Surgery for Scheuermann’s kyphosis

This resource is for children who have been offered surgery for their kyphosis.

Your child’s 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 before your appointment.

What is kyphosis?

When we look at ourselves from the side, we should have a natural S-shaped curve.

Increased kyphosis is when the part from the bottom of the neck to the lowest rib is abnormally larger. This makes the spine feel like it sticks out as a ‘round back’ or ‘hunch back’. This is normally around the shoulder blades.

It is thought to happens in 1 to 8 per cent of the population, and is slightly more common in boys than girls. It is generally first noticed between the ages of 11 and 17 years old.

In some people, it does not affect them, for others it can be associated with pain and poor self-perception. There is no single ‘normal value’ for kyphosis, and general health is not thought to be affected until curves increase above 75 to 80 degrees.

What are the benefits of surgery?

Surgery is offered to children who have a kyphosis that has an angle of 80 degrees or more to prevent it getting bigger through adult life. This is to prevent the kyphosis affecting quality of life through adulthood. Some adults with a large kyphosis are unhappy with their shape, have more back pain, and have poorer overall quality of life than those without.

The size of your kyphosis may get bigger through adult life, and if it does, it happen much more slowly than it has done during your recent growth spurt. However, not all curves get bigger. Apart from the kyphosis angle measurement, we have no other way of predicting who may be affected by it in their adult life.

Although the operation does improve the shape of your back (make the kyphosis smaller), the way you look is not the only reason for operating because some people are still unhappy with their shape after the operation. Also, back pain may or may not improve, and in some people can be worse after their operation.

It is vital that you consider all the information given to you in this resource before having the operation, to make sure you are making the correct decision. The risks of surgery are towards the end of this resource.

What is the surgery?

All surgeries involve a general anaesthetic and spinal cord monitoring. Once these have been started, your child will be turned onto their tummy so that the surgery can be done. At this stage we make sure that their eyes are not being pressed on directly, and their arms and legs are comfortable.

The surgery involves a long cut down the middle of your child’s back. 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 needed and attached to slightly different parts of the spine. The kyphosis is then improved by attaching rods to the screws.

At times during the procedure, we will remove the joints at the back of your child’s spine, and to remove the outer surface of the bone, to let them fuse together again. 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.

Arriving to the hospital

Please follow the latest guidance on protecting yourself from Covid-19 in the 2 weeks leading up to your child’s admission. You will also be given up-to-date information on the testing protocol near the time of your operation because this is constantly changing.

Your child will be admitted to Ward 2 the night before their 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.

What happens on the day of my child’s surgery?

Your child will not be allowed to eat anything from 2am, and will only be allowed clear fluids until their operation.

The anaesthetic and surgical teams will come and see you some time between 7.30am and 5.15am to check you still want to go ahead with the operation, and answer any final questions. The nurses will also go through some final checks with you.

Going for surgery

A member of the team will come and get your child from the ward, normally between 8.30am and 9am. They can either walk to theatre, or come on a trolley depending on how they are feeling and what medications you have been given.

Between 9am and 11am your child will be put to sleep and all necessary monitoring equipment will be attached to their body. This will include the spinal cord monitoring. When your child wakes up and comes out of theatre there will be spots of blood and pin-pricks on their arms and legs, and in their hair from this. A catheter will also be passed into their bladder.

The surgery

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

After the surgery

Your child will wake up in theatre or in the post anaesthetic care unit (PACU). They will need to stay there 30 to 60 minutes to be monitored. They will have their first neurological checks and be made comfortable with any additional painkillers they may need. You can come and see your child once the whole team is happy it is safe for you to do so.

A member of the surgical team will talk to you once your child is awake and tell you how the surgery went and if there were any difficulties or complications.

Once it is safe for your to leave PACU and their pain is under control, they can go back to the ward.

Once there, your child can move around in bed as much as they want to get comfortable. They can also drink, but still cannot eat.

Your child’s nurse will check everything is well at least every hour. One of the orthopaedic doctors will come and check everything is going well later that evening.

The next day after surgery

Your child will be seen on the orthopaedic ward rounds in the morning. The nursing team will continue to check on your child hourly, but later in the day this will change to every 2 hours. Your child will be encouraged to mover around and sit up in bed.

A member of the team will listen to your child’s tummy. If they have bowel sounds, and is not being sick, they will be allowed to start eating and drinking. They can start with something light such as soup, ice cream, yoghurt or toast.

Children 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 nurses will check on your child less often on day 2.

If your child has been sick, hopefully it will have stopped by now.

They will be encouraged to sit and stand out of bed, as long as everything else is going well. Some children will still be feeling very unwell from their surgery, and may not get this far.

If their pain is under control, the team will try to get your child onto normal painkillers tablets, rather than through a drip.

Days 3 to 7

Your child will be encouraged to get out of bed more and more, as long as they stay well.

They will be allowed to go home once they are walking around the ward freely, and can sit in a chair long enough to be able to get home in the car. You should also be confident that your child’s pain is under control on regular painkillers.

Most children will be going home on day 5 or 6, but we will not keep you in hospital if they are ready to go home sooner.

The catheter will be removed once your child can walk as far as the bathroom. They can also shower once they feel ready.

An X-ray is taken before you go home so that we can fully check the operation.

Your child may have not gone to the toilet for a poo yet, but as long as they feel well and have not been sick, then you do not need to worry about this. They will normally be able to go to the toilet by day 10.

After discharge

Once you are home, continue to build up your child’s activities at a steady pace. Increasing their activity levels will decrease the chance of certain complications.

You can decrease the number of painkillers you give them as the pain improves.

The wound should be dry and healed by 2 weeks after the surgery, and they will not need to wear a dressing after this time.

Your child should be back in school by 4 to 6 weeks, depending on their pain levels and school circumstances.

Risks of surgery

The majority of people who undergo major spinal surgery are happy and feel the hard work is worthwhile. However, sometimes things do not 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 your child having any complication up to 14 percent (or 1 in 7 operations). The risk of needing another operation is up to 10 percent (or 1 in 10) surgeries. This is higher than in scoliosis surgery.

Medical complications

Having a general anaesthetic and an operation is a big event for the body.

Your child could develop urine infections and chest infections which will be treated with antibiotics.

It is also a strain on the heart, particularly if they lose a lot of blood. Although rare in children, damage to the heart muscle or heart attacks can happen, and these will be treated by the anaesthetic and medical teams.

Ileus

Ileus is when the bowel slows down, and food and wind is not moved from the stomach through the bowels at normal speed. This can lead to bloating and being sick.

This is why we do not let people eat straight after your surgery. Once your child has have been told they can start eating and drinking, they can start with simple light food before returning to a full meal. For the first few days, if your child’s bowel is working normally, they will pass wind, but no poo. This is 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 your child is being sick a lot, a tube can be passed through their nose into the stomach so they will no need to be sick anymore. It is taken out when the ileus settles.

Blood clots

Blood clots are rare in children having surgery for scoliosis.

The best thing to do is make sure your child keeps moving on the first night of their operation.

You must tell us if your child is taking any hormone treatment or any contraceptives because we may need to stop them before your surgery.

If your child gets a blood clot in their leg, then they may have leg pain or swelling. Treatment is aimed at preventing you from having another one. This happens in less than 0.1 percent of surgeries.

Rarely 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 happens in 3 percent to 10 percent of surgeries.

It can happen early in the first few days or weeks after the operation, but can sometimes take months or years to become apparent.

A small infection in the wound 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. Your child would likely 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 does not get rid of the infection, then your child may need to some of the screws and rods removed. Depending on how long it is from the surgery, we may need to put the metalwork back in. If this is necessary, we may have to keep your child in bed in hospital for some time before replacing them to minimise the chance of the new metalwork becoming infected.

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 the surface of the bone off to achieve fusion, spine 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 make sure it is clean, and give it back to the body. We sometimes use blood transfusions, where your child might receive blood from someone else. This is very rare in this type of surgery, but we will do so if absolutely necessary.

Bleeding can also happen next to and around the spinal cord. If this happens, then pressure will build up on the spinal cord and your child could become paralysed. Your child will need regular checks on the movement in your child’s arms and legs after the operation. If there are any concerns, then they need more X-ray images of their 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 happens in less than 2 percent of surgeries.

Nerve injury

We can accidentally damage nerves and vessels during the time it takes to expose the spine, and when we are putting the screws in the spine. 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. This happens in around 1 percent to 8 percent of surgeries.

If this happens in the upper-middle part of your child’s spine, they may have some pain around your chest wall or patchy numbness. In the lower part of your child’s spine they may have pain shooting down their leg and numbness or 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. We may decide to leave the screws alone and see if the symptoms settle, or we may decide to take your child back in for another surgery to change the position of the screws that are in the wrong position.

Cerebrospinal fluid leakage and tearing

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. This happens in around 0.2 to 1 percent (or 1 in 500) of surgeries.

However, if they do not heal, your child may have a watery fluid leaking through their wound and get headaches. We may need to do another operation to find the where the fluid is leaking from and try to 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 the pelvis. When we position your child’s face down during the operation they may be lying on this nerve and be squashing it for the whole of the procedure. We place your child on soft cushions to try and make sure they are comfortable, but this can still happen despite our best efforts.

The nerve lets you feel the outside outside of your thighs. If it is damaged from lying on it, your child may 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 whilst it recovers. If it does not return to normal, your child will be left with numbness on the outside of their thighs which most people get used to.

If the tingling persists and is very uncomfortable, they may need painkillers to decrease how much it bothers them.

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. Your child may not have any symptoms, but may develop pain or be able to feel the screws and rods through their skin. If this happens we may need to take your child back for another operation to repair the problem. This happens in around 1 in 10 surgeries.

If the bone do not 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 happens, how many rods break and how long it is from surgery, we may not need to replace it. We will usually do a CT scan to help with this decision.

If your child develops 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 nearby

Although surgery focusses on the spine, there is a risk of damaging parts of the body next to the spine. There is 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 will mean your child will need a blood transfusion. They may also need emergency surgery to repair the damaged vessel and stop the bleeding.

Injury to the lung may mean your child will need a chest drain that you were not expecting.

We will only repair these nearby parts of the body without telling you, if it is an absolute emergency that needs treating immediately. Where possible, we will talk to you, explain what has happened, and decide what further treatments are necessary.

Non-union

If the spine does not fuse then this is called a non-union. The rate of this in Scheuermann’s kyphosis surgery is around 1 to 2 percent. Non-union will normally happen in a small area rather than across the whole spine. If this happens, then your child 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.

Back pain

There is no guarantee that your child’s 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 need to encourage your child to increase their activities over this period because this will improve symptoms in the majority of people.

If your child’s back pain does not improve, they may be offered physiotherapy after your first follow-up appointment.

Proximal junctional kyphosis (PJK)

Proximal junctional kyphosis (PJK) is when the spine bends suddenly over the top of the fixed spine, where the last screws are at the top of the back. It can happen as early as straight after the operation. It can occur in up to 30 percent of operations.

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 child’s arms or your legs, then they will need further investigations immediately. Rarely, they may need an emergency operation to correct the kyphosis.

If it occurs at the lower end of the rods and screws it is called distal junctional kyphosis (DJK).

Blindness

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

During the operation, your child’s 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 the operation, their eyes are checked regularly to make sure the cushion has not moved and the eyes are not under pressure.

You must tell us if your child is being investigated or being treated for any eye conditions.

Risk to life

There is always a small chance that someone could die during their operation, or during their recovery. This is uncommon in Scheuermann’s kyphosis, happening in around 0.6 percent (or 3 in 500) surgeries. If your child has a lot of other medical conditions requiring treatment, then the risk is higher.

Possible causes of death are:

• major bleeding that the surgeon is not able to control
• severe infections leading to sepsis
• other medical complications

The team looking after you will do everything they can to treat the cause, but sometimes they are not effective.

Paralysis

Paralysis can happen in around 0.6 percent (or 3 in 500) surgeries for Scheuermann’s kyphosis, but could be slightly higher.

The chance of injuring a single nerve or the spinal cord is around 2 to 8 percent of surgeries for Scheuermann’s kyphosis, although not all of these include damage to the spinal cord. It can happen because of the metalwork mal-position, or due to the instruments we use during the procedure.

The critical point in the operation is when the curve is straightened when the rods are placed. The spinal cord monitoring team will let the surgical team 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, your child may be left paralysed by this procedure and the spinal cord may never recover. In this case, your child will:

• have legs that are weak or do not move at all
• not be able to wee, and will need a need a long-term catheter
• need help with having a poo

If the spinal cord is injured in your child’s neck, then their arms will be weak as well. This can happen because of proximal junctional kyphosis (PJK), or if the spinal cord in the neck is injured during positioning your child on the theatre table.

You will have the opportunity to speak to your consultant before the operation. Please ask any questions in the appointment. This resource is not intended to try and discourage you from having surgery. It is vital that you understand this resource before giving your consent for the surgery.