Anterior Spinal Fusion to Cystic Hygroma (Lymphatic Malformation) Excision

Summary

COEXISTING DISEASE

1. ▪ Congenital: vertebral anomalies, rib anomalies, spinal dysraphism (neural tube defects)

2. ▪ Idiopathic: infantile (<3 years), juvenile (3–10 years), adolescent (>10 years)

3. ▪ Neuromuscular disease: CP, polio, myopathies, syringomyelia, Friedrich's ataxia

4. ▪ Associated syndromes: neurofibromatosis, Marfan's, osteogenesis imperfecta, JRA, mucopolysaccharidosis

5. ▪ Neoplastic: primary or secondary disease

6. ▪ Cardiac: hypertension (enlarged RV, RV Failure), mitral valve prolapse (25%)

7. ▪ Pulmonary: tachypnea, wheezing, crackles – symptoms when Cobb angle >65°

PREOPERATIVE ASSESSMENT

1. ▪ Determine location & degree of curvature (Cobb's angle), etiology of disease, exercise tolerance, respiratory symptoms, co-existing disease

2. ▪ Neurologic: document deficits

3. ▪ ECG, ECHO – assess structural disease, RV, pulmonary pressures

4. ▪ Pulmonary function testing, CXR, ABG if severe

5. ▪ Labs: CBC, coags, lytes, type & cross, autologous donations

PROCEDURAL CONSIDERATIONS

1. ▪ Location dictates position & approach.

2. ▪ Cervicothoracic (T1-T3): supine, possible removal of clavicle, manubrium & 1st rib

3. ▪ Endangers great vessels, thoracic duct, nerves (brachial plexus, sympathetic chain, vagus, phrenic), esophagus, trachea, heart & lungs

4. ▪ Requires one lung ventilation

5. ▪ Blood loss may be rapid & large.

6. ▪ Thoracic (T5–10): lateral decub, thoracotomy, DLT helpful

7. ▪ Transdiaphragmatic (T10–12): approach may be retroperitoneal & transthoracic

8. ▪ Lumbar: combined with posterior repair or as part of 2-stage repair

9. ▪ Lateral decub retroperitoneal, or supine transperitoneal

ANESTHETIC PLAN

1. ▪ Induction: dictated by patients clinical condition

2. ▪ NMB: short acting agent to enable neuromonitoring

3. ▪ Maintenance: TIVA, suggest propofol, remifentanil

4. ▪ Monitoring: std + A-line +/-central line

5. […]