Disclosures Avoiding Complications in I have nothing to disclose. Neuromuscular Spine Deformity Surgery Ozgur Dede, MD Assistant Professor of Orthopaedic Surgery University of Pittsburgh 1 2 Spine Fusion for Neuromuscular Deformity Spine Fusion for Neuromuscular Deformity Benefits Pre and intra-operative problems • Balanced sitting • Bad host • Nutrition/immune • Re-gain use of the compromise upper limbs • Recurrent infections • Better respiration and • Poor cardiopulmonary pulmonary clearance reserve • Better nutrition • Poor bone stock • Easier management of • Bleeding tendency (meds/osteopenia…) GI reflux • Large deformity • Improved nursing care 3 4
Pre-operative Planning Spine Fusion for Neuromuscular Deformity Post-operative problems Medical clearance • Care • Appropriate consultations – Pulmonology • Worsening pelvic obliquity – Neurology • Decubitus ulcers – Cardiology • Head support loss/position change – Nutrition/GI • Difficulty self feeding/self perineal care • Check seizure meds (Valproic Acid) • Junctional deformity • Optimize tone control (if possible) • Implant breakage or pull-out • Make sure parent/guardian/caretaker on board 5 6 Pre-operative Planning Pre-operative Planning Imaging - flexibility Imaging – sagittal plane vs 7 8
Pre-operative Planning Infection Prevention Optimize nutrition Develop a protocol – or use others’ • Check albumin levels • Many examples – vitale/gloetzbecker – MRSA eradication • Consult nutrition/GI medicine – Appropriate and timely prophylaxis • Supplement feeding – Limit traffic • Consider g-tube placement – Operative prep • Betadine scrub • Consider supplementing from central • Alcohol wipe (100 alcohol into a gauze tub) line post operatively • Two layers chlorhexidine prep (let dry in between) • Incise drape (ioban etc) 9 10 Infection Prevention Infection Prevention Intra-operative measures Intra-operative measures • Frequent irrigation (every 30 minutes 300 cc) • Multilayer closure • Change gloves (every hour or in between steps) – Loose muscle layer (1 vicryl) • Vancomycin 500 mg • Change gown after 4 hours – Water tight fascial closure (1 vicryl) • Wipe the incise drape clean with betadine before – Hypodermis (Fat) (0 vicryl) closure – Subcutaneous layer (2-0 • 3000 cc pulsatile irrigation absorbable) – Running subcuticular or staples • 3.5% betadine soak for 3 minutes – Occlusive dressing • Another 3000 cc pulsatile irrigation • 500 mg Vanco in bone graft • Multi-layer closure 11 12
Blood Loss Poor Bone Quality/Anchors • Have multiple options available • Pre-operative anti-seizure medication – Screws adjustment – Hooks • Hematology consult as necessary – Sublaminar wires (Luque) – Sublaminar bands • Tranexaminic acid – Polyester tape • Bone wax and other hemostatics – Supplemental rib fixation • Liberal use of bovie cautery (mine is • May consider post-op bracing set at 50/desiccate) • Dexa scan? Bisphosphonates? Cement augmentation? • Double-team in long cases 13 14 Residual pelvic obliquity Multiple Smith-Petersen osteotomies Prevented progression but still oblique pelvis and even stiffer with the metal Pressure sore producer 15 16
Pedicle Subtraction Osteotomy Pelvic Obliquity After Fusion • Expected • New onset 17 18 Pelvic Obliquity S2AI screws might help prevent some issues Pendulum Swings • For non ambulatory patients default to pelvis • If pelvis is tilted more than 15 degrees on weight bearing AP film fuse to pelvis 19 20
S2AI screws might also fail Larger and smooth shank screws? 21 22 Implant pull-out/junctional kyphosis Restore Sagittal Alignment • Children with NM disease have kyphotic tendency • Proximally go to T2 or T1 • Leave some proximal thoracic kyphosis • Proximal hooks maybe protective? 23 24
Take home Surgeon happy, Mom…not so much – Minimal residual pelvic obliquity • Head centered over pelvis – Restore sagittal alignment • Preserve some proximal thoracic kyphosis – Always T1 or T2 and very often to pelvis • Stable fixation and fusion – Have a protocol in place • High risk patients for infection and other complications 25 26 References • Vitale et al., Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013 Jul-Aug;33(5):471-8. • El Dafrawy MH, Raad M, Okafor L, Kebaish KM. Sacropelvic Fixation: A Comprehensive Review. Spine Deform. 2019 Jul;7(4):509-516. doi: 10.1016/j.jspd.2018.11.009. • Bekmez S, Ozhan M, Olgun ZD, Suzer A, Ayvaz M, Demirkiran HG, Karaagaoglu E, Yazici M. Pedicle Subtraction Osteotomy Versus Multiple Posterior Column Osteotomies in Severe and Rigid Neuromuscular Scoliosis. Spine (Phila Pa 1976). 2018 Aug 1;43(15):E905-E910. 27
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