Module 19: Orthopedic & Spine Surgery PDF

MODULE 19: Orthopedic and Spine Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 20 Tighe (2015) Instrumentation for the Operating Room Unit 5 ORNAC Standards 2023 Lear...

MODULE 19: Orthopedic and Spine Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 20 Tighe (2015) Instrumentation for the Operating Room Unit 5 ORNAC Standards 2023 Learning Outcomes Describe basic anatomy for orthopedic surgery. Describe basic procedural considerations for orthopedic surgeries. Explain the importance of specific orthopedic equipment used in surgery and the corresponding safety precautions. Orthopedic surgery is an ever-changing surgical specialty. Technologic advances in the numerous hardware systems have improved patient outcomes with orthopedic disorders. The perioperative nurse must have an understanding of these systems and principles of bone and tissue fixation and healing. A basic understanding of anatomic and physiological responses of the patient undergoing orthopedic surgery is essential in providing optimal care. Anatomy The skeletal system is composed of bone, muscle, and associated structures. The 206 bones of the body form the appendicular and axial framework that supports soft tissues, connections of ligaments and tendons, enables movement, is reservoirs for minerals, and forms blood cells. Bone is continuously forming and reabsorbing calcium, Vitamin D, and phosphorus. Muscles - are tissues that cover bones and provide movement to the skeletal system. Ligaments - are bands of connective tissue that hold bone to bone and provide joint stability. Tendons - form at the end of muscles and transmit forces to bone or cartilage. Cartilage - is an elastic tissue layer at the end of bones that provide support and stability. Joints - are articulations of bones that connect one to another. Bone Tissue There are two types of bone tissue: 1. Cortical bone – the hard bone that forms the outer shell and supports tissue 2. Cancellous bone – soft and spongy tissue located at the iliac crest, tibia, sternum, and ends of long bones. It contains the red bone marrow. Module 19: Ortho Spine Long bones consist of a shaft (diaphysis) and two ends (epiphysis) and consist of cancellous bone. The epiphyseal plate is a line of cartilage that separates the epiphysis from the diaphysis which is present until skeletal maturity. Periosteum is a layer of connective tissue that covers all bone. If a bone is being repaired for a fracture, the periosteal layer must be stripped away using instruments called periosteal elevators. The Synovial Membrane covers all articulating surfaces of joints. Module 19: Ortho Spine Blood Supply: Cortical (hard) bone and Cancellous (spongy) bone Shoulder and Upper Extremity The shoulder is a ball and socket joint and consists of 4 muscles that make up the rotator cuff including: supraspinatus, infraspinatus, teres minor, and subscapularis. The humerus is the longest bone of the upper extremity and has two ends. The proximal end connects to capsule of the shoulder joint and the distal end, which divides into the medial and lateral condyle, connects to the ulna and radius. Module 19: Ortho Spine Wrist and Hand The wrist and hand consist of 3 parts: 8 Carpals (wrist bones), 14 Metacapals (bones of the palm), Phalanges (bones of the digits). There is a radial and ulnar side. The median nerve is located in the palm of the hand and extends under the wrist. Module 19: Ortho Spine Hip The hip joint is surrounded by a capsule, ligaments, and muscles that provide stability. The hip bone is comprised of three parts: the ilium, pubis, and ischium. These 3 bones form a socket known as the acetabulum which articulate with the head of the femur bone. The greater trochanter protrudes from the outer, upper portion of the femur shaft. It is a point of insertion for the abductor muscle of the hip. The lesser trochanter projects from the posterior, inferior base of the neck of the femur. It is a point of insertion for the iliopsoas muscle. Module 19: Ortho Spine Knee The knee joint consists of two articulations; one between the femur and tibial plateau and the other between the patella and the femur. Commonly, this is where a reconstructive surgery occurs. The capsule of the knee joint is attached to the proximal femoral condyles and distally to the condyles of the tibia and fibula. The two collateral ligaments are medial collateral ligament (MCL) and lateral collateral ligament (LCL). These ligaments reinforce the knee capsule. The two menisci (medial and lateral) are between the condyles of the femur and tibia and are attached to the joint capsule. The two cruciate ligaments are the anterior and posterior cruciate ligaments. They are fibrous bands that attach to the anterior and posterior intercondylar surfaces of the femur and tibia. Module 19: Ortho Spine Ankle and Foot The ankle is a hinge joint formed by the end of the tibia and fibula. There are 7 tarsal bones, 5 metatarsal bones, and 14 phalanges. Module 19: Ortho Spine Spine The vertebrae form the longitudinal axis of the skeleton. The vertebral bodies are connected by cartilage joints which provides mobility. There are 7 cervical vertebrae that support the neck, 12 thoracic vertebrae that support the thoracic region, and 5 lumbar vertebrae that support the lower back. The sacrum and coccyx are fused at the bottom. Perioperative Nursing Considerations Nursing Assessment It is imperative the perioperative nurse ensures the correct operative side and site is marked by the surgeon. This is verified during the surgical safety checklist and x-ray films in the operating room. Many orthopedic surgical procedures will use fixation systems and strict aseptic technique must be adhered. Module 19: Ortho Spine Patient Positioning The surgical procedure determines the patient’s intraoperative position. Patient who are undergoing orthopedic surgery are placed in the supine, lateral or fowlers position. Specific positioning aids are used for the lateral position such as Vac packs or beanbags. Spinal patients will be in the prone position with special care in padding to prevent injury. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. Draping - The draping is dependent on the procedure, surgeon’s preferences, and institutional resources. Limb draping is the usual method. Tourniquets are used and placed on the patient pre prepping. Independent drapes followed by an extremity or split drape. Instrumentation and Counting A basic orthopedic instrument set will be used for all cases with additional instruments and special equipment based on the surgical intervention (Hip set, Total Knee set, Shoulder Set, Bone Graft, etc). Common instruments include: - Periosteal elevators - Hommann retractors - Bone Rongeurs - Bone Cutter - Pituitary Rongers - Bone Currettes Important Sequence of instruments to fixate a bone: 1. Hold the bone with the bone holder to stabilize the fracture 2. Drill the bone with the drill (to make a hole for the screw) 3. Tap the hole (create a stable canal for the screw) 4. Measure the depth with depth gauge (determines screw length) 5. Screw with screwdriver (to insert screw in bone) A Minor count is completed for all orthopedic cases. Initial (minor) → Closing (minor) → Final (minor) Equipment Powered Surgical Instruments (Drills) - reduce the need for handheld instruments in orthopedics. The scrub and circulating nurse must ensure these drills are not resting on the patient/drapes. If the safety is not on, there is a risk the drill will activate and can injure the surgical team or patient. Accidental activation of the drill can cause a ‘strike through,’ meaning a hole or break in sterile drapes or set up, resulting in contamination. To prevent this, always Module 19: Ortho Spine ensure the drill has the safety lock on when not in use. Forced-Air Warming Blankets - The large amount of skin exposure required for orthopedic cases and presents a risk for hypothermia. Operating Room Table- there are various types of tables specific to orthopedic surgery and are dependent on the surgical case. The Fracture Table (left) is used for a femoral neck, femoral shaft or tibial fixation procedure. Jackson Spinal table (right) is used when the patient is prone for spinal surgery. The perioperative nurse must be aware of appropriate positioning devices to secure the patient safely. Radiography – Imaging is frequently used in orthopedic surgery. The C-Arm (image intensifier) provides fluoroscopy throughout the procedure. This is operated by the surgeon or an x-ray technician. All personnel in the OR must wear X-Ray led gowns for protection. Pneumatic Tourniquets Tourniquets are used in procedures involving the extremities to create a bloodless surgical field and promote visualizations of the structures during the procedure. The tourniquet is applied, the arm is elevated and exsanguinated with the use of an esmark rubber bandage, and the tourniquet is then inflated. Inflation pressure are established based on the systolic blood pressure, age of the patient, and circumference of the extremity. Best practice should not exceed 250-300mmHg for the arm and 300- 350mmHg for the thigh. Cuffs should overlap between 3 – 6 inches. Best practice is the cuff should not be inflated for longer than 60 minutes on the upper extremity and 120 minutes on the lower extremity. After the time is reached, the surgeon may request additional time at 15-minute intervals. The inflation, deflation and total time is documented in the patient’s chart. Module 19: Ortho Spine Air Flow/Traffic Control Airflow control in the orthopedic OR is critical to prevent introduction of microorganisms. Reducing the entering and exiting from the room contributes to this. SSI may result from airborne bacteria as a result of OR traffic. Aseptic practices, sterile technique and surgical consciousness using conventional air flow may be used to maintain low rates of SSIs (see photo below). Suture Material Suture material requires increased tensile strength with minimal degradability for the specific tissue. Tendons and ligaments have a slower healing time than tissues that have a rich blood supply. Absorbable sutures may be used for suturing tendons or ligaments to bone. Non- absorbable like polyester and surgical steel may also be used. Bone Cement (Polymethylmethacrylate) (PMMA) A powder component (10% Barium Sulfate) is mixed with a liquid (methyl monomer) to create a cement that is radiopaque. This is done by the scrub nurse. The liquid is highly flammable and the OR should be properly ventilated. The mixture of the two substances, with excessive exposure, can cause irritation of the respiratory tract and eyes. Special hoods and mixing devices are available to minimize staff exposure to the fumes. PMMA impregnated with antibiotic has shown to reduce infection rates. Module 19: Ortho Spine Medications Antibiotics, hemostatic, and antibacterial agents are used. Antibiotics are delivered both intravenously and locally in irrigation solutions. These are sometimes delivered by pulsative lavage which is when Bacitracin is mixed with sterile saline, fills the asepto syringe, and is used to irrigate the dirty or contaminated bone/tissue. Bone Wax is applied topically to the bone surfaces to control bleeding of the bone surfaces. Topical Thrombin is a hemostatic agent used to help reduce bleeding and applied topically to the bleeding area. It is reconstituted prior to use following manufactures instructions. Protective Measures Orthopedic cases require extra precautions because of the nature of the instruments and the equipment used. Double or triple gloves may be worn due to the sharpness of bone that is handled and the heavy reaming type instruments. Face shields are mandatory for all personnel. Care is taken to avoid strike through on the setup tables. X-ray gowns must be worn throughout the case for the scrub personal is the image intensifier is being used. Handling Prosthesis - Prosthesis shall be meticulously handled to prevent damage or contamination. - Should be placed on a lint free surface - Visually inspected for defects by the scrub nurse and the surgeon - Handled as little as possible - If applicable, rinsed with appropriate solution (i.e. Bacitracin) - Implant information (Serial Number, Lot Number, Size, Quantity, Expiry date) will be documented - Sterilization process – biological indicator must be present for an implant! Module 19: Ortho Spine  Surgical Interventions Bone Grafts: Allografts and Autografts Purpose of a bone graft is to fill cavities after removal of large amounts of bone resulting in instability, fill bony defects, and promote union of fractures at the time of open reduction. Reason for a bone graft: Allograft – bone obtained from a tissue bank Autografts – harvested from patient’s own bone, usually the iliac crest which contains cortical and cancellous bone. Cancellous bone is spongy and vascular and is harvested from the anterior/posterior crest of the Ilium. Cancellous bone will grow into the host bones. Cortical bone grafts are hard dense bone which come from the iliac crest, ilium, tibia, or ribs. They generally need to be stabilized with ortho hardware (wire/screws) as these grafts will not fuse on their own. Instrumentation: - Minor orthopedic set - Periosteal elevators – remove periosteum - Power saw - Bone cutter - Rongeur Cortical Bone = Osteotome and Mallet (hammer) Cancellous Bone = Bone curette Procedural Considerations - Incision along border of iliac crest - Muscles on the outer portion are stripped, elevated, retracted with periosteal elevator - Cortical Bone are removed with an osteotome and mallet or oscillating saw. - A window is made in the crest and Cancellous (spongy) bone is removed with currettes. - Drain inserted and incision closed. Important Note: When discussing fractures and fixation of fractures, screws are classified as cortical or cancellous screws. The selected screw will depend on what type of bone the surgeon will be fixating! Fracture Surgery Module 19: Ortho Spine A fracture is a break in the continuity of the bone as a result of trauma, infection, or bone disease (i.e. osteoporosis). The most common infectious process is osteomyelitis. The most common degenerative musculoskeletal condition is osteoarthritis. The goal of fracture surgery is to reestablish the length, shape, and alignment of fractured bones or joints and restore anatomical function. 1. Closed Reduction Manipulation of the fragments without incising the skin. Reduction is confirmed with radiography. Benefits include reduced risk of infection, improved union of the fractured bone and minimizes recovery period. A splint or cast will be used to immobilize the fracture. 2. External Fixation This provides rigid fixation and reduction with the ability to manage soft tissue wounds and is usually used for severe open fractures, arthrodesis, congenital deformities, and highly comminuted closed fractures. An open fracture has an increased risk of infection. External fixation does not require a cast as the fracture is stabilized at a distance from the injury which allows for additional procedures to be completed for the soft tissue injuries if necessary (i.e. skin grafts). 3. Open Reduction and Internal Fixation (ORIF) ORIF is used when the surgeon is unable to correct or fix the fracture with the closed method. Internal fixation is the treatment of choice for correction of fractures of long bones or the hip. It includes the application of metal plates, screws, insertion of pins, IM rods, and/or nails. Open reduction provides exposure to the fracture site (skin incision) and fixating the fracture with internal fixation devices. The advantage is the surgeon has a direct view of the fracture and can ensure anatomic alignment is achieved. Examples of ORIF procedures include: - Pin Fixation – Unilateral frame, elbow - Wire Fixation – Patellar fracture (tension) - Screw Fixation – Scaphoid fracture - Plate and Screw Fixation – Distal humueral fracture - Rod or Nail Fixation – Fractures of the shaft bones (humerus, femur, tibia) Wires used for fixation are called K-wires (Kirschner) or Steinman Pins (larger sizes). Intramedullary (IM) Rods, Nails, Pins are inserted in the intramedullary canal of a fractured bone (femus, humerus, tibia) with the use of fluoroscopy. It can also be used for Sub Trochanteric Fractures. This procedure is considered closed reduction despite the small incision sites. Common Module 19: Ortho Spine names of systems are “Nancy” “Russel-Taylor” and “Gamma.” IM Rods are considered the gold standard as the procedure causes less scarring, blood loss, and reduced risk of infection. The nails/rods/pins distribute the weight-bearing stresses across the length of the bone. Versus a plate/screw fixation would emphasize the stress at the fracture site. Prosthesis are used to replace a joint capsule that has either become degenerated or fractured. This commonly occurs in the hip, knee and shoulder joint. Commonly, hip replacement surgery is a result of a sub-capital fracture of the femoral neck. A shoulder prosthesis is similar to a hip prosthesis only flattened and smaller in size. Plates and screws hold the fractured pieces of bone in place. Screws can be threaded or smooth and plates are designed to apply dynamic compression across the fracture site to promote bone healing. There are many variations of plates and screw systems and are selected based on the bone, type of fracture, and surgeon’s preference. A common system name used is the Association for the Study of Internal Fixation (ASIF). This set includes plates, screws, bone holders, drill bits, taps, guides, etc. that are used to fix fractures, insert IM rods, and arthroplasty surgeries. All sets are specific to the surgery. Fixing a basic fracture is not limited to orthopedics. Plastic/Oral Maxilla Facial and ENT surgeons can repair fractures of the jaw, nose, and orbits. The same principles apply when fixating the fracture. Important Sequence of instruments to fixate a bone: 1. Hold the bone with the bone holder to stabilize the fracture 2. Drill the bone with the drill (to make a hole for the screw) 3. Tap the hole (create a stable canal for the screw) 4. Measure the depth with depth gauge (determines screw length) 5. Screw with screwdriver (to insert screw in bone) Module 19: Ortho Spine Arthroscopy Arthroscopies are used for diagnostic and operative purposes, commonly for the knee, shoulder, and wrist joints. This procedure is similar to MIS surgery in that the surgeon uses a scope to visualize a joint. Normal Saline irrigation is infused via gravity for regulated distention of the knee joint. The ‘portal’ incision is for the scope and 3-4 other small incisions are made around the knee for the arthroscopic instruments. Arthroscopic procedures are extremely common as there are many advantages including: decreased recovery and rehabilitation time, smaller incisions, less post-op inflammation, pain, and scaring. Instrumentation - Telescope - Light Source - Camera and Camera drape - Suction, Cautery - NaCl (Normal Saline) 3000ml bags Surgery of the Knee Arthroscopy of the Knee This is the most common type of arthroscopy and is indicated for diagnostic viewing, synovial biopsies, shaving the patella, meniscus repair and ACL reconstruction. Anesthesia for the knee can be GA, Spinal or Local. A tourniquet is applied on the thigh but rarely inflated. *Torn medial collateral, medial meniscus, and anterior cruciate are the most common injuries of the knee!! Module 19: Ortho Spine  a) Arthroscopic Resection and Repair of Meniscal Tear Menisci are important structures in the knee joint that distribute load across the joint and provide capsular stability. A meniscus tear is the most common type of injury requiring a repair. Treatment includes preserving the knee structures. Procedural Considerations: - The surgeon cuts the attachment of the anterior horn of the meniscus - Debrides and resects any chronic tears in the meniscus - If suturing- this must be for tears in a vascular zone and will use a synthetic absorbable suture - Irrigates the joint - Closes skin b) Arthroscopic Anterior Cruciate Ligament Repair The ACL is an important stabilizing structure of the knee and is the most frequently torn ligament. The injury is a result of simultaneous anterior and rotational stresses. Usually this is for athletes or active individuals with instability that impedes their ADLs. The repair can sometimes require a replacement of the ligament. The most common one is a patellar tendon graft. Instrumentation - Arthroscopy instruments - ACL reconstruction system - Fixation device of surgeon’s preference Procedural Considerations: - Diagnostic arthroscopy - Meniscal tears or other injuries are treated - Debride ACL - Surgeon inserts guide pin from anterior tibial incision into the intercondylar notch (anatomic attachment site of ACL) - Replaces pin with suture through the femoral and tibial pin sites - Patellar incision - Patellar tendon with tibial and patellar bone plugs are harvested - Three drill holes are placed into each bone block of the patellar graft - Heavy suture is placed into each drill hole - The patellar tendon graft is fixed by tying sutures over the bone at the end of the tibial and femoral drill holes - Site irrigated - Skin sutured closed Module 19: Ortho Spine Total Knee Arthroplasty (TKA) This surgical procedure is to replace the worn surfaces of the knee. Arthritis (degenerative, rheumatoid, traumatic) is the most common diagnosis for this surgery and a TKA promotes improved mobility and stability of the joint. Total Knee Replacements (implants) should allow for the preservation of normal ligaments while maintaining soft tissue balance and stability. The goal is to maintain the normal motion of the knee: flexion, extension, abduction, adduction, and rotation. Types of Knee Implants: 1. Unicompartmental – replace one opposing articular surface (medial or lateral) of the femur and tibia 2. Bicompartmental – not used readily 3. Tricompartmental – replace the opposing femorotibial joint and the patellofemoral joint. Most commonly used! These can be metal or plastic prostheses and the level of constraint depends on the bone and tissue stability. a) Unconstrained Prostheses – little constraint between the femoral and tibial components b) Semiconstrained – more when there is deformity in the soft tissue and ligaments c) Fully constrained – prostheses that are ‘linked’ together with hinges. Used where there is high level of bone loss and instability. Knee implants can be fixed with cement or noncemented techniques. The choice of implant and fixation technique will be dependent on the predisposition of the bone, age and activity level, and the surgeon’s preference. It is important to remember that knee prostheses are Left and Right specific. It is imperative that the correct sided implant is selected and verified with the scrub nurse and surgeon before opening. There will be two components (implants), one tibia and one femoral. Module 19: Ortho Spine Instrumentation: Soft tissue and large bone set Total knee instrumentation Implants Power drill and saw PMMA (cement) supplies Module 19: Ortho Spine  Surgery of the Hip Hip Fractures Hip fractures are classified based on anatomic location. There are three classifications: 1. Femoral Neck Fractures 2. Intertrochanteric Fractures 3. Subtrochanteric Fractures Intertrochanteric Fractures Intertrochanteric fractures are common in elderly women due to osteoporosis. Fracture of the femur between the greater and the lesser trochanters. They are extracapsular fractures that is outside the hip joint’s fibrous capsule Blood supply is not compromised and fracture can be fixated with plates and screws. Instrumentation and Equipment OR Fracture Table - induced on stretcher and transferred to Fracture Table for positioning Lead Gowns – worn by all OR personnel Common instruments used: - Soft tissue and basic ortho instrument set - Hip-Screw Instrumentation → Commonly used is a Dynamic Hip Screw (DHS) - Bone holder - Power drill and reamer - Fluoroscopy Procedural Considerations: - Reduces the fracture - Confirmed with fluoroscopy Module 19: Ortho Spine  - Guide Pin is inserted in the middle of the femoral head - Bone holder - Drill - Measure with depth gauge for the lag screw size - Reamer over the pin to create channel for lag screw and barrel compression plate - Tap - Open implants - Scrub nurse assembles the plate, lag screw, and wrench - Surgeon places the assembly over the guide pin and advances the lag screw to the desired depth - Confirm with fluoroscopy - Secures plate with screws - Ensure appropriate traction and alignment - Irrigate wound and close Femoral Neck Fractures Reduction is required before internal fixation of the femoral neck because of the risk of nonunion and avascular necrosis of the femoral head. Blood supply is compromised. Instrumentation and Equipment OR Fracture Table – slight traction and external rotation on the affected side. Lead gowns – worn by all OR personnel Common Instruments used: - Soft tissue and basic ortho instrument set - Fixation Instrumentation → Cannulated screws (AO Technique) - Power drill - Fluoroscopy Procedural Considerations: - Guidewire x3 (2x middle of femoral bone (ant and post); (1x medial cortex) - Wires are measured for correct length of screw - Cannulated tap passed over guidewire - Cannulated screw inserted over guidewire - Repeat x2 (3 screws total) - Confirms placement of screws with fluoroscopy while moving the hip in range of motion - Irrigate wound and close Module 19: Ortho Spine Total Hip Replacement (THR) Femoral Head Prosthetic Replacement is used for Femoral Head Fractures. The endoprosthesis can be unipolar or bipolar design. Unipolar – are one union implants. No inner head to reduce friction. Bipolar endoprostheses reduce the shear stresses affecting the acetabular surface, decreasing the motion and friction between the prosthetic head and the acetabulum. Femoral head prosthesis (metal) is connected into a rotating polyethylene-lined (plastic like) cup. Together they move as a unit. The friction occurs between the ball and plastic instead of the head of the femur and the acetabulum. If completing a Bilateral Total Hip Replacement, the modular method of allows the surgeon to build up the hip and acetabulum so that both legs symmetrical in length and aligned. Procedural Considerations: - The acetabulum is prepared first - The femur is prepared second - Femoral head is excised with an oscillating saw - Reams the acetabulum to remove arthritic debris - Trial cups are used to size the socket - Socket (acetabulum) implant opened - Bone cement may be used to secure the prosthesis (or screws depending on the patient) - Femoral neck prosthesis is attached to ensure accurate fit - Full range of motion exercised are completed Module 19: Ortho Spine  - Femur is prepared and reamed to create canal for implant - Prosthesis is inserted and secured with or without bone cement - The unipolar or bipolar assembly is snapped into the neck of the femoral stem - Hip is reduced - Skin closed. Surgery of the Spine Back surgery is commonly performed on the lumbar and cervical regions of the spine as they are the most mobile and most susceptible in injury or degenerative and arthritic related pain and disease processes. Spinal fusion is considered for patients with post traumatic, post-surgical or with congenital defects such as scoliosis. Spine cases can be done by orthopedic or neurosurgeons. Lumbar Laminectomy Removal of a lumbar disk to relieve pressure on the spinal cord. This is the most common procedure to treat spinal stenosis or a ruptured disk. Positioning Patients undergoing spine surgery are placed in the prone position. The patient is first induced on a stretcher and then is positioned with the surgical team. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. Blood Replacement - Some patients may require extensive tissue dissection in highly vascular areas, resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, surgicel, etc to anticipate any critical surgical needs. Instrumentation and Equipment Common surgical instruments include: - Kerrison rongeur (to remove lamina) - Pituitary rongeur (to remove disc) - Cobb periosteal elevator - Howarth periosteal elevator - Bayonet forceps (improve view) - Neuro patties sponges used in small spaces (green string is used to identify the sponge) - Spinal retractor - Biopolar cautery Module 19: Ortho Spine Jackson Table- used to position patient’s in the prone position Forced-Air Warming Blankets - The large amount of skin exposure required for spinal surgery presents a risk for hypothermia. Procedural Considerations: - Remove lamina bone: Kerrison rongeur - Remove intervertebral disc tissue: Pituitary rongeur Spinal Fusion This surgery is for the treatment of scoliosis, a deformity with lateral deviation of the spinal column from the midline. This includes rotation of the vertebrae. Scoliosis can be idiopathic or congenital. Spinal fusion is frequently performed in adolescence when the laterally deviated curve is still flexible. Fixation instrumentation is achieved with Harrington Rods, however there are many alternative systems that may be used based on the surgeon’s preference. Harrington Rods are internal splints that help stabilize and straighten the spine. Distraction Rods – placed on the concave side of the curve Compression Rods – placed on the convex side Positioning Patients undergoing spine surgery are placed in the prone position. The patient is first induced on a stretcher and then is positioned with the surgical team. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. Module 19: Ortho Spine Blood Replacement - Some patients may require extensive tissue dissection in highly vascular areas, resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, surgicel, etc to anticipate any critical surgical needs. Instrumentation and Equipment Common surgical instruments include: - Spinal instrumentation - Bone graft instrumentation - Harrinton rod instrumentation - Pin cutter - Fluoroscopy Jackson Table- used to position patient’s in the prone position Forced-Air Warming Blankets - The large amount of skin exposure required for spinal surgery presents a risk for hypothermia. Procedural Considerations: - Cancellous bone from the iliac crest is sometimes harvested for grafting purposes to help with fusion of laminae - Instrumentation is always used Hand Surgery Carpal Tunnel Release Carpal tunnel results from the entrapment of the median nerve on the volar surface of the wrist as a result of thickened synovium. This is a quick operation where the surgeon will divide the carpal ligament to alleviate tension, assesses the median nerve, and sutures the skin closed. This if often done by plastic surgeons under local anesthetic or a Bier Block with the use of a tourniquet. Module 19: Ortho Spine