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As bowel function returns and patients are able to tolerate clear luids treatment 1st line discount zyprexa 10 mg amex, routine intravenous narcotics are replaced with oral narcotics as needed. On postoperative day 3, the drains are discontinued along with prophylactic antibiotics. Ater discharge, usually on postoperative day 4 or 5, patients may start to slowly resume activities. Complications Complications can occur during any of the treatment stages- preoperative, intraoperative, or postoperative. Hooks that do not hug the lamina or misplaced pedicle screws can lead to devastating complications, including spinal cord insults. Inappropriate decortication, inadequate bone grat material, and the use of bulky crosslinks can result in a higher rate of pseudarthrosis. Intraoperative neurophysiologic monitoring with somatosensory evoked potentials, motor evoked potentials, and/or descending neurogenic evoked potentials help alert the surgeon to any impending intraoperative spinal cord neurologic deicit. If intraoperative neurophysiologic monitoring declines past warning criteria, the surgeon should implement a course of action that includes ensuring that the irrigation being used is of adequate temperature, keeping mean arterial blood pressure elevated at a minimum greater than 80 to 90 mm Hg, and reversing instrumentation or spinal correction to the prewarning criteria state. If intraoperative neurophysiologic monitoring data do not return to baseline within a reasonable time, a wake-up test should also be performed to assess true neurologic function. In addition to adhering to the proven sequential technique of freehand screw placement, pedicle screw stimulation provides an added safety measure. Postoperative complications can arise from delayed consequences of technical errors, neurovascular compromise, medical comorbidities, and wound infections. Although perioperative antibiotics are commonly used, when wound infections do occur, they generally are treated aggressively with wound irrigation and debridement. Instrumentation well seated on the spine is always let in place; however, the decision to remove or maintain the bone grat is deined by the individual case and surgeon preference. With delayed or late infections, the instrumentation is initially removed and later usually replaced because the deformity can progress as the fusion mass is subject to repeated bending forces. Bracing of the juvenile idiopathic or skeletally immature adolescent idiopathic patient is still a viable option for those with curves between 25 degrees and 45 degrees. Brace compliance, the it of the orthosis, and the number of hours of brace wear per day are critical components to success, along with the genetic predisposition toward curve progression. Therefore, preoperative radiographic assessment should include not only upright radiographs, but also side-bending, supine, push-prone, traction (if applicable), and hyperextension (for hyperkyphosis) radiographs, alone or in combination. One must remember to include the thoracolumbar sagittal proile in preoperative planning to prevent misclassiication and incorrect surgical management. Satisfactory clinical and radiographic results can be achieved with selective thoracic fusions of properly selected lumbar C modiier curves. Disadvantages such as chest cage disruption (including suboptimal pulmonary function), risk of implants abutting the major vessels, and the ability to treat only a single curve at a time have limited these approaches over time. The use of posterior instrumentation and fusion with or without various forms of spinal osteotomies has become the mainstay for the surgical management of pediatric and adult idiopathic scoliosis deformities. All curve patterns can be managed by surgeons familiar with the classic midline posterior approach. Surgical outcomes are based on radiographic parameters and clinical assessments, such as scoliometer measurements and shoulder height, as well as patient-reported outcome questionnaires. The use of segmental pedicle screw ixation for the posterior treatment of pediatric and adult idiopathic scoliosis curves has become the primary instrumentation construct. In addition, thorough bone grafting with a combination of autogenous bone, allograft bone, and/or the use of osteobiologics, especially in the adult population, has become routine at many centers throughout North America. Optimal surgical outcomes in the treatment of idiopathic scoliosis deformities include proper patient selection, exacting surgical technique, and a well-balanced spinal alignment with minimal to no complications. Summary Understanding and treatment of spinal deformities has broadened; however, idiopathic scoliosis remains a diagnosis of exclusion. With advances in genetic mapping of idiopathic scoliosis, better understanding of the etiology and incidence of the disease is promising.

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For single-level fusion treatment management system order zyprexa overnight delivery, pass a 20-gauge wire through this hole and loop it around the inferior spinous process. For multiple-level and postlaminectomy facet stabilization, extend facet wires to adjacent facets. Tie facet wires to structural bone grats or metallic rods for additional stability. Multistrand, braided cables are stronger, more lexible, and more fatigue resistant than monoilament wire. Cable utilization increased ater reports of frequent fatigue failure, loosening, and bone cut-through with monoilament wires. If wires or cables break, the strands may penetrate the dura, leading to cerebrospinal luid leak or direct neurologic injury. Rigid ixation implies both a tight interface with the host bone and a rigid locking mechanism between the anchor and the longitudinal member (a plate or rod). Today, plates continue to be used because they are cheaper and lower proile than rod systems. Rods are more easily contoured and allow greater freedom in lateral mass screw placement. Finally, screw-rod systems permit the application of compression, distraction, and reduction forces within the construct. In cadaveric testing, plate failure occurred earlier and more likely fractured the superior lateral mass. Cervical hooks were initially used at the cranial end of long deformity constructs. Utilization for cervical pathologies has decreased with improved lateral mass systems and dedicated cervicothoracic junction constructs. Hook-plates provide one-level stabilization in which the screw is placed into the superior lateral mass and the hook captures the inferior lamina. Hook-plate designs remain practical for C6­C7 instabilities because they avoid screw placement in the thin C7 lateral mass. Biomechanical testing reveals that hook constructs are comparable to lateral mass screws in lexion and extension loading but less rigid in lateral bend and rotation. Lateral Mass Screws Most typically, rigid subaxial ixation relies on placement of lateral mass screws into C3­C6. Polytrauma patients typically beneit from the earlier mobilization and decreased bracing engendered by rigid stabilization. More rigid ixation should be considered in any patient in whom healing may be delayed, compliance is suspect, or multilevel fusion is required. Safe lateral mass screw placement requires familiarity with the articular pillar anatomy. Do not pass over the edge as bleeders in this region retract anteriorly and are diicult to control. Locate the center of the lateral mass by deining the notch between the lamina and the lateral mass. To decrease facet violation, Magerl recommended an entry point 2 to 3 mm medial and superior to the apex. He described a 25-degree lateral drill angle and a superior trajectory parallel to the facet (typically 45 degrees). Anderson,472 An,466 and others469 have described variations of entry site and angulation. When these trajectories were assessed in cadavers, the RoyCamille technique frequently violated neurovascular structures below C3, especially, with more lateral screw angulation, the nerve root. At C7, only the modiied Anderson technique (20­30 degrees of lateral angulation) was safe. Bicortical penetration improves failure resistance by 20% but increases root injury risk.

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Antiepileptic medications such as phenytoin and valproate have been linked to decreased bone turnover and decreased intestinal absorption of calcium medicine logo generic zyprexa 10 mg buy on line, resulting in osteopenia, which may afect implant ixation and should be considered in the selection of construct components. Drugs such as carbamazepine, phenytoin, and valproic acid can result in thrombocytopenia. However, other studies have shown that patients on valproic acid are not at increased risk of bleeding complications at surgery. Manohar and colleagues44 showed in a study of 84 children undergoing craniotomy for resection of seizure focus or hemispherectomy that none of the cohort showed signiicantly abnormal prothrombin time, activated partial thromboplastin time, or platelet count preoperatively. Poor upper airway tone and anatomic deviations can lead to increased risk of airway obstruction during and ater surgery. Patients may require a dietary change, placement of a gastrostomy tube, or a Nissen fundoplication with gastrostomy tube placement to control this aspiration tendency before undergoing spinal surgery. Reactive airway disease is common in these patients and may necessitate the use of preoperative bronchodilators and inhaled steroids. In addition, these patients may have chronic hypoventilation with carbon dioxide retention and poor oxygenation. Vital capacity that exceeds 500 mL and peak expiratory low greater than 180 mL/min are associated with decreased perioperative pulmonary complications. Although surgery may be considered in appropriately selected patients with preexisting respiratory failure, Chambers et al. If a patient cannot be assessed with formal pulmonary function tests, other signs of ventilatory capacity must be used, including crying, laughing, and other vocalizations. Many patients are malnourished secondary to a combination of relux, low calorie intake, and high metabolic demand from frequent illness. Malnourished patients are more prone to perioperative complications such as wound dehiscence, wound infection, and pulmonary complications. Conversely, older patients may be obese, presenting further operative complications associated with their body habitus. Nutritional status should be assessed preoperatively with albumin and total blood lymphocyte levels. Gastrointestinal Because patients with neuromuscular scoliosis are prone to gastrointestinal dysmotility, they are at risk for a postoperative ileus, requiring aggressive hydration, maximized nutritional status, and a rigid daily toilet regimen. In addition, some patients are very thin, and supine positioning and the acute straightening of their deformity put them at risk for superior mesenteric artery syndrome with obstruction of the duodenum. Although less common since the advent of segmental instrumentation and decreased use of casting, this prolonged obstruction carries signiicant morbidity; identifying at-risk patients and maintaining a high index of suspicion when encountering protracted vomiting is essential. Cardiovascular Patients may have cardiac problems secondary to their deformity and other cardiac issues that are comorbidities of the primary disorder. Hematologic Studies have shown that patients with neuromuscular scoliosis have greater blood loss than patients with idiopathic scoliosis undergoing similar procedures. In this neuromuscular group, the underlying disorder plays a major role in determining the extent of blood loss. Much of this diference is due to the requirement for larger fusions in patients with neuromuscular scoliosis, although osteopenia in these patients may also play a role. Patients should have partial thromboplastin time, prothrombin time, and platelet function evaluated as a part of their preoperative blood work. A more aggressive coagulopathy workup should be conducted if the patient has previously shown a tendency toward excessive blood loss. Chapter 28 Neuromuscular Scoliosis 477 For a posterior procedure, 2 to 4 units of packed red blood cells is generally suicient; however, the addition of a kyphectomy or an anterior procedure may increase this requirement. Intraoperative blood work may conirm a dilutional coagulopathy, necessitating the use of fresh frozen plasma, platelets, or cryoprecipitate to correct this imbalance. Several pharmacologic agents have been under investigation for their eicacy in reducing blood loss during surgery. Accurate measurements of the coronal Cobb angle, sagittal Cobb angle, and pelvic obliquity are crucial for complete preoperative planning and postoperative evaluations. In a more recent analysis of the interobserver and intraobserver variability of radiographic measurements of patients with neuromuscular scoliosis, Gupta and colleagues60 found that neuromuscular radiographs can be reliably analyzed with the use of the coronal Cobb angle. With the introduction of the Harrington rod in 1962, use of this instrumentation with fusion of the spine in patients with neuromuscular scoliosis became the standard. Series using only Harrington rods and posterior spinal fusion have been associated with high incidences of pseudarthrosis (19­40%), moderate initial correction (20­57%), and loss of correction ranging from 14% to 28%.

Syndromes

• Tricyclic antidepressants such as protriptyline or imipramine
• Iron poisoning
• Pain that does not go away
• Red and itchy skin
• Dizziness
• Blood tests, including tests to check liver function and for viruses that might affect the liver
• Drowsiness
• Infection in the brain
• If you are nursing, the doctor will probably recommend that you continue nursing. Breast-feeding helps prevent diarrhea, and it also speeds recovery.
• Have you been injured or in an accident recently?

In a more recent study of 21 patients with an average preoperative Cobb angle greater than 110 symptoms rotator cuff injury 20 mg zyprexa buy fast delivery. Previous abscess, pneumonia, and ipsilateral thoracic surgery may result in extensive pleural adhesions that would obstruct thoracoscopic visualization. Additionally, large and stif curves (scoliosis >70 degrees or thoracic bending >35 degrees) are relative contraindications. Patients with poor vertebral bone stock or insuicient vertebral size to accommodate the anterior screws are also inappropriate for this technique. Patients with a seizure disorder or mentally disabled patients who are unlikely to comply with postoperative instructions are poor candidates because of concerns about implant loosening with a single-rod construct. Since the visual ield of thoracoscopy is limited from T4 to L1, secondary structural curves in the cephalad thoracic and thoracolumbar regions that might require instrumentation beyond these endpoints should be ruled out. Since the irst thoracoscopic instrumented fusion of idiopathic scoliosis was accomplished in 1996, this technique has attracted considerable attention for the treatment of thoracic idiopathic scoliosis. Later, several authors also reported good scoliosis correction (mean, 55­65%) and cosmetic outcomes via this minimally invasive technique. Nevertheless, careful patient selection and the potential beneits and risks must be balanced before such surgery. Ater the patient has been properly positioned, a portable luoroscopy unit is brought into position to ensure that adequate radiographic visualization is possible. Prior to preparation, luoroscopy is used to plan the position of the skin incisions for thoracoport placement. One or two anterior portals are placed in the anterior axillary line to allow access to the discs for discectomy and for the scope as well as to assist in the application of spinal instrumentation. Spinal instrumentation and curve correction is performed under the guidance of Indications Anterior instrumented fusion has been thought to allow greater restoration of sagittal alignment and might be beneicial for thoracic scoliosis with signiicant hypokyphosis. Either a single-rod or dual-rod system may be used depending on the size of the vertebrae, concerns for rod breakage, and experience of the surgeon. However, biomechanical studies have suggested that dual-rod constructs are more stable than single-rod constructs. A screw path is initiated with an awl and tap, with the entry site in the middle of the vertebral body just 1 to 2 mm anterior to the rib head and approximately 10 degrees of anterior angulation. Penetration of the far cortex greatly enhances the ixation and is mandatory at the proximal levels to reduce the risk of screw pullout. Care must be taken to avoid placing successive screws increasingly anterior in the vertebral body because this may negatively afect ixation and restoration of kyphosis. Early studies reported high rates of pseudarthrosis, implant failure, and loss of ixation. A rod of appropriate length is cut and contoured to the desired level of postoperative scoliosis and kyphosis. Fully seating the rod into the screws may be accomplished with either a rod pusher or the use of a reduction device. As previously mentioned in the section on thoracoscopic release, autogenous grat provides the optimal base for a solid fusion and is recommended. An endoscopic suturing device is utilized to perform a running closure (2-0 suture) of the pleura. Nevertheless, it is associated with signiicant morbidity, yielding an opportunity for thoracoscopic techniques in select cases. However, loss of kyphosis correction and chronic pain have been demonstrated in some patients treated with posterior instrumentation alone. Twenty-six patients with acute burst fracture were included in the series and 23 of 26 patients (88. Tumor Of all spinal tumors, approximately 70% are located within the thoracic spine; 85% of these tumors predominantly invade the ventral vertebral body and anterior epidural space. Most patients resolve with nonoperative treatment, but for those with refractory radicular pain and progressive myelopathy, surgical intervention may be recommended.

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