Spinal Deformity Reconstruction

There are a variety of ways in which a spine may be misshapen, because of scoliosis, kyphosis, Scheuermann’s disease and other problems. In such spinal deformity patients, the spine is curved from side to side, rotated and/or curved forward too much. There are many ways to reconstruct a curved spine. The type of surgery for spinal reconstruction depends on the degree of the curve, where the curve is located within the spine, patient age, patient general health and other factors. Spinal reconstruction generally involves the use of screws, hooks or wires that grasp or attach to the vertebral bodies. The curve is then straightened as much as possible by attaching a rod to the attachment points. Sometimes an interbody fusion (fusion between the vertebrae in the disc space) is also performed. This may be performed using minimally invasive techniques. The fusion keeps the spine in its newly realigned position.

Conditions Treated with Spinal Reconstruction

Spinal deformity reconstruction is used to treat a wide variety of conditions that result in the spine being misshapen; these include scoliosis, kyphosis, Scheuermann’s disease and others.

While there are many different ways to reconstruct the spine, the exact surgery for spinal deformity performed will depend primarily on the location and severity of the curve(s). Described below are general descriptions for anterior interbody fusion (ALIF) and posterior lumbar fusion (PLF) with pedicle screws. If a large number of levels of the spine are involved, the front and back side surgeries may be done on separate days.

Treatments

WHAT TO EXPECT

Delivering high quality care to patients with complex deformities requires thorough history taking, review of available medical records, a physical examination with emphasis on spinal alignment and neurologic exam, and careful review of imaging studies.  Regular x-rays, and often specialized x-rays will be done to gain as much understanding about the spine as is possible.  Advanced imaging like CAT scans, MRI, myelograms and other tests may be needed.  The patient’s general medical history, as well as their spine history and previous surgeries should be discussed.  The surgeon will need to compile all of this complex information to arrive at an understanding of patient.  The goals, expectations and desires of the patient should be discussed, and proposed options explored.  If surgery is decided upon, the details of the procedures, including the potential risks, benefits and alternatives should be discussed clearly.  The details of your surgery may vary from descriptions you may find on the internet or in other educational materials.  Make sure you discuss the procedure with your surgeon directly so that what you expect to happen is as similar as possible to what the surgeon is proposing.  Routine preoperative medical clearance for anesthesia should be performed, including blood work, EKG, and Chest x-ray.  Other testing may be needed depending on your medical history and the details of your situation (echocardiogram, pulmonary function testing).  If you are at risk for osteoporosis, you may need a bone density test, and treatment may be necessary before surgery is done (as well as after).  This might include medication or just vitamin D supplementation.  You should pay attention to nutrition before surgery because extra calories and protein are necessary to heal well, and you may not feel like eating much after major surgery for a day to two.  Restricting your intake for several weeks and losing weight is not a good idea right before surgery.  Coming to the hospital having had a good bowel movement less than 24 hours prior is also a good idea, even if you have to take some laxatives.  Constipation after surgery is common and will make you more uncomfortable.  You should discuss how to manage your medications, as certain ones need to held for surgery and others should be continued.  You should not have anything to eat or drink for at least 8 hours before your surgery (nothing after midnight is routine).  It is a good idea to have nothing after midnight even if your surgery is scheduled later in the day, in case there are last minute scheduling adjustments.

In the hospital, you can expect a period of time in the preoperative holding area before surgery.  Family can generally be present while you are being prepared for surgery.  You will put on a hospital gown, go over medical history and basic medical questions, verify your surgery, and complete admission paperwork.  There is an administrative portion (insurance and legal documents, etc.) and a medical portion (history, examination, review of labs, EKG, etc.).  If any additional testing needs to be done, it will be done here.  IV access is established.  The surgeon will visit you, answer questions, verify the surgery site and mark it, and complete paperwork.  They will confirm your informed consent for the surgical procedure.  The Anesthesia team will perform a similar process, confirming your history and examination findings relevant to their role, and complete consent paperwork, etc.  Most patients do not have any memory of the operating room, although anesthesia is not initiated until in the room.  Any additional IVs, monitoring and foley (bladder) catheter are established after you are asleep.  We position you for the surgery, sterilely prep the area of interest and cover you with drapes to establish the sterile field.  The surgery is then executed and you wake up after you have been moved off of the operating table onto a regular bed.  The length of surgery depends upon the nature and extent of the surgery that is necessary, generally between 4-8 hours with standard techniques.  Next is the recovery room where you are closely monitored until fully awake.  Strong pain medications will be given for immediate postop pain.  The average time spent in the recovery room is between 1 and 2 hours, and you will likely not have visitors until after that.  The doctor and staff will update your loved ones that are waiting during and after the surgery.  

Pain medication is necessary after surgery, and will be carefully monitored and gradually weaned as postoperative discomfort subsides.  Physical therapy will help you walk after surgery, usually beginning the first day after.  A brace is not usually necessary after surgery, but there are times where it may be recommended depending on the details of the situation and the preferences of the surgeon.  The foley catheter is usually removed on the day after surgery, depending on the situation at the time.  A surgical drain is often placed in the wound at the time of surgery, and it is usually removed within the first few days after the procedure.  Blood work will be monitored, and blood transfusions may be necessary if you become anemic during or after surgery.  The length of the hospital stay will depend upon the details of which surgery was done, your medical history and age, and the progress you make with therapy.  Average hospital stay for simpler deformity surgeries ranges from 3-5 days, and some of that time may be spent in an intensive care unit.  Much more complex procedures in more medically challenging patients may require longer hospitalization.

Recovery:  You may be discharged home, with or without home health nursing and/or home physical therapy, depending on your functional status when your hospital stay is complete.  In some cases, inpatient rehabilitation (at a rehab hospital) is needed.  Travel by car is permitted, although you may want to make accommodations for comfort (pillows, reclining seats, making frequent stops, etc.).  You should discuss any plans for air travel within 30 days of your procedure with your surgeon before the surgery, as they may have specific recommendations.  You will likely need some degree of pain medicine for a while, but should wean down off of it as you heal and postoperative discomfort subsides.  You should not drive a car if you are taking sedating medications, like opioids.  You should avoid strenuous activity or heavy lifting after surgery until cleared by your doctor.  They will likely ask you to gradually increase your activity level over time, removing your activity restrictions as progress allows. The details are all individual decisions determined by the surgeon, and may vary depending on your specific situation.   Follow-up visits with your surgeon are vital to monitor your healing, check you for complications, follow your progress and obtain x-rays periodically.  Follow up after spine surgery of this magnitude may essentially be indefinite to monitor your progress long term.  You may feel that you are not “recovered” completely for 6-12 months after surgery, depending on your situation.

FAQ

There are many things you can do to positively affect the outcome of your surgery.  These include:

Smoking cessation (nicotine abuse increases risk of complications, including fusion failure)

Ensuring good nutrition (specifically, adequate protein and calories to heal your wound), take supplemental protein shakes after surgery if you have any trouble getting enough with a regular diet

Vitamin D supplementation (1,000 units per day before and after your surgery to make sure you are not deficient)

Know your bone density (a bone density test can be done before surgery, if you have risk factors for osteoporosis)

Have an accurate list of your medications and how you take them

Get cleared by your primary care physician (and cardiologist, if you have one) for surgery to help avoid last minute discoveries of unresolved medical issues

Discuss how to handle your medications around the time of surgery with your surgeon and the doctor who prescribes them to make sure everyone is on the same page,  for spine fusion surgery you will generally need to temporarily hold blood thinning medications/aspirin and anti-inflammatories, as well as certain other medications which should be determined by your treating doctors

Make sure any other significant medical issues are resolved/stable before you proceed (some issues may result in a last minute cancellation of your surgery if they are significant enough to affect the safety of the procedure)

Improve your fitness level if at all possible.  Increasing your level of activity even for a few short weeks can be helpful in improving your heart and lungs for surgery and recover.  You will also likely have an easier time mobilizing with physical therapy.

Avoid increasing your pain medicine usage, and try to reduce it if possible.  Your body develops tolerance to pain medications the more you are exposed to them, which means that over time and repeated usage their effect becomes less and less.

Usually, yes.  There are circumstances where surgery is the best option, and others where it is the only option.  For most patients, however, more conservative treatment (physical therapy, bracing, medications, and injections) is reasonable to try before considering surgery.

No.  These surgeries are of significant complexity, and are mostly performed by spine surgeons with special interest, training and experience in dealing with the advanced techniques required to achieve good results for these patients.  While any surgery has its challenges and requires specialized knowledge, this type of surgery is an extreme example of that, which means only a small minority of spine surgeons perform complex spinal deformity reconstruction surgery regularly.

For most situations simply reviewing MRI findings is not enough to make determinations like that.  A doctor has to know some history of a patient with emphasis on symptoms, prior treatment and relevant medical history.  The goals of that patient must be understood as well, before determining if surgery is appropriate, and which procedure is best.  Generally, standing x-rays are required before deciding about surgery, because an MRI does not tell you in as much detail as an x-ray the story of the patient’s spinal alignment.  Evidence of instability or deformity may often only be visible on a standing x-ray.  Other tests may also be needed, depending on your situation.  An MRI review is only one piece of the puzzle that must be put together to see the whole picture.

For most situations, a brace is not needed.  There is not really any definite evidence that a postoperative brace improves outcomes, however your surgeon may recommend one in certain situations, or according to their preference.

This is a combination of the judgment of the patient and their doctor.  Generally, it is reasonable to drive if you are not taking sedating medications that would impair your ability to drive and, in your judgment, you feel you can safely and competently control a vehicle.  For simple procedures, this may be only a few days after surgery, and for others it may be months.

This is also a combination of the judgment of the patient and the surgeon.  It depends heavily on the details of your situation, your procedure and what your responsibilities are at work.  Heavy lifting after a major reconstruction may be a longer time period than an office job that is sedentary.  You will need to discuss this with your surgeon to get a specific answer, but 2-4 weeks is typical for return to sedentary work after a limited procedure, and 4-6 weeks for more extensive surgery.  Heavy lifting averages 3-6 months, depending on the circumstances.  In extreme cases, your surgeon may have certain permanent limitations to assign.  These should also be discussed with your doctor.

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