1. Scoliosis & Anesthesia Considerations
Reed Tenney, SRNA
NURA 815
University of Kansas

2. Outline Introduction Assessment Diagnostics Treatment
Anesthesia procedures
Anesthetic considerations
Related complications & management
Summary

3. Introduction
Scoliosis is a deformity of the spine with lateral curvature and rotation of the vertebrae and ribcage.
Idiopathic – 75-90% of cases
10-25% of cases associated with:
Neuromuscular diseases
Congenital abnormalities ie .heart disease
Trauma
Mesenchymal disorders
Surgery Indicated for Cobb angle > 50 deg.
Untreated can lead to death by 45 years

4. Introduction (cont.)
Kyphoscoliosis is characterized by anterior flexion and lateral curvature.
Idiopathic – 80% of cases.
Occurring often during late childhood
Times of rapid growth
4 per 1000 population
Females 4x more prone than males
Other causative factors.
Diseases of neuromuscular system
Poliomyelitis
Cerebral palsy
Muscular dystrophy
Spinal curvature > 40 degrees considered severe.

5. Assessment Physical considerations:
Restrictive lung disease r/t lung tissue compression.
Pulmonary Hypertension r/t ↑ PVR from compressed lung vasculature and hypoxemia.
Core pulmonale from ↑ workload of right heart / ↑PVR
DOE r/t ↓ lung volumes.
Decreased VC.
PaCO2 normal, may rapidly decompensate with insult to system, ie. URI, trauma etc.
Ineffective cough → frequently pulmonary infections.

6. Diagnostics (pre op) ABG PFT (mainly VC) Exercise tolerance tests
Airway assessment
Baseline Hgb & Hct
T&S
Cardiac and Pulmonary work up

7. Barash et al.(2009) figure 53-2

8. Treatment Non-surgical (early onset idiopathic)
Bracing
Risser Casting
Young children may need GA to tolerate casting.
Airway! Airway! Airway!
Decreased compliance from cast setting (↑ PIP ↓ Vt) may require emergent opening of cast.
Dedicated person holding ETT T/O procedure (multiple repositioning of pt.)
Communication is key

9. Treatment Surgical / Spinal fusion and instrumentation
Anterior approach
Lateral position
Removal of one or more ribs
Manipulate diaphragm
OLV with DLT if ↑ T8
Associated with greater respiratory insufficiency
than prone
Posterior approach
Prone
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10. Anesthesia Procedures
Arterial line
+/- Central line- monitoring CVP, useful for evacuation of VAE
2 Good IV’s
Possible difficult intubation
DLT
OLV

11. Anesthetic Considerations
Pre-Op VC of < 40% of predicted likely requires post operative ventilator support (Past Board Question)
Potential for elevated blood loss - T &S current with blood ready to go.
Cell Saver
Hypothermia
Controlled hypotension
Prone positioning precautions
POVL
VAE monitor for S/S

12. Anesthetic Considerations
MEP
Avoid NMB when monitoring
Volatile anesthetics reduce NM conduction
SSEP
Avoid Nitrous Oxide- may ↑ PVR & exacerbate pulmonary HTN.
TIVA opioid / propofol combo with 0.33 MAC volatile anesthetic.
When spinal curvature is straightened / distracted (excessive traction) may be spinal cord ischemia.
“wake up test” still used by some in conjunction with MEP and SSEP monitoring. (0-20% may have recall) discussion pre op.

13. Complications / Management
POVL
Optic neuropathy, retinal artery occlusion, cerebral ischemia
Associated with instrumentation, prolonged intra-op hypotension, anemia, large blood loss and prolonged surgery.
VAE
Stems from large amounts of exposed open bone and elevated surgical incision relative to heart.
Capnography, mass spectrometry and precordial Doppler useful in detection. (↑ ET N2 & ↓ ETCO2)
Tx. with saline poured onto field, level bed, L lateral position, DC any N20, aspirate air with central line, flip supine and institute CPR.

14. Summary
See attached handout

15. References
Barash, P., Cullen, B., Stoelting,R., Cahalan, M., & Stock, M. (2009). Clinical Anesthesia. (6th Edition). Philadelphia: Lippincott Williams & Wilkins.
Hines, R., and Marschall, K. (2008). Stoelting’s anesthesia and co-existing disease. (5th Edition). Philadelphia: Churchill Livingston.
Urman, R., & Ehrenfeld, J. (2009). Pocket anesthesia. Philadelphia: Lippincott Williams & Wilkins.