laminectomies

It is recommended only after conservative treatment (physical therapy, anti-inflammatory medication) has been exhausted. Minimally invasive spine surgery can be used to treat conditions such as herniated or ruptured lumbar discs, bone spurs, synovial cysts, and lumbar spinal stenosis. Patients with a history of open spine surgery may be poor candidates for minimal procedures because of scar tissue.; illustration

Patient care

Preoperative: The patient's knowledge of the procedure is determined, misconceptions are corrected, additional information is provided as necessary, and a signed informed consent form is obtained. A baseline assessment of the patient's neurological function and of lower extremity circulation is documented. Health care providers discuss postoperative care concerns, demonstrate maneuvers such as log-rolling, assure the patient of the availability of pain medications on request, and prepare the patient for surgery according to the surgeon's or institutional protocol.

Postoperative: Vital signs and neurovascular status (motor, sensory, and circulatory) are monitored; antiembolism stockings or pneumatic dressings are applied, and anticoagulants are given if prescribed. The dressing is inspected for bleeding or cerebrospinal fluid leakage; either problem is documented and reported immediately, and the incision is redressed as necessary. The patient is maintained in a supine position, with the head flat or no higher than 45° according to the surgeon's preference, for the prescribed time (usually 1 to 2 hr), then repositioned side to side every 2 hr by log-rolling the patient with a pillow between the legs to prevent twisting and hip adduction and to maintain spinal alignment. Deep breathing (with use of an inspirometer in most cases) is encouraged, and assistance is provided with range-of-motion, gluteal muscle setting, and quadriceps setting exercises. Adequate assistance should be available when the patient is permitted to dangle his or her feet, stand, and walk in the early postoperative period. Prescribed anti-inflammatory, muscle-relaxant, and antibiotic agents are administered. Noninvasive measures to prevent and relieve incisional discomfort are provided in addition to prescribed analgesics. Fluid balance is monitored by administering prescribed intravenous fluids and by assessing urine output. The patient is encouraged to void within 8 to 12 hr postsurgery and is assessed for bladder distention, which may indicate urinary retention. Catheterization is used only after other measures to promote voiding have been attempted. The abdomen is auscultated for return of bowel sounds, and adequate oral nutrition is provided as prescribed. Patients who have undergone minimally invasive procedures are out of bed and resuming some normal activities (e.g., showering, engaging in activities around the house) within a day or two of surgery. Responses vary and may depend on the patient's personality, presurgical activity level, and overall health. Specific restrictions on postoperative activity should be outlined with the patient in detail at the time of discharge.

Rehabilitative and home care: Incisional care techniques are taught to the patient and family, and the importance is stressed of checking for signs of infection (increased local pain and tenderness, redness, swelling, and changes in the amount or character of any drainage) and of reporting these to the surgeon. A gradual increase in the patient's activity level is encouraged. Any prescribed exercises (pelvic tilts, leg raising, toe pointing) are reviewed, and prescribed activity restrictions are reinforced. Restrictions usually include sitting for prolonged periods, lifting heavy or moderately heavy objects, or bending over. Proper body mechanics are taught to lessen strain and pressure on the spine: these include maintaining proper body alignment and good posture and sleeping on a firm mattress. Involvement in an exercise program, beginning with gradual strengthening of abdominal muscles, is encouraged after 6 weeks. Walking is encouraged. The patient should schedule and keep a follow-up appointment with the surgeon and communicate any concerns to the surgeon (if necessary) before that visit.