spinal cord monitoring team will let the surgeon know if there are any concerns over spinal cord function at any stage during the operation. The rods may need to be removed and the operation abandoned.

All efforts are taken to prevent spinal cord injury and paralysis. With larger and / or atypical curves, there is a greater risk of spinal cord monitoring issues. If a spinal cord monitoring alert occurs and is not reversible, a wake-up test may be performed. This involves lightening the sedation to enable you, while under anaesthetic, to follow commands. You will then hear us asking if you can move your feet. If you are able to move your feet, then that reassures the team that the spinal cord is functioning. The anaesthetic is then deepened. Most individuals do not remember this. If there are ongoing spinal cord monitoring issues, your surgery may be abandoned, you woken up to ensure that the spinal cord is functioning well, investigations as to why such alerts may have occurred with a view of revisiting surgery if there is continued appetite to do so. This will be discussed with yourself and your parents/ carers. 

Occasionally if surgery is abandoned, you may wake up with a ring around your head and pins in your knees. This will allow us to apply gradual traction on the ward to slowly stretch your spinal cord and increase the tolerance of the spinal cord for a final correction a few weeks later. 

Despite the best efforts of the surgical and anaesthetic teams, you may be left paralysed by this procedure and the spinal cord may never recover. In this case you will be left with legs that are weak or don’t move at all, the inability to pass urine requiring a long-term catheter, and help with opening your bowels.

If the spinal cord is injured in your neck, then your arms will be weak as well. This can occur because of PJK or if the spinal cord in the neck is injured during positioning you on the theatre table.

You will have the opportunity to speak to your consultant before the operation. Please do bring any questions to that appointment. 

This information is not intended to try and discourage you from having surgery but does form a vital part of the consent process to ensure you understand what you are having done and the potential for things to go wrong.

For more information please contact:

Centre for Spinal Studies and Surgery

Queens Medical Centre Campus, D Floor, West Block

Telephone: 01159249924   

Choose the appropriate extension number for the waiting list coordinator based on the consultant whose care you are under:

Contact details

Extension	Waiting List Coordinator	Coordinates for
81024	Rachael Blow	Mr Patel
88469	Christine Pickard	Mr Yoon
86230	Julie Russell-Laing	Mr Shafafy & Mr Bayley