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Cervical Spine Surgery 101 France Ellyson Kuwait 2014.

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Presentation on theme: "Cervical Spine Surgery 101 France Ellyson Kuwait 2014."— Presentation transcript:

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 

32 References  Bader, M.K., & Littlejohns, L.R. (Eds.). (2004). AANN core curriculum for neuroscience nursing (4 th 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.

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