UBP 1.5 (Short Form): Orthopedics – Spinal Surgery

Question 1

Is it beneficial to administer steroids following spinal cord injury?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 1

I would NOT administer high dose steroids (i.e. methylprednisolone) for acute spinal cord injury, recognizing that this practice is no longer recommended due to the lack of evidence demonstrating any clinical benefit.

There is, on the other hand, substantial evidence (Class I, II, and III) indicating that high dose methylprednisolone administration is associated with a number of adverse side effects including – infection, gastrointestinal bleeding, respiratory compromise, and even death.

Other complications associated with steroid administration include – fluid retention, hypertension, electrolyte imbalances, hyperglycemia, impaired wound healing, and immunosuppression (i.e. increased rates of sepsis and pneumonia).

*Per online UBP – Steroids are not a standard of care, but there is some evidence of benefit if given within the first 8 hours of injury.*

Question 2

How would you assess this patient’s pulmonary status?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 2

I would start with a history and physical examination to determine the nature and severity of any pulmonary disease.

More specifically, I would attempt to identify signs and symptoms of COPD, such as –

• cough and sputum production, and obtain relevant history, such as
• frequency of pulmonary infections,
• frequency and severity of exacerbations,
• exercise tolerance,
• number and course of hospitalizations, and
• efficacy of past treatments.

Given the increased risk of pulmonary complications associated with neck injury, a long history of smoking, and significant hypoxia on room air, I would order –

• a CXR,
• PFTs,
• serum albumin (value < 35 g/L predicts an increased risk of postoperative pulmonary complications),
• ABGs, and/or a
• pulmonary consult to determine the type and severity of the patient’s lung disease.

Question 3

Would you order PFTs?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 3

I would order PFTs in this case (with Spo2 91% at room air).

While PFTs are not warranted in all preoperative patients with pulmonary disease, I believe they would be indicated in this patient who has a long history of smoking, is hypoxic on room air, and is about to undergo a surgical procedure associated with increased risk of postoperative pulmonary complications.

Although the history and physical would provide me with most of the needed information,

PFTs would provide additional information concerning

• the type and severity of the disease,
• baseline pulmonary function, and
• the presence of a reversible component (responsive to bronchodilators).

Also, given this patient’s hypoxemia, I would consider ordering ABGs, to identify CO2 retention and more accurately determine the severity of his pulmonary disease.

*Per online UBP, PFT’s may help determine whether you extubate or not.*

Question 4

Preoperative PFTs were ordered by the surgeon, revealing the following: FVC = 1.9 L, FEV₁ = 0.9 L, FEV₁/FVC = 47%, with mild improvement following administration of bronchodilators. What is your interpretation?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 4

Given the patient’s history of smoking, and an FEV₁/FVC less than 70%,

I would say this patient has obstructive pulmonary disease.

More specifically, an FEV₁/FVC < 50% showing mild improvement with bronchodilator therapy, suggests severe obstructive pulmonary disease with a reversible component.

**KNOW Normal PFT values**

Question 5

Is this patient’s pulmonary status optimized?

Would you cancel the case?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 5

Given his significant hypoxia, continued smoking, and lack of bronchodilator therapy, I doubt that his pulmonary status is optimized.

Therefore, if the case could be delayed, the patient would benefit from –

• smoking cessation for at least 8 weeks prior to surgery,
• preoperative chest physiotherapy,
• bronchodilators,
• glucocorticoids, and, if there were evidence of infection,
• antibiotic administration.

However, this case with evidence of spinal cord injury and worsening symptomatology should probably start without delay.

Therefore, I would proceed with the case following the administration of bronchodilators, supplemental oxygen, inhaled steroids, and antibiotics as appropriate;

recognizing that the patient’s surgical procedure and severe pulmonary disease place him at increased risk of postoperative pulmonary complications.

*Know timeline of smoking cessation effects*

Question 6

Is this patient at risk for perioperative alcohol withdrawal symptoms?

How can you evaluate that risk preoperatively?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 6

Yes, someone with daily alcohol consumption may be at risk for perioperative symptoms of alcohol withdrawal, with

• tremulousness starting at 6-8 hours;
• hallucinations and seizures starting around 24-36 hours; and
• life threatening delirium tremens – confusion, perceptual distortions, agitation, and autonomic instability (fever, tachycardia, and hypertension) – usually presenting within 72 hours (3 days) of withdrawal.

Therefore, I would obtain a thorough history of his alcohol consumption, including – the type, frequency, and quantity of alcohol consumed, and the time of last alcohol intake.

My physical exam would focus on signs and symptoms of chronic alcohol abuse, such as –

• cirrhosis,
• hepatic encephalopathy,
• Wernicke-Korsakoff syndrome,
• gait disturbances, and
• cardiomyopathy.

Next, I would obtain a –

• complete blood count,
• blood urea nitrogen,
• creatinine,
• serum electrolytes,
• glucose level,
• coagulation studies,
• liver function tests,
• an ECG, and
• a CXR, if not already ordered.

Finally, I would consider administering a benzodiazepine to prevent acute withdrawal.

Question 7

What concerns do you have in someone with chronic alcohol abuse?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 7

Chronic alcohol abuse can affect many systems in the body.

In general, it is a CNS depressant that may result in increased MAC, tolerance to other anesthetic drugs, cognitive impairment, cerebral atrophy, cerebellar degeneration, and peripheral neuropathy.

Other concerns when providing care for patients chronically abusing alcohol include –

• cardiomyopathy,
• cirrhosis,
• hypoglycemia,
• thrombocytopenia,
• electrolyte abnormalities,
• GI bleeding (varices),
• acute withdrawal symptoms,
• increased risk for aspiration
  
  • (secondary to increased gastric acid secretion with low or moderate doses of alcohol, reduced lower esophageal sphincter tone, and delayed gastric emptying), and
• nutritional deficiency.

Question 8

The patient’s morning glucose is 220 mg/dL. Would you delay the case to treat his hyperglycemia? What blood sugar would be acceptable to proceed with surgery?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 8

I would not make a decision to delay the case based solely on a glucose level of 220 mg/dL.

However, given the increased rate of infection, impaired wound healing, and osmotic diuresis associated with poor perioperative glycemic control,

I would administer regular insulin in an attempt to lower his plasma glucose to less than 150 mg/dL,

while at the same time avoiding significant hypoglycemia (some recommend a target level < 180 mg/dL).

Of course, this would require frequent measurements of plasma glucose levels until the target range were achieved, followed by hourly monitoring to maintain adequate control.

Question 9

What are the risks of poor perioperative glucose control?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 9

Poor perioperative glucose control has been associated with –

• worse neurological outcomes following traumatic brain injury, which may be of concern for this patient who was recently involved in a motor vehicle accident with subsequent whiplash injury.

Additionally, poor perioperative glycemic control is associated with –

• impaired wound healing,
• increased rate of infection, and
• osmotic diuresis.

Question 10

What lab work would you order for a diabetic patient?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 10

That would depend on the surgical case and the severity of disease as determined by the history and physical.

In general, I would order lab work that would identify end organ disease associated with poorly controlled diabetes such as a – complete blood count, blood urean nitrogen, creatinine, potassium, serum glucose level, and urinalysis.

Also, due to the potential for early atherosclerosis and silent ischemia in patients with diabetes mellitus, I would require a recent ECG.

*Xtra Q – Would you get an ECG for this patient if they were undergoing hand surgery?*

Question 11

If you were seeing this patient in pre-op clinic prior to surgery, how would you optimize him medically?

(A 53-year-old, 61 kg man presents for posterior cervical laminectomy with instrumentation. Three weeks prior he was involved in a motor vehicle accident (MVA) and sustained a whiplash injury. He reports gait problems and increasing neck pain radiating to both arms. MRI shows severe spinal stenosis and spinal cord contusion at C4 and C5 levels. His past medical history is significant for type II diabetes, HTN, tobacco use consisting of 2 packs per day x 25 years, and daily alcohol consumption. Vital Signs: P = 104, BP = 132/60 mmHg, RR = 20, T = 37.1 °C, SpO2 = 91% on room air)

Answer 11

Ideally, I would consult a pulmonologist for diagnosis and optimization of his pulmonary disease, as the patient may benefit from a course of steroids, bronchodilator therapy, and, possibly, antibiotics.

I would also recommend smoking cessation for at least 8 weeks prior to surgery to allow for optimal reductions in carboxyhemoglobin

(reduced levels improve oxygen availability by shifting the oxyhemoglobin dissociation curve to the right);

improved ciliary function; and

reduced nicotine levels, airway hyperreactivity, sputum production, and perioperative pulmonary complications.

GIven the patient’s abuse of alcohol, I would recommend discontinued use and detoxification prior to surgery.

Optimally, all metabolic abnormalities and nutritional deficiencies secondary to chronic alcohol abuse should be corrected.

FInally, I would examine him for signs of diabetic autonomic neuropathy, evaluate his glycemic control, and recommend he see an endocrinologist if this control were inadequate.