Nursing Care of the Postoperative Spine Patient Care Michael D
Smith MD Twin Cities Orthopedics October 2012 Slide 2 Objectives
Discuss indications for surgery Present perioperative complications
to watch for Review practical surgeon concerns regarding nursing
assessment * biased toward cervical spine procedures * Slide 3
Indications for Spinal Surgery The Big Three Neurologic compression
Instability Deformity Slide 4 Pain -Indication for Surgery? Pain-
unmanageable and associated with compression, deformity, or
instability Degenerative findings- common and incidental Slide 5
Slide 6 Disc Herniation Grade 1-4 based on morphology and extension
beyond PLL Slide 7 Neurological Indications Pain, numbness,
weakness, tingling from cord or root compression Slide 8
Instability Spine unable to tolerate daily loads without excessive
motion Degenerative, acquired, post- traumatic, neoplastic,
congenital Slide 9 Traumatic Instability Slide 10 Degenerative
Instability Slide 11 Cervical Deformity Slide 12 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): 649657 Slide 13 Risk Factors
for Complications Pulmonary circulation9.52 Renal disease5.55
Metastatic Cancer4.21 Electrolyte abnl3.97 CHF3.46 Etoh abuse1.16
Slide 14 Demographics for Mortality Male Posterior vs. anterior
Rural vs. Urban Older vs. younger A-American vs. Caucasian Slide 15
Risk Factors for Mortality Unproven* DM, simple DM, complicated
Obesity PVOD Slide 16 Common Cervical Spine Procedures Anterior
discectomy/fusion -ACDF Anterior corpectomy/fusion -ACCF Anterior
discectomy/replacement -ACD Posterior decompression
foraminotomy/laminaplasty - Posterior fusion -PSF Slide 17 Surgical
Technique-Anterior Decompression/Fusion Slide 18 Operative Approach
Transverse incision -cosmetic Left sided preferred (recurrent
laryngeal nerve at less risk) Careful anatomic exposure Slide 19
Incision Localization Slide 20 Exposure Superficial Dissection
Slide 21 Exposure Deep Dissection Slide 22 Completed Exposure Slide
23 Fusion Bone Graft Insertion Slide 24 Slide 25 Typical ACDF
Fixation Slide 26 Cervical Corpectomy Anterior approach Extensive
exposure Longer OR times More complicated stenosis Increased
complication rate, airway, dysphagia Slide 27 Cervical Corpectomy
Slide 28 Cervical Disc Replacement Slide 29 Posterior Procedures
Positioning Padding of neurovascular points Peruse facial- cervical
area Slide 30 Posterior Procedure Positioning Slide 31 Posterior
Procedures Adhere to demonstrated ROM to avoid impingement
cord/root Slide 32 Indications and Need for Nursing Care Varied
patient population Varying neurologic presentation Broad age range
and support structures Outpatient to lengthy hospitalizations Slide
33 Phases of Nursing Care Preoperative Education, counseling,
support Slide 34 Phases of Nursing Care Perioperative Routines,
time outs, counts, cross pollination Slide 35 Phase of Nursing Care
Postoperative Dependent on nursing input and remote assessment
Typical defines patient perception f care Slide 36 Complications
Anything that is touched, moved, looked at, exposed, intubated,
extubated, cooled, or heated can be injured. Slide 37 Postoperative
Edema Slide 38 Nursing Concerns Tracheal obstruction- expanding
hematoma, lymphatic congestion, vocal cord paralysis Stridor- an
impending arrest Slide 39 Nursing Concerns Esophageal retraction,
local change in motility, laceration Indigo carmine for leak
assessment Difficulty > barium swallow, steroids, feeding tube
Slide 40 Esophageal Perforation Slide 41 Slide 42 Displaced Bone
Graft Slide 43 Nursing Concerns Neurological assessment- compare
pre to post op status Pain management separate topic Slide 44
Mental Health Issues Anxiety Depression Somatization Unrealistic
expectations Slide 45 Anxiety Disorders 18% of general population
(40M) Pervasive and variable in expression Kessler RC Arch Gen
Psychiatry, 2005 Jun;62(6):617-27. Slide 46 Anxiety Disorders OCD
PTSD Social phobias Specific phobias GAD Slide 47 Depression 10% of
general population Variable expression Surgeons do poor job in
pre-op recognition May coexist with anxiety syndromes Slide 48
Depression The 3 Rs Reduced threshold for need for surgery Reduced
threshold for reporting pain after surgery Reduced support systems
and preop physical prowess Slide 49 Substance Abuse 240M 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/substanceab use.html Slide 50
Coping Skill Set Point Readjusted Slide 51 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. Sjling MSjling M Patient Educ Couns. 2003
Oct;51(2):169-76Patient Educ Couns. Slide 52 Thank You Slide 53
Slide 54 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.
