Post operative care will vary from center to center but are basically the same:
- Slow mobilization: Prone position starting in recovery room for first 24 hours. This is then liberalized to alternating lateral decubitus positioning starting at 24 hours. Progressive head elevation starts at 72 hours post-SDR, after removal of the epidural catheter. The child is then allowed to sit in adapted wheelchair for 1 hour x 3 on postoperative day 4. Routine out of bed starts only on day 5.
- Decubitus risk: Careful care is needed with positioning to minimize the risk for decubitus ulceration.
Advance diet as tolerated: Start feeding as soon as awake and able to tolerate. Remember that after surgery most children will have reduced appetites.
- Bowel program: Be prepared for constipation. We prefer to only treat this after 5 days as the risk of wound infection from treatment induced diarrhea outweighs risks of constipation.
- Analgesics and muscle relaxants: Morphine and diazepam are given orally or parenterally for control of pain and painful spasms as well. At 72 hours, analgesia can be changed to oral codeine and acetaminophen. Dysesthesias due to deafferentation can be a problem, and this is discussed in morbidity below.
- Foley catheter removed after epidural morphine stopped: The foley catheter is removed 24 hours after the epidural morphine catheter is removed because the risk for urinary retention is then significantly reduced.
- Physiotherapy starting on postoperative day 3: Bedside exercises and stretching that avoids stretching back muscles around incision is begun on postoperative day 3. The initial focus is on the core muscles for standing and abdominal stability, quadriceps and gluteal muscles for hip extension and hip abduction. Twisting of the back is avoided. Therapy is initially begun in bed, transitioning to out-of-bed, light therapy sessions as the child is mobilized. Full therapy is usually instituted at the time of discharge from the acute care hospital.
- Rehabilitation center on postoperative day 5: Transfer to rehab center on postoperative day 5.
- Painful spasms: The incisional pain present after surgery may trigger spasms that will, in turn, exacerbate the pain, creating a vicious cycle of increasing pain. Parenteral pain medication may prove inadequate, and judicious use of muscle relaxants is often helpful for this problem.
- Dysesthesia: Approximately 40% of patients undergoing SDR will experience transient “pins and needles”-type dysesthesia in their feet after surgery for several weeks. Simply wearing socks while in bed may be all that is needed to manage this problem. The Cape Town group routinely prescribes gabapentin for a 6-week postoperative period to avoid this problem.
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