A spinal fusion is performed if an unstable bony mechanism is present (Brown & Edwards 2005). This may be caused by lumbar spondylosis, spondylolisthesis, spondylolysis, and degenerative disc disease. A solid bony fusion must be achieved to provide permanent spinal stability. The use of instrumentation (as you can see via the video link below) provides only temporary internal fixation. Nursing staff must reinforce and explain to the patient the importance of allowing bony healing. The patient should be made aware that if this bony healing does not occur that it may lead to the failure of supporting instrumentation and persistence and worsening of symptoms (Strayer 2006).
BONE REMODELLING
nursing staff should understand and be able to educate patients regarding basic principles bone remodelling. The three stages of bone remodelling include:
Early inflammatory stage (weeks 1-2)
Repair stage (weeks 2-6)
Late remodelling stage (months to years)
BONE GRAFT MATERIALS
BONE REMODELLING
nursing staff should understand and be able to educate patients regarding basic principles bone remodelling. The three stages of bone remodelling include:
Early inflammatory stage (weeks 1-2)
- Microhaematoma forms in the bone
- The are of the graft experiences inflammatory changes
- Granulation is promoted by this inflammation
- Bone healing and fusion formation may be inhibited at this stage with the use of anti-inflammatory drugs
- Vascular ingrowth progression leads to a collagen matrix being laid down and a soft callus forms
Repair stage (weeks 2-6)
- Vascular and capillary supply develops in the new bone.
- Collagen and callus bone form (the bone formed at this time remains weak for 4-6 weeks)
- The use of nicotene during this time may result in failure of bone to heal. This is because it can inhibit capillary growth.
Late remodelling stage (months to years)
- The restoration of the original bone shape and structure occurs
BONE GRAFT MATERIALS
- Autograft - from recipients own body
- Allograft - from cadaver
- Demineralised bone matrices - bone that has been decalcified under acidic conditions
- Recombinant human bone morphogenic protein - derived from bone matrix
- Synthetic osteoconductive materials
Spinal Fusion
In spinal fusion, the spine is stabilised by creating a fusion (ankylosis) of vertebrae with a bone graft. Metal fixation devices including rods, plates or screws can be implanted during surgery to provide further support and stability to decrease vertebral movement (Brown & Edwards 2005).
PLEASE FOLLOW THE LINK BELOW TO SEE A LUMBAR DECROMPRESSION AND FUSION
http://www.youtube.com/watch?v=RukqSLdbczE&feature=relatedweeblylink_new_window
Fusion Techniques
Posterolateral lumbar fusion with or without instrumentation
Posterior lumbar interbody fusion (PLIF)
Transformaminal lumbar interbody fusion (TLIF)
Minimally invasive fusion techniques
- Incision is made over the lumbar spine with fusion of two or more lumbar verterbrae
- The procedure involves decortication of the transverse processes, pars interarticularis and facet joints
- Autograft bone (from iliac crest or decrompression site) is placed over decorticated surfaces
- If instrumentation is used, autograft bone is placed after the instrumentation is in place
- The largest screw the pedicle is able to hold is used for pedicle screw fixation
Posterior lumbar interbody fusion (PLIF)
- In gaining access to the disc space, posterior elements are removed
- An interbody spacer (eg cages or allograft bone dowel) is placed into the disc space with disc distractors once the disc space is cleared
- The distractors are then removed
- The spacer remains in the disc space
- Pedicle screw fixation then strengthens the fusion
- Adequate spine stabilisation is secured by instrumentation by adding internal support and correct spine alignment while the vertebral bones fuse (approx. 6 months).
Transformaminal lumbar interbody fusion (TLIF)
- A facetectomy and laminectomy are performed
- Spacer packed with autograft bone are placed into the disc space
- Pedicle screw and rod instrumentation are used.
Minimally invasive fusion techniques
- Uses microsurgical and endoscopic techniques
- Interbody distractor device is placed into the disc space, this restores intervertebral height
- An appropriate sized graft is then placed
- Pedicle screw and rod instrumentation can be placed through the same incision by passing over a guiding k- wire
- It can then be inserted into the pedicle
- Each ipsilateral pair of pedicles has a rod inserter passed through the screw heads.
Postoperative nursing care of the spinal fusion patient
Care of the spinal fusion patient is slightly more complicated to that of the laminectomy and discectomy. Differences may be that the nurse must have increased knowledge regarding bone remodelling. The nurse should also be comfortable with helping the patient with a brace if required to wear one. Observations, pain control and wound and drain care are also essential, as with other lumbar surgery.
BASIC OVERVIEW OF CARE
OBSERVATION
A baseline set of observations should be performed on the patients arrival to the ward and throughout their stay in hospital as per protocol. This will help to assess for any complications post operatively. These observations include:
Neurovascular assessment:
This involves checking the patients limbs for movement and sensation and is performed in a distal and proximal manner below the level of spinal involvement (Harvey 2005). It is important to perform neurovascular observations and to know the patients preoperative deficits so that a baseline can be established and subtle changes can be noted quickly (Harvey 2005). Changes in neurovascular observations may indicate complications including development of spinal cord edema or inflammation of the tissues secondary to damage to motor nerve roots from surgical manipulation. Tissue hemorrhage, compressing the spinal cord may also lead to changes in movement and sensation of the limbs (Doenges et al 2006:262).
Vital observations:
Vital signs need to be monitored frequently to watch for signs of hypovolaemia, including decreased blood pressure and increased pulse rate. Abnormal vital signs such as increased temperature may indicate infection (Harvey 2005).
Pain observation:
Nursing staff can assess patients’ pain by using a verbal numerical scale, zero being no pain and ten being the worst pain imaginable. Increased pain may affect the patients recovery, eg. the patient may be in too much pain to mobilise (Brown et al 2005). The patient may arrive to the ward with patient controlled analgesia (PCA). PCA observations need to be attended as per protocol.
Surgical wound observation:
Nursing staff must also visually check and palpate the surgical site. Change in contour of the surgical site suggests hematoma, or edema formation. Inspection may also reveal bleeding, because vascular injury is a complication of disk surgery; or dura leak of cerebrospinal fluid (CSF) (Doenges et al 2006:262). Redness, heat or abnormal discharge from the surgical site may indicate infection and must be monitored daily (Strayer 2006). The patient should be informed to take measures to reduce strain on the surgical area. This may help to prevent bleeding and haematoma formation in the surgical area. The nurse may need to administer corticosteroids to reduce inflammation of the surgical area in some circumstances, as per the doctor (Ulrich & Canale 2005). The donor site for the bone graft must be assessed regularly if the bone was taken from the patient (Brown & Edwards 2005).
PAIN MANAGEMENT
Acute unrelieved pain may lead to stress, anxiety and fear, impacting on the patients recovery. Immobility related to pain may lead to poor venous return and deep vein thrombosis and the possibility of pulmonary embolism and hypoxaemia. Pain relief is very important for postoperative fusion patient, as with other post operative patients. The nurse must implement effective pain control methods including regular pain assessment and pharmacological management as well as the use of non-pharmacological measures. Nursing staff need to make sure the patient has adequate pain relief charted by the doctor. Nursing staff also need to encourage patients to take pain relief regularly to prevent pain from becoming too severe. Remember that bone healing and fusion formation may be inhibited during the first two weeks with the use of anti-inflammatory drugs. Inform the patient of side effects of medications (Brown & Edwards 2005).
Patients who undergo lumbar fusion might have patient controlled analgesia (PCA) on return to the ward. PCA allows the patient to titrate their own analgesic requirements thus reducing unwanted side effects including sedation, nausea, vomiting and hallucinations (King & Walsh 2007). Additionally, in lumbar fusion there are a few non-pharmalogical methods of pain relief the nurse can teach the patient including positioning techniques. The patient should maintain a position that allows the flattening of the lumbosacral spine. This may include slight knee flexion when supine, knees flexed while lying on the side and feet elevated on a foot stool when sitting in a chair. This leads to decreased stretching of the nerves and muscles in the lower back. The patient should avoid sitting or standing for longer than 30 minutes at a time. Patients must be advised not to strain to have a bowel motion and avoid coughing (Ulrich & Canale 2005).
IDC AND CONSTIPATION
The postoperative fusion surgery patient is at risk for constipation due to swelling and pain around the surgical area; decreased physical activity; lack of privacy; and due to the use of narcotic analgesia. Nursing staff need to administer aperients and educate the patient regarding becoming constipated postoperatively (Doenges et al 2006). The patient should have an indwelling catheter (IDC) postoperatively. This should be removed preferably within 24 hours, or when the patient is able to mobilise and comfortably stand to void or mobilise to the toilet (Strayer 2006). The nurse must complete normal IDC care, including encouraging adequate personal hygiene, emptying and measuring urine output, and removal of the IDC as per the doctor.
DRAIN CARE
The wound site must be monitored regularly, see 'surgical wound observation' for further details. As well as this, in fusion surgery, often a drain is inserted. Drains are used to prevent the formation of a haematoma or to remove an accumulation of fluid (Walker 2007). If the surgeon has requested for the drain be on suction, the nurse must make sure that it remains on suction, and that the wound drain remains patent. This reduces the accumulation of blood in the surgical area, thus preventing pressure on blood vessels and nerves. The drain is a site of infection, the site should be monitored as well as patient temperature (Ulrich & Canale 2005). The nurse is also responsible for removal of the drain in most cases. Please see hospital protocol for removal of drains if unsure how to remove. The following website includes a journal article that you may find helpful regarding the safe removal of drains: http://www.snjourney.com/ClinicalInfo/Proced/SurgicalDrainRemove.pdf. The journal article is: "Walker J (2007) Patient preparation for safe removal of surgical drains. Nursing Standard. 21, 49, 39-41."
MOBILITY
The patient will be able to mobilise as per postoperative orders by the surgical team. This is usually the day or second day following surgery and should be within the first 24 hours post operatively; however, if a complication such as CSF leak has occurred the patient may have to remain on bed rest, lying flat, for a period of time depending on the surgeon's preference. The patient may be required to wear a brace. This decision to use a brace and which type of brace is dependent on the surgery, bone quality and preference of the surgeon. The nurse may have to educate the patient regarding when to wear the brace, how to put it on correctly and how to prevent pressure sores (wear a shirt underneath the brace to prevent rubbing and pressure) (Strayer 2006).
The patient may also benefit from a walker if he/she is deconditioned or has difficulty mobilising. The patient may benefit from physiotherapy on the ward. Nursng staff, allied health and the surgical team should monitor and assess the patient for the need for rehabilitation, either as an inpatient or outpatient (Strayer 2006). The patient should be taught mobilisation techniques eg; when moving out of the bed the patient should be instructed to roll on his/her side and slowly bring the legs over the side of the bed while simultaneously rising up from the torso. This technique minimizes twisting at the waist; minimising pain and stress on the lumbar. Additionally, when standing the patient must use their legs to rise and not push off with the back (Strayer 2006).
DISCHARGE PLANNING
The nurse will need to reinforce to the patient a few strategies for caring for their back and themselves post discharge, these may include:
BASIC OVERVIEW OF CARE
- Observations: neurovascular, vitals, pain and PCA, wound observations.
- Pain management: Administer regular analgesic medication. Encourage the use of PCA and nurse administered analgesia.
- Monitor IDC: including output and signs of infection. Remove as soon as possible, when appropriate.
- Monitor bowels: administer eperients as needed
- Drain care: monitor for signs of infection. Monitor output. Make sure drain is on suction if requested. Remove when written order by doctor.
- Mobility: Assist the patient when ambulating if necessary, encourage to mobilise within 24 hours post operatively, as per post operative instructions.
- Discharge: Make sure patient is aware of strategies to care for their back. Encourage patient not to smoke (the use of nicotene may prevent bone healing).
OBSERVATION
A baseline set of observations should be performed on the patients arrival to the ward and throughout their stay in hospital as per protocol. This will help to assess for any complications post operatively. These observations include:
Neurovascular assessment:
This involves checking the patients limbs for movement and sensation and is performed in a distal and proximal manner below the level of spinal involvement (Harvey 2005). It is important to perform neurovascular observations and to know the patients preoperative deficits so that a baseline can be established and subtle changes can be noted quickly (Harvey 2005). Changes in neurovascular observations may indicate complications including development of spinal cord edema or inflammation of the tissues secondary to damage to motor nerve roots from surgical manipulation. Tissue hemorrhage, compressing the spinal cord may also lead to changes in movement and sensation of the limbs (Doenges et al 2006:262).
Vital observations:
Vital signs need to be monitored frequently to watch for signs of hypovolaemia, including decreased blood pressure and increased pulse rate. Abnormal vital signs such as increased temperature may indicate infection (Harvey 2005).
Pain observation:
Nursing staff can assess patients’ pain by using a verbal numerical scale, zero being no pain and ten being the worst pain imaginable. Increased pain may affect the patients recovery, eg. the patient may be in too much pain to mobilise (Brown et al 2005). The patient may arrive to the ward with patient controlled analgesia (PCA). PCA observations need to be attended as per protocol.
Surgical wound observation:
Nursing staff must also visually check and palpate the surgical site. Change in contour of the surgical site suggests hematoma, or edema formation. Inspection may also reveal bleeding, because vascular injury is a complication of disk surgery; or dura leak of cerebrospinal fluid (CSF) (Doenges et al 2006:262). Redness, heat or abnormal discharge from the surgical site may indicate infection and must be monitored daily (Strayer 2006). The patient should be informed to take measures to reduce strain on the surgical area. This may help to prevent bleeding and haematoma formation in the surgical area. The nurse may need to administer corticosteroids to reduce inflammation of the surgical area in some circumstances, as per the doctor (Ulrich & Canale 2005). The donor site for the bone graft must be assessed regularly if the bone was taken from the patient (Brown & Edwards 2005).
PAIN MANAGEMENT
Acute unrelieved pain may lead to stress, anxiety and fear, impacting on the patients recovery. Immobility related to pain may lead to poor venous return and deep vein thrombosis and the possibility of pulmonary embolism and hypoxaemia. Pain relief is very important for postoperative fusion patient, as with other post operative patients. The nurse must implement effective pain control methods including regular pain assessment and pharmacological management as well as the use of non-pharmacological measures. Nursing staff need to make sure the patient has adequate pain relief charted by the doctor. Nursing staff also need to encourage patients to take pain relief regularly to prevent pain from becoming too severe. Remember that bone healing and fusion formation may be inhibited during the first two weeks with the use of anti-inflammatory drugs. Inform the patient of side effects of medications (Brown & Edwards 2005).
Patients who undergo lumbar fusion might have patient controlled analgesia (PCA) on return to the ward. PCA allows the patient to titrate their own analgesic requirements thus reducing unwanted side effects including sedation, nausea, vomiting and hallucinations (King & Walsh 2007). Additionally, in lumbar fusion there are a few non-pharmalogical methods of pain relief the nurse can teach the patient including positioning techniques. The patient should maintain a position that allows the flattening of the lumbosacral spine. This may include slight knee flexion when supine, knees flexed while lying on the side and feet elevated on a foot stool when sitting in a chair. This leads to decreased stretching of the nerves and muscles in the lower back. The patient should avoid sitting or standing for longer than 30 minutes at a time. Patients must be advised not to strain to have a bowel motion and avoid coughing (Ulrich & Canale 2005).
IDC AND CONSTIPATION
The postoperative fusion surgery patient is at risk for constipation due to swelling and pain around the surgical area; decreased physical activity; lack of privacy; and due to the use of narcotic analgesia. Nursing staff need to administer aperients and educate the patient regarding becoming constipated postoperatively (Doenges et al 2006). The patient should have an indwelling catheter (IDC) postoperatively. This should be removed preferably within 24 hours, or when the patient is able to mobilise and comfortably stand to void or mobilise to the toilet (Strayer 2006). The nurse must complete normal IDC care, including encouraging adequate personal hygiene, emptying and measuring urine output, and removal of the IDC as per the doctor.
DRAIN CARE
The wound site must be monitored regularly, see 'surgical wound observation' for further details. As well as this, in fusion surgery, often a drain is inserted. Drains are used to prevent the formation of a haematoma or to remove an accumulation of fluid (Walker 2007). If the surgeon has requested for the drain be on suction, the nurse must make sure that it remains on suction, and that the wound drain remains patent. This reduces the accumulation of blood in the surgical area, thus preventing pressure on blood vessels and nerves. The drain is a site of infection, the site should be monitored as well as patient temperature (Ulrich & Canale 2005). The nurse is also responsible for removal of the drain in most cases. Please see hospital protocol for removal of drains if unsure how to remove. The following website includes a journal article that you may find helpful regarding the safe removal of drains: http://www.snjourney.com/ClinicalInfo/Proced/SurgicalDrainRemove.pdf. The journal article is: "Walker J (2007) Patient preparation for safe removal of surgical drains. Nursing Standard. 21, 49, 39-41."
MOBILITY
The patient will be able to mobilise as per postoperative orders by the surgical team. This is usually the day or second day following surgery and should be within the first 24 hours post operatively; however, if a complication such as CSF leak has occurred the patient may have to remain on bed rest, lying flat, for a period of time depending on the surgeon's preference. The patient may be required to wear a brace. This decision to use a brace and which type of brace is dependent on the surgery, bone quality and preference of the surgeon. The nurse may have to educate the patient regarding when to wear the brace, how to put it on correctly and how to prevent pressure sores (wear a shirt underneath the brace to prevent rubbing and pressure) (Strayer 2006).
The patient may also benefit from a walker if he/she is deconditioned or has difficulty mobilising. The patient may benefit from physiotherapy on the ward. Nursng staff, allied health and the surgical team should monitor and assess the patient for the need for rehabilitation, either as an inpatient or outpatient (Strayer 2006). The patient should be taught mobilisation techniques eg; when moving out of the bed the patient should be instructed to roll on his/her side and slowly bring the legs over the side of the bed while simultaneously rising up from the torso. This technique minimizes twisting at the waist; minimising pain and stress on the lumbar. Additionally, when standing the patient must use their legs to rise and not push off with the back (Strayer 2006).
DISCHARGE PLANNING
The nurse will need to reinforce to the patient a few strategies for caring for their back and themselves post discharge, these may include:
- Gradually return to activities of daily living and lifestyle
- Reinforce no smoking
- No anti-inflammatory drugs for at least the first two weeks
- Avoid heavy lifting for 4-6 weeks postoperatively
- Reinforce no lifting, bending twisting
- No sitting for extended periods for 6 weeks postoperatively (including long car trips)
- Instruct patient to walk progressively long distances 2-3 times per day
- Patient must change positions frequently
- Remind the patient not to drive while taking analgesic medications as they may cause drowsiness
- Sexual activity may be resumed 2 weeks postoperatively
- The surgical team should inform the patient of appropriate return to work recommendations
- Nursing staff will need to work with allied health teams to ensure the patient will be able to cope on return home. The patient should be able to make alternate arrangements in regards to everyday living activities including vacumming and laundry. Services including child care and cleaning services should be made available to patients who may not have support systems available to assist postoperatively.
- Assess the patients need for rehabilitation or outpatient physiotherapy
- The patient should be discharged with adequate analgesia eg, oxycodone
- Instruct patient regarding wound care eg. redness and swelling are signs of infection and doctor should be notified, even after leaving hospital