The Center for Spinal Disorders

Neuromuscular Spinal Fusion

Spinal Fusion

The Spine is consisted of 26 bones known as vertebrae (7 cervical, 12 Thoracic, 5 Lumbar, the sacrum and the coccyx). Each vertebra is separated (except the top two in the neck) by a disc. Each disc has a soft jelly like center surrounded by a tough outer layer of fibers known as the annulus. Discs, bony structures ligaments and strong muscles stabilize the spine.

The spinal cord is composed of nerves leading to and from the brain. It controls and transmits all muscle movement and sensation for the trunk, arms and legs. Nerve roots come from the spinal cord and carry electrical impulses to and from muscles, organs and other structures. These nerve roots can become pinched or irritated by abnormal conditions.

Types of Spinal Fusions:

Posterior Spinal Fusion

The incision is down the middle of your back. The length depends on the number of vertebrae needing to be fused.
The majority of spinal fusion incisions made by Dr. Luhmann are completed this way.

Anterior Fusion

The incision will be on your side near your rib cage.

Anterior/posterior Fusions

The incisions will be both on your back and on your side.

Checklist prior to Surgery:

Pre-op Visit: date________________________
Anesthesia consult
This is typically coordinated with the pre-op visit
Primary care doctor/ Pediatrician Clearance
Clearance from other services seen
Blood Donation to Red Cross (If you want direct donor blood)
Pulmonary Function Tests if able to perform
Lab work

Preparing your Home:

You cannot sleep on a waterbed or on a mattress on the floor
clearing a track for a wheelchair

Planning for Discharge needs:

You may need equipment at home after surgery. The doctor, nurse, and physical therapist will review each child’s individual needs after surgery to decide what equipment will be needed.

Common equipment needs include: wheelchair, bedside commode, hospital bed, shower seat, hoyer lift and wheeled walker.

This will be ordered after surgery by the orthopedic home coordinating nursees.

Common Questions:

What do I need to bring to the hospital? You may bring:

Current List of Medications, dosages and frequency
T-shirt/undershirt for under brace, if necessary
Robe
Slippers
Personal Items of comfort (blanket, stuffed animal, books, movies)
Toiletry items you feel you will need during your stay
Comfortable clothes for day of going home

Can my mom, dad or caregiver stay at the bedside?

In the Pediatric Intensive Care Unit (PICU) two people can visit at a time, but they can not sleep in the room with the patient.
Parents can sleep in the PICU lounge.
On the Floor- One parent can sleep at the bedside. The other parent can sleep in the parent lounge. Typically there is not a roommate. If there is not a roommate… both parents are welcome to stay the night.

What do we do the night before surgery?

If you live far…you may want to stay at a local hotel because you will be required to be here early. (about 6 am)
The patient may not have anything to eat or drink after Midnight
Please shower thoroughly shampooing your hair the night prior to surgery and be sure to use the Hibiclens back wash for the last night
Please remove any nail polish, and be sure your nail beds are clean for surgery.

Please let surgeon know all Medications!

STOP!!!

ASPIRIN products and BLOOD THINNERS (Coumadin, Persantine) need to be stopped 1-2 weeks prior to surgery.

Stop all NON-STEROIDAL ANTI_INFLAMMATORY medications/arthritis medicines (such as Advil, Aleve, Ibuprofen, Motrin, Clinoril, Indocin, Daypro, Naprosyn, Celebrex, Vioxx, etc.) one week before surgery. Tylenol products are suggested for pain.

Some antidepressants will need to be stopped a few days to 1 week prior to surgery.

Some medications such as Insulin and Prednisone have specific instructions that may need to adjust prior to surgery.

Anesthesia staff will let you know what medications, if any you should take the morning of surgery.

Patients with pacemakers will need to check with their cardiologists to see if the pacemaker settings need to be reset 1-2 days prior to surgery. The electrical currents in the operating room could alter pacemaker rhythm if the settings are not adjusted.

STOP SMOKING in the household… it decreases healing time! Dr. Luhmann usually does not do spine fusion if you smoke or use smokeless tobacco.

Walking Through the Surgery Steps…

Pre Op care: Patients are given a prescription and asked to bath/shower with Hibiclens solutions for the 3 consecutive days prior to surgery.

You will receive a call if your child tests positive for Staph Auerus, and if this is the case you will be required to place Bactroban in the nasal passage twice a day for 5 days prior to surgery.

Dr. Luhmann: will see you at the preoperative visit. He does not typically see patients prior to surgery. If there are any questions or concerns prior to surgery, please call Debbie or Kim before the day of surgery.

Same Day Surgery:

The 6^th Floor Same Day Surgery Unit is where you and your family will begin your journey. The day of surgery you will be able to meet with the, anesthesiologist, child life therapist and nurses. Your weight, height and vitals signs will be obtained. You may be given medication prior to surgery by the nurse.

Operating Room:

You will be able to pick a flavor for the mask that will help us put you to sleep. Most likely while you are a sleep, we will place an IV (intravenous catheter), Foley catheter (bladder) and NG (nasal gastric tube) if needed.

Your back and or abdomen/chest will be cleaned prior to surgery with special soap. Gel pads and pillows will be used to have you placed in a comfortable position for surgery.

We will have special electrodes placed on your body to check for neuro/sensory movement. This decision for spinal cord monitoring is personalized to each child and reached by Dr. Luhmann.

Post Anesthesia Care Unit (PACU):

We will wake you up when the surgery is complete. You will then be wheeled in a bed to the PACU. When you are awake, we will be able to call your parent(s) or caregiver to be with you. In the PACU, you will be closely monitored by the doctors and nurses.

Pain Control You will have a Patient Controlled Anesthesia (PCA). This is controlled by the Pain Service Team. The pain service team is a special team of doctors (anesthesiologists) and nurses who are trained in monitoring your post operative pain. If the patient is able to comprehend, the patient will be able to press the button for pain medication. The patient may also be delivered medication continuously through the PCA.

The back incision will be covered with steri strips, a bulky back dressing, and one or more Hemovac(s), wound drains, may be present. You will be asked to lay flat for 6 hours.

Pediatric Intensive Care Unit/PICU:

Patients will typically stay at least one night in the PICU. The PICU is set up to allow close patient monitored care. The nurses in the PICU will have 1-2 patients at a time depending on the acuity.

Parents are allowed to visit, but they are not allowed to sleep in the PICU. There is a parent lounge with lockers to hold personal items and chairs that pull out for sleep.

Patients will be turned approximately every 2 hours while in the hospital. Patients will be turned using the log roll method. The nurses and physical therapists will go over with the family how to turn the patient properly. The physical therapist will be available to get the patient out of bed for the first time the morning after surgery. Some patients may have to wait until the brace is available.

Patients will have a bulky back dressing that will remain intact until taken off by the orthopedic resident physician on day 4. Patients may have one or more Hemovac(s). A Hemovac helps to drain out access blood under the incision. The Hemovac is typically emptied every four hours.

Pain medication will be delivered through the PCA until the pain service has made a decision to change to oral medications. Typically the patient needs to be drinking, eating, and tolerating a diet for this to occur.

Generally after surgery the patient will only be allowed ice chips until return of bowel function.

Patients will also be receiving Intravenous Fluids (IV fluids). Some patients may require additional nutritional supplementation of TPN and Intralipids this decision will be made by Dr. Luhmann.

Patients will then require a larger IV access. A central line will be placed in the operating room.

It is important for the patient to use the incentive spirometer to encourage pulmonary toilet. The patients can also do things like blow bubbles or pretend to blow out candles of a birthday cake. The patient with a history of asthma, CP, or neuromuscular issues may have respiratory therapy involved with either breathing treatments and or continuous pulmonary toileting CPT (every four hours).

For girls, typically surgery can change ones cycle. It is not out of the ordinary for one to have their menstrual cycle after surgery.

Lab work will be obtained for at least the first three days after surgery. The nurse or lab technician will be taking blood by sticking the patient’s finger or by a venous stick with a small butterfly needle.

Surgical Floor/ 10^th Floor:

The typical stay for a patient in the hospital is 7-10 days. Patients are typically transferred to the 10^th floor which is home to the orthopedic patient. This is a 30 bed unit with both single and double rooms. You may have a roommate.

The 10^th floor has a parent lounge and small kitchen with a refrigerator and microwave.

Patients are turned every two hours. Patients need to be up out of bed two to three times a day. Some patients may require a brace this is decided upon by Dr. Luhmann. The patient will need to be up out of bed the patient sit in the bedside chair or wheelchair several times a day when the brace is available.

Pain medication is adjusted per the Pain Service.

Respiratory therapy is involved with most neuromuscular patients. They typically see patients every four hours. Respiratory therapy is involved to increase pulmonary toileting and decrease the risk of pneumonia.

Patients will have a bulky back dressing that will remain intact until taken off by the resident physician on day 4. The Steri-Strips on the back should remain intact until they fall off. Do not pull them off.

The Foley catheter is typically removed day 4. If patient is stool/urine incontinent the lower 1/3 of the back incision will be covered with a dressing. This will be changed per nursing staff every shift as needed.

Diet - Patients may experience some difficulty with nausea and bloating. It is important to take it slow with food. When you have signs of bowel sounds, we can progress from ice chips. We will first start you off with clear liquids and then progress to food.

Patients requiring tube feedings are evaluated and slowly progressed based on how the patient’s stomach “wakes up.”

Patients tend to burn a large amount of calories. Patients are evaluated routinely by nutritional services.

You will be given a stool softener twice a day after you are eating. The stool softener helps moves things along! The pain medication that you will be taking can lead to constipation.

It is important to drink plenty and encourage fluids when the child is able to drink.

On the fifth day you will be given a suppository to assist you in having a bowel movement.

Patients will be required to wear a TLSO thigh cuff brace for up to four months after surgery. The patient will only be able be elevated to a 30 degrees position. Below are pictures of one of our patients in a TLSO thigh cuff brace.

Rehabilitation

Some patients may require an extended stay for physical therapy.

The typical stay for a patient in the hospital is 7-10 days.

Patients are ready to go home when pain is well under control, tolerating a diet, and cleared from physical therapy.

Follow up in 6 weeks after surgery. You can call Debbie when you are at home after surgery.

Try to plan going home with medication timing. The outpatient pharmacy is located on the first floor near the information desk. The ride in the car can often be bumpy! Bring your pink bucket home just in case you get sick to your stomach.

Going home can sometimes be a struggle as to find the best seat in the car or van. The front seat of a car tilted all the way back or the back row seat can be the two most comfortable.

The patient needs to remain in the BRACE!!!!!!!!!!!!

2 weeks after surgery -The patient may shower with the shower brace.

Please note that the patient may not have body piercing or tattoos placed until 4 weeks after surgery.

When to call the doctor