Download Supporting Children with Neuromuscular Spinal Deformity Needing

Supporting Children with Neuromuscular Spinal Deformity Needing
Scoliosis Surgery: a Team Approach
Presenter:
Mohan Belthur MD, FRCS (Tr & Orth) , FRCS(C) - Attending Pediatric Orthopedic Surgeon,
Clinical Assistant Professor in Pediatrics & Orthopedics, Phoenix Children's Hospital, University
of Arizona College of Medicine - Phoenix
OUTLINE:
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Introduction
Prevalence
Risk Factors
Natural History and impact on function
Treatment
Outcomes
Complications
Case Presentation
Introduction:
Cerebral palsy is a disorder of movement and posture secondary to a static encephalopathy
affecting the immature brain.
Incidence: 2-3/1000 live births
Causes: Pre, peri and postnatal causes
Co-morbidities:
It may be associated with a number of comorbidities depending on the extent of the brain lesion .
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CNS – seizure disorder, abnormal tone, poor cognition, learning disabilities, attention &
communication issues
Vision, Hearing & dental - impairment
RS – Reactive / restrictive pulmonary disease, sleep apnea
GI – GERD, dysphagia, G tube, constipation, drooling
Nutrition – poor
GU – Incontinence, UTI, voiding dysfunction
MSK – contractures, deformities, decreased ambulation, osteoporosis
Psychiatry – behavioral issues, sleep
Pain – MSK, GI causes, dental, GU
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Surgery in children with CP: national utilization rates
Children with cerebral palsy may need a number of inpatient admissions for surgery. The top
five surgeries they have during their life time are as follows:
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Gastrostomy
Musculoskeletal soft tissue surgery
Fundoplication
Scoliosis surgery
Bony hip surgery
Costs and Complications of Hospitalizations in children with CP
As compared to normally developing children, inpatient admissions in children with cerebral
palsy are more likely to have:
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Longer Hospital stays
Higher total charges
More associated diagnosis
More procedures
Higher complication rates
More likely to be transferred
CP Neuromuscular Scoliosis:
Overall prevalence: 25%
Risk factors: GMFCS 4 &5, increasing age, Spastic diplegia and quadriplegia. Prevalence is
around 50% in children with GMFCS 4& 5 level function by the age of 18 years.
Natural History of untreated NM scoliosis:
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Slow Progression initially
Once curve is > 50 degrees will rapidly progress with pelvic obliquity
Difficulty with sitting and loss of upper extremity function
Increased risk of ischial decubiti
Increased risk of costo-pelvic impingement and pain
Progression of restrictive lung disease
Treatment of NM scoliosis – nonsurgical options:
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Better tone management
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Maintaining ambulation / standing
Proper seating and positioning, bracing
Treatment of NM scoliosis – surgical options:
.a) Indications for surgery:
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Progressive curve > 50
Loss of sitting balance
Ischial decubiti
Costo-pelvic impingement
Deteriorating Pulmonary function
b) Goals of surgery:
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Prevent progression
Correct safely to restore spinal balance
Facilitate seating & positioning
Pain relief & reduce complications (decubiti, pulmonary)
Improve quality of life
c) Details of surgery:
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Posterior spinal fusion
Posterior spinal instrumentation from T2 to pelvis
Severe, rigid curves (> 100 degrees)
– Anterior spinal release ??
– Anterior spinal fusion ??
Young children
– Fusionless spine surgery
Outcomes of surgery:
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HRQL improved significantly 71 %
CPCHILD score increased from 45 to 58
Change in Pain was the most significant factor affecting QOL changes
Parent satisfaction 92%
Sitting balance improved 93%
Cosmesis improved 94%
Functional improvement limited 8 – 40%
Complications: 30% Overall
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1) Pulmonary: 22 (30%) - pneumonia, pneumothorax, atelectasis, pleural effusion,
prolonged mechanical ventilation and longer stay in intensive care unit (ICU).
2) Hardware related: 12.5 % (implant perforation and penetration, revision of implant for
infection and skin irritation, implant breakage, loosening or cut-out of implant.
3) Infections: 10 .9 %
a. Prevalence: 3 – 15 % vs 0.5% in AIS
b. Risk factors: ASA score >= 2 , Cerebral palsy, GMFCS 4/5, VP shunt, bladder /
bowel incontinence, malnutrition, obesity, hypothermia, prolonged operative time,
blood loss and transfusions, number of levels fused > 10, fixation to pelvis,
implant prominence, implant type – unit rods Vs contoured rods, implant material
– stainless steel Vs Titanium, postop drains reduces risk,
c. Steps to prevent SSI: see above
4) GI: paralytic Ileus (5 % vs 3%), pancreatitis,
5) Wound healing:
6) Bleeding:
7) Neurologic: 3 % (0.5%)
8) UTI: 5 % vs 0.7 %
9) Central lines placed in 6 % vs 1.3 %
10) Pseudarthrosis: 11 %
Review of Literature:
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Does PSF improve quality of life of CP children with NM scoliosis?
Complication rates of PSF for NM scoliosis in CP children.
What measures optimize outcomes of PSF for NMS in CP children?
TEAM Approach to children with childhood disabilities:
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Team: ‘‘a small group of people with complementary skills who are committed to a
common purpose, performance goals, and approach for which they are mutually
accountable.’’
Steps to Optimize care in CP children having surgery for NMScoliosis.
1) Preoperative:
a. Detailed multisystem Evaluation – pulmonary, GI, GU, CNS, dental, CVS
b. Care pathway with a dedicated care coordinator: Matched case comparison study
-reduces LOS, PICU stay and complication rates
c. Preoperative chlorhexidine prep night before and morning of surgery
d. Preoperative urine cultures and treatment if positive
e. Nutritional evaluation & supplementation
f. Preoperative patient education sheet, shared decision making
g. Preoperative nasal decolonization
h. Alteration of seizure medications,
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Optimizing bone health
Treating constipation
Optimizing dental health
Understand communication issues – CFCS classification, assistive technology
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2) Intraoperative:
a. Maintaining optimal pre & intraoperative body temperature (> 36C)
b. Total intravenous Anesthesia (TIVA)
c. Multimodal neural monitoring – SSEPS, MEPS
d. Anti fibrinolytics- TXA
e. Hair clipping preferred to shaving
f. IV antibiotics – (ancef + gram –ve cover, Vancomycin powder in bone graft)
agent, timing, dosing, redosing (every 4 hours)
g. High efficiency teams – select surgeons, anesthetiologists, scrub techs, select
circulating nurses
h. Two surgeons – Shrader MW et al matched case comparison study showed
decreased surgical time, less EBL, LOS, fewer complications
i. Cell saver
j. Reduce traffic in OR / limited access
k. Minimising infections – Irrigation
l. Impervious dressings
m. Closing lower ½ of incision with a nonabsorbale stitch
3) Postoperative:
a. Hospitalist co-management: Reduces variation in outcomes, improves quality but
with increased initial costs.
b. Postoperative IV antibiotics till removal of catheters & drains (day 3)
c. Reducing postop dressing changes
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