Dr. Luhmann's Neuromuscular Spine Education Booklet

Spinal Fusion

You are going to have a spinal fusion. This decision has been reached by you, your family and Dr. Luhmann. There a 3 types of spine fusion; posterior (from the back), anterior (from the front), and anterior-posterior. Dr. Luhmann typically does surgery from the back (posterior).

Preparing your Home

After surgery, you cannot sleep on a waterbed, couch, or on a mattress on the floor.
Shopping for snacks and drinks for home after surgery.
Arrange home to allow room for wheelchair/equipment use.

Planning for Discharge
You may need equipment at home after surgery. The doctor, nurse, and physical therapist will review each child’s individual needs after surgery to decide what equipment will be needed. Common equipment needs include: wheelchair, bedside commode, hospital bed, shower seat, hover lift and wheeled walker. If you are currently working with a company, please inform the staff.

Common Questions

When to notify Dr. Luhmann’s office ASAP before surgery?

Illness or hospitalization prior to surgery (within one month)
Skin break down or Acne on back.
Significant weight loss/feeding intolerance within one month of surgery date.

What do I need to bring to the hospital?

Current list of medications, dosages and frequency.
Personal items of comfort (blanket, pillows, books, movies).
Toiletry items you feel you will need during your stay.
Comfortable clothes for day of going home.

Can my mom, dad or caregiver stay at the bedside?

In the Pediatric Intensive Care Unit (PICU) two people can visit at a time, but only ONE person can sleep in the room with the patient.
Parents can also sleep in the PICU lounge.
10^th floor, regular inpatient- If there is availability, patients have their own room and both parents are welcome to sleep at the bedside. If there is a roommate, only one parent can sleep at the bedside, and the other parent can sleep in the lounge on the 10^th floor.

What do we do the night before surgery?

If you live far, you may want to stay at a locally at a hotel or with family or friends, because you will be required to be here early (about 6 am).
The patient may not have anything to eat or drink after midnight-this includes candy, mints, gum, water, etc.
Please shower thoroughly shampooing your hair the night prior to surgery and be sure to use the antibacterial back wash for the last night.
Please remove any nail polish, and be sure your nail beds are clean for surgery.
Please let surgeon and anesthesiologist know about all medications!

Please STOP:

ALL NON-STEROIDAL ANTI-INFLAMMATORY medications/arthritis medicines (such as Advil, Aleve, Ibuprofen, Motrin, Clinoril, Indocin, Daypro, Naprosyn, Celebrex, Vioxx, etc.) two weeks before surgery. Tylenol products are suggested for pain. If you are taking aspirin for any reason, please inform anesthesia and our staff. Anesthesia staff will let you know which of your current medications should be stopped prior to surgery and what meds your child should take the morning of surgery.
STOP SMOKING!! Family members should not smoke in the household. It impairs wound healing.

Surgical Timeline

Patients are asked to bath/shower (chin to toes) with antibacterial soap (Hibiclens) for the 3 consecutive days prior to surgery.
Your child will be screened for staph via nasal swab. We will call you with instructions if this is positive.
Some patients need a special IV placed the day before surgery (PICC line). This is done the day before surgery by interventional radiology, located on the 7^th floor, and patients go home afterward.

Dr. Luhmann: will see you at the preoperative visit. He does not typically see patients the day of surgery until they are in the operating room. If you have questions prior to surgery please, call Marie or Jenn at (314) 454-4191.

Morning of surgery:
The 6^th Floor Same Day Surgery Unit is where you and your family will begin your journey. The day of surgery you will be able to meet with the anesthesiologist, child life therapist and nurses.

Your weight, height and vitals signs will be obtained.
You may be given medication prior to surgery by the nurse to decrease anxiety.
You may have an IV catheter placed in a way that is as “Ouchless” as possible.
Your parents or the nurse will wipe your back with antibacterial wipes prior to going to the operating room.
Girls will have to give a urine sample, if able.

Operating Room:

You will go to sleep first.
You will have additional IVs and lines placed.
We will put a catheter in your bladder.
Spinal cord monitoring team will place electrodes on your body to check for spinal cord function throughout the surgery.
You will have pain medication that will keep you comfortable at all times during the surgery.

Family Waiting Room:
Parents will be in the Same Day Surgery waiting room in either a cubicle or a room. Parents are called every couple of hours during the surgical procedure to notify them of where their child is in the process of the surgery. Parents are given a pager if they leave the area that works ONLY in the hospital.

Post Anesthesia Care Unit (PACU):
We will wake you up when the surgery is complete. You will then be wheeled in a bed to the PACU (recovery room) or taken to the Pediatric ICU directly. When you are awake, we will bring your parents to the bedside.

Pediatric Intensive Care Unit (PICU):
It may be determined that your child needs to go to the PICU after surgery. If so, they will typically stay 1-2 nights in the PICU. The PICU is set up to allow close patient monitored care. Parents are allowed to visit, and one parent is allowed to sleep in the PICU. There is a parent lounge with lockers to hold personal items and chairs that pull out for sleep. Visitors are limited to two at a time.

Surgical Floor/ 10^th Floor:
Patients are typically transferred to the 10^th floor which is home to the orthopedic patient after the night in the ICU. There are both single and double rooms. You may have a roommate.

The 10^th floor has a small kitchen with a refrigerator and microwave for family use.

There is also a Ronald McDonald family lounge on the 5^th floor that is also available

Pain Control:
Patients will have pain. We try to keep pain low; ideally no more than a 5 out of 10.

Your pain will be managed by the pain service team. The pain service team is a special team of doctors (anesthesiologists) and nurse practitioners who are trained in monitoring and treating your Post-Operative pain medication.
24-48 hours after surgery patients are transitioned to oral medications by mouth or by g-tube. This will be a combination of narcotics, over the counter medications (i.e. Tylenol) and, possibly, medication for spasms. The patients will have IV medication for “break through pain”, if needed.

Incision Site:
The actual incision will be closed with sutures and glue that does not need to be removed.

Immediately after the surgery, the incision site will be covered with a dressing. This will remain intact until the orthopedic resident or nurse practitioner removes this on day 3 or 4.
The incision site should then remain intact. Do NOT pick at or remove the glue. It will come off in gradually in 3-4 weeks.
Do NOT put any ointments, creams or lotions on the incision site.

Post Operative Activity:
The doctors, nurses, and physical therapists will partner with the patient and family in order to:

Turn the patient every 2 hours using the log roll method.
Get the patient out of bed at minimum three times a day.
The physical therapist will visit with you the day of surgery, go over the plan of care, and initiate care the morning after surgery. The goal is to be up sitting and walking (if able) prior to leaving the hospital.

Post operative diet:
Progression of diet can be slow after spine surgery.

Patients are often started on clear liquids post-op day one (trickle feeds) and then transitioned to their regular diet, either by mouth or per g-tube.
Patients may also be receiving either TPN (total parental nutrition) and Lipids or Intravenous Fluids (IV fluids). This is to provide essential nutrients and calories needed for recovery and wound healing.
Nausea can occur early on and we can give medications to help.

Pulmonary (lungs):

If you have a history of significant breathing problems, you may need to keep the breathing tube in for an extended period after surgery. Anesthesia will discuss this you with prior to surgery.
If you have a pulmonologist (lung) doctor, you may need to see them prior to surgery. Sometimes, they may suggest adding new treatments to minimize the chance of surgical complications.
You will receive breathing treatments 4 times a day to prevent pneumonia. The respiratory therapist will deliver these treatments.

Neuromuscular Spine Discharge Instructions

Hospital to home:
Patients are typically hospitalized 5-7 days.

Diet:

High fiber and high protein- encourage small frequent meals with plenty of hydration.
Tube fed patients may need to do smaller, more frequent feeds initially.
Tube fed patients may need to add protein to their formulas (Benepro).
Patients may be discharged prior to first bowel movement.

Activity:

Light activity recommended.
If ambulating — walk 30 minutes a day, which can be broken up into three increments.
Patient should continue to be out of bed at least three times per day.
Patient can return to Physical Therapy and Occupational Therapy with restrictions of no spine twisting or torsion.
If using a stander/walker, may resume using when patient is ready. Typically two to four weeks post-operative.

Restrictions:

No spine twisting or torsion.
NO IBUPROFEN OR IBUPROFEN PRODUCTS FOR SIX MONTHS postoperatively.
If laying on the stomach do not use pillow under head for 6 weeks post operatively; thin pillow is best for sleeping otherwise.

Shower:

2 weeks post-op: should sponge bathe until this time.
Gentle soap suggested (Dove).

Baths:

Three weeks post-op if incision is completely healed and no drainage.

Swimming:

Two weeks post-op in chlorinated pool if no drainage.
NO natural bodies of water for six weeks postoperatively.

Incision care:

No creams, lotions or ointments to incision site until completely healed.
Keep incision covered, or if healed completely use 50 SPF sunblock.
If incision is draining, please keep covered.
If patient wears diapers, please keep lower half of incision covered for one month.

Medication calendar:

Calendar given by the pain service
PAIN MEDICATIONS will only be filled during office hours Monday through Friday 8am-4:30pm.
Stool softeners and/or MiraLAX should be given when taking narcotic medications. Please refer to discharge bowel management sheets.

School:

Four weeks Post-Operative will go full day of school; may start with half days initially.
NO PE one year. *May resume PT/OT per IEP goals with the following restrictions; no spine twisting or torsion.

When to call the doctor:

Fevers greater than 101.5 not relieved by Tylenol.
Vomiting
Incision site redness, warmth or drainage.
Increased irritability/fussiness that is not consolable.
Change in bowel or bladder pattern.
Rash.
Increased pain not relieved by pain medication.
Significant weight loss after 6 weeks post-op.

Dental appointment/ other planned procedures:

For 2 years post operatively - We will have your child take an antibiotic prior to appointment, and 4 doses 8 hours apart to decrease risk of infection. We will phone the medication to your local pharmacy.

Typical follow-up appointments with Dr. Luhmann:

6 weeks post-operative
6 months post-operative
One year, two years, three years, and five years post-operative.

Important Contact Information

Dr. Luhmann's Team:
Amanda Robertson, Medical Assistant: (314) 454-4191
Jenn Ledbetter, Nurse Practitioner: (314) 454-4261
Kirsten Brouillet, Research Coordinator

St. Louis Children's Hospital:
Orthopedics Appointment Desk: (314) 454-2500
Main Number: (314) 454-6000
Same Day Surgery: (314) 454-6174
PICU: (314) 454-6213
10^th Floor: (314) 454-6038
After-hours Number: (866) 582-8055

Online Resources

St. Louis Children's Hospital
Pediatric Orthopaedic Society of North America
American Academy of Orthopaedic Surgery

Washington University Orthopedics