Neuromuscular Scoliosis Spinal Fusion — Surgical Considerations for Providers — Clinical Pathway

Neuromuscular Scoliosis Spinal Fusion Clinical Pathway — ICU, Inpatient, Outpatient Specialty Care

Initial Clinic Visit — Surgical Considerations for Providers

Surgical Considerations for Providers

Patients with neuromuscular scoliosis generally require a spinal fusion of 13+ segments and may fall into one of the following surgical categories based on severity of underlying disease and risk for potential post-operative complications. These criteria are based on the experience of surgery, anesthesia and PICU providers and Gross Motor Function Classification System (GMFCS) scoring.

Guidance for Risk Stratification and Postoperative Observation Needs

Surgical Complexity Curve Anticipated Osteotomy Anticipated Blood Loss Expectations/Comments Recommended Postoperative Disposition
Low Risk
GMFCS I-III		 Uncomplicated, < 70°
Typical of patients
with AIS		 None < 500 mL
  • Typically patients with minimal neuropathic involvement
  • Likely to recover on surgical unit
  • Similar post-operative recovery as AIS Spinal Fusion patient
 Surgical unit (4E/4S)
Moderate Risk
GMFCS IV-V		 Flexible, 70-90°
or
Stiff, < 70°		 Multilevel Ponte osteotomies 500-1000 mL
  • Majority of patients will fall into this category
  • Likely to require ICU monitoring for at least one night for:
    • Hemodynamic monitoring: vasopressors +/- fluid resuscitation via CVL
  • Completion of a staged repair
 Acute postop recovery: PICU

Transfer to appropriate specialty care floor (Pulmonary or PCU) or 4E/4S after 24-48 hrs
High Risk
GMFCS IV-V		 Flexible, > 90°
or
Stiff, 70-90°		 3 column osteotomy Large blood volume loss > 1 L
  • Medically complex patients who will require longer ICU stays > 1 day for:
    • Hemodynamic monitoring
      (CVL access)
    • Coagulopathy monitoring
  • Anesthesia: consider 1:1 transfusion ratio with PRBCs/FFP intraoperatively if concerned
 Acute postop recovery: PICU

Transfer to appropriate specialty care floor (Pulmonary or PCU) or 4E/4S