Nursing care of the postoperative spine patient care
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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

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 SurgeryThe 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 HerniationGrade 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 circulation9.52

  • Renal disease5.55

  • Metastatic Cancer4.21

  • Electrolyte abnl3.97

  • CHF3.46

  • Etoh abuse1.16


Demographics for Mortality

  • Male

  • Posterior vs. anterior

  • Rural vs. Urban

  • Older vs. younger

  • A-American vs. Caucasian


Risk Factors for MortalityUnproven*

  • 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 Abuse240M in Risk Group

  • Chemical5%12M

  • Alcohol 10%24M

  • Tobacco19%46M

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

    www.hhs.gov/od/about/fact_sheets/substanceabuse.html


Coping Skill Set PointReadjusted


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


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.


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