Cervical Spine Surgery 101

1. Cervical Spine Surgery 101 France Ellyson Kuwait 2014

2. Introduction Degenerative cervical spine disease is a common problem associated with aging Often asymptomatic or experienced as episodic neck pain Peak incidence among 50-54 years of age Most common etiology spondylosis Usually 6 weeks of conservative treatment is recommended before surgery is considered

3. Cervical Spine Anatomy • Cervical spine has 7 vertebrae • Body is located anteriorly • To either side of body – transverse process • Vertebral foramen – known as spinal canal

4. C1 Vertebra C2 Vertebra Atlas Axis

5. Cervical Spine Anatomy • Intervertebral disc resides between each cervical vertebral bodies except C1 and C2 • Disc permit flexion and rotation • Composed of nucleus pulposus and annulus fibrosus

6. Cervical Spine Anatomy • Ligaments between vertebral bodies maintain discs in place • Instrumental in spine alignment • Spinal cord extends from foramen magnum to ?_________

7. Cervical Spine Anatomy • The meninges cover the spinal cord • CSF bathes spinal cord and is found in SA space • There are 8 pairs of cervical spine nerve roots • A dermatome is an area of skin innervated by fibers of individual nerve root

8. Dermatomes

9. Diagnostic Studies Plain radiography: Inexpensive and non-invasive – shows arthritis and bony alignment CT scan: Used as adjunct to MRI or in pts who cannot undergo MRI MRI: Study of choice. Contrast agents may be used to highlight masses, abnormal tissue or fluid collection Bone scan: Assess increased bone production, tumor, infection EMG:Assess muscle activity and nerve conduction Somatosensory Evoked Potentials: Evaluates function of sensory fibers

10. Cervical Spine Disorders • Neck pain is common problem, often episodic and self-limiting • Can be a symptom of degenerative cervical disorders, neoplastic disease, deformity or infection

11. Neck Pain without Radiculopathy Mechanical Pain: • Associated with spine • Usually deep and agonizing • Aggravated by activity • Alleviated by rest • Usually associated with degenerative conditions Myofascial Pain • Associated with muscle • Often results in muscular spasms and posterior occipital H/A • Best respond to exercise and stress-reducing interventions

12. Cervical Radiculopathy Radiculopathies are the result of nerve root compression In cervical spine, the most common cause is foraminal narrowing and impingement onto spinal nerve 25% cases result HNP Majority of cases caused by cervical spondylosis S/S include – neck pain and upper extremity pain

13. Cervical Myelopathy Myelopathy results from spinal cord compression Usually caused by acute disc herniation S/S: hyperreflexia, poor coordination or lack of motor dexterity, bowel or bladder changes balance problems, falling episodes, varying degree of weakness and sensory changes

14. Degenerative Cervical Spine Disorders Herniated Nucleus Pulposus– Bulging, protrusion, sequestered fragment, radiculopathy Spondylosis – Age- and use-related degenerative changes in spine Cervical Stenosis – Narrowing of spinal canal, congenital or degenerative changes

15. Cervical Spine Disease Rheumatoid Arthritis – chronic systemic autoimmune disease characterized by erosive synovitis that destroys joints in body Metastatic – Spinal involvement can lead to vertebral collapse and instability, causing pain and potential neurological compromise Osteoporosis – Low bone mass and structural deterioration Infection – Hematogenous spread from urinary tract, skin, cardiac valve, abdominal, postsurgical

16. Nonsurgical Medical Treatment • Non-surgical treatment is warranted for 6-12 weeks unless progressive neurologic deficit • Promotion of smoke cessation • Promotion of weight management • Promotion of adequate physical activity

17. Non-Surgical Spine Disorders Medication – Muscle relaxants to reduces spasm, NSAIDs to reduce inflammation of nerve root, opioids for sort-term acute pain Epidural Steroid Injections – Interlaminar injection of corticosteroid, methylprednisone to inhibit prostaglandin sythesis and decrease immunologic response – Significant success rate but complication may be severe

18. Nonsurgical Medical Treatment Physical Therapy – PT often reduces pain and improves function Spinal Manipulation – Chiropractic or ostheopathic – strong evidence for the benefit of multimodal approach Bracing – Short-term (<2weeks) immobilization with either soft or hard collar may be recommended Acupuncture – ? Influence the body’s electromagnetic field which can alter chemical neurotransmitters. Evidence is emerging. (Irnich et al.,2001;White, Lewith, Prescott & Conway, 2004)

19. Surgical Treatment • Indicated persistent S/S despite conservative Rx • Several studies inconclusive – whether risks of surgery offset benefits

20. Anterior Approach • Cervical Discectomy (ACD) with and without Fusion (ACDF) • To relieve pressure on spinal cord and nerve roots • ACDF uses graft material (Ileac crest) and plate fixation to prevent disc prolapse • Many surgeons now favor interbody fusion devices and cages

21. Anterior Approach • Corpectomy – removal of one or more vertebral bodies and adjacent disks - requires stabilization with graft or hardware • Disc Arthroplasty – Artificial disc is an alternative to bone grafts and hardware. New technique in USA

22. Posterior Approach • Laminectomy with or without Fusion – Removal of the vertebral lamina to decompress spinal cord, • Laminectomy may include fusion if concerns cervical stability (screws, rods, bone)

23. Grafts Materials • Autograft – From recipient’s own body, usually ileac crest • Allograft – Cadaver bone • Biologics – Demineralized bone matrices, recombinant human BMP • Instrumentation – plates, rods, screws, wires, etc

24. Preoperative Care Preop teaching – Surgical procedure, informed consent, anticipation of postop needs (home help, ?driving) OT consult if cervical collar ordered (remind to bring to hospital) Consult anesthesia – if unstable C-spine D/C medications; herbal products, NSAIDs, anticoagulants, aspirin, warfarin, plavix Antibacterial pre-op shower, remove nail polish NPO after midnight prior to OR

25. Intraoperative Care Perform “Time out” Verify that prophylactic DVT prevention is implemented PRN – TEDs, SCDs Verify that preoperative antibiotics are administered PRN Alert staff of patient allergies PRN Monitor patient positioning

26. Postoperative Care Monitor neurological status – compare to preop – focus on upper extremity strength and sensation Administer antibiotics as ordered – MD specific and controversial Monitor complications – hematoma or swelling at incision, CSF leak, wound infection

27. Anterior Posterior • Assess airway patency – dysphagia, sore throat, pain, lump feeling when swallowing, excessive phlegm, production, hoarse voice • Monitor incision for swelling and drainage • Collar PRN • Expect rather lengthy incision 10-15 cm) • Monitor incision site for serosanguinous drainage • Pain ++ at incision site along with posterior cervical muscle spasm • Collar PRN

28. Postoperative Care Mobility – varies greatly on diagnosis, preop mobility and type of surgery, ie, single-level ACDF may be ready to mobilize 2 hours after return to in-pt unit Monitor pain and provide analgesics as ordered Encourage oral feeding as soon as tolerated Prevent constipation – ensure adequate water intake, diet should include fruits, vegetables and fiber Administer stool softeners (Ducosate) / motility (Senna) agents as ordered

29. Postoperative Care Remove Foley catheter until patient can stand to void, use bedpan or urinal. Goal: D/C Foley catheter within 24 hours of surgery Assess adequate bladder emptying – use bladder scan Discharge planning: Mobility restrictions if any – avoid heavy lifting , avoid excessive neck flexion, such as reading, desk work. Ensure computer is at right height. Reinforce incision care to patient and caregivers – evaluate for S/S infection

30. Postoperative Care • Collar maintenance: Pts should wear collar at all times. Sometimes they may remove to shower or sleep, at MD’s discretion. • Teach pt how to clean pads and change collar in front of mirror

31. Aspen Collar http://www.youtube.com/watch?v=UUd2JNMPWLM

32. References Bader, M.K., & Littlejohns, L.R. (Eds.). (2004). AANN core curriculum for neuroscience nursing (4th ed.). St-Louis, MO: Elsevier Health Sciences Hickey, J.V. (2006) The Clinical Practice of Neurological and Neurosurgical Nursing. Lippincott. American Association of Neuroscience Nurses [AANN]. (2011). Cervical Spine Surgery: A Guide to Preoperative and Postoperative Patient Care. AANN clinical practice guideline series.