Adult spinal deformity

As we get older, our bones undergo wear and tear that is part of the natural aging process, this is known as degeneration.

Degenerative scoliosis is a condition where this wear and tear mainly of the discs and joints in the spine cause it to bend.

Symptoms usually start gradually and can include:

• Pain in the back, thighs and buttocks
• Stiffness
• Muscle tightness
• Sagittal imbalance – when your centre of gravity alters and you are always being
  pushed forwards, the back muscles have to work overtime trying to keep the spine
  straight, causing back pain and fatigue.

A scoliosis is a sideways curve, when viewed from the back or front, and a twist of the spine resulting in prominence of the ribs.

Idiopathic scoliosis is where the exact cause is not known. Adult idiopathic scoliosis may be the result of the progression (worsening) of childhood idiopathic scoliosis.

Kyphosis is curvature of the spine that causes the top of the back to appear more rounded than usual and can cause a hunch-like appearance.

The causes of kyphosis include poor posture, Scheuermann’s disease (when you develop irregular, wedge-shaped bones in your spine that cause the forward curvature of the spine), congenital (present at birth) and age.

Spinal injury can also lead to kyphosis. Serious kyphosis can cause pain and be disfiguring.

Flatback syndrome is an abnormal spine condition when the spine loses its natural curves and
becomes flat over time.

The use of Harrington rods, (a stainless-steel spinal instrument to treat the curvature of the spine) have also been widely linked to the development of flatback syndrome. This can lead to an imbalance that causes the patient to lean forward.

Initially, patients may not notice significant changes, but over time they may struggle to stand upright or experience worsening back and leg pain.

Lordosis is a condition in which the spine curves significantly inward at the lower back or neck, mostly in the lumbar region, giving a backward leaning appearance. This forces muscles and tendons to work harder to provide necessary support leading to pain, either in the neck or the lower back.

Lordosis can also cause numbness, tingling, weakness and bladder incontinence.

The surgical approaches used, which your surgeon will decide upon depending on your presentation, are:

• Lateral lumbar interbody fusion (LLIF/XLIF) The spine is approached from the side of the body, through an incision just above the pelvis.
• Posterior lumbar interbody fusion (PLIF) The spine is approached through an incision in
  the midline of your back
• Anterior lumbar interbody fusion (ALIF), performed through an incision in the tummy
• Transforaminal lumbar interbody fusion (TLIF), performed through an incision in your
  back.
• Oblique lumbar interbody fusion (OLIF) The spine is approached through an incision to
  one side of the tummy.

Once your surgery has been discussed you will be invited to attend pre assessment for tests
and investigations. This will involve some or all the following:

• Bloods, vital signs, MRSA swabs, height, and weight
• Lung function test, this is performed on an exercise bike, don’t worry its gentle exercise
  just to see how your body will react to the anaesthetic. You may be contacted by a
  therapy team to support with advice and guidance, as there is a minimal threshold you
  must meet
• You may also have further X-rays, MRI or CT
• If you are on any medications, these will be reviewed. Please bring along a list of all your current medication including any over the counter medications.

You will have the opportunity to discuss the exact operation with your specialists and decide
whether you are fit for surgery.

For those who may be frail or have health problems which could increase their risk of potentially life-threatening medical complications, then a ‘smaller’, shorter operation to take the pressure off the nerves (decompression) alone, may well be the safest option

All operations involve risk and potential complications. Most of these risks are rare however it is crucial that you take these into consideration before making your decision to proceed. These
risks vary between patients; this will be further discussed in clinic with your consultant.

• Bleeding: this is different for each patient, and you will be asked if you will be happy to
  have a blood transfusion if needed during surgery in case there was bleeding.
• Infection: all precautions are taken to avoid infection during the operation. Skin infections are treated with antibiotics however if metalwork becomes infected it may need to be removed.
• Developing an ileus. This is a slowing of the bowel’s natural movement of food and
  waste, often causing delayed bowel movements or flatus (wind), abdominal distension,
  and possibly nausea or vomiting. This is treated with changes to diet and fluid intake.
• Nerve injury: such as numbness, weakness, paralysis and bladder and bowel problems.
  Every precaution is taking to avoid nerve damage during surgery; special tests are done
  to check that the spinal cord is still functioning normally.
• Failure to fuse which may result in further surgery.
• Metalwork Failure: for example snapped rods resulting in pain and/or further surgery.
• Failure to improve current symptoms or increase back pain
• CSF leak: this is a tear of the lining or covering which surrounds the spinal cord, causing
  fluid to leak. Usually, the hole or tear is repaired with stitches, a patch or a special glue
  during the operation. This means you may wake up with a headache or have to return to surgery for further repair of the leak.
• Deep vein thrombosis (DVT): which is a blood clot in the deep vein in the calf or thigh.
  Pulmonary embolism (which is a blood clot in the lungs). To prevent this; you will be
  given stockings to wear and a small daily injection during your stay.
• Bone graft non-union or lack of solid fusion (known as pseudoarthrosis, when the bone
  does not fuse together).
• Cage/implant movement, possibly resulting in further surgery.
• Ongoing pain: corrective surgery is a complex procedure, and not all patients get pain
  relief
• Anaesthetic complications: those who do suffer side-effects or complications typically
• have mild symptoms that are easily managed like nausea/vomiting, sore throat. However, there are rare side effects like drug allergies and death.
• Extremely rarely: death

• Eat healthy – this includes fruit, vegetables and food rich in iron and vitamin D which will help you recover and heal well after the surgery.
• Healthy weight, obesity and very low weight pose surgical risks factors and can
  delay recovery.
• Maintaining an active lifestyle and completing a regular form of exercise can support your scoliosis and help reduce pain. Swimming, cycling, pilates or yoga are low impact exercises and help to strengthen your muscles and physical function.
• Avoid mixing with people with any infections leading up to surgery.
• Make sure your back is healthy. If you suffer from back acne or have any sores it may
  postpone your surgery. Please see your GP for the correct treatment.
• Stock up on food and identify someone who will help once you are home after surgery.
  You may struggle to normal tasks due to pain. If you do not have anyone, please let the pre – assessment team know.
• Plan adequate time off work – this will be at anywhere between six weeks up to six months depending on your work, the operation you have had, or your employment.
• Adaptations may be needed depending on your job role for your return to work. Speak
  with your employer. This will be discussed more when you see the surgeon.
• You must not smoke or vape as this will delay or prevent the bone fusing process.
  Smoking affects on your blood supply and tissue healing. Please see your GP for
  stop smoking support.
• Ensure you are not constipated as the surgery and or medication given can slow your
  bowels down. You can buy over the counter medication or see your GP for this.

Please bring in any medications that you normally take at home.

• Pyjamas or nighties, loose fitting and front-fastening. This will avoid having to reach over your head, or you can choose to wear the hospital gowns.
• Dressing gowns for your comfort throughout the day
• Underwear for your comfort if needed, however you may find wearing a bra
  uncomfortable for the first few days.
• Slippers – ensuring they are non-slip and have a back to prevent trips and falls.
• Comfort: whether this is a teddy, pillow, blanket etc. We want you to be comfortable
  during your stay.
• Toiletries: for example toothbrush and toothpaste, shower gel, shampoo.
• Food and drink: it is important to eat and sometimes the hospital food may not be what you want. Please remember, the ward is not allowed to heat any food up for you, however, they will be able to store small supplies in the fridge.
• Female patients: please bring in sanitary products if applicable.
• Entertainment: you are able to bring in your phones, books, tablets, but please be aware the trust cannot accept responsibility for any money or other valuables or property kept by patients.
• Any walking aids your use.

You will go the ward printed on your hospital letter where you will be met by nursing staff the
morning your surgery is due. There you will be admitted and prepared for theatre.

You will be seen by your surgeon and anaesthetist before your procedure. Please follow the
instructions on your letter.

• You will be in theatre most of the day. Once on the ward, staff will ensure you are comfortable and monitor you closely.
• You will receive intravenous fluids and painkillers through several drip sites over the next one-to-two days.
• You will have a patient-controlled pain killers which allows you to control your own pain relief. This has a ‘lock out’ setting that does not allow you to give yourself too much, which we’ll show you how to use. You will also have an epidural.
• You may have a small tube in the wound to drain away small amounts of blood. You will have a mask or tubes in the nose to administer oxygen.
• A urinary catheter is inserted in theatre and will remain in place until you are mobile and able to get safely to a toilet.
• You will be allowed to sip water after the surgery and, if this is tolerated, you can have something light to eat. Nausea is very common after major surgery from the anaesthetic and some pain-relieving drugs. Please let the ward staff know as we can give you medication to help.
• You may be given laxatives to prevent or help with constipation which is another common side effect following major surgery

The day after surgery you will see a physiotherapist. They will encourage good movement in the bed; you may sit on the edge of the bed and if able stand with safe assistance. This is highly encouraged to prevent any post-operative complications and speed up recovery.

The physiotherapist will continue to work with you to build confidence and mobility. Once you are managing safely, you will be encouraged to practice climbing the stairs. Once able you will be allowed home, usually a week or more after surgery depending on your procedure and recovery.

You may see occupation therapist if you have advised us of any difficulties you may have on
discharge or the ward staff have any concerns.

Depending on your surgical procedure the above information and time frames may alter.

You will be in hospital for approximately one week depending on the type of procedure you
have and how quickly you recover. An x-ray will be taken prior to discharge and reviewed by the surgeons to check the positioning of the metalwork.

You will be given pain relief medication and possible laxatives to take home with you. You can travel home in a car on discharge but take breaks if it is a long journey. Please arrange
family or friends to take you home.

If you do not have access to transport inform the ward staff on arrival, they can arrange hospital transport home if necessary.

The ward staff will arrange a two-week wound check with either your GP practice nurse, community nurse or at the RVI fracture clinic. You will receive a letter through the post for a six-week clinic review after your surgery.

• Always sit in a high supported chair, increasing sitting times gradually as comfort allows. When lying down you should lie in bed with only one or two pillows. It is advisable to have a firm mattress if possible
• For the first six weeks you will be recovering from the acute effects of surgery including pain and increased fatigue levels. You should build up your time sitting in a chair, standing, and gradually increasing your walking. It is very important to move around to help speed your recovery.
• It is recommended that you do not lift any heavy objects, and be cautious with heavy kettles and laundry. When trying to pick things up, it is important that you lower your body gently by bending the knees, hips and ankles, while taking care not to twist the back
• You are able to return to gentle forms of exercise and gym activities at six months. Any strenuous activities or heavy lifting would be recommended from nine to twelve months; this would be guided by your consultant.
• Your sex life can be resumed when you are comfortable, this is usually about six weeks post operatively. However, avoid any vigorous sexual activity until your fusion is confirmed by your consultant.
• You can take short flights after six weeks and you should wait three months for long haul flights.
• You will be seen in clinic at around six weeks, three month, six months, one year and yearly as needed.
• If you notice any redness, swelling, oozing, pain or tenderness at the operation site, please contact us for advice using the numbers at the end of this guide, or see your community/practice nurse/GP.
• You may commence driving after consulting with your surgeon during your post-operative clinic review at six weeks. Legally, if your driving capability has been impaired, you must notify the DVLA, and it may also be necessary to inform your insurance provider about your surgery, as your coverage could be rendered invalid