Laparoscopic Spinal Fusion Procedures

OCTOBER 1997, VOL 66, NO 4 Forsythe 9

Laparoscopic Spinal Fusion Procedures egenerative disc disease involves a narrowing planted spinal device. My part in the study involved of the vertebral disc space and a thickening of conducting preoperative interviews, assisting during the surrounding ligaments, which in turn nar- surgery, and providing postoperative care to patients. rows the foramen through which the spinal Although fusions using this device can be performed nerve roots travel. These spinal nerves are the at the cervical, thoracic, and lumbar levels, our study communication paths between the spinal cord tracks involved only the lumbar spine. The implant we and the peripheral nerves. Each pair of spinal nerves is studied is a threaded cylinder made of a porous titaconnected to the spinal cord by two points of attach- nium alloy (Figure 1). The surgical procedure ment called roots. The structure of the spinal nerve involves implanting two of these threaded cylinders consists of an anterior and posterior root, which unite into the disc space at the affected vertebral level to to form a spinal nerve at the intervertebral foramen. restore disc height, provide three-dimensional stabilThe lumbar plexus (ie, network of nerves) is ity of the affected area, restore foramenal patency, formed by the ventral rami of spinal nerves L1 and minimize microscopic motion. through LA,each of which is located on either side of Patient selection. The study had explicit criteria the first four lumbar vertebrae. The lumbar plexus for patient selection. These criteria related to each supplies the anterolateral abdominal wall, external patient’s genitals, and part of the lower extremities. The sacral occupational activity level before the onset of symptoms, plexus is formed by ventral rami of spinal nerves L4L5 and S 1-S4. This plexus supplies the buttocks, per- 0 compensation related to the injury, 0 duration of symptoms, ineum, and lower extremities. Impingement of the nerve roots in the lum- 0 recreational activity level before the onset of symptoms, bosacral region area causes 0 patients discomfort and pain in previous spinal surgeries, conservative noninvasive treattheir backs and legs. Recurring A B S T R A C T 0 ments undertaken, disc herniations and reuetitive disLa Da roscoDic Drocedures, previous tests pertaining to the cectomies and failed fusions also Such as spinal fusions, facilitate spine, and contribute to patients’ spinal patients’ faster returns to funcanalgesic medications used for pathologies. Fusion of the affect- tioning lifestyles. Fusions using present back symptoms. ed lumbosacral discs using porous implanted threaded cylinders The patient had to assume titanium alloy implants restores made of a porous titanium alloy disc space height and foramenal can be performed at the cervi- responsibility for his or her own patency and provides three- cal, thoracic, and lumbar spine postoperative care, which includlevels. This article discusses ed maintaining the postoperative dimensional stability.’ preoperative, intraoperative, and activity level (eg, walk as much postoperative care of patients as tolerated) designated by the IMPIANT CLINICAL TRW I worked as an RN first assis- undergoing laparoscopic spinal surgeon. I assessed each patient’s tant (RNFA) on an investigational fusion. AORN J 66 (Oct 1997) understanding of what was expected of him or her as an active study of a laparoscopically im- 637-643.

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and to facilitate eventual US Food and Drug Administration approval. We had to complete the study case report forms correctly and in a timely manner.

Figure 1 Spinal fusion insert.

PREOPERATIVE PlllLSE

(Ail illustrotions feprinted with permission from Spine-Tech, lnc, Minneapolis.)

participant during the recovery period. I recorded all this information during the patient’s initial office visit to determine if the patient was impaired substantially in the job or daily activities performance. Criteria that disqualified the patient were multilevel vertebral degenerative disease, medication-seeking behavior, or secondary gain or nonorganic symptoms (eg, tenderness, regional disturbance, overreaction). Preoperative data collection. The surgeon made the primary diagnosis (eg, painful degenerative disc disease, foramenal stenosis, disc space pain. nerve deficit) by using information gained from x-rays, magnetic resonance imaging (MRI) and computed tomographic (CT) scans, discography studies to determine disc level associated with the pain, patient history, and physical examination. I obtained the patient history, and the surgeon completed the physical examination. I also compiled a list of the patient’s significant medical problems and any relevant medical history. The surgeon and I worked together to complete the preoperative and postoperative patient profiles. Postoperative data collection. In addition to obtaining postoperative clinical data, the surgeon and radiologist read the patient’s x-rays to document the postoperative condition of the involved disc space and adjacent vertebral bodies and compare them to preoperative x-rays. They looked for any migration of the implant and for any further degeneration or spondylolistheses (ie, forward displacement) of the patient’s vertebral levels above and below the implant. The x-rays included anteroposterior, lateral, Ferguson, and flexionlextension views. These x-rays were performed during the preoperative and postoperative period at specifically designated intervals (ie, one month preoperatively; three, six, 12, 24 months postoperatively). Documentation. Documentation was vital because of the investigational status of the device

The surgeon and I explained the surgical procedure and potential risks to patients during their initial office visits, and the patients signed consent forms to participate in the study to undergo the planned spinal fusion procedures with the implants. The potential surgical risks include infection, bleeding, and spinal fluid leak, adverse reactions to metal or plastic; displacement or breakage of the implant; nerve or spinal cord damage, paralysis, injury, or damage to adjacent bones or discs; need for further surgery; circulatory problems, venous thrombosis, myocardial infarction, stroke; adverse reactions to anesthesia; pneumonia; potential surgical wound infections and delayed healing; and retention of oxygen or carbon dioxide in the abdomen, gas or air embolisms, or organ damage from instruments used during surgery. We also explained the risks associated with laparoscopic surgery, which are bowel or organ injury; mechanical complications resulting from use of trocars; oxygen retention in the abdomen, chest, blood stream, and around the lungs; decreased oxygen to local tissues; infection in the abdominal cavity; carbon dioxide absorption; formation of cysts in the lymph nodes; and herniated incision, At the preoperative visit, I also informed patients of their expected arrival times at the hospital on the day of surgery, the importance of being NPO before surgery, the approximate length of stay, events on the day of surgery (eg, preoperative holding area experience, entry into surgical suite, postanesthesia care unit [PACU] stay, inpatient unit care), their planned food and water intake progression after surgery (ie, IV fluids progressing to liquids

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and then to solid food), prominences with foam and gel postoperative physical therapy, foam pads. The entire surgical and team was responsible for ensuring postoperative pain management. that the patient was comfortable at The surgeon selected the all times. The circulating nurse proper size implants using a teminserted a Foley catheter to decomplate, patients’ x-rays, and CT press the patient’s bladder, which and MRI scans. Proper length helped decrease the risk of injuring and width of the implants is the patient’s bladder during the important to the success of the surgical procedure. The circulating surgery and thus patient outnurse shaved the patient’s comes. The surgeon used a temabdomen and suprapubic area and prepped the patient’s entire abdoplate to determine the size of the disc spaces above and below each men and chosen iliac crest site with a povidone-iodine solution. patient’s affected lumbar verteThe anesthesia care provider bral levels. The surgeon’s goal was to maintain a distance of 4 placed a nasogastric tube to decompress the patient’s stomach. mm between implants in each The laparoscopic surgeon disc space (Figure 2). who performed the entry and disBefore each patient’s fusion section to ~ 5 - s 1stood on the left Drocedure. I ensured that all me- Figure 2 The Spinal fUSi0n inserts or right of the patient depending operative tests needed for are 4 mm apart. on surgeon preference. As the surgery were completed and the RNFA, I stood on the opposite results were brought to the OR. I helped coordinate the participants (eg, OR team side of the surgeon to operate the camera and create a members, implant company representatives) for clear visual field for the surgeons. The laparoscopic surgeon began the procedure by each fusion procedure to ensure a smooth surgical making an infraumbilical incision and placing a 10-mm course. On the day of surgery, I assisted in organizing trocar and inflating the patient’s abdomen with carbon the OR for the laparoscopic spinal procedure with dioxide. The 10-mm port was at the umbilicus and was implant placement. I worked with the circulating used for the camera. Lateral ports (ie, 5-mm, 10-mm trocars) were placed at an equal distance between the nurse and scrub person to test and position suction equipment and bipolar electrosurgical umbilical port and the anterior superior iliac spine and functioned as working ports for dissection. unit, two video monitors at the foot of the OR bed, The anesthesia care provider then adjusted the a fluoroscopy unit at the head of the OR bed, and OR bed to place the patient in steep Trendelenburg’s position to displace the small bowel superiorly. The a radiolucent OR bed. The anesthesia care provider set up anesthesia orthopedic surgeon retracted the sigmoid colon to equipment at the head of the bed. We also had an the left and held it in place while I operated the camautotransfusion device and instrumentation for an era. The laparoscopic surgeon exposed the L5-SI disc space through careful dissection. After good open procedure available. exposure was obtained, the laparoscopic surgeon inserted a suprapubic 15- or 20-mm port just below INTRAOPERATlVEPHASE The surgical team consisted of the orthopedic sur- the pubic hair line. This port was the main working geon, laparoscopic surgeon, RNFA, camera operator, portal for the spine instrumentation. The orthopedic surgeon placed a radiopaque anesthesia care provider, scrub person, and a circulating nurse. Either the circulating nurse or I assisted the marker with the use of lateral fluoroscopy. The marker anesthesia care provider with intubation of the patient. was used to ensure proper placement and exposure of The spine surgeon and I then positioned the patient in the L5-SI disc space, which lies directly between the a supine position with his or her arms placed horizon- bifurcation of the great vessels. These vessels musf be tally on arm boards. We padded the patient’s bony protected with a retractor by the orthopedic surgeon or 639 AORN JOURNAL

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Figure 3 * A distraction plug is inserted into one side of the disc space.

then marked the anterior portion of the annulus using a starter alignment guide. The orthopedic surgeon had determined the 4-mm distance between the left and right implants preoperatively using a template and the patient’s x-rays. The orthopedic surgeon then placed a pin into the 20-mm working port to ensure colinear placement of the laparoscopic hand drill. The surgeon enlarged left and right sides of the port with an 8mm drill, which also was used to perform the discectomy at this time. The orthopedic surgeon inserted a distraction plug into one side of the disc space and left the plug in place to elevate the disc space (Figures 3 and 4). He or she then advanced a drill tube guide toward the 8-mm hole and pushed it into place. As the drill tube teeth entered the bone to the depth of the anterior vertebral end plates, a vertebral reamer created a satisfactory hole for the implant. The orthopedic surgeon and I took a bone graft from the patient’s iliac crest and placed the graft into the implant. The orthopedic surgeon then placed the implant through the 20-mm port and threaded it into place. The surgeon used C-arm fluoroscopy throughout the procedure to proper placement of the implant. The surgeon removed the distraction device from the opposite side and repeated the implantation

laparoscopic surgeon throughout the procedure. The laparoscopic surgeon clipped the medial sacral artery at the LS-SI disc space. The surgeons worked together to achieve adequate exposure of the annulus at the disc space of the affected levels. The orthopedic surgeon then began placing the implants. The primary consideration at this stage was to protect the patient’s epidural vessels by controlling the depth of the reaming through C-arm fluoroscopy and instrumentation with positive stops to control depth. The orthopedic surgeon performed the reaming with hand reamers (ie, no power tools) and

Figure 4 The distraction plug is left in place to elevate the disc space.

Figure 5 A distraction plug is removed from the disc space. 640 AORN JOURNAL

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No postoperative bracing of the patient’s back was needed, unlike in traditional open spinal W o n procedures.

procedure on that side (Figure 5). Cancellous bone graft was added to each implant using a laparoscopic bone impactor through the 20-mm port. The bone is placed to create the beginning process for the actual fusion, which takes approximately six months. When the implants were placed properly, the procedure was complete. The surgeon used 0-0 polypropylene to close the peritoneum, 2-0 polyglactin f o r subcutaneous tissue, and 3-0 polypropylene for skin closure. At the iliac graft site, I inserted a drain and the surgeon closed the wound with 0-0 polyglactin for fascia, 2-0 for subcutaneous tissue, and 3-0 polypropylene for skin closure. I applied wound-approximating tape strips to both wounds and covered these with sterile dressings. The circulating nurse documented the implant in the patient’s record. The anesthesia care provider, RNFA, and circulating nurse transported the patient to the PACU.

PosroPERATlvECARE

The PACU nurses monitored the patient’s vital signs, level of consciousness, and sensation and movement of the lower extremities. When the patient was awake and stable, he or she was moved to the inpatient spine unit. After the patient was in the inpatient spine unit, I noted the patient’s bowel sounds and wrote an order to increase the diet slowly from liquid to solid food. The first day postoperatively the physical therapist assisted the patient in ambulating. N o postoperative bracing of the patient’s back was needed, unlike in traditional open spinal fusion procedures. The patient could ambulate as much as he or she could tolerate. After the patient was capable of eating solid food and could ambulate with the use of an assistive device (eg, walker, cane) or alone, he or she was ready to go home. DISCUSSION

An open anterior-posterior spinal fusion entails a hospital stay of at least one week, whereas patients undergoing the laparoscopic fusion procedures with implants stay only two to four days (Table 1). Patients’ pain levels throughout the postoperative course are less with the laparoscopic procedure than with a comparable open procedure. In open anterior spinal fusions, extensive layers of muscle are stripped from the bone and pulled open and internal organs are manipulated more forcefully than in the laparoscopic procedure. The patient receives IV narcotics for one to two days after surgery and then is given oral analgesic medications as soon as food is tolerated.

Table 1 IAPAROSCOPIC SPINAL FUSION V OPEN ANTERIOR-POSTERIOR SPINAL FUSION’

Fusion mean 190

Surgery to stationary status (days)

360 fusion mean 277

Hospital stay (days)

3.5

5.3

Operative time (minutes)

120

250

Operative blood loss (mL)

300

900

Patients working at three months after surgery

47%

0%

Patients reporting graft pain

17%

45%

Hospital-related costs

$17,713

$1 9,832

NOTE 1 . R J Hacker, *Comparison of interbody fusion approaches for disabling low back pain,” Spine 22 (June 1997) 660.

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rent medical problems I have?” “Will my recovery be different than that of any other patient’s?”), reinforces this information, and answers other questions. The patient begins physical therapy a few weeks after the procedure to strengthen spinal muscles and increase endurance. The follow-up office visits also include physical examinations performed by the surgeon and a review of the patient’s x-rays with the implant depth and progression of fusion noted (Figure 6). I mark the x-rays for degrees of flexion and extension, lucency, thickness, and coverage of bone graft. During the postoperative period, the surgeon and I worked as a team to monitor complications, implant migration, progression of the fusion, and each patient’s state of wellness. CONCLUSION

Figure 6 Proper placement of the implants is indicated in this x-ray.

The patient may return to work within four to six weeks, depending on the type of work he or she does. The activity level that is required during the patient’s normal work day (ie, sedentary, light, moderate, heavy) plays a determining factor on the return to work status. The study protocol dictates the frequency of patients’ postoperative office visits at specific intervals-at seven days, 80 to 120 days, five to seven months, 10 to 14 months, 22 to 26 months, and 36 months postoperatively. During the first postoperative visit, I assess the patient’s wound and remove the skin suture if appropriate. When the skin suture is removed, no bandage is required. I then teach the patient about the importance of walking as much as he or she could tolerate to promote recovery. We also discuss pain medication, proper diet, and any other concerns the patient might have (eg, activity, status of the implant). The surgeon would then discuss any medical concerns the patient might have (eg, “How will this procedure affect any cur-

The recovery of damaged tissue and healing of internal structures, therefore, is much faster with the laparoscopic approach due to less damage. Laparoscopic spinal fusion is a minimally invasive procedure that decreases duration of hospitalization and postoperative soft tissue pain, particularly paraspinal muscular discomfort. Patients are able to return to normal lifestyles similar to before the onset of their spinal problems. A Lydia L. Forsythe, RN, BA, CNOR, is director of surgical services at Saint Mary’s Regional Medical Center, Reno. Nev. The author would like to thank Mike Hurd, MTH Medical, Escondido, Calif;J . H . Maxwell, MD, Scottsdale (Ariz)Spine Care: James Rappaport, MD, Sierra Regional Spine Institute, Reno, Nev; and the OR staff members of the Scottsdale (Ariz)Memorial Hospital for their assistance in the preparation of this article. NOTE 1. G J Tortora, Principles of Anatomy and Physiology, eighth ed (New York: Harper Collins College, 1996).

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