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Scoliosis

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1 Scoliosis www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com

2 Patient Particulars Name : Preeti Age : 11 yrs Sex : Female Student : Class six Address : Uttar Pradesh Date of examination : 22/08/07 Proposed date of surgery : 23/08/07

3 Chief Complaints Deformity of back & chest x 7 yrs Back pain, Leg length discrepancy, An abnormal gait, Uneven hips Clothes no longer fit correctly (for example, the legs of pants may seem uneven). One shoulder higher than the other

4 History of Present Illness Patient was alright till the age of 7 yrs Deformity of back with left-ward tilt along with deformity of chest became apparent Insidious in onset Gradually progressive

5 HOPI- (consequences-CNS, RS, CVS) No H/O localized or radiating back pain No H/O weakness in either LL, bowel, bladder incontinence No H/O frequent chest infection No H/O Breathlessness during exertion or at rest No H/O chest pain, pedal swelling No H/O palpitation, syncopal attack

6 HOPI- (etiology) No H/O trauma to the backbone (traumatic) No H/O pain, fever or swelling of the back (TB) The deformity does not get corrected in supine position (postural ) No H/O leg length discrepancy, neck deformity (compensatory) No H/S/O neuro-muscular weakness or muscle rigidity (neuromuscular) No H/S/O seizure disorder No c/o other body part deformity

7 Associated conditions Cerebral palsy Spinal muscular dystrophy Familial dysautonomia Friedreich’s ataxia Skeletal dysplasia Marfan’s syndrome Neurofibromatosis Connective tissue disorders craniospinal axis disorders (e.g., syringomyelia)

8 HOPI Exercise tolerance good Birth History F.T.N.V.D. Cried immediately after birth Normal developmental mile stones Immunized appropriately for the age

9 History of Past Illness No other major medical or surgical illness Family History Nothing significant

10 Personal History Vegetarian Appetite, sleep, Bowel, bladder, –normal Treatment History None- No h/o Rx in the form of braces or exercises

11 Anesthetic History No past h/o anesthetic exposure Allergic History none

12 General Examination Alert, conscious, cooperative, playful child Thin built Pallor - Cyanosis - Clubbing – Icterus – Edema – Neck vein- not engorged

13 Vitals PR-80/min, regular, normal volume,equally well felt all peripheral pulses, no radio- radial or radio-femoral delay, no special character B.P.- 110/70mmHg, in right upper limb in supine position RR- 16/min, regular, thoraco- abdominal Temperature - afebrile

14 Examination of the Deformity Lateral curvature of spine Limited to the thoracic region Convexity right ward Spinous processes and interspinous spaces are felt without any gibbus No tenderness Rib cage is prominent anteriorly in left side with crowding Rib cage is prominent posteriorly in the right side

15 Uneven shoulder heights Prominence of shoulder blade Increased space between the body and the elbow while standing in natural posture Uneven hips or waist One breast appears larger than the other Chest or rib prominence One leg appears longer than the other Appearance of leaning to one side

16 Systemic Exminations Respiratory system: Inspection Bony deformity of thorax Trachea- mid line Unequal bilateral chest expansion(Rt>Lt) RR-i6/min, thoraco-abdominal

17 Respiratory System Palpation Chest expansion-2 cm(unequal: rt>lt) Trachea- mid line No tenderness Vocal fremitus- normal in all regions Percussion Normally resonant over all regions Auscultation Normal vesicular breath sound No adventitious sound

18 Cardiovascular System Inspection Bony deformity over the precordium Palpation Apex beat-left mid-clavicular line at 5 th ICS No thrill, parasternal heave or lift, no plpable heart sound Auscultation Heart rate-80/min, regular Normally heard S1 & S2 No murmur No other adventitious sound

19 CNS Clinically normal Abdmen Clinically normal

20 Airway No obvious facial abnormality Mouth opening- 4 cm Modified Mallampati Class-1 Neck movement- adequate TMD-6 cm Teeth- intact I.V. Access Good

21 BHT 35 sec Ability to Cough Positive

22 Clinical Diagnosis 11 yr old female child with idiopathic juvenile dorsal scoliosis without clinically apparent cardio-respiratory or neuromuscular complication posted for one stage anterior instrumentation and posterior spinal fusion surgery.

23 Investigations Hb-13.8 gm/dl Hct- 41.1% TLC-5600 Platelet count- 2.18 lacs/cmm CXR- Rt sided dorsal scoliosis, crowding of rib in left side, decreased left lung volume ECG- normal PFT -

24 Definition Lateral curvature of the spine combined with a rotational component, due to various etiologies, according to the Scoliosis Research Society (SRS).

25 Anatomy

26 Prevalance Curves >10° -2-3% of the population Curves >20° affect about 1 in 2500 people. Curves convex to the right are more common 'C' curves are slightly more common than double or 'S' curve patterns. Males are more likely to have infantile or juvenile scoliosis Female predominance of adolescent scoliosis. Girls are 7 times more likely than boys to develop a significant progressive curvature Adolescent Idiopathic Scoliosis, there is a clear mendelian inheritance but with incomplete penetrance

27 C and S curve

28 Causes Congenital –result of an abnormality of the development of the vertebrae-hemivertebra, rib anomalies, spinal dysrapism Ass with other congenital anomalies – CHD Neuromuscular Poliomylitis, Syringomylia, Muscle dystrophies, cerebral palsy, spina bifida, spinal cord injuries Poor posture Unequal leg length Idiopathic scoliosis –cause unknown –most common form (80%)

29 Associated conditions Cerebral palsy Spinal muscular dystrophy Familial dysautonomia Friedreich’s ataxia Skeletal dysplasia Marfan’s syndrome Neurofibromatosis Connective tissue disorders craniospinal axis disorders (e.g., syringomyelia)

30 Infantile idiopathic scoliosis is a/c ↑ incidence of mental retardation inguinal hernia cong dislocation of hip cong heart disease Adolescent idiopathic scoliosis most common form most common in girls

31 Prevention Tips - Scoliosis The most important is early examination and getting doctor’s advice Unlike poor posture, scoliotic spinal curves can't be corrected simply by learning to stand up straight Carry weight balanced between two hands Don’t watch TV always sitting/lying in the same position Exercise and do sports / physical activities

32 Prevention Tips Backache is a condition that is often caused by weak muscles These exercises will help strengthen the muscles which support back and improve posture

33 Symptoms Back pain, Leg length discrepancy, An abnormal gait, Uneven hips Clothes no longer fit correctly (for example, the legs of pants may seem uneven). One shoulder higher than the other

34 Signs of Scoliosis Uneven shoulder heights Prominence of shoulder blade Increased space between the body and the elbow while standing in natural posture Uneven hips or waist One breast appears larger than the other Chest or rib prominence One leg appears longer than the other Appearance of leaning to one side

35 Signs of scoliosis

36 Physical Findings Uneven shoulders Prominent shoulder blade Uneven waist Elevated hips Leaning to one side

37 Physical examination Café au lait spots The feet for cavovarus deformity Abdominal reflexes Muscle tone for spasticity Gait Signs of other abnormalities (e.g., dysraphism evidenced by a dimple, hairy patch, lipoma, or hemangioma). A thorough neurological examination is also performed..

38 Telescreening study Measures A. With student standing (grid), observe for: a) high shoulder, b) curved spine, c) uneven shoulder blades, d) uneven hips or waist creases, and e) unequal distance from arm to side of body B. Adams forward bend test Scoliometer measurement (thoracic, thoracolumbar, lumbar) -Angle of trunk rotation (ATR) > 7 degree – referral)

39 Classification Infantile children ages 3 and under Juvenile 3-9 years old Adolescent 10-18 years old Adult after skeletal maturity Most common is Adolescent Idiopathic Scoliosis

40 Curves Non-structural = Lateral curvature vertebral column bends from side-to-side S-shaped curvature of the spine Structural = Rotation curvature usually subtle, but is always present in a true scoliosis deformity twisting deformity of the vertebral bodies

41 Types of curves

42 Diagnosis Leg length Both legs are measured to determine if they are of equal length Plumb line A plumb line is "dropped" from the C7 vertebra (in the neck) and is allowed to hang below the buttocks. In scoliosis the line does not hang between the buttocks. Neurological assessment

43 Cobb’s angle

44

45 Cobb’s angle and symptoms <10 normal curvature >25 ECHO evidence of increased pulmonary artery pressure >40 surgical intervention >65 restrictive lung disease >100 dyspnoea on exertion >120 alveolar hypoventilation

46 Adams Forward Bend Test  Student should stand erect with feet together  knees fully extended  The palms of both hands touching each other  The student bends forward until the back is horizontal  Asymmetry of the thoracic or lumbar spine may be detected by using a scoliometer  To measure the angle of trunk rotation (ATR) at the thoracic, thoracolumbar, and lumbar areas of the spine

47 Adams test

48 Adams test…

49 Diagnosis… Scoliometer (inclinometer) is used to measure a rib hump while the patient is bent at the waist. X-rays (radiographs)-an upright lateral view and side bending. Risser Sign - x-ray for knowing skeletal maturation. Lenke Classification King classification

50 Scoliometer

51 Scoliometer

52

53 Risser’s sign

54 Respiratory system Decreased compliance Decreased ventilatory response to CO2 V/Q mismatch Arterial hypoxemia Hypercapnia Respiratory failure

55 PFT (Features of RLD) Volumes –Vital capacity -  ed Important prognostic predictor 70% POV not required –TLC -  –FRC -  –RV -  –VD/VT ratio -  Chest wall compliance -  

56 ABG –  PaO2 (early) –  AaDO2 –  PaCO2 (Late) Pulmonary Vasculature –  Pulmonary Vascular resistance –  PAH Flows –Maximum Insp press at FRC - <30cm of H2O – ineffective coughing

57 Cardiovascular system Pulmonary hypertension Right ventricular hypertrophy and cor-pulmonale a/c Mitral valve prolapse (25%) a/c Congenital heart diseases Impaired development of pulmonary vascular bed Increased incidence of hypoxic pulmonary vasoconstriction Reduction in the number of functional vascular units

58 Treatment Observation (Below 20 degrees) –patients are seen by a spine specialist about every six months until skeletal maturity is reached Bracing (25-40 degrees) –control any worsening of a spine curvature, but do little to correct an existing deformity –most effective when used in children that are rapidly growing and have worsening scoliosis curves

59 Non surgical management Small curves (those less than 15-20 degrees) observation Larger curves (those between 20-40 degrees) - bracing to prevent further progression of the curve. Braces can be uncomfortable, unattractive, hot, and can make a child self-conscious However, when bracing works and surgery is avoided, the commitment required is worthwhile. At this point a carefully designed exercise program may also be recommended. Unfortunately, some curves do not respond to bracing. Cervicothoracic curves (from the middle of the back up into the neck) and curves greater than 40 degrees tend not to respond well to bracing. Also, older patients who are closer to skeletal maturity may not respond to bracing.

60 Treatment... Surgery (45 degrees or greater) –best option for more severe curves. –fuse vertebrae in a more normal anatomic position –severe curves carry a risk that lung and heart function may become affected

61 Indications for surgery Spinal curvature (Cobbs’s angle) >45°/progressive Trunk deformity Pain Deteriorating cardio-pulmonary status Family H/O severe scoliosis Cosmetic

62 Aims of surgery Correction of curve Prevent further progression Relief / prevent back pain Maintain posture Prevent progression of cardio-pulmonary dysfunction

63 Surgical Options Posterior correction and instrumentation Anterior correction and instrumentation Anterior release / fusion, plus posterior instrumentation Posterior release/fusion, plus anterior instrumentation Combined anterior and posterior instrumentation and fusion

64 PROBLEMS IN SCOLIOSIS SURGERY Compromised respiratory function  TV/  RR Consider postop. Ventilation up FVC <40° Prone position Armoured E/T tube Prevent pressure / traction injuries Neurological injuriy Detect / treatment intraoperative SC injury Wake-up test Neurophysiological monitoring Maximize S/C perfusion

65 PROBLEMS IN SCOLIOSIS SURGERY (Contd…) Massive blood loss  blood loss Avoid homologous transfusion Hypothermia Prolonged surgery Large area of exposure VAE Large open Vn plexus Area of surgery above heart Sport respiration during wake-up test Visual loss

66 Pre-op evaluation Age of onset – Lungs grow and develop till 8 yrs of age NO of alveoli at birth-20 million, at 4 yrs-250 million Thoracic scoliosis at earlier age- impaired lung development ↑ risk of impaired gas exchange/pulm HTN Location of spinal curvature- thoracic- deranged PFT, cervical- difficult airway, ass cong anomalies Cause of scoliosis- Neuromuscular scoliosis-Sch, MH Exercise tolerance Coexisting diseases Congenital anomalies

67 Severity <10Normal >25Echo evidence of raised PA pr. >40Indication for surgery >65Restrictive Lung Disease - PFT/ABG indicated >100Symptomatic lung disease-DOE >120Alveolar hypoventilation >70Pulmonary HTN on exercise >110Pulmonary HTN at rest

68 Airway assessment cervical scoliosis-difficult inyubation neurofibromatosis high arched palate Cardiovascular system involvement pul HTN- loud P2 RVH-RV lift RVF-engorged neck veins, enlarged liver, lower extremity edema Respiratory system involvement wheezing/rales- restictive lung disease, parenchymal disorder

69 Investigation Cobb’s angle Bedside pulmonary function tests Arterial blood gas analysis ECG ECHO Coagulation studies Electrolytes Liver function tests

70 Pre-operative preparation Incentive spirometry /coughing Parenchymal /obstructive lung disease - Aggressive bronchopulmonarytoilet/ bronchodilator therapy Wake up test preparation-explain, inform, reassure, reherse Considers ‘autologous blood donation’

71 Pre-medication Anxiolysis –Oral midazolam (0.5mg/kg) –Alprazolam Aspiration prophylaxis –Metochlorpropamide –H2 blockers (Ranitidine) Antisialoguge –Glycopyrorate

72 Monitoring Routine standard monitoring - ECG - NIBP - SpO2 - EtCo2 - Temperature, U/O, NMT Invasive – indwelling arterial line - central venous line (PAC- Duchenee’s cardiomyopathy, PHTN, RVF) Neurologic monitoring –SSEP, MEP, awake test

73 Induction / Intubation –Difficult airway – awake fibreoptic –IV agent (propofol/thiop) + short acting NDMR (avoid scoline) –Armoured E/T tube – secure firmly Maintenance –Analgesia – Fantanyl infusion –Less total dose –Steady plasma level –Least effect on SSEP –IPPV  TV +  RR O2+N2O+ISO(0.4-1%) (avoid halo) Avoid hypocapnia –Fluids Guided by CVP + urine output Blood loss replaced by blood

74 INTRA-OPERATIVE NEUROLOGICAL MONITORING Detect spinal cord injury intraoperatively Incidence – (Harrington Rod) – 0.6-1% (sublaminar wiring) Devastating / undesirable / avoidable Cause Direct spinal cord injury – excessive destraction Compromised spinal cord perfusion At risk groups Severe rigid deformity >120° Kyphosis Neurofibromatosis Congenital /post infectious scoliosis Pre existing neurological deficit Sublaminar wire (Luque rod) intrsumentation

75 Investigate- preop myelogram/MRI Monitor- SSEP/awake test Prophylaxis- high dose corticosteroid for pt with pre existing neurological deficit Intra-operative neuronal changes correlate well to postop. neurological deficit Take corrective measure –Readjust instrumentation,  degree of correction, high dose steroid, remove bone graft, maximize spinal cord perfusion

76 WAKE-UP TEST Vauzelle (1973) Awaken patient partially and asked to move lower limbs, after spinal instrumentation. How to perform PAC Patient explained the procedure Reassure - ‘no pain’ or ‘recall’ Intraoperative After complete surgical correction stop volatile (15-20 min Allow neuro-muscular blockers to wear off Ensure adequate analgesia (top-up of fantanyl) Switch off N2O Address the patient by his name First move upper limbs (squeeze my fingers) Next move feet (wriggle your toes) If unable to perform latter corrective measures taken Test repeated Benzodiazepine - amnesia

77 WAKE-UP TEST (Contd…) Advantage Few false negative results Checks the motor functions Disadvantage Needs patients co-operation Unpleasant if patient has ‘recall or pain’ VAE due to spontaneous respiration Dislocation of spinal instrumentation Extubation / Removal of IV, IA cannulae Cannot be performed repeatedly (at the most twice)

78 NEUROPHYSIOLOGICAL MONITORING Real time, continuous assessment of spinal cord function No need for patient movement, arousal or cooperation Special technology and expertise required Stimulate one part nervous system Measure response at distant part (evoked potented) Across spinal cord at risk 2 types used in scoliosis surgery Somatosensory evoked potencial (SSEP) Used extensively Easier to perform Motor evoked potential (MEP)

79 SSEP Cortical, subcortical response to peripheral nerve stimulation Peripheral nerves –median (for comparison), peroneal, post tibial Evoked potential wave form amplitude plotted against time (latency)  amplitude and  latency indicates disruption in neural pathway Pass through dorsal column Continuous monitoring done Bilateral stimulation gives exaggerated response Unilateral lesions may be missed Each lower limb stimulated separately.

80 SSEP (Contd…) Disadvantages Does not measure motor function Similar changes produced by several other factors All volatile anaesthetic (max. Enflurane) & N 2 O Some IV anaesthetic, Propofol Hypothermia, hypotension, hypoxia, hypocapnia No effect on (SSEP) Ketamine, elomidate Opioid (Fantanyl least) How to differentiate Compare limb SSEP of unaffected limb Reliability Good predictor of postop. Neurological deficit False negative +ve

81 MOTOR EVOKED POTENTIAL Direct motor response is seen SC is stimulated electrically / magnetically Two types MMEP – Myogenic (twitch recorded in distal muscle) Partial reversal of NMB required (TOF = 2-3) NMEP – Neurogenic (magnetic stimulus via scalp electrodes, Neural conduction recorded at lateral column of SC or peripheral nerve) Same systemic effects

82 MOTOR EVOKED POTENTIAL Direct motor response is seen SC is stimulated electrically / magnetically Two types MMEP – Myogenic (twitch recorded in distal muscle) Partial reversal of NMB required (TOF = 2-3) NMEP – Neurogenic (magnetic stimulus via scalp electrodes, Neural conduction recorded at lateral column of SC or peripheral nerve) Same systemic effects

83 NEUROPHYSIOLOGICAL MONITORING Real time, continuous assessment of spinal cord function No need for patient movement, arousal or cooperation Special technology and expertise required Stimulate one part nervous system Measure response at distant part (evoked potented) Across spinal cord at risk 2 types used in scoliosis surgery Somatosensory evoked potencial (SSEP) Used extensively Easier to perform Motor evoked potential (MEP)

84 PRONE POSITION Airway secured with armoured tube Antisialogogue – glycopryolate preoperative Caution during positioning Both arms anteriorly flexed and abducted   traction on brachial plexus Head turned laterally slightly flexed Eyes Taped closed, padded, Retinal damage, blindness, corneal abrasion seen after spinal surgery Abdomen – free by chest and iliac crest supports Pressure on abdomen -  VR, diaphargmatic splinting, epidural vessel congestion Jackson/Wilson orthopaedics frames also used.

85 HOW TO MINIMIZE Total blood loss can be substantial (upto 50% BV) Depends on No. of segments fused / decoretecated (200ml/segment) Duration of surgery Methods- Decrease blood loss Proper prone positioning – avoid epdirural vessel congestion Induced ‘moderate’ hypotensive MAP – 70mmHg Further  Bp – SC ischemia, visual loss Antifibrinolytic Aprotinin (esp M disorder)  Blood loss by 50% Hypersensitivity (esp. with reexposure) Vasoconsctritor infiltration – Adr. 1:500,000. Meteculous surgical technique

86 AIM Autologous blood transfusion Autodonation starts 3wks prior 2-3 units (Hb permits) Hb>11gm Gap 4-7 days between subsequent collections for volume repletion Hast donation 7 days before surgery Oral Fe therapy / Erythopoetin Final Hb >10gm/ PCV>30 Intraoperative Isovolemic haemodilution After induction 1-2 units withdrawn Volume replaced by colloids (1:1)or crystalloids (3:1) Intraoperative blood salvage Surgical site – cell savers AVOID HOMOLOGOUS TRANSFUSION

87 VENOUS AIR EMBOLISM Due to Large open venous plexus Above level of heart Spontaneous respiratory during ‘wake-up test’ Presentation Sudden, unexplained  Bp (CV-collapse)  PCO 2 /  End tidal N 2 Treatment Flood the field with normal saline Symptomatic – 100% O 2 Ionotropic support Resuscitation – then supine Post thorecotomy – int defiberllation Aspirate air via CVP?

88 HYPOTHERMIA Prolonged surgery Large area of exposure Precaution Contensions temperature monitoring (np, LE, Re) Warmup blankets Warm fluid / blood  Temperature Affect SSEP, Delay recovery Visual loss – in prone spinal surgery reported Cause Commonest – Ischaemia to optic nerve Risk factor I/o hypotension, Anemia, Prolonged surgery, Direct press due to positioning Precaution Slight head up Repeated check eye for pressure

89 Post op care Extubation CPAP Ventilation

90 Predictors of Post-op Ventilation Patient factors: Severe Restrictive Lung Disease: Vital Capacity < 35 % P i max > - 40cmH2O P e max < +40cmH2O PaO2 < 60mmHg PaCO2 > 50mmHg Right Ventricular Failure Pre-existing neuro-muscular diseases Congenital heart disease Obesity Surgical factors: Blood loss > 30ml/kg Surgical invasion to thoracic cavity

91 Postoperative care Post operative pain – very severe Choices Regional Intra-thecal MsO 4 -5µg/kg (300µg); Given intraop Caudal MsO 4 -50µg/kg (3mg); Combine with LA Epidural infusion Surgically placed epidural catheter Infuse LA + opioids ‘Patchy effect’

92 –Systemic Best PCA –Steady plasma level –Less total dose –No respiratory depressions –Patient should operate it NSAD –Role controversial –Alone not enough –Affect fusion / delay fracture healing –Cox-’2’ better choice (no effect on platelets)

93 Postoperative care (Contd…) Other known complication Superior mesenteric syndrome Kinking 3 rd part duodenum Treatment conservative Paralytic ileus Oliguria  ADH Hourly urine output Fluids / diuretics guided by CVP Respiratory complication Atelactasis/Retained secretions Deterioration of PFT uoto 7 days post operative Intense pain management Early respiratory physiotherapy

94 Post-op pulmonary complications Significant positive correlation of post-op pulmonary complications with – pre-op PFT Pre-op PFT Post-op pulmonary complications FVC – 60-<80% 2.72% 40-<60% 7.40% <40% 31.60% Surgical approach – transthoracic >> posterior approach No correlation with age or cobb’s angle. - Spine,2005

95 Complications-Monitoring Cardiovascular collapse -extensive blood loss, inadequate venous return, air embolism, latex anaphylaxis, Pneumothorax or hemothorax Myoglobinuria, renal insufficiency (Rhabdomyolysis) Coagulopathies, Acid-base imbalance Electrolyte disturbances (hyperkelemia, hypocalcemia-.. Massive BT)

96 Complications related to prone position Airway Blood vessels Nerves Head and neck

97 Neurologic monitoring Post-operative paralysis or sensory loss - direct injury to spinal cord - during instrumentation - excessive traction during distraction - compromised perfusion of spinal cord www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com


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