Many things need to be considered when planning surgery for scoliosis. This article provides answers to common questions about cost, risks and complications, as well as concerns teenagers have about how they will look after surgery.
When should surgery be scheduled?
Most scoliosis surgeons agree that there is rarely a need for emergency or urgent surgery. Most surgeries can be scheduled for a time that works for both the patient and the doctor. If you decide to postpone your surgery until a school break, your doctor will follow up with you every few months to make sure there is not a rapid increase in the size of the curve once it is greater than 50 degrees.
Should I have allograft bone used for my fusion or my own bone harvested?
At this time, your own bone is still an excellent option, but many scoliosis surgeons now use allograft bone instead. The reason for this is that some patients end up having pain at the donor site (from where the bone was taken) and this can last a long time. Other problems such as bleeding, nerve irritation, infection, or fracture can happen on rare occasions.
Allograft bone is taken from a deceased donor. It goes through an extensive sterilizing (cleaning) process before it is used on a patient. Allograft bone is often mixed with the patient's own marrow blood to improve its bone fusion capability.
In addition, spine surgeons are also using synthetic (artificial or man-made) products to get the spine to fuse. These products can be used with your own bone or with an allograft (donor bone). They act as a scaffold (framework) to allow new bone to form and mature. Some of the synthetic materials available can actually stimulate new bone to form in the operated area. They go by the name BMP (stands for bone morphogenetic protein) and your surgeon may bring it up while discussing your surgery. It has been used extensively in the spine and other bony areas in the body for the past several years.
The exact type of bone graft used will depend on many factors, the most important of which is surgeon preference and experience. That is to say, if your surgeon has had very good success with one method or approach, he or she will probably recommend it to you. Of course you and your family should ask about other options available to you and then decide which method you would prefer.
How much does spinal fusion surgery cost?
The cost of surgery for scoliosis and other types of spinal curvatures depends on many factors. They include the cost of being in the hospital for several days, types of materials used (hooks, screws, rods), bone graft material, surgeon's fees, and anesthesia charges. Unexpected events that result in an extended hospital stay will also increase the overall cost.
The actual costs vary from region to region in the United States, and from country to country.
In the United States, costs also vary depending on the type of insurance coverage you have. Many insurance companies cover the cost of the surgery, the hospital stay, and the instruments to straighten the spine. You may owe a co-payment or you may be billed the balance of what your insurance does not cover.
Be sure to contact your insurance provider prior to surgery to discuss the extent of your coverage. Talk with your doctor's office, as well as the hospital billing department to make sure you understand all the costs involved.
Although the exact costs vary from patient to patient, in general, spinal surgery for scoliosis is an expensive operation.
How many spinal surgeries has my surgeon performed and has he or she had good results?
Talk with your surgeon. Because not all spinal surgeons treat scoliosis patients, it is important to ask your surgeon if treating scoliosis is an important part of his or her practice. There are many regional spine centers and teaching institutions that specialize in treating teenagers with scoliosis and other curvatures of the spine.
Should my child see a neurosurgeon?
The vast majority of surgeries for scoliosis and other curvatures of the spine have been performed by orthopaedic spine surgeons. Over the last several years, however, some neurosurgeons have taken a special interest in treating teenagers with scoliosis and have gone through specialized training.
Certain types of curvatures are associated with problems related to the spinal cord. If your child has other symptoms with the curve, like pain, weakness, or numbness, it may mean that the nerves from the spine are being compressed by the bones or the disks. This is rare, but should be watched out for. A neurosurgeon may be requested to be a part of the surgical team.
As with any operation, there are potential risks associated with spinal fusion. Most problems occur as a result of not having a solid fusion, which may result in implant failure (broken rod) and a need for more surgery.
It is important to discuss all of these risks with your surgeon before your procedure.
- Infection. Antibiotics are regularly given to the patient before, during, and often after surgery to lessen the risk of infections.
- Bleeding. A certain amount of bleeding is expected, but this is not typically significant. A portion of the blood lost during surgery may be saved and given back to the patient. This is known as cell saver. It is not unusual for a patient having spine surgery to require a blood transfusion even if a cell saver is used.
- Pain at graft site. A small percentage of patients will experience persistent pain at the bone graft site.
- Pseudarthrosis. Older teenagers and adults who smoke are more likely to develop a pseudarthrosis. This is a condition where there is not enough bone formation. If this occurs, a second surgery may be needed in order to obtain a solid fusion.
- Nerve damage. It is possible that the nerves or blood vessels may be injured during these operations. These complications are very rare.
- Blood clots. Another uncommon complication is the formation of blood clots in the legs. These pose significant danger if they break off and travel to the lungs.
- Lung complications. Problems with lung function following surgery are rare, especially for healthy teenagers.
What happens if the rod breaks?
Most rods are made of either titanium or stainless steel. The type of implant used in your surgery will depend on your surgeon's experience, as well as your specific needs. Both types of rods are capable of breaking.
A broken rod is a sign that a portion of the spine is not fused. In most cases, rod breakage requires another operation for revision of the fusion and replacement of the rods.
Will I need more than one spinal fusion?
Most surgeries for scoliosis are done with the purpose of being the only surgery. However, the repeat surgery rate has been reported in studies to range from 4-13% in the first few years after the procedure. Few patients require planned multiple surgeries. Rarely is repeat surgery necessary as an adult.
What are the permanent side effects of long fusion?
After fusion, the forces that go through the spine with running, jumping, bending, lifting, and twisting, are distributed between fewer motion segments. We think that this puts more wear and tear on the unfused joints in the spine. This could lead to earlier development of arthritis, and wear and tear changes in the remaining segments.
However, areas of the spine that are twisted are also prone to early arthritis. Many patients with scoliosis who do not have fusion end up with stiff, painful, and arthritic areas of the spine.
Will surgery increase the chances for developing arthritis?
Everyone develops "wear and tear" arthritis in their spines as they age, whether they have scoliosis or not. This process is accelerated in patients who have scoliosis, because the forces that are transmitted through the twisted and bent spine are concentrated over a smaller area and intensified.
Scoliosis specialists think that most people with large scoliotic curves will be less likely to develop severe and limiting arthritis pain if their curves are corrected with surgery.
Is there a risk of future back pain?
After surgery, some people have trouble with ongoing back pain in the lower or upper back. This is usually managed with exercise and other conservative treatments, without the need for medication or extensive therapy on an ongoing basis.
Occasionally, patients will have a lot of trouble with ongoing back pain and require physical therapy, medications, or even an additional surgery (called a revision surgery). Over a 20-year period, ongoing back pain has caused between 3% and 10% of patients to require revision surgery or removal of instrumentation.
How long will the scar be?
The incision will be as long as the part of your spine that will be fused. Incisions for a single curve are generally 10 inches long. If you have two or more curves, your scar may start in the middle of your shoulder blades and end up even with your pelvis.
Will the scar be wide?
Your surgeon will try to prevent the scar from spreading by placing the sutures beneath the skin. Some surgeons use a special type of glue to promote wound healing.
Will the surgery stunt my growth?
When the spine is fused, spinal growth will only stop in the area of the spine that is operated on. However, most fusions are not performed until a child's spinal growth is complete (usually 2 years after periods start, for girls). In addition, most of a child's height comes from the legs. Most fusions on adolescents do not significantly stunt a child's height.
Will surgery make me taller?
Yes. When your spine is made straighter, it becomes longer. After surgery, you may be 3/8 to 3/4 of an inch taller.
Will surgery correct the hump on my back?
A "hump" on the back can come from the spine being prominent or the ribs being prominent. Surgery should make the hump smaller, but it probably will not disappear. Your surgeon will explain to you how much any deformity may improve with the surgery.
After fusion will I be able to bend over and move my back?
When you bend over to pick something up off of the floor, most of the movement comes from your hip joints, which are not affected by scoliosis surgery. You will have less flexibility in your back after fusion. You can simulate what this loss of motion may be like by keeping your upper back straight with "perfect posture" while bending forward at the hips.
Will it be possible for people to see the hardware in my back?
Only on rare occasions will the shape of the implants be noticeable under the skin, and this is only if you are very thin.
What will happen to the uneveness of my chest (breasts)?
Surgery should reduce the protruding ribs beneath the breast on the side of the scoliosis, making your chest more even. However, there may still be a difference in the size of your breasts.
Reviewed by members of the Pediatric Orthopaedic Society of North America and the Scoliosis Research Society
The American Academy of Orthopaedic Surgeons
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Rosemont, IL 60018