Nursing Care of the Postoperative Spine Patient Care Michael D Smith MD Twin Cities Orthopedics October 2012

Objectives • Discuss indications for surgery • Present perioperative complications to watch for • Review practical surgeon concerns regarding nursing assessment * biased toward cervical spine procedures *

Indications for Spinal Surgery The Big Three • Neurologic compression • Instability • Deformity

Pain -Indication for Surgery?

• Pain- unmanageable and associated with compression, deformity, or instability • Degenerative findings- common and incidental

Disc Herniation Grade 1-4 based on morphology and extension beyond PLL

Neurological Indications • Pain, numbness, weakness, tingling from cord or root compression

Instability • Spine unable to tolerate daily loads without excessive motion • Degenerative, acquired, post traumatic, neoplastic, congenital

Traumatic Instability

Degenerative Instability

Cervical Deformity

Perioperative Complications • General medical- cardiac (MI), respiratory, urologic pulmonary (UTI) • Specific- device related (posterior > anterior) • Surgical- hematoma, vascular or visceral injury, infection Clin Orthop Relat Res. 2011 March; 469(3): 649–657

Risk Factors for Complications • Pulmonary circulation • Renal disease • Metastatic Cancer • Electrolyte abnl • CHF • Etoh abuse 9.52

5.55

4.21

3.97

3.46

1.16

Demographics for Mortality • Male • Posterior vs. anterior • Rural vs. Urban • Older vs. younger • A-American vs. Caucasian

Risk Factors for Mortality Unproven* • DM, simple • DM, complicated • Obesity • PVOD

Common Cervical Spine Procedures • Anterior discectomy/fusion -ACDF • Anterior corpectomy/fusion -ACCF • Anterior discectomy/replacement -ACD • Posterior decompression – foraminotomy/laminaplasty • Posterior fusion -PSF

Surgical Technique-Anterior Decompression/Fusion

Operative Approach • Transverse incision -cosmetic • Left sided preferred (recurrent laryngeal nerve at less risk) • Careful anatomic exposure

Incision Localization

Exposure Superficial Dissection

Exposure Deep Dissection

Completed Exposure

Fusion Bone Graft Insertion

Typical ACDF Fixation

Cervical Corpectomy • Anterior approach • Extensive exposure • Longer OR times • More complicated stenosis • Increased complication rate, airway, dysphagia

Cervical Corpectomy

Cervical Disc Replacement

Posterior Procedures • Positioning • Padding of neurovascular points • Peruse facial cervical area

Posterior Procedure Positioning

Posterior Procedures • Adhere to demonstrated ROM to avoid impingement cord/root

Indications and Need for Nursing Care • Varied patient population • Varying neurologic presentation • Broad age range and support structures • Outpatient to lengthy hospitalizations

Phases of Nursing Care • Preoperative  • Education, counseling, support

Phases of Nursing Care • Perioperative  • Routines, time outs, counts, cross pollination

Phase of Nursing Care • Postoperative  • Dependent on nursing input and remote assessment • Typical defines patient perception f care

Complications • Anything that is touched, moved, looked at, exposed, intubated, extubated, cooled, or heated can be injured.

Postoperative Edema

Nursing Concerns • Tracheal obstruction- expanding hematoma, lymphatic congestion, vocal cord paralysis • Stridor- an impending arrest

Nursing Concerns • Esophageal – retraction, local change in motility, laceration • Indigo carmine for leak assessment • Difficulty –> barium swallow, steroids, feeding tube

Esophageal Perforation

Esophageal Perforation

Displaced Bone Graft

Nursing Concerns • Neurological assessment- compare pre to post op status • Pain management – separate topic

Mental Health Issues • Anxiety • Depression • Somatization • Unrealistic expectations

Anxiety Disorders • 18% of general population (40M) • Pervasive and variable in expression Kessler RC Arch Gen Psychiatry , 2005 Jun;62(6):617-27 .

Anxiety Disorders • OCD • PTSD • Social phobias • Specific phobias • GAD

Depression • 10% of general population • Variable expression • Surgeons do poor job in pre-op recognition • May coexist with anxiety syndromes

Depression The 3 Rs • Reduced threshold for need for surgery • Reduced threshold for reporting pain after surgery • Reduced support systems and preop physical prowess

Substance Abuse 240M in Risk Group • Chemical • Alcohol • Tobacco 5% 10% 19% 12M 24M 46M • Associated mental health issue (i.e., anxiety+Etoh) 54% www.hhs.gov/od/about/fact_sheets/substanceab use.html

Coping Skill Set Point Readjusted

Postoperative Anxiety • Assurance • Adequate analgesia • Anxiolytics-Ativan, Valium, Xanax • Allied health approach (aroma therapy, massage, music, pets, spouse) • Anticipation and preop teaching

The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management.

Sjöling M Patient Educ Couns.

2003 Oct;51(2):169-76

Thank You

CONFLICT OF INTEREST

I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting.