Disclosures Avoiding Complications in I have nothing to disclose. - - PDF document

▶
disclosures
SMART_READER_LITE
LIVE PREVIEW

Disclosures Avoiding Complications in I have nothing to disclose. - - PDF document

Mar 01, 2024 136 likes •222 views

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

slide-1
SLIDE 1

Avoiding Complications in Neuromuscular Spine Deformity Surgery

Ozgur Dede, MD Assistant Professor of Orthopaedic Surgery University of Pittsburgh

Disclosures

I have nothing to disclose.

Spine Fusion for Neuromuscular Deformity Benefits

  • Balanced sitting
  • Re-gain use of the

upper limbs

  • Better respiration and

pulmonary clearance

  • Better nutrition
  • Easier management of

GI reflux

  • Improved nursing care

Spine Fusion for Neuromuscular Deformity Pre and intra-operative problems

  • Bad host
  • Nutrition/immune

compromise

  • Recurrent infections
  • Poor cardiopulmonary

reserve

  • Poor bone stock
  • Bleeding tendency

(meds/osteopenia…)

  • Large deformity

1 2 3 4

slide-2
SLIDE 2

Spine Fusion for Neuromuscular Deformity Post-operative problems

  • Care
  • Worsening pelvic obliquity
  • Decubitus ulcers
  • Head support loss/position change
  • Difficulty self feeding/self perineal care
  • Junctional deformity
  • Implant breakage or pull-out

Pre-operative Planning

Medical clearance

  • Appropriate consultations

– Pulmonology – Neurology – Cardiology – Nutrition/GI

  • Check seizure meds (Valproic Acid)
  • Optimize tone control (if possible)
  • Make sure parent/guardian/caretaker on

board

Pre-operative Planning

Imaging - flexibility

vs

Pre-operative Planning

Imaging – sagittal plane 5 6 7 8

slide-3
SLIDE 3

Pre-operative Planning

Optimize nutrition

  • Check albumin levels
  • Consult nutrition/GI medicine
  • Supplement feeding
  • Consider g-tube placement
  • Consider supplementing from central

line post operatively

Infection Prevention

Develop a protocol – or use others’

  • Many examples – vitale/gloetzbecker

– MRSA eradication – Appropriate and timely prophylaxis – Limit traffic – Operative prep

  • Betadine scrub
  • Alcohol wipe (100 alcohol into a gauze tub)
  • Two layers chlorhexidine prep (let dry in between)
  • Incise drape (ioban etc)

Infection Prevention

Intra-operative measures

  • Frequent irrigation (every 30 minutes 300 cc)
  • Change gloves (every hour or in between steps)
  • Change gown after 4 hours
  • Wipe the incise drape clean with betadine before

closure

  • 3000 cc pulsatile irrigation
  • 3.5% betadine soak for 3 minutes
  • Another 3000 cc pulsatile irrigation
  • 500 mg Vanco in bone graft
  • Multi-layer closure

Infection Prevention

Intra-operative measures

  • Multilayer closure

– Loose muscle layer (1 vicryl)

  • Vancomycin 500 mg

– Water tight fascial closure (1 vicryl) – Hypodermis (Fat) (0 vicryl) – Subcutaneous layer (2-0 absorbable) – Running subcuticular or staples – Occlusive dressing

9 10 11 12

slide-4
SLIDE 4

Blood Loss

  • Pre-operative anti-seizure medication

adjustment

  • Hematology consult as necessary
  • Tranexaminic acid
  • Bone wax and other hemostatics
  • Liberal use of bovie cautery (mine is

set at 50/desiccate)

  • Double-team in long cases

Poor Bone Quality/Anchors

  • Have multiple options available

– Screws – Hooks – Sublaminar wires (Luque) – Sublaminar bands – Polyester tape – Supplemental rib fixation

  • May consider post-op bracing
  • Dexa scan? Bisphosphonates? Cement

augmentation?

Residual pelvic obliquity

Prevented progression but still oblique pelvis and even stiffer with the metal Pressure sore producer

Multiple Smith-Petersen osteotomies

13 14 15 16

slide-5
SLIDE 5

Pedicle Subtraction Osteotomy

Pelvic Obliquity After Fusion

  • Expected
  • New onset

Pelvic Obliquity

Pendulum Swings

  • For non ambulatory patients default to

pelvis

  • If pelvis is tilted more than 15 degrees
  • n weight bearing AP film fuse to pelvis

S2AI screws might help prevent some issues

17 18 19 20

slide-6
SLIDE 6

S2AI screws might also fail

Larger and smooth shank screws? Implant pull-out/junctional kyphosis

  • Children with NM

disease have kyphotic tendency

  • Proximally go to T2
  • r T1
  • Leave some

proximal thoracic kyphosis

  • Proximal hooks

maybe protective?

Restore Sagittal Alignment

21 22 23 24

slide-7
SLIDE 7

Surgeon happy, Mom…not so much

Take home

– 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

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.

25 26 27