Nursing Care of the
Postoperative Spine Patient
Care
Michael D Smith MD
Twin Cities Orthopedics
October 2012
Objectives
• Discuss indications for surgery
• Present perioperative complications to
watch for
• Review practical surgeon concerns
regarding nursing assessment
* biased toward cervical spine
procedures *
Indications for Spinal Surgery
The Big Three
• Neurologic compression
• Instability
• Deformity
Pain -Indication for Surgery?
• Pain- unmanageable and associated
with compression, deformity, or
instability
• Degenerative findings- common and
incidental
Disc
Herniation
Grade 1-4 based
on morphology
and extension
beyond PLL
Neurological Indications
• Pain,
numbness,
weakness,
tingling from
cord or root
compression
Instability
• Spine unable to tolerate daily loads
without excessive motion
• Degenerative, acquired, posttraumatic, neoplastic, congenital
Traumatic
Instability
Degenerative
Instability
Cervical Deformity
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): 649–657
Risk Factors for Complications
•
•
•
•
•
•
Pulmonary circulation
Renal disease
Metastatic Cancer
Electrolyte abnl
CHF
Etoh abuse
9.52
5.55
4.21
3.97
3.46
1.16
Demographics for Mortality
•
•
•
•
•
Male
Posterior vs. anterior
Rural vs. Urban
Older vs. younger
A-American vs. Caucasian
Risk Factors for Mortality
Unproven*
•
•
•
•
DM, simple
DM, complicated
Obesity
PVOD
Common Cervical Spine
Procedures
• Anterior discectomy/fusion -ACDF
• Anterior corpectomy/fusion -ACCF
• Anterior discectomy/replacement -ACD
• Posterior decompression –
foraminotomy/laminaplasty • Posterior fusion -PSF
Surgical Technique-Anterior
Decompression/Fusion
Operative Approach
• Transverse incision -cosmetic
• Left sided preferred (recurrent
laryngeal nerve at less risk)
• Careful anatomic exposure
Incision Localization
Exposure Superficial Dissection
Exposure Deep Dissection
Completed
Exposure
Fusion Bone Graft Insertion
Typical ACDF Fixation
Cervical Corpectomy
•
•
•
•
Anterior approach
Extensive exposure
Longer OR times
More complicated
stenosis
• Increased
complication rate,
airway, dysphagia
Cervical Corpectomy
Cervical Disc Replacement
Posterior Procedures
• Positioning
• Padding of
neurovascular
points
• Peruse facialcervical area
Posterior Procedure
Positioning
Posterior Procedures
• Adhere to
demonstrated ROM
to avoid
impingement
cord/root
Indications and Need for
Nursing Care
•
•
•
•
Varied patient population
Varying neurologic presentation
Broad age range and support structures
Outpatient to lengthy hospitalizations
Phases of Nursing Care
• Preoperative 
• Education,
counseling,
support
Phases of Nursing Care
• Perioperative

• Routines,
time outs,
counts, cross
pollination
Phase of Nursing Care
• Postoperative 
• Dependent on
nursing input and
remote assessment
• Typical defines
patient perception f
care
Complications
• Anything that is touched, moved,
looked at, exposed, intubated,
extubated, cooled, or heated can be
injured.
Postoperative Edema
Nursing Concerns
• Tracheal obstruction- expanding
hematoma, lymphatic congestion, vocal
cord paralysis
• Stridor- an impending arrest
Nursing Concerns
• Esophageal – retraction, local change in
motility, laceration
• Indigo carmine for leak assessment
• Difficulty –> barium swallow, steroids,
feeding tube
Esophageal Perforation
Esophageal Perforation
Displaced Bone Graft
Nursing Concerns
• Neurological assessment- compare pre
to post op status
• Pain management – separate topic
Mental Health Issues
•
•
•
•
Anxiety
Depression
Somatization
Unrealistic expectations
Anxiety Disorders
• 18% of general
population (40M)
• Pervasive and
variable in
expression
Kessler RC Arch Gen Psychiatry,
2005 Jun;62(6):617-27.
Anxiety Disorders
•
•
•
•
•
OCD
PTSD
Social phobias
Specific phobias
GAD
Depression
• 10% of general population
• Variable expression
• Surgeons do poor job in pre-op
recognition
• May coexist with anxiety syndromes
Depression
The 3 Rs
• Reduced threshold for need for surgery
• Reduced threshold for reporting pain
after surgery
• Reduced support systems and preop
physical prowess
Substance Abuse
240M in Risk Group
•
•
•
•
Chemical
5%
12M
Alcohol
10%
24M
Tobacco
19%
46M
Associated mental health issue (i.e.,
anxiety+Etoh)
54%
www.hhs.gov/od/about/fact_sheets/substanceab
use.html
Coping Skill Set Point
Readjusted
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 M Patient Educ Couns. 2003 Oct;51(2):169-76
Thank You
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.