Spinal Column Shortening
Why is this surgery done?
Spinal column shortening is done on patients with secondary tethered cord syndrome. Tethered cord syndrome (TCS) is a disorder involving abnormal stretching of a tethered spinal cord caused by several pathological conditions. It is thought to result from mechanical stretch at the end of the spinal cord, causing harmful changes in blood supply and metabolism. Untethering (tethered cord release) is the gold standard treatment for TCS. However, untethering carries risks of spinal cord injury and re-tethering.
Repeat tethering of the spinal cord is common after the first surgery as fibrous tissue develops. This can lead to recurrence of symptoms in as many as 25% of patients. The management of the recurrent TCS is significantly more challenging because of scar tissue and adhesions to the spinal cord, dura and spinal nerve roots. A second surgery for recurrent tethering is associated with increased operative morbidity related to progressive neurological decline in up to 50% of patients.
Spinal column shortening is an alternative procedure to avoid these risks. It has been shown to successfully help reduce the spinal cord tension seen in tethered spinal cord syndrome without causing direct neural damage and can help stabilize the patient’s symptoms and/or help delay neurological decline.
How is spinal column shortening done?
The surgery for spinal column shortening involves removal of a vertebral body or a large portion of one of the spine bones. This procedure reduces traction on the spinal cord by shortening the length of the spinal column. The goal of the surgery is to shorten the spinal column by 1.5 to 2.5 cm. to obtain relief of traction on the spinal cord and nerve roots. This procedure can reduce the risk of cerebrospinal fluid ( CSF ) leak and direct spinal cord injury.
Some of the joints of the spine and disc are removed and rods and screws are placed to help fuse the missing bone area. This fusion will likely be assisted with placement of bone graft material. Special monitoring is used throughout the procedure to make the surgery as safe as possible.
What are my child’s risks? What are common complications?
The risks include but are not limited to a small amount of bleeding, infection (especially if your child picks open the incision), cerebrospinal fluid leak (low risk), new neurological deficits (such as worsening bowel and/or bladder function, leg weakness) or persistence or worsening of existing deficits and anesthetic complications. Pseudomeningocele (a collection of CSF fluid under the skin) and CSF leakage are the most common complications after an untethering procedure.
What do I need to know before surgery?
- Prior to surgery, a urodynamic study is needed to assess bladder function. This test is preformed by the urology department. This will tell us if the child has bladder dysfunction (i.e., a neurogenic bladder with small bladder capacity and uninhibited contractions) that may improve with a tethered spinal cord release. This study will also provide us with a baseline for future comparison.
- You will receive communication before coming to the hospital with specifics on where to go the day of surgery and specific instructions for the day before and day of surgery. This information will include details about home medications and when to stop eating and drinking.
- The length of surgery will depend on the degree of difficulty of the surgery. Your child will spend at least 2 – 3 nights in the hospital. The first night will be in the pediatric intensive care unit (PICU) for close monitoring. Your child will come out of surgery very sleepy and their medical team will likely give them medicine that makes them extra sleepy for the first 12 hours after surgery to help with pain control. Your child will have a tube in their bladder (Foley catheter) to drain their urine while sedated and also additional monitoring devices to closely monitor their blood pressure and heart rate. Your child will be allowed to drink and eat slowly as soon as they are able, and they will be allowed to get up out of bed as soon as they are awake and the extra monitoring devices and bladder catheter have been removed.
- In some circumstances, your child may have drainage tube placed at the site of surgery for drainage of blood away from the wound.
- The Foley catheter will remain in place until the child can get out of bed to go to the bathroom.
- Your child will be given intravenous (IV) fluids, IV pain medications and IV anti-nausea medication until they are able to take medications by mouth.
- IV antibiotics will be given for 24 hours after surgery.
- Steroids will be ordered for the first 48 hours through the IV. Steroids can upset the stomach, so your child will be given medication to help to decrease this.
- Your child will be started on a bowel regimen immediately after surgery to prevent constipation.
Our staff are specially trained on this diagnosis and experts in the care of secondary tethered cord syndrome. We know it can be a scary time, and we have a team of medical professionals available to answer any questions or discuss any concerns that you might have.
General discharge instructions
- In order to be discharged from the hospital, your child will need to be able to urinate without any problems. They must be able to tolerate oral/tube feeds without vomiting. Their pain must be able to be controlled with oral pain medications. They need to be passing gas and have a bowel movement. Your child should be fever free for 24 hours.
- The course and length of stay is variable in this patient population. It can range from 3 – 5 days to up to a month depending on any complications that were present prior to or after the surgery.
- Your child may need to go to outpatient physical and/or occupational therapy once discharged from the hospital. The social worker will help set this up as close as possible to your home.
- A child is usually out of school for at least two weeks while they heal. Some children may require a more specialized time frame.
- A child is not to participate in any sports, and must keep their feet on the ground at all times (no swinging, jumping, climbing or running) for 4 – 6 weeks after surgery, until they are cleared in clinic.
What should I expect while my child is recovering?
- There will be a follow-up appointment with neurosurgery two weeks after the surgery or sooner if needed.
- Reasons to call the neurosurgery office include: if the incision has any swelling, redness or drainage; fever of 101.5 degrees F or higher; seizures; persistent vomiting; worsening pain; trouble going to the bathroom; or any numbness, tingling or weakness in the arms or legs.
- The region of the incision is typically sore after surgery. This should gradually improve and be relieved by the oral pain medications prescribed for your child.
- Tiredness and fatigue are also very common and will gradually improve with time. It is common for it to take up to three months before your child feels back to normal. Make sure they have plenty of rest during the day and eat healthy foods (avoiding candy, soda, and fast food). Set a regular bedtime and wake-up time to ensure they get plenty of sleep.
Possible physical therapy exercises
Your child will be evaluated by a physical therapist and occupational therapist typically on the first day after surgery to help them with ambulation and to determine their needs when they go home.