The Center for Spinal Disorders

VEPTR

Vertical Expandable Prosthetic Titanium Rib (VEPTR)

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.

What is the VEPTR device?

The VEPTR device is a metal rod curved to fit the back of the chest and spine which is placed in an up and down position. It can be expanded as the child grows.
This allows the spine to be straighter and the lungs to grow and fill with enough air to breathe.
The attachments can be attached to the ribs, spine or pelvis.
The device is used to keep the ribs separated and the spine better aligned after the operation.
The device is made of titanium because of its strength and has the ability to stay inside your child without causing a bad reaction.
Your child will still be allowed to have a Magnetic Resonance Imaging (MRI).

What is the purpose of the VEPTR device?

The VEPTR device is for the treatment of Thoracic Insufficiency Syndrome (TIS) in skeletally immature patients. TIS is defined as the lack of ability of the chest to support normal breathing or lung growth, and is considered to be a uncommon condition.

For the purpose of identifying potential TIS Patients, the categories in which TIS patients fall are as follows:

Flail Chest Syndrome
Constrictive Chest Wall Syndrome, including
-Rib fusion and scoliosis
Hypoplastic thorax syndrome, including
-Jeune’s syndrome
-Achondroplasia
-Jarcho-Levin syndrome
-Ellis van Creveld syndrome
Progressive scoliosis of congenital or neurogenic origin without rib anomalies

A child suffers from TIS because the thorax, which is the area made up of the spine, the ribs and the breastbone fails to support normal breathing and lung growth.

If your child’s chest can not grow, his/her lungs cannot grow and life-threatening breathing problems can develop.
Any of the above conditions could cause your child to have trouble breathing. Your child may eventually need a machine that will help his/her breathing (ventilator).
The VEPTR device has been made to give the rib cage and lungs room to grow, in children like yours who suffer from chest wall/spine defects. While your child’s natural ribs run across his/her chest, the VEPTR device is placed up and down to give the chest more space. The device is used to rebuild your child’s chest by making it larger, longer or more normal in shape and size

Checklist prior to Surgery:

Pre op Visit
Anesthesia consult
Primary care doctor/ Pediatrician Clearance
Clearance from other services patient is under the care of (i.e. Pulmonology)
Blood Donation to Red Cross (If you want direct donor blood)
Pulmonary Function Tests
Lab work

Preparing your Home:

You cannot sleep on a waterbed or on a mattress on the floor
Clearing a track for a wheelchair, if necessary

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 and wheeled walker.

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. (Approximately 6 am)
The patient may not have anything to eat or drink after Midnight or as instructed by same day surgery phone nurse
Please shower thoroughly shampooing your hair the night prior to surgery
During shower Hibiclens must be used on back 3 consecutive days prior to surgery
Please remove any nail polish, and be sure your nail beds are clean for surgery.

Please let surgeon and anesthesiologist 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.

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

Dr. Luhmann: will see you at the preoperative visit. He does not typically see patients the morning of 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.

Parents will be called approximately every 1 to 1 ½ hours during surgery to be notified of progress.
Dr. Luhmann will speak to you after surgery is complete.

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 function of muscle and sensation. There may be a time during surgery that we will ask you to move parts of your body. You will not fully be awake. You will have pain medication that will keep you comfortable.

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(s) will be covered with steri strips and a back dressing.

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 back dressing that will remain intact until taken off by the orthopedic resident physician.

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.

It is important for the patient to use the incentive spirometer to encourage pulmonary (lung) function. 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 may 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 very small needle.

Surgical Floor/ 10^th Floor:

The typical stay for a patient in the hospital is 3-5 days. Patients are typically transferred to the 10^th floor which is the main 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 the doctor. For the patient to be up out of bed the patient will need sit in the bedside chair, wheelchair or ambulate in the hall.

Pain medication is adjusted per the Pain Service.

It is important for patients to use the incentive spirometer, blow bubbles and or pretend to blow out candles on a birthday cake. The bedside nurse will be able to assist with this. These are all ways to help expand the lungs. Some patients will require respiratory therapy.

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

The Foley catheter is typically removed after the procedure. 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. Please let the nurses know if you are experiencing nausea because a medication such as Zofran can be given to help alleviate symptoms. 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. On the fifth day you will be given a suppository to assist you in having a bowel movement.

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

Follow up in 1-2 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.

2 weeks after surgery -The patient may shower, bath or swim in a chlorinated or salt water pool. NO swimming in natural body of water for 6 weeks.

Please note that the patient may not have body piercing or tattoos placed until after the 6 week postoperative visit with the doctor.

When to call the doctor