cervical spine surgery 101
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Cervical Spine Surgery 101. France Ellyson Kuwait 2014. 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 - PowerPoint PPT PresentationTRANSCRIPT
Cervical Spine Surgery 101
France EllysonKuwait 2014
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
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
C1 Vertebra C2 Vertebra Atlas Axis
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
Cervical Spine Anatomy
Ligaments between vertebral bodies maintain discs in place
Instrumental in spine alignment
Spinal cord extends from foramen magnum to ?_________
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
Dermatomes
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
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
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
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
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
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
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
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
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
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)
Surgical Treatment
Indicated persistent S/S despite conservative Rx
Several studies inconclusive – whether risks of surgery offset benefits
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
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
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)
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
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
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
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
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
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
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
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
Aspen Collar
http://www.youtube.com/watch?v=UUd2JNMPWLM
References
Bader, M.K., & Littlejohns, L.R. (Eds.). (2004). AANN core curriculum for neuroscience nursing (4th 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.