Managing complications of posterior spinal instrumentation and fusion

Complications of posterior spinal instrumentation for adolescent idiopathic scoliosis are often preventable. Preoperative planning helps to minimize intraoperative and postoperative problems. Late recurrence of rotational deformity (crankshaft) in skeletally immature patients can be prevented by adding anterior surgery. Intraoperative complications are minimized by controlled hypotensive anesthesia and sequencing of surgical steps to allow for autocoagulation, reducing blood loss. Use of spinal cord monitoring, Stagnara wakeup test, and careful distraction decreases the risk of neurologic deficit. Good hook-site preparation helps avoid dural tears. The incidence of postoperative pneumothorax and hemothorax is decreased by careful hook attachment, avoiding pleural penetration, judicious use of rib excision thoracoplasty, and roentgenographic verification of central venous pressure line position. Postoperative recommendations include bed position at 30 degrees, frequent log rolling, incentive spirometry, early sitting and standing, early Foley catheter and nasogastric tube removal, prophylactic antibiotics, and prompt attention to wound infections. Postoperative orthotic wear, prescribed exercise, and activity restriction decrease the risk of early instrumentation failure and help correct early postoperative trunk imbalance. The late complications include suspected pseudarthrosis; this should be surgically treated again if there is persistent pain or marked loss of curve correction.