You have developed a curvature of your spine called scoliosis. Scoliosis and other back problems are treated by a bone and joint specialist called an orthopaedic surgeon. The purpose of this booklet is to give you some information concerning scoliosis and possible treatments. We hope that knowing a little bit about scoliosis treatment will help you and your parents be better prepared for your visit with the orthopaedic staff

What is Scoliosis?
Scoliosis is a problem with your backbone, or spine, causing it to bend sideways and twist. Scoliosis can occur in either the upper back (thoracic), lower back (lumbar), or very rarely, in the neck (cervical region). Idiopathic scoliosis (scoliosis of an unknown cause) is the most common type of scoliosis in the United States. Eighty percent of diagnosed cases are of the idiopathic type. Idiopathic scoliosis is usually noticed at the onset of puberty and is more often seen in females. People with scoliosis often have uneven shoulders or hips, and a shoulder blade which sticks out. Changes are especially noticeable when the person is bending over. Most scoliosis is found during school screening.

Treatment
If the spinal curvature progresses despite the use of conservative measures such as bracing, the doctor might recommend surgery called a "posterior spinal fusion with instrumentation." The purpose of this surgery is to halt progression of the curve and stabilize that portion of the spine. Doctors recommend surgery when the curve gets to a certain size, usually 45-50 degrees. If the curve is getting bigger and it's not treated, it can cause physical deformities and possibly lead to back, lung and heart problems in later years.

How the Surgery Works
Deciding to have surgery is a big decision and can be very frightening for you and your family. This booklet was prepared to answer your questions about surgery if you and your doctor decide it is necessary. If you have any further questions, please write them down so you will remember to ask your doctor.

Risks Related to Surgery
There are always risks involved with the surgery itself, and with being put to sleep during surgery. Some of these risks include the possibility of infection or problems with the metal rod the doctor will attach to your spine. The chance that these complications will occur is very low, and we do everything we can to prevent them. The doctors and nurses will make sure you know what the risks are and answer all your questions before surgery.

To straighten your spine, the doctor attaches two stainless steel rods to either side of your spine by hooks attached to the vertebral bodies. A piece of bone from your hip (a bone graft) will be applied to portions of your spine to fuse it. This bone will grow into the spaces between your backbones (vertebrae) and will hold them straight, acting like a cement. This is called a "spinal fusion." Until these bones heal together, they need to be supported and kept from curving again. This is the purpose of the rods. The rods are attached to your backbone and hold everything straight until the bones are fused together. Many types of instrumentation (rods) are available including the Cotrel Dubosset (CD) and Moss Miami (MM), which are used at this hospital.

X-rays taken before surgery will tell the doctor where on the spine to put the rods and hooks and how long and how curved to make the rods. By using two rods, your curve can be straighten back to front and side to side. Casting or bracing is usually not necessary after surgery.

Before Surgery
All patients lose some blood during surgery, and sometimes you need to get some back afterwards. You may get blood either from our blood bank, or, if you're medically able, you may donate your own blood prior to surgery. Then if you require transfusions, you will receive your own blood. This is called autologous blood donation. The first unit of blood must be given within 42 days of the surgery and the last, not less than seven days before your surgery. Your doctor usually asks that patients donate four units of blood. You may be asked to give the first unit of blood here at the University of Iowa Blood Bank. You and your parents will have all your questions about donation answered and will sign the necessary paperwork.

The blood bank staff will then attempt to make arrangements to have the rest of the blood drawn nearer your home. Blood taken elsewhere is transported here automatically, so you will not need to be involved with this.

When donating blood, you may not be on antibiotics and you must be healthy, without a cold, flu or infection, as you could get this same illness when your blood is given back to you. Eat a nourishing meal two to four hours prior to donation, and avoid strenuous exercise for twelve hours following the procedure.

The blood donor center will check your blood counts before drawing any blood. To help keep your red blood cell count high, you'll get a prescription for iron tablets. Iron may cause you to be constipated, so it is a good idea to increase the fluids, fruits and vegetables in your diet.

What Happens on the "Work Up" Day?
One to three days before surgery you will come to the Orthopaedic Clinic for what we call your "pre-op workup." You can plan on being at the hospital approximately five hours on this day. The doctor will listen to your heart and lungs, and in general make sure you are in good shape for surgery. If you are sick on this day, or a few days before, notify the doctor or nurse. Your surgery might have to be postponed if you are sick.

The nurses and doctors will ask you and your parents some questions and answer any questions that you may have. This will enable them to give you the best care while you are hospitalized.

Urine and blood samples will be obtained. We will give you a bracelet that matches you to your blood sample. You may either put the bracelet on when your blood is drawn or take it home with you and put it on before you come for your surgery. It is very important to keep the band clean and dry so that your name and hospital number are legible. Remember to have the band with you on your surgery day, or another blood sample will need to be taken.

You will have several x-rays taken. A medical photographer will take some pictures of you and your back, so we can compare how you look before and after surgery.

You may need to go to a special laboratory for an EEG (electroencephalogram) so we can check the nerve messages going through your spine before and during your surgery. The technologists do this by attaching special wires to your head and your legs. This doesn't hurt. The wires will be removed after this first test, and then put back on the day of your operation.

You will also spend some time talking to the surgeon who will do your operation, as well as to the doctor who will be putting you to sleep. This doctor, the anesthesiologist will explain to you how they put you to sleep, and will answer any questions you might have about that. You will talk about any medications that you take on a daily basis. The anesthesiologist may instruct you to take these medications with a small sip of water the morning of your operation. You should tell the doctors or nurses about any allergies you may have to medications, foods, tape or latex (rubber products).

The nurses will describe what will happen the day of your surgery and give you general information about being in the hospital. You should make plans to be in the hospital for 7 days.

We will teach you how to use a small breathing device (incentive spirometer or voludyne. You will use this device after surgery to 'exercise' your lungs by making you cough and breathe deeply. Coughing and deep breathing are extremely important to help clear your lungs and prevent pneumonia. We will also teach you how you'll need to roll over after your surgery. This is called logrolling (turning as a unit). It's a good idea to practice rolling like a log so it'll be easier to do later. The nurse will also teach you leg and ankle exercises to keep the blood moving in your legs while you are recuperating. We'll also make sure you know the various ways we'll monitor and treat any pain you might have. One of these methods is called a PCA pump (patient controlled analgesia), which is a machine to give you pain medicine through a needle in your arm. We'll give you a booklet about the pump so you'll know all about how it works. We'll also talk to you about pain rating scales we use to find out how well the pain medicine is working.

The operating room people will call you the day before your surgery to let you know what time you need to be at the hospital. You do not have to spend the night before your operation in the hospital.

The nurse will give you two scrub brushes with iodine soap in them. You'll use them to scrub your back and right hip on the night before surgery and then again the next morning. This will help remove any germs on your skin and cut down on the risk of infection. If you are allergic to iodine, please let your clinic nurse know and we can give you some other kind of soap. You can do the scrubs in the shower or tub, but will need help from another person to make sure you get everything really clean. You will need to wash your hair the night before surgery, and remove any finger or toenail polish.

Your stomach needs to be empty when you go to sleep. Therefore, you may not eat or drink anything after midnight the night before surgery. This will help keep your stomach from getting upset afterwards. You may want to avoid salty foods the night before surgery to prevent waking up really thirsty.

You cannot have a sunburn, bad rash, or sores on your back at the time of surgery, as this could be a potential source of infection.

Please feel free to ask any questions you might have (even if you think they sound silly or stupid). We want to make sure you know everything you need to before you leave the hospital on your workup day.

The Day of Surgery
Before you come to the hospital, you need to wash your back again with another scrub brush for five minutes. Go ahead and brush your teeth and rinse out your mouth, but do not swallow the water. Do not chew gum.

When you get to the hospital, you'll need to check in at the pre surgical area on the 5th floor (Elevator H). The nurse will record your vital signs (temperature, pulse and blood pressure), talk briefly with you and apply your identification and blood bands. You'll get into a hospital gown and the nurses will help you onto a special bed. From here you will go back to the EEG lab, where they will put the special monitoring wires on your head. Sometimes they will put these wires on in the operating room. The operating room transport person will take you to the 5th floor Presurgical Care Unit (PSCU) when it is time for your surgery.

Surgery
While you are in surgery, your family can wait for you in the Boulware Day of Surgery Lounge (Elevator H to 6th floor). The doctors will talk to them periodically during and after your operation and let them know how you're doing.

A nurse will greet you as you arrive in the operating room. The room is sometimes cool and noisy. Please let the nurses know if you are not comfortable. Warm blankets are available. In the operating room, you will be connected to many monitors and a needle will be put into a vein in your arm. This is called an IV. The anesthesiologist will give you medications to put you to sleep. A mask may be placed over your nose and mouth to help you breathe. After you are asleep a tube is placed in the back of your mouth and throat to provide air to your lungs. This tube will be removed before you wake up. Once you are asleep, the doctor will begin the operation. You will lie on your stomach on the operating bed with your arms and legs supported with pads. Your back will be scrubbed before starting the operation. The operation generally takes 4 hours, but you will be in the operating room a total of 4 5 hours.

A tube, called a Foley catheter, is placed in your bladder while you're asleep. The Foley drains urine from your bladder so the nurses can measure it, and keep track of how well your body is getting rid of fluids. This tube will be removed on Post-op Day 3 (the third day after your surgery). After it's out, you'll be able to use the bathroom normally.

A drain is placed in the incision during surgery. This is called a Hemovac. It's a small tube that drains excess fluid from your back into a little collection container. The doctors will remove it on Post-op Day 2. There is a mild burning feeling when the drain is removed.

Post Anestheia Care Unit (PACU or Recovery Room)
When you wake up you will be lying on your back in the recovery room area. You'll already be in your bed. You may feel stiff from being in one position for a long time. A nurse will check you frequently and make you comfortable with warm blankets. You will receive oxygen and be encouraged to cough and deep breath to help clear your lungs.

The nurse may ask you to rate your pain on a scale of 1 to 10 and will give you pain medicine to make you comfortable. It's also not uncommon to feel sick to your stomach after surgery just let the nurse know we have medicine for that, too.

You'll have some more x-rays while you are in the recovery room.

You will be in the recovery room for 2-4 hours, or until the anesthesiologist says you're awake enough and doing fine. If you are 16 or younger, your parents or 2 adults may see you in the recovery room.

If the doctor thinks you need to be hooked up to monitors overnight (in case of breathing or heart problems) you will go to the Pediatric Intensive Care Unit (PICU).

Your parents may see you in the PICU. Your doctor will decide when you are ready to come to your room on the Orthopaedic Unit from either the PACU or PICU. You will be taken to the Orthopaedic Unit in your bed.

Orthopaedic Unit After Surgery
After surgery the nurses will frequently take your vital signs (blood pressure, temperature, respiration rate, and pulse). This is so important that they'll even wake you up at night to do it.

The doctors and nurses will be touching your hands and feet, and asking if you have any numbness or sleepy sensations in your arms or legs. Let the nurse or doctor know if your arms and legs tingle or feel numb or just plain funny.

The IV that was started in the operating room will give you fluids during and after surgery. The IV will remain in until you are able to eat and drink, usually 4 to 5 days after surgery.

During surgery the anesthetic slows the motion of your intestines and may cause you to be nauseated or even vomit after surgery. The nurses will listen to your stomach every few hours to determine if your bowels are working again. You may not drink anything until your bowels are returning to normal. This may take up to 4-5 days. You may rinse your mouth out with water and brush your teeth. If you drink or eat before your bowels are ready, you may become nauseated and bloated.

You will have pain medicine to keep you comfortable. For the first few days, you'll get this medicine through your IV using the PCA pump. The PCA is a computerized pump that has a tube of pain medicine inside. This tube is attached to your IV line and gives you a small amount of pain medicine continuously. You can push a button if you need a little extra medicine. If you are unable to push this button, either a family member or a nurse can push it for you. You may need an occasional shot for pain along with the PCA. This depends on how severe your pain is. Usually the PCA medicine keeps you comfortable and you don't need any extra shots. Your PCA will continue until your stomach wakes up and you are able to drink and take pain medicine by mouth. Antibiotics will also be given through your IV. The Antibiotics will decrease the chance of infection.

The antibiotics will continue until one dose after your hemovac drain and foley catheter are removed. We'll take a sample of blood from you each morning after surgery for 3 days to check your blood count. If you're short on red blood cells, it might be necessary to give you a blood transfusion. In the operating room a big bandage is applied to your back. This will be changed on Post-op Day 2 and removed on Post-op Day 3. The stitches used to close your wound are under your skin. Your body will just absorb them, so they do not have to be removed. On top of your skin will be pieces of tape called steri-strips- these will gradually fall off on their own after you go home.

The day of surgery you will be flat in bed. The nursing staff will help you move from side to side by logrolling every 2 to 4 hours. When turning, your shoulders and hips must go all at the same time, like your back is one big log. We'll help you to move either onto your back or your side and will use pillows to keep you comfortable. You'll sit up in bed 3 times on the day after surgery with your hips flexed at 90 degrees. You need to go slow to get your body used to sitting up again. The second day after surgery you will get up into a chair 3 times. On Post-op Day 3, you will be up walking with assistance. You will gradually find it easier to get around. You'll also go to Physical Therapy to get assistance with walking and going up and down stairs.

The nurse or your parent may help you with your bed bath for the first few days. However, it is important that you do as much as you can for yourself to keep your arms and legs from getting stiff.

A Child Life Specialist will come to your room and offer you activities to do while you are in bed. When you can be up and out of your room, you will be invited to attend group activities in the playroom.

During your hospital stay, your parents will be taught how to take care of you. The nursing staff will encourage them and you to do as much as you are comfortable with. Please ask the nurses about anything that you may have a question about.

Going Home
We'll take X-rays of you standing up before you go home. This is usually 5-7 days after surgery if no problems arise. No cast or brace is usually necessary following surgery.

Keep your incision clean and dry. The steri strips will gradually fall off. You may shower two weeks after surgery if your back incision is well healed and has no drainage. Direct the water stream on your front and shoulders, letting it trickle down your back. Do not direct the water stream on your back incision. Your back incision may be numb for 4 to 6 months.

We'll send you home with a prescription for pain medicine. You should also continue taking your iron as you were before surgery.

No lifting greater than ten pounds (examples: 2 five lbs. sugar or 2 gallons of milk). No bending, stooping, or twisting. No lying on your stomach for six months.

No driving for the first six weeks. Always wear your seatbelt.

You may return to school in 2-4 weeks depending on how you feel.

Walk for exercise as tolerated, gradually increasing the pace and distance. Continue leg and ankle exercises. Jogging may be resumed in 4 months.

If sexually active, do not resume this activity until checking with your doctor at your 6 week follow-up appointment. Surgery may cause irregular menstrual cycles.

Light exercise (like swimming - no diving) may be resumed in two months. Stationary bike riding may be resumed in 3 to 4 months. Sit upright when using a bike. You may not participate in contact sports for 6 months or until given permission by your doctor.

Your first return appointment will be about 6 weeks after your discharge from the hospital, then 4 months, 6 months, and one year after surgery, and then every year after that. It's really important that you return for your scheduled appointments.

If any of the following problems occur, please notify your doctor:

• fever, chills, redness, warmth, or foul smelling drainage at the surgical site.
• increase in pain.
• numbness, tingling, or weakness in your arms or legs.
• change in bowel or bladder control.

We hope you've found this booklet helpful. Please let us know if you have any questions or concerns. The orthopaedic nursing staff can be reached at (319) 356-3844 (Orthopaedic Clinic). The orthopaedic surgeon can be reached at (319) 356-1872, 8 a.m. to 5 p.m., Monday through Friday. If you have urgent questions at any other times, please call (319) 356-1616, and ask to speak with the orthopaedic resident on call. If you need to change or confirm your return appointment, call Orthopaedic Scheduling at (319) 356-2223.