A Case of Scoliosis Repair:

Pathophysiology, Special Considerations,

and Intraoperative Management

Karim Rafaat, M.D.

Outline

Case presentation
Overview of diagnostic/treatment
considerations
Intraoperative management
Case Presentation

Karim Rafaat, M.D.

Fellow in Pediatric Anesthesia

Lucile Packard Childrens Hospital
Stanford University
Case Report:
C.C.
Identification

12 yo male with complex medical

history
Scheduled for posterior spinal
instrumentation and fusion with multiple
vertebrectomies
Past Medical History

Midthoracic Myelomeningocele -
repaired as an infant in Mexico
paralysis to T6
Chiari II malformation
Hydrocephalus, s/p VP Shunt
placement
Developmental Delay
Scoliosis
Past Medical History

Failure to Thrive
Seizures
Past Surgical History

Per mothers report, has had over 30

surgeries:
Repair of midthoracic myelomeningocele
VP Shunt, s/p multiple revisions
Urostomy
Ventral hernia repair
Bilat ear tubes
G-tube placement
Birth/Developmental History

Born at 32 wks
Wheelchair dependent
Cannot stand
Urostomy - incontinent of urine
Incontinent of stool
Sensory level approximately at
umbilicus
Family History

Negative for any bleeding problems

Negative for any problems with
anesthesia
Medications

Phenobarbital 15mg per G-tube bid

Nitrofurantoin 3mg per G-tube bid
Physical Exam

Vital Signs:
T - 36.8 C
HR - 90
BP - 122/85
RR - 20
SpO2 - 99% on RA
Physical Exam

Weight 20.3 Kg
General - seated in wheelchair, NAD,
interactive and pleasant
HEENT - Macrocephalic with multiple
surgical scars over scalp
Airway - MP 1, good thyromental
distance, good mandibular mobility,
short, stiff neck
Physical Exam

Pulmonary - severe scoliosis, BS

decreased over R, o/w clear
CV - RRR, no m/r/g
Abdomen - G-Tube. Normal bowel
sounds
Musculoskeletal - very pronounced
scoliotic curve. Curve is rigid and does
not move with bending
Neuro - No sensation below umbilicus.
No lower extremity motor function
The Cobb Angle
Labs

Chem 7 - wnl
CBC - Hct 43
Coags - wnl
Operation

Consisted of:
Vertebrectomy T12-L1
Spinal cord excision below T12
Posterior spinal instrumentation and fusion
T1-S1
Intraoperative Course

Intubated easily with 5.0 cuffed ETT

and MAC blade
3 PIVs total: 1x22G, 2x20G
Radial A-line
RIJ 5Fr double lumen central catheter
Intraoperative Course

Amicar bolus 75mg/kg, drip at 75

mg/kg/hr
Lungs with reasonable compliance (!)
and no difficulties with gas exchange
Stable hemodynamics (when surgical
losses properly attended to)
Stable UOP
Persistent and significant bleeding from
bony surgical sites
Intraoperative Course

Operative course stable (with some

effort), with no unexpected
complications until......
Guess Whats Missing..........
The spinal cord was incised and excised
below T12
Intraoperative Course

Acute spinal shock manifested as

sudden hypotension, unresponsive to
fluids
Neosynephrine bolused frequently,
while drip prepared
Dose ranged from 0.1 - 2 mcg/kg/min
Vasopressin drip started
Dose ranged from 0.2 - 1.2 units/hr
Usual shock dose 10-50 mU/kg/hr
Intraoperative Course

Volatiles reduced, and midazolam

bolused to ensure amnesia
Despite mild, persistent hypotension
(MAPs in 50s, with visits to the 40s),
sufficient end-organ oxygen delivery
maintained as evidenced by continued
UOP > 0.5 cc/kg/hr and lack of a base
deficit on ABG
Intraoperative Course

Case ended smoothly, secondary to

consistent leg work
1200 cc crystalloids
250cc colloids
6 units PRBC, 2 units FFP, 1 unit Platlets
Aforementioned pressors, plus boluses
Brief Post-Op Course

Pt admitted to PICU on 0.5 mcg/kg/min

Neosynephrine and 1 unit/hr
Vasopressin
Hct 30 with Coags wnl
Pressors off by next morning
Extubated that same day to NC
Discharged home after 5 days
Bilateral lung Fields visible!
Scoliosis: An Overview
Outline

Definition
Etiology
Associated co-morbidities
Conservative treatment
Indications for surgery
Predictors of complications
Definition
A lateral spinal curvature of >10
~2% of children affected at some stage
of life
~10% of affected patients will require
corrective surgery
Plain Radiographs of the Spine in Two Children With Idiopathic Scoliosis

Musson et al., Postgrad Med J 2010.

 The Cobb Angle
Line across top of
cephalad and bottom
of caudad vertebrae
that are maximally
displaced
Perpendiculars from
these two lines are
intersected
Angle between
perpendiculars =
Cobb Angle

http://www.pediatriceducation.org/2006/12/11/
Idiopathic Scoliosis
Most common ~70% of all cases
Infantile, juvenile, or adolescent forms
Exact cause unknown, but many
contributing factors identified
Collagen abnormalities
Abnormal growth
Hormonal abnormalities
Possible genetic basis with
incomplete
penetrance may explain female
predominance

Musson et al., Postgrad Med J 2010.

Other Etiologies
Congenital
Osteogenic - vertebral anomalies
Neuropathic - tethered cord, myelomeningocele
Neuromuscular
Neuropathic - cerebral palsy, polio
Myopathic - Duchenne muscular dystrophy
Developmental Dysplasia
Neurofibromatosis
Tumor-associated
Vertebral/Intraspinal
Infection
Pulmonary Comorbidities
Restrictive lung pattern
Decrease in lung volumes
capacity most significant
Vital
FRC, TLC, IC, ERV also
Impaired respiratory muscle function
Chest wall deformity = inspiratory muscles
working at mechanical disadvantage
Arterial hypoxemia from V/Q mismatch
Pulmonary Comorbidities
Slope of ventilatory response to CO2
may be decreased
Higher respiratory rates and lower tidal
volumes minimize work of breathing
Pulmonary compromise increases with
curve progression
Cardiac Comorbidities
Chronic hypoxemia HPV
Pulmonary Hypertension
RVH RV failure
MVP common among scoliosis patients
Scoliosis associated with congenital
heart disease (no specific lesion)
Natural History

Significant curve progression may

eventually lead to intolerable
cardiopulmonary compromise
Treatment is either conservative (aimed
at slowing/stopping curve progression)
or surgical
Examples of Braces Used in Scoliosis Treatment

Sponseller PD. J Pediatr Orthop 2011.

Conservative Management
Bracing is the mainstay of treatment
Goal = slow or prevent curve
progression via external forces guiding
growth of spine
Curve correction with bracing is not
commonly observed
Indications for Bracing

Curve of 25-45 in patient going through

a rapid growth period (Risser 0-1 years)
Some patients with smaller curves
showing recent progression

Sponseller PD. J Pediatr Orthop 2011.

Characteristics Predicting
Failure of Bracing Treatment
Overweight
High thoracic curve (above T8)
Lordotic thoracic spine
Within a year of skeletal maturity
1-year post-menarche
Treatment non-compliance

Sponseller PD. J Pediatr Orthop 2011.

Indications for Surgical Treatment
Cobb Angle >50
Cobb Angle >40 in skeletally immature
patient
Progression of scoliosis in spite of
bracing
Unacceptable (cosmetically or
functionally) deformity

Bridwell KH, Spine 1999.

Risk Factors for Postoperative
Complications
Etiology of scoliosis
Neuromuscular pts have higher surgical
complication rates (17.9%) vs congenital (10.6%)
or idiopathic scoliosis (6.3%) - higher mortality,
increased LOS, increased costs
Respiratory, cardiac, transfusion-related
complications predominate
Anticonvulsant use
VPA, phenytoin, phenobarbital associated with
greater EBL, more transfusions

Erickson MA and Baulesh DM. Curr Opin Pediatr 2011.

Risk Factors for Postoperative
Complications
Pulmonary status
Poor baseline function predicts
complications/need for postop ventilation
Frequent PNA, inability to handle
secretions, prolonged desaturation during
sleep, lung damage/fibrosis are red flags
preoperatively
Cardiac status
Be mindful of congenital heart disease and
pulmonary hypertension
Erickson MA and Baulesh DM. Curr Opin Pediatr 2011.
Risk Factors for Postoperative
Complications
Nutritional status
Delayed wound healing and greater
susceptibility to infection
Immune status
Increased infection risk if compromised
Social considerations
Postoperative care needs can be intense
so suitability of home
environment/caregivers must be assessed

Erickson MA and Baulesh DM. Curr Opin Pediatr 2011.

Surgical Considerations

Bigger surgery = more complications

Anterior posterior spinal fusion associated
with longer operative times, more EBL, more
transfusion, more pulmonary complications
than anterior or posterior fusion alone
Rule of 6
if operative time is longer than 6h, or if more than
6 levels fused, complication risk is higher

Erickson MA and Baulesh DM. Curr Opin Pediatr 2011.

Summary

Definition and Etiology

Cobb Angle
Comorbidities
Bracing
Risk factors for complications
References
Bridwell KH. Surgical treatment of idiopathic adolescent scoliosis.
Spine 1999; 24: 2607-16.
Erickson MA, Baulesh DM. Pathways that distinguish simple from
complex scoliosis repair and their outcomes. Curr Opin Pediatr
2011; 23: 339-45.
Musson RE et al. Imaging in childhood scoliosis: a pictorial review.
Postgrad Med J 2010; 86: 419-27.
Sponseller PD. Journal of Pediatric Orthopaedics 2011; 31: S53-
S60.
Zayas VM. Scoliosis in Anethesiology: Problem-Oriented Patient
Management. Yao et al. Eds. 2008; Lippincott Williams & Wilkins.
http://www.pediatriceducation.org/2006/12/11/
Intraoperative Management
Outline

Airway management
Access and monitors
Prone positioning
Anesthesia and neurophysiologic
monitoring
Transfusion management
Postoperative pain management
Management of spinal shock
Airway evaluation
Assessment of cervical spine stability (Chiari II
malformation)
flexion of the neck may cause compression of the
medulla1
Assessment of any coexisting craniofacial
abnormalities
Implications for mask ventilation and intubation:
is the patient is a difficult airway?
what is the primary plan for airway management?
what are the backup plans in case the primary
plan fails?
Positioning during induction

Patient positioning during induction and

airway management:
can the patient be laid supine? (severe
kyphosis/meningomyelocele)
lateral or semi-lateral induction and airway
management may be necessary
Access and monitors

Access
in addition to large bore peripheral access,
consider central access for patients with
anticipated increased bleeding risk
Monitoring
In addition to standard ASA monitors, CVP as a
monitor for trending volume status
Arterial line as a close monitor of hemodynamic
changes with the ability to sample blood gases for
Hct, assessment of acid base status, etc.
Intraoperative prone positioning1,2
Sources of morbidity in the prone position
Facial compression, ocular injury -> loss of vision/blindness
Neck/cord injury from excessive extension or flexion
Inadequate intraabominal excursion leading to impaired
ventilation and increased venous pressure (more bleeding)
Brachial plexus injury from excessive extension (greater than
90 degrees)
Femoral nerve injury from compression by bolsters
Tape ETT securely
Frequent checks of eyes, face, airway, and neck
positioning
Intraoperative management

If the airway is unexpectedly lost in the

prone position, what is the plan for
reacquiring airway control?
Plan for supporting oxygenation and
ventilation in the prone position
Expeditious turning of patient to supine
position (proximity of OR stretcher)
Plan for reintubation
Intraoperative anesthetic
management
Stable, balanced anesthetic consisting of
volatiles and intravenous infusions to provide
satisfactory and consistent conditions for
neurophysiologic monitoring
Avoid large boluses or sudden changes in
anesthetic
Communication with neurophysiologist
Backup anesthetic plans in the event of
hemodynamic instability (conversion to more
cardiostable medications i.e. ketamine)
Anesthetic effects on SSEPs
and MEPs2,3
All anesthetics affect spinal monitoring to
varying degrees
Nitrous oxide decreases SSEP amplitude
without an increase in latency
Volatiles anesthetics cause dose dependent
decrease in amplitude and increase in latency
Hypoxia, hypotension, hypothermia, and
hematocrit below 15% also affect both SSEPs
and MEPs
Abnormal SSEPs and MEPs

What if SSEPs and MEPs become

abnormal during surgery?
Ensure adequate oxygenation, ventilation,
and hemodynamics (adequate spinal cord
perfusion)
Communication with surgeon as to
possible surgical causes (instrumentation?)
Risk factors associated with increased
perioperative and postoperative
complications4

Neuromuscular disease Frequent pneumonias

Genetic syndromes Sleep apnea
Traumatic nerve/muscle Malnutrition
injuries Cardiac disease
Seizure disorders Immune compromised
Decreased cognitive Social status
ability Ambulatory status
Poor pulmonary status
Increasing complexity of
Restrictive lung disease surgical procedure
Risk factors associated with increased
perioperative and postoperative
complications4

Pediatric patients with secondary

scoliosis tend to have greater blood loss
than those with idiopathic scoliosis
The exact reasons are unknown and
are still under investigation but platelet
dysfunction, poor vascular response,
increased bleeding time, and fibrinolysis
are some of the proposed reasons
Transfusion management
Blood loss is estimated to be in the range of
15-25 mL/kg in scoliosis surgery involving
instrumentation2
For a 20 kg patient, blood loss can be
estimated to be 300-500 mL
Patients estimated blood volume (EBV)
assuming an average of 70 mL/kg is 1400 mL
Estimated allowable blood loss (ABL) is
calculated as follows:
ABL = EBV x [Hct (initial)- Hct (final lowest
acceptable)] / Hct (initial)
 Given a starting Hct of 43 and assuming
a lowest acceptable Hct of 20, the
allowable blood loss would be:
ABL = 1400 mL (43-20) / 43 = 750 mL
 Given the anticipated large bleeding
from a long complicated multilevel
repair as well as patient risk factors,
what evidence based interventions can
minimize blood loss?
 Minimize intraabdominal pressure to
prevent further engorgement of the
vertebral venous plexus and venous
bleeding
Isovolemic hemodilution
Intraoperative blood salvage
Deliberate hypotension
Antifibrinolytic drugs
Antifibrinolytic therapy5,6
Antifibrinolytic drugs have been shown to reduce
blood loss and the amount of transfusion in children
undergoing scoliosis repair
In a meta analysis of 6 randomized prospective
controlled double blinded trials evaluating the use of
antifibrinolytics versus control:
the amount of blood loss in the antifibrinolytic group was
decreased by 426.53 mL (95% CI -602.51 to -250.56)
the amount of blood transfused in the antifibrinolytic group
was decreased by 327.41 mL (95% CI -469.04 to -185.78)
the risk of being transfused with homologous blood was 13%
lower in the antifibrinolytic group (95% CI 0.67 to 1.12)
the risk of being transfused with allogeneic blood was 29%
lower in the antifibrinolytic group (95% CI -47% to -10%)
 There were no mortalities in either the treatment or
control groups
Aprotinin, tranexamic acid, and aminocaproic acid
seem to be similarly effective with excellent safety
profile (no evidence of hypercoagulability or
thrombotic complications)
High dose aminocaproic acid was used in the
studies: 100 mg/kg bolus administered as an infusion
over 15 to 20 minutes followed by a continuous
infusion of 10 mg/kg throughout the remainder of the
procedure
No comparisons of antifibrinolytics head to head
No comparisons of different doses
 Given the large surgical incision and
musculoskeletal work over many levels,
what are the best evidence based
interventions for postoperative pain
control?
Epidural anesthesia superior to IV
PCA in pediatric scoliosis surgery7
In a meta analysis of four randomized prospective
controlled trials evaluating PCEA vs. IV narcotic PCA
in adolescent patients undergoing scoliosis repair,
epidural anesthesia was shown to provide superior
postoperative analgesia at 24, 48, and 72 hours
Patients randomized to the epidural group underwent
placement by the surgeon under direct visualization
prior to closure
The treatment group received epidural analgesia in
the form of a continuous infusion of local anesthetic
with or without an opioid in addition to parenteral
opioids
The control group received parenteral opioids only
 Blinding was not possible because placement of a
sham epidural is associated with morbidity
visual analog scale pain scores in the PCEA group
were found to be lower at 24, 48, and 72 hrs
VAS pain scores were 15 points lower at 24 hours (p=0.03)
VAS pain scores were 10.1 points lower at 48 hrs (p=0.03)
VAS pain scores were 11.5 points lower at 72 hrs (p=0.02)
Patient satisfaction was higher by 1.7 on a 0-10 scale
in the two studies that assessed it (p<0.0001)
Some but not all studies showed decreased nausea,
pruritis, and number of rescue analgesics in epi grp
Some but not studies demonstrated shorter time to
return of bowel function in the epidural group
Management of spinal shock8,9
Ensure adequate tissue perfusion with volume
resuscitation
Favorable outcomes reported in uncontrolled studies
using fluid resuscitation and vasopressive
medications to maintain a minimum mean ABP of 85
mmHg during the 1st week following spinal cord
injury in adults
Assess for bradycardia and arrhythmias associated
with neurogenic shock and treat appropriately
To counter the loss of sympathetic tone and provide
chronotropic support, vasopressors with both alpha
and beta adrenergic actions are recommended
unless contraindicated
References
1. Cote. A Practice of Anesthesia for Infants and
Children, 3rd ed. 2001
2. Zayas, V, Yao, F, et al. Scoliosis. Anesthesiology:
Problem Oriented Patient Management, 6th ed.
2008
3. Miller, R. Millers Anesthesia, 6th ed. 2005
4. Erickson M, et al. Pathways that distinguish simple
from complex scoliosis repair and their outcomes.
Current Opinion in Pediatrics 2011, (23):339-345
5. Tzortzopoulou A, et al. Antifibrinolytic agents for
reducing blood loss in scoliosis surgery in children.
Cochrane Database of Systematic Reviews 2008,
Issue 3
6. Florentino-Pineda I, et al. The effect of Amicar in
perioperative blood loss in idiopathic scoliosis. The
results of a prospective randomized double blind
study. Spine 29(3):233-238
7. Taenzer A, et al. Efficacy of postoperative epidural
analgesia in adolescent scoliosis surgery: a meta
analysis. Pediatric Anesthesia 2010 (20):135-143
8. Furlan J, et al. Cardiovascular complications after
acute spinal cord injury: pathophysiology,
diagnosis, and management. Neurosurg focus
24(5):E15, 2008
9. Consortium for Spinal Cord Medicine: Early
acute management in adults with spinal cord injury:
a clinical practice guideline for health-care
providers. Washington, DC: Paralyzed Veterans of
America, 2008