A Patient's Guide to Single Stage Posterior Scoliosis Correction Surgery

Scoliosis is a sideways curvature of the spine when viewed from the back or front. It is often accompanied by a twisting of the body resulting in prominence of the ribs.

Typical signs include:

• A visibly curved spine
• One shoulder being higher than the other
• One shoulder or hip being more prominent than the other
• Clothes not hanging properly
• A prominent ribcage
• A difference in leg lengths

Back pain is common in adults with scoliosis. Young people with scoliosis may also experience some discomfort but it's less likely to be severe.

There is no known way of preventing scoliosis from occurring. In most cases the cause is unknown. This is called idiopathic scoliosis.

A small number of cases are caused by other medical conditions, including, but not limited to:

• Cerebral palsy
• Muscular dystrophy
• Marfan syndrome

There are two main approaches used in scoliosis surgery:

• Anterior, where the surgical cut is made on the side of your chest
• Posterior, where the surgical cut is made on your back.

Your surgeon will chose which approach is best for you based on the type and location of your curve. This booklet is designed for patients undergoing a single stage posterior scoliosis correction.

Surgery involves inserting metal screws and rods into the vertebrae of the spine to reduce the amount of your curvature. Bone is then added to encourage your spine to fuse. This is often your own bone which has been recycled and mixed with proteins that stimulate bone growth. The bone continues to fuse after surgery is completed. The fusion process usually takes about 3 to 6 months, and can continue for up to 12 months.

Once the bone fuses, the spine does not move and the curve cannot progress. The rods are used as a temporary splint to hold the spine in place while the bone fuses together. The rods are generally not removed since this is a large surgery and it is not necessary to remove them. Occasionally rods do need removing however, if they are irritating any soft tissues around the spine. The bones (not the rods) hold the spine in place once the spine has fused.

All operations involve risk and potential complications. Although rare, it is important that you understand them. There are risks to you in general and risks of the procedure itself.

Risks of the procedure itself include:

• Sickness, nausea, heart problems, breathing problems and nervous system problems relating to the anaesthetic. The anaesthetic risks will be discussed with you by the anaesthetist on your admission.
• Bleeding
• Infection – all possible precautions are taken to avoid infection during your operation. A superficial skin infection is treated with antibiotics. However, if the metalwork becomes infected it may need to be removed and replaced.
• Nerve injury around the surgical site. Nerve injury can cause numbness, weakness, paralysis and bladder / bowel problems. If this happens we will investigate it carefully and may ask other experts in the hospital for their advice and help in restoring function.
• Blood vessel injury around the surgical site. If this happens we will investigate it carefully and may ask other experts in the hospital for their advice and help in restoring blood vessels.
• Bowel injury
• CSF leak
• Blindness (very rare)
• Leg length discrepancy
• Increased back pain 6
• Failure of fusion
• Failure to improve current symptoms
• Metalwork misplacement
• Metalwork failure
• Adjacent segment disease
• Deep Vein Thrombosis (DVT) – a DVT is a blood clot in the deep veins of the calf or thigh. To reduce the risk of developing a DVT and to help your circulation you will be given stockings and will be asked to wear special inflatable sleeves around your legs whilst in bed. These inflate automatically and provide pressure at regular intervals, increasing blood circulation in your legs. You may require blood thinning medication which will be decided by the consultant depending on risk factors. The physiotherapist and nursing staff will show you how to exercise your legs and ensure that you start to move about quickly after your operation. If a clot develops and part of it breaks away, it can travel to the lungs where it is called a Pulmonary Embolus (PE). A PE is potentially life threatening and so everything is done to prevent a DVT from developing. We ask you to help by wearing your stockings at all times while you are in hospital, except when you are bathing.

Fortunately most of these risks are rare, however, it is crucial that you consider these carefully before making a decision. Please discuss the procedure thoroughly with your surgeon when you see them in clinic.

Pre-assessment

Shortly before your operation you will be asked to attend a pre-assessment anaesthetic and medical screening and you may require a further pre-assessment appointment for the anaesthetist to see you. This is a medical examination to make sure that you are well enough for surgery.

Whilst at this clinic you may have some tests / investigations including:

• Taking your past medical history
• Blood tests
• Vital signs
• Height and weight
• MRSA screening

You will be given some instructions to prepare you for the procedure. It is important to follow these instructions to reduce the risks associated with surgery.

Contraceptive pill or hormone replacement therapy (HRT)

You will need to discuss with your doctor about possibly stopping any medicines containing hormones (for example, the oral contraceptive pill, HRT or Tamoxifen) six weeks before surgery.

Wearing nail polish, nail decorations or false nails (hands and feet)

Please remove nail varnish, decorations or false nails prior to coming in. Failure to do so could lead to your operation being cancelled or delayed. This is due to the monitoring that is used in theatres whilst under anaesthetic and to reduce risks of infection.

Good nutrition before the surgery will help you to recover and heal well after the operation. Avoid periods of not eating, strict weight reduction and fasting in the weeks and days before the surgery, as this will affect your body’s nutrient store.

Please refrain from smoking cigarettes. Smoking can greatly impact on the success of the surgery. If you do not, your surgeon may not go ahead with the procedure as you are at greater risk of non-union (your spine does not successfully fuse). This is due to the affect that smoking has on your blood supply and tissue healing.

Pre-operative therapy

You willreceive a questionnaire from the occupationaltherapy (OT) department that needs to be returned to the department. The OT will review the information you provide to highlight any functional concerns that may arise about how you will cope with daily life following surgery. If you have any particular concerns regarding how you will manage after your surgery please contact the OT team on the number provided at the back of this booklet.​​​​​​​

It is important that you consider your home set up and environment in order to allow you to effectively and safely function when you are discharged from hospital, particularly in the initial six to eight week recovery period;

• Ensure you have made alternative arrangements for anyone you care for (children, parents, pets)
• Remove any trip hazards from your home
• Stock up on food or identify someone who may be able to assist you with some shopping initially
• Consider moving essential itemsso that they are more accessible to you
• Plan adequate time off work
• Plan your travel arrangements to and from hospital. Patients are responsible for their own transport to and from the hospital. You will be informed of your admission and discharge date in advance so that you can arrange for a relative, friend, or taxi to transport you. In most cases it will not be appropriate to use public transport when you are discharged from hospital. Please note that patients who wish to claim their travel costs must prove that they are eligible to do so by providing relevant benefit documentation and travel receipts. 10 If you are eligible for patient transport, the assessment team will be able to assess your needs through a brief telephone conversation. The interview remains completely confidential. The transport control room can be contacted on 0800 953 4138. Any enquires relating to booked journeys please call 020 8909 5895.

What to pack for coming into hospital

• Wash items such as shower gel, shampoo, toothbrush and toothpaste
• Loose fitting pyjamas and slippers with backs
• Clothes to wear during the day
• Any regular medication
• Books, laptop / tablet
• Mobile phone charger
• Any walking aids you use, for example, sticks or crutches
​​​​​​​• Any dressing aids you use, for example, helping hand or long-handled shoe horn

You will be advised to take a shower before coming into hospital. You will be told not to eat or drink from midnight on the day of your operation, depending on the anaesthetist's instructions. Failure to follow these instructions will result in your operation being delayed or even cancelled. In some instances, you may be asked to arrive the day before your operation. When you arrive on the ward, you will be shown to your bed space and introduced to the nursing staff looking after you. You will then be settled onto the ward.

Before your operation one of the surgical team will discuss the surgical procedure with you. You will be asked to sign a form giving your consent to the operation, if not already done so in clinic. You will also be visited by an anaesthetist to discuss your anaesthetic.

Our porters will take you to the operating theatre and a member of the nursing team will accompany you and hand you over to the care of the theatre team. The operation is usually carried out under general anaesthetic and the procedure usually takes between four to five hours. You will then be taken to the recovery area and cared for there until you are deemed fit to transfer to Alan Bray Unit. This is a high dependency / intensive care unit. This is routine and allows us to closely monitor you after your surgery.

After the operation you will feel some pain and discomfort, which will be helped by medication. You may have the following:

• Small drainage tubes coming from your wound
• A drip to replace lost fluids
• Patient Controlled Analgesia (PCA) Device
• An oxygen mask
• A catheter to drain your urine

These will be removed as soon as possible following the surgery.

You are likely to stay in the hospital for five days after your surgery.

You will be informed by a member of the team when and how much you can sit up in bed. You will be encouraged to sit up as much as you can tolerate for short periods, using the controls of the bed to help you. This allows your body to adapt to its new position, it helps to maintain your blood pressure and it helps to restore and improve your respiratory and digestive functions. It is important that you are positioned high enough up the bed so that when you do sit up; your bottom is in the crease of the bed. If you are too low in the bed you are likely to be uncomfortable and not in the best position for your spine.

You will be encouraged to move around in bed as much as pain allows you, providing you adhere to your precautions. It is safe for you to shuffle up the bed and lift your bottom as long as you are not twisting or bringing your knees up higher than your hips.

You may need to wear a brace after your surgery. This will be confirmed by your surgical team after your operation. You may be given a soft corset initially, for comfort, to allow you to get up, sit in the bedside chair and to walk. You will be guided by the therapists on the ward as to when you need to wear the corset or brace, and for how long.

When you are able to stand you will be booked for casting of your brace. This is done early in the morning in plaster theatre. Your nurse will prepare you by dressing you in a stockinette. You will be permitted to stand for 5 to 10 minutes whilst the orthotist moulds a plaster cast type substance to your body. This shell is then used to create a TLSO (thoracolumbosacral orthosis) brace. The brace will be ready the following day. It often requires alterations to ensure the best fit. The brace is supplied to you to prevent you from excessive bending and twisting and to encourage an upright posture.

Physiotherapy

The physiotherapist will see you for the first time either on the day of surgery (if you are operated on early in the day) or on the day after surgery. You will be provided with exercises to perform whilst you are in bed. These are given to reduce post-operative complications, such as blood clots and a chest infection, while you are less mobile.

Your physiotherapist will teach you how to get out of bed correctly and they will work with you every day to improve your mobility and function. The provision of walking aids are often discouraged, unless you required them prior to your surgery. This is to encourage a symmetrical upright posture. Sitting in a chair for short periods is advised. Initially you will be instructed to sit for 20-25 minutes, building up the time gradually, as comfort allows.

The physiotherapist will discharge you when you are able to independently transfer out of bed, mobilise safely and independently on the ward and you can perform a small flight of stairs (if required). You will be advised to continue to increase your sitting and walking tolerance daily when you go home. If you do not require a brace you will be referred to your local outpatient physiotherapy department, to be seen at six to eight weeks post-operatively. Here they will teach you core stability exercises and they will ensure that your mobility and function is improving accordingly. If you are required to wear a brace on discharge, you will be referred for outpatient physiotherapy by your surgical team from clinic. Outpatient physiotherapy is usually advised when the brace is no longer needed.

Occupational Therapy

You will be assessed by an occupational therapist (OT) after your surgery who will discuss how you will manage your daily activities. Following your surgery you will have some precautions that you need to comply with:

• Avoid bending your hips more than 90 degrees whether lying, sitting or standing
• Avoid twisting your back
• Avoid lying on your stomach
• Avoid lifting heavy objects (more than 1 kg in each hand)

The OT will give you tips on how to manage and may also make suggestions about equipment that can be purchased to assist. Any equipment suggested can be purchased through the companies detailed at the end of this booklet.

Washing and dressing

Your OT will discuss your personal care activities with you, taking into consideration any post-operative restrictions. Using a bath is not advised post-operatively. If you have a shower over your bath you can shower sitting on a bath board which the OT will issue if necessary. If you use a shower cubicle, a high quality non-slip mat is essential and a shower seat may be helpful. You may need a long handled sponge to reach your feet or get someone to help you. If you are required to wear a brace, more often than not you will be allowed to remove it when washing. Your OT will clarify this with your surgical team and they will instruct you accordingly. It is best to wear loose fitting clothing and front opening garments if possible. If you are wearing a brace, the brace should be worn over clothing (ideally a vest or t-shirt).

Outer garments and jackets can be worn on top of the brace if required. Try and sit to dress and undress as this provides more stability. Lower body dressing such as underwear, trousers, socks and shoes will be more difficult. You can get assistance from a family member and / or your OT will show you some techniques which may include using a “helping hand”. Shoes should be comfortable and have low heels. Slipon shoes with backs are easier to manage than laces.

You will also need to wear anti-embolism stockings for six weeks after your surgery. These must be removed once a day for washing your legs. If you feel that you will require assistance with this please discuss it at your pre-assessment screening.

Whilst on the ward we encourage patients to get dressed in their own clothes once any drips or drains have been removed. This is for your own comfort as well as promoting dignity within the ward area.

Domestic tasks

Sit for as many jobs as possible. A high stool is useful so that you can still reach worktops.​​​​​​​

For several weeks after your operation, you are likely to need help from your spouse, relatives or friends with activities such as shopping, laundry and vacuuming.

Sleeping

If you are to wear a brace, you do not need to wear it in bed (unless told otherwise by your therapist). You are encouraged to sleep on a bed with a supportive mattress. You can place a pillow underneath you knees when lying on your back for comfort. You may also lie on your side but use pillows to prevent yourself from twisting and place a pillow between your knees. Your OT will discuss this with you on the ward. Remember that you should not lie on your tummy for a minimum of six weeks, until your surgeon states that it is safe for you to do so.​​​​​​​

Returning to work

You should be able to return to work at approximately six weeks post-operatively, but this depends upon your surgical procedure and the nature of your work. If you undergo extensive surgery or have a job that involves heavy manual work you may not be able to return for six months. Please discuss any queries with your surgical team.​​​​​​​

Driving

You may start driving once you have spoken to your consultant in your post-operative clinic review. If your ability to drive has been affected you are required by law to contact the DVLA and you may need to inform your insurance company of your operation as your insurance may be invalid.​​​​​​​

Returning to leisure activities

Prior to restarting any leisure activities it is advised that you discuss them at your post-operative clinic review or with your outpatient physiotherapist. The ability to return to leisure activities will depend on pain, range of movement, strength and the procedure undertaken.​​​​​​​

Avoid any strenuous exercise, especially if pulling or pushing is involved. Contact or high impact sports, i.e. rugby, football, horse riding, skiing should not be attempted until about one year after your operation, and then only when given permission by your consultant.

Non-contact sports, including swimming and cycling, may be started earlier, however ask your consultant first. Every sport should be resumed gradually

Your sex life can be resumed when you are comfortable (usually about four to six weeks post-operatively). However, vigorous sexual activity should be deferred until fusion is confirmed.

We aim to discharge you from hospital within five days of the surgery however this may vary depending on your needs. Prior to discharge we need to ensure that:

• You can mobilise safely
• You have adequate social support
• You understand your precautions
• Your pain is managed with effective pain relief
• Your wound is clean and dry
• You have opened your bowels
• Your post-operative X-ray is satisfactory.

On discharge you will be asked to see your GP for a wound check. If you are not able to attend your GP practice then a district / practice nurse appointment will be arranged to check your wound. Excessive redness, inflammation or discharge from the wound must be reported to your GP, but it is normal to expect some bruising and swelling.

It is expected that you will have some pain on discharge from hospital. We will supply you with pain relief for your initial hospital discharge. If you require further pain relief, you are advised to visit your GP.

A surgical clinic appointment will be arranged for approximately six to eight weeks after your operation and this date will be sent to you at home. We suggest you bring this booklet with you when you come into hospital and use it as a guide.

In the event that you are unable to contact a member of your surgical team and feel you have an urgent problem you should visit your GP or local emergency department for advice.

Spinal Consultant Secretaries
Contact via the hospital switchboard Tel: 020 8954 2300

Mr. Molloy - Extension 5677
Mr Lehovsky - Extension 5566
Mr Shaw - Extension 5848
Mr Gibson - Extension 5864
Mr Noordeen - Extension 5412

Clinical Nurse Specialists Tel: 020 8909 5828
Patient Transport Assessment Team Tel: 0800 953 4138
Physiotherapy/Occupational Therapy Service Tel: 020 8909 5480
Pre-assessment clinic Tel: 020 8909 5630​​​​​​​
Customer Care and Patient Advice and Liaison Service (PALS)​​​​​​​
Tel: 020 8909 5439/5717​​​​​​​

Trust website: www.rnoh.nhs.uk​​​​​​​

Equipment​​​​​​​
Disabled Living Foundation www.dlf.org.uk
Patterson Medical www.pattersonmedical.co.uk
Nottingham Rehab Supplies www.nrs-uk.co.uk