Surgical Morbidity and Mortality
Pediatric Spine Surgery
Masahiro Nonaka
Kansai Medical University
Postoperative complication of
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
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
• 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
• 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
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
Case Report
tethered cord with scoliosis
• What was happening?
– Retethering
– Failed back surgery(radicular
• 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
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
• 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
Spinal cord stimulation
• Pain relief by electric
stimulation to dorsal
column of spinal cord
• Electrodes are placed
in epidural space
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
Strength of pain
before 1m
6m before after
1st op after after after after after SCS
1st op 1st op 1st op 2nd op 2nd op
Assessment and Analysis
– 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
• Never twice without three times!