Posterior spinal fusion - Revision history

Bsumida1 at 10:03, 24 May 2025

2025-05-24T10:03:20Z

← Older revision		Revision as of 03:03, 24 May 2025
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	\| airway = ETT		\| airway = ETT
	\| lines_access = Large bore IV (bolus/resuscitation), 2nd PIV (infusions), A-line		\| lines_access = Large bore IV (bolus/resuscitation), 2nd PIV (infusions), A-line
	\| monitors = Standard, neuromuscular monitoring (e.g. ~~SSEV~~)		\| monitors = Standard ASA, neuromuscular monitoring (e.g. SSEP)
	\| considerations_preoperative = Starting Hb, pulmonary function (restrictive physiology)		\| considerations_preoperative = Starting Hb, pulmonary function (restrictive physiology)
	\| considerations_intraoperative = Nerve injury, significant blood loss, controlled hypotension		\| considerations_intraoperative = Nerve injury, significant blood loss, controlled hypotension
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	}}		}}

	'''Posterior spinal fusion''' is an orthopedic procedure performed to correct idiopathic scoliosis. It is the most common treatment for idiopathic scoliosis. The surgery involves placement of implants (an array of hooks, screws, and wires) which are attached to disc segments and tightened to straighten the spine. Bone grafts are placed between vertebrae and encourage spine fusion.		'''Posterior spinal fusion (discussed primarily in the pediatric context)''' is an orthopedic procedure performed to correct idiopathic scoliosis. It is the most common treatment for idiopathic scoliosis. The surgery involves placement of implants (an array of hooks, screws, and wires) which are attached to disc segments and tightened to straighten the spine. Bone grafts are placed between vertebrae and encourage spine fusion.

	== Overview ==		== Overview ==
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	A MAC of 0.5 for inhalational agents is used to prevent interference with intra-op neuro monitoring. Iso-nitrous is often used with these procedures but sevo and iso at low MAC is still appropriate. A mix of gas and an IV Propofol infusion can lower the MAC needed to maintain general anesthesia.		A MAC of 0.5 for inhalational agents is used to prevent interference with intra-op neuro monitoring. Iso-nitrous is often used with these procedures but sevo and iso at low MAC is still appropriate. A mix of gas and an IV Propofol infusion can lower the MAC needed to maintain general anesthesia.

	Administering ketamine may be considered to improve ~~SSEV~~ signals.		Administering ketamine may be considered to improve SSEP signals.

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

Bsumida1 at 22:44, 6 April 2023

2023-04-06T22:44:25Z

← Older revision		Revision as of 15:44, 6 April 2023
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	=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

	# Evoked potentials (~~SSEV~~) are followed by a technologist.		# Evoked potentials (SSEP) are followed by a technologist.
	# Continuous arterial line blood pressure is monitored to ensure precise blood pressure control.		# Continuous arterial line blood pressure is monitored to ensure precise blood pressure control.
	# ABGs prn		# ABGs prn

Bsumida1 at 16:45, 10 July 2022

2022-07-10T16:45:14Z

← Older revision		Revision as of 09:45, 10 July 2022
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	}}		}}

	Posterior spinal fusion is an orthopedic procedure performed to correct idiopathic scoliosis. It is the most common treatment for idiopathic scoliosis. The surgery involves placement of implants (an array of hooks, screws, and wires) which are attached to disc segments and tightened to straighten the spine.		'''Posterior spinal fusion''' is an orthopedic procedure performed to correct idiopathic scoliosis. It is the most common treatment for idiopathic scoliosis. The surgery involves placement of implants (an array of hooks, screws, and wires) which are attached to disc segments and tightened to straighten the spine. Bone grafts are placed between vertebrae and encourage spine fusion.

	== Overview ==		== Overview ==
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	# Standard monitors/equipment including temperature probe/bear hugger (important given prolonged exposure		# Standard monitors/equipment including temperature probe/bear hugger (important given prolonged exposure
	# Ancillary equipment: Cell-saver, neuromuscular monitors		# Ancillary equipment: Cell-saver, neuromuscular monitors
			#Tranexamic acid infusion for bleeding, blood pressure agents (norepinephrine infusion for hypotension, nitroglycerin infusion for hypertension)

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
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	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
	Consider slowly starting to wean the Propofol infusion when the surgeons begin with deep dermal suturing. This will help with faster emergence. Wean the gas when ~~finished~~ skin closure is finished and the patient is flipped back to supine positioning.		Consider slowly starting to wean the Propofol infusion when the surgeons begin with deep dermal suturing. This will help with faster emergence. Wean the gas when skin closure is finished and the patient is flipped back to supine positioning.

	Consider extubating in the OR to perform a neuro exam prior to leaving for the PACU.		Consider extubating in the OR to perform a neuro exam prior to leaving for the PACU.

Bsumida1 at 16:41, 10 July 2022

2022-07-10T16:41:35Z

← Older revision		Revision as of 09:41, 10 July 2022
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type =		\| anesthesia_type = General
	\| airway =		\| airway = ETT
	\| lines_access =		\| lines_access = Large bore IV (bolus/resuscitation), 2nd PIV (infusions), A-line
	\| monitors =		\| monitors = Standard, neuromuscular monitoring (e.g. SSEV)
	\| considerations_preoperative =		\| considerations_preoperative = Starting Hb, pulmonary function (restrictive physiology)
	\| considerations_intraoperative =		\| considerations_intraoperative = Nerve injury, significant blood loss, controlled hypotension
	\| considerations_postoperative =		\| considerations_postoperative = Nerve injury, pain control
	}}		}}

Bsumida1 at 16:38, 10 July 2022

2022-07-10T16:38:50Z

← Older revision		Revision as of 09:38, 10 July 2022
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	}}		}}

	Posterior spinal fusion is an orthopedic procedure performed to correct idiopathic scoliosis. It is the most common treatment for idiopathic scoliosis. ~~Involved are the~~ placement of implants (an array of hooks, screws, and wires) which are attached to ~~affected~~ segments of spine.		Posterior spinal fusion is an orthopedic procedure performed to correct idiopathic scoliosis. It is the most common treatment for idiopathic scoliosis. The surgery involves placement of implants (an array of hooks, screws, and wires) which are attached to disc segments and tightened to straighten the spine.

	== Overview ==		== Overview ==

	=== Indications ===		=== Indications ===
	Generally indicated for severe scoliosis (Cobb angle >50 degrees).		Generally indicated for severe scoliosis (Cobb angle >50 degrees). Even after skeletal maturity, such severe Cobb angles can progress to extreme curvature of up to 80 degrees.

			Such severe deviation of spine curvature can lead to chronic back pain and decreased pulmonary function (akin to restrictive lung physiology).

	=== Procedure ===		=== Procedure ===
	Patients are initially supine for intubation, line placement, and monitors. Once complete, they are flipping to the prone position. A large midline incision is made cutting through the back muscles to expose the spine. The surgeon will clear the tissue from the spine in order to create a surface for hardware placement. Controlled hypotension (MAPs no greater than the 70s, sometimes lower) limits bleeding during this part of the procedure.		Patients are initially supine for intubation, line placement, and monitors. Once complete, they are flipping to the prone position. A large midline incision is made cutting through the back muscles to expose the spine. The surgeon will clear the tissue from the spine in order to create a surface for hardware placement and graft bone. Bone grafts are used between vertebrae to stimulate growth and ultimately spinal fusion. Controlled hypotension (MAPs no greater than the 70s, sometimes lower) limits bleeding during this part of the procedure.

	~~Then, tightening~~ of the wire implants stretches/distracts the spine~~, straightening it~~ into midline position. It is important to maintain ''normotension'' once this begins in order to perfuse the spinal cord during distraction (which inevitably causes stretching of the nerves/nerve damage). Close neuromuscular monitoring by a technician allows surgeons to detect this early and stop manipulation. Steroids may be given if concern for nerve injury.		Tightening of the wire implants stretches/distracts the spine into midline position. It is important to maintain ''normotension'' once this begins in order to perfuse the spinal cord during distraction (which inevitably causes stretching of the nerves/nerve damage). Close neuromuscular monitoring by a technician allows surgeons to detect this early and stop manipulation. Steroids may be given if concern for nerve injury.

	If the spine remains off center from the pelvis, a pelvic fixation may also be performed.		If the spine remains off center from the pelvis, a pelvic fixation may also be performed.
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	=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
	ABG monitoring if ~~observing~~ significant blood loss. ~~Should~~ generally include lytes and iCa.		A pre-op Hb as well as Type and Screen should be drawn pre-procedure. ABG monitoring can be performed if significant blood loss is observed. ABGs should generally include lytes and iCa.

	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
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	=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
	~~Prone~~.		Patient is prone during hardware placement and flipped to supine after skin closure is complete.

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
			''Bleeding''

			Generally, a bolus of tranexamic acid followed by a continuous tranexamic infusion is started to limit excessive blood loss.

			''Maintenance of anesthesia''

	A MAC of 0.5 for inhalational agents is used to prevent interference with intra-op neuro monitoring. Iso-nitrous is often used with these procedures but sevo and iso at low MAC is still appropriate. A mix of gas and an IV Propofol infusion can lower the MAC needed to maintain general anesthesia.		A MAC of 0.5 for inhalational agents is used to prevent interference with intra-op neuro monitoring. Iso-nitrous is often used with these procedures but sevo and iso at low MAC is still appropriate. A mix of gas and an IV Propofol infusion can lower the MAC needed to maintain general anesthesia.

	~~Ketamine~~ may be considered to improve SSEV.		Administering ketamine may be considered to improve SSEV signals.

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
	Consider slowly starting to wean the Propofol infusion when surgeons begin ~~throwing their~~ deep dermal ~~sutures which~~ will help with faster emergence. Wean the gas when finished ~~with~~ skin and the ~~patients~~ is flipped back to supine positioning.		Consider slowly starting to wean the Propofol infusion when the surgeons begin with deep dermal suturing. This will help with faster emergence. Wean the gas when finished skin closure is finished and the patient is flipped back to supine positioning.

	Consider extubating in the OR to perform a neuro exam prior to leaving for the PACU.		Consider extubating in the OR to perform a neuro exam prior to leaving for the PACU.
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	=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
	~~Admitted~~ to inpatient		Admit to inpatient.

	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
	Ketamine and opiate PCA. Valium prn.		Ketamine gtt and opiate PCA. Valium prn.

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
	Nerve injury. Significant blood loss.		Nerve injury from spine distraction. Significant blood loss leading to hypovolemic shock and increasing risk for spinal cord ischemia/damage.

	== References ==		== References ==

			# Peterson LE, Nachemson AL. Prediction of progression of the curve in girls who have adolescent idiopathic scoliosis of moderate severity. Logistic regression analysis based on data from The Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am 1995; 77:823.
			# Weinstein SL. Adolescent idiopathic scoliosis: prevalence and natural history. Instr Course Lect 1989; 38:115.
			# Weinstein SL, Ponseti IV. Curve progression in idiopathic scoliosis. J Bone Joint Surg Am 1983; 65:447.
			# Lonstein JE. Adolescent idiopathic scoliosis. Lancet 1994; 344:1407.
			# Ascani E, Bartolozzi P, Logroscino CA, et al. Natural history of untreated idiopathic scoliosis after skeletal maturity. Spine (Phila Pa 1976) 1986; 11:784.
			# Sponseller PD. Bone, joint, and muscle problems. In: Oski's Pediatrics: Principles and Practice, 4th ed, McMillan JA, Feigin RD, DeAngelis CD, Jones MD Jr (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.2488.
			# Winter RB, Lovell WW, Moe JH. Excessive thoracic lordosis and loss of pulmonary function in patients with idiopathic scoliosis. J Bone Joint Surg Am 1975; 57:972.
			# Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am 1999; 30:353.
			# Newton PO, Wenger DR, Yaszay B. Idiopathic scoliosis. In: Lovell and Winter's Pediatric Orthopaedics, 7th ed, Weinstein SL, Flynn JM (Eds), Lippincott Williams & Wilkins, Philadelphia 2014. p.629.
			# Stasikelis PJ, Pugh LI, Allen BL Jr. Surgical corrections in scoliosis: a meta-analysis. J Pediatr Orthop B 1998; 7:111.
			# Sarwark JF. Idiopathic scoliosis: New instrumentation for surgical management. J Am Acad Orthop Surg 1994; 2:67.
			# Geck MJ, Rinella A, Hawthorne D, et al. Comparison of surgical treatment in Lenke 5C adolescent idiopathic scoliosis: anterior dual rod versus posterior pedicle fixation surgery: a comparison of two practices. Spine (Phila Pa 1976) 2009; 34:1942.
			# Newton PO. Thoracoscopic anterior instrumentation for idiopathic scoliosis. Spine J 2009; 9:595.
			# McNicol ED, Tzortzopoulou A, Schumann R, et al. Antifibrinolytic agents for reducing blood loss in scoliosis surgery in children. Cochrane Database Syst Rev 2016; 9:CD006883.
			# Goobie SM, Zurakowski D, Glotzbecker MP, et al. Tranexamic Acid Is Efficacious at Decreasing the Rate of Blood Loss in Adolescent Scoliosis Surgery: A Randomized Placebo-Controlled Trial. J Bone Joint Surg Am 2018; 100:2024.
			# Reames DL, Smith JS, Fu KM, et al. Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality database. Spine (Phila Pa 1976) 2011; 36:1484.

	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]

Bsumida1 at 16:16, 10 July 2022

2022-07-10T16:16:04Z

Show changes

Bsumida1: Created page with "{{Infobox surgical procedure | anesthesia_type = | airway = | lines_access = | monitors = | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }} Posterior spinal fusion is an orthopedic procedure performed to correct idiopathic scoliosis. It is the most common treatment for idiopathic scoliosis. It involves implants (an array of hooks, screws, and wires) being attached to segments of spine. Harrington rods were the o..."

2022-07-10T15:10:40Z

Created page with "{{Infobox surgical procedure | anesthesia_type = | airway = | lines_access = | monitors = | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }} Posterior spinal fusion is an orthopedic procedure performed to correct idiopathic scoliosis. It is the most common treatment for idiopathic scoliosis. It involves implants (an array of hooks, screws, and wires) being attached to segments of spine. Harrington rods were the o..."

New page

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Posterior spinal fusion is an orthopedic procedure performed to correct idiopathic scoliosis. It is the most common treatment for idiopathic scoliosis. It involves implants (an array of hooks, screws, and wires) being attached to segments of spine. Harrington rods were the original method but are no longer current as segmental implants allow surgeons more control and early mobilization without the need for bracing.

== Overview ==

=== Indications ===
Generally indicated for severe scoliosis (Cobb angle >50 degrees).

=== Procedure ===

=== Other Interventions ===
Anterior spinal fusion is another surgical method that comparatively has less blood loss and risk of neurologic injury. Advantages of posterior spinal fusion over anterior spinal fusion include avoidance of entering the thoracic cavity and potentially impairing pulmonary function.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
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|-
|Neurologic
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|-
|Cardiovascular
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|-
|Pulmonary
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|-
|Gastrointestinal
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|-
|Hematologic
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|-
|Renal
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|-
|Endocrine
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|-
|Other
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|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]