Perioperative Nursing in Spinal Surgery - Literature review Example

RUNNING HEAD: Spinal Surgery Analytical Essay: Perioperative Nursing in Spinal Surgery of the Under the guidance of submission Introduction “The spine is integral to every movement in the body” (Olds, 2004, p.132; cited in Harvey, 2005; p.439). It functions not only to support the body and protect the spinal cord, but also to allow flexibility and free movement. Many muscles and ligaments are attached to it. Disorders and diseases of the spine can lead to miserable pain and difficulty in body movements. While many pathological conditions of the spine are treated conservatively with bed rest, anti-inflammatory medications and pain relievers, some may require surgical intervention. The type of spinal surgery depends on the pathology of the disease, the site of lesion and the extent of discomfort it causes. The duration of spinal surgeries can vary from few minutes to several hours. Based on the duration and type of surgery and the pathological condition of the patient, patient may develop complications and discomfort in the intraoperative and post-operative period. Perioperative nurses in spinal surgery unit have a duty bestowed upon them to provide holistic care to spinal surgery patients in the preoperative, intraoperative and postoperative period to enable proper evaluation, enhance patient comfort levels, prevent complication and allow early mobilization, rehabilitation and recovery. This essay explores literature pertaining to perioperative nursing for spinal patients. Anatomy and physiology of spine The spine or the vertebral column lies in the central portion of the posterior aspect of the body. It is made up of 33 vertebrae, of which 7 are cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 sacral vertebra and 4 coccygeal vertebrae (RTIICS, 2009) (Fig.1). The sacral and coccygeal vertebrae are fused while others are not. A typical vertebra consists of a vertebral body with two pedicles, 2 transverse processes, 2 laminae and one spinous process (Fig.2). Between the bodies of vertebrae intervertebral discs which are fibrocartilagenous in nature are present. The disc is spongy for the purpose of absorption of stress. Spinal canal which contains the spinal cord runs through the middle parts of the verterbrae. From the spinal cord, spinal nerves arise which come out of the vertebral column and innervate various parts of the body. Cervical spine is the most mobile portion of the spine. It allows the body to flex more than 20 deg and rotate the head axially 40-50 deg. Thoracic spine also allows axial rotation but only upto T9. Below T9, the spine allows only flexion and extension (Harvey, 2005, p.426). Figure.1. Anatomy of spine (Harvey, 2005) Figure.2. Anatomy of vertebral body and disc (Harvey, 2005) Diseases and trauma of the spinal cord The spinal cord can get affected by diseases and trauma. The diseases can be categorized into infections like meningitis and poliomyelitis, tumors, inflammatory diseases, autoimmune diseases and degenerative diseases like amyotrophic lateral sclerosis and spinal muscular atrophy (Gondim and Thomas, 2008). Based on the type and extent of injury, trauma can lead to syndromes like anterior cord syndrome, complete spinal cord transection syndrome, central cord syndrome, cauda equina syndrome, conus medullaris syndrome and Brown-Sequard syndrome (Medline plus, 2009). While some conditions can be treated with bed rest, medications and physiotherapy, some many require surgical interventions. Surgical treatment for spinal diseases Most of the times, surgical intervention is initiated only after exhaustion of non-operative treatment methods. The type of surgery will be based on the site and pathology of the lesion. Spinal surgeries are mainly intended to either reduce factors that cause the distressing signs and symptoms, or to cause stabilisation. Thus the procedures can be categorized into decompression procedures and stabilization procedures. Some of the commonly employed decompression procedures are laminotomy, laminectomy and discectomy (Harvey, 2005, p.435). Laminotomy is nothing but creating a small opening over the bone of laminae with the intention to free the nerve roots. However, most of the times, this involve removal of portion of the laminae (Harvey, 2005, p.435). Laminectomy is performed mainly in spinal stenosis to expose abnormal portions of the disc and also to give room for nerve roots. The procedure involves removal of some parts of the laminae and also some portions of protuding osteophytes, ligamentum flavum and facet joints. Pain relief ensues after subsidence of inflammation. In discectomy, parts of disc like nucleus pulposus which has herniated through the annulus is removed. The removal is done either through micro, open or percutaneous routes (Harvey, 2005, p.435). Spinal fusion involves anatomical realignment of spine, especially after decompression discectomy in spinal arthrodesis (Harvey, 2005, p.435). Other indications for spinal fusion include spinal deformities and trauma. During fusion, usually autobone graft is employed. Some of the recent developments in spinal surgery are "vertebroplasty for wedged compression fracture of the thoraco-lumbar spine" which causes extension and corrects the deformity (Lee, 2005), spondoplasty, newer implants for spinal fusion which allow better anchoring and fixation, disc replacement instead of fusion for cervical spine herniation to prevent adjacent segment symptoms, endoscopic disectomy for lumbar herniation for minimal invasion, blood loss and discomfort and decompressive laminectomy for sciatica (Lee, 2005). Perioperative nursing for spinal surgery Perioperative nursing is a very important aspect of spinal surgery. Planned perioperative nursing is crucial to promote comfort, enhance recovery, establish rehabilitation and prevent complications Preoperative nursing Preoperative nursing mainly involves evaluation of the patient, preparation of the patient for surgery and education of the patient. During evaluation of the patient, the goals of the surgery must be established. For example, some patients may want to regain employment, while others may want to get involved in sports or other activities. Establishing the goal will ascertain as to what extent the surgery needs to be performed. Other aspects of evaluation are investigations like complete blood picture, erythrocyte sedimentation rate, clotting factors, chest X-ray and electrocardiogram. Patient should be educated about pain management, tubes and drains if any, legrolling, use of bedpan, use of ankle-pumps for prevention of deep vein thrombosis and methods to eat in lying down position. Teaching pain coping abilities and providing pain management information in preoperative period helps good management of pain in the post-operative period. Nurses must educate the patient and provide proper information because proper education can help the patient maintain optimum independence and good quality of life. Lamontagne et al (2003) conducted a randomised controlled trial to evaluate the effects of patient education on postoperative pain and found that effective coping instructions and provision of concrete-objective information causes decrease in postoperative pain. Another aspect which needs to be taught in the preoperative period is correct legrolling in preoperative period will improve the level of comfort in the patient after surgery. Patients who require brace must provide their measurements and the brace must be fabricated before surgery so that mobility in postoperative period is initiated as soon as possible (Harvey, 2005). Patients with spinal fusion surgery will require some blood transfusion during surgery. Since most of the times, spinal fusion is a planned procedure atleast weeks ahead, autologous blood transfusion can be planned and the patient can donate 1unit of blood every week for 2 to 3 weeks to store blood. Other aspects which need importance in the preoperative period are preparation for bone grafting, HIV and hepatitis B testing, keeping post-op equipment needs like commode and walker ready, insurance issues, remodelling of home environment, discharge planning and social services management after reaching home (Harvey, 2005). Intraoperative nursing The surgical team will consist of the patient, surgeons, anesthesiologist, circulating nurse, scrub nurse and scrub technicians. The composition of team of surgeons will depend on the nature of surgery and may involve orthopedician and neurosurgeon. The circulating nurse will coordinate various activities of the surgical team and will evaluate and monitor the working condition of the operating room and equipment. Other responsibilities of circulating nurse are verification of consent, monitoring of aseptic technique and documentation of events in the operating room. Scrub nurse is one who is specially trained to work with surgeons in the operating room (wisegeek, 2009). The responsibilities of scrub nurse are setting up of sterile tables, preparation of sutures, equipment and ligatures, anticipation and keeping ready of equipment and items, counting of needles, instruments and sponges before closure and labeling and transfer of specimens. Intraoperative nursing during surgery is a critical function of perioperative nurses. Perioperative nurses function to enhance comfort of the patient, assist surgeons in the surgery and monitor the patient to prevent complications. Perioperative nurses also coordinate various aspects of the surgery like taking hand-over from the ward, arranging the equipment and drugs required for the patient, coordinating with the laboratory personnel and blood bank and such other issues. Other responsibilities include insertion of urinary catheter, securing of intravenous line and prophylactic administration of antibiotics. Once the patient is shifted to the operating room, the patient must be placed on the operating positioning frame which is sufficiently positioned and padded to prevent nerve impingement and pressure. Padding can be done with pillows, foam, blankets and arm boards. Positioning of the patient is very important to ensure optimal exposures, safety, and also to prevent certain complications like neuropathies, pressure injuries and cardiovascular and respiratory compromises (McEwen, 1996). Transferring the patient to operating table and positioning the procedure must be dictated by standard protocols of management of vertebral fractures (Head, 1990). Early warning signs of neurologic complications must be ascertained by determining nerve conduction and muscle responses through somatosensory-evoked potentials and electromyogram (Bose, Sestokas, Schwartz, 2004). Transcranial elctric motor evoked potentials monitoring may be superior to somatosensory evoked potentials monitoring (Swartz, Auerbach and Dormans, 2007). In some surgeries like corrective surgery for scoliosis, intraoperative wake-up testing to assess motor function is important for early detection of sensory-motor loss (Gambrall, 2007). Since many spinal surgeries are performed for many hours and the risk of postoperative infection is high, high standards must be maintained for sterilility. Prophylactic antibiotics must be given and accurate gauze count must be maintained. During the course of surgery, the patient must be monitored for blood loss and fluid requirements and blood and fluids must be provided appropriately. Hypotension must be vigilantly prevented in spinal surgery patients (Cann, 2009). Other aspects to be monitored during surgery are vital signs, urine output and drain output. Cell saver may be employed to replace lost blood (Harvey, 2005). Other intraoperative complications which need to be watched are hypoventilation, cardiac dysarrhythmia, malignant hyperthermia and hypothermia (Nettina, 2006). Postoperative nursing Postoperative nursing is the crux of management of spinal patient. In the immediate postoperative period, frequent monitoring of vital signs is essential to detect hypotension and tachycardia (Harvey, 2005). During the first 24 hours, neurovascular responses must be monitored in a distal to proximal manner every 2 hours. Knowledge about preoperative deficits of the patient is essential to analyze the post-operative neurovascular assessment results. Measures like ankle pumps and elastic stockings must be taken to prevent deep vein thrombosis. The patients must be turned frequently to prevent bedsores and also to aid in pulmonary hygiene. The amount, color and nature of drainage must be recorded and informed to the physician. Presence of pale yellow ring around the drainage is known as halo sign and an indication that the drainage has CSF fluid, and hence must be informed to the physician. Most of the times, the drain output in the first 24 hours should not be more than 250ml for 8 hours. When the fluid collection is less than 30ml in 8 hours, the drain can be successfully removed. Most patients will need drain for 48- 72 hours (Harvey, 2005, p.437). Another issue which needs to be taken care of in the postoperative period is paralytic ileus which is caused due to retraction of spinal nerves. The biggest concern for the patient in the postoperative period is pain. This symptom must be monitored frequently on a 0-10 scale. Non-steroidal anti-inflammatory drugs and patient-controlled analgesia pump may be employed to relieve pain. In the initial phase, respiratory depression needs to be monitored with the help of pulse oximetry. Other aspects which need to be taken care in the postoperative period are stress ulcers, nausea, sleep, constipation, itching, relaxation, physical therapy, brace application, logrolling and ambulation (Harvey, 2005, p.437). Potential complications of spinal surgery Knowledge of complications pertaining to spinal surgeries is essential to make quick diagnosis of the complications and provide appropriate treatment (An and Jenis, 2005). Some of the immediate complications are Secretion of inappropriate antidiuretic hormone or SIADH, fat embolism, cauda equina syndrome, CSF leak, paralytic ileus, neurogenic bowel and neurogenic bladder (Harvey, 2005, p.438). SIADH is a common complication in spinal fusion patients and many go unrecognized many times. It is caused due to blood loss and anesthetic agents. This syndrome must be suspected when decreased urine output is not responding to fluid challenges. Once a diagnosis of SIADH is made, fluid boluses must not be given until and unless there is hypotension (Harvey, 2005, p.438). SIADH usually resolves in 24 hours time (Harvey, 2005, p.438). It is important to detect this condition as early as possible because it is associated with significant mortality and morbidity (Rafailov and Sinert, 2009). Long-term complications include infection, pressure sores, failed back syndrome and other complications like graft failure, pseudoarthrosis and hardware problems. CSF leak occurs when there is tear in duramater. It must be suspected in patient with halo ring in the drainage fluid and also in those with severe spinal head ache. Most of the times, CSF leak stops when the patient is positioned in Trendelenberg position for 7-10 days (Harvey, 2005, p.438). Subarachnoid catheter may be placed to depressurize the collection if necessary. Fat embolism can occur in spinal fusion surgery. This condition is caused by lodging of fat globules in fine capillary network of the lungs and can be detected by signs of poor oxygen exchanges, petechia over membranes, axilla and chest, throbocytopenia, "snow storm" appearance in chest X-ray and decreased PaO2 (Harvey, 2005, p.438). Fat embolism is a medical emergency and must be managed in critical care unit with monitoring, intravenous fluids, respiratory support and antiinflammatory steroids. Caudaequina syndrome occurs when blood supply to caudaequina nerve plexus is compromised and when this is suspected, the diagnosis must be established with MRI/CT scans and treated immediately by decompression (Harvey, 2005, p.438). Conclusion Spinal surgery is a complicated specialty with high demands from perioperative nurses. In the preoperative period, proper evaluation and assessment of the condition of the patient is crucial to provide appropriate treatment. Education of the patient prior to surgery can facilitate in post-operative comfort, pain relief and rehabilitation. In the operative period, depending on the nature of the disease and the type of surgery, the patient may be vulnerable to many complications, some of which can be life threatening. Thus vigilant monitoring of the patient is critical to detect complications in early stages and manage them appropriately. Proper documentation of events in the operative room is indispensable. The postoperative period is cruciall and demands skilled management on the part of nurses. In this period, short term and long term complications must be looked for and the patient must be managed with a goal for early recovery and rehabilitation. Spine, being the vital part for movement of human body, deserves enough attention when procedures are performed on it. References An, H.S., and Jenis, L.G. (2005). Complications of spine surgery: treatment and prevention. London: Lippincott Williams and Wilkins Bose, B., Sestokas, A.K., Schwartz, D.M. (2004). Neurophysiological monitoring of spinal cord function during instrumented anterior cervical fusion. Spine J., 4(2), 202-7. Cann, D.F. (2009). Acute hypotension in a patient undergoing posttraumatic cervical spine fusion with somatosensory and motor-evoked potential monitoring while under total intravenous anesthesia: a case report. AANA J., 77(1), 38-41. Gambrall, M.A. (2007). Anesthetic implications for surgical correction of scoliosis. AANA J., 75(4), 277-85. Gondim, F.A.A and Thomas, F.P. (2008). Spinal Cord Trauma and Related Diseases. Emedicine from WebMD. Retrieved on August 14 th 2009 from http://emedicine.medscape.com/article/1149070-overview Harvey, C.V. (2005). Spinal Surgery Patient Care. Orthopedic Nursing, 24(6), 426- 439. Head, J.M. (1990). Multilevel spine fractures: intraoperative nursing management. J Neurosci Nurs., 22(6), 370-4 LaMontagne, L., Hepworth, J. T., Salisbury, M.H., Cohen, F. (2003). Effects of Coping Instruction in Reducing Young Adolescents Pain after Major Spinal Surgery. Orthopaedic Nursing, 22(6), 398- 403 Lee, P. (2005). Recent Advances in Spinal Surgery. Medical Bulletin, 10(10). Retrieved on August 14 th 2009 from http://www.fmshk.org/article/136.pdf McEwen, D.R.. (1996). Intraoperative positioning of surgical patients. AORN J., 63(6), 1059-63, 1066-79 Medline Plus. (2009). Spinal cord diseases. Retrieved on August 14 th 2009 from http://www.nlm.nih.gov/medlineplus/spinalcorddiseases.html Nettina. S.M. (2006). Manual of Nursing Practice. 8th edition. London: Lippincott Williams and Wilkins. Rafailov, A., and Sinert, R.H. (2009). Syndrome of Inappropriate Antidiuretic Hormone Secretion. Emedicine from WebMD. Retrieved on 15th August, 2009 from http://emedicine.medscape.com/article/768380-overview RTIICS. (2009). Spine Anatomy. Retrieved on 15th August, 2009 from http://www.rtiics.org/actc/spineanatomy.html Schwartz, D.M., Auerbach, J.D., Dormans, J.P. (2007). Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am., 89(11), 2440-9. WiseGeek. (2009). What is a Scrub Nurse? Retrieved on 15th August, 2009 from http://www.wisegeek.com/what-is-a-scrub-nurse.htm Read More