Dural Tears & Hardware Fracture
What is a dural tear?
Dural tears, also known as a durotomy, are tears or punctures in the dura mater, the tough outer membrane surrounding the brain and spinal cord. They are a common “complication” of spine surgery.
PS is a 71 YO male who comes in for elective lumbar surgery. He arrives to the unit status post L4-5 laminectomy and fusion for lumbar stenosis with neurogenic claudication. The nurse greets the patient and encourages them to ambulate from the PACU cart to their hospital bed. The patient refuses and states they are in 10/10 pain and there is no way they can walk due to the pain. What do you do?
A. Document the refusal (Flowsheets – Daily Cares/Safety - Mobility - Activity)
B: Document Pain Assessment
C: Treat Pain with appropriate medication based on pain scale and physician orders
D: Encourage ambulation after pain medication has taken effect and pain is more tolerable and document ambulation
What is osteoporosis?
Osteoporosis is a bone disease that occurs when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break.
The World Health Organization defines osteoporosis as a bone mineral density (BMD) that is 2.5 standard deviations (SD) or more below the mean value for young healthy adults. This is equivalent to a T-score of –2.5 or less.
What are the signs and symptoms of hypoglycemia?
Early signs include shakiness, sweating, rapid heartbeat, and anxiety. Later, more severe symptoms can include confusion, difficulty speaking, headaches, dizziness, and in severe cases, seizures or coma.
True or False: Patient Reported Outcome Measure Surveys (e.g., ODI, NDI, VAS, VR-12, EQ-5D-5L) are one component of the elective spine surgery program’s performance measures we are measuring, monitoring and analyzing?
True
What is the most common symptom of a dural tear?
Posture-related headaches are a common symptom of dural tears. Other symptoms include dizziness, nausea, and vomiting. Drain output color and consistency may change in the presence of a dural tear.
KM is a 40 YO female who comes in for elective cervical surgery for cervical myelopathy. She has been wheelchair bound since she was 15. Upon arrival to the unit, the nursing staff help transfer the patient to bed. How do you address ambulation with this patient?
Document (Flowsheets – Daily Cares/Safety - Mobility – Activity) that they are unable to ambulate since they were wheelchair bound / non-ambulatory pre-operatively
What is the most common way healthcare providers measure bone health?
Through a bone density test, also called a DXA scan.
What are the signs and symptoms of hyperglycemia?
Increased thirst (polydipsia), Frequent urination (polyuria), Fatigue and weakness, Blurred vision, Dry mouth, Weight loss
At what intervals do spine patients receive patient reported outcome measure surveys?
Preoperatively, 3-months/90-days postoperatively, 6-months/180-days postoperatively, 365-days/1 year postoperatively, and 2 years postoperatively
What is one postoperative intervention you may find ordered after a patient experiences a dural tear intraoperatively?
HOB flat orders (timeframe is usually specified within the order)
GK is a 68 YO female who comes in for an elective lumbar surgery for lumbar radiculopathy. She arrives to the nursing unit status post L4-L5, L5-S1 TLIF. She rates her pain 5/10. When she arrives, the nurse encourages her to walk from the PACU cart to the bed. She says, “But I just had surgery!”; the nurse explains the importance of post-op day zero ambulation and the patient is agreeable. She walks steadily, with minimal assistance from cart to bed. What do you do?
Document Ambulation and ambulation response (Flowsheets – Daily Cares/Safety - Mobility – Activity)
Which type of exercise is particularly beneficial for improving bone density in individuals with osteoporosis?
Weight-bearing exercises
For elective spine surgeries, we ideally want an A1C below what level?
<8
What is the Neck Disability Index (NDI)?
The Neck Disability Index (NDI) is a 10-item questionnaire sent to cervical spine patients. The NDI assesses how neck pain impacts a person's ability to perform daily activities. Unlike simple pain scales, the NDI specifically examines how neck pain affects everyday functions by looking at aspects like pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreation. Each question is scored on a scale from 0 (no disability) to 5 (extreme disability), with the total score ranging from 0 to 50; a higher score indicates greater disability.
Name at least two factors that can cause spinal hardware fractures.
Hardware fractures can be caused by a variety of factors including trauma, spine instability, slow healing after spinal fusion, poor hardware quality or placement, and overuse
Trauma: Accidents or injuries can cause fractures in the spine hardware; Spinal Instability: A spine that is inherently unstable may put more stress on the hardware, leading to fractures; Slow Healing: If the bone fusion process is delayed or incomplete, the hardware might fracture before the fusion is strong enough; Hardware Quality: While typically strong, the hardware can still break if not designed or placed correctly, or if the bone quality is poor; Overuse: Excessive stress on the spine from lifting or activities can also lead to hardware failure.
TS is a 57 YO male who comes in for an elective outpatient lumbar laminectomy. His PACU recovery is going well, and he is eager to discharge home. Physical therapy comes to evaluate the patient in phase 2. The patient is very unsteady on his feet and requires the assistance of a walker. He lives alone and has a flight of stairs to enter his apartment. Physical therapy deems him unsafe for discharge and recommends a walker for when he does discharge home. What do you do?
Contact the surgical team to discuss the physical therapist’s recommendations, barriers to discharge, and patient’s DME needs. Advocate for the patient’s safety by encouraging admission or observation until we can assure a safe discharge.
What are two major modifiable risk factors of osteoporosis?
Major modifiable risk factors include diet (inadequate nutritional absorption, low calcium and vitamin D intake, poor/excessive protein intake, excessive caffeine), exercise (lack of physical activity), cigarette smoking, and alcohol consumption.
What order would you expect to see when caring for a postoperative diabetic patient?
POCT Glucose with frequency (i.e. 4 times daily before meals and at bedtime)
What is the Oswestry Disability Index (ODI)?
The Oswestry Disability Index (ODI) is a 10-item questionnaire sent to lumbar spine patients. THE ODI assesses the impact of low back pain on a person's daily activities. ODI specifically looks at aspects like pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sexual function (optional), social life, and travel, with each area rated on a scale to determine the overall level of disability a person experiences due to their back pain; higher scores indicate greater disability. Each question is scored on a scale from 0 (no disability) to 5 (severe disability), and the total score is calculated as a percentage. Scores are interpreted as follows: 0-20%: Minimal disability; 20-40%: Moderate disability; 40-60%: Severe disability; 60-80%: Crippled; 80-100%: Bedbound or extreme functional impairment.
What are symptoms of and treatment options for spine hardware fractures?
Symptoms may include increased pain, limited mobility, or new neurological issues (new or increased weakness, numbness or tingling). Treatment options range from conservative measures like pain medication, physical therapy and bracing to revision surgery to remove or replace the broken hardware.
BG is a 33 YO female who comes in for elective outpatient L5-S1 microdiscectomy for Lumbar radiculopathy. He was intended to be the first case; however, a poly-trauma required emergent surgery, so his case was bumped. There were no surgical complications. The patient says he “feels fantastic” and states that his calf pain is already improved, he rates his pain 4/10. He has a physical therapy evaluation ordered but it is 6:30PM and there are no physical therapists available to evaluate him. What do you do?
Determine the patient’s post-operative mobility and safety awareness by ambulating the patient. Complete a discharge note that includes equipment needs, mobility status, distance ambulated, and patient’s response to activity and barriers.
Why are prunes beneficial to bone health?
Prunes improve absorption of calcium. They act as an antioxidant at the cellular level. Prunes support healthy bones by providing microminerals and vitamins such as potassium, boron, magnesium, manganese, copper and vitamin K. Vitamin K and manganese contribute to the maintenance of normal bone.
Eating prunes every day is an easy way to be preventative, protective and proactive when it comes to bone health.
When a patient’s diabetes is uncontrolled, they are at increased risk for what?
Poor/delayed wound healing, surgical site infection
Who fills out the Veterans Rand 12 (VR-12)?
All surgical spine patients; It is not just for veterans. The Veterans RAND 12 (VR-12) is a 12-item questionnaire. The survey assesses a patient's overall health by looking at eight key domains: general health perceptions, physical functioning, role limitations due to physical problems, bodily pain, energy/fatigue, social functioning, mental health, and role limitations due to emotional problems, summarizing the information into two scores: a Physical Component Score (PCS) and a Mental Component Score (MCS) to evaluate both physical and mental aspects of disability.