Adolescent idiopathic scoliosis surgery

This information is intended for those patients who have been offered surgery for adolescent idiopathic scoliosis. Your treating surgeon will go through all the information in this document in clinic during the consent process. This will hopefully help you understand the terms used and allow you to think of any questions prior to your appointment. All quoted risks are from research published in peer reviewed journals.

Benefits of surgery

Surgery is offered to those who have a scoliosis that has a Cobb angle of 50 degrees or more to prevent it getting bigger through adult life. This is to prevent a much larger curve causing heart or lung problems in later life.

The size of your scoliosis will get bigger much more slowly than it has done during your recent growth spurt, and not all curves get bigger. However, apart from the Cobb angle measurement, we have no other way of trying to predict who will develop very large curves in later life.

Although the operation does improve the shape of your back (by making the Cobb angle smaller), the way you look is not the main reason for operating because we do not achieve a straight back after surgery. This means that some people are still unhappy with their shape after an operation. Back pain may or may not improve, and in some people can be worse after surgery for scoliosis.

The surgery

All surgeries involve a general anaesthetic and spinal cord monitoring. When the anaesthetists are happy and all monitoring is in place, you are turned onto your tummy so that the surgery can be performed. At this stage we ensure your eyes are not being pressed on directly, and your arms and legs are placed comfortably.

In most cases the surgery involves a long cut down the middle of your back. If your surgery is going to be performed using an approach from the front (anterior), please see the separate section on this.

The muscles are peeled off the spine to allow placement of screws in the pedicles and vertebra of the spine. Hooks are also often used where necessary and attached to slightly different parts of the spine. The spine is then straightened by attaching rods to the screws.

At times during the procedure, hammers and chisels are used to remove the joints at the back of the spine, and to remove the outer surface of the bone, to allow fusion. This is where the bone grows across the spine where the rods and screws have been placed, and prevents further change in shape of the spine.

Hospital stay

Please follow the latest guidance on protecting yourself from COVID-19 in the 2 weeks leading up to your admission. Assuming your swab is negative, you will be admitted to Ward 2 the night before your surgery. During the winter months, if there are ‘winter bed pressures’ you may be asked to come into the hospital on the morning of your surgery.

The day of your surgery (all timings are approximate)

You won’t be allowed to eat anything from 2am, and will be allowed clear fluids until your operation. The anaesthetic and surgical teams will normally come and see you between 7.30am and 8.15am to check you still want to go ahead, and answer any final questions. The nurses will also go through some final checks with you.

The theatre team meet at 8.30am to discuss the cases on the theatre list and ensure we have enough staff and all the right equipment to proceed. Once everyone is happy, a member of the team will come and get you from the ward, normally between 8.30am to 9am. You will either walk to theatre, or come on a trolley, depending on how you are feeling and what medications you have been given.

Between 9am and 11am you will be put to sleep and all necessary monitoring will be attached to your body. This will include the spinal cord monitoring: when you wake-up you will find spots of blood and pin-pricks on your arms and legs, and in your hair, from the tiny needles used. A catheter (a tube to allow you to wee) will also be passed into your bladder.

Once all the monitoring is placed, you will be positioned on the operating table and the surgery will start: this normally occurs between 10.30am and 11.30am. It will normally take between 4 and 6 hours to perform your surgery, but unexpected events can make it last longer.

You will wake-up in theatre or in the Post Anaesthetic Care Unit (PACU) and spend 30 to 60 minutes being monitored there. You will have your first neurological checks and be made comfortable with any additional painkillers you may need. A member of your family will be allowed down once the whole team is happy it is safe for them to do so.

A member of the surgical team will talk to you and your parents once you are awake and inform them of how the surgery went and any difficulties or complications.

Once it is safe for you to leave PACU, and your pain is under control, you will return to the ward. Once there you can move around in bed as much as you want to get comfortable, and you will be allowed to drink, but not eat, overnight. You will have a nurse checking everything is well with yourself at least every hour. One of the orthopaedic doctors will check everything is going well later that evening.

Day 1

You will be seen on the orthopaedic ward rounds in the morning. The nursing team will continue to check on you hourly, but later in the day this will change to every two hours. You will be encouraged to mover around and sit-up in bed.

A member of the team will listen to your tummy. If you have bowel sounds (a gurgling tummy), and you are not being sick, you will be allowed to start eating, as well as drinking. Start with something light such as soup, ice cream, yoghurt, toast.

People who are not in significant pain, and are well, may be able to sit on the edge of the bed or even sit out of bed on day 1.

Day 2

The nursing checks will become less frequent on day 2, and hopefully any sickness has stopped. You will be encouraged to sit and stand out of bed, as long as everything else is going well.

Some patients will still be feeling very unwell from their surgery, and may not get this far.

If your pain is under control, the team will be looking at getting you onto painkillers you take by swallowing, rather than through a drip.

Day 3 to 7

You will be encouraged to get out of bed more and more, as long as you remain well. You will be allowed to go home once you are walking around the ward freely, and can sit in a chair long enough for you to be able to get home in the car. You should also be confident that your pain is under control on regular painkillers. Most patients will be going home day 5 or 6, but we will not keep you in hospital if you are ready to go home sooner.

The catheter will be removed once you can walk as far as the bathroom. You can also shower once you feel ready. An X-ray is taken before you go home so that we can fully assess the operation.

You may find that you have not done a poo before going home, but as long as you feel well and are not being sick you do not need to worry about this. You will normally be able to go to the toilet by day 10.

After discharge

Once you are home, continue to build up your activities at a steady pace. You can decrease the number of painkillers you are taking as the pain improves. Increasing your activity levels will decrease your chance of certain complications.

Your wound should be dry and healed by two weeks after your surgery, and you do not need to wear a dressing after this time.

You should expect to be back at school or college by 4 to 6 weeks, depending on your pain levels and school circumstances.

Anterior approach

Some scoliosis surgery is performed through a front (anterior) approach. The main advantage to this is that it means we need to fuse fewer spinal bones together, which we believe will benefit you in the long-term.

The surgical cut (incision) is normally on your left-hand side, running along a rib and then curving into your tummy towards the belly button. You will therefore be laid on your side during the procedure. Some patients will have shoulder pain when they wake up from lying on their side all day.

In order to get to the spine, the diaphragm has to be removed from the ribs. The discs between the vertebra are removed and bone graft is placed in these to allow fusion between them. The screws are also placed through the sides of the vertebra, rather than down the pedicle, but are still joined together with a rod.

When you wake up you will have a chest drain for 1 to 2 days, and will need to go to the High Dependency Unit (HDU) for at least 1 night. After that, you will follow the standard rehabilitation described above.

Risks of surgery

There is no doubt that the majority of people who undergo scoliosis surgery are happy and feel the hard work is worthwhile. However, sometimes things don’t go as well as expected. For this reason, we have to tell you about things that could possibly go wrong. Some complications happen more often than others, and often these are treatable. Life-changing complications are thankfully rare.

The risk of any complication, no matter how big or small, is between 1 and 5 in 100 surgeries (1 to 5 percent), with a risk of re-operation for any reason in up to 1 in 20 (5 percent) at 10 years after the first operation.

To put any figures in context, we perform approximately 70 to 80 surgeries a year for adolescent idiopathic scoliosis at Sheffield Children’s.

Medical complications

Having a general anaesthetic and an operation is a big event for your body. You can develop urine and chest infections which will be treated with antibiotics. It is also a strain on your heart and kidneys, particularly if you lose a lot of blood. Although rare in children, damage to the kidneys and heart muscle or heart attacks can occur, and these will be treated by the anaesthetic and medical teams.

Ileus

This is when the bowel slows down and food and wind is not moved from the stomach through your bowels at normal speed. This can lead to bloating and being sick. This is why we do not let you eat straight after your surgery. Once you have been told you can start eating and drinking, start with simple light food before returning to a full meal. For the first few days, if your bowel is working normally, you will find you pass wind, but no stools. This is entirely normal.

Ileus can last several days and is uncomfortable. There are no specific treatments, and we just have to wait for the bowels to start working again. If you are vomiting a lot, a tube can be passed through your nose into the stomach so that you do not need to actually vomit. It is taken out when the ileus settles.

Blood clots (deep vein thrombosis and pulmonary embolus)

Blood clots are rare in young people undergoing surgery for scoliosis. Your main defence is movement and so we will encourage you to start moving as soon as the first night of your operation. You must tell us if you are taking any hormone treatment or any contraceptives because we may need to stop them before your surgery.

If these occur only in the leg, (deep vein thrombosis or DVT), then you may have leg pain or swelling. Treatment is aimed at preventing you from having another one. DVTs happen after around <0.01 percent (less than 1 in 10,000) of surgeries.

Rarely (0.03 percent of the time) these blood clots can move and travel to the lung. This can lead to chest pain, breathing problems and, in severe cases, death. Treatment is aimed at supporting your breathing and preventing you from developing further blood clots.

Infection

Infection occurs in 0.5 percent to 2 percent of surgeries. It can occur early in the first few days or weeks after the operation, but can sometimes take months or years to become apparent.

A superficial infection in the wound, skin or scar will often be treated with antibiotics and nothing more is needed.

However, a deep infection around the metalwork and spine is much harder to treat. You are likely to need antibiotics given through a drip in the arm, and an operation to ‘clean’ the metalwork. Sometimes we need to do this more than once. If this doesn’t get rid of the infection, then you may need to have all, or part, of the screws and rods removed. Depending on how long it is from your surgery, we may need to put the metalwork back in. If this is necessary, we may have to keep you in bed in hospital for a period of time before replacing them to minimise the chance of the new metalwork becoming infected.

We will keep you informed of our treatment and decision making at all times.

Bleeding

All surgeries cause some bleeding, but more complex operations can lead to a large amount of blood loss. Bone contains many blood vessels, and so because we are placing screws in the bone, and peeling off the surface of the bone to achieve fusion, scoliosis surgery can lead to significant blood loss.

During the surgery we use cell salvage where we collect the blood from the wound. We then filter it to ensure it is clean, and give it back to you. We therefore use blood transfusions, where you receive blood from someone else, very rarely in this surgery but will do so if absolutely necessary.

Bleeding can also occur next to and around the spinal cord, an epidural haematoma. If this happens, then pressure will build up on the spinal cord and you may become paralysed. You will have regular checks on the movement in your arms and legs after the operation. If there are any concerns, then you will undergo further imaging of your spine. If there is something obvious pressing on the spinal cord, then an emergency operation may be needed to remove this and give the spinal cord chance to recover. This is thought to occur in less than 0.01 percent of surgeries.

Nerve injury

We can damage nerves and vessels during the time it takes to expose the spine, but also when we are putting the screws in the pedicles and vertebra. If we are unhappy with the position of a screw during the procedure, we will replace it, however some nerve injuries are not apparent until after the surgery.

If this happens in the thoracic spine you may have pain coming around your chest wall or patchy numbness. In the lumbar spine you may have pain shooting down the leg, areas of numbness or even weakness in some muscles.

Depending on the severity of the symptoms, we will check the position of the screws with X-rays, CT, or MRI scans. In discussion with you, we may decide to leave the screws alone and see if the symptoms settle, or we may decide to take you back to theatre and change the position of the screws that are in the wrong position.

CSF Leak and dural tear

The nerves and spinal cord are surrounded by a thin layer called the dura. This helps protect them, and maintain the flow of cerebrospinal fluid (CSF) around them. This thin layer may be injured by our instruments or the screw. Most dural tears will heal with repair in theatre, or with a period of bed rest after the operation.

If, however, they do not heal, you may have a watery fluid leaking through your wound and develop headaches. We may need to do another operation to find the location of the leaking fluid and try and repair it. Please do contact the spinal nursing team if you are ever concerned about a wound healing problem.

Once the wound is healed, most dural tears will not give you any side effects in the long-term.

Lateral cutaneous femoral nerve injury

This is a small nerve that runs across the prominent bone at the front of your pelvis. When we position you face down during the operation you may be lying on this nerve and be squashing it for the whole of the procedure. We place you on soft cushions to try and make sure you are comfortable, but this can still happen despite our best efforts.

The nerve supplies sensation to the outside of your thighs. If it is damaged from lying on it, you may notice numbness or tingling in these areas (it can occur on only one side). It normally gets better over days and weeks, and can cause tingling (paraesthesia) whilst it recovers. If it doesn’t return to normal, you will be left with numbness on the outside of your thighs which most people get used to. If the tingling persists and is very uncomfortable, you may need painkillers to decrease how much it bothers you.

Metalwork mal-placement and failure

Metalwork may not always be placed in the correct position, and we have mentioned the possibility of nerve injury above.

Sometimes rods and screws move or detach from each other after the operation. You may not have any symptoms, but you may develop pain or be able to feel the screws and rods through your skin. If this occurs we may need to take you back for another operation to repair the problem.

If the bone doesn’t fuse together, then the rods may break. This can lead to increased pain in the back, but sometimes it is simply seen on a routine X-ray. Depending on where it occurs, how many rods break and how long it is from surgery, we may not need to replace it. We will usually perform a CT scan to help with this decision.

If you develop an infection, the screws and rods can become loose. The main aim of the treatment will be to get rid of the infection, and more details about this are discussed in the infection section.

Damage to adjacent structures

Although surgery focusses on the spine, there is a risk of damaging structures next to the spine. Although there is a greater risk with the anterior approach, the posterior approach also carries with it the chance of damage to the bowel, the lung, the kidney or the large vessels running in front of the spine. Any injury will be treated dependent on the nature of it.

Injuring a large vessel can cause major bleeding which can be life threatening, and will mean you require a blood transfusion. You may also need emergency surgery to repair the damaged vessel and stop the bleeding.

Injury to the lung may mean you wake up with a chest drain that you were not expecting.

Non-union

One of the aims of surgery is to create a fused spine. This is where the bone grows around the screws and rods. If the spine does not fuse then this is called a non-union.

Non-union will normally occur in a small area rather than across the whole spine. If this happens, then you may experience increasing back pain or prominent metalwork. It may also be only picked up on a routine X-ray showing a broken rod.

This will normally be investigated further with a CT scan and depending on your symptoms you may need further surgery to try and get the area of non-union to fuse.

Add-on phenomenon (selective thoracic fusion procedures)

If you have the surgery whist you are still growing, there is a chance that curves that are not included in the original fusion get bigger as you grow. In approximately 1 in 8 to 1 in 10 selective thoracic fusions a patient will need to go back to theatre to have the second curve included in the fusion. This may be several years later.

However, the reason we don’t include the second curve, is because up to 9 in 10 children will have a smaller operation, and therefore more movement, than if we had included the whole scoliosis in the first operation.

Back pain

There is no guarantee that your back pain will improve, and some people are left with more back pain than they started with. The majority of back pain will improve over weeks and months, and you will be encouraged to increase your activities over this period because this has been shown to improve symptoms in the majority of people.

If your back pain does not improve you may be offered physiotherapy after your first follow-up appointment.

Shoulder imbalance

Depending on the type of scoliosis you have, you may notice that your shoulders aren’t level before your operation. During the surgery, attempts will be made to try and level your shoulders or make them look symmetrical. However, it is not always possible to get this absolutely right.

People who notice their shoulders aren’t level after the operation will be given some physiotherapy exercises to perform to try and help level them. Research has shown that your shoulder balance can improve over the first year after your surgery.

Proximal junctional kyphosis (PJK)

This is when the spine suddenly bends forward over the top of the fixed spine, that is, where the last screws are at the top of the back. It can occur as early as straight after the operation.

In severe circumstances this can cause paralysis at this level of the spine. If there are any concerns after the operation with the function in your arms, legs or both, then you will undergo further investigations immediately. Rarely, a patient may need an emergency operation to correct the kyphosis.

Blindness

Surgery in the prone position (lying on your tummy) is associated with blindness. This is very rare, found in less than 0.01 percent (less than 1 in 10000) of surgeries

During the operation your face is placed in a special cushion which is cut out to allow space for the eyes. The weight of your head is supported by your jaw, cheeks and forehead. During your operation the eyes are checked regularly to ensure the cushion has not moved and the eyes are not under pressure.

You must tell us if you are being investigated or being treated for any eye conditions.

Risk to life

There is always a small chance that a patient dies during their operation, or during their recovery. This is rare in adolescent idiopathic scoliosis surgery, occurring in approximately 0.02 percent to 0.18 percent of surgeries (1 to 9 in 5000). If you have a lot of other medical conditions requiring treatment, then your risk is higher.

Possible causes of death are major bleeding that the surgeon is not able to control, severe infections leading to sepsis, or other medical complications. The team looking after you will do everything they can to treat the cause, but sometimes they are not effective.

Paralysis

This is thought to occur in approximately 1 in 850 to 1 in 1000 (0.1 to 0.11 percent) of surgeries for adolescent idiopathic scoliosis. It can occur if screws are put in the wrong part of the spine, or if instruments we use during the procedure hit the spinal cord.

The critical part of the operation is when the curve is straightened as the rods are attached to the spine. The spinal cord monitoring team will let the surgeon know if there are any concerns over spinal cord function at this stage. The rods may need to be removed and the operation abandoned.

Despite the best efforts of the surgical and anaesthetic teams, you may be left paralysed by this procedure and the spinal cord may never recover. In this case you will be left with legs that are weak or don’t move at all, the inability to pass urine requiring a long-term catheter, and help with opening your bowels.

If the spinal cord is injured in your neck, then your arms will be weak as well. This can occur because of PJK or if the spinal cord in the neck is injured during positioning you on the theatre table.