Tethered Cord Evaluation and Perioperative Management — Intraoperative Considerations for OR Staff — Clinical Pathway: Inpatient and Primary Care

Tethered Cord Evaluation and Perioperative Management Clinical Pathway — Inpatient and Primary Care

Intraoperative Considerations for OR Staff

Component Goals
Neuromonitoring
  • Standard of care for all simple and complex cords
  • Check baseline signals after child is placed in the prone position
  • Simple cords:
    • Differentiate neural from non-neural
    • Assure no roots are stuck to filum
  • Complex cords:
    • Preserving function while untethering
    • Foley catheter with neuromonitoring lead placed
Instruments Microscope available per surgeon preference
Infection Prevention
  • Limit traffic in/out of room
    • Yellow traffic tape up
  • Standard measures to prevent intraoperative surgical site infections
Positioning
  • After vascular access and airway secured by anesthesia team and neuromonitoring leads placed, Foley placed in select children with complex tethered cord; positioning can be performed
  • While supine:
    • Mepilex padding on skin pressure points
    • Neuromonitoring Foley placement for complex tethered cords
    • Neuromonitoring leads placed
  • When prone:
    • Child placed on chest and hip bolsters
    • Surgeon marks and preps surgical site
    • Neuromonitoring checks baseline signals
Surgical Skin Prep
  • Hair removal: electric clipper and 2-inch silk tape
  • Square out surgical site: clear plastic drapes
  • Prescrub: betadine scrub brush with alcohol for prep
  • Local anesthetic: for simple tethered cords
  • Final scrub: chlorhexidine twice, wait full 3 minutes between preps
  • Draping: 2 split sheets and Ioban
Skin Closure
and Drains
  • Simple cords:
    • Dura: 2 6-0 GORE-TEX (1 should be cut in half)
    • Muscle and Fascia: 3-0 Vicryl Pop
    • Dermal-subdermal: 3-0 Vicryl Pop
    • Skin: 4-0 Monocryl Cutting Needle
    • Adhesive: Dermabond or Prineo
    • Dressing: Folded pieces of gauze, square Mepilex cut in half
    • Drain: None
  • Complex cords:
    • Dura: Nurolon
    • Muscle and Fascia (Review with plastic surgeon):
      • Option 1: 2-0 Vicryl Pop tapered needle, 2-0 Vicryl running
      • Option 2: 0 Vicryl pop tapered needle, 2-0 Vicryl pop tapered needle
    • Dermal-subdermal: Review with plastic surgeon
      • Option 1: 3-0 Vicryl pop
      • Option 2: 3-0 PDS, 4-0 Monocryl
      • Option 3: 3-0 Monocryl cutting needle
    • Skin: 4-0 Monocryl cutting needle =/- 5-0 FAST
    • Adhesive: Dermabond or Prineo
    • Dressing: Silver Mepilex, 4 in x 4 ¾ in Tegaderm
    • Drain:
      • 3-0 Nylon, 3-0 Monocryl, 2 ⅜ in x 2 ¾ in
      • Tegaderm
      • Antibiotic-impregnated drain, connector piece, reservoir
Surgical Duration
  • Simple cords:
    • Skin-to-skin is 30-45 min
  • Complex cords:
    • Skin-to-skin varies 1-3 hrs