Pediatric complex care and surgery comanagement: Preparation for spinal fusion.

The aim of this study is to assess the impact of preoperative comanagement with complex care pediatricians (CCP) on children with neuromuscular scoliosis undergoing spinal fusion. We performed chart review of 79 children aged 5-21 years undergoing spinal fusion 1/2014-6/2016 at a children's hospital, with abstraction of clinical documentation from preoperative health evaluations performed regularly by anesthesiologists and irregularly by a CCP. Preoperative referrals to specialists, labs, tests, and care plans needed last minute for surgical clearance were measured. The mean age at surgery was 14 (SD 3) years; cerebral palsy (64%) was the most common neuromuscular condition. Thirty-nine children (49%) had a preoperative CCP evaluation a median 63 days (interquartile range (IQR) 33-156) before the preanesthesia visit. Children with CCP evaluation had more organ systems affected by coexisting conditions than children without an evaluation (median 11 (IQR 9-12) vs. 8 (IQR 5-11); p < .001). The rate of last-minute care coordination activities required for surgical clearance was lower for children with versus without CCP evaluation (1.8 vs. 3.6). A lower percentage of children with CCP evaluation required last-minute development of new preoperative plans (26% vs. 50%, p = .002). Children with CCP involvement were better prepared for surgery, requiring fewer last-minute care coordination activities for surgical clearance.

Implementation of an Obstructive Sleep Apnea Protocol in the Postanesthesia Care Unit for Patients Undergoing Spinal Fusion Surgery.

PURPOSE: The purpose of this project was to implement and evaluate the effectiveness of a postanesthesia care unit (PACU) obstructive sleep apnea (OSA) protocol in patients undergoing spinal fusion surgery. DESIGN: The structure of this project was a preimplementation and postimplementation design. METHODS: A convenience sample of 63 patients admitted to the PACU after spinal fusion surgery, with diagnosed or high-risk OSA, was included in protocol implementation. FINDINGS: The prevalence of diagnosed and high-risk OSA at the project implementation site totaled 74% in the spinal fusion population. The incidence of oxygen desaturations was 41% in the preimplementation group and 35% in the postimplementation group. The PACU to intensive care unit transfers were 10% in the preimplementation group and 3% in the postimplementation group. CONCLUSIONS: Protocols for surgical patients with OSA require further examination but may function as a guide for postoperative nursing care.

The Role of the RN Circulator in a Navigated Posterior Spinal Fusion: 1.3 www.aornjournal.org/content/cme.

The RN circulator plays a vital role in preparing for a minimally invasive spinal fusion with navigation by confirming that the necessary equipment and stakeholders are available and ensuring that the amount of equipment and the number of people in the room do not compromise patient safety or the sterility of the surgical field. Patients who undergo minimally invasive spinal fusion experience less blood loss, shorter hospital stays, and reduced costs than those who undergo open spinal fusion procedures. The overall successful fusion rates and improvement in patient quality of life are equivalent between the two approaches. Using navigation during minimally invasive and open spinal fusion procedures decreases radiation exposure to the patient and surgical team and helps ensure a more accurate placement of pedicle screws compared with nonnavigated minimally invasive or open spinal fusions.

Patient Care During Minimally Invasive Lateral Spine Surgery: 1.7 www.aornjournal.org/content/cme.

Perioperative nurses care for patients undergoing a wide range of surgical procedures. One fast-growing surgical specialty is spine surgery performed using minimally invasive techniques. Patients may be candidates for minimally invasive spine surgery based on their presenting signs and symptoms and medical imaging test results. Open anterior and posterior surgical approaches to spine surgery are how surgeons traditionally have performed these procedures. However, new technology has enabled a minimally invasive lateral approach to the spine. This approach minimizes many of the risks and challenges associated with both the anterior and posterior approaches. Minimally invasive lateral interbody fusion requires the perioperative nurse to have a thorough understanding of the necessary patient positioning, spinal anatomy, and OR suite setup to ensure a safe and successful surgical experience for the patient.

Effects of Localized Cold Therapy on Pain in Postoperative Spinal Fusion Patients: A Randomized Control Trial.

BACKGROUND: Cold therapy used in the sports medicine settings has been found to be effective in reducing postoperative pain; however, there are limited studies that examine the effect of cold therapy on postoperative pain in patients with posterior lumbar spinal fusion. PURPOSE: The purpose of this study was to determine the effects of cold on postoperative spine pain and add to the body of knowledge specific to practical application of cold therapy in the spine surgery setting. METHODS: Researchers used a two-group randomized control design to evaluate the effects of local cold therapy on postoperative pain and analgesia use after lumbar spinal fusion surgery. The primary outcome was postoperative pain. Secondary outcomes included analgesia use and perceived benefit of cold therapy. RESULTS: The intervention (cold) group had a marginally greater reduction in mean Numerical Rating Scale score across all 12 pain checks (M ± SD = -1.1 ± 0.8 points reduction vs. -1.0 ± 0.8 points reduction, p = .589). On average, the intervention group used less morphine equivalents (M ± SD = 12.6 ± 31.5 vs. 23.7 ± 40.0) than the control group across pain checks seven to 12 (p = .042). CONCLUSIONS: This study provides additional evidence to support the use of cold therapy as an adjuvant pain management strategy to optimize pain control and reduce opioid consumption following spine fusion surgical procedures.

Unknown Pseudocholinesterase Deficiency in a Patient Undergoing TIVA with Planned Motor Evoked Potential Monitoring: A Case Report.

Pseudocholinesterase abnormalities are a genetic cause of aberrant metabolism of the depolarizing muscle relaxant succinylcholine. This article examines a case where succinylcholine was chosen to facilitate intubation due to its ultra short duration and the request of the surgeon to monitor motor evoked potentials. Following succinylcholine administration the neurophysiologist was unable to obtain motor evoked potentials. This case study highlights the intraoperative and postoperative management of an elderly patient with an unknown pseudocholinesterase deficiency.

[Nursing Care of Lumbar Spine Fusion Surgery Using a Semi-Rigid Device (ISOBAR)].

Aging frequently induces degenerative changes in the spine. Patients who suffer from lumbar degenerative disease tend to have lower back pain, neurological claudication, and neuropathy. Furthermore, incontinence may be an increasing issue as symptoms become severe. Lumbar spine fusion surgery is necessary if clinical symptoms continue to worsen or if the patient fails to respond to medication, physical therapy, or alternative treatments. However, this surgical procedure frequently induces adjacent segment disease (ASD), which is evidenced by the appearance of pathological changes in the upper and lower sections of the spinal surgical sites. In 1997, ISOBAR TTL dynamic rod stabilization was developed for application in spinal fusion surgery to prevent ASD-related complications. The device has proven effective in reducing pain in the lower back and legs, decreasing functional disability, improving quality of life, and retarding disc degeneration. However, the effectiveness of this intervention in decreasing the incidence of ASD requires further research investigation, and relevant literature and research in Taiwan is still lacking. This article discusses lumbar degenerative disease, its indications, the contraindications of lumbar spine fusion surgery using ISOBAR, and related postoperative nursing care. We hope this article provides proper and new knowledge to clinical nurses for the care of patients undergoing lumbar spine fusion surgery with ISOBAR.

Guided Imagery for Adolescent Post-spinal Fusion Pain Management: A Pilot Study.

Orthopedic surgery for adolescent idiopathic scoliosis entails anxiety and severe postoperative pain. The aim of this pilot study was to investigate an intervention for adolescent post-spinal fusion pain management in patients from a tertiary care hospital in Montreal, Canada. Participants were adolescents and young adults ages 11 to 20 years undergoing spinal fusion. Participants were randomized to standard care or standard care with adjunct intervention. The intervention consisted of a DVD with information and guided imagery/relaxation exercises to practice at least three times a week at home. A nurse screened the DVD with the patient preoperatively and at discharge (T1) and telephoned 2 weeks post-discharge (T2) to reinforce the technique. Both groups completed questionnaires at T1, T2, and T3 (1-month postoperative follow-up). Outcome measures included pain intensity, anxiety, coping mechanisms, and daily activities. From March 2010 to June 2011, we enrolled 40 of 45 eligible participants (n = 20 per group), average age 15 ± 2.1 years, 7 participants were male. Compared with the control group, the experimental group experienced significantly less overall pain at all time points, with moderate to large effect sizes at T2, T3 (p ≤ .007). Worst pain in 24 hours was moderately decreased at T2 (p = .01). State-trait anxiety remained high. On a 10-point scale, a median 2.5-point benefit was seen in eating and sleeping (Mann-Whitney test, p = .002), and 2 points in walking (Mann-Whitney test, p = .003). Coping strategies showed no significant differences. Addition of a guided imagery and relaxation exercise DVD for home use was more effective than standard care alone for postoperative pain. Our nonpharmacologic adjunct looks promising. Larger sample size and longer (6-9 months) follow-up will permit refinement.

Paediatric spinal fusion surgery and the transition to home-based care: provider expectations and carer experiences.

There are more than 12 million children with special healthcare needs (CSHCNs) in the United States, many of whom require specialised health-care to treat chronic physical and developmental conditions. This study is a qualitative investigation of programme, surgical and at-home recovery experiences among CSHCNs and their family carers who participated in a spine surgical care programme at a paediatric hospital in the Western United States. The programme is designed to manage increased surgical risk and the transition of care from hospital to home for children with severe scoliosis undergoing spinal fusion surgery. We conducted 30 semi-structured in-depth interviews with 14 surgical team members and 16 family carers of children who had programme evaluations and spinal surgeries in 2006. Data were collected in 2008 and 2009 in hospital or at home locations to gather programme participation feedback from families and inform the adequacy of programme support to families during at-home recovery. Data were analysed by reflexive team and content analysis methodologies. Results showed the programme was effective at improving preoperative surgical evaluation and helping families to anticipate some aspects of the surgical experience and hospital discharge. However, the impact of spinal fusion surgery and the subsequent transition to home-based care was profoundly emotional for patients and their carers. Our data indicate that programme providers underestimated the extent of emotional trauma experienced by patients and families, particularly during the at-home recovery process. The data also suggest meaningful differences in providers' and carers' expectations for surgery. Carers' disappointment with their recovery experiences and the perceived lack of post-discharge support impacted their interpretations of and perspectives on their surgical experience. Implications of this research for surgical care programmes include the need for assessment and provision of support for physical, social, and emotional burdens experienced by patients and carers at pre-surgical, surgical and at-home recovery phases.

Adolescents' experience with scoliosis surgery: a qualitative study.

This article reports a study of adolescents' narrated experiences of undergoing scoliosis surgery. Six adolescents were interviewed. Open and semistructured questions were asked, and a qualitative content analysis of the text was performed. The results are presented in three main categories followed by subcategories. The three main categories of experience were emotional, physical, and social. The emotional aspects that emerged were fear, nightmares, nervousness, and helplessness. These had a great impact on adolescents' well-being before, during, and after the hospital visit. The physical aspects were mobilization, scars, different hip levels, pain, nausea, appetite, and urinary catheter. These aspects caused much discomfort, mostly during the hospital visit. The social aspects were friends, power, coaching and comfort, and sports. Some of the social aspects had a strong negative impact on the adolescents' well-being mostly after the hospital visit. This study suggests that both before and long after the surgery adolescents have strong emotions that they should be better prepared and helped to manage. To optimize perioperative care an interdisciplinary, a holistic approach must be taken that incorporates the complexity and whole of the adolescent's experiences. The findings of this study suggest that perioperative care of adolescents during scoliosis surgery needs to be optimized. To improve patients' psychologic preparation before surgery pediatric nurses should learn more about the individual patient and make care plans from a holistic perspective. Follow-up after discharge should address emotional, social, and physical aspects of the adolescent's health.

Effect of minimally invasive technique on return to work and narcotic use following transforaminal lumbar inter-body fusion: a review.

PURPOSE OF STUDY: Low back pain is one of the most prevalent and disabling musculoskeletal conditions affecting the working population in the United States. Informed, shared decision making among patients, clinicians, and case managers about treatment options for chronic low back pain-including the role of spinal fusion where medically necessary-can have a meaningful impact on return to work, normal function, and economic outcomes. Minimally invasive techniques for lumbar spinal fusion, including transforaminal lumbar interbody fusion (MIS TLIF) have recently been introduced with the goal of smaller operative wounds, less tissue trauma, and faster postoperative recovery when compared with open fusion. Although similar long-term clinical outcomes have been reported for MIS TLIF and open TLIF, the relative merits with respect to workplace productivity have not been comprehensively investigated. Time to return to work and narcotic independence after MIS TLIF and open TLIF are important parameters that may affect overall workplace productivity, and as such are the focus of this study. PRIMARY PRACTICE SETTING(S): This study was performed via a review of the literature. METHODOLOGY AND SAMPLE: We performed a systematic literature review to identify all published articles that reported on the postoperative outcomes of patients, as assessed by return to work or narcotic independence status or both, following MIS TLIF or open TLIF. A cumulative comparison was made for all included MIS TLIF versus open TLIF surgeries. RESULTS: Seventy-four published studies reported postoperative outcomes following MIS TLIF or open TLIF; only five (6.8%) studies directly described time to return to work or duration of narcotic use postoperatively or both, and were therefore included into the analysis of this review. Four studies in the published literature describe time to return to work following MIS TLIF or open TLIF, and two studies describe time to narcotic independence. Overall, the reviewed literature suggests that MIS TLIF may be associated with an accelerated time to narcotic independence and return to work versus open TLIF. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: There are limited data regarding time to return to work and duration of postoperative narcotic use following TLIF for low back pain. The available data appear to suggest that MIS TLIF may be associated with accelerated return to work and narcotic independence compared with open TLIF. Further analysis will be necessary to quantify the impact of MIS TLIF on workplace productivity and the indirect costs borne by patients and employers. Such information will be of value to case managers, disability managers, employers, patients, and clinicians aligned on reducing morbidity and hastening return to normal function.

[The "wake-up correction" for preventing spinal cord injury in scoliosis surgery].

OBJECTIVE: To observe the effects of "wake-up correction" technique for preventing iatrogenic spinal cord injury in scoliosis surgery. METHODS: Twenty-one patients who had scoliosis with Cobb's angle 92 degrees - 145 degrees received operation of pedicle screw insertion in all or important vertebral bodies, release of stiff segments, decompression and osteotomy. All the patients were trained how to wake up before anesthesia. Maintenance of anesthesia was achieved with infusion of propofol at target-controlled concentration 3-4 mg/L and remifentanil at 0.15 microg/(kg.min). Fresh gas 2 L/min of N(2)O:O(2) 1:1 was inhaled during mechanical ventilation. Wake-up methods:the muscle relaxant was stopped injection 30 min before wake-up, decreasing propofol's target-controlled concentration to 1-2 mg/L and remifentanil to 0.05 - 0.10 microg/(kg x min). Once the spontaneous respiration returned, woke up the patients and asked them move both toes following our orders (the first wake-up). Then patients inhaled 6% sevoflurane in fresh gas 6 L/min (N(2)O:O(2) 1:1). When the end-tidal anesthetic gas concentration was arrived 1.3 - 1.5 MAC, all of the anesthetics were stopped. The correction operation was completed and the patient was woke up again (the second wake-up). Recorded data included time used to wake up, directive action returning time, whether the patient had memory of wake-up during operation when following up. RESULTS: All patients woke up with satisfaction. The time taken the first wake-up was (10.3 + or - 4.5) min, and for the second was (4.3 + or - 2.3) min. There were two patients who had slightly agitation during correction. There was no one who had neurological injury. There was no memory of wake-up and no pain in all patients during operation. Cobb' angle was corrected to 22 degrees - 38 degrees (average 29 degrees ), and the correction rate was 74%. CONCLUSION: The "wake-up correction" is effective and satisfactory by detecting the cord function in time.

Laminectomy and fusion after spinal cord injury: national inpatient complications and outcomes.

There is little information about national in-hospital complication rates, adverse outcomes, and mortality after spinal fusion for spinal cord injury (SCI). The National Inpatient Sample (NIS) was utilized to identify 31,381 admissions of acute spinal cord injured patients who underwent spinal decompression with laminectomy and/or fusion (lam/fusion) in the United States from 1993 to 2002. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on outcomes such as mortality, complications, and discharge disposition, which were then stratified by age, level, and type of injury. The overall mortality was 3.0%, with a complication rate of 26.3% and mean length of stay (LOS) of 17 days. Pulmonary complications (14.4%) and postoperative hemorrhages or hematomas (3.8%) were the most common complications reported. One postoperative complication doubled the length of stay, increased the mortality rate by fivefold and added over $50,000 to hospital charges. Age and comorbidities were the main significant predictors of mortality on multivariate analysis. Patients aged >85 or 65-84 had a 44- and 14-fold greater risk of dying compared with patients in the 18-44 age group respectively. Patients with >3 comorbidities also had an increased risk of mortality (odds ratio [OR] = 1.8). Alcohol abuse was the most common medical comorbidity (present in 12% of patients treated). This study represents the first major national estimate of in-hospital mortality and complication rates after nonoperative and operative treatment for SCI.

Anesthetic implications for surgical correction of scoliosis.

Patients undergoing surgical correction of scoliosis present many challenges to anesthetists because of the pathophysiologic derangements caused by the disease and the demanding nature of the anesthetic care that is required. A thorough understanding of the pathophysiology of the disease, intraoperative concerns specific to the procedure, and the efficacy of various anesthetic management techniques is required by anesthetists to optimally care for patients undergoing surgical correction of scoliosis. This literature review focuses on key considerations for anesthetists, including common comorbidities in patients with scoliosis, the need for induced hypotension, large surgical blood loss, the need for transfusion of blood and blood products, possible autologous blood donation and acute normovolemic hemodilution, patient positioning, possible intraoperative wake-up testing to assess motor function, spinal cord monitoring, and hypothermia.

Posterior lumbar interbody fusion: an old concept with new techniques.

The estimated cumulative cost of health care attributable to back pain exceeds 25 billion dollars per year in the United States, and more than 200,000 spine fusion procedures are performed each year in an effort to relieve discogenic back pain and instability. These numbers are projected to rise in the face of our aging population. As new interbody grafting sources have been developed, posterior lumbar interbody fusion (PLIF) is being used with increasing frequency. PLIF was once a procedure that required extensive dissection of the musculoligamentous complex of the dorsal spine. Advances in surgical technique and technology now allow access to spinal structures with minimal trauma to surrounding tissue. Knowledge of the various fusion procedures can assist nurses caring for the unique needs of patients undergoing spinal surgery.

Anterior lumbar interbody fusion--advances in spinal fusion technology.

AS MUCH AS 80% OF THE US POPULATION will be affected by back pain at some time during their lives. Some of the most common disorders are herniated disc, degenerative disc disease, degenerative spondylolisthesis, spinal stenosis, and revision of previously failed low back surgery. IF CONSERVATIVE TREATMENT for back pain fails, spinal fusion may be performed. Anterior lumbar interbody fusion effectively manages degenerative joint disease, instability, and spondylolisthesis. NURSES WHO PROVIDE CARE for patients undergoing this procedure help ensure patient safety and promote positive outcomes.

The disease process of spinal cord injuries: a case study reflecting holistic nursing management.

There are more than 10,000 cases of traumatic spinal cord injuries each year in the United States. The systemic injuries, along with nursing care, will be presented in this article.

Anterior cervical discectomy and fusion for cervical disc disease.

Anterior cervical discectomy and fusion (ACDF) is a surgical procedure proven successful in the treatment of symptoms caused by cervical degenerative disc disease that is unresponsive to conservative therapy. Retrospective studies of patients who have undergone ACDF indicate that this procedure has a high rate of success for relieving symptoms and a low rate of associated complications. This article discusses normal cervical spine anatomy, the pathology of degenerative cervical disc disease, and perioperative nursing care for patients undergoing ACDF. Cortical ring allograft bone grafting and internal fixation with cervical locking plates also is discussed.