Spinal Fusion Surgery for Neuromuscular Scoliosis

Spinal fusion surgery is a treatment option for children with neuromuscular scoliosis. In this procedure the bones in the back are fused together with bone taken locally from the spine. Metal rods are placed alongside of the spine to hold the bones in a straight position while the bone heals and fuses into one long bone. The goal of the surgery is to stop progression of the curve and safely straighten the spine. It offers a permanent solution that rarely requires repeat procedures or leads to long-term spine problems.

As children with significant untreated neuromuscular scoliosis advance through their adult years, the spinal curve can progress, causing breathing problems to develop, and pain and deformity to worsen. If your child’s neuromuscular scoliosis progresses to the point where there will most likely be a problem in the future if it is left untreated, spinal fusion surgery will be recommended to prevent this unfavorable outcome.

Spinal fusion for severe progressive spine deformity is a very big, complex operation that involves many team members and many cutting-edge technologies. While spinal fusion is a rare procedure at most hospitals, it is commonly done at Children’s Hospital of Philadelphia (CHOP). CHOP is one of a few high-volume scoliosis centers in the United States. That means our team is experienced, guiding several children each week through spinal fusion surgery and recovery.

Our spine deformity team takes every imaginable precaution to make this complex operation go as smoothly and safely as possible. We are constantly refining our techniques, checklists and protocols. The combination of a strong safety culture, significant experience, and the large number of spinal fusions conducted at CHOP create the safest possible environment to get your child’s spinal deformity fixed.

Some of the precautions we take to make this complex operation go as smoothly and safely as possible include:

• Neuromonitoring — Our spinal deformity program has participated in groundbreaking research on neurologic monitoring during spinal surgery. To minimize the risk of neurologic injury, we work closely with world-renowned group of neurophysiologists who monitor the spinal cord and nerve roots throughout the surgical procedure. This technology is used in cases of neuromuscular scoliosis where possible. In some cases the neurological condition is such that the nerves are unable to be monitored. In these cases, your surgeon will update you on this situation.
• Implant navigation — It is essential that spinal implants be placed with great accuracy. We use a high-tech image-guided navigation system to place the spinal implants. The system (“O-arm”) uses a low-radiation CT scan to match spine markers with actual anatomy. This allows our surgical team to “see” in real time the actual bony elements in three dimensions, thereby maximizing the safety of implant placement in the deformed spine. 
• Rapid recovery pathway — We have developed a new combination of pain medications that reduces post-operative pain, decreases hospital length of stay, and speeds recovery.
• Neuromuscular spine pathway — This pathway was developed to minimize ICU and hospital time, minimize infection risk, and promote a more predictable pathway for these complex patients.

Your child will have a pre-operative visit approximately one to two weeks before surgery.

This consultation will include:

• A review of the surgical procedure with your surgeon and the anesthesia team
• New X-rays taken of your child’s spine for pre-operative planning
• A review of your child’s medical history, any medications they are taking, and results from their physical examination with the nurse practitioner or physician’s assistant
• A review of surgical complications. Although unusual, complications can include infection, nerve problems, medical problems and unplanned return to the operating room. In neuromuscular diseases such as cerebral palsy, the infection rate is much higher due to patient incontinence, and general medical condition.  Special precautions we take in these patients will be discussed with you during this pre-op visit. Our nurses and surgeons are very experienced and have seen almost any problem that might occur, even those that occur rarely.
• Time to answer any questions you may have regarding the surgery, the hospitalization, and the post-surgical rehabilitation

On the day of the procedure, your child will be given calming medication and be transported to the operating room. In the operating room, your child will be gently put to sleep and IVs will be placed. Your child will receive a catheter and, in most cases, an epidural is placed for pain control.

The surgical team will then perform the procedure. All incisions will be closed with absorbable sutures, so that no stitch removal is necessary. If requested, we can have the plastic surgery team close the incision.

The actual time it takes to repair the spinal deformity ranges from three to eight hours, but when factoring in surgical prep, anesthesia and wake-up after surgery, the entire procedure takes five to 12 hours. There is a very large, comfortable family lounge where you can spend the hours during surgery. Members of our Family Services team will check in on you several times throughout the day to give you updates on the progress of surgery. Once surgery is over, the surgeon will meet with you to discuss the surgery and answer any questions you have. Once your child has been stabilized in the recovery room, Family Services will bring you to see your child.  

A typical length of stay in the hospital after surgery is five to seven days.

Initially after surgery, your child will have a large bandage and drains to remove extra fluid from the incision. Your surgeon may decide to use an incisional VAC device which protects the wound from soilage. Physical therapists will begin working with your child the morning after surgery, helping your child return to some of their normal activities safely. Wheelchair clinic will consult with you pre-operatively and should plan to make early wheelchair adjustments to accommodate the superior post-operative seating posture.

Your child will be able to go home once they:

• Are eating and drinking enough so that IV fluids are not necessary
• Have the pain under control to the extent that oral pain medicines are sufficient
• Can be safely managed at home
• Have no ongoing medical problems

Before you leave the hospital, the floor nurse practitioner or resident will give you important information regarding medications, incisional care, and who to call with questions. In addition to any medicine you ordinarily take, you will likely be given a prescription for pain medicine when you are discharged from the hospital. They should only be taken if the pain is not controlled with a dose of plain acetaminophen.

Once home, return to activities should be slow. Your child will need to wear a brace when out of bed for the first six weeks. After the first couple weeks at home, if your child is not having much pain, they should be able to make a gradual return to many regular activities. Your child can go back to school as soon as they can comfortably sit through part of a school day and are off prescription medication.

Your child will have post-operative appointments with us approximately six weeks after surgery, six months after surgery, one year after surgery, and then annually until about five years after surgery.