FAQ Medical (Nursing & OR)
In a regular MRI, the patient is lying down and there is no pressure on the disc, insert and situation. This may prevent us from visualizing the pathology.
In an upright MRI, the patient is standing up and putting load on the spine. This is a more realistic scenario to what provoked the patient’s pain. There are only few machines around that are able to perform a study like this. We are grateful to have one of them in Alexandria, easily available to our patients.
The discogram is an invasive study, but has more diagnostic value. The disc is entered with a small needle and each disc is individually pressurized. Radiographically we can see a leaking out of the contrast in bad discs. The most important part is to be able to provoke the patient’s pain by increasing the pressure inside the disc, which is called concordant pain.
If disease of the disc is proven, it will give us a justification for surgical therapy.
Subject 1: Postoperative wound care and management
After the closure of the incision I usually apply bacitracin, Telfa, and a sterile dressing with a non-occlusive breathing tape. This is the most sterile dressing and should usually stay for 2 days after the surgery. This dressing is usually removed after 2 days and the wound is kept open to air. The buildup of thick dead tissue at this time, the so-called scab, is the best sterile dressing nature has to offer. The scab should not be softened with ointment or wet. This would allow the diffusion of the bacteria into the wound. If the patient is still spending most of the time in bed, a sterile dressing should be applied to separate the wound from the bed sheets. Most of the patients who are ambulating the wound can be kept open to air. In the first 24 hours after the surgery, some oozing of blood from the incision is possible. Usually the reinforcement of the incision with pads and tapes can stop this bleeding. A grossly wet dressing is a good medium for bacterial growth. This should be changed with dry sterile dressing. If the incision is still bleeding after 2 days the physician needs to be notified for additional reinforcement of the incision with stitches or staples.
Subject 2: Bracing post surgery
Generally the brace is not needed for stability after fusion, the metal hardware we put in acts as internal bracing. In older generation, if the bone is soft or if the screws are not fitting perfectly, sometimes supplementing the internal bracing with an external one becomes necessary. This certainly will limit motion, but is exactly the brace’s function, limiting the motion. Long term use of brace can lead to muscle atrophy by immobility and be detrimental by itself.
In everyday activities, our para-spinal muscle performs hundreds of micro adjustments a second and can go into spasm if they go out of balance, especially shortly after surgery. In many cases, the short term pain after surgery is because of this muscle spasm. Often a muscle relaxant like Flexeril is used to counteract the spasm. These medications have side effects of their own, and short term use of brace can be helpful, providing pain relief and comfort to patients. Especially in rural areas when patients need to travel long distances to and from the hospital, a brace can prevent tiring of the para spinal muscles, reduce muscle spasms and help with healing in weeks following surgery.
In clinical practice if it is necessary, from the stability standpoint, we put proper order for the brace to be worn at all times. All other patients are provided with a brace to be worn for comfort for few weeks to few months after surgery, especially when driving a car or performing more stressful activities. The new braces we use can be readjusted and reused for a long time as needed for pain relief and comfort.
In non-fusion procedures like laminectomies or microdiscectomy, internal bracing is not provided, so more often external bracing may be necessary. Many variations exist, based on the patient’s anatomy and operative findings. Orders after the surgery may be like:
Subject 3: Pain management
I tell all of my patients not to expect to be pain-free right after the surgery. The surgery by itself is a painful process. Preparing the patient for postoperative pain management is crucial and I always have detailed discussion with the patient regarding this.
Many of the surgical candidates have been on pain medication for a long period of time before the surgery, pain management in these patients is most of the time a challenge. The amount of pain medication should always be adjusted to the extent of the patient’s pain, keeping in mind other safety measures. Pain medication is necessary for pain and not for patient’s annoyance! PCAs are very strong and effective measures to treat postoperative pain. Morphine, Dilaudid, Fentanyl are all very effective. Morphine is mostly used with the dose of 1 mg every 6 min(demand does) or in some cases 2 mg every 6 min(demand dose). I found Fentanyl to be a good drug in advanced age with better side effect profile. Starting at 25 mcg every 10 minutes up to 50 every 6 minutes, are possible doses. I never use any basal rate. Overdosing can happen if the high basal rate is used or family member or staff press the button. A good communication must exist with the family not to push the PCA button. I usually try to reduce and discontinue the PCA on the first postoperative day. Oral medications are introduced at this point, mostly based on what the patient was taking before the surgery. Vicodin doses 5/500, 7.5/500, 10/500 are used for most patients. In younger and older generation, Tylenol #3 is very effective. I usually reserve Percocet for most severe pain. I generally try to avoid non-steroidal pain medication specifically Toradol, but sometimes this becomes necessary. If given, I prescribed Toradol for 30 mg IV every 6 for 24 or 48 hours. Because of side effects affecting the kidney and GI tract, Toradol should be stopped after 48 hours regardless of the pain situation. Other long acting medication will be introduced at this time in cooperation with the medical team caring for the patient. Flexeril is very effective for the management of postoperative spasm and does not suppress patient’s other functions like breathing or ambulation. In this regard Flexeril is superior to Valium.
Subject 4: PT/OT timing
There are two general facts in medicine: “No disease benefits from starvation, no disease benefits from continuous immobilization”. All my patients are generally mobilized with PT OT in the morning after the surgery. From long studies provided with strong data we know that the lack of ambulation is very detrimental to the patient’s health. I consult PT OT for every single patient of mine, except cases with CSF leak, when lumbar drain is placed. PT should start as soon as possible, even the day of the surgery. Accordingly, all my patients get PT OT clearance before discharge. The goal of the physical therapy is to help the patient with ambulation, teach the patient the right behavior regarding daily activities, and exercises they need to continue at home. In the process of clearance for discharge, patients need to be observed, and it needs to be confirmed that patients are able to perform basic daily activities at home. They need to be taught to perform basic daily activities without overstressing the spine.
Subject 5: Where are cranial and complex cases performed?
The goal of my services is to provide the best care possible, safely, as close to a patient’s location as possible. Realistically, not all services can be provided at every location. My goal is to start performing routine procedures at every location and build a service of excellence, providing best care for more and more complex cases, as we go. I will appreciate all feedback and participation to help us to build a better, safer and more complex surgery ability, locally.
Subject 6: How fast should diet be resumed after surgery?
All clinical and scientific papers in recent years confirm that the best clinical practice is to start diet and advance it to regular diet the same day of surgery. The old practice to wait until bowel signs or passing gas before starting diet is widely abandoned even in abdominal surgery. There are good indications that keeping the GI tract empty and giving narcotic, actually increases the risk of ileus. Furthermore, many times, the required energy after a surgery is up to 5000-7000.Denying our body the required need is going to delay the healing and hospital discharge, increase risk of infection. Additionally, in spine surgery the ambulation and overall outcome is reduced by late start of diet, the new concept is that “No disease benefits from starvation, not even obesity.”
Subject 7: Traction Therapy/Devices
Traction is a form of therapy used to help relieve pain and decompress. This form of therapy can be of danger to the fusion site if applied post-operatively. Thus, the patient should avoid any traction for 4 months at least after surgery. Traction may be given in a different part of the body apart from the surgical site, which does not affect the surgical area. If you feel that you or your patient needs traction, please have them visit our clinic to be assessed prior to proceeding with the traction. We will evaluate them and make sure it is safe for the patient to undergo the therapy.