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Scoliosis

Scoliosis. Pathology Assessment Anaesthesia Maintenance Monitoring Post-operative care Analgesia. Scoliosis. Classification. Congenital. Vertebral anomalies Spina Bifida Syndromic. Ito’s Riley Day/ Shy Drager VATERs. Retts Neurofibromatosis Marfans Prader-Wili

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Scoliosis

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  1. Scoliosis Pathology Assessment Anaesthesia Maintenance Monitoring Post-operative care Analgesia

  2. Scoliosis Classification Congenital Vertebral anomalies Spina Bifida Syndromic Ito’s Riley Day/ Shy Drager VATERs Retts Neurofibromatosis Marfans Prader-Wili Mucopolycaccharidoses

  3. Scoliosis Classification Neuromuscular Muscular dystrophies Duchennes Spinal Muscular Atrophy Cerebral palsy Spina Bifida Polio Spinal cord injury

  4. Scoliosis Classification Idiopathic

  5. Scoliosis Treatment Non-progressive curve <25-30o Watch and wait 25-40o curve and skeletal immaturity Bracing >40o or rapidly progressing Surgery

  6. Scoliosis Why operate? Curves >40o will worsen Pain Cardiorespiratory dysfunction Cor Pulmonale Paraparesis Cosmetic disfigurement

  7. Female age 16 No previous hospitalisation Fit Gymnast 60Kg Male age 16 Cerebral palsy, blind, deaf Poorly controlled epilepsy Poor nutrition Recurrent chest infections Poor dentition Uncooperative 34 Kg Female age 12 Neurofibromatosis 4 previous spinal/neurosurgical operations Paraparetic, one functioning diaphragm Tracheal compression from tumour Macroglossia from tumour Lung function 20% predicted Exertional dyspnoea 25 Kg

  8. Assessment Are they fit ? If Not... Is there anything that could be improved ? Are the risks appropriate ? Is there anything we don’t know about ? Is there anything that will cause difficulties ?

  9. Respiratory function All have a restrictive defect Curves < 600 rarely have significant respiratory impairment Curves of 750 have 75% of normal forced vital capacity Significant impairment with curves > 1000 FVC < 40% risk of developing chronic respiratory failure Muscular dystrophies Paralytic conditions Secretion clearance

  10. Respiratory function Measure…… FVC Peak flow flow/volume loops SpO2 Sleep studies Oximetry TcCO2 & TcO2 ECG Rarely blood gasses History of….. Recurrent chest infections ‘Wheeze’ Dyspnoea Disturbed sleep Early morning headaches Poor function at school Enuresis

  11. Cardiac function History of….. Cardiac surgery Syndrome associated with cardiac abnormalities Dyspnoea Poor nutrition Measure…… ECG Echocardiography

  12. Surgery Usually two stage procedure:… Anterior release +/- fusion Lateral approach. Diaphragm splitting thoracoabdominal incision 3-5 hours 200mls-4000 mls blood loss Posterior fusion Posterior approach 3-6 hours 1000-5000 mls blood loss Rarely single stage anterior surgery or posterior surgery Rarely both stages at once

  13. The Anaesthesia Requirements…. Anaesthesia Analgesia Suitable for spinal cord monitoring Warmth and comfort Prepared for massive blood loss Post operative analgesia

  14. Spinal cord monitoring SomatoSensory Evoked Potentials Peripheral electrical stimulation Central averaging of signals from Electrodes over cortex Electrodes over C2 Electrode in epidural space placed surgically or by anaesthetist Motor Evoked Potentials Central stimulation of motor tracts by Transcranial electrical stimulation Transcranial magnetic stimulation Electrode in epidural space Peripheral sensing of EMG Wake up test

  15. Spinal Cord Monitoring SSEP’s Affected by Inhalational agents Epidural local anaesthetics MEP’s Affected by Inhalational agents Nitrous oxide Muscle relaxants Epidural local anaesthetics

  16. Anaesthesia Induction Propofol / gaseous Intubating dose of muscle relaxant Maintenance Inhalational + Opiates Propofol TCI + Opiates

  17. Anaesthesia Arterial line Wide bore I.V. Access (13g) X2 Central venous access Temperature probe Warming blanket Fluid warmer Rapid transfusion device Autologous cell saver Epidural Epidural monitoring electrode No epidural local anaesthetics Epidural opiates Epidural clonidine

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