Conservative and Surgical Management of Thoracolumbar Intervertebral Disc Herniation Flashcards
Fill the blank: In cases of disc extrusion around [blank] of patients may deteriorate or relapse when conservative management is used.
1/3
Conservative treatment options? (7)
NSAIDS for 7 to 14 days
And/or Paracetamol (10 mg/kg q12hrs for 7 to 10 days)
Gabapentin (10-20 mg/kg q8h for 2 weeks then q12hrs for 2 weeks)
Cage rest 4 weeks and lead walks only for 5-10 minutes with sling support if required
Physiotherapy
Pain clinic
Weight control
A re-examination is recommended in the first week after starting a conservative management followed by rechecks. How often should rechecks be performed?
In the first week, after two weeks and at four weeks
What needs to be considered re health with spinal surgery?
Health co-morbidities
Use of steroids in spinal dx?
Contraindicated; high risk of side effects
Common complications of spinal surgery include? (6)
Venous sinus bleed,
Redistribution of disc material,
Incomplete decompression,
Relapse of intervertebral disc disease,
Approaching the wrong disc space
Intra-operative trauma.
Two important factors to ensure a satisfactory outcome in spinal cases are (2)
Regular assessment of the patient
Good communication with the client
Pre-medication?
Opioid and ACP
ABx for spinal surgery?
(e.g. amoxicillin or cephalosporins) can be initiated at induction and continued during surgery (every 2 hours).
- Not usually needed post op
In which recumbency should the patient be positioned during hemilaminectomy?
The patient is positioned in ventral recumbency with a mild tilt away from the surgeon.
Hemilaminectomy
A) what blade is used for the skin?
B) What blade is used to incise fascia adjacent to spinous process?
A) 10
B) 11
Hemilaminectomy:
A) What muscle is retracted with periosteal elevator?
B) What is exposed after inciding muscle, and using periosteal elevators and cautery?
A) paraspinal muscles
B) articular facet
Hemilamenectomy;
On the approach use gelpi retractors to exposure and expose what process?
Mammillary process
Hemilamenectomy;
What tendon is cut close to its insertion on the accessory process.?
longissimus tendon
Hemilaminectomy;
Once the surgical site is identified, remove what with rongeurs?
the articular facet
Hemilaminectoyl use a spinal burr to remove what? (3)
cranial and caudal articular facets,
mammillary process
dorsal aspect of articular facet.
Once a fine osseous window is achieved, open the window and remove the fine cortical bone with(3)
small rongeurs, a curette or Kerrison bone punch
Hemilamenectomy:
In cases of a chronic disc, material can be removed using? (2)
forceps
haemostats.
Following hemilamenectomy where to check the window for remaining disc material?
Dorsal
Cranial
Caudal
Ventral
What is performed on the disc Following hemilamenectomy?
Fenestration
Following hemilamenectomy what happens prior to closing? (2)
Flush
Check for haemorrhage
Hemilamenectomy;
A) Suture the fascia with?
B) Close subcut with?
C) Skin closure?
A) PDS
B) monocryl
C) Ethilon or staples
With a hemilamenectomy; ensure the incision is ventral enough; what landmark is used?
The accessory process as a ventral landmark
Why does the hemilamenectomy need to be ventral enough? (2)
explore the vertebral canal below the spinal cord
identify the nerve root and venous sinus.
If the disc is not properly fenestrate; what is the risk?
Relapse
What is used as a marker to confirm surgical site?
Needle for localization of the intervertebral disc space. The needle can be inserted into a spinous process and radiographs performed prior to surgery to confirm positioning.
What are the most common complications following a laminectomy? (8)
Incorrect surgical site
Venous sinus bleed
Redistribution of disc material
Incomplete decompression
Post-operative haematoma
Further intervertebral disc extrusion
Trauma during surgery
Development of post surgical seroma.
T or F:
Make your hemilaminectomy ventral enough (using the accessory process as a ventral landmark) to be able to explore the vertebral canal above the spinal cord.
False
T or F
Make your hemilaminectomy ventral enough (using the accessory process as a ventral landmark) to identify the nerve root and venous sinus.
True
T or F
The risk of relapse without fenestration is 70% vs 4% if fenestrated.
False
T of F
For localisation of the intervertebral disc space, a marker needle can be inserted in a spinous process.
True
