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Scoliosis
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Patient Particulars
Name : Preeti
 Age : 11 yrs
 Sex : Female
 Student : Class six
 Address : Uttar Pradesh
 Date of examination : 22/08/07
 Proposed date of surgery : 23/08/07

Chief Complaints

Deformity of back & chest x 7 yrs
Back pain,
Leg length discrepancy,
An abnormal gait,
Uneven hips
Clothes no longer fit correctly
(for example, the legs of pants may seem uneven).
One shoulder higher than the other
History of Present Illness
Patient was alright till the age of 7 yrs
 Deformity of back with left-ward tilt along
with deformity of chest became apparent
 Insidious in onset
 Gradually progressive

HOPI- (consequences-CNS, RS, CVS)
No H/O localized or radiating back pain
 No H/O weakness in either LL, bowel,
bladder incontinence
 No H/O frequent chest infection
 No H/O Breathlessness during exertion or
at rest
 No H/O chest pain, pedal swelling
 No H/O palpitation, syncopal attack

HOPI- (etiology)
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No H/O trauma to the backbone (traumatic)
No H/O pain, fever or swelling of the back (TB)
The deformity does not get corrected in supine
position (postural )
No H/O leg length discrepancy, neck deformity
(compensatory)
No H/S/O neuro-muscular weakness or muscle
rigidity (neuromuscular)
No H/S/O seizure disorder
No c/o other body part deformity
Associated conditions
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Cerebral palsy
Spinal muscular dystrophy
Familial dysautonomia
Friedreich’s ataxia
Skeletal dysplasia
Marfan’s syndrome
Neurofibromatosis
Connective tissue disorders
craniospinal axis disorders (e.g., syringomyelia)
HOPI

Exercise tolerance good
Birth History
 F.T.N.V.D.
 Cried immediately after birth
 Normal developmental mile stones
 Immunized appropriately for the age
History of Past Illness

No other major medical or surgical illness
Family History
 Nothing
significant
Personal History
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Vegetarian
Appetite, sleep, Bowel, bladder, –normal
Treatment History

None- No h/o Rx in the form of braces or exercises
Anesthetic History

No past h/o anesthetic exposure
Allergic History

none
General Examination
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Alert, conscious, cooperative, playful child
Thin built
Pallor Cyanosis Clubbing –
Icterus –
Edema –
Neck vein- not engorged
Vitals
PR-80/min, regular, normal volume,equally
well felt all peripheral pulses, no radioradial or radio-femoral delay, no special
character
 B.P.- 110/70mmHg, in right upper limb in
supine position
 RR- 16/min, regular, thoraco- abdominal
 Temperature - afebrile

Examination of the Deformity
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Lateral curvature of spine
Limited to the thoracic region
Convexity right ward
Spinous processes and interspinous spaces are felt
without any gibbus
No tenderness
Rib cage is prominent anteriorly in left side with
crowding
Rib cage is prominent posteriorly in the right side
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Uneven shoulder heights
Prominence of shoulder blade
Increased space between the body and the elbow while
standing in natural posture
Uneven hips or waist
One breast appears larger than the other
Chest or rib prominence
One leg appears longer than the other
Appearance of leaning to one side
Systemic Exminations
Respiratory system:
Inspection
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Bony deformity of thorax
Trachea- mid line
Unequal bilateral chest expansion(Rt>Lt)
RR-i6/min, thoraco-abdominal
Respiratory System
Palpation
 Chest expansion-2 cm(unequal: rt>lt)
 Trachea- mid line
 No tenderness
 Vocal fremitus- normal in all regions
Percussion
 Normally resonant over all regions
Auscultation
 Normal vesicular breath sound
 No adventitious sound
Cardiovascular System
Inspection
 Bony deformity over the precordium
Palpation
 Apex beat-left mid-clavicular line at 5th ICS
 No thrill, parasternal heave or lift, no plpable heart sound
Auscultation
 Heart rate-80/min, regular
 Normally heard S1 & S2
 No murmur
 No other adventitious sound
CNS
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Clinically normal
Abdmen
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Clinically normal
Airway
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No obvious facial abnormality
Mouth opening- 4 cm
Modified Mallampati Class-1
Neck movement- adequate
TMD-6 cm
Teeth- intact
I.V. Access

Good
BHT
35 sec
Ability to Cough
Positive
Clinical Diagnosis

11 yr old female child with idiopathic
juvenile dorsal scoliosis without clinically
apparent cardio-respiratory or
neuromuscular complication posted for one
stage anterior instrumentation and posterior
spinal fusion surgery.
Investigations
Hb-13.8 gm/dl
 Hct- 41.1%
 TLC-5600
 Platelet count- 2.18 lacs/cmm
 CXR- Rt sided dorsal scoliosis, crowding of
rib in left side, decreased left lung volume
 ECG- normal
 PFT 
Definition

Lateral curvature of the spine combined with a
rotational component, due to various etiologies,
according to the Scoliosis Research Society
(SRS).
Anatomy
Prevalance
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Curves >10° -2-3% of the population
Curves >20° affect about 1 in 2500 people.
Curves convex to the right are more common
'C' curves are slightly more common
than double or 'S' curve patterns.
Males are more likely to have infantile or juvenile
scoliosis
Female predominance of adolescent scoliosis.
Girls are 7 times more likely than boys
to develop a significant progressive curvature
Adolescent Idiopathic Scoliosis, there is a clear
mendelian inheritance but with incomplete
penetrance
C and S curve
Causes

Congenital
– result of an abnormality of the development of the
vertebrae-hemivertebra, rib anomalies, spinal
dysrapism
• Ass with other congenital anomalies – CHD

Neuromuscular
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Poliomylitis, Syringomylia, Muscle dystrophies, cerebral
palsy, spina bifida, spinal cord injuries
Poor posture
Unequal leg length
Idiopathic scoliosis
– cause unknown
– most common form (80%)
Associated conditions
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Cerebral palsy
Spinal muscular dystrophy
Familial dysautonomia
Friedreich’s ataxia
Skeletal dysplasia
Marfan’s syndrome
Neurofibromatosis
Connective tissue disorders
craniospinal axis disorders (e.g., syringomyelia)
Infantile idiopathic scoliosis is a/c
↑ incidence of mental retardation
inguinal hernia
cong dislocation of hip
cong heart disease
 Adolescent idiopathic scoliosis
most common form
most common in girls
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Prevention Tips - Scoliosis
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The most important is early examination and
getting doctor’s advice
Unlike poor posture, scoliotic spinal curves can't
be corrected simply by learning to stand up
straight
Carry weight balanced between two hands
Don’t watch TV always sitting/lying in the same
position
Exercise and do sports / physical activities
Prevention Tips
Backache is a condition that is often caused
by weak muscles
 These exercises will help strengthen the
muscles which support back and improve
posture
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Symptoms
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Back pain,
Leg length discrepancy,
An abnormal gait,
Uneven hips
Clothes no longer fit correctly
(for example, the legs of pants may seem uneven).
One shoulder higher than the other
Signs of Scoliosis
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Uneven shoulder heights
Prominence of shoulder blade
Increased space between the body and the elbow while
standing in natural posture
Uneven hips or waist
One breast appears larger than the other
Chest or rib prominence
One leg appears longer than the other
Appearance of leaning to one side
Signs of scoliosis
Physical Findings
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Uneven shoulders
Prominent shoulder
blade
Uneven waist
Elevated hips
Leaning to one side
Physical examination
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Café au lait spots
The feet for cavovarus deformity
Abdominal reflexes
Muscle tone for spasticity
Gait
Signs of other abnormalities (e.g., dysraphism
evidenced by a dimple, hairy patch, lipoma, or
hemangioma).
A thorough neurological examination is also
performed..
Telescreening study
Measures
A. With student standing (grid), observe for:
a) high shoulder,
b) curved spine,
c) uneven shoulder blades,
d) uneven hips or waist creases, and
e) unequal distance from arm to side of
body
B. Adams forward bend test
Scoliometer measurement (thoracic, thoracolumbar, lumbar)
-Angle of trunk rotation (ATR) > 7 degree – referral)
Classification
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Infantile
children ages 3 and under
Juvenile
3-9 years old
Adolescent
10-18 years old
Adult
after skeletal maturity
Most common is Adolescent Idiopathic Scoliosis
Curves
Non-structural = Lateral curvature
 vertebral column bends from side-to-side
 S-shaped curvature of the spine
Structural = Rotation curvature
 usually subtle, but is always present in a
true scoliosis deformity

twisting deformity of the vertebral bodies
Types of curves
Diagnosis
Leg length Both legs are measured to
determine if they are of equal length
 Plumb line A plumb line is "dropped" from
the C7 vertebra (in the neck) and is allowed
to hang below the buttocks. In scoliosis the
line does not hang between the buttocks.
 Neurological assessment

Cobb’s angle
Cobb’s angle and symptoms
<10 normal curvature
 >25 ECHO evidence of increased
pulmonary artery pressure
 >40 surgical intervention
 >65 restrictive lung disease
 >100 dyspnoea on exertion
 >120 alveolar hypoventilation

Adams Forward Bend Test
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Student should stand erect with feet together
knees fully extended
The palms of both hands touching each other
The student bends forward until the back is
horizontal
Asymmetry of the thoracic or lumbar spine
may be detected by using a scoliometer
To measure the angle of trunk rotation
(ATR) at the thoracic, thoracolumbar, and
lumbar areas of the spine
Adams test
Adams test…
Diagnosis…
Scoliometer (inclinometer) is used to
measure a rib hump while the patient is bent
at the waist.
 X-rays (radiographs)-an upright lateral view
and side bending.
 Risser Sign - x-ray for knowing skeletal
maturation.
 Lenke Classification
 King classification

Scoliometer
Scoliometer
Risser’s sign
Respiratory system
Decreased compliance
 Decreased ventilatory response to CO2
 V/Q mismatch
 Arterial hypoxemia
 Hypercapnia
 Respiratory failure
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PFT (Features of RLD)
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Volumes
– Vital capacity - ed
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–
–
–
–
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Important prognostic predictor <40% of predicted –
postoperative ventilation required, >70% POV not
required
TLC - 
FRC - 
RV - 
VD/VT ratio - 
Chest wall compliance -  
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ABG
– PaO2 (early)
–  AaDO2
–  PaCO2 (Late)
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Pulmonary Vasculature
–  Pulmonary Vascular resistance
–  PAH
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Flows
– Maximum Insp press at FRC - <30cm of H2O –
ineffective coughing
Cardiovascular system
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Pulmonary hypertension
Right ventricular hypertrophy and cor-pulmonale
a/c Mitral valve prolapse (25%)
a/c Congenital heart diseases
Impaired development of pulmonary vascular bed
Increased incidence of hypoxic pulmonary
vasoconstriction
Reduction in the number of functional vascular
units
Treatment

Observation (Below 20 degrees)
– patients are seen by a spine specialist about every six
months until skeletal maturity is reached
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Bracing (25-40 degrees)
– control any worsening of a spine curvature, but do little
to correct an existing deformity
– most effective when used in children that are rapidly
growing and have worsening scoliosis curves
Non surgical management
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Small curves (those less than 15-20 degrees) observation
Larger curves (those between 20-40 degrees) - bracing to
prevent further progression of the curve.
Braces can be uncomfortable, unattractive, hot, and can make
a child self-conscious However, when bracing works and
surgery is avoided, the commitment required is worthwhile.
At this point a carefully designed exercise program may also
be recommended.
Unfortunately, some curves do not respond to bracing.
Cervicothoracic curves (from the middle of the back up into
the neck) and curves greater than 40 degrees tend not to
respond well to bracing. Also, older patients who are closer
to skeletal maturity may not respond to bracing.
Treatment...
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Surgery (45 degrees or greater)
– best option for more severe curves.
– fuse vertebrae in a more normal anatomic
position
– severe curves carry a risk that lung and heart
function may become affected
Indications for surgery
Spinal curvature (Cobbs’s angle)
>45°/progressive
 Trunk deformity
 Pain
 Deteriorating cardio-pulmonary status
 Family H/O severe scoliosis
 Cosmetic
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Aims of surgery
Correction of curve
 Prevent further progression
 Relief / prevent back pain
 Maintain posture
 Prevent progression of cardio-pulmonary
dysfunction
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Surgical Options
Posterior correction and instrumentation
 Anterior correction and instrumentation
 Anterior release / fusion, plus posterior
instrumentation
 Posterior release/fusion, plus anterior
instrumentation
 Combined anterior and posterior
instrumentation and fusion
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PROBLEMS IN SCOLIOSIS SURGERY
• Compromised respiratory function
• TV/RR
• Consider postop. Ventilation up FVC <40°
• Prone position
• Armoured E/T tube
• Prevent pressure / traction injuries
• Neurological injuriy
• Detect / treatment intraoperative SC injury
• Wake-up test
• Neurophysiological monitoring
• Maximize S/C perfusion
PROBLEMS IN SCOLIOSIS SURGERY (Contd…)
• Massive blood loss
•  blood loss
• Avoid homologous transfusion
• Hypothermia
• Prolonged surgery
• Large area of exposure
• VAE
• Large open Vn plexus
• Area of surgery above heart
• Sport respiration during wake-up test
• Visual loss
Pre-op evaluation
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Age of onset –
Lungs grow and develop till 8 yrs of age
NO of alveoli at birth-20 million, at 4 yrs-250 million
Thoracic scoliosis at earlier age- impaired lung development
↑ risk of impaired gas exchange/pulm HTN
Location of spinal curvaturethoracic- deranged PFT,
cervical- difficult airway, ass cong anomalies
Cause of scoliosis- Neuromuscular scoliosis-Sch, MH
Exercise tolerance
Coexisting diseases
Congenital anomalies
Severity
<10 Normal
>25 Echo evidence of raised PA pr.
>40 Indication for surgery
>65 Restrictive Lung Disease - PFT/ABG
indicated
>100 Symptomatic lung disease-DOE
>120 Alveolar hypoventilation
>70 Pulmonary HTN on exercise
>110 Pulmonary HTN at rest
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Airway assessment
cervical scoliosis-difficult inyubation
neurofibromatosis
high arched palate
Cardiovascular system involvement
pul HTN- loud P2
RVH-RV lift
RVF-engorged neck veins, enlarged liver, lower
extremity edema
Respiratory system involvement
wheezing/rales- restictive lung disease,
parenchymal disorder
Investigation
Cobb’s angle
 Bedside pulmonary function tests
 Arterial blood gas analysis
 ECG
 ECHO
 Coagulation studies
 Electrolytes
 Liver function tests
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Pre-operative preparation
Incentive spirometry /coughing
 Parenchymal /obstructive lung disease
- Aggressive bronchopulmonarytoilet/
bronchodilator therapy
 Wake up test preparation-explain, inform,
reassure, reherse
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Considers ‘autologous blood donation’
Pre-medication

Anxiolysis
– Oral midazolam (0.5mg/kg)
– Alprazolam
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Aspiration prophylaxis
– Metochlorpropamide
– H2 blockers (Ranitidine)
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Antisialoguge
– Glycopyrorate
Monitoring
Routine standard monitoring
- ECG
- NIBP
- SpO2
- EtCo2
- Temperature, U/O, NMT
 Invasive – indwelling arterial line
- central venous line
(PAC- Duchenee’s cardiomyopathy, PHTN, RVF)
 Neurologic monitoring –SSEP, MEP, awake test
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Induction / Intubation
–
–
–
–
Difficult airway – awake fibreoptic
IV agent (propofol/thiop) + short acting NDMR (avoid scoline)
Armoured E/T tube – secure firmly Maintenance
Analgesia –

Fantanyl infusion
– Less total dose
– Steady plasma level
– Least effect on SSEP
– IPPV
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TV + RR
O2+N2O+ISO(0.4-1%) (avoid halo)
Avoid hypocapnia
– Fluids
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Guided by CVP + urine output
Blood loss replaced by blood
INTRA-OPERATIVE NEUROLOGICAL MONITORING
•
•
•
•
Detect spinal cord injury intraoperatively
Incidence – (Harrington Rod) – 0.6-1% (sublaminar wiring)
Devastating / undesirable / avoidable
Cause
• Direct spinal cord injury – excessive destraction
• Compromised spinal cord perfusion
• At risk groups
Severe rigid deformity >120°
Kyphosis
Neurofibromatosis
Congenital /post infectious scoliosis
Pre existing neurological deficit
Sublaminar wire (Luque rod) intrsumentation
Investigate- preop myelogram/MRI
 Monitor- SSEP/awake test
 Prophylaxis- high dose corticosteroid for pt
with pre existing neurological deficit
 Intra-operative neuronal changes correlate
well to postop. neurological deficit
 Take corrective measure

– Readjust instrumentation,  degree of correction,
high dose steroid, remove bone graft, maximize
spinal cord perfusion
WAKE-UP TEST
• Vauzelle (1973)
• Awaken patient partially and asked to move lower limbs, after
spinal instrumentation.
• How to perform
• PAC
• Patient explained the procedure
• Reassure - ‘no pain’ or ‘recall’
• Intraoperative
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After complete surgical correction stop volatile (15-20 min
Allow neuro-muscular blockers to wear off
Ensure adequate analgesia (top-up of fantanyl)
Switch off N2O
Address the patient by his name
First move upper limbs (squeeze my fingers)
Next move feet (wriggle your toes)
If unable to perform latter corrective measures taken
Test repeated
Benzodiazepine - amnesia
WAKE-UP TEST (Contd…)
• Advantage
• Few false negative results
• Checks the motor functions
• Disadvantage
•
•
•
•
•
•
Needs patients co-operation
Unpleasant if patient has ‘recall or pain’
VAE due to spontaneous respiration
Dislocation of spinal instrumentation
Extubation / Removal of IV, IA cannulae
Cannot be performed repeatedly (at the most twice)
NEUROPHYSIOLOGICAL MONITORING
• Real time, continuous assessment of spinal cord
function
• No need for patient movement, arousal or
cooperation
• Special technology and expertise required
• Stimulate one part nervous system
• Measure response at distant part (evoked potented)
• Across spinal cord at risk
• 2 types used in scoliosis surgery
• Somatosensory evoked potencial (SSEP)
• Used extensively
• Easier to perform
• Motor evoked potential (MEP)
SSEP
• Cortical, subcortical response to peripheral nerve
stimulation
• Peripheral nerves –median (for comparison),
peroneal, post tibial
• Evoked potential wave form amplitude plotted
against time (latency)
•  amplitude and  latency indicates disruption in
neural pathway
• Pass through dorsal column
• Continuous monitoring done
• Bilateral stimulation gives exaggerated response
• Unilateral lesions may be missed
• Each lower limb stimulated separately.
SSEP (Contd…)
• Disadvantages
• Does not measure motor function
• Similar changes produced by several other factors
• All volatile anaesthetic (max. Enflurane) & N2O
• Some IV anaesthetic, Propofol
• Hypothermia, hypotension, hypoxia, hypocapnia
• No effect on (SSEP)
• Ketamine, elomidate
• Opioid (Fantanyl least)
• How to differentiate
• Compare limb SSEP of unaffected limb
• Reliability
• Good predictor of postop. Neurological deficit
• False negative +ve
MOTOR EVOKED POTENTIAL
• Direct motor response is seen
• SC is stimulated electrically / magnetically
• Two types
• MMEP – Myogenic (twitch recorded in distal muscle)
• Partial reversal of NMB required (TOF = 2-3)
• NMEP – Neurogenic (magnetic stimulus via scalp
electrodes, Neural conduction recorded at lateral column
of SC or peripheral nerve)
• Same systemic effects
MOTOR EVOKED POTENTIAL
• Direct motor response is seen
• SC is stimulated electrically / magnetically
• Two types
• MMEP – Myogenic (twitch recorded in distal muscle)
• Partial reversal of NMB required (TOF = 2-3)
• NMEP – Neurogenic (magnetic stimulus via scalp
electrodes, Neural conduction recorded at lateral column
of SC or peripheral nerve)
• Same systemic effects
NEUROPHYSIOLOGICAL MONITORING
• Real time, continuous assessment of spinal cord
function
• No need for patient movement, arousal or
cooperation
• Special technology and expertise required
• Stimulate one part nervous system
• Measure response at distant part (evoked potented)
• Across spinal cord at risk
• 2 types used in scoliosis surgery
• Somatosensory evoked potencial (SSEP)
• Used extensively
• Easier to perform
• Motor evoked potential (MEP)
PRONE POSITION
• Airway secured with armoured tube
• Antisialogogue – glycopryolate preoperative
• Caution during positioning
• Both arms anteriorly flexed and abducted   traction on
brachial plexus
• Head turned laterally slightly flexed
• Eyes
• Taped closed, padded,
• Retinal damage, blindness, corneal abrasion seen after
spinal surgery
• Abdomen – free by chest and iliac crest supports
• Pressure on abdomen -  VR, diaphargmatic splinting,
epidural vessel congestion
• Jackson/Wilson orthopaedics frames also used.
HOW TO MINIMIZE
• Total blood loss can be substantial (upto 50% BV)
• Depends on
• No. of segments fused / decoretecated (200ml/segment)
• Duration of surgery
• Methods- Decrease blood loss
• Proper prone positioning – avoid epdirural vessel congestion
• Induced ‘moderate’ hypotensive
• MAP – 70mmHg
• Further Bp – SC ischemia, visual loss
• Antifibrinolytic
• Aprotinin (esp M disorder)
• Blood loss by 50%
• Hypersensitivity (esp. with reexposure)
• Vasoconsctritor infiltration – Adr. 1:500,000.
• Meteculous surgical technique
AVOID HOMOLOGOUS TRANSFUSION
• AIM
• Autologous blood transfusion
•
•
•
•
Autodonation starts 3wks prior
2-3 units (Hb permits)
Hb>11gm
Gap 4-7 days between subsequent collections for volume
repletion
• Hast donation 7 days before surgery
• Oral Fe therapy / Erythopoetin
• Final Hb >10gm/ PCV>30
• Intraoperative Isovolemic haemodilution
• After induction 1-2 units withdrawn
• Volume replaced by colloids (1:1)or crystalloids (3:1)
• Intraoperative blood salvage
• Surgical site – cell savers
VENOUS AIR EMBOLISM
• Due to
• Large open venous plexus
• Above level of heart
• Spontaneous respiratory during ‘wake-up test’
• Presentation
• Sudden, unexplained Bp (CV-collapse) PCO2/End tidal
N2
• Treatment
•
•
•
•
•
•
Flood the field with normal saline
Symptomatic – 100% O2
Ionotropic support
Resuscitation – then supine
Post thorecotomy – int defiberllation
Aspirate air via CVP?
HYPOTHERMIA
• Prolonged surgery
• Large area of exposure
• Precaution
•
•
•
•
Contensions temperature monitoring (np, LE, Re)
Warmup blankets
Warm fluid / blood
 Temperature
• Affect SSEP, Delay recovery
• Visual loss – in prone spinal surgery reported
• Cause
• Commonest – Ischaemia to optic nerve
• Risk factor
• I/o hypotension, Anemia, Prolonged surgery, Direct press due to positioning
• Precaution
• Slight head up
• Repeated check eye for pressure
Post op care
Extubation
 CPAP
 Ventilation

Predictors of Post-op Ventilation
Patient factors:
 Severe Restrictive Lung Disease:
Vital Capacity < 35 %
Pi max > - 40cmH2O
Pe max < +40cmH2O
PaO2 < 60mmHg
PaCO2 > 50mmHg
 Right Ventricular Failure
 Pre-existing neuro-muscular diseases
 Congenital heart disease
 Obesity
Surgical factors:
Blood loss > 30ml/kg
 Surgical invasion to thoracic cavity
•
Postoperative care
• Post operative pain – very severe
• Choices
• Regional
• Intra-thecal
• MsO4-5µg/kg (300µg); Given intraop
• Caudal
• MsO4-50µg/kg (3mg); Combine with LA
• Epidural infusion
• Surgically placed epidural catheter
• Infuse LA + opioids
• ‘Patchy effect’
– Systemic

Best PCA
–
–
–
–

Steady plasma level
Less total dose
No respiratory depressions
Patient should operate it
NSAD
–
–
–
–
Role controversial
Alone not enough
Affect fusion / delay fracture healing
Cox-’2’ better choice (no effect on platelets)
Postoperative care (Contd…)
• Other known complication
• Superior mesenteric syndrome
• Kinking 3rd part duodenum
• Treatment conservative
• Paralytic ileus
• Oliguria
• ADH
• Hourly urine output
• Fluids / diuretics guided by CVP
• Respiratory complication
• Atelactasis/Retained secretions
• Deterioration of PFT uoto 7 days post operative
• Intense pain management
• Early respiratory physiotherapy
Post-op pulmonary complications
Significant positive correlation of post-op
pulmonary complications with –

pre-op PFT
Pre-op PFT
Post-op pulmonary complications
FVC – 60-<80%
2.72%
40-<60%
7.40%
<40%
31.60%
Surgical approach – transthoracic >> posterior
approach
No correlation with age or cobb’s angle.

•
•
Complications-Monitoring






Cardiovascular collapse -extensive blood loss,
inadequate venous return, air embolism, latex
anaphylaxis,
Pneumothorax or hemothorax
Myoglobinuria, renal insufficiency
(Rhabdomyolysis)
Coagulopathies,
Acid-base imbalance
Electrolyte disturbances (hyperkelemia,
hypocalcemia-.. Massive BT)
Complications related to prone
position
Airway
 Blood vessels
 Nerves
 Head and neck

Neurologic monitoring
Post-operative paralysis or sensory loss
- direct injury to spinal cord
- during instrumentation
- excessive traction during distraction
- compromised perfusion of spinal cord
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