Surgical Morbidity and Mortality Pediatric Spine Surgery Masahiro Nonaka Kansai Medical University • • Postoperative complication of pediatric spine surgery This graph shows Incidence of complications by diagnosis This data is based on 23,918 pediatric spine surgery cases that were reported from 2004 to 2007 in North America http://www.healio.com/orthopedics/pediatrics/news/print/orthopedics-today Case Report Tethered cord with scoliosis • Diagnosis: symptomatic tethered cord (Symptom: limbic and low back pain) • Operation: untethering of tethered cord • Adverse outcome: worsening of limbic and low back pain half year after surgery Case Report tethered cord with scoliosis background • 38 y.o. female • History: – 0Y: myelomeningocele repair , VPS – 20y: shunt malfunction→VPS revision – 30y:Neurogenic bladder → ileocystoplasty – 31y:limbic pain+low back pain Incidence of symptoms in patients who had MMC repair • 10 to 30% of children will develop symptomatic tethered cord syndrome following repair of a myelomeningocele • Their symptoms include increased weakness (55%), worsening gait (54%), scoliosis (51%), pain (32%), orthopedic deformity (11%), urological dysfunction (6%) Hudgins et al. Neurosurg Focus. 2004 Effect of untethering surgery Result of surgery for TCS following repair of a myelomeningocele: • pain 100% improvement • Lower extremity muscle strength 70% improvement • Urological 64% improvement on postop bladder evaluation • scoliosis 52% postop progression Bowman et al. J Neurosurg Pediatr. 2009 Case Report tethered cord with scoliosis Pre op T2 sagittal view showing tethered cord, and 3D CT showing scoliosis Case Report tethered cord with scoliosis • Untethering was performed for improvement of pain • Conus of spinal cord was detached • No duraplasty Case Report tethered cord with scoliosis • Recognition of the complication – 1 month after surgery, she was pain-free. – 6 month later, she came back to hospital complaining her pain came back. • Management of the complication – Loxoprofen(NSAIDs), gabapentine, and carbamazepine was prescribed to control pain. – Drug therapy was effective only temporarily, and her pain got worse. Case Report tethered cord with scoliosis Pre 1st op 4d after 1st op 1 year after 1st op Retethering Case Report tethered cord with scoliosis • What was happening? – Retethering – Failed back surgery(radicular pain/radiculopathy)+arachnoiditis • What is your decision? – Medication(i.e. fentanyl patch) – Blocks – Consult psycologists – Re-Surgery (untethering) Case Report tethered cord with scoliosis Pre-surgical planning was performed based on 3D fusion image. In order to relieve stretched cord, adhesions in the sacral portion must be detatched. 3D CT-MRI fusion image Case Report tethered cord with scoliosis • We decided to undergo 2nd surgery 15 mos after 1st surgery • Thick arachnoid adhesion was observed • No duraplasty Case Report tethered cord with scoliosis • Postoperatively, her pain relieved. • However, her pain worsened 6 months after 2nd surgery Before 2nd op 1w after 2nd op Assessment and Analysis • What happened? – retethering of cord – failed back syndrome + arachnoiditis • Why did it occur? – Human errors • failed to create dorsal subarachnoid space for two times. – Patient related factors • scoliosis, arachnoiditis Assessment and Analysis review of literature effect of scoliosis • Scoliosis was not associated with an increased prevalence of retethering, but was associated with significantly earlier retethering (32.5 vs 61.1 months; p = 0.042) in patients who underwent additional untethering operations. Mehta VA, Spinal cord tethering following myelomeningocele repair ,JNSP 2010 Assessment and Analysis review of literature role of expansive duraplasty • The increased rate of symptomatic retethering observed with complex pediatric TCS (pTCS) etiologies after primary dural closures was not observed when duraplasty was instituted. Expansile duraplasty may be valuable specifically in the management of patient subgroups with complex pTCS etiologie Samuels etal. Incidence of symptomatic retethering after surgical management of pediatric tethered cord syndrome with or without duraplasty. Childs Nerv Syst 2009 Assessment and Analysis What we can do for intractable pain • Lessons from failed back surgery How to manage pain caused by failed back surgery • Medication: – Analgesics acetaminophen – Nonsteroidal anti-inflammatory agents (NSAIDs) aspirin, ibuprofen, naproxen and COX-2 inhibitors. – Muscle relaxants . – Narcotic medications Since use of narcotics entails risk of habituation or addiction if not properly supervised, they are not often used for chronic conditions. – Antidepressants and anticonvulsants - used to treat neuropathic ("nerve") pain. – Neuromodulating medications - used to treat neuropathic and muscular pain. How to manage pain caused by failed back surgery • Injections (also known as blocks) – effective transiently – this procedure is challenging for patients with abnormal anatomy • Radiofrequency radioablation/DREZtomy – effective for 60% – irriversible damage to spinal cord • Surgically implanted electrotherapy devices – effective for 50% – no damage to spinal cord Spinal cord stimulation: Is this the right answer? Spinal cord stimulation • Pain relief by electric stimulation to dorsal column of spinal cord • Electrodes are placed in epidural space electrodes controller and recharger for patients nerve stimulator 3rd operation 5 years after 2nd untethering • • • Implantation of spinal cord stimulation device Percutaneous placement was unsuccessful Electrode was placed directly by open surgery VAS (visual analogue scale) score 10 9 8 7 6 5 4 3 2 1 0 Strength of pain before 1m 6m 1y 1m 6m before after 1st op after after after after after SCS SCS 1st op 1st op 1st op 2nd op 2nd op Assessment and Analysis Recommendation – expansive duraplasty • However, ideal graft for duraplasty (bovine pericardial patch) is not approved in some countries, including Japan (In Japan, fascial graft is commonly used) – Consider another approach to manage pain • Spinal cord stimulation is choice of treatment • Never twice without three times!
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