Thoracolumbar Spine Surgery: a Guide to Preoperative and Postoperative Patient Care

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care

AANN Clinical Practice Guideline Series

This publication was made possible through an unrestricted educational grant from DePuy Spine.

8735 W. Higgins Road, Suite 300 Chicago, IL 60631-2738 888.557.2266 • International phone 847.375.4733 Fax 847.375.6430 [email protected] | www.AANN.org AANN Clinical Practice Guideline Series Editor Patricia A. Blissitt, PhD RN CCRN CNRN ACNS-BC CCM CCNS AANN Clinical Practice Guideline Series Editorial Board Sheila Alexander, PhD RN Patricia Zrelak PhD RN NEA-BC CNRN Content Authors Angela Starkweather, PhD RN ACNP-BC CNRN, Chair Kristy Darnell, MSN RN APN CNRN Carey Heck, MSN RN ACNP-BC CCRN CNRN Karen Merchant, MSN RN CNRN Charlotte S. Myers, MS RN APN-C CNRN Kristen Smith, MSN RN ANP-BC CNRN Content Reviewers Narendra Ballard, MSN APN CCRN ACNP-BC RNFA Cynthia Bautista, PhD RN CNRN Kathy S. Bomar, BSN RN ONC CNRN Katherine Kenny, DNP RN ANP-BC CCRN Judi Kuric, DNP MSN RN ACNP-BC CNRN AANN National Office Joan Kram, MBA RN FACHE Executive Director Monica Piotrowski Associate Editor Terri Taylor Graphic Designer

Publisher’s Note The authors, editors, and publisher of this document neither represent nor guarantee that the practices described herein will, if followed, ensure safe and effective patient care. The authors, editors, and publisher further assume no liability or responsibility in connection with any information or recommendations contained in this document. These recommendations reflect the judgment from the American Association of Neuroscience Nurses regarding the state of general knowledge and practice in our field as of the date of publication and are subject to change based on the availability of new scientific information.

Copyright © 2012, revised 2012 and 2014, by the American Association of Neuroscience Nurses. No part of this publication may be reproduced, photocopied, or republished in any form, print or electronic, in whole or in part, without written permission of the American Association of Neuroscience Nurses.

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care i Contents

I. Introduction...... 1 A. Purpose...... 1 B. Statement of the problem...... 1 C. Critical clinical questions these guidelines are intended to answer...... 1 D. Search strategy...... 1 E. Levels of evidence supporting the recommendations...... 1

II. Thoracic and Lumbar Spine Anatomy and Pathophysiology...... 2 A. Thoracolumbar vertebrae...... 2 B. Thoracolumbar intervertebral disks...... 3 C. Thoracolumbar ligaments...... 3 D. Biomechanics of the thoracolumbar spine ...... 3 E. Spinal cord segment of the thoracolumbar region...... 4 F. Thoracolumbar nerve roots...... 4 G. Thoracolumbar spinal vasculature...... 4

III. Thoracolumbar Conditions...... 4 A. Nursing responsibilities...... 4 B. Herniated nucleus pulposus of the thoracolumbar spine...... 5 C. Degenerative disk disease (DDD) of the thoracolumbar spine...... 8 D. Stenosis and spondylosis of the thoracolumbar spine...... 10 E. Spondylolisthesis and spondylolysis of the thoracolumbar spine...... 13 F. Scoliosis and kyphosis of the thoracolumbar spine...... 17 G. Fractures of the thoracolumbar spine ...... 21 H. Cauda Equina Syndrome (CES)...... 23

IV. Review of Diagnostic Studies ...... 25 A. Nursing responsibilities...... 25 B. X ray ...... 26 C. Computed Tomography (CT) Scan ...... 26 D. Magnetic Resonance Imaging (MRI)...... 26 E. Bone scan...... 26 F. Diskogram ...... 26 G. Myelogram/postmyelogram CT...... 26 H. Electromyography/nerve conduction velocities...... 26

V. Preoperative, Intraoperative, and Postoperative Nursing Care ...... 26 A. Preoperative nursing responsibilities...... 26 B. Intraoperative nursing responsibilities...... 29 C. Postoperative nursing responsibilities...... 31

References...... 36

Appendix A...... 41 ii AANN Clinical Practice Guideline Series Preface In 1997 the American Association of Neuroscience Nurses (AANN) created a series of patient care guidelines, the AANN Reference Series for Clinical Practice, to meet its members’ needs for educational tools. To better reflect the nature of the guidelines and the organization’s commitment to developing each guideline based on current literature and evidence- based practice, the name of the series was changed in 2007 to the AANN Clinical Practice Guideline Series. Each guide has been developed based on current literature and is built upon best practices. This document represents a revision of a guideline for care of patients undergoing lumbar spine surgery that first was published in 2006 and now has been expanded to include thoracic issues. The purpose is to help registered nurses (RNs), patient care units, and institutions provide safe and effective care to patients who are undergoing thoracolumbar spine surgery. Surgeries for thoracolumbar disorders in the United States are among the most frequently performed in the world, and direct and indirect costs of spine disorders amount to billions of dollars annually (Chou, Baisden, et al., 2009). Low back pain is the most common cause of disability in persons younger than 45 years of age (Chou, Loeser, et al., 2009; Duffy, 2010). Evidence of spinal pathology with potential or actual neurological compromise, including pain, may indicate the need for surgical interventions (Chou & Huffman, 2009). Neuroscience nurses are pivotal throughout the perioperative period because they implement best practices when patients experience back pain or thoracolumbar spine pathology refractory to conservative management. Resources and recommendations for practice help nurses make decisions that will optimize patient outcomes. This reference is an essential resource for nurses responsible for the perioperative care of patients with spine disorders. It is not intended to replace formal education, but rather to augment clinician knowledge and provide a readily available reference tool. Neuroscience nursing and AANN are indebted to the volunteers who devoted their time and expertise to this resource created for those who are committed to the care of neuroscience patients.

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care iii I. Introduction the perioperative period of patients with thora- A. Purpose columbar disorders in assessing and monitoring The purpose of this document is to provide recom- neurological status, implementing interventions mendations based on current evidence that will help to enhance healing and recovery, and providing registered nurses (RNs), other healthcare person- patient and family education. Efforts to reduce the nel, and institutions provide safe and effective care occurrence of DVT and rates of infection while to patients before and after thoracic or lumbar spine optimizing nutritional status, pain management, surgery. Because of the complex nature of spinal and physical function may improve outcomes for pathophysiology, the variety of diagnostic studies patients undergoing thoracolumbar surgery and used to evaluate spinal disorders, and the spectrum reduce associated healthcare costs. These guide- of surgical approaches used for treatment, a de- lines address major topics that can be applied in scription of the most common spinal pathologies is all thoracolumbar spine surgery cases. provided here as a resource for practicing clinicians. C. Critical clinical questions these guidelines are in- The goal of the guidelines that follow is to offer tended to answer evidence-based recommendations on nursing • What are the anatomical and pathophysiological activities that have the potential to maximize pa- processes leading to spine disorders? tient outcomes in all cases of spinal surgery. These • Which surgical procedures typically are used for recommendations are not inclusive of all activities each specific thoracolumbar spine disorder? that might improve outcomes, but reflect inter- • What are the nursing responsibilities in the as- ventions commonly found in the literature that sessment, planning, and coordination of care for have been scientifically examined within the past patients undergoing thoracolumbar surgery? decade. Not all recommendations concern activi- • What are the nursing implications of diagnostic ties independently performed by nurses, but nurses studies? are responsible for implementing and monitor- • What nursing interventions related to preoper- ing the outcomes of these activities. The evidence ative planning, intraoperative positioning, pain presented here may help neuroscience nurses make management, infection control, DVT, wound appropriate choices when caring for patients before care, bladder and bowel management, bracing, and after thoracolumbar surgery. nutrition, physical functioning, and rehabilita- B. Statement of the problem tion needs should be used to enhance optimal It is estimated that more than 1 million spine sur- outcomes and decrease complications? geries are performed each year in the United States, • What resources for preoperative and post- with fusion procedures accounting for almost one- operative care are available to clinicians, patients, third of these (Katz, 2006). Although most spinal and families? surgeries are elective, they are not without risk. In D. Search strategy addition to the risks associated with anesthesia, A computerized search of Medline and the Cumu- postoperative complications include the following lative Index to Nursing and Allied Health Literature (Schuster, Rechtine, Norvell, & Dettori, 2010): was performed using the names of specific nursing • unintended durotomy/cerebrospinal fluid (CSF) interventions with particular spine pathologies and leak (0.3%–13% incidence) surgery as keywords. The search was restricted to • sensory-motor deficit (1%–8% incidence) works in English published between 2000 and 2011 • deep vein thrombosis (DVT; 1%–5% incidence) in which the sample included patients with thoracic • superficial wound infections (0.9%–5% or lumbar spine disorders. incidence) E. Levels of evidence supporting the • pseudomeningocele (0.7%–2% incidence). recommendations The most commonly performed spine sur- • Class I: Randomized controlled trial (RCT) geries (microdiskectomy, laminectomy) have without significant limitations or meta-analysis lower complication rates than multilevel or • Class II: RCT with important limitations (e.g., fusion procedures and, as the result of advances methodological flaws or inconsistent results) or in technology and surgical techniques, many observational studies (e.g., cohort or case-control) of these surgeries now are performed in same- • Class III: Qualitative studies, case study, or series day ambulatory centers or require only a short • Class IV: Evidence from reports of expert com- course of hospitalization (Deyo, Nachemson, & mittees or expert opinion of the guideline panel, Mirza, 2004). Regardless of the surgical setting, standards of care, and clinical protocols. neuroscience nurses have a critical role during

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 1 The Clinical Practice Guidelines and recommen- joints have a loose capsule and a synovial lin- dations for practice are established based upon ing; consequently, they are apophyseal joints evaluation of the available evidence (AANN, 2005, (Figure 2). adapted from Guyatt & Rennie, 2002; Melnyk, 2004). Figure 1. Lumbar vertebra • Level 1 recommendations are supported by class I evidence. • Level 2 recommendations are supported by class II evidence. • Level 3 recommendations are supported by class III and IV evidence.

II. Thoracic and Lumbar Spine Anatomy and Pathophysiology A. Thoracolumbar vertebrae 1. Twelve thoracic vertebrae make up the middle segment of the vertebral column between the cervical and lumbar vertebrae. The thoracic vertebrae increase in size down the length of the spine and are numbered from T1, being clos- est to the skull, to T12, which abuts the lumbar From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by spine. Each thoracic vertebra has facets on the Medtronic. sides of the body for articulation with the heads of the ribs as well as facets on the transverse processes, except for T11 and T12, for articula- Figure 2. Lumbar spine: Posterior view tion with the tubercles of the ribs. In contrast, the lumbar spine is formed by five vertebrae. The vertebrae commonly are referred to as L1 through L5. L1 is the most superior vertebra in the lumbar spine, and it abuts the thoracic spine, whereas L5 is the most inferior vertebra and abuts the sacral spine. The anterior or ventral element of each vertebra is called the vertebral body. The vertebral bodies of the middle and lower lumbar spine are more substantial in size so they can bear greater loading forces. 2. Posteriorly, or dorsally, each vertebra has a bony arch that encircles the spinal canal. It is composed of two transverse processes, two sets of facet joints, two pedicles, two laminae, and From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- one spinous process (Duffy, 2010). The bony nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by arch, also referred to as the posterior elements, Medtronic. is quite bulky. It provides the necessary support for upright posture (Figure 1). The noncom- promised spinal canal has ample room for the 4. The nerve root canal, also called the lateral re- cauda equina and for CSF. cess, is adjacent to the pedicles and facet joints in 3. Facet joints (bilaterally) are composed of a su- the region of the foramina. It encompasses the perior articulating process and an inferior ar- nerve root as it exits the spinal cord (Figure 3). ticulating process (Hicks, Morone, & Weiner, The neural foramina, also referred to as the in- 2009). The superior articulating process forms tervertebral foramina, is the actual far lateral exit a joint with the inferior articulating process of opening of the nerve root canal (Choi, 2009). the vertebra above (e.g., the superior articulat- The thoracolumbar vertebral, or spinal, canal is ing processes of L3 form two facet joints with supported anteriorly by the posterior edge of the the inferior articulating processes of L2). Facet vertebral body and the posterior longitudinal

2 AANN Clinical Practice Guideline Series ligament. This ligament lies on the posterior the posterior longitudinal ligament. The lami- vertebral body surface. The lateral elements of nae are connected by an elastic yellow liga- the vertebral canal are the pedicles and the facet ment called the ligamentum flavum. joints, with corresponding articular capsules. 2. Each facet joint is connected to a capsular liga- Posteriorly, the vertebral canal is formed by the ment. The transverse processes are connected laminae and ligamenta flava. by intertransverse ligaments. The rotator bre- vis and rotator longus ligaments connect the Figure 3. Lumbar spine: Lateral view transverse processes to the laminae of the superior two vertebrae. 3. The spinous processes are connected by supra- spinous and interspinous ligaments (Figure 6).

Figure 4. Intervertebral disk

From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by Medtronic.

From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- B. Thoracolumbar intervertebral disks nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by 1. Each intervertebral disk in the thoracolumbar Medtronic. spine provides support and facilitates movement while resisting excessive movement. The disk Figure 5. Intervertebral disk in relation to endplate and permits slight anterior flexion, posterior exten- vertebral body sion, lateral flexion, rotation, and some circum- duction (Shankar, Scarlett, & Abram, 2009). 2. The disk is the largest avascular structure in the body (Singh, Masuda, Thonar, An, & Cs-Szabo, 2009). It is composed of the nucleus pulposus and the annulus fibrosus. In people who are younger than 35 years of age the nucleus pulposus is soft and similar to crab meat in texture. With aging, the nucleus pulposus dehydrates. 3. Surrounding the nucleus pulposus is the annulus fibrosus (Figure 4), which is tough and fibrous. The fibers of the annulus fibrosus are concentric, like the layers of a radial tire. The From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- concentric arrangement provides resistance nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by and strength. Medtronic. 4. Each disk is bonded to the vertebral body below and above it by a thin cartilaginous plate, D. Biomechanics of the thoracolumbar spine referred to as the endplate (Figure 5). The end- 1. The functional unit of the spinal column is the plate resists herniation of the disk into the ver- motion segment. A motion segment is com- tebral body and gives the disk its shape (Hicks posed of two adjacent vertebrae, the disk be- et al., 2009). tween them, the facet joints connecting them, C. Thoracolumbar ligaments and the ligaments attached to the vertebrae 1. Each disk is reinforced anteriorly by the ante- (McGill & Karpowicz, 2009). rior longitudinal ligament and posteriorly by Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 3 2. The geometry and health of the functional Figure 7. Termination of spinal cord at conus medullaris; units help a surgeon determine which patients cauda equina; and termination of dura in coccyx will benefit from surgery and the most appropriate surgical intervention for a given patient.

Figure 6. Ligaments of the lumbar spine

From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by Medtronic.

E. Spinal cord segment of the thoracolumbar region From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by 1. The spinal cord ends at approximately the L1– Medtronic. L2 level in an adult. 2. The conus medullaris is the end of the spinal 4. Near the posterior wall of the vertebrae, each cord. segmental artery bifurcates into a posterior 3. The filum terminale is an extension of the pia branch and spinal branch. The spinal branch mater, which descends below the conus medul- enters the vertebral canal through the inter- laris and is anchored to the coccyx. vertebral foramen and supplies portions of the F. Thoracolumbar nerve roots posterior vertebral body. It joins other spinal 1. The cauda equina is a fanning bundle of lumbar branches at other levels to form the anterior and sacral nerve roots exiting off the spinal cord spinal artery. at the conus medullaris. This mass of nerve roots 5. The anterior spinal artery supplies the anterior provides communication with the lower ex- two-thirds of the spinal cord. tremities and controls bowel, bladder, and sexual 6. Segmental veins drain into the inferior vena cava function (Figure 7). (IVC), which originates at the convergence of the 2. The cauda equina is relatively resistant to neu- left and right common iliac veins at the L4 level rologic insults compared to the spinal cord (Becske & Nelson, 2009). The IVC terminates in (Shankar et al., 2009). the right atrium of the heart. 3. The exiting nerve root in the thoracic and lumbar spine is numbered according to the pedicle III. Thoracolumbar Conditions above it. For example, the L5 nerve root passes A. Nursing responsibilities below the L5 pedicle. 1. Obtain a complete history and review of G. Thoracolumbar spinal vasculature symptoms and perform a neurological exam 1. The abdominal aorta follows the left side of the on patients presenting with signs and symp- spine until L4, where it bifurcates into the left and toms associated with thoracolumbar condi- right common iliac arteries. The femoral arteries tions. Establish a baseline symptom assess- arise from the common iliac arteries. ment and neurological exam to help monitor 2. The middle sacral, iliolumbar, and internal iliac treatment efficacy. arteries supply blood to L5 and the sacrum. 2. Symptom assessment includes a patient’s report 3. Segmental arteries branch off the aorta and of physical, cognitive, emotional, or behavioral supply the vertebral body, posterior elements, symptoms. This should include an evaluation of and paraspinal muscles of the lumbar spine.

4 AANN Clinical Practice Guideline Series psychological comorbidities including depres- Figure 8. Progression of disk herniation sion and a thorough assessment of pain, current level of activity, and physical functioning. 3. Psychosocial factors can affect surgical outcomes. Optimizing social support and mental health is imperative (Laxton & Perrin, 2003). Screening tools to identify psychosocial risk factors of chronic low back pain and disability are available (Chou, Atlas, Stanos, & Rosen- quist, 2009). Screening tools can be used to help determine the need for psychosocial interventions such as cognitive behavioral therapy. A. Normal disk; B. Bulging disk, pressure placed on exiting nerve root; C. Disc extru- sion, disc material outside annulus. From AANN Core Curriculum for Neuroscience Nurs- 4. Nurses should assess patient care needs and ing (4th ed.). edited by M.K. Bader & L. Littlejohns. 2004. St. Louis: Saunders. Used with support systems and identify potential resourc- Permission. es for patients and families. Resources should include self-management strategies to address symptoms. Figure 9. Lumbar spine, MRI, saggital view; herniated disk 5. Nurses should provide preoperative and post- at L5-S1 operative teaching that describes procedure goals, the expected course of recovery and outcomes, and potential complications. 6. Nurses should help coordinate care, which may entail referrals to other healthcare providers, transportation to and from therapies, and management of pharmacological and nonphar- macological interventions. B. Herniated nucleus pulposus of the thoracolumbar spine 1. Description and etiology a. Intervertebral disk herniation also is known as herniated nucleus pulposus (HNP). HNP may be asymptomatic despite radiographic evidence of bulging, protrusion, or an extruded disk (Figures 8 and 9). b. The etiology may be either spontaneous or attributable to a precipitating event. Even © 2011 by Andrea Strayer. Reproduced with permission. when a patient is symptomatic, surgical intervention often is not required. ii. Protrusion: Focal area of bulge or disk c. An HNP may be symptomatic as the result extension that still is attached to the of a combination of direct nerve root com- disk (annulus fibrosis) pression, the release of inflammatory chemi- iii. Extruded fragment: Nucleus pulposus cals (e.g., matrix metalloproteinases, prosta- no longer connected to the disk glandin E2, Interleukin-6, nitric oxide), and iv. Sequestered fragment (i.e., free frag- hypoxia of the nerve root and basal ganglion ment): Nucleus pulposus in the poste- (Ireland, 2009). rior longitudinal ligament. d. Radicular pain can be accompanied by par- f. Nonsurgical treatment is important in the esthesias or paresis (i.e., weakness) in the care of patients with an HNP. Many epi- anatomic distribution of the affected nerve sodes of acute back pain due to HNP are root (Figure 10). HNP-associated back or leg self-limiting and do not require intervention pain may be aggravated by coughing, sneez- (Duffy, 2010). Chou, Atlas, and colleagues. ing, or assuming certain positions. (2009) noted that 90% of acute attacks re- 3. Segmental arteries branch off the aorta and solve with conservative management alone. supply the vertebral body, posterior elements, and paraspinal muscles of the lumbar spine.

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 5 Figure 10. Dermatomal distribution of lumbar nerve roots Table 1. Nerve roots and corresponding sensory, motor, and reflex functions

Nerve Sensory Motor Reflex Root L2 Groin area Hip flexor (iliopsoas) None L3 Groin, anterior Knee extension (quadriceps) None thigh L4 Anterior thigh, Knee extension (quadriceps) Patella knee, medial calf (knee jerk) L5 Lateral thigh, EHL (extensor hallicus longus)— none lateral calf, top raise great toe of foot Foot dorsiflexion (anterior tibialis) Knee flexion (hamstrings) S1 Posterior thigh, Foot plantarflexion (gastrocnemius) Achilles posterior calf, (ankle jerk) From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- lateral aspect of nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by foot Medtronic. d. Lumbar nerve root tension may be tested 2. Incidence and epidemiology with a straight-leg raise test or other provoc- a. Symptomatic HNP is more common in ative maneuvers. younger patients, with peak incidence e. Gait, forward flexion, and general mobility among those ages 35–55 (Weinstein, Lurie, should be noted. et al., 2008). Recommendation: Nurses should be alert for “red b. Most HNPs occur at the L4–L5 or L5–S1 flags” in the patient history and neurological ex- levels. amination, including a history of cancer, recent c. The majority of lumbar HNPs occur in a trauma or infection, progressive neurological defi- posterolateral direction, compressing the ip- cits such as weakness or sensory changes, or altera- silateral nerve root as it exits the dural sac. tions in bowel and bladder functioning. Abnormal d. HNPs in the thoracic region are much less findings should be reported to the healthcare pro- common due to stabilization by the rib cage, vider (Level 3). which reduces mechanical stress to the in- 4. Surgical treatment options tervertebral disks (Matsumoto et al., 2010). a. Surgical treatment may be indicated when It is estimated that fewer than 1% of the total conservative management fails to alleviate reported disk herniations occur in the tho- a patient’s symptomatology. Before surgical racic spine, with men being affected more intervention is considered for patients with frequently than women. This gender differ- isolated HNP-induced low back pain, a trial ence has been reported to be as high as 2:1 of maximal nonoperative therapies for at in respect to patients with low back pain at- least 6 weeks is recommended (Jegede, Ndu, tributable to HNP. & Grauer, 2010). This time frame is ex- 3. Diagnostic and physical exam findings tended for up to 6 months in patients with a. Magnetic resonance imaging (MRI) stud- thoracic HNP. Exceptions are indicated if a ies are the best diagnostic tool to evaluate the patient with a lumbar HNP develops cauda spinal structures, HNP, and nerve root com- equina syndrome (CES), if a patient with a pression. A computed tomography (CT) scan thoracic HNP develops signs of myelopathy may be required to further evaluate bony due to cord compression from the herniated structures in some patients. disk, or if progressive neurologic deficits b. Motor weakness, sensory changes, or altera- are present in any patient (Matsumoto et tion in deep tendon reflexes are noted. (Refer al., 2010). to Table 1 for more information.) b. The best surgical results are obtained when c. Neurological dysfunction and symptoms back pain is associated with a radiculopathy should correlate with the location of the in a distribution consistent with radiograph- HNP on diagnostic tests. ic findings (Moschetti, Pearson, & Abdu, 2009). The literature regarding the benefits

6 AANN Clinical Practice Guideline Series of surgery for low back pain is conflicting. recovery period and less postopera- Several studies have attempted to evaluate tive pain the efficacy of surgery versus conservative e. Surgical options for lumbar HNP management in the treatment of acute back i. Microdiskectomy pain. The findings of these studies revealed a) Microdiskectomy is performed un- a trend toward reported improvement in der general or regional anesthesia. short-term outcomes with surgical interven- b) The patient is in a prone position. tion, but longer-term outcomes were similar c) Following deep dissection, the cor- when comparing conservative and surgical rect disk space is confirmed radio- interventions (Jegede et al., 2010). Weinstein graphically. Once confirmed, the et al. (2008a) found that patients treated ligamentum flavum and lamina are surgically for intervertebral disk herniation dissected to expose the nerve root. showed significantly greater improvement The opening in one lamina is termed in pain, function, satisfaction, and self-rated a semihemilaminectomy. progress over 4 years compared to patients d) After the nerve root is identified, all treated nonoperatively. A literature review by ligaments obstructing the view of Chou, Baisden, and colleagues (2009) found the disk and nerve roots are cleaned that diskectomy and microdiskectomy for away. A retractor is used to gen- low back pain were moderately superior to tly bring the nerve root structures nonsurgical therapy for improvement in pain medially. and function in the short term, but long- e) The disk often is excised and the term benefits (longer than 3 months) were disk fragments, which will vary in inconsistent. size, are carefully removed. c. Surgery for patients with a thoracic HNP is f) The area is then irrigated, hemostasis less nebulous because the strongest indica- is achieved, and the wound is closed. tion for surgery is the presence of myelopa- ii. Open diskectomy thy (Matsumoto et al., 2010). Open diskectomy is the same proce- d. Surgical options for thoracic HNP dure as microdiskectomy, except the i. Surgical planning may include decom- surgeon does not use an operative mi- pression and fusion depending on the croscope. Consequently, a larger inci- patient’s anatomy and degree of insta- sion is required. bility. Preoperative patient education iii. Minimal-access or minimally invasive should include chest tube management diskectomy because these procedures often neces- This technique permits a diskectomy sitate the placement of a chest tube to be performed through a very small intraoperatively. incision and with minimal disruption ii. Posterior or posterolateral approach of adjacent tissues (Figure 11). It often a) Useful for disks located within the is performed on an outpatient basis or lateral half of the spinal canal or in with a 23-hour observation stay. This the neural foramen technique is increasing in popularity in b) Best for soft HNPs; not as useful if all settings, especially in freestanding the disk is large or calcified surgery centers. c) The limitation of the posterior ap- a) The surgeon uses a tubular retractor proach is the surgeon’s inability to system and loupe magnification or visualize the ventral surface of the an operating microscope. dura. b) The tubular retractor is placed iii. Anterior approach through a small incision and deep a) Allows a more complete visualiza- dissection. tion of and access to the ventral sur- c) The diskectomy is performed, as de- face of the spine and spinal cord scribed above, through the tubular b) Options include thoracotomy or less retractor. invasive thoracoscopy; benefits of 5. Preoperative, intraoperative, and postoperative thoroscopy over thoracotomy in- management of HNP of the thoracolumbar clude a shorter hospitalization and spine

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 7 radiographic degenerative disk changes; how- Figure 11. Minimal-access microdiscectomy ever, most do not experience any pain (Schi- zas, Kulik, & Kosmopoulos, 2010) b. The lumbar region is the most prone to degenerative changes as a result of increased mechanical stresses in this area. c. Current evidence indicates that disk degeneration is a result of a combination of mechanical, biochemical, and genetic factors. With aging, the moisture content of the inner nucleus pulposus decreases due to pro- teoglycan changes and the resulting desiccat- ed disk provides less support. The annulus fibrosis, with its higher collagen content, must absorb more of the mechanical stresses as the inner nucleus pulposa loses strength, lead- From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by ing to higher incidences of annular tears. As Medtronic. tears develop, the inner nucleus material may begin to seep out. If the nerves surrounding 5. Preoperative, intraoperative, and postoperative the outer region of the annulus fibrosis are management of HNP of the thoracolumbar exposed to noxious stimuli such as pressure spine from the nucleus pulposa, extreme pain may a. The general recommendations for the pre- result (Ferguson & Steffen, 2003). operative, intraoperative, and postoperative 2. Incidence and epidemiology management found in Sections V–VII of this a. Patients often are relatively young; they guideline should be followed. present with a history of gradually worsen- b. Patients should receive information regarding ing back pain. Disk degeneration is a natu- the possibility of postoperative residual sen- ral process; up to 34% of the population be- sory disturbances. Although low back pain tween 20 and 40 years of age has MRI evi- and sciatica may significantly decrease after dence of DDD, and up to 95% of those 65 surgery, patients may experience sensory dis- years of age and older show signs of disk de- turbances in the affected dermatomes as the generation (Hicks et al., 2009). nerve heals during the postsurgical months. b. Many patients with DDD are asymptomatic c. General wound care instructions should be despite radiographic degenerative changes provided upon discharge. Typically, Steri- (Figure 12). Strips are used after microdiskectomy and staples are used after open diskectomy. Figure 12. L4–L5 and L5–S1 degenerative disk disease: d. Analgesics should be provided to manage Lumbar spine MRI, T2-weighted image surgical wound pain and enhance postoperative physical functioning. Recommendation: Nurses should provide a clearly defined plan for increasing activity and weaning pain medications during the first few weeks following surgery based on the patient’s status. Gen- erally, the goal is to resume normal activities and be titrated off of opioid medications by weeks 2–4 postoperatively (Level 3). C. Degenerative disk disease (DDD) of the thoracolumbar spine 1. Description and etiology a. DDD is one of the most common causes of low back pain, especially in the younger popu- © 2011 by Andrea Strayer. Reproduced with permission. lation. It is estimated that up to 93% of people between 60 and 80 years of age have some

8 AANN Clinical Practice Guideline Series c. Those with symptoms commonly report in- of motion across fused segments, creased pain with sitting, sciatica (often bi- loss of normal sagittal balance; Berg, lateral) and disability (Chou, Baisden, et al., Tullberg, Branth, Olerud, & Tropp, 2009). 2009). d. DDD is most common in the lumbar spine c) Correct patient selection and ac- because of increased compressive loads in curate and correct disk placement this region. Evidence exists for a genetic are important for optimal surgical disposition to DDD (Paassilta et al., 2001). results. Changes in specific proteoglycans in the nu- d) Clinical indications for the Chari- cleus pulposa that are associated with aging té include single-level DDD at L4– also have been studied (Gruber et al., 2009). L5 or L5–S1 confirmed by provoca- These changes contribute to decreased water tive diskography, back or leg pain content and, along with structural changes, without nerve root compression, reduce the load-bearing capacity of the inter- and failure of nonsurgical treatment vertebral disk and affect the efficiency of nu- (Guyer et al., 2009). trient transport throughout the disk. e) Clinical indications for the ProDisk 3. Diagnostic and physical exam findings are disabling low back pain caused by a. Pain is described as deep, midline, and ach- one or two adjacent levels between ing. Pain may radiate into the buttocks or L3–S1. The pain must primarily origi- upper thighs; it may be unilateral or bilateral. nate from the disk and be refractory to It usually is worse when patients stand in one aggressive nonoperative treatment for position or sit for long periods of time. at least 6 months (Berg et al., 2009). b. Various scales have been developed to at- f) Both devices are placed through an tempt to correlate the degree of disk degen- anterior approach. eration with radiographic findings. Thomp- ii. IDET son and colleagues (1990) developed a a) The clinical indications for IDET in- screening scale ranging from I–V to evaluate clude back pain caused by DDD that gross changes in disk morphology, and Pfir- is refractory to at least 6 months of rmann, Metzdorf, Zanetti, Hodler, and Boos conservative treatment. (2001) developed a I–V scale based on T2- b) A specialized catheter is threaded weighted MRIs. through an introducer to the af- c. Surgical treatment options fected area. The catheter is heated to Correlation of physical exam findings with 90°C for 17 minutes. The purpose diagnostic imaging is necessary to determine is to cauterize the annular tear and the potential benefit of surgical interven- pain fibers, thereby decreasing or al- tions, which may include disk arthroplas- leviating low back pain. ty, intradiskal electrothermal annuloplasty c) This minimally invasive procedure is (IDET), laminectomy, or fusion procedures done in an interventional radiology (described below). suite or operating room under fluo- i. Disk arthroplasty (artificial disk roscopy. It is performed as an out- replacement) patient procedure using conscious a) To date, the only U.S. Food and sedation. Drug Administration-approved iii. Laminectomy lumbar artificial disk replacements a) A laminectomy may be used to treat are the Charité™ and the ProDisk™. DDD by removing a portion or en- Other devices are being investigated. tire segment of the lamina (Papave- b) Proponents of artificial disk replace- ro et al., 2009). The number of levels ment cite its stabilization and preser- decompressed is dependent on the vation of the motion segment, citing number of levels that may be caus- decreased adjacent level disease and ing a patient’s symptoms. a reduction in other complications b) After deep-tissue dissection, localiza- of lumbar fusion (i.e., hardware fail- tion is confirmed with X ray. ure, graft problems, graft site pain, c) Bony removal begins with the spi- symptomatic pseudoarthrosis, loss nous process. The amount of bone

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 9 removed depends on the amount of following surgery based on the patient’s status. Gen- stenosis. erally, the goal is to resume normal activities and d) The lamina is thinned with a drill. begin titrating off of opioid medications by weeks The thinned lamina is then re- 2–4 postoperatively (Level 3). moved; the spinal canal is carefully D. Stenosis and spondylosis of the thoracolumbar decompressed. spine e) The ligamentum flavum lies between 1. Description and etiology the lamina and the thecal sac. The a. Thoracolumbar stenosis ligamentum flavum often is thick- i. Central canal stenosis ened in cases of spinal stenosis. The The normally triangular-shaped spinal dura often is physically protected canal becomes flattened, compressing while the ligamentous and bony dis- the thecal sac. As it progresses, the cau- section is completed. da equina or spinal cord is compressed. f) The lateral recesses are then checked Central spinal stenosis of the thoracic and ligamentous or bony material is region may cause myelopathy, which in removed, with particular attention turn may result in lower-extremity paid to the medial aspect of the fo- weakness and gait disturbance. This ramen. This approach ensures good condition can be caused by any one or a nerve root decompression. combination of the following: g) The wound is irrigated and closed. A • facet hypertrophy drain may be used. • thickening and bulging of the liga- iv. Fusion procedures menta flava a) A lumbar fusion procedure may • outward disk bulging be used for DDD that is refracto- • disk degeneration ry to 6–12 months of conservative • spondylosis (Figures 13 and 14) treatment. • degenerative spondylolisthesis. b) The type of lumbar fusion procedure Central canal stenosis is aggravated will depend on the levels involved by positions of extension or flexion, and existing spinal instability. The which produce more central canal and various types of fusion techniques lateral-recess narrowing. are described in Section III.E.4.d. ii. Lateral-recess stenosis 4. Preoperative, intraoperative, and postoperative Lateral-recess stenosis may occur at any management of DDD of the thoracolumbar region of the spine. It is a narrowing in spine the area in which the nerve roots exit a. The general recommendations for preop- the spinal canal, which leads to nerve erative, intraoperative, and postoperative root compression. Complaints of radic- management in Sections V–VII should be ular pain, weakness, or numbness along followed. the distribution of the affected spinal b. Patients should receive information regard- nerve may be observed. Causes include ing the possibility of having residual pain facet hypertrophy, disk bulging, loss of and sensory disturbances during the post- disk height, spondylosis, or degenera- operative period. Consider formal physical tive spondylolisthesis. rehabilitation programs or pain manage- iii. Neurogenic claudication ment services for patients with preoperative Compression of the microvasculature chronic pain. of the lumbar nerve roots, which re- c. General wound care instructions should be sults in ischemia and pain, is believed provided upon discharge. Typically, Steri- to be a major contributing factor to Strips or staples are used to close wounds. neurogenic claudication. In addition to d. Analgesics should be provided to manage ischemia, postural changes can cause surgical wound pain and enhance postopera- stenosis. Postural neurogenic claudica- tive physical functioning. tion is induced when the lumbar spine Recommendation: Nurses should provide a clear- is extended and lordosis is accentuat- ly defined plan for increasing activity and weaned, whether at rest or during exercise ing pain medications during the first few weeks in the erect posture. With extension of

10 AANN Clinical Practice Guideline Series the spine, degenerated intervertebral b. Spondylosis disks and thickened ligamenta flava i. Spondylosis is the result of disk de- protrude posteriorly into the lumbar generation, which leads to bulging of canal, producing transient compres- the annulus fibrosus. The degenerat- sion of the cauda equina. In the isch- ed, bulging annulus fibrosus creates an emic form, it is theorized that transient elevation of the periosteum. Bony re- ischemia occurs in compressed lumbo- actions occur, resulting in osteophyte sacral roots when increased oxygen de- formation (Figure 13). The osteophytes mand occurs during walking (Siebert most commonly occur in the lordotic et al., 2009). spinal canal of the lumbar and cervical spine (Middleton & Fish, 2009). Figure 13. Spondylosis in the lumbar spine In addition, there may be hypertrophy or thickening and buckling of the ligamentum flavum, leading to further narrowing of the central spinal canal. With disk collapse, the neural foramina will decrease in height, resulting in neuroforaminal stenosis, which may result in nerve root compression. ii. Alterations in axial loads may lead to posterior facet osteophyte formation, which also can result in nerve root compression (Singh & Phillips, 2005). iii. Spondylosis often results in axial spine pain (Middleton & Fish, 2009). Motion From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- segment degeneration can lead to stiff- nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by Medtronic. ened levels, exhibiting disk degeneration, ligament calcification, and osteophyte formation. Conversely, the mo- Figure 14. Spondylosis: Posterior view tion segment can be hypermobile, as in degenerative spondylolisthesis (Watters et al., 2009). iv. The degenerative cascade, a part of the aging process, is caused by many factors and affects the disks, facet joints, surrounding soft tissue, ligaments, vertebrae, and articular processes. Mid- dleton and Fish (2009) noted that the spondylotic process may be lessened by surgical fusion or immobilization with orthosis. 2. Incidence and epidemiology a. A person with severe congenital lumbar ste- From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- nosis may become symptomatic as early as nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by Medtronic. age 20; someone with acquired lumbar spinal stenosis becomes symptomatic between ages iv. Types of stenosis 60 and 70 (Aliabadi & Isaacs, 2009). a) Congenital stenosis: A patient is b. Back pain as a result of degenerative chang- born with a small narrow spinal es is seen more frequently in older adults; in canal. one study, 47.2% of a sample 60–69-year-old b) Acquired stenosis: The spinal canal age group showed radiographic signs of lum- has narrowed because of degenera- bar spinal stenosis (Kalichman et al., 2009). tive changes. Hicks and colleagues (2009) found that more than 90% of older adults in their study had

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 11 radiographic evidence of degenerative spine viii. Symptoms often improve with a for- disease. ward flexed posture. Patients may de- c. Although L4–L5 is the most frequently in- scribe increased walking tolerance if volved level, lumbar stenosis may be found using a supportive device such as a gro- over one or two segments or at multiple lev- cery cart, walker, or cane. els. As is the case with herniated disks, ste- ix. The degree of pain does not always cor- nosis in the thoracic spine is rare due to the relate with the severity of stenosis. comparative immobility of the thoracic cage x. Posture often is stooped forward (i.e., (Matsumoto et al., 2010). forward flexion). This sort of posture, d. Men have a higher incidence of spinal steno- referred to as the simian stance, is more sis than women. There does not appear to be pronounced with ambulation. a correlation between race and spinal steno- xi. Patient strength generally is intact, but sis, although ossification of the posterior lon- deep tendon reflexes may be decreased gitudinal ligament leading to development or absent. of spinal stenosis is seen more frequently xii. Sensation usually is normal but may in those of Asian ethnicity (Yang, Bi, Fu, & temporarily be affected after ambula- Zhang, 2010). tion. If comorbidities such as diabe- 3. Diagnostic and physical exam findings tes are present, the patient may have a. Symptoms of thoracic stenosis decreased sensation in a stocking i. Radicular pain is managed with conser- distribution. vative therapies as described below. 4. Surgical treatment options ii. Physical symptoms associated with ste- a. The goals of treatment for patients with spinal nosis of the thoracic spine most often stenosis are pain alleviation and mobility pres- are seen in patients with myelopathy ervation or improvement. Conservative man- and may include spastic gait, lower- agement is recommended before considering extremity motor and sensory loss, and surgical intervention unless clearly defined bladder changes (Yang et al., 2010). neurologic emergencies are present (Papavero iii. If myelopathic signs are present, a pa- et al., 2009). tient may be hyper-reflexic with posi- b. The literature regarding surgery for low tive Babinski sign, clonus, and de- back pain resulting from stenosis, like that creased motor strength in the lower for HNP, is conflicting. Pearson and col- extremities. leagues (2011) found that patients with low b. Symptoms of lumbar stenosis back pain improved significantly more with i. Lower extremity symptoms may be de- surgery compared to patients treated with scribed as burning, cramping, aching, nonoperative strategies. Further investiga- numbness, tingling, or dull fatigue. tion by the authors revealed that patients ii. Early stenosis may present with non- with predominant leg pain improved sig- specific back pain. nificantly more with surgery than patients iii. Leg fatigue, pain, numbness, and weak- with predominant low back pain. Weinstein, ness occur, possibly several months to Tosteson and colleagues (2008) reported that years after back pain first is noticed. patients with spinal stenosis without degen- iv. Symptoms usually are exacerbated by erative spondylolisthesis who underwent walking; symptoms are immediately re- surgery showed significantly better improve- lieved by sitting down. ment in pain, function, satisfaction, and v. Walking distance usually gradually de- self-rated progress than did patients treated clines over time, reflecting symptom nonsurgically. Atlas, Keller, Wu, Deyo, and onset at shorter and shorter distances. Singer (2005) found that patients with lum- vi. Symptoms generally are bilateral but bar spinal stenosis treated surgically and can be more pronounced on one side. nonsurgically had similar low back pain re- vii. Pain radiates from the buttocks to the lief, predominant symptom improvement, posterior or posterolateral thighs and and satisfaction at 8–10 years. However, occasionally spreads distally to the the surgical treatment group experienced calves and feet. greater improvement in leg pain relief and back-related functional status. The benefits

12 AANN Clinical Practice Guideline Series associated with surgery must be weighed the surgery to address recommendations or against potential complications, particular- the need for additional testing. ly because many of these patients are elderly c. Patients should receive information regard- and may have comorbidities that place them ing the possibility of having residual pain, at increased risk for surgery. Chou, Baisden, weakness, or sensory disturbances during the and colleagues (2009) noted that “decisions postoperative period. Consider rehabilitation regarding surgery for this condition should or pain-management services for those with take into account several factors, including preoperative chronic pain. Formal rehabili- the availability of intensive rehabilitation…, tation programs may be more effective than the small to moderate benefit associated standard care for postoperative improvement with surgery compared to standard (nonin- in functional status (McGregor et al., 2013). tensive) nonsurgical therapy…and the fact Recommendation: Nurses should assess for poten- that most patients do not experience an op- tial rehabilitation needs based on the patient’s preop- timal outcome following fusion” (p. 1105). erative status. If the patient is deconditioned, con- c. Laminectomy and partial facetectomy (typi- sider coordinating preoperative referral to a physical cally medial one-third) is the standard sur- medicine and rehabilitation specialist (Level 3). gery for lumbar stenosis (Papavero et al., E. Spondylolisthesis and spondylolysis of the thora- 2009). The number of levels decompressed columbar spine (Figure 15) is dependant on the number of 1. Description and etiology levels suspected to cause the patient’s symp- a. Spondylolisthesis comes from the Greek toms. Care is taken to avoid dural tear, nerve words spondylo, meaning vertebrae, and lis- root injury, or complete facetectomy, which thesis, meaning slipping or sliding. can lead to segmental instability or acquired b. It most often occurs at L4–L5, followed by spondylolisthesis. L5–S1. 5. Preoperative, intraoperative, and postoperative c. The most frequent cause of spondylolisthe- management of stenosis and spondylosis of the sis is degenerative change related to chronic thoracolumbar spine motion between two vertebrae that results in a. The general recommendations for preopera- anterior subluxation and the development of tive, intraoperative, and postoperative man- lumbar pain. agement found in Sections V–VII should be d. Spondylolysis is the dissolution of, or a defect followed. in, the pars interarticularis (the bony region between the superior and inferior articulating Figure 15. Decompression laminectomy processes of individual vertebra; Sang-Bong & Sang-Wook, 2011). The defect may be an elongated, but intact, pars; an acute fracture; or a lytic lesion representing a fatigue fracture. Spondylolysis also is known as isthmic spondylolysis or type II spondylolisthesis. e. Spondylolisthesis is classified as follows: i. Type I: Dysplastic a) Type I is a developmental disorder and characterized by the presence of dysplastic sacral facet joints that allow forward translation (movement) of one vertebra over another. Un- due stress on the pars may result in From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- fracture. nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by b) It often is associated with spina bifi- Medtronic. da and congenital defects of the pars interarticularis. b. Patient age and relevant comorbidities should ii. Type II: Isthmic be considered preoperatively to determine a) Repeated fatigue fractures followed by the need for preoperative cardiac clearance. remodeling causes the development of This should be done well in advance of a stress fracture of the pars interarticularis, most often affecting L5–S1. Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 13 b) Type II also can be a developmental iv. Type IV: Traumatic injury for some adolescents during a) Type IV results from a fracture of growth spurts. the pedicles, the pars, or the su- c) This is the most common cause of perior/inferior articular processes low back pain in children. caused by traumatic injury. iii. Type III: Degenerative b) Type IV is rare. a) Type III is characterized by forward c) Type IV can occur acutely after an slipping of the lumber verebrae with injury, although most often it will an intact neural arch, with associ- develop during the weeks to months ated degeneration of the facet joints after the injury. (Monticone & Giovanazzi, 2008; d) Type V: Pathological Figure 16). e) Type V occurs as the result of an in- Figure 16. L4–L5 degenerative spondylolisthesis ternal alteration causing destabiliza- tion of the facet mechanism producing a pathologic spondylolisthesis. These alterations can result from tumors, infection, Paget’s disease, osteoporosis, or hyperthyroidism, among other disorders. f) Grading: The degree of subluxation generally is measured using the Meyerding method. The superior surface of the sacrum is divided into fourths along its anteroposteri- or (AP) diameter. Then the degree of subluxation is noted as a grade. · Grade 1: 1%–25% slippage · Grade 2: 26%–50% slippage · Grade 3: 51%–75% slippage · Grade 4: 76%–100% slippage · Grade 5: More than 100% slippage From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- 2. Incidence and epidemiology nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by a. Type I: Of all populations, Inuit are most at Medtronic. risk for this type. As many as 50% of Inuit acquire this condition as a result of both ge- b) Type III is the most common netic and environmental factors. There is a subtype. 2:1 ratio of women to men. In children this c) Etiology is not known (Monticone & condition has been diagnosed as early as 3.5 Giovanazzi, 2008). months of age; 4% of cases are recognized by d) Type III is seldom seen in people age 6, and 6% by age 14 (Herkowitz, 2009; younger than 50 years of age (Mon- Jones & Rao, 2009). ticone & Giovanazzi, 2008). b. Type II: Although type II spondylolisthe- e) Female to male ratio 1:5–6 (Monti- sis is not a congenital condition, there is cone & Giovanazzi, 2008) a positive correlation between congeni- f) Slippage most often occurs at the L4- tal defects, including spina bifida occul- L5 level (Monticone & Giovanazzi, ta and scoliosis, and the development of 2008). type II spondylolisthesis. As many as 50% g) Type III may produce low back, sci- of spondylolysis cases will become type II atic, or radicular pain and leg weak- spondylolisthesis. Affected men outnumber ness and may progress to spinal women by 2:1, although women have a high- stenosis (Monticone & Giovanazzi, er likelihood of having a more severe grade. 2008). There is a higher incidence among Whites than among African Americans (6:1 ratio).

14 AANN Clinical Practice Guideline Series c. Type III: This condition commonly occurs smoke or will only schedule the surgery af- after the age of 40. Women are affected more ter a predefined period of smoking cessation than men by a 5:1 ratio. African American (Whitesides, Hanley, & Fellrath, 2004). women are affected more than White wom- d. Fusion techniques en. Most commonly, type III spondylolisthe- i. Posterior spinal fusion (PSF) with or sis occurs at L4–L5. Incidence increases with without instrumentation. advancing age; other risk factors include dia- This procedure is performed via an betes, arthritis, smoking, and obesity (Wat- incision over the thoracolumbar spine ters et al., 2009). with fusion of two or more vertebrae. d. Type IV: Traumatic spondylolisthesis is rare. The procedure involves decortica- Falls and parachuting injuries are most fre- tion of the transverse processes, facet quently associated with this type. More often, joints, and pars interarticularis. Au- spondylolisthesis occurs after trauma and is tograft bone is harvested from either related to the sequela of the recovery process. the surgical decompression site or an e. Type V: Type V spondylolisthesis occurs iliac crest and is placed over all de- with other disease processes and determin- corticated surfaces. If instrumentation ing its incidence has been difficult. Incidence is used, it is laid down after pedicle is increased with diseases affecting the bone screws are in place. Pedicle screw fix- structure, the generation of osteoblast, and ation is done using the largest screw conditions that increase the osteoclasts. the pedicle is able to hold (Figure 17). 3. Diagnostic and physical exam findings A 3-D image guidance system may be a. Symptoms are dependent on the type and used for visualization. grade of spondylolisthesis. b. Pain can begin insidiously and is aggravated Figure 17. Pedicle screw fixation: Posterior view by activity, especially back-extension types of movements. c. Pain is in the low back with or without radiation. d. Pain usually is worse with prolonged walking or standing and improves with sitting. e. Symptoms often are similar to those of lumbar stenosis, but the patient may experience more back pain. f. Patients may complain of a slipping sensation in the lower back. g. Patients may have difficulty walking. h. On examination the clinician may be able to palpate the “step-off” of the vertebrae. From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- i. In most cases the patient does not present nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by with radicular pain because it occurs more Medtronic. often in high grades. 4. Surgical treatment options ii. Posterior interbody fusion (posterior a. Surgical approaches depend on the degree of lumbar interbody fusion [PLIF]/ subluxation, patient symptoms, and neuro- transforaminal lumbar interbody fu- logical function. sion [TLIF]). b. Fusion procedures typically are necessary to During the PLIF procedure posteri- stabilize the vertebrae. or elements are removed to gain access c. A retrospective review of 426 patients under- to the disk space. After the disk space is going fusion found that smoking 10 or more cleared, an interbody spacer (e.g., cages, cigarettes per day increased the rate of non- allograft wedges, allograft bone dowel) union (Andersen et al., 2001). Smoking ces- is placed into the disk space with disk sation lowered the risk to levels of nonsmok- distraction. The distractors then are re- ers. For this reason, some surgeons will not moved. The spacer remains in the disk perform fusion procedures on patients who space and is left under compression. The

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 15 fusion is strengthened by adding pedicle a) Generally the anterior longitudinal screw fixation (Figure 18). Instrumen- ligament is divided and reflected to tation adds internal support to correct opposite sides to allow spine and disk spine alignment (by replacing lumbar work. lordosis) and secures adequate stabiliza- b) The disk space is cleaned and an in- tion while the vertebral bones fuse at ap- terbody device is placed in the disk proximately 6 months (Andersen, Vide- space. baek, Hansen, Bunder, & Christensen, c) The interbody device can be packed 2008). The TLIF procedure entails us- with recombinant human bone mor- ing a posterior approach to perform a phogenetic protein (Burkus, 2004). unilateral facetectomy and laminecto- d) The femoral ring is packed with au- my. Spacers (e.g., cages, femoral rings, tograft (Figure 19). allograft) packed with autograft bone and recombinant human bone morpho- Figure 19. Anterior lumbar interbody fusion: Lateral view genetic protein are placed into the disk space. The operative site is supplement- ed with pedicle screw and rod instrumentation (Starkweather, 2006). Figure 18. L5–S1 posterior lumbar interbody fusion: Lateral X ray

iv. Direct lateral interbody fusion (DLIF) or extreme lateral interbody fusion provides an alternative to cutting through the psoas muscle. Instead of accessing the spine through an anterior or posterior approach, the incision is made in the lateral flank and the © 2011 by Andrea Strayer. Reproduced with permission. fibers of the psoas muscle are gently iii. Anterior interbody fusion separated (trans-psoas). Serial dilators An anterior lumbar interbody fusion and retractors are placed through the is performed using an abdominal ap- psoas muscle to be seated on the lateral proach. Indications include DDD with aspects of the disk space and vertebral associated back pain. There should be bodies. This is an open minimally inva- no neural compression or degenera- sive procedure performed under direct tive spondylolisthesis because no direct visualization. nerve root decompression is achieved v. Combined anterior/posterior fusion intraoperatively. During exposure care Anterior/posterior lumbar fusions are is taken to avoid vascular injury and indicated when instability from spon- superior hypogastric stretching or in- dylolisthesis or other degenerative jury leading to retrograde ejaculation problems lead to the need for both an- (Truumees & Brebach, 2004). terior and posterior column fixation.

16 AANN Clinical Practice Guideline Series vi. Minimal-access/minimally invasive fu- the image data set and then identi- sion techniques fied in the operative field and reg- a) Minimally invasive percutaneous istered. This information allows PLIF or TLIF procedures use a hy- the surgeon to have real-time 3-D brid of microsurgical and endoscop- information about the patient’s ic techniques through four 2-cm in- bony anatomy during the operative cisions (Figure 20). The DLIF pro- procedure. cedure is an open minimally inva- 5. Preoperative, intraoperative, and postoperative sive procedure that is performed un- management of spondylolisthesis and spondy- der direct visualization in contrast to lolysis of the thoracolumbar spine percutaneous. a. The general recommendations for preopera- Figure 20. Minimal-access (minimally invasive) fusion tive, intraoperative, and postoperative management found in Sections V–VII should be followed. b. Patient age, cormorbidities, intraoperative positioning, and length of time for the procedure should be considered when determining the need for preoperative cardiac clearance. c. The patient should receive information regarding activity and work restrictions during the postoperative period. Generally, he or she will need assistance with activities of daily living for the first week and will be off of work for 4–6 weeks. d. Although movement of the fused vertebrae From Schnuerer, A., Gallego, J., & Manuel, C. (2003). Core Curriculum for Basic Spi- may be restricted following surgery, patients nal Training (2nd ed.). Memphis, TN: Medtronic Sofamor Danek. Image provided by Medtronic. should be encouraged to increase walking distance weekly to maintain cardiovascular b) During percutanous procedures, an health. interbody distractor device is placed e. Analgesics should be provided to manage into the disk space to restore inter- surgical wound pain and enhance postopera- vertebral height, and an appropriate- tive physical functioning. size graft is placed. The pedicle Recommendation: Nurses should provide a clear- screw rod instrumentation is placed ly defined plan for increasing activity and weaning through the same incisions. pain medications during the first few weeks follow- c) The guiding K-wire is advanced to ing surgery based on the patient’s status. Generally, the planned segmental fusion site. the goal is to resume normal activities and begin ti- A multiaxial pedicle screw is passed trating off of opioid medications by weeks 2–6 post- over the K-wire, and the pedicle operatively (Level 3). screw is then inserted into the pedi- F. Scoliosis and kyphosis of the thoracolumbar spine cle. For each ipsilateral pair of pedi- 1. Description and etiology cles within the motion segment that a. Adult spinal deformities occur as a result of is fused, the rod inserter is passed alterations in the skeletally mature spine (Li through both screw heads. et al., 2009). vii. Intraoperative image guidance b. The spinal column is a 3-D structure with a) Preoperatively, a CT or MRI scan sagittal, coronal, and axial planes. These through the appropriate spinal levels planes collectively determine one’s posture. is obtained and image data are trans- c. The balanced spine consists of three curva- ferred to the computer work station tures including cervical lordosis, thoracic ky- in the operating suite. phosis, and lumbar lordosis. Values for these b) Three to five reference points for curvatures are on average 40 degrees of cer- each spinal segment to be instru- vical lordosis, 20–50 degrees of thoracic ky- mented are selected and stored in phosis, and 31–79 degrees of lumbar lordosis

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 17 (Heary & Albert, 2007). Variations to these & Lenke, 2010). Patients often present measurements can leave patients with altered with pain and disability, which like- equilibrium and subsequent deformity. Ab- ly are the results of one or a combina- normal curvatures can occur as the result tion of the following: DDD, central or of trauma, inflammatory responses, osteo- foraminal stenosis, facet arthropathy, porotic fractures, infection, previous sur- spinal imbalance, and muscle fatigue gery, and degenerative changes (Roussouly & (Smith et al., 2009a). Nnadi, 2010). f. Kyphosis is a sagittal deviation of the spinal d. In patients with thoracolumbar deformities, column. One of the spinal column’s most im- the degenerative cascade often starts with portant functions is to maintain balance with asymmetric disk deterioration. This can re- the head over the pelvis (Heary & Albert sult in a lack of competency of the posterior 2007). When this position becomes altered, elements. This lack of competency, especially sagittal imbalance may result. at the facet joints, can result in ligamentous i. Spinal extension exercises, usually the laxity, rotation, or listhesis. Increased hy- first intervention prescribed, have been permobility can lead to curve initiation and shown to prevent the natural progres- progression in all planes of the spine (Silva & sion of kyphosis (Ball, Cagle, Johnson, Lenke, 2010). Lucasey, & Lukert, 2009). e. Scoliosis is a coronal or lateral curvature of ii. A deviation in normal spinal balance the spine with a Cobb angle of more than 10 causes increased energy depletion, degrees (Aebi, 2005). Scoliosis in adults can which can lead to several undesirable be characterized as idiopathic or de novo. symptoms in this population. Symp- i. Adult idiopathic scoliosis refers to a toms consistent with sagittal plane im- history of adolescent idiopathic sco- balance include fatiguing back pain, liosis with symptom or curve progres- muscle spasms, difficulty with horizon- sion into adulthood. Weinstein and tal gaze and balance, loss of height, and Ponsetti (1983) examined 102 subjects a progressive leaning-forward posture. with idiopathic scoliosis. Their find- iii. Many patients progress to needing assis- ings revealed that 68% of this cohort tive devices because of unnatural pos- had curve progression as adults. Con- ture. Patients begin to find ways to com- sequently, many of these patients will pensate and often alter the position of need interval follow-up for their sco- their hips and knees, which may cause liosis as they age. The most common further diskomfort (Chang et al., 2011). treatment goal for adolescent idiopath- iv. Sagittal alignment is one of the most ic scoliosis is to prevent progression of important predictors of surgical out- deformity; in adult idiopathic scoliosis comes in adults with spinal deformity a common goal is to improve mani- and is an important variable in the sur- festations of the condition (Bess et al., gical plan (Roussouly & Nnadi, 2010). 2009; Trobisch, Suess, & Schwab, 2010). 2. Incidence and epidemiology ii. De novo scoliosis describes a new on- a. As our population lives longer, the number of set of scoliosis in adulthood as a result people with spinal deformities will increase. of degenerative changes or arthritis. b. Degenerative changes are likely the source of Degenerative curves likely are accom- increased prevalence of scoliosis and kypho- panied by a loss of normal lumbar lor- sis in adults. Prevalence of scoliosis rises to dosis with associated sagittal imbal- 8% in adults 25 years of age and older, and ance. These curves generally do not up to 68% of those ages 60–90 (Trobisch et have rotation above the T10 vertebrae, al., 2010). which is likely in idiopathic scoliosis c. Scoliosis is more common in women. In the (Ploumis, Liu, Mehbod, Transfeldt, & United States it affects approximately 2%–3% Winter, 2009). Presenting symptoms of the female population. of adult degenerative scoliosis may be 3. Diagnostic and physical exam findings multifactorial and often are consistent a. Cobb angle measurements are best measured with worsening back pain, radicular on long cassette (14 x 36-inch, or scoliosis) pain, or a combination of both (Silva standing AP radiographs.

18 AANN Clinical Practice Guideline Series b. Sagittal alignment is measured from the re- iv. Decompression with anterior and pos- lationship of the C7 plumb line to the posterior spinal fusion. The following in- terior superior aspect of S1. It also is mea- terbody approaches are used in an at- sured on a standing long cassette X ray. If tempt to promote a circumferential the plumb line falls in front of the sacrum by spinal fusion. These approaches of- more than 2–4 cm, the patient has positive ten are used at the lumbosacral junc- sagittal balance. Negative sagittal balance oc- tion at which spinal load is the greatest curs if the plumb line falls behind this land- (Maeda, Buchowski, Kim, Mishiro, & mark (Heary & Albert, 2007). Bridwell, 2009). Interbody fusions often c. Determining a surgical plan involves many are done in a second-stage approach. variables. Surgeons use different X-ray tech- a) Anterior lumbar interbody fusion niques to help determine the best surgical (ALIF) option for patients with deformities. Stand- b) DLIF ing, supine, supine sidebending, and lateral c) TLIF lumbar bolster scoliosis X rays all are helpful v. Thoracic instrumentation and fusion when making these decisions. With supine extension sidebending X rays, if the scoliotic deformity vi. Inclusion of osteotomies for specific corrects more than 30%, the curve is consid- deformities ered flexible and is not likely to require os- a) A Smith-Peterson osteotomy is a pos- teotomies for correction. Those with curves terior column osteotomy used with that do not correct more than 30% with flexible deformities. Each level of oste- bending maneuvers are determined to be otomy will produce approximately 10– rigid and commonly will need osteotomies to 15 degrees of correction (Figure 21). correct their deformity (Silva & Lenke, 2010). b) A pedicle subtraction osteotomy 4. Surgical treatment options (PSO) is a three-column osteotomy a. When nonoperative measures fail to help used to treat fixed deformities. A PSO adults with deformities, many will seek sur- is likely to achieve 30–40 degrees of gical treatment. Surgical treatment varies for correction by shortening the poste- each patient because each case is unique. Im- rior column while the vertebral body provements in operative techniques and in- undergoes a wedge resection. strumentation and increased knowledge of c) Vertebral column resection: Osteot- biomechanics have led to surgical advance- omies alone cannot fix some severe ments in recent years (Yadla, Maltenfor, deformities; in such cases vertebral Ratliff, & Harrop, 2010). column resection may be considered. b. Indications for surgery This procedure involves a spinal- i. Curve progression shortening vertebral body resection. ii. Pain despite conservative treatments d. Advancements in surgical techniques have iii. Neurological deficit produced posterior segmental fixation sys- iv. Pulmonary compromise also should be tems with contoured rods and pedicle considered, but is not likely with coro- screws. These systems presently are used in nal curves less than 90 degrees (Heary the spinal deformity population (Heary & & Albert, 2007). Albert, 2007). v. Age, rate of progression, magnitude e. Treatment goals of spinal deformity surgery of deformity, and functional status all i. Decrease pain, stop deformity progres- should be a part of the decision-making sion, and improve function (Heary & process (Pekmezci, Berven, Hu, & De- Albert, 2007). viren, 2009). ii. Obtain solid fusion and establish a bal- c. There are six levels of surgical treatment for anced 3-D spine (Heary & Albert, the deformity population (Silva & Lenke, 2007). Rebalancing the spine is criti- 2010). cal and is linked to patient satisfaction i. Decompression and improved outcomes (Silva & Lenke, ii. Decompression and limited fusion 2010). iii. Decompression and lumbar curve iii. A majority of patients who under- fusion go spinal deformity surgery report

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 19 improvements in back and leg pain i. Cardiac status: Patients with clini- (Smith et al., 2009a, 2009b) and func- cal risk factors should likely undergo tional ability (Zimmerman, Mohamed, a preoperative cardiology consult and Skolasky, Robinson, & Kebaish, 2010); cardiac stress test. however, there is a higher morbidity and ii. Pulmonary status: Patients with known mortality risk compared to other fusion pulmonary disease may require a pul- procedures (Smith et al., 2011). monology evaluation with possible pulmonary function tests. Smoking Figure 21. Stage 1: T4-S1/Ilium posterior spinal fusion with cessation is important for this popula- Smith Peterson osteotomies, Stage 2: L4/5 L5/S1 ALIF (pre- and postoperative, lateral view) tion. Smoking can delay bone healing and increase rates of pseudoarthrosis. Nicotine screening before surgery is recommended (Andersen et al., 2001; Glassman et al., 1998; Whitesides et al., 1994). iii. Nutritional status: A patient’s nutritional status can greatly affect surgical outcomes. It has been shown to take approximately 6–12 weeks for nutritional parameters to return to baseline after spinal reconstructive surgery (Len- ke, Bridwell, Blanke, & Baldus, 1995). Consequently, optimizing preoperative nutritional stores is essential. If preoperative malnourishment is suspected, albumin, prealbumin levels, and total lymphocyte count should be tested (Halpin et al., 2010). iv. Hepatic and renal evaluations should include correcting any coagulopathy and optimizing renal function. If a patient has a history of coagulopathy, © 2011 by Kristen Smith. Reproduced with permission. DVT, or pulmonary embolism (PE), a f. Spinal deformity surgeons also will see pa- prophylactic inferior vena cava (IVC) tients to manage complications resulting filter should be considered. from previous operations (Heary & Albert, v. Weight loss: Weight loss should be en- 2007). Revision surgeries sometimes are couraged for obese patients because necessary to treat flat-back deformity, adja- those who are obese are at increased cent segment degeneration, proximal junc- risk for perioperative complications tional kyphosis, and pseudoarthrosis. (Pull ter Gunne, van Laarhove, & Co- 5. Preoperative, intraoperative, and postoperative hen, 2010). management of scoliosis and kyphosis of the vi. Bone health: A recent dual-energy X- thoracolumbar spine ray absorptiometry (DEXA) scan and a. The general recommendations for preopera- vitamin D level should be assessed tive, intraoperative, and postoperative man- and treatment for osteopenia and os- agement found in Sections V–VII should be teoporosis should be initiated if not followed. already started. Bone-morphogenic b. In anticipation of the extent and length of proteins (BMP) have been introduced surgery, preoperative assessment of risk into spinal fusion surgeries within the factors that may impair optimal outcomes past decade. BMP consists of a fam- is recommended well in advance of the ily of growth factors that induce bone date of surgery. Assessments include the growth. With the use of these proteins, following: findings suggest increased frequency of fusion when compared to fusions using

20 AANN Clinical Practice Guideline Series iliac crest bone graft (Maeda et al., 2009). Figure 22. L5 compression fracture Recommendation: A preoperative evaluation to identify and treat intraoperative and postoperative risk factors should be performed preoperatively with coordination of appropriate consulting services (Level 3). G. Fractures of the thoracolumbar spine 1. Description and etiology a. Fractures along the thoracolumbar spine may occur as the result of high-energy forces from trauma such as vehicle accidents or falls. These traumatic fractures may cause acute neurological problems; some may be nonrecoverable spinal cord injuries. b. Less often, fractures occur spontaneously or © by Angela Starkweather. Reproduced with permission. as the result of low impact due to weakened bones from osteoporosis, tumor growth, or iv. Burst fractures are axial compression congenital conditions. fractures with which the vertebrae los- c. Identifying the type, location, and stability of es height in two columns; they may be the fracture is key to determining the opti- stable or unstable depending on the mum treatment protocol. degree of damage to the posterior col- i. Stability: The vertebral column by con- umn. There may be a risk of neurologi- vention is divided into the Denis 3 col- cal compromise with this type of frac- umn system (Denis, 1983). The ante- ture that is associated with retropulsion rior column consists of the anterior of bony fragments into the spinal canal. half of the vertebral body and disk and Burst fractures occur most frequently the anterior longitudinal ligament. The at the thoracolumbar junction. middle column consists of the poste- v. Flexion-distraction fractures, also rior half of the vertebral body and disk known as Chance or seatbelt frac- and the posterior longitudinal liga- tures, lead to damage in all three of the ment. The posterior column consists of columns as defined by Denis (1983). the osseous structures and ligaments Damage to the posterior column is posterior to the posterior longitudinal variable and neurological impairment ligaments. As a general rule, stability is dependent on the degree of this may be compromised if there is dam- damage and the number of vertebrae age in more than one of the three col- affected. umns as outlined by Denis. vi. Rotational fracture-dislocation inju- ii. Compression or wedge fractures are ries are unstable shear-type failures and flexion fractures with which the ante- involve damage to both the vertebral rior portion of the vertebrae fails and body and surrounding soft tissues, with the posterior portion of the vertebrae relative motion between two vertebrae remains relatively stable (Figure 22). often leading to significant spinal cord Vertebral height loss in the anterior compression and severe neurological column usually does not lead to neu- consequences. rological deficits, but loss of vertebral vii. The Spine Trauma Study Group (Vacca- body height exceeding 50% may lead ro et al., 2006) developed a systematic to instability. If multiple compression approach to classifying thoracolumbar fractures are present, kyphosis and loss spine injuries based on input from rec- of overall body height may be noticed. ognized expert spinal surgeons. Using iii. Osteoporosis-related fractures in the this system, healthcare providers can thoracolumbar spine typically are rate injuries based on physical mor- wedge compression fractures. phology, degree of neurological deficits, and condition of posterior ligaments

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 21 surrounding the injured vertebrae. This lifetime (Old & Calvert, 2004). rating system is a general guideline re- 3. Diagnostic and physical exam findings garding the appropriateness of conser- a. Plain radiographs initially are used to char- vative nonsurgical treatment as well as acterize the type of fracture. CT scans and the necessity and type of surgery that MRI may be indicated for traumatic frac- may be required. Patel and colleagues tures or to better visualize the soft tissues (2009) demonstrated the reliability and surrounding the fractures. Marrow edema validity of this tool on various spinal surrounding a fracture is an indication of a trauma cases. more recent fracture. d. Conservative nonsurgical treatment of frac- b. Symptoms of vertebral fractures are dependent tures is indicated for patients with intact on the location and type of fracture. Patients neurological status and an intact posterior with traumatic fractures may present with se- ligamentous complex. These patients typi- vere pain and acute neurological deficits. cally are those with anterior wedge frac- c. Osteoporotic fractures may be asymptomat- tures and mild burst fractures. Wood and ic and be discovered during routine testing; in colleagues (2003) found that patients with some cases acute pain may be the presenting mild burst fractures treated with nonsurgi- symptom. Patients may show signs of kyphosis, cal interventions had equivalent outcomes in loss of overall height, and reduction in mobil- terms of pain and functioning compared to ity. Loss of pulmonary function and weight loss those who underwent surgical procedures. or decreased appetite may result from pres- Nonoperative treatment generally involves sure on internal organs resulting from kyphotic bracing or casting and medications to con- changes in the spine (Lemke, 2005). trol pain. Braces or casts are worn for a num- 4. Surgical treatment options ber of weeks in many cases to help with sta- a. The type of surgical management of thoraco- bilizing the spine during initial healing. For lumbar fractures is highly dependent on the patients who present with nonacute wedge type and severity of the fracture. Using input fractures, bracing usually is not indicated. from various experts in the Spine Trauma e. Osteoporotic fractures typically are treat- Study Group, Vaccaro and colleagues (2006) ed with bisphosphonates, calcium, and vi- described possible treatment protocols for tamin D supplements. Calcitonin is a hor- patients with more complicated types of mone used to slow bone resorption and has fractures while discussing the need to evalu- been shown to improve pain in osteoporotic ate each case. A recent systematic review of fractures. Calcitonin is available in injectable eleven articles supports early rather than and nasal spray forms. It also is used to treat late surgical stabilization of spine injuries. hypercalcemia and should not be used in pa- Early stabilization, for individuals both with tients with low blood calcium. Physical thera- and without spinal cord injury, may lessen py and activity as tolerated should be encour- the patient’s critical case and hospital length aged as soon as possible to prevent complica- of stays and days on mechanical ventilation tions from immobility. Weight-bearing exer- (Carreon & Dimar, 2011). cise is important for patients at risk for fur- b. For patients with neurological compromise, ther osteoporotic compression fractures and surgical strategies include anterior decom- can improve strength and balance (Dusdal pression, posterior decompression, and com- et al., 2011). All exercise programs should be bined surgeries. carried out under the supervision of health- c. Although single-level flexion-distraction inju- care professionals after the appropriate rest ries may be treated with a brace if a patient is time for patients with vertebral fractures. neurologically intact, treatment with internal 2. Incidence and epidemiology fixation and instrumentation may be needed; a. Vehicular accidents, violence, and falls ac- fusion usually is avoided, especially in young- count for the majority of high-energy trau- er patients, to preserve normal motion (Eich- matic spinal cord injuries, including fractures, inger, Arrington, Kerr, & Molinari, 2007). and are most common in younger men. d. Vertebroplasty and kyphoplasty are mini- b. Spinal fractures associated with osteoporo- mally invasive surgical procedures that have sis are most common in postmenopausal gained popularity for treatment of com- women, with approximately 25% having at pression and burst fractures (Doody, Czar- least one compression fracture during their necki, Given, & Lyon, 2009) in the absence 22 AANN Clinical Practice Guideline Series of neurological deficits. These procedures are variable and highly dependent upon factors used to treat recent fractures as evidenced by such as neurological status at the time of injury. bone marrow edema via MRI. The method 5. Preoperative, intraoperative, and postoperative involves a percutaneous injection of cement management of fractures of the thoracolumbar into the vertebral body, with the goal of frac- spine ture stabilization. In the case of kyphoplasty, a. The general recommendations for preopera- a balloon-tipped catheter is inserted into a tive, intraoperative, and postoperative man- pathway made by needle access into the ver- agement found in Sections V–VII should be tebral body. Using this method, the cement is followed. inserted at a lower pressure than used in ver- b. Due to the wide range of effects on neuro- tebroplasty, allowing for better control and logical functioning, rehabilitation needs vary the benefit of expanding the vertebral body considerably. and improving the kyphotic curve (Sinha, Recommendation: Nurses should perform a thor- Sedgley, Sutcliffe, & Timothy, 2010). These ough assessment of functional needs and coordi- methods have been shown by some authors nate consultation services accordingly (Level 3). to provide statistically significant improve- H. Cauda Equina Syndrome (CES) ments in pain control and vertebral body 1. Description and etiology height when compared to control groups a. The cauda equina consists of nerve roots, (Farrokhi, Alibai, & Maghami, 2011). both motor and sensory, below the level of i. Although there have been reports of the the conus medullaris and within the spinal benefits of vertebroplasty and kypho- canal as described in Section II. plasty in the literature, Buchbinder and b. The cauda equina provides motor innervation colleagues (2009) carried out a double- to the lower extremities, sensory innervation to blinded study in which the control the saddle region, and parasympathetic inner- group received sham surgery instead of vation to the bladder and distal bowel. typical conservative nonsurgical treat- c. Compressive damage to these lumbar and ment. There was no significant differ- sacral nerve roots with associated neurologi- ence in patient outcomes between the cal damage results in CES. two groups, suggesting that the surgi- d. The most frequent cause of CES is midline cal intervention led to a placebo effect. prolapse of an intervertebral disk, and the This outcome strongly suggests that most common levels reported are in the low- nonsurgical management of compres- er lumbar region, particularly L4–L5. Other sion and burst fractures without neuro- conditions that may cause CES include tu- logical deficits may be equally effective. mor, trauma, spinal epidural hematomas and ii. Complications from vertebroplasty and abscesses, and free fat graft following diskec- kyphoplasty include standard post-op- tomy. CES also may be a postoperative com- erative complications along with al- plication after lumbar spine surgery. CES lergic reactions and possible cement rarely occurs without a precipitating event; leakage that can potentially lead to in these cases a history of spinal stenosis of- compression within the spinal cord or ten is present. pulmonary embolism (Robinson, Hey- e. Compressive lesions may create a partial de, Försth, & Olerud, 2011). block, causing varying degrees of impair- iii. Kasperk and colleagues (2010) tracked ment in addition to asymmetry of the distur- patients for 3 years after kyphoplasty sur- bance. A complete block is not required to gery and found they exhibited reduced produce a CES. Clinical evidence has dem- pain and higher levels of mobility com- onstrated little correlation between the de- pared with a control group. In addition, gree of block and the development of CES their data indicated the kyphoplasty- (Olivero et al., 2009). treated group had fewer additional ver- f. Significant neurological changes can occur tebral fractures when compared to those with 75% restriction of the cauda equina. in the control group, although the sam- 2. Incidence and epidemiology ple size was small. CES is rare, affecting an estimated 1% of e. Outcomes for patients with traumatic flexion- people secondary to disk herniation (Olivero distraction and rotational injuries are et al., 2009).

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 23 3. Diagnostic and physical exam findings in determining optimum surgical treatment. a. Low back pain with bilateral sciatica is a pre- CT and X ray analyses also may help to de- senting symptom. Radicular pain often is determine the diagnosis if MRI is unavailable scribed as stabbing, shooting, or burning. or contraindicated. b. Saddle and perineal anesthesia are hallmark Frequently there is incomplete CES with signs. The patient may describe difficulty asymmetric motor and sensory changes and urinating, overflow incontinence, or the ab- variability in bowel and bladder symptoms. sence of or decreased feeling in the perineal These cases are treated in a similarly urgent region (Table 2). manner as complete CES to prevent progres- Table 2. Symptoms Related to CES sive neurological deterioration. Involvement Symptoms 4. Surgical treatment options Motor Limb weakness or weakness of movements; hypo- a. CES from a herniated lumbar disk is an ab- tonia in the limb or muscle group; diminished or solute indication for decompressive surgery. absent reflexes Transcanal approaches include standard Sensory Hypoesthesia or hyperesthesia with objective signs open lumbar laminectomy for the resection of sensory loss in a dermatomal or myotomal distribution of a compressive lesion or diskectomy and Urinary sphincter control Difficulty initiating micturition, retention, stress microdiskectomy for the treatment of herni- incontinence; loss of urethral sensation ated disks. Bowel dysfunction Constipation, loss of appreciation of rectal disten- b. Although controversy exists regarding the ef- sion; loss of anal tone and sensation fectiveness of early surgical intervention, sur- Sexual dysfunction Sudden onset of difficulty achieving an erection or gery continues to be recommended within orgasm 48 hours after a patient presents with CES c. Urinary retention of more than 500 ml using symptoms. the bladder scanner method in the presence c. Some controversy surrounding the effec- of two or more classic CES symptoms was tiveness of early intervention stems from found by Domen, Hofman, van Santbrink, both the low incidence of this condition and Weber (2009) to strongly predict CES and mixed data regarding patients present- findings on MRI. ing with both complete and incomplete CES d. Progressive symptoms likely are the result of symptoms (DeLong, Polissar, & Neradilek, a combination of compressive damage to the 2008). nerves along with ischemic changes in the i. In a prospective study Qureshi and Sell relatively hypovascular region of the cauda (2007) found no significant difference equina (Jensen, 2004). in residual symptoms, including dis- e. Healthcare providers should assess motor ability, pain, and incontinence, be- weakness (specifically motor nerve root), tween patients who received surgery sensory changes (numbness or tingling along within 24 hours of symptom onset and a specific distribution), and reflexes (de- those who received surgery more than creased or absent) to evaluate patients pre- 24 hours after symptom onset. How- senting with low back pain for CES. ever, a significantly improved outcome was found in patients who were conti- f. If CES is suspected, an examination and nent of urine at presentation. In many evaluation of perianal sensation is warrant- cases early intervention may prevent ed. Sensory assessment of the perineal region the progression of partial sphincter dis- should include the perianal area, the natal turbance to complete lesions. This pro- cleft, and the posterior scrotal or labial areas. gression has been documented to occur g. Due to the potential for permanent neuro- even within the first 24 hours of symp- logical impairment for patients with CES, tom onset (Kennedy, Soffe, McGrath, it is recommended that patients presenting Stephens, & Walsh, 1999). with likely CES symptoms undergo urgent ii. Predictors of residual dysfunction are MRI evaluation (Bell, Collie, & Statham, the presence of significant sphinc- 2007). ter disturbance and complete perine- h. MRI studies are standard practice to deter- al anesthesia at presentation. Patients mine the level of pathology, aid in diagnosis with complete CES and those exhibit- of the primary pathologic lesion, and assist ing urinary retention may have a poor

24 AANN Clinical Practice Guideline Series prognosis even if surgery is carried out d. Nurses should assess functional needs and within the 24- to 48-hour time frame help patients identify potential resources (Arrigo, Kalanithi, & Boakye, 2011). to enhance patient and family coping and iii. The goal of surgery is to prevent pro- adjustment. gression of neurological dysfunction; Recommendation: Nurses should perform a post- resolution of presenting symptoms operative assessment of mental health and function- of neurologic dysfunction is variable al needs of patients to determine the need for con- and often proceeds over a number of sultation services and discharge teaching (Level 3). months. Some patients continue indefi- nitely with neurological deficits. IV. Review of Diagnostic Studies iv. Although a retrospective review by Oli- A. Nursing responsibilities vero and colleagues (2009) found that 1. Although it is not within the RN scope of prac- recovery of sensory, motor, and blad- tice to order diagnostic studies, nurses should der function was not related to the tim- be familiar with each diagnostic modality and ing of the surgical intervention, other be able to provide education and guidance authors (Arrigo et al., 2011) presented when preparing patients for their procedures. data indicating earlier intervention led 2. Obtain a medical history and inform the pro- to improved outcomes. Arrigo and col- vider of any possible contraindications to the leagues (2011) also found that patients examination. For procedures requiring the in- with CES undergoing surgery after 48 jection of a contrast material, the nurse will hours had higher complication rates need to obtain data on the patient’s allergies, and more nonroutine hospital dis- medications, and renal function. If the patient charges. Current guidelines encourage has allergies to contrast material, is currently early surgical intervention on an emer- taking medications such as metformin that in- gency or urgent basis within 48 hours crease risks associated with contrast, or has a of symptom onset. decreased glomerular filtration rate, the order- d. Patients who present postoperatively with ing provider should be informed and appropri- CES symptoms after lumbar spine surgery ate interventions taken. may require further surgical intervention to 3. Patients undergoing MRI should be assessed prevent long-term complications even in the for the presence of ferromagnetic foreign bod- absence of lesions detected with MRI imag- ies such as spinal hardware, implanted pumps, ing (Jensen, 2004). or spinal stimulators. The radiologist should be 5. Preoperative, intraoperative, and postoperative made aware of any foreign bodies because they management of CES may contraindicate the MRI or require posttest a. The general recommendations for preopera- reprogramming. tive, intraoperative, and postoperative man- 4. Nurses should assess for anxiety and treat pa- agement found in Sections V–VII should be tients appropriately with anxiety-reducing in- followed. terventions such as visualization techniques b. Patients should be made aware that improve- and deep-breathing exercises. In addition, sed- ments may not be immediate and arrange- atives may be necessary to alleviate anxiety and ments should be made for appropriate short- promote tolerance of the examination. Ear- and long-term follow-up care. Pay special at- plugs or earphones can be offered to patients to tention to assessing for return of bladder and increase their tolerance. bowel function. Bladder scanning should 5. Provide information to patients regarding the be used to ensure adequate bladder empty- indications, risks, and contraindications of the ing during the postoperative period. Patient diagnostic test and let them know what to ex- teaching should be implemented for patients pect before, during, and after the procedure. who have residual neurological deficits. Pa- Instructions should be provided regarding tients may need instruction on intermittent which medications to take before the test and catheterization in the hospital setting and as how to resume home medications, oral intake, a part of discharge planning. and activities before and after the test; cloth- c. To reflect the wide range of effects on neuro- ing and accessories to wear; and transportation logical functioning, rehabilitation needs vary needs. considerably.

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 25 6. Inform the patient about when to expect study degenerated disk seen on an MRI or CT scan is results and encourage him or her to contact the cause of the patient’s symptoms; however, the their provider to follow up. utility of this test remains controversial (Carragee B. X ray: X rays are inexpensive and noninvasive. X et al., 2009; Manchikanti, Glaser, Wolfer, Derby, & rays show the general changes of arthritis and bony Cohen, 2009). alignment, but are limited to assessment of bony G. Myelogram/postmyelogram CT: A contrast agent structures only. Flexion/extension X rays may help is injected under fluoroscopy into the intrathe- to identify segmental instability. Serial X rays may cal space through either lumbar puncture or cis- be used to evaluate bone healing and maturation ternal puncture. The contrast agent then is visu- of surgical fusion. alized with radiographs, commonly with CT. The C. CT: A CT scan may be used either as an ad- resulting images are useful for evaluating patients junct to MRI or for patients with thoracolum- who cannot undergo MRI studies (e.g., people bar spine issues who cannot undergo MRI evalu- who have pacemakers) or as an adjunct to MRI. ation. A CT scan shows the bony elements of the This test also is useful in evaluating for suspect- spine very well, as well as the disks, nerves, and ed CES (any mass lesion or infection that is within ligaments. Although it provides excellent visual- or impinging upon the thecal sac, arachnoiditis, or ization of the bony components, the CT scan is nerve root lesions). less sensitive to changes in the soft tissues of the H. Electromyography/nerve conduction velocities: spine. Contrast agents may be useful to highlight Small needles are inserted into specific muscles to masses and abnormal tissue and fluid collections. assess muscle activity and nerve conduction time A CT scan also is occasionally used in conjunc- and amplitude of electrical stimulation along spe- tion with computerized neuro-navigation for in- cific nerves. Electromyography may be indicated traoperative 3-D image guidance during thoraco- for patients without a clear radiculopathy (i.e., pain lumbar fusions. in the anatomic distribution of the affected nerve D. MRI: Using strong magnetic fields and radio fre- root) to further assess and diagnose their pathology quencies, MRI can provide useful information on (Carstensen, Al-Harbi, Urbain, & Belhocine, 2011). all tissues in the spine (e.g., bones, soft tissues, spinal cord, nerves, ligaments, musculature, disks). V. Preoperative, Intraoperative, and Postoperative MRI is superior to CT for the evaluation of soft- Nursing Care tissue structures (Lurie, Doman, Spratt, Toste- A. Preoperative nursing responsibilities son, & Weinstein, 2009). Contrast agents may be 1. Preoperative planning several weeks before used to highlight masses, epidural scarring as a re- surgery sult of previous spine surgeries, and abnormal tis- a. Describe the surgical procedure to the patient sue or fluid collections. MRI is contraindicated for and family, including expected postoperative patients who have metallic implants or a cardiac and long-term outcomes. Emphasize realistic pacemaker. expectations based on the patient’s preopera- E. Bone scan: Radioactive tracers are injected into the tive status and prepare the patient and family patient. These tracers attach themselves to areas of for potential care needs during recovery, such increased bone production or increased vascular- as assistance with activities of daily living. ity associated with tumor or infection. Bone scans b. Arrange for required preoperative testing. are often used when evaluating for spondylolysis For procedures during which a substantial (i.e., destructive lesion of the vertebra), occult frac- amount of blood loss is expected, the option tures, or suspected bony metastasis. for autologous blood donation may be of- F. Diskogram: A diskogram may be used to evalu- fered at least 3–5 weeks before the scheduled ate for DDD. Under fluoroscopic guidance, a con- procedure. trast agent is injected into the nucleus pulposus. c. Psychosocial factors can greatly affect surgi- The clinician performing the procedure assesses cal outcomes. Optimizing social support and the amount of contrast agent administered and at mental health is imperative (Laxton & Perrin, what point the patient experiences pain. The clini- 2003). cian then notes whether the patient’s typical pain d. When cardiac clearance is indicated by the is elicited. Radiographs are taken to assess wheth- surgeon, make sure that preoperative medi- er the contrast agent stays within the nucleus cal clearance has been obtained and en- pulposus or leaks out of the disk. All of these data sure that all recommendations have been may be useful in determining whether a specific implemented.

26 AANN Clinical Practice Guideline Series e. Assess nutritional status preoperatively. scheduling the surgical procedure, learn Recommendation: Preoperative nutritional from the surgeon whether special equipment assessment and treatment may improve tho- is necessary, including fusion hardware, racolumbar surgical outcomes (Level 3). which may necessitate contacting the device i. Nutritional status may affect surgi- representative; intraoperative nerve conduc- cal outcomes such as infection poten- tion monitoring or image guidance, which tial and the quality and rate of healing; may require specific personnel; and cadav- however, no evidence has been identi- er bone or human recombinant bone mor- fied in the literature addressing surgical phogenic protein, which may require special outcomes in patients undergoing spinal ordering. surgery. Regardless, it has been shown 2. Preoperative planning the week before and day to take approximately 6–12 weeks for of surgery nutritional parameters to return to a. Verify that informed consent has been ob- baseline after spinal reconstructive sur- tained by the surgeon. gery (Lenke, Bridwell, Blanke, & Bal- b. Ensure that a recent preoperative history and dus, 1995). Consequently, optimizing physical has been performed and document- preoperative nutritional stores may be ed. Verify the findings of the physical exam beneficial, particularly in patients with and document any changes. Report changes severe malnourishment, which can to the surgeon. be evaluated with albumin, prealbu- c. Explain to patients where and when to arrive min levels, and total lymphocyte count and the surgery time. (Halpin et al., 2010). No evidence was d. Instruct patients about their medications. identified to guide interventional strat- Specific instructions should be provided egies for malnourishment. regarding medications to be taken the ii. Another concern regarding fusion sur- morning of surgery with a sip of water. Ad- gery is bone health, and a bone health vise patients regarding which medications evaluation with a recent DEXA scan should be discontinued before surgery, such and vitamin D level to guide preopera- as herbal products, nonsteroidal antiinflam- tive treatment for osteopenia and osteo- matory drugs (NSAIDs), anticoagulants, an- porosis has been advocated. A recent tiplatelet medications, and direct thrombin retrospective study among 176 women inhibitors. who underwent surgery for scoliosis e. Ensure patients have adequate pain medica- did not show correlations among bone tions that can be administered until the time mineral density measured by DEXA, of surgery. rate of fusion, or complications, howev- f. Instruct patients about eating and drinking er (Yagi, King, & Boachie-Adjei, 2011). restrictions. f. Encourage patients to anticipate and arrange g. Remind patients to wear comfortable cloth- for perioperative and postoperative care ing and to leave jewelry and valuables at needs. Patients should arrange for help with home. household chores, yard work, pets, and other h. Tell patients to remove dentures, partial tasks. plates, eyeglasses, contact lenses, nail polish, g. Patients undergoing multilevel spinal fu- and sculptured nails. sions must be informed that they may lose a i. Implement measures to reduce DVT risk. significant amount of flexibility depending Recommendation: The use of mechanical on the levels of their fusion. Simple hygiene prophylaxis may decrease the rate of DVT in tasks and activities of daily living often be- patients undergoing spinal surgery (Level 2). come difficult because of this loss of flexibil- i. Antithrombotic Therapies in Spine ity when patients’ lumbar vertebrae are fused Surgery, a comprehensive review of down to their sacrum. Preoperative physical the literature performed by the North therapy concentrating on leg flexibility and American Spine Society, was published strengthening may be of significant benefit in 2009. The work group found lim- for this population. ited information regarding the rela- h. Coordinate the equipment and personnel tive incidence of DVT or PE com- required for the operative procedure. When plications for specific prophylactic

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 27 measures according to particular spine against the risk of epidural hematoma procedures. because there is no available literature to ii. The most common elective spine sur- support an ideal duration (NASS, 2009). geries performed through a posterior iv. A review of the literature did not find approach (e.g., microdiskectomy, lami- evidence to address wound complica- nectomy) are associated with low risk tions or neurologic decline from epi- for DVT. dural hematoma related to the use of iii. Because of their ease of use and low DVT chemoprophylaxis. rate of complications, mechanical pro- j. Infection control measures should be imple- phylaxis of any type, including pneu- mented to reduce the risk of infection. matic sequential compression devices Recommendation: Patients undergoing or compression stockings, should be spine surgery should receive preoperative considered for any inpatient spine pro- prophylactic antibiotics (Level 2). cedures and for those at risk for DVT i. After a comprehensive review of the in accordance with recommendations literature, evidence-based guidelines from the Agency for Healthcare Re- were published by NASS (2007) en- search and Quality (AHRQ). titled Antibiotic Prophylaxis in Spine iv. Initiation of mechanical compression Surgery. Recommendations include the before or at the beginning of surgery use of preoperative prophylactic antibi- and continuation until patients are fully otics for instrumented and noninstru- ambulatory is an established standard mented spine surgery (Shaffer, Baisden, of care (Geerts et al., 2004). Fernand & Matz, 2013). Recommendation: Low-molecular-weight ii. Little evidence was found to guide the heparin (LMWH) or low-dose warfarin may selection of a specfic agent or dosing; be used postoperatively following elective however, the work group recommend- combined anterior-posterior (circumferen- ed considering an appropriate broad tial) spine surgery or in patients with high- spectrum antibiotic when instrument- risk for thromboembolic disease (Level 3). ed fusion is performed for those at risk i. Recommendations in Antithrombotic for polymicrobial infection (patients Therapies in Spine Surgery on the use with neuromuscular scoliosis, myelo- of LMWH or low-dose warfarin for dyplasia, or traumatic complete spinal patients undergoing circumferential cord injury; Shaffer et al., 2013). spine surgery and those at high risk for iii. Older age, obesity, malnutrition, diabe- thrombembolic disease (patients who tes, higher American Society of Anesthe- have experienced multiple trauma, ma- siologists score, and posterior approach- lignancy, or hypercoagulable states) are es were associated with increased infec- based on work group consensus (North tion rates after spine surgery (Schuster et American Spine Society [NASS], 2009). al., 2010; Shaffer et al., 2013). ii. Limited data exist concerning outcomes iv. Besides intraoperative interventions, no in patients undergoing other types of additional evidence was identified that spine surgery, and only one study was addressed infection-control measures identified since the publication of An- since the publication of Antibiotic Pro- tithrombotic Therapies in Spine Surgery phylaxis in Spine Surgery. (NASS, 2009). A retrospective cohort Recommendation: Standards of practice analysis that included 3,870 patients to reduce infections in hospitalized patients undergoing elective spine surgery should be implemented in patients undergo- found that preoperative DVT prophy- ing spinal surgery (Level 3). laxis did not influence the incidence of i. Although no evidence was identified DVT, PE, or subdural hematoma (Cun- specifically pertaining to patients un- ningham, Swamy, & Thomas, 2011). dergoing spinal surgery, AHRQ rec- iii. The work group also recommended ommends several important infec- that the duration of chemoprophylaxis tion-control standards of care. These should be decided based on the underly- include hand hygiene and measures to ing pathological condition and weighed reduce catheter-related urinary tract

28 AANN Clinical Practice Guideline Series infections, such as aseptic insertion and by procedure and small samples were used catheter care and prompt removal of (fewer than 100 subjects). Collectively, these unnecessary catheters. studies support the use of preemptive or in- ii. Recommendations to reduce central ve- traoperative pain management interventions nous catheter infections and ventilator- for patients undergoing spine surgery. Be- associated pneumonia also should be cause of wide variations in pain techniques implemented when appropriate. and study samples, however, no specific in- B. Intraoperative nursing responsibilities tervention has been identified as superior to 1. Perform a “time out”—right patient, right sur- others. gery, right site. b. Preemptive oral controlled-release oxyco- 2. Verify that prophylactic DVT prevention mea- done for elective lumbar diskectomy (one sures have been implemented if appropriate. or two levels) along with morphine patient- 3. Verify that preoperative antibiotics have been controlled analgesia (PCA) reduced pain administered. scores and nausea and vomiting and was as- 4. Alert surgical staff of patient allergies, particu- sociated with earlier recovery of bowel func- larly to latex, so that appropriate measures can tion and higher patient satisfaction com- be implemented. pared to placebo (Blumenthal, Min, Mar- 5. Ensure the correct and most recent diagnostic quardt, & Borgeat, 2007). imaging equipment is available for the surgeon. c. Among 73 patients undergoing PLIF, con- Intraoperative CT image-guided navigation tinuous subcutaneous morphine was associ- systems have been introduced and are demon- ated with significantly fewer side effects and strating increased safety and accuracy in the lower equivalent pain scores compared with placement of posterior spinal instrumentation continuous epidural morphine and diclof- (Tormenti et al., 2010). enac sodium (Voltaren®; Yukawa, Kato, Ito, 6. If autologous blood donation was provided, no- Terashima, & Horie, 2005). tify the blood bank at which the donation was d. Two studies evaluated preemptive gabapen- collected to allow for adeqate preparation time. tin (Neurontin®), but the results were incon- 7. Monitor proper patient positioning throughout sistent. In the first study a preemptive dose the procedure. of gabapentin was evaluated for postopera- a. Table options are surgeon specific. tive pain relief after single-level lumbar dis- b. If the patient is obese, consider using a Jack- kectomy and its effect on fentanyl consump- son table. tion during the initial 24 hours after surgery c. The patient’s abdomen should hang freely to (Pandey et al., 2005). Patients were divided reduce intraoperative bleeding by minimiz- into five groups to receive placebo or gaba- ing vena cava compression and epidural ve- pentin 300, 600, 900, or 1,200 mg 2 hours nous pressure. before surgery. Patients receiving 600 mg or d. Appropriately pad pressure points to de- higher had significantly lower pain scores crease the incidence of pressure sores at- than patients receiving 300 mg; however, tributable to long operating times. Pressure there were no differences in pain scores be- points and genitalia should be checked fre- tween groups receiving at least 600 mg. The quently to avoid positioning injuries. authors concluded that gabapentin 600 mg is 8. Assist in the coordination of a pain- the optimal dose for postoperative pain relief management plan based on patient needs. after lumbar diskectomy. In contrast, pre- Recommendation: Preemptive or intraop- emptive gabapentin 800 mg (in two equally erative pain management interventions may divided doses) or placebo was given pre- reduce opioid requirements postoperatively operatively to 60 adult patients undergo- (Level 1). ing elective lumbar laminectomy or diskec- a. Numerous studies were identified that evalu- tomy (Radhakrishnan, Bithal, & Chaturvedi, ated preemptive and intraoperative methods 2005). Pain scores, total morphine consump- of pain management in patients undergoing tion, and side effects were similar in the two spinal procedures. Although most studies groups. were double-blind RCTs, there were a lim- e. Patients undergoing elective single-lev- ited number of studies for each pain regimen el lumbar microdiskectomy who received for which the patient sample was selected two doses of rofecoxib 50 mg preoperatively

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 29 required significantly less morphine postop- evening before surgery did not significantly eratively compared to placebo (Bekker et al., reduce morphine consumption (Karst et al., 2002). 2003). f. Reuben, Buvanendran, Kroin, and Raghu- l. Patients who received 20–80 mg dexametha- nathan (2006) demonstrated that celecox- sone (Decadron®) intravenously during sur- ib (Celebrex) alone or in combination with gery because of visible signs of compression pregabalin (Lyrica®) dosed 1 hour preopera- of the affected nerve root had significantly tively and 12 hours after 1–2-level spinal fu- less pain on movement and lower morphine sion with harvest of iliac crest bone graft was requirements. In another study methylpred- effective at significantly reducing pain at rest nisolone locally applied to the affected nerve and with activity. Study patients receiving ce- roots was effective in patients undergoing lecoxib alone or in combination with prega- posterior lumbar diskectomy and decom- balin demonstrated decreased opioid use and pressive laminectomy with or without instru- less postoperative sedation and nausea than mented fusion for degenerative spinal diseas- the placebo group, which received PCA mor- es in reducing the cumulative morphine dose phine alone. The celecoxib/pregabalin combi- and postoperative pain compared to placebo nation had more effect than either agent giv- (Jiraattanaphochai, Jung, Thienthong, Kri- en alone. sanaprakornkit, & Sumananont, 2007). Both g. Many intraoperative interventions for pain 40-mg and 80-mg intravenous dexametha- management also showed effectiveness in sone versus placebo in patients with a single- reducing postoperative pain compared to level diskectomy resulted in lower pain scores usual care or placebo. Intravenous ketamine and less opioid use postoperatively (Amin- administered to patients undergoing major mansour, Khalili, Ahmadi, & Nourian, 2006). lumbar spine surgery was effective (Lof- m. A comparison of pain interventions in lum- tus et al., 2010), and a mixture of ketamine bar diskectomy cases revealed that intrathe- and morphine in patients undergoing lum- cal or epidural morphine resulted in lower bar disk surgery was superior to either postoperative pain scores than paraspinal agent alone (Aveline, Hetet, Vautier, Gauti- bupivacaine or placebo (Yorukoglu, Ates, er, & Bonnet, 2006). Temiz, Yamali, & Kecik, 2005). h. Magnesium sulfate infusion in patients un- n. Preoperative epidural anesthesia with mor- dergoing lumbar disk surgery (Oguzhan, phine for posterior lumbar spinal fusion re- Gunday, & Turan, 2008) and in those who sulted in more stable blood pressure and less had major lumbar surgery (Levaux, Bon- blood loss and analgesic requirements than homme, Dewandre, Brichant, & Hans, 2003) placebo (Yoshimoto et al., 2005). was more effective in reducing pain than o. Adcon-L, an adhesion control in a barrier usual care. A one-time dose of intrathecal gel that acts as a barrier to the development morphine after posterior lumbar interbody of epidural fibrosis when mixed with mor- fusion resulted in lower opioid requirements phine, resulted in lower pain scores, less an- than seen in the placebo control group up to algesic use, and shorter hospital stays com- 20 hours after surgery (Ziegeler et al., 2008). pared with placebo (Mastronardi, Pappagal- Epidural morphine combined with cloni- lo, Puzzilli, & Tatta, 2002). dine for postoperative pain relief after lum- p. Intrathecal administration of neostigmine bar disk surgery was superior to bupivicaine after single-level lumbar diskectomy was or placebo in reducing pain and analgesic re- more effective in reducing pain and analgesic quirements (Bonhomme et al., 2002). requirements compared to placebo (Khan, j. A single epidural injection of bupivacaine Hamidi, Miri, Majedi, & Nourijelyani, 2008). and tramadol in patients undergoing diskec- q. Bupivacaine injected into the paraverte- tomy by the posterior approach with or with- bral muscles and subcutaneus tissues along out instrumentation resulted in lower pain with a piece of autologous fat soaked in 40 scores and significant delay in the first de- mg of methylprednisolone for 10 minutes mand for analgesic medications compared to did not lead to a significant reduction in placebo (Sekar et al., 2004). pain scores compared with placebo among k. Celecoxib administerd at a dose of 200 patients with lumbar diskectomy (Mirzai, mg twice a day for 72 hours starting the Tekin, & Alincak, 2002).

30 AANN Clinical Practice Guideline Series r. Continuous epidural infusion of 0.1% ropi- (Dahners & Mullis, 2004; Li, Zhang, & Cai, vacaine (Gottschalk et al., 2004) or 0.5% 2011). marcaine into the subfascial aspects of the b. Park, Moon, Park, Oh, and Lee (2005) evalu- wound (Elder, Hoh, & Wang, 2008) resulted ated rates for lumber fusion for patients who in lower pain scores, lower opioid consump- received PCA continuous infusions of ketor- tion, and higher patient satisfaction when olac and morphine versus morphine alone compared with placebo. for the first 3 days postoperatively. They re- Recommendation: Opioid analgesics ported that patients were nearly six times administered via patient-controlled devices more likely to develop a nonunion of fusion can effectively reduce postoperative pain with the addition of PCA ketorolac and dis- (Level 1). couraged the use of NSAIDs after posterolat- a. Although not all patients undergoing eral fusion. thoracolumbar spine procedures require C. Postoperative nursing responsibilities intravenous or epidural analgesics, the use of 1. Monitoring neurological functioning patient-controlled devices has been shown to a. Although standards of monitoring neuro- be superior compared to patient-requestion logical functioning vary by setting (inten- (as needed) administration. The studies sive care unit versus care unit), neurological reviewed included a meta-analysis, RCTs, assessments should be carried out on a fre- and retrospective studies. quent basis during the postoperative peri- b. A recent meta-analysis demonstrated slightly od to gauge effects of surgical intervention. higher patient satisfaction and pain control Changes in sensation, strength, or pain levels scores with use of PCA when compared to should be reported to the surgeon immedi- traditional patient-requested or nurse ad- ately, especially if patients show deterioration ministered opioid analgesics (Hudcova, Mc- compared to the preoperative state. Patients Nicol, Quah, Lau, & Carr, 2006). Patients us- should be made aware that improvements ing PCA took more opioids and demonstrat- may not be immediate and arrangements ed more itching compared to their cohorts, should be made for appropriate short- and but no other significant differences in side ef- long-term follow-up care. fects were found (Hudcova et al., 2006). b. In the event of significant intraopeartive c. Patient-controlled epidural analgesia (PCEA) nerve root manipulation or postoperative has been shown to provide adequate post- neurological deficits, the physician may or- operative pain control and patient satisfac- der postoperative steroids for 24–48 hours. tion as an alternate to PCA (Fisher et al., Antibiotics may be continued for 24 hours. 2003). A clinical advantage of PCEA over c. Monitor for postoperative complications PCA for patients undergoing spine fusion including was the lower quantity of opioids consumed, i. Superficial wound infections (0.9%–5% although the PCEA group experienced sig- incidence) nificantly more side effects than the PCA a) Increased risk with age, long-term group. steroid use, obesity, or diabetes d. The use of PCEA has been shown to pro- mellitus vide better postoperative analgesia and to b) Most superficial infections are decrease the amount of opioid consumption caused by S. aureus. compared with patient-controlled intra- c) Mild infections usually are treated venous analgesia in a retrospective review with 7–14 days of oral antibiotics. of 245 medical records of adult patients un- ii. Increased motor deficit (1%–8% dergoing major spine surgery (Cata et al., incidence) 2008). a) Can be sustained during intraopera- Recommendation: High-dose nonsteroidal tive positioning: compression neu- anti-inflammatory drugs (NSAIDs) should be ropathies, anterior tibial compart- avoided in patients receiving lumbar fusion ment syndrome, pressure on the eye, procedures (Level 2). cervical spine injuries a. NSAIDs should be avoided for the first sev- b) Can be transient with nerve root eral months after spinal fusion because these stretching or manipulation medications may decrease the rate of fusion

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 31 c) Diagnostic imaging may be required vii. Deep infections: Lower than 1% inci- to ensure spinal stability and integ- dence; this includes diskitis at 0.5%, rity of the spinal cord. spinal epidural abscess at 0.67%, and iii. Unintended durotomy (CSF leak; 0.3%– osteomyelitis 13% incidence) viii. Thrombophlebitis and DVT with risk of a) Generally revealed intraoperatively pulmonary embolism: 0.1% incidence but may present postoperatively as 2. Wound care a wound leak, a collection, or a pos- a. Closely monitor surgical wounds for signs tural headache and symptoms of excessive blood loss and b) In most circumstances activity is re- infection. stricted to a flat-lying position for b. Wound drainage amounts should be mea- 24–48 hours; gradually raise the sured per protocol and significant changes in head of the bed. drainage quickly reported. c) May be repaired with a 4.0 silk or c. Changes in temperature and white blood nylon sutures, fibrin glue, or mus- cell count should also be monitored because cle plug (may be necessary for poor changes can indicate wound infection. quality dura or difficult locations) 3. Mobility d) Possible sequelae include a CSF a. Patients should mobilize quickly unless or- fistula (external CSF leak) or dered differently because of the type of sur- pseudomeningocele. gery or complication (e.g., CSF leak). If a e) In some situations the physician CSF tear has occurred, the surgeon may or- may elect to have a blood patch der flat bed rest. This often is dependent on placed to plug the tunnel. the degree of tear, ease of repair, and surgeon iv. Pseudomeningocele (0.7%–2% preference. For a persistent CSF leak, a lum- incidence) bar drain or external ventricular device may a) Appears similar radiographically to be implemented. a spinal epidural abscess b. Instruct and help patients to roll to the side b) If a dural tear is suspected or visual- and bring their legs down while simultane- ized, the patient is maintained in a ously rising up with the torso from the bed. flat position for 24–48 hours to min- This minimizes twisting at the waist. imize dural pressure. Raise the head c. Instruct and help patients to rise from a chair of the bed slowly (10 degrees every using their legs rather than pushing off with hour) until upright. If the patient their back. complains of positional headache d. Patients may benefit from use of a walker (i.e., headache when upright), then or other assistive devices if they are decon- resume a flat-lying position. ditioned, had a multilevel laminectomy, or c) Some surgeons may place a lumbar have difficult mobility. drain to decrease dural pressure and e. Evaluate patients for inpatient physical thera- allow for dural repair. py referral needs for gait training and a walk- d) Surgical exploration may be neces- er evaluation. sary if symptoms do not resolve. f. Instruct patients to take short walks to avoid v. Instability excessive fatigue; note their preoperative a) Instability usually is found in predis- walking endurance. posed patients undergoing decom- Recommendation: Prescribing an exercise pression without fusion, especial- program starting 4–6 weeks postsurgery may ly if a significant amount of facet is lead to a more rapid reduction in pain and removed. disability than no treatment (Level 1). b) Obtain flexion and extension films i. A recent meta-analysis evaluated the to determine the amount of move- effectiveness of rehabilitation after ment and the need for fusion. lumbar disk surgery and found low- vi. Direct injury to neural structures dur- quality evidence showing that exercise ing surgery may result in transient or is more effective than no treatment for permanent neurological deficits (<1% pain, and moderate-quality evidence incidence). showing that exercise is more effective

32 AANN Clinical Practice Guideline Series for functional status at short-term fol- i. A recent meta-analysis found low- low-up (Ostelo, Costa, Maher, de Vet, quality evidence that high-intensity & van Tulder, 2008, 2009). None of the exercises are slightly more effective studies reported that exercise increased than low-intensity exercise programs the reoperation rate. In addition, the for pain in the short term, and moder- analysis found low-quality evidence ate evidence that they are more effec- showing no significant differences be- tive for functional status in the short tween supervised and home exercises term (Ostelo et al., 2008, 2009). and their effects on short-term pain ii. In an RCT to evaluate a progressive ex- relief or functional status. ercise program patients who had un- ii. In contrast, an RCT examined the ef- dergone a single-level lumbar micro- fects on outcome up to 2 years after diskectomy were randomly allocated to spinal decompression surgery of two receive education only or exercise and types of postoperative physiotherapy, education (Kulig et al., 2009). The exer- spine stabilization exercises or mixed cise intervention consisted of a 12-week techniques, versus simply instructing periodized program of back extensor patients to stay active (Mannion, Den- strength (force-generating capacity) zler, Dvorak, Muntener, & Grob, 2009). and endurance training and mat and There was no significant difference be- upright therapeutic exercises. Patients tween groups in levels of pain or dis- who received the progressive exercise ability at 12 and 24 months after sur- program and education had significant- gery. The authors concluded that advis- ly lower disability scores and greater ing patients to keep active by carrying improvement in distance walked. out the type of physical activities they g. If a brace is ordered, instruct patients in its most enjoy appears to be just as effec- use and assist during the first few times to en- tive as administering a supervised re- sure correct use. habilitation program. Recommendation: When spinal bracing is iii. An RCT was conducted to investigate ordered, the patient should have it properly the effectiveness of a psychomotor ther- fitted and receive information on how to apy focusing on cognition, behavior, wear the brace (Level 3). and motor relearning compared with i. Braces are widely used to decrease back exercise therapy applied during the first pain and disability despite the lack of 3 months after lumbar fusion (Abbott, conclusive evidence regarding their Tyni-Lenné, & Hedlund, 2010). Both efficacy. groups received a home-based exercise ii. A recent meta-analysis found there was program with pain-contingent train- little or no difference in back pain pre- ing of back, abdominal, and leg mus- vention or reduction of sick leave be- cle functional strength and endurance; tween people with low back pain who stretching; and cardiovascular fitness. used back supports and those who re- The psychomotor therapy improved ceived no treatment, or between people functional disability, self-efficacy, out- who received education on lifting tech- come expectancy, and fear of move- niques (van Duijvenbode, Jellema, van ment or (re)injury significantly more Poppel, & van Tulder, 2008). than exercise therapy at 3-, 6-, 9-, and iii. Spinal braces can be used for numer- 12-month follow-ups. Similar results ous conditions including fractures and occurred for pain coping, but group scoliois or as an intervention after lum- differences were nonsignificant at 2–3 bar fusion to reduce flexion/extension, years follow-up. which is thought to interfere with the Recommendation: High-intensity exercise fusion process (Agabegi, Ferhan, As- programs appear to provide a faster decrease ghar, & Herkowitz, 2010). in pain and disability than low-intensity pro- iv. A systematic review found no evidence grams for patients receiving lumbar micro- that bracing had an effect on traumat- diskectomy (Level 2). ic thoracolumbar fractures (Giele et al., 2009).

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 33 v. A recent meta-analysis found low- j. Gentle massage may be used away from the quality evidence showing that a brace incision. curbed adolescent scoliosis curve pro- k. Make sure patients frequently change gression at the end of growth better positions. than observation and electrical stimula- 5. Nutrition tion, and low-quality evidence showing a. As with other types of surgery, oral feedings that a rigid brace is more effective than should be given with or without supplements an elastic one (Negrini et al., 2010). as soon as patients are stable and able to tol- vi. In patients with lumbar stenosis, braces erate oral intake. may be used to decrease lumbar lor- b. Glucose control has been shown to decrease dosis. Although prolonged use theo- postsurgical complications such as wound retically can cause muscle atrophy and infections and pneumonia. Perioperative weakness, this has not been substanti- intensive glucuse control is recommended ated with evidence. The efficacy of lum- (Halpin et al., 2010). bar braces for treating acute and chron- Recommendation: Enteral or parenteral nu- ic lumbar stenosis is unknown (Siebert trition may lead to more rapid normalization et al., 2009). of nutritional parameters in patients under- 4. Pain control going staged or complex spinal procedures a. Medication to control pain varies widely (Level 2). with the type of surgery performed. i. A prospective randomized trial was b. For patients undergoing complicated fusion conducted to evaluate the effects of to- surgeries with instrumentation, PCA systems tal parenteral nutrition (TPN) among with morphine or dilaudid frequently are 46 patients undergoing same-day or used during the early postoperative days; pa- staged fusion of 10 or more levels (Lapp tients undergoing less invasive surgeries may et al., 2001). The results indicated that start with oral pain medications directly after TPN administration was safe and pa- surgery. tients randomized to receive TPN c. In all cases patients should be weaned from showed a trend toward more rapid nor- intravenous pain medications as soon as is malization of nutritional parameters. feasible. Patients should be educated about However, there was no statistically sig- the complications of opioid pain medications, nificant reduction in complications, including long-term dependence, constipa- which was consistent with past studies tion, dizziness, and respiratory depression. (Hu, Fontaine, Kelly, & Bradford, 1998). d. Morphine, hydrocodone (Vicodin®), or oxy- ii. Although not specific to spinal surgery, codone (Roxicodone®), with or without ac- Story and Chamberlain’s (2009) litera- etaminophen (Tylenol®), may be prescribed ture review found that early enteral as needed when patients are able to take oral feeding decreased the duration of post- medications. operative ileus and length of stay. They e. NSAIDs taken as needed can be beneficial to noted that because early feeding does manage postoperative pain (Cassinelli, Dean, not increase the occurrence of associ- Garcia, Furey, & Bohlman, 2008). However, ated complications, it may be used as a NSAIDS should be avoided during the first strategy to prevent postoperative ileus. several months after spinal fusion because 6. Constipation prevention they are thought to possibly decrease the rate a. Consider initiating techniques of fusion (Dahners & Mullis, 2004; Li et al., preoperatively. 2011). b. Ensure adequate water intake. f. Neuropathic pain medications (e.g., gaba- c. Diet should include adequate fresh fruits, pentin) may be beneficial. vegetables, and fiber. g. Antispasmodics may be prescribed if muscle d. Stool softeners such as docusate should be spasms are present. administered two to three times per day in h. Heat may be applied to treat spasms and patients receiving opioid analgesics. Ge- muscular tension. riatric patients are particularly prone to Ice may be applied to treat radicular pain constipation. for no more than 20 minutes per hour.

34 AANN Clinical Practice Guideline Series e. Motility agents such as senna should be used f. Ensure the patient is aware of return-to- only as needed. work and activity recommendations. Return 7. Urination to work will vary depending on the type of a. A Foley catheter should be kept in place un- work (sedentary roles earlier than heavy la- til patients can stand to void or reliably use a bor). Return to work may be a gradual pro- urinal or bedpan. The goal should be to re- gression to full time. move the Foley catheter within 24 hours of g. Reinforce alternative planning and problem surgery. solving for practical everyday activities (e.g., b. Urinary hesitancy, especially immediately vacuuming, doing laundry, performing child postoperative, usually is transient. care). c. Assess urinary output, frequency, and h. Incision care varies with the type of closure. volume. i. Assess the incision to be sure it is clean d. Assess whether there is adequate empty- and dry. ing. Bladder scanning or intermittent blad- ii. Care varies widely depending on the der catheterization may be necessary to as- type of closure (staples, sutures, skin sess for retention or incomplete emptying. glue). For patients with residual bowel or bladder iii. In general, the incision needs to be functional deficits, a bowel/bladder program monitored daily for redness, drain- should be developed and patient teaching age, and signs of infection. Patients should be implemented. and caregivers need to be instructed 8. Discharge planning on incision care, evaluating for signs a. Discharge planning should be initiated and symptoms of infection, and when preoperatively. and whom to call with questions or b. Reinforce the following: no lifting, bend- problems. ing, or twisting; no sitting for long periods of i. Follow-up scoliosis X rays should be con- time. Avoid heavy lifting (anything heavier sidered at intervals of 6 weeks, 12 weeks, 6 than a gallon of milk) for the first 4–6 weeks. months, 1 year, and 2 years after deformi- Avoid prolonged sitting or standing for the ty correction. These X rays will help evalu- first 4–6 weeks, including long car trips. ate for hardware failure, proximal junctional c. Remind patients to frequently change kyphosis, pseudoarthrosis, and adjacent seg- positions. ment disease. d. Remind patients to not drive while using j. Review medications, including those for pain opioids or other medications that may cause management, and provide a plan to decrease drowsiness. the use of opioid medications during the fol- e. Explain to patients that sexual activity may lowing weeks as incisional pain subsides. resume as indicated by the surgeon; generally this is 2–6 weeks after surgery.

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40 AANN Clinical Practice Guideline Series Appendix A

Clinician, Patient, and Family Resources American Spinal Injury Association (http://asia-spinalinjury.org) Provides patient and family resources and publications and resources for clinicians.

North American Spine Society (www.spine.org) A professional society offering free patient and family information on spinal disorders and treatment options and guidelines for clinicians.

Spine Health (www.spine-health.com) Delivers free resources for patients and families on spine conditions and surgical and nonsurgical treatment options.

Spine Universe (www.spineuniverse.com) Provides information for clinicians, patients, and families. No-cost videos featuring back exercises and patient teaching resources are available.

Thoracolumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 41 42 AANN Clinical Practice Guideline Series