Recovery After Surgery for Metabolic Bone Disease in Children

Postoperative Orders

• Neurological observations of limb function: Motor and sensory assessments are carried out every 30 minutes immediately after surgery. The frequency of observations is then tailored according to the level of the surgery and the child’s clinical progress. Neurological evaluations are vital in the postoperative period, and therefore mechanical ventilation postoperatively is to be avoided where possible.
• Ventilatory drive at risk: Surgery in the region of the cervicomedullary junction and upper cervical spine may result in reduced respiratory drive. There may also be pre-existing respiratory compromise due to interstitial lung disease or restrictive ventilation that has developed as a result of a thoracic deformity. Either creates an additional risk factor for respiratory complications during recovery. The child should be monitored in an intensive care or a high-dependency (step-down) facility in the immediate postoperative period.
• Analgesia provided with NSAIDs after first 1–2 days: Intravenous opiate analgesic infusion is used in the immediate postoperative period. This administration can be adjusted according to need and tapered in favor of NSAIDs.
• Antibiotics: Prophylactic antibiotics are indicated. The author’s recommendation is flucloxacillin and amikacin at the time of induction of anesthesia, and two postoperative doses of each. Local antibiotic prophylaxis policy should be discussed with a microbiologist.
• Imaging to document spine alignment, fixation, and decompression: Spine x-rays are indicated to evaluate any spinal instrumentation. CT scan through the operative levels is indicated following decompressive procedures.
• Spinal orthoses needs vary: Orthotics are tailored to the clinical situation. After successful instrumented rigid fixation, no additional orthotic support is routinely required. Cervical collars provide minimal mechanical support but may be a useful adjunctive measure in early postoperative pain control. Custom molded orthoses are indicated for very young children and infants. Halo-body orthoses are useful for craniocervical immobilization where immobilization is required to allow healing of autologous onlay grafts.
• Mobilization: Mobilization can usually be commenced as soon as pain control permits.

Postoperative Morbidity

• Discomfort of orthoses: Children undergoing major spinal surgery should be appropriately prepared, particularly if a halo-jacket or external orthosis is anticipated after surgery.
• Pain: Postoperative pain is common. Intravenous infusion of opiate analgesia is usually required in the first 48–72 hours.
• Blood loss: Blood loss from spinal surgery can be substantial. Ongoing losses postoperatively need to be monitored and appropriately replaced.
• Immobilization: There is no advantage to prolonged bed rest after spinal surgery. Early mobilization should be encouraged as soon as pain control permits.