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Nursing Care of the Postoperative Spine Patient Care Michael D Smith MD Twin Cities Orthopedics October 2012.

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Presentation on theme: "Nursing Care of the Postoperative Spine Patient Care Michael D Smith MD Twin Cities Orthopedics October 2012."— Presentation transcript:

1 Nursing Care of the Postoperative Spine Patient Care Michael D Smith MD Twin Cities Orthopedics October 2012

2 Objectives Discuss indications for surgery Present perioperative complications to watch for Review practical surgeon concerns regarding nursing assessment * biased toward cervical spine procedures *

3 Indications for Spinal Surgery The Big Three Neurologic compression Instability Deformity

4 Pain -Indication for Surgery? Pain- unmanageable and associated with compression, deformity, or instability Degenerative findings- common and incidental

5

6 Disc Herniation Grade 1-4 based on morphology and extension beyond PLL

7 Neurological Indications Pain, numbness, weakness, tingling from cord or root compression

8 Instability Spine unable to tolerate daily loads without excessive motion Degenerative, acquired, post- traumatic, neoplastic, congenital

9 Traumatic Instability

10 Degenerative Instability

11 Cervical Deformity

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 March; 469(3): 649–657

13 Risk Factors for Complications Pulmonary circulation9.52 Renal disease5.55 Metastatic Cancer4.21 Electrolyte abnl3.97 CHF3.46 Etoh abuse1.16

14 Demographics for Mortality Male Posterior vs. anterior Rural vs. Urban Older vs. younger A-American vs. Caucasian

15 Risk Factors for Mortality Unproven* DM, simple DM, complicated Obesity PVOD

16 Common Cervical Spine Procedures Anterior discectomy/fusion -ACDF Anterior corpectomy/fusion -ACCF Anterior discectomy/replacement -ACD Posterior decompression – foraminotomy/laminaplasty - Posterior fusion -PSF

17 Surgical Technique-Anterior Decompression/Fusion

18 Operative Approach Transverse incision -cosmetic Left sided preferred (recurrent laryngeal nerve at less risk) Careful anatomic exposure

19 Incision Localization

20 Exposure Superficial Dissection

21 Exposure Deep Dissection

22 Completed Exposure

23 Fusion Bone Graft Insertion

24

25 Typical ACDF Fixation

26 Cervical Corpectomy Anterior approach Extensive exposure Longer OR times More complicated stenosis Increased complication rate, airway, dysphagia

27 Cervical Corpectomy

28 Cervical Disc Replacement

29 Posterior Procedures Positioning Padding of neurovascular points Peruse facial- cervical area

30 Posterior Procedure Positioning

31 Posterior Procedures Adhere to demonstrated ROM to avoid impingement cord/root

32 Indications and Need for Nursing Care Varied patient population Varying neurologic presentation Broad age range and support structures Outpatient to lengthy hospitalizations

33 Phases of Nursing Care Preoperative  Education, counseling, support

34 Phases of Nursing Care Perioperative  Routines, time outs, counts, cross pollination

35 Phase of Nursing Care Postoperative  Dependent on nursing input and remote assessment Typical defines patient perception f care

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

37 Postoperative Edema

38 Nursing Concerns Tracheal obstruction- expanding hematoma, lymphatic congestion, vocal cord paralysis Stridor- an impending arrest

39 Nursing Concerns Esophageal – retraction, local change in motility, laceration Indigo carmine for leak assessment Difficulty –> barium swallow, steroids, feeding tube

40 Esophageal Perforation

41

42 Displaced Bone Graft

43 Nursing Concerns Neurological assessment- compare pre to post op status Pain management – separate topic

44 Mental Health Issues Anxiety Depression Somatization Unrealistic expectations

45 Anxiety Disorders 18% of general population (40M) Pervasive and variable in expression Kessler RC Arch Gen Psychiatry, 2005 Jun;62(6):

46 Anxiety Disorders OCD PTSD Social phobias Specific phobias GAD

47 Depression 10% of general population Variable expression Surgeons do poor job in pre-op recognition May coexist with anxiety syndromes

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

49 Substance Abuse 240M in Risk Group Chemical5%12M Alcohol 10%24M Tobacco19%46M Associated mental health issue (i.e., anxiety+Etoh)54% use.html

50 Coping Skill Set Point Readjusted

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. Sjöling MSjöling M Patient Educ Couns Oct;51(2):169-76Patient Educ Couns.

52 Thank You

53

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.


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