Orthopaedic - Spine Flashcards
What are the precautions and instructions (and must not do’s) 0-14 days post ACDF (Anterior Cervical Discectomy and Fusion) Sx
Precautions and Instructions:
- Cervical Collar: Use as directed by the surgeon, typically for up to 2 weeks.
- Activity Limitations: Avoid lifting anything heavier than 1.5 liters of milk, overhead movements, strenuous activities, and prolonged sitting or standing.
- Positional Precautions: Avoid sleeping on the stomach or with arms overhead.
- Hygiene: Keep the incision dry until healing is sufficient (around 10 days) and avoid soaking the wound.
Must-Not-Do’s:
- Do not perform large cervical ROM (rotations); gentle rotations may be done only if cleared.
- Do not lift or carry heavy objects, especially overhead.
- Avoid strenuous physical activities and prolonged static positions to reduce neck strain.
- Avoid driving until cleared by a physician
Brief describe the evidence for surgery for cervical radiculopathy
Evidence for surgical intervention in cervical radiculopathy, particularly ACDF, supports surgery for cases where conservative management fails or when there are progressive neurological deficits:
Evidence Summary:
- Surgery is generally recommended for patients with symptoms that do not improve after a period of conservative treatment (usually 6-12 weeks).
- Studies suggest that ACDF can improve symptoms such as radicular pain, weakness, and sensory deficits, often with faster relief than non-surgical treatments.
- However, evidence indicates that long-term outcomes (1-2 years) of surgical and conservative treatments are similar, with surgery offering faster initial symptom relief but not necessarily better long-term function
Outline factors that may influence the length of time of the precautions
- Bone Healing Rate: Influenced by factors like age, smoking, nutrition, and comorbidities.
- Type of Surgery: More invasive procedures or multi-level fusions may require extended precautions.
- Surgeon Protocols: Different surgeons may recommend varied timelines based on their experience and patient needs.
- Patient Adherence and Pain Tolerance: Patients with higher pain tolerance or who are more active may feel tempted to exceed limits, potentially affecting healing.
- Radiographic Evidence of Healing: Typically required to confirm the progression before easing precautions
Describe the precautions and length of time of precautions following LSF
For lumbar spine fusion (LSF), precautions are implemented to ensure stabilization of the fusion site and optimal healing:
Standard Precautions (for the first 6-12 weeks):
- Avoid BLT: Bending, Lifting (over 5 kg), and Twisting.
- Limit sitting to short periods (30-60 minutes).
- Avoid high-impact activities, prolonged sitting, or standing, and refrain from driving until cleared.
Duration: These precautions generally last for at least 6 weeks, with gradual easing based on radiographic evidence and healing progress. The full fusion process can take 12-24 months, so high-stress activities may be limited during this time
Provide advice to a patient when they are struggling to do movements (this will be embedded within a case)
If a patient is struggling with movement post-surgery, reassure them that it is a common part of the recovery process. Some guidance includes:
- Breaking Down Movements: Encourage them to perform movements slowly and in segments if a full motion is too difficult.
- Gentle Mobilization and Short Sessions: Advise starting with short, manageable sessions with rest breaks to build tolerance.
- Breathing and Relaxation: Encourage diaphragmatic breathing to reduce tension, especially if they are unintentionally bracing.
- Reassurance and Goal Setting: Reinforce that gradual improvement is expected, and set small goals to keep them motivated.
- Adaptive Strategies: Offer alternatives to painful activities, like using pillows for support or adjusting body mechanics
Describe indications for further referral / testing, sometimes emergency (pseudoarthrosis / DVT / infection / cauda equina syndrome)
Certain symptoms post-surgery may indicate complications requiring urgent attention or further referral:
- Pseudoarthrosis: Persistent pain and lack of fusion visible on imaging may indicate a failure to heal, suggesting a need for additional intervention.
- DVT (Deep Vein Thrombosis): Symptoms like sudden leg swelling, pain, warmth, or redness necessitate immediate testing (e.g., D-dimer or ultrasound) due to the risk of pulmonary embolism.
- Infection: Signs of surgical site infection include increased redness, warmth, drainage, or fever, requiring urgent medical assessment.
- Cauda Equina Syndrome: Symptoms such as bowel or bladder dysfunction, saddle anesthesia, or severe bilateral leg pain need immediate emergency care due to risk of permanent nerve damage
Compare the outcomes of surgical (LSF) vs conservative management for spinal stenosis.
Surgical Outcomes: Lumbar spine fusion can provide faster relief from pain and improve function in patients with severe or progressive symptoms that limit daily life. However, surgery carries risks such as infection, re-operation, and adjacent segment disease.
Conservative Outcomes: Conservative management (e.g., physical therapy, NSAIDs, lifestyle modifications) can be effective in mild to moderate cases. Long-term studies show that outcomes for some patients can be comparable to surgery, particularly for those with less severe symptoms
Briefly outline the types of conservative management.
Conservative management options focus on symptom relief and functional improvements:
- Physical Therapy: Tailored exercises to strengthen core, improve posture, and increase flexibility around the spine.
- Medication: NSAIDs or other pain management medications for symptom relief.
- Epidural Steroid Injections: To reduce inflammation and pain.
- Activity Modification: Teaching patients how to avoid triggering positions or activities, and encouraging low-impact exercises like walking and swimming
