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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

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Nursing care of the postoperative spine patient care
Nursing Care of the Postoperative Spine Patient Care

Michael D Smith MD

Twin Cities Orthopedics

October 2012


Objectives
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
Indications for Spinal SurgeryThe Big Three

  • Neurologic compression

  • Instability

  • Deformity


Pain indication for surgery
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
Disc HerniationGrade 1-4 based on morphology and extension beyond PLL


Neurological indications
Neurological Indications

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


Instability
Instability

  • Spine unable to tolerate daily loads without excessive motion

  • Degenerative, acquired, post-traumatic, neoplastic, congenital



Degenerative instability
Degenerative Instability



Perioperative complications
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
Risk Factors for Complications

  • Pulmonary circulation 9.52

  • Renal disease 5.55

  • Metastatic Cancer 4.21

  • Electrolyte abnl 3.97

  • CHF 3.46

  • Etoh abuse 1.16


Demographics for mortality
Demographics for Mortality

  • Male

  • Posterior vs. anterior

  • Rural vs. Urban

  • Older vs. younger

  • A-American vs. Caucasian


Risk factors for mortality unproven
Risk Factors for MortalityUnproven*

  • DM, simple

  • DM, complicated

  • Obesity

  • PVOD


Common cervical spine procedures
Common Cervical Spine Procedures

  • Anterior discectomy/fusion -ACDF

  • Anterior corpectomy/fusion -ACCF

  • Anterior discectomy/replacement -ACD

  • Posterior decompression –foraminotomy/laminaplasty -

  • Posterior fusion -PSF



Operative approach
Operative Approach

  • Transverse incision -cosmetic

  • Left sided preferred (recurrent laryngeal nerve at less risk)

  • Careful anatomic exposure








Cervical corpectomy
Cervical Corpectomy

  • Anterior approach

  • Extensive exposure

  • Longer OR times

  • More complicated stenosis

  • Increased complication rate, airway, dysphagia




Posterior procedures
Posterior Procedures

  • Positioning

  • Padding of neurovascular points

  • Peruse facial-cervical area



Posterior procedures1
Posterior Procedures

  • Adhere to demonstrated ROM to avoid impingement cord/root


Indications and need for nursing care
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
Phases of Nursing Care

  • Preoperative 

  • Education, counseling, support


Phases of nursing care1
Phases of Nursing Care

  • Perioperative 

  • Routines, time outs, counts, cross pollination


Phase of nursing care
Phase of Nursing Care

  • Postoperative 

  • Dependent on nursing input and remote assessment

  • Typical defines patient perception f care


Complications
Complications

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



Nursing concerns
Nursing Concerns

  • Tracheal obstruction- expanding hematoma, lymphatic congestion, vocal cord paralysis

  • Stridor- an impending arrest


Nursing concerns1
Nursing Concerns

  • Esophageal – retraction, local change in motility, laceration

  • Indigo carmine for leak assessment

  • Difficulty –> barium swallow, steroids, feeding tube





Nursing concerns2
Nursing Concerns

  • Neurological assessment- compare pre to post op status

  • Pain management – separate topic


Mental health issues
Mental Health Issues

  • Anxiety

  • Depression

  • Somatization

  • Unrealistic expectations


Anxiety disorders
Anxiety Disorders

  • 18% of general population (40M)

  • Pervasive and variable in expression

    Kessler RC Arch Gen Psychiatry, 2005 Jun;62(6):617-27.


Anxiety disorders1
Anxiety Disorders

  • OCD

  • PTSD

  • Social phobias

  • Specific phobias

  • GAD


Depression
Depression

  • 10% of general population

  • Variable expression

  • Surgeons do poor job in pre-op recognition

  • May coexist with anxiety syndromes


Depression the 3 rs
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
Substance Abuse240M in Risk Group

  • Chemical 5% 12M

  • Alcohol 10% 24M

  • Tobacco 19% 46M

  • Associated mental health issue (i.e., anxiety+Etoh) 54%

    www.hhs.gov/od/about/fact_sheets/substanceab use.html



Postoperative anxiety
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 MPatient Educ Couns. 2003 Oct;51(2):169-76



Conflict of interest

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.


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