Preparation for Surgery for Spinal Lipoma in Children

Indications for Procedure

The indications for surgery for lumbosacral lipoma are controversial. The following points should be considered:

• Asymptomatic lipomas: At least 30% of infants appear asymptomatic at presentation. At least half of this group will develop symptoms during follow-up (10) . Transitional, chaotic, and caudal/terminal lipomas appear more prone to develop symptoms.
• Symptomatic lipomas: For children with symptoms — particularly symptoms that are new or progressive — surgery is indicated. On the other hand, symptoms that have been present since birth are unlikely to be reversed by surgery.
• Reason of clinical progression: The pathogenesis of deterioration in lumbosacral lipoma includes tethering of the spinal cord (which can be improved by surgery) and congenital dysplasia of the conus (which is unlikely to be improved by surgery).
• Risk of surgical intervention: Surgery carries a risk of causing new, potentially permanent neurological and urological deficit. The risk of deterioration following partial debulking of lipomas may be worse than natural history, but at the same time, aggressive resections carry higher risks. This higher risk should be counterbalanced by a higher likelihood of progressive deterioration over time as the child grows to adulthood.

Preoperative Orders

When preparing the patient for spinal lipoma surgery, consider the following:

• Antibiotics: Prophylactic antibiotics are administered concomitantly with anesthesia induction. The choice of antibiotic should be determined by local policy.
• Surgical site preparation: Employ standard protocols for cleaning and preparing the surgical site to mitigate infection risks. A preoperative antiseptic bath is recommended.
• Catheter: A urinary catheter should be placed at the time of surgery, irrespective of urological status.
• Thromboprophylaxis measures: Thrombosis prevention treatment should be initiated in older children.
• Equipment and devices: Ensure the availability of appropriate neuromonitoring  tools (See Ancillary/Specialized Equipment (11).

Anesthetic Considerations

• Accommodations for IOM: Lumbosacral lipoma surgery requires TIVA, avoiding the use of muscle relaxants and volatile anesthetic agents to facilitate IOM and mapping.

Devices to be Implanted

• Duroplasty: For dural expansion, a dural graft is advocated. The authors prefer bovine pericardium.

Ancillary/Specialized Equipment

• Radiography: Intraoperative fluoroscopy is useful for determining anatomical levels, particularly in cases where external cutaneous markers are absent or minimal.
• Ultrasound: Intraoperative ultrasound can be employed before opening the dura to ensure adequate surgical exposure, confirming that at least one level of normal spinal cord is included above the upper margin of the lipoma.
• Magnification tools: Surgical loupes, in combination with an operating microscope, are recommended to enhance precision during the procedure.
• IOM: Neurophysiological monitoring and mapping are crucial to the success of lipoma surgery, aiding in the preservation of nerve function and improving surgical safety.