CLINICAL SUMMARY

PRIMARY DIAGNOSIS

NEUROLOGICAL STATUS

• C8 Complete Tetraplegia (ASIA A) - originally no motor or sensory function below C8; no hand intrinsic function, dependent in all transfers and ADLs
• T11 Incomplete Paraplegia (current) - partial preservation of motor and/or sensory function below T11; consistent with ASIA B, C, or D classification (incomplete lesion)

1. Successful surgical decompression removing compressive tumor/bony elements
2. Resolution of spinal cord edema and cord contusion
3. Neuroplasticity and functional recovery over the post-operative period

• Upper extremity function (full hand/arm use recovered from prior tetraplegia)
• Trunk stability partially preserved to lower thoracic level
• Some preservation of hip flexors, knee extensors, or distal limb function depending on the degree of incompleteness

SURGICAL HISTORY

• Multi-level compressive pathology involving cervical and upper thoracic cord (consistent with NF2-related spinal tumors/schwannomas at multiple levels)
• Posterior approach with instrumented fusion: likely pedicle screws, rods, and bone graft from C5 to T8
• Decompression (laminectomy/foraminotomy) to relieve cord and nerve root compression

COMPLICATION

"Spinal cord injury patients are especially prone to developing pressure sores... tissue injury caused by physical pressure... prolonged tissue ischemia leads to local tissue necrosis."

• Motor paralysis with impaired positional feedback
• Reduced/absent sensation below the level of injury (unable to perceive pressure discomfort)
• Prolonged immobilization
• Possible nutritional compromise, urinary/bowel incontinence, muscle spasms

• Stage I-II: conservative (offloading, local wound care, pressure-relief mattresses/cushions, nutrition optimization)
• Stage III-IV: surgical debridement, possible flap reconstruction; osteomyelitis must be excluded via X-ray, CT, or MRI

PROBLEM LIST SUMMARY

KEY MANAGEMENT CONSIDERATIONS

1. NF2 surveillance: Regular MRI of brain and spine to monitor for new/growing schwannomas or ependymomas that may cause further neurological deterioration
2. Pressure ulcer management: Pressure-relieving equipment (low-air-loss mattress, specialized wheelchair cushion), wound care protocol, nutritional support, glucose/incontinence management; surgical referral if Stage III/IV
3. Rehabilitation: Ongoing physical/occupational therapy to maximize functional gains from incomplete injury; upper extremity recovery is a major focus given the prior tetraplegia
4. Bladder/bowel program: Intermittent catheterization, bowel schedule
5. Spasticity management: Baclofen, physiotherapy, positioning
6. Spinal implant monitoring: Surveillance of fusion hardware integrity; dystrophic NF scoliosis can progress above and below a fusion construct
7. Multidisciplinary team: Neurosurgery, rehabilitation medicine, neurology, wound care nursing, physiotherapy, occupational therapy, urology

Causes of the Spirometry and Respiratory Muscle Findings

What the Tests Show

• FVC: 0.58 L (only 20.7% of predicted) - severely reduced
• FEV1: 0.56 L (only 21.3% of predicted) - severely reduced
• FEV1/FVC ratio: 96.19% - normal/elevated (no obstruction)
• Post-bronchodilator: minimal change (FVC 0.63 L, 22.7%)
• Physician conclusion: restrictive ventilatory defect (no obstruction; low FVC suggests restriction; TLC/DLCO recommended for confirmation)

• PI max (maximal inspiratory pressure): 4.57 kPa = only 40% of predicted - severely reduced
• PE max (maximal expiratory pressure): 3.94 kPa = only 42.8% of predicted - severely reduced
• Technical note: poor PI max effort (could not sustain >2 seconds), suggesting the true weakness may be even worse than measured

Causes - Specific to This Patient

1. Respiratory Muscle Weakness from Spinal Cord Injury (PRIMARY CAUSE)

"In C5 or lower spinal cord injured patients, inspiratory muscle strength was reduced to approximately 60% of predicted... PImax values in low cervical, midthoracic, and lower thoracic-upper lumbar lesions were 61%, 69%, and 75% of predicted... PEmax values were 30%, 32%, and 54% of predicted respectively. The lower PEmax values were explained by paralysis of abdominal and intercostal muscles."

• Diaphragm (C3-C5): likely partially preserved at T11 but may be deconditioned
• Intercostals (T1-T12): paralyzed or weakened - reduces chest wall expansion
• Abdominal muscles (T6-L1): paralyzed or severely weakened - loss of active expiration and cough
• Accessory muscles (scalenes, sternocleidomastoid): may be compensating

2. Thoracic Scoliosis with Multi-level Spinal Fusion (C5-D8)

• Chest wall deformity: scoliosis deforms the thoracic cage, reducing its ability to expand symmetrically
• Reduced chest wall compliance: the fused spine and corrected/rigid thoracic cage cannot flex normally during breathing
• Reduced lung volumes: the distorted thorax compresses lung parenchyma on the concave side

3. Neurofibromatosis Type II - Direct Pulmonary Involvement

• Intraspinal/paraspinal tumors compressing intercostal nerve roots, adding to respiratory muscle denervation beyond the SCI level
• Meningiomas at thoracic levels affecting ventral horn motor neurons that supply respiratory muscles

4. Prolonged Immobilization and Deconditioning

• Disuse atrophy of all respiratory muscles
• Reduced chest wall mobility and compliance
• Basal atelectasis reducing functional lung volumes

5. Sacral Pressure Ulcer and Chronic Illness

• Diaphragm and respiratory muscle catabolism
• Reduced effort capacity (as noted in the technical comment: "patient effort was just satisfactory")

Summary Table

Clinical Implication

• Secretion retention and chest infections
• Aspiration pneumonia
• Respiratory failure if there is any intercurrent illness

• Full lung volumes (TLC, RV) by plethysmography to confirm restriction
• DLCO to determine if there is any parenchymal component
• Respiratory physiotherapy with assisted cough techniques
• Consider non-invasive ventilation (NIV) assessment if nocturnal hypoventilation is suspected

How NF Causes These Respiratory Findings

1. Dystrophic Scoliosis - Chest Wall Restriction (MAIN CAUSE of Low FVC)

2. Intercostal / Spinal Nerve Root Compression by Spinal Tumors (MAIN CAUSE of Low PI/PE max)

• Intercostal muscle weakness - reduces chest wall expansion (lowers PI max and FVC)
• Abdominal muscle denervation (T6-L1 nerve roots) - impairs active expiration and cough generation (lowers PE max)

3. Intrinsic Lung Disease from NF1 (Less relevant here, but worth noting)

"Abnormal chest CT findings are documented in 15% of patients with NF1... The loss of neurofibromin protein accelerates Ras-mediated fibroblast proliferation, resulting in benign neurofibroma-type tumors, and perhaps interstitial lung disease."

• Interstitial lung disease / pulmonary fibrosis - adds a parenchymal restrictive component
• Cystic/bullous lung disease - upper lobe cysts (8-25 mm), which paradoxically can reduce FVC
• Pulmonary hypertension (group 5, unclear mechanism) - reduces exercise capacity and DLCO
• Pulmonary artery stenosis
• Mediastinal masses (neurofibromas, malignant nerve sheath tumors, meningoceles) - can compress lung parenchyma

Summary - NF2 Specific Mechanism in This Patient

The Difference: NF1 vs. NF2 as the Cause of the Spinal Cord Injury

NF1 (Neurofibromatosis Type 1) - "Secondary to Neurofibromatosis"

NF2 (Neurofibromatosis Type 2) - "Secondary to Neurofibromatosis II"

Why "NF2" Changes the Clinical Picture of This Patient's Cord Injury

In Plain Terms

• "Secondary to Neurofibromatosis" (NF1) = cord compressed by neurofibromas eroding into the spine, with aggressive scoliosis driven by bony destruction. Higher cancer risk.
• "Secondary to Neurofibromatosis II" (NF2) = cord compressed by schwannomas and/or ependymomas, often at multiple levels simultaneously, with bilateral deafness as an added burden. Lower cancer risk but lifelong tumor recurrence requiring surveillance.

Prognosis for T11 Incomplete Paraplegia

General Principle: Incomplete > Complete

"The severity of spinal cord injury determines the prognosis for recovery of function - it is important to distinguish between complete and incomplete spinal cord injuries."

T11 Level - What Function Is Expected

"Independent with all self-care. As per C8-T4 but with more ease."

Walking Potential at T11 Incomplete

• Incomplete injury means some lower limb motor function is preserved below the lesion
• Hip flexors (L1-L2), knee extensors (L3-L4), and possibly ankle dorsiflexion (L4-L5) may be partially intact
• With preserved partial motor function + intensive rehabilitation, community or household ambulation is achievable with:
  • Knee-ankle-foot orthoses (KAFOs) or ankle-foot orthoses (AFOs)
  • Walking aids (forearm crutches or walker)

This Patient's Specific Trajectory: Already Exceptional

1. ASIA A (complete) to incomplete conversion is itself a major positive prognostic indicator
2. The neurological level improved by 3 full spinal segments (C8 to T11) - reflecting successful decompression and genuine cord recovery
3. Recovery from complete to incomplete status within the first 1-2 years is the strongest predictor of further functional gains

Timeline of Recovery

Factors Modifying Prognosis in This Patient

Life Expectancy

• At age 20 at injury: ~45.6 additional years (vs. 58.4 for no SCI)
• At age 40 at injury: ~28.0 additional years (vs. 39.5 for no SCI)

Bottom Line

• Full independence in ADLs and self-care
• Wheelchair independence (already likely achieved)
• Potential household or limited community ambulation with orthoses and aids

What It Means When Scoliosis Compresses One Side of the Lung

What Scoliosis Does to the Chest

• Concave side (the inside of the curve) - the ribs are pushed inward and together, crowding the lung
• Convex side (the outside of the curve) - the ribs are pushed outward and apart

The Concave Side - The Compressed Lung

The Convex Side - The Overworked Lung

What This Produces Clinically

"Restrictive lung disease and increased alveolar-arterial oxygen difference may be present, as well as pulmonary hypertension as a result of compression of pulmonary vasculature and arterial hypoxia."

A Simple Visual Way to Think About It

NORMAL SPINE          SCOLIOSIS
    |                    /
  [  ][  ]           [  ][ ]  ← concave side
    |                  /        (compressed, small)
  Both balloons      /
  equal size       /

Relevance to This Patient

Left - Normal Spine

• Spine is straight
• Both lungs are equal in size
• Ribs are evenly spaced on both sides
• Equal airflow enters both lungs with each breath

Right - Scoliosis

• Ribs are pushed together and inward
• The lung on this side is physically squashed - smaller, partially collapsed
• Less air can enter - reduced ventilation
• Blood still flows through but cannot pick up enough oxygen (V/Q mismatch)

• Ribs are pushed outward and wider apart
• The lung on this side has more space but is distorted and overworked
• It tries to compensate but cannot fully make up for the other side

The Rotation Problem (Cross-section view)

In This Patient

What Each Imaging Study Shows

1. Chest X-Ray (PA View) - Top Left

2. Full Spine X-Ray - Cobb Angle - Top Right

• Lines are drawn along the top of the uppermost vertebra and the bottom of the lowest vertebra in the curve
• The angle between these lines = the Cobb angle
• >10° = scoliosis confirmed
• >40-50° = severe; surgery indicated
• >70° = lung compression becomes clinically significant
• >90-100° = severe respiratory failure risk

3. CT Chest - Axial (Cross-Section) - Bottom Left

• Rotated vertebra at the centre - the vertebral body spins, pulling ribs with it
• Smaller, denser lung on the concave side (less black = less air)
• Rib hump visible - posterior rib cage pushed backward on the convex side
• Compressed airways - bronchi narrowed on the concave side
• In NF2: can also show paraspinal schwannomas/neurofibromas causing the deformity

4. CT Chest - Coronal (Front-to-Back) View - Bottom Right

• One lung clearly smaller in total volume
• Basal atelectasis (white opaque areas at the bottom of the compressed lung)
• Mediastinal shift toward compressed side
• Can quantify lung volume asymmetry between the two sides
• Shows pulmonary vasculature compression - narrowed vessels on concave side

Additional Investigations for This Patient

Reading the Patient's Own X-Rays

Image 1 (Lateral/Oblique view)

• Severe chest cage deformity visible - the entire thorax is rotated and distorted
• The ribcage is not a normal oval shape - it is compressed and asymmetric
• Surgical hardware from the cervical spine visible at the top

Image 2 (PA Chest X-Ray) - Most informative

Image 3 (Full spine/CT scout)

• Shows the entire spinal curvature from cervical to lumbar
• Fusion hardware visible in upper thoracic region
• Below the fusion, the spine continues to curve - the thoracolumbar region shows residual deformity
• The vertebral bodies are rotated - visible as asymmetric shapes in the lower thoracic/lumbar region

What This Means for Lung Function

• annotated PA

  Image · JPG

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• annotated spine

  Image · JPG

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• annotated lateral

  Image · JPG

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How to Read Each of Your X-Rays

Image 2 - PA Chest X-ray (Most Important)

• The "R" marker = patient's Right side
• On a PA (front-facing) X-ray, the patient's right is on your left as you look at it

• The spine should be perfectly straight down the middle
• In your X-ray: the spine is curved and displaced - this confirms scoliosis
• The bright white metallic structure = fusion rods + pedicle screws running from C5 down to T8 (the surgery from Feb 2020)

• Normal: both lungs should be equally black (dark = air = good)
• In your X-ray:
  • One side is whiter/more opaque = COMPRESSED LUNG (less air, collapsed segments)
  • The other side is darker = relatively more aerated
  • This asymmetry directly explains the low FVC (20% predicted) on spirometry

• On the concave (compressed) side: ribs are crowded together, stacked close - no room for the lung to expand
• On the convex side: rib spaces are wider apart

• The heart shadow is pushed toward the compressed side = mediastinal shift
• This happens because the compressed lung pulls everything toward it

• Should be a central dark tube in the midline at the top
• If shifted, confirms mediastinal displacement

Image 3 - Spine X-ray (Post-fusion)

• Fusion hardware visible in upper spine
• Below the fusion (T8 downward): residual spinal curve continues
• The vertebrae in the lower thoracic/lumbar region appear asymmetric and rotated

Image 1 - Lateral/Oblique View

• This shows the depth of chest cage deformity
• The chest is not a normal oval - it is severely compressed front-to-back and twisted
• The white opaque area at the lower zones = atelectasis (lung collapse from compression)

The Golden Rule for This X-ray

White = No air (bone, fluid, collapsed lung, hardware) Black = Air (healthy aerated lung)

How the Spirometry and Respiratory Drive Reports Match

The Two Tests Explained Simply

Side-by-Side Correlation

What the X-ray Confirms They Are Both Showing

X-RAY shows:                    SPIROMETRY shows:              PI/PE max shows:
──────────────                  ─────────────────              ────────────────
Compressed lung                 → Low FVC (20%)                → Low PI max (40%)
(less space for air)              (less air getting in)          (weak inspiratory muscles
                                                                  can't expand compressed chest)

Crowded ribs / rigid            → Restrictive pattern          → Low PE max (43%)
fused spine                       (FEV1/FVC normal)              (weak expiratory muscles
                                                                  can't squeeze air out)

Asymmetric lung fields          → No bronchodilator            → Both PI and PE equally
(not airway disease)              response                        reduced (not one-sided)

Why Both Tests Are So Severely Reduced (20-43%)

• The spirometry detects this as low FVC
• The PI max is low because even strong muscles cannot expand a locked rigid chest

• The PI/PE max directly measures this weakness
• Weak muscles + rigid chest = spirometry even worse

• Collapsed lung segments cannot participate in breathing at all
• This permanently reduces the available lung volume (FVC)

One Simple Summary

The chest X-ray shows WHY the lungs are compressed (structural) The spirometry measures HOW MUCH air is lost (volume) The PI/PE max measures HOW WEAK the muscles are (strength)

All three point to the same conclusion: the chest wall is restricted by scoliosis AND the muscles are too weak to overcome it - together producing severely reduced breathing capacity.

Clinical Significance - Why This Matters

• Risk of chest infection / pneumonia is very high - weak cough (low PE max) cannot clear secretions
• Risk of respiratory failure if any additional stress (infection, surgery, sedation)
• The patient needs respiratory physiotherapy (breath stacking, assisted cough, incentive spirometry)
• Non-invasive ventilation (NIV/BiPAP) at night should be considered - weak muscles + restricted chest = likely nocturnal hypoventilation
• Any future surgery requires post-operative ventilatory support planning

Specific Respiratory Interventions for This Patient

Patient's Problem Summary (Quick Recap)

• FVC 20% predicted - severely restricted chest
• PI max 40%, PE max 43% - severely weak inspiratory AND expiratory muscles
• Cause: scoliosis (chest wall restriction) + T11 SCI/NF2 (muscle weakness)
• Risk: impaired cough, secretion retention, nocturnal hypoventilation

INTERVENTION 1: Assisted Cough Techniques (MOST URGENT)

A. Manual Assisted Cough (Quad Cough)

• Patient takes the deepest breath possible
• Caregiver/therapist places hands on the upper abdomen
• At the moment the patient tries to cough, the caregiver gives a sharp inward-upward thrust to the abdomen
• This forces the diaphragm up, generating expiratory pressure the patient cannot produce alone

B. Breath Stacking (Lung Volume Recruitment)

"Breath stacking involves taking multiple breaths to increase lung volumes above the single breath volume and holding each successive breath using a closed glottis... may help with improving cough function and with maintaining lung compliance and FVC."

• Patient inhales, holds breath (closes throat/glottis)
• Inhales again on top of the first breath
• Repeats 3-5 times to "stack" air
• Then attempts a cough with the maximum volume in the lungs
• Can be done with a resuscitator bag (Ambu bag) by a therapist

C. Mechanical Cough Assist Device (CoughAssist / In-Exsufflator)

"This device generates positive and negative pressures of up to 50 cmH₂O to insufflate then rapidly exsufflate the lung... by simulating a cough, this moves secretions out of the airway noninvasively."

• Applied via face mask or mouthpiece
• Settings: +30 to +50 cmH₂O insufflation, then -30 to -50 cmH₂O exsufflation
• Duration: 1-3 seconds each phase
• Used 4 times per day when stable; more frequently during chest infections

INTERVENTION 2: Non-Invasive Ventilation (NIV / BiPAP)

Why This Patient Needs It

"NIV is indicated for symptoms and signs of hypoventilation - orthopnea, disturbed sleep, reduced lung function, nocturnal hypoxemia, daytime hypercapnia."

Assessment First

• Overnight oximetry - screens for nocturnal oxygen dips
• Arterial blood gas (ABG) or capillary blood gas - checks for CO₂ retention (hypercapnia)
• Sleep study (polysomnography) if available - gold standard

NIV Settings for This Patient

• Mode: BiPAP-ST (bilevel positive airway pressure with spontaneous/timed backup rate)
• IPAP (inspiratory support): start 10-12 cmH₂O, titrate up
• EPAP (expiratory pressure): keep low (4-5 cmH₂O) - no airway obstruction present
• Backup rate: 10-12 breaths/min (ensures breaths are delivered even if patient does not trigger)
• Target tidal volume: 6-8 mL/kg ideal body weight
• Interface: Full face mask initially (given restriction pattern)
• Use: Nightly during sleep as minimum; daytime use if needed

INTERVENTION 3: Chest Physiotherapy (CPT)

A. Postural Drainage

• Position patient in different angles to allow secretions to drain from the compressed lower zones of the restricted lung
• Particularly important as atelectasis is present at lung bases (seen on X-ray)

B. Active Cycle of Breathing Technique (ACBT)

1. Breathing control - relaxed tidal breathing (3-4 breaths)
2. Thoracic expansion exercises - deep slow breaths with 3-second hold at top
3. Forced expiration technique (FET/Huffing) - medium-force huff to clear secretions

C. Incentive Spirometry

• Patient inhales slowly and deeply, watching a ball/piston rise in the device
• Maintains open alveoli and prevents further atelectasis
• Use 10 breaths per hour when awake

INTERVENTION 4: Positioning

• Avoid prolonged supine position - in SCI patients with weak abdominal muscles, lying flat causes abdominal contents to push up on the diaphragm, further reducing FVC
• Upright/semi-reclined positioning (30-45°) helps diaphragm descend more freely
• Note: in quadriplegic/paraplegic patients, FVC can actually be higher lying flat than sitting due to diaphragm lengthening (unique to this population) - physiotherapist should test both positions

INTERVENTION 5: Secretion Management

• Adequate hydration - keeps secretions thin and easier to clear
• Nebulized saline (0.9% or hypertonic 3%) - loosens thick secretions before CPT
• Mucolytics (e.g., carbocisteine) - if secretions are consistently thick
• Suction - only if cough assist and manual techniques fail to clear secretions

INTERVENTION 6: Vaccination and Infection Prevention

• Annual influenza vaccine
• Pneumococcal vaccine (Pneumovax + Prevenar)
• COVID-19 vaccine up to date
• Early antibiotic treatment at first sign of chest infection - do not wait
• Early hospital admission threshold for any respiratory illness

INTERVENTION 7: Further Respiratory Investigations Needed

Priority Order for This Patient

IMMEDIATE (now):
1. Measure peak cough flow → start cough assist if <270 L/min
2. Blood gas → if CO₂ elevated, start NIV urgently
3. Overnight oximetry

SHORT TERM (this admission/clinic):
4. Daily chest physiotherapy with assisted cough
5. Teach breath stacking to patient and carer
6. Incentive spirometry every hour when awake
7. Upright positioning

MEDIUM TERM (outpatient):
8. Formal NIV setup and titration if indicated
9. CoughAssist device prescription
10. Full lung volumes + DLCO + echo
11. Vaccination update

⚠️ URGENT: Surgery in 2 Days (26 May 2026) - Respiratory Risk Assessment

The Core Problem: This Patient's FVC is Below the Critical Threshold

"The incidence of prolonged postoperative ventilation (>36 hours) was greatest in patients who had a preoperative FVC of less than 40% of the predicted value." "Patients with a VC of greater than 30% of the predicted value can usually be extubated immediately after surgery."

This patient's FVC = 20.7% of predicted

• Below 40% → high risk of needing prolonged ventilation post-op
• Below 30% → may NOT be safely extubated immediately after surgery

The Direct Answer: Should Surgery Proceed on 26 May?

Clinical Opinion:

Complications That CAN Happen if Surgery Proceeds

1. Failure to Extubate (Cannot Come Off the Breathing Machine)

• After general anaesthesia + muscle relaxants, the already-weak breathing muscles are further depressed
• With FVC at 20%, there is no respiratory reserve
• She may need to remain on a ventilator post-operatively for >36 hours or longer
• Risk of needing emergency tracheostomy if prolonged ventilation is required

2. Post-Operative Respiratory Failure

• Anaesthetic gases, opioid pain relief, and lying flat all further suppress breathing
• Atelectasis (already present on X-ray) worsens dramatically after general anaesthesia
• Weak cough (low PE max) means she cannot clear secretions - mucus plugs build up
• This leads to: mucus plugging → lobar collapse → pneumonia → respiratory failure

3. Aspiration Pneumonia

• Impaired cough reflex + post-anaesthesia sedation = risk of inhaling secretions/food
• In a patient with already compromised lungs, this can be fatal

4. Autonomic Dysreflexia During Surgery

• The patient has a T11 SCI - though below the T6 threshold for classic severe autonomic dysreflexia, any surgical stimulation below the injury level (sacral wound, bladder catheterisation, skin incision) can trigger:
  • Sudden extreme hypertension
  • Bradycardia
  • Profuse sweating above the lesion
  • Stroke risk if unrecognised
• The anaesthetist must be aware of this risk and have treatment ready

5. Prone Positioning Risk (Implant Removal is Posterior Surgery)

• Posterior spinal implant removal requires the patient to lie face-down (prone)
• In a patient with FVC 20% and compressed lungs, prone positioning:
  • Further reduces functional residual capacity
  • Abdominal contents compress the diaphragm
  • Already compromised breathing worsens dramatically under anaesthesia

6. Spinal Instability After Hardware Removal

• The C5-T8 fusion hardware has been in place since Feb 2020 (6+ years)
• Removing the implants (if the indication is infection, pain, or prominence) risks:
  • Loss of spinal stability - risk of cord injury worsening
  • Re-occurrence of scoliosis curve if fusion is incomplete
  • Neurological deterioration - potentially reversing the recovery from C8 complete to T11 incomplete

7. Pressure Ulcer Complications Intra-operatively

• The patient has an active sacral ulcer
• Prone positioning for posterior spinal surgery places direct pressure on the sacrum
• Prolonged surgery will worsen the ulcer significantly
• Surgical positioning must protect the sacral area

What Should Happen Before Surgery on 26 May

URGENT - Must Happen NOW (24-25 May)

Decision Points for the Anaesthetist

FVC <30% predicted
        ↓
Plan for POSSIBLE DELAYED EXTUBATION
        ↓
Book HDU/ICU bed post-operatively
        ↓
Have NIV/BiPAP ready at bedside post-op
        ↓
Consider regional anaesthesia instead of GA if feasible
        ↓
Avoid long-acting muscle relaxants
        ↓
Use sugammadex for reversal (complete neuromuscular reversal)
        ↓
Keep patient warm, upright post-op as soon as possible

Should Surgery Be Delayed?

Bottom Line

The spirometry and respiratory muscle tests from 22 May 2026 show FVC at 20% of predicted - below the published threshold of 30% for safe immediate extubation after surgery. This result must be communicated to the anaesthetic and surgical team TODAY (24 May) before the planned 26 May procedure. The surgery is not necessarily contraindicated, but it must proceed with full ICU/HDU backup, a plan for possible delayed extubation, and post-operative NIV ready at the bedside. If an arterial blood gas shows CO₂ retention, the surgery should be reconsidered and potentially deferred for respiratory optimisation.

What's in the Checklist

Section 1 - Respiratory Assessment (Red - URGENT)

Section 2 - Anaesthesia Planning (Orange)

Section 3 - Investigations (Blue)

Section 4 - Medications (Blue)

Section 5 - Sacral Pressure Ulcer (Red - URGENT)

Section 6 - Post-Operative Plan (Green)

Sign-Off Block

⚠ The most critical action: ABG results and anaesthetist review of the respiratory report must happen TODAY (24 May) - before surgery proceeds on 26 May.

Detailed Explanation: Risks of Removing Spinal Implants (Indication: Pain) in This Patient

First - Understanding What the Implants Are Doing

1. Mechanical stabilisation - the rods and screws act as an internal scaffolding, holding the spine in corrected alignment
2. Fusion facilitation - the hardware holds everything still while bone graft slowly grows between vertebrae (like a broken bone healing)

RISK 1: Loss of Spinal Stability

What Spinal Fusion Actually Means

IDEAL OUTCOME after 6 years:
Vertebra C5 → [solid bone bridge] → C6 → [solid bone bridge] → ... → T8
The hardware is now like scaffolding on a completed building — removable

The Problem: NF2-Associated Dystrophic Bone

• Vertebrae are dysplastic (poorly formed, scalloped, eroded)
• Bone quality is reduced — neurofibromas invade and destroy normal bone architecture
• Pseudarthrosis (false joint / failure of fusion) is a well-recognised complication of NF-associated scoliosis surgery
• Reported pseudarthrosis rates in NF scoliosis are significantly higher than in idiopathic scoliosis

What Happens if Fusion is Incomplete

No hardware + No solid bone fusion =
Spine has NO structural support
         ↓
Vertebrae shift, rotate, or collapse
         ↓
Spinal canal narrows or deforms
         ↓
Cord compression at multiple levels

How to Assess This Before Surgery

• CT scan of the fusion mass is the gold standard - thin-cut CT can show whether solid bone has bridged across each level
• Plain X-rays may miss early pseudarthrosis
• Flexion-extension X-rays reveal abnormal movement if fusion has failed

RISK 2: Re-occurrence of Scoliosis Curve

Why the Curve Came Back Would Be Catastrophic Here

• New tumor growth into vertebral pedicles and paraspinal tissues
• Continued vertebral erosion and remodelling
• Ongoing dural ectasia (widening of the spinal canal lining) weakening the bony structures

The Cascade if the Curve Returns

Hardware removed
        ↓
Residual scoliosis forces now unopposed
        ↓
Curve progresses (potentially rapidly in NF)
        ↓
Chest cage deformity worsens
        ↓
Lung compression increases further
        ↓
FVC (already 20%) drops even lower
        ↓
Respiratory failure accelerated

Additionally

• Re-operation to re-fuse and re-instrument a spine that has lost correction is technically far more difficult and carries higher complications than the original surgery
• Hardware failure (broken rods/screws) can occur if the spine is unstable and the hardware is under repeated stress cycles

RISK 3: Neurological Deterioration - Reversing C8 Complete to T11 Incomplete Recovery

How Recovery Was Achieved

1. Compressive tumors/bony deformity were removed from the cord
2. The cord was given space to recover
3. The fused and stabilised spine stopped the ongoing mechanical trauma to the cord

The Cord Is Still Vulnerable

• Already been compressed and injured once
• Undergone decompression surgery with the associated surgical trauma
• Been living in a surgically-altered anatomical environment for 6 years
• Possible residual intramedullary changes (syrinx, myelomalacia, gliosis)

• New compression
• Vascular compromise (stretching or kinking of spinal arteries)
• Mechanical disturbance from surgical manipulation

How Implant Removal Can Cause Neurological Worsening

• Surgical dissection around the hardware risks damaging scar tissue adherent to the dura (outer covering of the cord)
• Pedicle screw removal at C5-T8 risks pedicle fracture - bone fragments can enter the spinal canal
• Traction on the spine during hardware manipulation
• Bleeding into the epidural space post-operatively = epidural haematoma compressing the cord

• If fusion is incomplete and the spine becomes unstable, new abnormal movement at each segment creates repetitive microtrauma to the cord
• Gradual re-compression as the scoliosis recurs and vertebrae shift
• New canal stenosis from scar tissue remodelling post-operatively

What Neurological Deterioration Would Mean

Current: T11 INCOMPLETE paraplegia
         ↓  (if cord re-injured)
Could return toward: C8 COMPLETE tetraplegia

This means:
- Loss of lower limb function (whatever has been regained)
- Loss of upper limb function (return to no hand/arm movement)
- Loss of bowel/bladder continence
- Return to full dependence for all ADLs
- Worse respiratory function (higher lesion level = worse breathing)
- Potentially permanent - spinal cord does not reliably recover twice

The Central Dilemma: Pain vs. Risk

• Local soft tissue irritation
• Cold sensitivity over hardware
• Mechanical pain with movement
• In NF patients, neurofibromas growing around hardware causing nerve pain

Risk-Benefit Analysis

What Should Be Discussed With the Patient and Team Before 26 May

1. Has a CT scan confirmed solid bony fusion at all C5-T8 levels? - If not confirmed, removal is extremely high risk
2. Has pain management been optimally tried first? - Neuropathic pain medications (gabapentin, pregabalin), local anaesthetic patches, physiotherapy
3. Is partial hardware removal possible? - Removing only the most prominent/painful screws while leaving the rod structure intact reduces instability risk
4. Is the patient aware that neurological worsening could be permanent? - Full informed consent requires this discussion explicitly
5. Has the respiratory risk been communicated to the patient? - FVC 20% means this surgery carries a real risk of not coming off a ventilator post-operatively

Summary

The key message: Hardware removal for pain is a legitimate operation in the right patient, but in this patient it carries risks that could permanently undo 6 years of neurological recovery and precipitate life-threatening respiratory failure. The surgical team must confirm solid bony fusion on CT, explore non-surgical pain management options first, and ensure the patient fully understands that this surgery could, in the worst case, result in return to complete tetraplegia.

Re-Reading the X-rays in the Correct Clinical Context

What 5 Months Post-Op Means for Fusion

• Bony fusion is NOT yet complete - solid bridging bone typically takes 12-18 months minimum, longer in NF patients
• The hardware (rods + screws) at this stage is doing 100% of the mechanical work - the spine has zero bony self-support yet
• This X-ray represents the early post-operative state, not a mature fusion

What the PA Chest X-ray (5 Months Post-Op) Shows

• The two parallel cervicothoracic rods are clearly visible running from the upper cervical spine downward
• Pedicle screws visible as the bulbous anchor points (the "wing nut" shapes at cervicothoracic junction, approximately C5-T4 region)
• Below those, additional screw heads continue down the thoracic spine
• A long drainage tube / central venous line is still in situ running from the neck - consistent with early post-op period (still in ICU/HDU at 5 months, or a tunnelled line for long-term IV access)
• Small ECG electrodes visible - patient still on monitoring

• Looking carefully, the pedicle screws are visible only at the upper thoracic levels
• The rods extend from cervical down to approximately T4-T5 based on vertebral counting - this may represent the upper construct only, or the lower screws are less visible due to spinal rotation

• Significant residual scoliosis is visible even post-operatively - the spine is not straight
• The thoracic spine curves to the right (convex right / concave left) below the instrumented levels
• The hardware has partially corrected the upper curve but the lower thoracic/lumbar curve persists uncorrected

• Right lung (image left, patient's right): severely compressed, opaque, crowded ribs - this is the concave side of the residual curve
• Left lung: relatively more aerated but also compromised
• The large white opacity across the lower chest - likely a combination of:
  • Atelectasis (collapsed lung segments, very common in early post-op period)
  • Possible pleural effusion (fluid accumulation post-major surgery - common at 5 months if not fully resolved)
  • Elevated right hemidiaphragm from phrenic nerve paresis or eventration
  • Scoliosis-related compression

What the Full Spine X-ray Shows (5 Months Post-Op)

• Cervicothoracic junction hardware clearly visible - the large cross-connector and screw assembly at C5-T2 area
• Two rods running parallel down the upper thoracic spine
• The lower thoracic and lumbar spine shows persistent curvature - the vertebrae are rotated and the spine curves to the right
• The rib-vertebra relationships show the classic NF dystrophic appearance - irregular, pencilled ribs
• Below the hardware, the residual curve continues - no instrumentation protecting the lower thoracic spine

Critical Implications for the 26 May 2026 Surgery

The Important Question This Raises

1. The hardware construct appears limited to the upper thoracic levels - not the full C5-D8 stated
2. Residual scoliosis was already significant 5 months post-op
3. The patient needed prolonged post-op monitoring (lines/tubes still in at 5 months)

• A current X-ray (2025 or 2026) to compare with the July 2020 films - has the curve progressed? Has hardware failed (broken rods, pulled screws)?
• A CT scan of the fusion mass to confirm solid bone at all levels
• Assessment of whether the lower thoracic curve has progressed since 2020, which would indicate the fusion below the hardware has failed

Summary of How This Changes the Risk Assessment

The surgeon must have a current imaging study (ideally CT spine + current X-ray) to confirm:

1. The fusion is solid and mature throughout C5-D8
2. No hardware failure (broken rod/screw) has occurred in 6 years
3. The residual lower thoracic curve has not progressed
4. The spinal canal is not stenotic from new NF2 tumor growth at any level

Removing hardware based only on a 2020 X-ray would be clinically unsafe.

What the Image Shows

What I Can See

1. A long vertical surgical scar running down the midline of the neck/upper back - this is the healed incision from the February 2020 C5-D8 posterior spinal fusion
2. Two visible swollen raised areas on the right side of the upper back/lower cervical region - these are clearly visible as bumps under the skin, positioned paramedian right, approximately at the C5-T2 level (matching the upper end of the fusion construct)
3. The skin over these areas appears intact but stretched and thinned from the underlying prominence
4. Multiple scattered hyperpigmented spots on the back - these are consistent with NF2-associated skin lesions (cutaneous neurofibromas or café-au-lait spots)

What Is Causing the Swollen Painful Areas

The Two Bumps = Prominent Pedicle Screw Heads / Rod Connectors Breaking Through

Why This Is the Correct Indication for Implant Removal

1. The pain source is clearly identifiable (the prominent hardware is visibly pressing through the skin)
2. The hardware is at the upper cervical end of the construct (C5-T2 area) - not at the thoracic levels where the scoliosis was corrected
3. Removing only the prominent upper screws/connectors may be possible without removing the entire construct - preserving lower thoracic stability
4. The skin is at risk of breaking down over the screw heads - if the skin ulcerates over the hardware, infection of the implant becomes a serious complication (implant infection in a spine fusion is a surgical emergency)

Important Nuance: Partial vs. Full Hardware Removal

Skin Risk Warning - Urgent

If the skin breaks down over a spinal implant before surgery, bacteria can track down to the hardware and infect the entire fusion construct. This is a catastrophic complication requiring emergency removal of all hardware - far more dangerous than elective removal.

Why This Is the Correct Indication for Implant Removal - Full Analysis

Recap: What the Photo Shows

• Two distinct raised, swollen bumps on the right paramedian upper back/lower cervical region
• Positioned directly along and beside the surgical scar from the 2020 C5-D8 fusion
• The skin over these areas is stretched, thinned, and under tension
• Surrounding skin shows NF2 cutaneous lesions (multiple scattered pigmented spots)
• The bumps correspond precisely to the upper pedicle screw heads / rod connector visible on the July 2020 X-ray

The 5 Reasons This Is the CORRECT Indication

Reason 1: The Hardware Is Physically Threatening the Overlying Skin

Stage 1: Skin stretched and thinned (CURRENT STATE - visible in photo)
         ↓
Stage 2: Skin becomes erythematous (red, warm) - chronic irritation
         ↓
Stage 3: Skin ulcerates - a small hole forms over the screw head
         ↓
Stage 4: Hardware becomes EXPOSED - metal visible through the wound
         ↓
Stage 5: Deep INFECTION tracks down the screw along the rod
         ↓
Stage 6: Osteomyelitis (bone infection) at every instrumented vertebra
         ↓
Stage 7: Emergency explantation of ALL hardware in an infected field
         = Highest risk surgery possible, with catastrophic consequences

• Elective
• Controlled
• Lower risk
• Performed in a clean, uninfected field

• Dramatically increases surgical risk
• May require removal of ALL hardware (not just the upper screws)
• Risks spreading infection to the fused vertebrae (vertebral osteomyelitis)
• May require prolonged intravenous antibiotics (6+ weeks)
• Risks the infection tracking to the spinal canal causing epidural abscess - a neurosurgical emergency that can cause paralysis

Reason 2: The Pain Is Directly Attributable to a Removable Cause

Reason 3: This Patient Cannot Use Standard Pain Management

• NSAIDs (anti-inflammatory drugs)
• Lying on padding/cushions to offload the area
• Physiotherapy

• Impaired sensation below T11 means pain signals from the hardware are already partially abnormal - the fact that she IS feeling pain from the prominent hardware at C5-T2 level (above her injury) means it is genuinely significant
• Pressure relief is impossible - as a paraplegic patient spending significant time in positions that put her back in contact with surfaces (wheelchair, bed), she cannot simply "avoid" pressure on the hardware bumps
• The sacral pressure ulcer demonstrates that this patient is already prone to pressure-related tissue breakdown - the same mechanism will affect the hardware prominence area

Reason 4: 6 Years is Sufficient Time for Fusion - Hardware Is Likely Redundant

Reason 5: The Location of the Prominent Hardware Is the UPPER End of the Construct

Fusion construct:  C5 ── C6 ── C7 ── T1 ── T2 ── T3 ── T4 ── T5 ── T6 ── T7 ── T8
                   ↑_________________________↑              ↑__________________________↑
                   UPPER END (prominent,                    LOWER END (scoliosis
                   painful screws here)                     correction hardware here)

• The thoracic scoliosis correction hardware remains in place
• The lower thoracic spine remains stabilised
• The risk of scoliosis curve recurrence is minimised
• The neurological risk to the cord is lower (operating further from the area of cord injury/recovery)

Full Surgical Risk Analysis for the 26 May Partial Implant Removal

Procedure-Specific Risks (Upper Cervicothoracic Hardware Removal)

• The spinal cord at C5-T2 is the level of the original injury and recovery
• Surgical dissection must navigate scar tissue from the 2020 surgery
• Risk of epidural haematoma post-op - blood collecting in the spinal canal pressing on the cord
• Risk of dural tear during dissection if the dura is adherent to the old hardware
• In NF2: additional risk of disturbing schwannomas or neurofibromas that may have grown around the hardware since 2020

• Broken/seized screws - after 6 years, titanium screws can bond to bone (osseointegration). Removal may require specialised extraction tools; forced removal can fracture the pedicle
• Pedicle fracture during screw extraction - bone fragments can enter the canal
• Rod fracture - if a rod has a fatigue crack (common after years of cyclical loading), removal attempts may snap it, leaving a fragment
• Surgeons must have extraction instruments (screw extractors, trephines, reverse-torque drivers) available

• Impaired wound healing - SCI patients have reduced blood flow and tissue perfusion in denervated areas
• The skin over the hardware bumps is already thinned - closure after hardware removal requires healthy skin flaps; may need plastic surgery assistance
• Sacral ulcer represents systemic vulnerability to wound healing
• Nutritional status - chronic illness, pressure ulcers, and NF2 all contribute to malnutrition, which directly impairs wound healing

• Upper cervical surgery requires neck positioning - challenging in a patient with previous C5-T8 fusion and limited neck mobility
• The fused cervical spine is rigid - any forceful positioning risks cord injury
• FVC 20% - all previous respiratory concerns apply in full

• Even though surgery is at C5-T2 (above the T11 injury level), skin incision and wound closure are stimuli that can trigger AD in SCI patients
• More relevant: post-operative bladder management (catheter), pain, bowel - all common AD triggers in the recovery period

Why Proceeding on 26 May Is Justified

The Two Non-Negotiable Conditions Before Proceeding

1. ABG must be done today (24 May) - if CO₂ is retained, the respiratory team must be involved in the decision to proceed
2. The surgeon must confirm the surgical scope is upper construct removal only (not full C5-T8 explantation) - this single factor changes the risk-benefit analysis from "borderline" to "clearly justified"

How to Read the ABG Report Tomorrow

The 5 Key Values and What They Mean for This Patient

The Decision Tree Based on PaCO₂ (Most Critical Value)

PaCO₂ RESULT TOMORROW:
│
├── PaCO₂ 35-45 mmHg (NORMAL)
│   ├── No CO₂ retention
│   ├── Surgery can proceed on 26 May
│   └── Plan: ICU/HDU bed + BiPAP post-op (still needed due to FVC 20%)
│
├── PaCO₂ 46-50 mmHg (MILDLY ELEVATED)
│   ├── Early/mild chronic respiratory failure
│   ├── Surgery can likely proceed BUT anaesthetist MUST know
│   ├── Post-op ventilatory support is MANDATORY (not optional)
│   └── Plan: ICU bed (not just HDU) + immediate BiPAP post-extubation
│
├── PaCO₂ 51-59 mmHg (MODERATELY ELEVATED)
│   ├── Established chronic respiratory failure
│   ├── Surgery timing decision must be discussed urgently with surgeon + anaesthetist
│   ├── Consider starting NIV (BiPAP) BEFORE surgery to optimise
│   └── This level does not automatically cancel surgery but requires senior review
│
└── PaCO₂ ≥ 60 mmHg (SEVERELY ELEVATED)
    ├── Severe chronic hypercapnic respiratory failure
    ├── Surgery on 26 May should be RECONSIDERED and likely DELAYED
    ├── Patient needs NIV optimisation first (days to weeks)
    └── Urgent respiratory physician review before any surgical decision

The Bicarbonate (HCO₃) Clue

• This means the kidneys have been compensating for high CO₂ for weeks or months
• It is a sign of chronic (not just acute) CO₂ retention
• Even if PaCO₂ appears near-normal on the day of the test, the body has adapted to living with higher CO₂
• This still increases anaesthetic risk and post-op ventilatory support requirement

What to Do With the Report Tomorrow

• The surgeon (operating on 26 May)
• The anaesthetist (must see it before the operation)
• The ICU/HDU team (so they can prepare the right level of post-op care)

One More Thing to Check on the Report

• If taken on room air → the values reflect true baseline respiratory function
• If taken on oxygen → PaO₂ will look artificially good; the PaCO₂ is still valid

The Direct Answer

What You MUST Ask Your Surgeon Before 26 May

Question 1:

"Are you removing ALL the hardware (C5-T8), or only the upper screws that are causing the swelling and pain?"

Question 2:

"Is my bone fusion solid enough that removing the hardware will not affect my spinal stability?"

Question 3:

"Could removing this hardware cause any neurological change - could I lose any of the movement or sensation I have regained since 2020?"

What the Evidence Suggests (Based on What We Know)

The Honest Reality

1. Exactly what is being removed
2. Whether your fusion is confirmed solid on imaging
3. What the realistic chance is of any neurological change

My Recommendation

• ✅ "Only upper screws" + ✅ "CT shows solid fusion" + ✅ "Neurological risk is low" → you can proceed with reasonable confidence
• ⚠️ "Full hardware removal" OR ⚠️ "No recent CT" → ask for more time and imaging before proceeding

Upper Screws Only - What This Means for You

Your Hardware Has Two Distinct Parts

YOUR SPINE (C5 to T8 fusion):

UPPER CONSTRUCT (being removed 26 May):
C5 ── C6 ── C7 ── T1 ── T2
↑ These are the painful swollen bumps
↑ These screws are pushing through your skin
↑ THESE ARE COMING OUT ✓

─────────────────────────────────────────

LOWER CONSTRUCT (staying in place):
T3 ── T4 ── T5 ── T6 ── T7 ── T8
↑ These hold your scoliosis correction
↑ These protect your thoracic spine
↑ THESE REMAIN INTACT ✓

Will This Affect Your Neurological Recovery?

Will Your Scoliosis Return?

• The lower thoracic rods and screws (T3-T8) remain in place
• These are the levels that hold your scoliosis correction
• By 6 years post-op, bony fusion across the thoracic levels is highly likely to be solid
• Even if some upper cervical alignment shifts slightly after removing C5-T2 screws, the major thoracic correction is preserved

The Main Benefit You Will Gain

What the Remaining Risk Is (Being Honest)

Bottom Line

Removing only the upper screws is the right, targeted, and proportionate intervention for your problem. Your T11 incomplete paraplegia recovery, your scoliosis correction, and your thoracic spinal stability are all protected because the lower hardware remains in place.

The Honest Truth About Respiratory Recovery in Your Case

1. Recover what CAN be recovered (atelectasis, muscle strength, cough function)
2. Protect and maintain what you have (prevent it getting worse)

What You Can Do - A Practical Daily Respiratory Programme

🔵 LEVEL 1: Do These Every Day (Essential)

• Sit upright (or as upright as possible in wheelchair/bed)
• Place one hand on your belly
• Breathe in slowly through your nose for 4 seconds - feel your belly push out
• Hold for 2 seconds at the top
• Breathe out slowly through pursed lips for 6 seconds
• Repeat 10 times, every 1-2 hours when awake

This is the single most important exercise. It directly counters the atelectasis visible on your X-ray.

• A device (ask your physiotherapist for one) with a ball inside a tube
• Inhale slowly and as deeply as possible - watch the ball rise
• Hold at the top for 3 seconds
• Do 10 repetitions every hour when awake
• Record how high the ball reaches each week - this is your progress marker

• Take a breath in and hold it (close your throat / hold your glottis)
• Without breathing out, take another breath in on top
• Hold again - take a third breath on top if possible
• Now you have 3 breaths stacked - hold for 2-3 seconds
• Then breathe out slowly
• Do 5 repetitions, 3 times per day

• Take the deepest breath possible (use breath stacking first)
• Your helper places both hands on your upper abdomen / lower chest
• On the count of 3, you try to cough while your helper gives a firm inward-upward thrust
• The combined effort produces a much stronger cough than you can alone
• Do this after every meal and before sleep
• During any chest infection: every 2-4 hours

🟡 LEVEL 2: Weekly Progress (Strengthening)

• Breathe in through the device - it has a resistance you must overcome
• Start at 30% of your PI max - low resistance
• 30 breaths per day, 5 days per week
• Increase resistance every 2 weeks as it gets easier
• Studies show PI max can improve 20-30% with consistent training over 8-12 weeks in SCI patients

• Wear an abdominal binder (wide elastic support band around the abdomen)
• This gives the diaphragm something to push against
• Has been shown to improve FVC by 10-15% in thoracic SCI patients when worn upright
• Wear it during all upright/seated activities
• Remove at night

• Upright sitting is best for lung expansion in most people
• But in SCI (especially with weak abdominal muscles): lying slightly reclined (30°) or even flat may allow the diaphragm to work more efficiently - try both positions and notice where breathing feels easier
• Avoid slumping in wheelchair - this collapses the chest and further reduces your already limited FVC
• Use a lumbar support and chest strap in your wheelchair to maintain upright posture

🟢 LEVEL 3: If Available (Maximise Recovery)

• If CO₂ is elevated → BiPAP is needed now, before surgery
• Even if CO₂ is normal → BiPAP at night is still beneficial to:
  • Rest your fatigued respiratory muscles
  • Recruit atelectatic lung segments overnight
  • Prevent nocturnal hypoventilation from gradually worsening

• Applied via face mask
• Machine pushes air IN (+pressure) then immediately pulls air OUT (-pressure)
• Simulates a cough far stronger than any manual technique
• Used 4 times daily when stable, more during chest infections
• Ask your respiratory therapist or pulmonologist for a prescription

Realistic Goals - What to Expect

What Will NOT Recover (Being Honest)

• The chest wall deformity from scoliosis is structural and permanent - the FVC will never reach 100% predicted
• The intercostal muscle paralysis from SCI will not fully reverse
• The compressed lung on the concave side has years of atelectasis - some segments may be permanently consolidated

After the 26 May Surgery - Respiratory Recovery Priority

• Anaesthetic effects
• Pain reducing deep breathing effort
• Prone positioning effects on the lungs
• Post-op sedation

1. BiPAP/NIV applied as soon as you are extubated
2. Physiotherapist at bedside within 2 hours of waking up
3. Assisted cough every 2-4 hours
4. Deep breathing exercises from Day 1 post-op
5. Sit upright as soon as surgically safe to do so