Transcript Michael Smith Presentation
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.