Before the surgery it was hard for me to walk or stand for long periods of time. It even hurt to go shopping! After surgery I began feeling so much better. Now I don’t hurt when I run or play. I am able to hike, play sports, swim and do lots of other things without pain!
Meet Maggie. This bright, articulate 12-year-old is active in soccer and swimming, and she loves school and hanging out with her friends. But during the summer of 2013, her mother, Jennifer, noticed that Maggie’s shoulders were uneven. She asked Maggie to reach for her toes and noticed that when she did, the right side of her rib cage was very prominent. Jennifer knew it must be scoliosis.
A visit to Johns Hopkins pediatric spine surgeon Paul Sponseller confirmed the diagnosis of adolescent idiopathic scoliosis. An X-ray was done in the office, showing Maggie’s spine had curved severely, to 72 degrees. She was only 11 at the time. The significant growth she had ahead of her was sure to lead to further worsening of this deformity if left untreated.
After meeting with Dr. Sponseller, Maggie’s parents made the decision that it would be best to move forward with the surgery he suggested. Maggie was scheduled to have a posterior spinal fusion with instrumentation in February 2014. To prepare for her surgery, Maggie started taking an iron supplement a month before surgery. She also spoke with her school counselor about the time she would miss during the four to six weeks she would be recovering at home. It was determined that a teacher would visit her at home and help her keep up with her studies during that time.
Preoperative Visit for Scoliosis
Maggie was scheduled for a preoperative visit, during which time new X-rays were taken. She had a discussion with nurse practitioner Kristen Venuti and asked Dr. Sponseller some follow-up questions. Her parents brought the school’s form for homebound instruction and their own FMLA paperwork to be signed. Maggie then stopped in the lab for a quick blood test before heading home. Now, all she had to do was wait two weeks for her surgery date.
Surgery for Adolescent Idiopathic Scoliosis
For a child with severe adolescent idiopathic scoliosis, a posterior spinal fusion with instrumentation is the most common surgery performed by the Department of Orthopaedic Surgery’s highly specialized pediatric spine surgeons. This surgery involves exposing the bones and muscles of the spine through an incision made straight down the middle of the back. The incision is only the length of the deformity needing correction. The bones of the spine are released and prepared.
Each vertebra has a strong strut of bone on either side called a pedicle, where 2-inch screws made of titanium are placed. The center of the vertebral column is hollow, forming a channel to house the spinal cord and cerebral spinal fluid. Extreme caution is taken to protect the spinal cord. Steps include pedicle screw placement using real-time X-ray (fluoroscopy) for guidance and continuous monitoring of the activity of the spinal cord. The latter is done by placing electrodes on the child from the head to the toes and measuring the signals back and forth. A specialist called a neurophysicist is in charge of interpreting the spinal cord monitoring and alerting the surgeon of any changes.
Once all of the pedicle screws are in position, the spine is derotated, correcting the rotational deformity caused by scoliosis. The rods made of cobalt chrome are then threaded through the screws, and the screws are locked down. Bone graft is taken from the patient’s own rib, cut into pieces the size of matchsticks and packed in along the back of the spine to create the spinal fusion.
Finally, the muscle layers are closed with stitches that dissolve inside the body. The outermost skin layer is closed with butterfly stitches or stitch tapes. These adhesive stitches fall off on their own, after the skin has knit itself back together.
The Day of Surgery
Maggie arrived at the Johns Hopkins Children’s Center, her parents by her side. Her surgery took 4 ½ hours, and when she opened her eyes again, mom and dad were the first people she saw. Maggie then spent an hour in the pediatric postanethesia care unit, where her vital signs were monitored and her pain was addressed. She was breathing on her own with stable vital signs and didn’t need to spend any time in the intensive care unit.
Maggie stayed in her hospital bed and was taken to the 10th floor, where she stayed for the next three nights in the adolescent medical-surgical nursing unit. Her parents were relieved to have comforts and distractions available in her spacious single room, including a wall of windows that provided abundant natural light and views of the Baltimore harbor, a television, a video game system, a Wi-Fi connection and a private bathroom.
Staying at Johns Hopkins Hospital
The first three to four days of recovery from scoliosis surgery are spent in the hospital. Maggie was cared for around the clock by a staff of highly trained pediatric registered nurses. The nurses monitored the movement and feeling in her legs, her pain and other vital signs, her digestion, and the surgical site. The nurses used interventions like oxygen, adjusted dosing of pain medication and comfort measures to help Maggie through her first few days of recovery.
Pain medication, usually morphine or hydromorphone, is initially given through an IV. A computerized delivery system is used, allowing the medication to be given as a slow, constant drip. Maggie was given a dose that was calculated according to her weight and had a button to push to give herself an extra dose of pain medication as needed. She was quite nauseated from the narcotic pain medication, so her nurse gave her ondansetron, an antinausea medication, to minimize this side effect. Maggie also started taking a stool softener and laxative, as the narcotic leads to constipation.
Physical therapy is needed while in the hospital. A physical therapist visited Maggie the day after surgery to help her learn the basics of moving in a way that avoided pain. Maggie learned how to logroll and sit up in bed. Then she stood and took a couple of steps to a bedside chair. She was tired and sat in her chair for an hour before it was time to get back in bed. The second day after surgery, Maggie worked with the physical therapist again, this time walking in the hall. By then, Maggie was able to sit and stand with guidance, and she was feeling well enough to start eating. She also started taking her pain medication in pill form.
Leaving the Johns Hopkins Hospital
Maggie felt well enough after three nights in the hospital to be discharged to home and was excited to get back to her own room. She was able to ride in a car with the support of an extra pillow for comfort, so along with her parents, she made the hour trip to her home in Pennsylvania.
Maggie’s parents learned how to recognize pain, give her pain medication, and provide assistance with mobility and other activities of daily living. They were home with Maggie for the next four weeks, helping her through this phase of recovery.
Recovery After Surgery to Treat Adolescent Idiopathic Scoliosis
The first week at home, Maggie faced challenges with decreased appetite and constipation — common side effects of narcotic pain medication. Maggie’s mom called the Johns Hopkins staff for advice; laxatives, time and more walking did the trick. Each day brought more energy and a decrease in pain. Maggie felt strong enough to get out of the house for visits with friends and to do a little shopping. By the four-week mark, she felt well enough to start easing back into school. She started with half days and then quickly felt energetic enough to return to a full day of school by six weeks after her operation.
As Maggie’s parents, we wanted the best for our daughter. We didn’t really doubt the need for surgery, but of course we were nervous. Information was provided to us before, during, and after surgery. Deciding on this course of action was the best thing we could have done for Maggie. We truly believe she had been living in pain and had accepted it as “normal.” She didn’t know how bad she hurt until she didn’t hurt anymore! We are so pleased with the care and treatment she received at Hopkins!
- Jennifer Scarborough