Surgical Morbidity and Mortality Pediatric Spine Surgery. Masahiro Nonaka Kansai Medical University

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1 Surgical Morbidity and Mortality Pediatric Spine Surgery Masahiro Nonaka Kansai Medical University

2 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

3 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

4 Case Report tethered cord with scoliosis 38 y.o. female History: background 0Y: myelomeningocele repair, VPS 20y: shunt malfunction VPS revision 30y:Neurogenic bladder ileocystoplasty 31y:limbic pain+low back pain

5 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

6 Effect of untethering surgery Result of surgery for TCS following repair of a myelomeningocele: pain Lower extremity 100% improvement muscle strength 70% improvement Urological scoliosis 64% improvement on postop bladder evaluation 52% postop progression Bowman et al. J Neurosurg Pediatr. 2009

7 Case Report tethered cord with scoliosis Pre op T2 sagittal view showing tethered cord, and 3D CT showing scoliosis

8 Untethering was performed for improvement of pain Conus of spinal cord was detached No duraplasty Case Report tethered cord with scoliosis

9 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.

10 Case Report tethered cord with scoliosis Pre 1 st op 4d after 1 st op 1 year after 1 st op Retethering

11 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)

12 Case Report tethered cord with scoliosis 3D CT-MRI fusion image Pre-surgical planning was performed based on 3D fusion image. In order to relieve stretched cord, adhesions in the sacral portion must be detatched.

13 We decided to undergo 2 nd surgery 15 mos after 1 st surgery Thick arachnoid adhesion was observed No duraplasty Case Report tethered cord with scoliosis

14 Case Report tethered cord with scoliosis Postoperatively, her pain relieved. However, her pain worsened 6 months after 2 nd surgery Before 2 nd op 1w after 2 nd op

15 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

16 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

17 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

18 Assessment and Analysis What we can do for intractable pain Lessons from failed back surgery

19 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.

20 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

21 Spinal cord stimulation: Is this the right answer?

22 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

23 3 rd operation 5 years after 2 nd untethering Implantation of spinal cord stimulation device Percutaneous placement was unsuccessful Electrode was placed directly by open surgery

24 VAS (visual analogue scale) score Strength of pain before 1st op 1m after 1st op 6m after 1st op 1y after 1st op 1m after 2nd op 6m after 2nd op before SCS after SCS

25 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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