- The reasons (indications) for Anterior Posterior Fusion (APF): Fusion is indicated as a last resort, to address instability, spondylolisthesis, or as a salvage procedure for painful degenerative disc conditions. Patients must have had at least 6 months of severe unresponsive pain. Most have had several years of severe back and leg pain, unresponsive to PT, medications, injections, etc. I ask them to think about all options and alternatives for at least several months before deciding to proceed with fusion. The APF involves safely restoring the lost vertebral height, anteriorly. Posteriorly we have to retract the nerves / thecal sac and there is a significantly higher risk of nerve stretch or damage. Anteriorly higher risk of vascular damage, but little to no risk of nerve damage. 2-Stage surgery reduces the total down-time in anesthesia, vs. 1-stage which may become a very long case and not safe for the patient. Most patients tolerate 2 consecutive days. Older patients may need a couple of days in between. Each approach may vary between 2 hours 5 hours, depending on how easy the anatomy is, if any vascular repairs needed. The problem with the traditional posterior alone fusions: The disc annulus is innervated and remains a major potential pain source. In APF we resect most of the annulus . Better chances of fusion (and less chances of pseudarthrosis: a major cause of continued pain after fusion). Most of the work is done anteriorly. Posteriorly I utilize 2 paraspinal incisions, split the muscles (vs. traditional midline incision where the muscles are completely detached and stripped off midline - never heal completely). 2 paraspinal incisions heal much better, compared to midline. Less pain, faster recovery.
- Preop Nurse: Nurse to verify: 1 week off aspirin or any blood thinners, NSAIDs, herbal supplements (Turmeric, Co QA). Light dinner the night before like a soup. NPO after 10PM night before. Take BP meds or inhalers at 5 AM with a sip of water only. Make sure consents for BOTH stages are signed and witnessed (hospital consent and my consent.) Nurses only witness the signature, they're not legally responsible for the content. I've explained the contents in the clinic for at least a couple of hours. Vancomycin 1 gm, Ancef 2 Gm IV preop. Vanco to run over 1-2 hours, super slow (red man syndrome). Place SCDs on both legs (no compression stockings), and start the pump before going to the OR.
- Intraop Nurse, Stage 1, Anterior ALIF: Before going to the room please verify the vascular surgeon is here, the implants, bone graft, neuromonitoring are all present. If any questions or any of these components not present Do Not take the patient to the room! Check with blood bank if any Type and Cross matched units available and how many units available. Place SCDs on both legs. (no compression stockings), and start the pump BEFORE induction. (induction is the critical event when vascular resistance changes and DVT may start). 2 pillows under the knees (to bend the knees, and relax the anterior vessels). Anterior incision is either horizontal (1 level, or vertical, 2-3 levels). Always instrumented: a titanium prosthesis with screws are used. Typically 1 screw is placed going up, and 1 going down, attaching the implant to both the superior and inferior vertebrae. The Vascular surgeon will utilize a retroperitoneal approach, and we move the intestines, and vessels to the right. The left sympathetic chain may get stretched, causing a temporary sympathectomy, resulting in warming of the left leg and foot. Note the time if Duramorph is given intrathecally by me, document time and dose. Note the EBL, Cell-saver volume given back.
- Post-op Nurse in PACU, after Stage 1 ALIF: Check bilateral feet, vascular status: for example, usually feet are warm, with palpable pulses. If one leg is colder: is there a pulse? If yes, then the other leg is warmer due to temporary sympathectomy neuropraxia. Document and let me know, it's not a problem! If no pulse AND cold, call me and the Vascular surgeon immediately. If any O2 desaturation, get the Narcan to bedside. Check for mental status. If drowsy AND de-sating AND not arousable to take deep breaths, administer Narcan and call me. IF Narcan is given, keep in mind that Narcan has a very short half-life and Duramorph has a long half-life, and either repeat Narcan or a Narcan infusion is usually needed, and patient likely would need an ICU admission. Neurochecks. Report to the accepting nurse what time and the dose of intrathecal Duramorph that was given, to monitor O2 sats continuously x 24 hours. Remember: Duramorph dose is usually 150-200 microgram intrathecal. Duramorph has a Biphasic pattern for respiratory depression: 1-3 hours for phase 1, and 6-12 hours for phase 2. The first 24 hours needs continuous O2 sat monitoring after any intrathecal Duramorph. Limit other postop opioids or sedatives, or muscle relaxants.
- Postop Nurse, Floor or ICU, after Stage 1 ALIF: Keep patient NPO after Stage 1, until bowel sounds start, which usually occurs in the afternoon of Stage 2. Check neurovascular status: Upon accepting the patient confirm and document that feet are warm, pulses are intact. If any concerns or questions call me right away in the beginning of your phase care. NV checks q 4 hours. SCDs pump on at all times (no exceptions!). No compression stockings needed. IV fluids 120cc / hr. Check for pain levels. If needed, give smallest dose of opioids IV (if Duramorph intrathecally has been given), but be careful, and please monitor O2 sats for 1 hour after each dose. Do not give benzo's (Ativan, lorazepam) at the same time as opioids. Check the abdomen: is it soft, nontender, nondistended. Any bowel sounds (present, not present, hypoactive present). No NG tubes needed. Keep the abdominal binder on in bed. However, if uncomfortable, may open the abdominal binder. May sit up to 80 degrees in bed, for 30 - 60 min, then recline down in bed. Log roll every 2 hours. Place 2 pillows under the knees in supine, and between the legs in lateral. Encourage using the incentive spirometer, may place a pillow over the abdomen during incentive spirometer use. Ice packs to abdomen as needed.
- Intraop Nurse, Stage 2, Posterior PLF: Before going to the room please verify the implants, neuromonitoring, and double C-arm are all present. If any questions or any of these components not present Do Not take the patient to the room! Place SCDs on both legs. (no compression stockings), and start the pump BEFORE induction. (induction is the critical event when vascular resistance changes and DVT may start). Call for additional help for moving the patient from gurney to prone position on the Jackson Table open frame. Check eyes, face, hips, ankles, feet. 3-4 pillows under the feet, to bend the knees, and to prevent patient sliding down, when positioned in Reverse Trendelenberg 10 degrees. Check groin and ensure no compression on the groin or Foley. Ask Anesthesia if they'd like the Foley at the head or the foot of the table. Female staff check breasts. Have Duramorph in a 1 cc TB syringe with a 22 and 25 Whitaker (pencil-tip) spinal needle, I would usually use only 150 to 200 microgram (0.15 to 0.2 cc's). Note the time if Duramorph is given intrathecally by me, document time and dose. Note the EBL, Cell-saver volume given back.
- Post-op Nurse in PACU, after Stage 2 PLF: Check bilateral feet, vascular status: for example, usually feet are warm, with palpable pulses. If any O2 desaturation, get the Narcan to bedside. Check for mental status. If drowsy AND de-sating AND not arousable to take deep breaths, administer Narcan and call me. If Narcan is given, keep in mind that Narcan has a very short half-life and Duramorph has a long half-life, and either repeat Narcan or a Narcan infusion is usually needed, and patient likely would need an ICU admission. Neurochecks. Report to the accepting nurse what time and the dose of intrathecal Duramorph that was given, to monitor O2 sats continuously x 24 hours. Remember: Duramorph dose is usually 150-200 microgram intrathecal. Duramorph has a Biphasic pattern for respiratory depression: 1-3 hours for phase 1, and 6-12 hours for phase 2. The first 24 hours needs continuous O2 sat monitoring after any intrathecal Duramorph. Limit other postop opioids or sedatives, or muscle relaxants.
- Postop Nurse, Floor or ICU, after Stage 2 PLF: NPO after Stage 2, until Bowel Sounds return (may take 1-2 days). IV fluids 120cc / hr. Confirm feet warm, pulses intact. NV checks q 4 hours. SCDs pump on at all times (no exceptions!). No compression stockings needed. Check for pain levels. If needed, give the smallest dose of opioids IV (if Duramorph was given), but be careful, and monitor O2 sats. Do not give benzo (Ativan, lorazepam) at the same time as opioids. Check abdomen: soft nontender, nondistended. BS present. or No BS. or BS hypoactive. No abdominal binders needed. Start PT and OT the afternoon of Stage 2 PLF. Wear LSO brace when out of bed with PT / OT. In bed LSO may be taken off. May sit up to 90 degrees in bed, up for 30 - 60 min, then down. No LSO needed in bed. Log roll Q 2 hours (pillow under the knees in supine, between the legs in lateral. Minimize Benzos with opioids. If required, keep a very close eye on O2 sats for 1 hour after the Benzo given, and record O2 sat, RR, VS. Walker or cane for first few days or 2 weeks. If no BS by day 3 (1st day after stage 2): give an enema in the morning, and repeat in the afternoon (not intended for BM, but it stimulates to colon). Strictly NPO until BS returns. When BS return, start clear liquids, then advance as tolerated. Start PO meds. Be encouraging to the patients. BM by day 3-4, before going home. Recovery is as important as the surgery. Encourage positive outlook. Everyday gets a little better.
Medical Director, Spine Service at Sky Lakes Medical Center
2 年Thank you so much Zoe!
President at Industrial Athlete Pros
2 年Looks great Fred! Thank you for posting!