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Patients with this type of surgery have experienced significant long-term pain before surgery and may be apprehensive about perioperative pain, or they may expect to be completely free of discomfort after surgery. They should know that there probably will be some discomfort and that analgesic medications will be given promptly when requested.
Immediately after surgery the vital signs are noted and recorded and level of consciousness assessed. Peripheral pulses are palpated, and color, range of motion, temperature, and sensation in the feet and toes are checked. Dressings are checked for unusual drainage. Evidence of spinal fluid leakage on the dressing is immediately reported. Patients who have had a spinal fusion will have two dressings, one at the spinal column where the affected disk is located and one at the iliac crest where bone was removed for the graft.
The patient is assessed frequently and regularly for pain. In general, patients with laminectomies have less pain after than before surgery because pressure on the nerve root has been relieved. In contrast, those who have had spinal fusion often experience more postoperative pain at both operative sites. In keeping with the preoperative promise of prompt response to a request for relief, analgesics are given as needed. Transcutaneous electrical nerve stimulation (TENS) may be prescribed to provide relief and facilitate ambulation and recovery.
Positioning after surgery will depend on the preference of the surgeon. In general, the patient's head is not raised beyond a 45-degree angle. This avoids placing a strain on the lumbar region. Log-rolling spinal fusion patients while they are in bed prevents twisting of the spine and nonsetting or failure of the fusion. When these patients are allowed up they are instructed to avoid sudden movements and twisting of the spine. They also must wear lumbar orthoses to stabilize the spine when walking. They should be watched for orthostatic hypotension, which can occur if sympathetic nerves were traumatized during surgery.
Physical therapy and exercises to strengthen abdominal, back, and leg muscles are begun as soon as permitted by the surgeon. These usually are carried out under the direction of a physical therapist. Several months of rehabilitation and recuperation are usually needed to completely rehabilitate the spinal fusion patient. Patients who have had a diskectomy or laminectomy typically return to sedentary work in one month. If lifting or manual labor are necessary on the job, the patient should be able to resume work in three to six months.
laminectomy/lam·i·nec·to·my/ (lam″ĭ-nek´tah-me) excision of the posterior arch of a vertebra.
laminectomyOrthopedics A procedure for managing intervertebral disk herniation; the 'classic' laminectomy entails bilateral removal of the lamina of a vertebral body adjacent to a diseased disk as well as varying portions of both articular facets. See Cervical laminectomy, Diskectomy, Hemilaminectomy, Laminotomy.
laminectomy(lăm″ĭ-nĕk′tō-mē) [″ + Gr. ektome, excision]
It is recommended only after conservative treatment (physical therapy, anti-inflammatory medication) has been exhausted. Minimally invasive spine surgery can be used to treat conditions such as herniated or ruptured lumbar discs, bone spurs, synovial cysts, and lumbar spinal stenosis. Patients with a history of open spine surgery may be poor candidates for minimal procedures because of scar tissue.; illustration
Preoperative: The patient's knowledge of the procedure is determined, misconceptions are corrected, additional information is provided as necessary, and a signed informed consent form is obtained. A baseline assessment of the patient's neurological function and of lower extremity circulation is documented. Health care providers discuss postoperative care concerns, demonstrate maneuvers such as log-rolling, assure the patient of the availability of pain medications on request, and prepare the patient for surgery according to the surgeon's or institutional protocol.
Postoperative: Vital signs and neurovascular status (motor, sensory, and circulatory) are monitored; antiembolism stockings or pneumatic dressings are applied, and anticoagulants are given if prescribed. The dressing is inspected for bleeding or cerebrospinal fluid leakage; either problem is documented and reported immediately, and the incision is redressed as necessary. The patient is maintained in a supine position, with the head flat or no higher than 45° according to the surgeon's preference, for the prescribed time (usually 1 to 2 hr), then repositioned side to side every 2 hr by log-rolling the patient with a pillow between the legs to prevent twisting and hip adduction and to maintain spinal alignment. Deep breathing (with use of an inspirometer in most cases) is encouraged, and assistance is provided with range-of-motion, gluteal muscle setting, and quadriceps setting exercises. Adequate assistance should be available when the patient is permitted to dangle his or her feet, stand, and walk in the early postoperative period. Prescribed anti-inflammatory, muscle-relaxant, and antibiotic agents are administered. Noninvasive measures to prevent and relieve incisional discomfort are provided in addition to prescribed analgesics. Fluid balance is monitored by administering prescribed intravenous fluids and by assessing urine output. The patient is encouraged to void within 8 to 12 hr postsurgery and is assessed for bladder distention, which may indicate urinary retention. Catheterization is used only after other measures to promote voiding have been attempted. The abdomen is auscultated for return of bowel sounds, and adequate oral nutrition is provided as prescribed. Patients who have undergone minimally invasive procedures are out of bed and resuming some normal activities (e.g., showering, engaging in activities around the house) within a day or two of surgery. Responses vary and may depend on the patient's personality, presurgical activity level, and overall health. Specific restrictions on postoperative activity should be outlined with the patient in detail at the time of discharge.
Rehabilitative and home care: Incisional care techniques are taught to the patient and family, and the importance is stressed of checking for signs of infection (increased local pain and tenderness, redness, swelling, and changes in the amount or character of any drainage) and of reporting these to the surgeon. A gradual increase in the patient's activity level is encouraged. Any prescribed exercises (pelvic tilts, leg raising, toe pointing) are reviewed, and prescribed activity restrictions are reinforced. Restrictions usually include sitting for prolonged periods, lifting heavy or moderately heavy objects, or bending over. Proper body mechanics are taught to lessen strain and pressure on the spine: these include maintaining proper body alignment and good posture and sleeping on a firm mattress. Involvement in an exercise program, beginning with gradual strengthening of abdominal muscles, is encouraged after 6 weeks. Walking is encouraged. The patient should schedule and keep a follow-up appointment with the surgeon and communicate any concerns to the surgeon (if necessary) before that visit.