Monday, December 17, 2018

The Risks of Spinal Deformity Surgery

In order to minimize the risks of spinal deformity surgery for scoliosis, kyphosis, spondylolisthesis, spondylolysis, etc….. Obtaining a thorough medical history is necessary, along with a physical examination, blood work and imaging studies.  Shared decision-making is important during discussion about surgery, along with the alternatives to surgery, the benefits of surgery, potential complications and risks.  Below is the first part of the routine preoperative discussions on spinal deformity surgery in children and adolescents.

Overall there are two layers of risks in spinal deformity surgery: 1) Those common to any surgical procedure, and 2) those unique to spinal deformity surgery.  The below information are those risks common to all surgical procedures which require general anesthesia.

1.      Risks common to any surgical procedure: general anesthesia and the need to incise the skin for the surgery
a.      General Anesthesia = being asleep for the entire procedure
                                                    i.     Statistically there is a greater risk of a fatal car crash over a year (1 in  4,000 to 8,000) than there is of a catastrophic event due to general anesthesia in a healthy adolescent or child (1 in 100,000 surgeries).  The riskiest part of the day may be the drive to the hospital, so drive safely and buckle up.
                                                   ii.     Nausea and vomiting are common after general anesthesia, in up to 30% of surgical case.  The Anesthesiology team give medications during surgery to minimize nausea and vomiting after surgery
                                                  iii.     Being under general anesthesia is like taking a nap, only medication-produced.  You won’t know how much time you have been asleep until you wake up and see a clock or someone tells you….it is just like taking a nap.
b.      Surgery requires creating an incision on the skin, which means the area of surgery can develop a bacterial infection. 
                                                    i.     In medical terms this is call a SSI or Surgical Site Infection
                                                   ii.     There are many things the surgical team will do to minimize the chance of an infection. 
1.      The use of antibiotics is very important.  They are given before incision is made, during the surgical procedure and after surgery to minimize the risk of a SSI.  It is also important the correct antibiotic is give, at the correct dose and at the optimal time.
2.      Before surgery, usually at the preoperative visit, a nasal swab will be performed.  This is to try to identify people with MRSA on their bodies, specifically their noses.  MRSA = Methicillin-Resistant Staphylococcus Aureus, which is a very bad infection to get due to its being resistant to most antibiotics which can be given to prevent infection.  It is important to know who carries MRSA before surgery to make sure the correct antibiotic is given before an incision is being made.
3.      And there are many things you will not see the surgical team doing, such as the sterile skin preparation, surgical draping, sterile surgical technique, etc…. which also help minimize surgical infections.
                                                  iii.     Due to the large amount of metal used in spine deformity surgery a deep infection of SSI (an infection which is on the spinal metal) is a major problem.  It can be difficult to get rid of a deep infection around the metal since many bacteria strongly adhere to the metal.  In addition bacteria can put up a protective wall around itself which prevents antibiotics from reaching the bacteria and killing it.  If a SSI occurs it usually requires several surgical procedures (called irrigation and d├ębridement) to wash out the wound in order to remove the bacterial load.  The use of antibiotics is essential, with the initial treatments given intravenous (through tubing) and then switched over to oral.
                                                  iv.     The surgical site infection rate for patients with idiopathic scoliosis (which means no known cause) is at Washington University is much lower than the average for pediatric hospitals in the U.S.  However we will not be satisfied until ALL infections are prevented.

The next post will be on risks unique to spinal deformity surgery…..such as neurologic deficit, failure of fusion, implant breakage or dislodgement, need for repeat surgery, etc…..

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