Scoliosis Surgery

(This is the section that explains the detail of the operation or procedure above and should be read in conjunction with the section Your Back Operation).

Surgery for scoliosis is indicated when non-operative measures fail. The reason for surgery may be an extremely large curve or deformity or evidence that the curve is progressing and a large curve is expected in the future. This is typically the case in teenagers who develop scoliosis during their growth spurt. If these curves become enlarged, not only do they have cosmetic effects, but they also have a negative effect on respiratory function (breathing difficulties). Another reason for intervention would be in the adult age group where excessive wear and tear has occurred resulting in a degenerative scoliosis. This is typically in the lower back (lumbar) area and can cause both back and leg pain.

The aim with scoliosis surgery is to correct the curve and to hold it in a corrected position while a bony fusion occurs. In other words, the patient trades a skew spine for a straight, rigid one. It is not possible to correct the curve without taking away spinal movement and this needs to be considered before embarking on surgery.

Before surgery, certain investigations are necessary. Dynamic X-rays, where the patient bends to the left and the right during the X-ray process, assists in deciding which part of the spine needs to be treated. A Magnetic Resonance Scan (MRI) may be necessary to exclude other spinal cord pathology.

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Image used with permission from Dr RN Dunn

 

A thorough history of other medical problems and medication used is needed to minimise complications. There are various surgical options with increasing complexity and risk. The following procedures are available.

Anterior release

Anterior means from the front and describes an approach either through the chest or abdomen. The release is never done as the only procedure and needs to be followed by a stabilisation operation.

The release increases the flexibility of the skew spine. It is indicated in patients with an extremely rigid spinal curve, which is not easily correctable.

If the scoliosis is in the thoracic (chest) spine, this requires an approach through the chest. Here, an oblique incision is made in line with one of the ribs, the chest opened, the lung moved to the side and the spine inspected. The intervertebral discs are then removed from between the vertebral bodies to allow more spinal movement and to encourage bony growth between the vertebrae at a later stage. Some of the rib heads may be resected to further increase the flexibility.

The patient needs to have a chest drain (intercostal drain) inserted post-operatively to drain the air and blood and patients can expect a degree of discomfort for a few weeks due to the motion of breathing that causes movement at the repaired rib entry site.

Anterior corrective fusion

Should the curve be readily correctable, as assessed pre-operatively with dynamic X-rays and a clinical examination, the whole corrective process can be done with surgery from the front. This is typical for lumbar (lower back) scoliosis. In this instance the discs are removed as above, but in addition screws are placed into each vertebral body and connected with a rod. During this process the skew spine is forced to connect to a straight rod and thus straightened out. This technique has the advantage of minimal blood loss and muscle damage.

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Image used with permission from Dr RN Dunn and Synthes 

 

Posterior corrective fusion

This is the commonest option employed in the management of scoliosis. The spine is exposed from behind, by stripping the muscles to the side. Hooks and screws are fixed into the spine. This carries some risk as they are close to the nerves.  

Once the connection points are placed, the facet joints are resected from the spine to encourage a fusion, in other words the formation of a solid bony bridge. Two rods are then applied, one on the left and one on the right. The rods are attached to the connectors in a sequential fashion, forcing the spine into a straight line. This corrects the scoliosis.

These interventions are considerable and a patient can expect to stay in hospital for seven to ten days including one to two nights in the High Care Unit. Blood transfusions are generally required. The first few days following surgery are extremely painful and morphine type medication is required which may cause nausea and drowsiness.

Risks of scoliosis surgery

All surgery brings risk. The general risk of infection is present, but relatively low at around 0,8%.  It is even lower with the anterior approaches. There is  a risk of non-union, or failure of the bone to grow together (fuse). Should   this occur, the instrumentation will probably fatigue and break at around 12-18 months post-operatively with pain and a loss of correction.

The risk most feared is neurological injury (paralysis). Although this risk is ever present, it is rare, with a chance of 1:300 of any neurological event ranging from some numbness to total paraplegia (unable to move or feel legs). This can occur from the corrective process and increased strain on the spinal cord or from reduced blood supply to the cord.   

To reduce the risk of neurological damage, some surgeons use spinal cord electrical monitoring during the procedure, although this is not fail-safe and has its own technical challenges. Should there be a problem in the immediate post-operative phase, urgent instrumentation removal may be required.

Ward Care

Generally these patients start to walk one to two days after the surgery. They do not usually need a brace unless there is concern regarding the grip of the screws/hooks in the bone. The physiotherapist and nursing staff will ensure that the mobilisation is done safely.

Discharge

You would normally be discharged about a week after your operation. Staff at the hospital will take care of your follow-up consultation, analgesia to take home, sick leave-certificate and wound care provisions in the post-operative period.

Rehabilitation

It is incredibly important to get a lot of rest and exercise following your surgery. Do not try to rush back to work. It is important to walk for exercise and also exercise in conjunction with the guidelines from your physiotherapist. You may perform activities only as prescribed by your specialist. There will be permanent restrictions in terms of sport and one cannot play contact sport, however, controlled activity is recommended.

Follow-up

Typically patients will be off school or work for six to twelve weeks. Regular follow-up with X-rays are done to assess the fusion process.

It is important to realise that you will have to protect your back for the rest of your life and apply good back habits (see the section Caring for your Spine).
 

 
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This website is a patient resource compiled from information from leading spinal surgeons practicing in South Africa and complements the My Spine – Lumbar and My Spine – Cervical information booklets that you can obtain directly from your spinal specialist. You will find information about spinal conditions and treatment on this website.

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