Scoliosis Spinal Fusion (Adolescent Idiopathic)
Patient phenotype
Adolescent (12-18) with adolescent idiopathic scoliosis (AIS), Cobb angle > 50°. Otherwise healthy in AIS. Or syndromic scoliosis (cerebral palsy, neuromuscular) — much more complex.
Procedure
Posterior approach (most common): T2-L4 multi-level fusion with pedicle screws + rods. Long surgery (4-8h), prone, significant blood loss. Neuromonitoring (SSEPs + MEPs) throughout.
Anesthetic plan
GETA, TIVA-favorable for MEP monitoring. Two A-lines + central. Aggressive transfusion preparation. Postop pain: PCA + multimodal. PICU overnight.
Setup
- ·Standard ASA + temp + Foley + UOP
- ·Two A-lines (radial + femoral)
- ·Central line
- ·Two large PIVs + cell saver
- ·Type & cross 4 units PRBC + FFP/platelets available
- ·TIVA: propofol + remifentanil
- ·Forced air warmer + fluid warmer
- ·Eye protection + frequent face check (POVL prone case)
- ·Wake-up test capability if surgeon requests
Biggest concerns by phase
Pulmonary function — restrictive defect from scoliosis
Severe scoliosis (Cobb > 70°) restricts chest expansion. Pre-op PFTs document baseline. Postop atelectasis + pneumonia common. Plan for postop incentive spirometry + early mobilization.
Standard induction + careful tube fixation
Standard induction. NMB only for intubation if MEPs needed. Tape ETT bilaterally — prone case, gravity pulls.
Prone positioning — POVL + brachial plexus
Same as adult lumbar fusion but longer + younger. Eye check q15-30 min. Arms supinated, abducted < 90°. Breast/genital padding. Document position in note.
Massive blood loss — TXA + cell saver
Average 500-2000 mL EBL, sometimes much more. TXA 10-20 mg/kg + 1 mg/kg/hr infusion. Cell saver. Transfuse to keep Hb > 8 (allow some hemodilution for flow + reduced viscosity).
Neuromonitoring — TIVA + no NMB
MEPs essential — propofol + remi maintenance, NO NMB after intubation. SSEPs + MEPs both monitored. Signal loss = surgical pause + correction. Wake-up test rare with modern monitoring but be prepared.
Wake-up + neuro exam in PICU
Often kept intubated to PICU due to long case + fluid shifts + airway edema. Sedation weaned + extubated in PICU. Neuro check on awakening (move all extremities, sensory exam).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
16-year-old AIS spinal fusion, 4 hours in. MEPs bilaterally lower extremity disappear suddenly. BP 95/60, MAP 70. No NMB given. Surgeon was placing a thoracic pedicle screw. What's happening?
What an examiner probes for
- ▹Concern: spinal cord injury from pedicle screw (medial breach)
- ▹Action: tell surgeon, raise MAP > 80 (improve cord perfusion)
- ▹Surgeon may back out screw + reposition
- ▹Steroid (methylprednisolone) controversial; some use it for acute SCI
- ▹If signals don't return: wake-up test, abort + close
Sources
- Miller's Ch 57
- SRS pediatric scoliosis guidelines
- ASA POVL Practice Advisory
Anatomy reference
Sourced reference images. 4 matches for "spine vertebra thoracic lumbar".
Browse the full image library →
