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Localizer cast, fusion for scoliosis
Localizer cast, fusion for scoliosis June Lorig, RN
June Lorig, RN, is clinical supervisor, operating room, University Hospitals of Cleveland. She is a B S N graduate of the School of Nursing and Health at the University of Cincinnati.
360
coliosis or lateral curvature of the spine is a common problem encountered in the teenage patient population. The Scoliosis Research Society estimates there are about 10,000growing children in the United States and Canada currently being treated for scoliosis. The role of the operating room nurse can and should play a central part in the care and recovery of these patients. The effective fulfillment of this role has become an increasing challenge over the past decade as treatment and surgical techniques have become more complex. Scoliosis can be associated with a wide variety of health problems but is most commonly idiopathic or genetic in origin, and the child is otherwise healthy. It generally affects girls eight times more frequently than boys and is most often found in the adolescent age group. In general, there are three groups of scoliosis: infantile, juvenile, and adolescent. Although each has specific characteristics, all are growth related and until cessation of growth, the curve may become progressively worse. Therefore, any treatment program must effectively manage the problem until skeletal maturity is achieved. The most significant long-term problems related to scoliosis include early degenerative arthritis of the spine and increased cardiopulmonary problems, particularly cor pulmonale, which can be serious enough to shorten a person’s life by 10 to 15 years. In addition to the physical problems which may develop, significant emotional problems can arise relative to the cosmetic aspects of this spinal deformity. Treatment of scoliosis varies according to etiology and location of the curve, as well as age of the patient. Unless the curve is mild and growth is completed, the treatment will consist of either external bracing or internal support or a combination of both. External forces used to achieve correction include the Risser-Ferguson turnbuckle cast, Milwaukee brace, Risser localizer cast, and the haloskeletal traction apparatus. Internal support includes either posterior or anterior bone graft and internal metallic support using Harrington distraction and/or compression rods or Dwyer anterior spinal fixation. The selection of the external and
AORN Journal, September 1975, Vol 22, No 3
internal support mechanisms to be used will depend on the etiology of the scoliosis, the age of the patient, and other associated health problems. Although the majority of surgical patients will have a posterior spine fusion using autogenous bone graft and internal support with Harrington instrumentation, each patient is unique and a variety of combinations may be used. As community awareness and screening programs become more efficient, the need for scoliosis spine surgery for idiopathic cases should diminish and the use of braces, such as the Milwaukee brace, should be increasingly common. However, as health care improves, patients with more severe health problems are surviving long enough to develop spine problems that require a more ingenious variety of treatment approaches. In either case, children afflicted with scoliosis become very sophisticated and knowledgeable in the types of treatment and significance of their problem, The long-term nature of their problem frequently encompasses the teenage years, thus adding to the stresses and natural emotional changes of that age. For these reasons, the operating room nurse must be proficient in operating room technique and instrumentation to support extensive spine surgical procedures. She must also be able to meet the other major needs of the patient who will come to the operating room area for a variety of treatments. Nursing care goals for patients undergoing spinal fusion for scoliosis are divided into four main categories: 1. the health of the child pre, intra, and postoperatively 2 . maintenance and/or improvement of pulmonary function 3. appearance of the child 4. psychological support. With respect to these goals, this ar-
ticle concerns care given to patients in the plaster room and the operating room at University Hospitals of Cleveland. Other centers may vary in their health care approach. Plaster room. If the operating room nurse does not visit the patient, her active role starts in the plaster room where she endeavors: 1. to assist the physician to obtain partial correction of the spinal curvature by applying a Risser cast; 2 . to maintain a safe environment by having the room and equipment readily available and in proper working condition; 3. to develop rapport with the patient by supporting physiological and psychological needs; 4. to coordinate efforts of the involved staff for optimal efficiency and success in fdfilling the aforementioned goals. It is essential that the plaster room be ready before the patient arrives from the unit. The Risser table should be clean and set up properly with additional parts easily accessible. The patient must be unclothed during the procedure; hence, the room temperature should be comfortably regulated (at least 72 F [22 C]).l Equipment such as stockinette, felt, Webril, knives, and plaster should be placed in order of use to eliminate fumbling and lessen the time the patient must be on the table. Procedure manuals and physicians’ preference cards should be checked in advance to insure that desired equipment is available. While verifying the patient’s name and availability of the chart and signed permits, the nurse may assess individual needs. These include the child’s size, physical development, and mental maturity. Patients, who are usually between 11and 18 years old, are particularly sensitive a t this stage of their
AORN Journal, September 1975, Vol 22, No 3
361
The Risser table or frame used in making the localizer cast is ready for use.
The patient, in a stockinette suit, is placed on the frame’s longitudinal band. The localizer cast is applied in two stages. First, the pelvic cast is applied. When the plaster sets, cervical and pelvic traction are applied. Then, the Risser localizer is placed over the maximum part of the convexity of the curve to elongate the spine while decreasing the curve by lateral pressure over the maximum rib rotation. The upper part of the cast is applied after correction is obtained. Finally, the two parts of the cast are joined by plaster, traction is released, and the cast trimmed.
362
AORN Journal, September 1975, Vol 22, No 3
physical and emotional growth and development. Their need to communicate is acute, and they have many questions whether they ask them or not. The OR nurse needs to use perception and communication skills to ensure that the patient knows such things as how and what she can eat, how she will move, how she will go to the bathroom, and what she generally can and cannot do. This information must correlate with data given to the patient by her physician, floor nurses, and in written material. Girls are particularly concerned whether instrumentation and fusion will affect pregnancy in later years. It will
not, unless the curvature is severe in the lumbar area and there is associated pelvic distortion. General appearance, including fear that the cast will inhibit breast development or interfere with handling of menstrual secretions, is often of major concern to girls, The nurse should conduct discussions of feminine hygiene without embarrassing the patient. Young male patients usually try to appear manly and unafraid. They are conscious of underarm and pubic hair and the size of their genitals. Sportsoriented patients need to know that contact sports such as football and activities such as trampolining are barred
The patient is padded with various layers of Webril. Bony prominences such as the iliac crest are padded with felt.
AORN Journal, September 1975, Vol 22, No 3
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for about three years. Golf, swimming, and riding are permitted as soon as the fusion heals, usually about 1 2 to 18 months. Before being moved from the cart to the Risser table, the patient is placed in a stockinette body suit. The stockinette may be 8, 10, or 12 inches wide and long enough to cover the patient from ankles to neck with allowance for coverage of the head later. The suit must fit snugly
but not tightly and without wrinkles. Wrinkles must be avoided as they may cause pressure points. Additional threeinch stockinettes may be used as sleeves to protect the arms from plaster and give added warmth. When the suit is on, the patient is transferred to the Risser table and padded with various thicknesses of felt. Felt edges must be beveled to prevent them from cutting into the skin. Three
Plaster is applied over the padding.
Muslin straps are Incorporated into the pelvic plaster and tied to the distal winch for use in applying pelvic traction.
364
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The patient's head is placed in a halter. When the pelvic cast plaster sets, the patient is pulled out to tolerance by head and pelvic traction. The localizer stem is then abutted against the felt-protected prominent ribs and pressure is applied. Shown is Clyde Nash,
MD. to four layers of four- to six-inch Webril are wrapped over the stockinette and padding. The Risser cast is applied in two stages: (1) to cover the pelvis and (2) to cover the upper part of the body. I t is formed from about four- to six-inch rolls of plaster and several 5 x 30-inch plaster splints. Plaster should be dipped in water at 98.6 F (37 C) as it sets ten degrees higher than the original water temperature. Cooling the water five to ten degrees will slow the rate of setting. P l a s t e r rolls a n d splints m u s t be thoroughly saturated by dipping in a vertical motion until bubbles cease to rise in the water. Held horizontally, the ends should be gently squeezed to remove excess water and to prevent them from unraveling. The patient will feel
hands moving over her body as the plaster is molded to conform to her contours. To avoid local pressure points, such as dents from fingers, the hands should always be kept flat while smoothing and polishing the cast.2 After plaster over the pelvis sets, traction is applied. The girdle is placed over the hips and the muslin straps fastened to the lower end of the table. Head traction is obtained by putting the patient's head in a halter and securing it to the opposite end of the table. Only as much traction as the patient can tolerate is applied. The Risser localizer is then placed over the maximum part of the convexity of the curve to elongate the spine while decreasing the curve by lateral pressure over the maximum rib r ~ t a t i o nOther .~ straps and devices may The upper cast is applied after correction forces (traction and localizer) are in place.
be applied as the individual situation warrants. The second stage of cast application is undertaken once corrective forces are in place. This involves the upper part of the body and completion of the cast. The excess body stockinette is pulled over the face and head and a hole cut a t the nose area. The eyes are kept covered to protect them from irritation due to plaster spatters. During this stage, the
Once the cast is molded, trimmed, and set, traction is released and t h e localizer removed.
patient feels constricted and may become panic stricken and hyperventilate. Therefore, it is important that the OR nurse provide continued explanation, encouragement, and reassurance, as well as touch contact. The patient should be told she will experience sensation of increasing heat as the plaster sets and reassured that she will not be burned. The cast will feel wet, cold, and heavy as setting occurs and
Bivalving allows the Risser cast to be removed easily and reapplied as necessary.
moisture in the plaster C O O ~ S .The ~ cast will actually weigh 12 to 15 pounds, but it will feel like 50 pounds to the patient. Once the cast is molded and set, head traction is released and the localizer removed. Two rolls of six-inch plaster bandage are applied to cover the localizer holes and secure the top and bottom of the cast. The stockinette is turned down to the neck exposing the face, and the patient may then be moved from the Risser table to the cart for final cast trimming. A t least four people are required to move the patient safely. The patient is placed on the cart in the prone position with her head extending over the end of the cart. Care must be taken during moving to protect her arms from injury. The cast is trimmed around the patient’s head, armholes, anal, and groin areas to prevent it from pinching the skin and to allow functional motion. Care is needed to ensure that overtrimming does not reduce the cast’s effi~iency.~Trimming equipment includes a sharp, short-bladed, carbonsteel knife; plaster scissors; and, if necessary, a cast saw. After trimming around the head, the
stockinette is turned over the cast edges and fastened down by a plaster bandage or staples or both. If staples are used, the patient should be forewarned that the staple gun is noisy but harmless. Sometimes, the patient’s chin becomes irritated from the traction and rubbing by the stockinette. A pinch of cornstarch in this area will soothe the skin. The groin and buttock area should be covered to protect hair from plaster trimmings, as well as for the patient’s modesty. The patient is then turned onto her back, and after the front of the cast is trimmed, she is transported to the unit for final drying. Blankets should be available for exposed extremities, but the cast must be uncovered for the first 24 hours to allow evaporation of moisture, thus hastening drying6 If the cast is to be bivalved, remind the patient that you will see her in a few days when she will return for this procedure. Some operators prefer to window the cast rather than bivalve. In bivalving, the Risser cast is split in half by cutting both sides open from the neck down. This allows the cast to be removed easily and reapplied as neces-
AORN Journal, September 1975. Vol 22, No 3
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sary. An electric plaster saw is used to cut the cast. The blade vibrates and does not go around; therefore, it will cut only rigid plaster and not loose Webril or skin. Because the blade oscillates, the patient will feel vibrations as the cast is cut. The OR nurse can reassure the patient by demonstrating on his or her hand how the blade works. Axillary and head hair must be covered to protect it from being entangled in the saw’s blade. Spreaders are used to separate the cast after it is cut. The stockinette is cut with scissors and the patient removed from the cast. The cast is checked for needed repairs and soilage, and the stockinette is stapled over the cut edges. The cast is then placed back on the patient and secured with buckled canvas straps. The patient is returned to the unit where, depending on the type of curve and physician’s orders, she may be allowed to remove the cast briefly to shower or take a tub bath to remove desquamating skin. If the patient is male, the nurse should explain that he will have his back shaved to remove hairs that carry microscopic bacteria. He should be reassured that you or a member of the team will see him tomorrow when he returns for surgery and explain that this time he will come in his bed. The operating room. The following are outcomes and processes to achieve on the operative day. 1. The operation will produce the desired satisfactory correction by use of internal instrumentation (Harrington rods are most common), a bone graft, or both. 2. The patient is assured safe practices by having the room, equipment, and instruments available and in good working condition. 3. The potential for reduced infection will be maintained by aseptic technique.
4. The patient will be safely trans-
ported to the postanesthesia recovery room by the surgical team. The process of assuring safe practices starts with checking the chart and identification of the patient as well as insuring that x-rays and blood are available. The patient is brought to the operating room in her bed. Upon arrival, the Risser cast is removed and again checked for soilage. If necessary, repairs are made. The patient’s skin is checked for pressure points and contact dermatitis and necessary care administered. The patient is then moved from her bed to the OR table. After the patient is transferred into the operating room, the doors are kept closed, and only authorized personnel should be permitted to enter. Instruments must be in proper working condition, and chisels and gouges must be sharp. If forceps are used in handling metal implants, the jaws should be protected with short lengths of plastic or rubber tubing to prevent marring or flaking. The wound edges should be protected with towels and irrigated after use of a mallet. Components of instrumentation should be of similar alloys to lessen electrochemical reaction in the body and must be sterilized far enough in advance to allow for proper cooling. The reusing or bending of implants is not recommended since micro defects may be created that will weaken the instrument. Sufficient number of sterilizing or washer trays or both must be used to eliminate overloaded or layered instrument pans. Finally, a practical system of inventory control must be maintained to insure a full range of each type implant used. Stored implants must not be in contact with each other or hard surfaces.? The nurse should always remain with the patient during induction of anesthesia. The anesthesiologist focuses his
AORN Journal, September 1975, Vol22. No 3
attention entirely on the patient a t this time, and the nurse should curtail outside diversions as well as give needed assistance. Once the patient is asleep, a Foley catheter is inserted and connected to a drainage bag. The body-support frame should be checked for proper adjustment before putting it under the patient. Again four to six people are required to safely position the anesthetized patient. Great care must be exercised in regard to head, neck, and arms as the patient is turned. Care also must be taken to insure that breasts are positioned for the least pressure and the genitals are free inside the frame. Catheter tubing should be free from kinks and positioned on the outside of the frame with the drainage bag visible to the anesthesiologist. The toes and
feet must be sufficiently supported to hang free of the table. Pressure areas, particularly the iliac crest, should be checked and padded. The Bovie electrosurgical plate must be placed securely in contact with the patient, yet not contact or interfere with electrocardiogram equipment. Lower extremities should be covered with blankets. A plastic drape is used to block off the anal area, and the knee strap is secured. To insure maintenance of aseptic technique, the room has been cleaned and wet dusted before the patient arrives. Equipment, such as the electrosurgical cautery, pillows, and frame, has also been cleaned and placed in the room. Wrapped sterile supplies are placed on the tables. It is imperative that strict technique be used in opening sterile supplies, gowning, gloving, and
For surgical positioning, the body support frame is adjusted properly, the Bovie (plate) is placed securely in contact with the patient, her feet are supported to hang free of the table, and the anal drape is in place.
AORN Journal, September 1975, Val 22, N o 3
369
draping and that movement is kept to a minimum. In applying the accepted prep solution, care must be taken to see that it does not run into the face, ears, eyes, or genital areas. Protection of the operative site is mandatory when marker x-ray films are taken. Again, the importance of monitoring personnel entering the operating room must be emphasized. The nurse must be the watchdog of aseptic technique. The use of disposable linen is advocated for gowning and draping since it does not allow penetration of blood or moisture during the procedure. Sterile agar plates may be placed on the operative field and instrument tables and sent to bacteriology for readings a t the end of the case to further assure and monitor good aseptic technique. All patients receive antibiotics pre and postoperatively, but should any pathogenic growth occur on the Agar plates, antibiotics would be changed accordingly. Sponges and tapes must be weighed to accurately estimate blood loss. Once counted, they should be placed in a clear plastic bag for easy final sponge count and to prevent them from drying and releasing bacteria into the OR environment.
Sterile dressings are applied at the close of the operation. Drapes are removed, and the back of the Risser cast is placed on the patient. Pillows are placed along the side of the table and bed, and the patient, frame, and jacket are turned as a unit onto the bed. The catheter and drainage bag are again checked for proper functioning. The frame is then removed, and the patient’s skin is checked for pressure points and her general condition assessed. The front of the Risser is then put on and the cast lightly strapped together. The anesthesiologist may not want the front of the Risser applied immediately because it may interfere with monitoring respirations. Accompanied by the anesthesiologist, the patient is transferred to the PAR room where vital signs are immediately checked. In addition to chart data, the anesthesiologist verbally reports replacem e n t a n d e s t i m a t e d blood loss, anesthetic agent used, and pertinent medical history to PAR personnel. Mutual agreement on the patient’s condition must be confirmed before the anesthesiologist leaves the area. The interval of cast changes varies depending on the case and the physi-
Table set up with instruments for Harrington rod insertion.
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cian’s preference. Usually, the patient will return to the plaster room in about two weeks for removal of stitches and application of a new Risser localizer cast. Hip flexion is restricted approximately 45 degrees to prevent excessive strain on the spine during sitting on an elevated level. Generally, the patient will then be permitted to go home, returning in five months for application of an ambulatory Risser body cast. This cast is less constricting and allows the patient more head movement and the joy of sitting. After three months (eight months postsurgery) the patient returns to the plaster room for x-rays and final removal of the cast. This time span is average, varying with physicians. It is a satisfying experience for the OR nurse to know that adherence to the standards described in this article is essential in the care and recovery of the scoliotic adolescent and will help him or her return to a normal, healthy, and ac0 tive life.
Notes 1. R Roaf, L J Hodkinson, Textbook of Orthopaedic Nursing (Oxford: Blackwell Scientific Publications, 1971) 466-475. 2. Roaf, Hodkinson, Textbook. 3. P A Zorab, Scoliosis (London: Heinemann Medical Books Limited, 1969) 17. 4. Roaf, Hodkinson, Textbook. 5 . Roaf, Hodkinson, Textbook. 6. Roaf, Hodkinson, Textbook. 7. Orthopaedic Metallurgy (Warsaw, Ind: Zimmer Manufacturing Company, 1967) 13-19.
Acknowledgment The author gratefully acknowledges the assistance of Clyde L Nash, MD, assistant professor of orthopedics; Mary Daunt, orthopedic assistant; and the Youth Spine Center, University Hospitals of Cleveland, in the preparation of this paper. Photography by Case Western Reserve University medical photography division.
True versus pseudociaudlcation Leg pain that mimics the cramp-like pain due to an insufficient blood supply to the muscles is caused by nerve compression in the ‘‘tail’’ end of the spinal cord, a group of investigators reported at the convention of the American Academy of Orthopaedic Surgeons in San Francisco. Frederick C Feiler, MD, and his coauthors, Donald P Gazibara, MD, and Jerry R Graul, MD, of St Francis Hospital, Colorado Springs, Colo, noted several signs that differentiate true claudication from pseudoclaudication. In true claudication, after about a block of walking, pain usually starts in the large calf muscle and goes upward. The pain is deep and aching, the skin blanches, and there is coldness of feet. Standing still relieves discomfort. In pseudoclaudlcation, a burning-type pain travels down the leg as walking continues. There is no blood vessel involvement, and only sitting or lying down relieves the pain. Causes of pseudoclaudication include congenital narrowing of the spinal canal, degenerative changes (spurs off the spinal vertebra), spinal column deformities, and spinal bone fractures.
Hospital admissions increase The American Hospital Association (AHA) Panel Survey, a monthly survey of 999 community hospitals selected at random, indicated hospital admissions in 1974 increased 4% over 1973. Average length of stay for all patients was reduced to 7.2 days, the lowest recorded by the AHA surgery in 11 years. In 1974, health care recorded a 10.6% increase over 1973. The third largest national industry, it accounted for about 7.7% of the gross national product, a total of $104.2 billion.
AORN Journal, September 1975, Vol 22, No 3
371
June Lorig, RN, is clinical supervisor, operating room, University Hospitals of Cleveland. She is a B S N graduate of the School of Nursing and Health at the University of Cincinnati.
360
coliosis or lateral curvature of the spine is a common problem encountered in the teenage patient population. The Scoliosis Research Society estimates there are about 10,000growing children in the United States and Canada currently being treated for scoliosis. The role of the operating room nurse can and should play a central part in the care and recovery of these patients. The effective fulfillment of this role has become an increasing challenge over the past decade as treatment and surgical techniques have become more complex. Scoliosis can be associated with a wide variety of health problems but is most commonly idiopathic or genetic in origin, and the child is otherwise healthy. It generally affects girls eight times more frequently than boys and is most often found in the adolescent age group. In general, there are three groups of scoliosis: infantile, juvenile, and adolescent. Although each has specific characteristics, all are growth related and until cessation of growth, the curve may become progressively worse. Therefore, any treatment program must effectively manage the problem until skeletal maturity is achieved. The most significant long-term problems related to scoliosis include early degenerative arthritis of the spine and increased cardiopulmonary problems, particularly cor pulmonale, which can be serious enough to shorten a person’s life by 10 to 15 years. In addition to the physical problems which may develop, significant emotional problems can arise relative to the cosmetic aspects of this spinal deformity. Treatment of scoliosis varies according to etiology and location of the curve, as well as age of the patient. Unless the curve is mild and growth is completed, the treatment will consist of either external bracing or internal support or a combination of both. External forces used to achieve correction include the Risser-Ferguson turnbuckle cast, Milwaukee brace, Risser localizer cast, and the haloskeletal traction apparatus. Internal support includes either posterior or anterior bone graft and internal metallic support using Harrington distraction and/or compression rods or Dwyer anterior spinal fixation. The selection of the external and
AORN Journal, September 1975, Vol 22, No 3
internal support mechanisms to be used will depend on the etiology of the scoliosis, the age of the patient, and other associated health problems. Although the majority of surgical patients will have a posterior spine fusion using autogenous bone graft and internal support with Harrington instrumentation, each patient is unique and a variety of combinations may be used. As community awareness and screening programs become more efficient, the need for scoliosis spine surgery for idiopathic cases should diminish and the use of braces, such as the Milwaukee brace, should be increasingly common. However, as health care improves, patients with more severe health problems are surviving long enough to develop spine problems that require a more ingenious variety of treatment approaches. In either case, children afflicted with scoliosis become very sophisticated and knowledgeable in the types of treatment and significance of their problem, The long-term nature of their problem frequently encompasses the teenage years, thus adding to the stresses and natural emotional changes of that age. For these reasons, the operating room nurse must be proficient in operating room technique and instrumentation to support extensive spine surgical procedures. She must also be able to meet the other major needs of the patient who will come to the operating room area for a variety of treatments. Nursing care goals for patients undergoing spinal fusion for scoliosis are divided into four main categories: 1. the health of the child pre, intra, and postoperatively 2 . maintenance and/or improvement of pulmonary function 3. appearance of the child 4. psychological support. With respect to these goals, this ar-
ticle concerns care given to patients in the plaster room and the operating room at University Hospitals of Cleveland. Other centers may vary in their health care approach. Plaster room. If the operating room nurse does not visit the patient, her active role starts in the plaster room where she endeavors: 1. to assist the physician to obtain partial correction of the spinal curvature by applying a Risser cast; 2 . to maintain a safe environment by having the room and equipment readily available and in proper working condition; 3. to develop rapport with the patient by supporting physiological and psychological needs; 4. to coordinate efforts of the involved staff for optimal efficiency and success in fdfilling the aforementioned goals. It is essential that the plaster room be ready before the patient arrives from the unit. The Risser table should be clean and set up properly with additional parts easily accessible. The patient must be unclothed during the procedure; hence, the room temperature should be comfortably regulated (at least 72 F [22 C]).l Equipment such as stockinette, felt, Webril, knives, and plaster should be placed in order of use to eliminate fumbling and lessen the time the patient must be on the table. Procedure manuals and physicians’ preference cards should be checked in advance to insure that desired equipment is available. While verifying the patient’s name and availability of the chart and signed permits, the nurse may assess individual needs. These include the child’s size, physical development, and mental maturity. Patients, who are usually between 11and 18 years old, are particularly sensitive a t this stage of their
AORN Journal, September 1975, Vol 22, No 3
361
The Risser table or frame used in making the localizer cast is ready for use.
The patient, in a stockinette suit, is placed on the frame’s longitudinal band. The localizer cast is applied in two stages. First, the pelvic cast is applied. When the plaster sets, cervical and pelvic traction are applied. Then, the Risser localizer is placed over the maximum part of the convexity of the curve to elongate the spine while decreasing the curve by lateral pressure over the maximum rib rotation. The upper part of the cast is applied after correction is obtained. Finally, the two parts of the cast are joined by plaster, traction is released, and the cast trimmed.
362
AORN Journal, September 1975, Vol 22, No 3
physical and emotional growth and development. Their need to communicate is acute, and they have many questions whether they ask them or not. The OR nurse needs to use perception and communication skills to ensure that the patient knows such things as how and what she can eat, how she will move, how she will go to the bathroom, and what she generally can and cannot do. This information must correlate with data given to the patient by her physician, floor nurses, and in written material. Girls are particularly concerned whether instrumentation and fusion will affect pregnancy in later years. It will
not, unless the curvature is severe in the lumbar area and there is associated pelvic distortion. General appearance, including fear that the cast will inhibit breast development or interfere with handling of menstrual secretions, is often of major concern to girls, The nurse should conduct discussions of feminine hygiene without embarrassing the patient. Young male patients usually try to appear manly and unafraid. They are conscious of underarm and pubic hair and the size of their genitals. Sportsoriented patients need to know that contact sports such as football and activities such as trampolining are barred
The patient is padded with various layers of Webril. Bony prominences such as the iliac crest are padded with felt.
AORN Journal, September 1975, Vol 22, No 3
363
for about three years. Golf, swimming, and riding are permitted as soon as the fusion heals, usually about 1 2 to 18 months. Before being moved from the cart to the Risser table, the patient is placed in a stockinette body suit. The stockinette may be 8, 10, or 12 inches wide and long enough to cover the patient from ankles to neck with allowance for coverage of the head later. The suit must fit snugly
but not tightly and without wrinkles. Wrinkles must be avoided as they may cause pressure points. Additional threeinch stockinettes may be used as sleeves to protect the arms from plaster and give added warmth. When the suit is on, the patient is transferred to the Risser table and padded with various thicknesses of felt. Felt edges must be beveled to prevent them from cutting into the skin. Three
Plaster is applied over the padding.
Muslin straps are Incorporated into the pelvic plaster and tied to the distal winch for use in applying pelvic traction.
364
AORN Journal, September 1975, Vol 22, No 3
The patient's head is placed in a halter. When the pelvic cast plaster sets, the patient is pulled out to tolerance by head and pelvic traction. The localizer stem is then abutted against the felt-protected prominent ribs and pressure is applied. Shown is Clyde Nash,
MD. to four layers of four- to six-inch Webril are wrapped over the stockinette and padding. The Risser cast is applied in two stages: (1) to cover the pelvis and (2) to cover the upper part of the body. I t is formed from about four- to six-inch rolls of plaster and several 5 x 30-inch plaster splints. Plaster should be dipped in water at 98.6 F (37 C) as it sets ten degrees higher than the original water temperature. Cooling the water five to ten degrees will slow the rate of setting. P l a s t e r rolls a n d splints m u s t be thoroughly saturated by dipping in a vertical motion until bubbles cease to rise in the water. Held horizontally, the ends should be gently squeezed to remove excess water and to prevent them from unraveling. The patient will feel
hands moving over her body as the plaster is molded to conform to her contours. To avoid local pressure points, such as dents from fingers, the hands should always be kept flat while smoothing and polishing the cast.2 After plaster over the pelvis sets, traction is applied. The girdle is placed over the hips and the muslin straps fastened to the lower end of the table. Head traction is obtained by putting the patient's head in a halter and securing it to the opposite end of the table. Only as much traction as the patient can tolerate is applied. The Risser localizer is then placed over the maximum part of the convexity of the curve to elongate the spine while decreasing the curve by lateral pressure over the maximum rib r ~ t a t i o nOther .~ straps and devices may The upper cast is applied after correction forces (traction and localizer) are in place.
be applied as the individual situation warrants. The second stage of cast application is undertaken once corrective forces are in place. This involves the upper part of the body and completion of the cast. The excess body stockinette is pulled over the face and head and a hole cut a t the nose area. The eyes are kept covered to protect them from irritation due to plaster spatters. During this stage, the
Once the cast is molded, trimmed, and set, traction is released and t h e localizer removed.
patient feels constricted and may become panic stricken and hyperventilate. Therefore, it is important that the OR nurse provide continued explanation, encouragement, and reassurance, as well as touch contact. The patient should be told she will experience sensation of increasing heat as the plaster sets and reassured that she will not be burned. The cast will feel wet, cold, and heavy as setting occurs and
Bivalving allows the Risser cast to be removed easily and reapplied as necessary.
moisture in the plaster C O O ~ S .The ~ cast will actually weigh 12 to 15 pounds, but it will feel like 50 pounds to the patient. Once the cast is molded and set, head traction is released and the localizer removed. Two rolls of six-inch plaster bandage are applied to cover the localizer holes and secure the top and bottom of the cast. The stockinette is turned down to the neck exposing the face, and the patient may then be moved from the Risser table to the cart for final cast trimming. A t least four people are required to move the patient safely. The patient is placed on the cart in the prone position with her head extending over the end of the cart. Care must be taken during moving to protect her arms from injury. The cast is trimmed around the patient’s head, armholes, anal, and groin areas to prevent it from pinching the skin and to allow functional motion. Care is needed to ensure that overtrimming does not reduce the cast’s effi~iency.~Trimming equipment includes a sharp, short-bladed, carbonsteel knife; plaster scissors; and, if necessary, a cast saw. After trimming around the head, the
stockinette is turned over the cast edges and fastened down by a plaster bandage or staples or both. If staples are used, the patient should be forewarned that the staple gun is noisy but harmless. Sometimes, the patient’s chin becomes irritated from the traction and rubbing by the stockinette. A pinch of cornstarch in this area will soothe the skin. The groin and buttock area should be covered to protect hair from plaster trimmings, as well as for the patient’s modesty. The patient is then turned onto her back, and after the front of the cast is trimmed, she is transported to the unit for final drying. Blankets should be available for exposed extremities, but the cast must be uncovered for the first 24 hours to allow evaporation of moisture, thus hastening drying6 If the cast is to be bivalved, remind the patient that you will see her in a few days when she will return for this procedure. Some operators prefer to window the cast rather than bivalve. In bivalving, the Risser cast is split in half by cutting both sides open from the neck down. This allows the cast to be removed easily and reapplied as neces-
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sary. An electric plaster saw is used to cut the cast. The blade vibrates and does not go around; therefore, it will cut only rigid plaster and not loose Webril or skin. Because the blade oscillates, the patient will feel vibrations as the cast is cut. The OR nurse can reassure the patient by demonstrating on his or her hand how the blade works. Axillary and head hair must be covered to protect it from being entangled in the saw’s blade. Spreaders are used to separate the cast after it is cut. The stockinette is cut with scissors and the patient removed from the cast. The cast is checked for needed repairs and soilage, and the stockinette is stapled over the cut edges. The cast is then placed back on the patient and secured with buckled canvas straps. The patient is returned to the unit where, depending on the type of curve and physician’s orders, she may be allowed to remove the cast briefly to shower or take a tub bath to remove desquamating skin. If the patient is male, the nurse should explain that he will have his back shaved to remove hairs that carry microscopic bacteria. He should be reassured that you or a member of the team will see him tomorrow when he returns for surgery and explain that this time he will come in his bed. The operating room. The following are outcomes and processes to achieve on the operative day. 1. The operation will produce the desired satisfactory correction by use of internal instrumentation (Harrington rods are most common), a bone graft, or both. 2. The patient is assured safe practices by having the room, equipment, and instruments available and in good working condition. 3. The potential for reduced infection will be maintained by aseptic technique.
4. The patient will be safely trans-
ported to the postanesthesia recovery room by the surgical team. The process of assuring safe practices starts with checking the chart and identification of the patient as well as insuring that x-rays and blood are available. The patient is brought to the operating room in her bed. Upon arrival, the Risser cast is removed and again checked for soilage. If necessary, repairs are made. The patient’s skin is checked for pressure points and contact dermatitis and necessary care administered. The patient is then moved from her bed to the OR table. After the patient is transferred into the operating room, the doors are kept closed, and only authorized personnel should be permitted to enter. Instruments must be in proper working condition, and chisels and gouges must be sharp. If forceps are used in handling metal implants, the jaws should be protected with short lengths of plastic or rubber tubing to prevent marring or flaking. The wound edges should be protected with towels and irrigated after use of a mallet. Components of instrumentation should be of similar alloys to lessen electrochemical reaction in the body and must be sterilized far enough in advance to allow for proper cooling. The reusing or bending of implants is not recommended since micro defects may be created that will weaken the instrument. Sufficient number of sterilizing or washer trays or both must be used to eliminate overloaded or layered instrument pans. Finally, a practical system of inventory control must be maintained to insure a full range of each type implant used. Stored implants must not be in contact with each other or hard surfaces.? The nurse should always remain with the patient during induction of anesthesia. The anesthesiologist focuses his
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attention entirely on the patient a t this time, and the nurse should curtail outside diversions as well as give needed assistance. Once the patient is asleep, a Foley catheter is inserted and connected to a drainage bag. The body-support frame should be checked for proper adjustment before putting it under the patient. Again four to six people are required to safely position the anesthetized patient. Great care must be exercised in regard to head, neck, and arms as the patient is turned. Care also must be taken to insure that breasts are positioned for the least pressure and the genitals are free inside the frame. Catheter tubing should be free from kinks and positioned on the outside of the frame with the drainage bag visible to the anesthesiologist. The toes and
feet must be sufficiently supported to hang free of the table. Pressure areas, particularly the iliac crest, should be checked and padded. The Bovie electrosurgical plate must be placed securely in contact with the patient, yet not contact or interfere with electrocardiogram equipment. Lower extremities should be covered with blankets. A plastic drape is used to block off the anal area, and the knee strap is secured. To insure maintenance of aseptic technique, the room has been cleaned and wet dusted before the patient arrives. Equipment, such as the electrosurgical cautery, pillows, and frame, has also been cleaned and placed in the room. Wrapped sterile supplies are placed on the tables. It is imperative that strict technique be used in opening sterile supplies, gowning, gloving, and
For surgical positioning, the body support frame is adjusted properly, the Bovie (plate) is placed securely in contact with the patient, her feet are supported to hang free of the table, and the anal drape is in place.
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draping and that movement is kept to a minimum. In applying the accepted prep solution, care must be taken to see that it does not run into the face, ears, eyes, or genital areas. Protection of the operative site is mandatory when marker x-ray films are taken. Again, the importance of monitoring personnel entering the operating room must be emphasized. The nurse must be the watchdog of aseptic technique. The use of disposable linen is advocated for gowning and draping since it does not allow penetration of blood or moisture during the procedure. Sterile agar plates may be placed on the operative field and instrument tables and sent to bacteriology for readings a t the end of the case to further assure and monitor good aseptic technique. All patients receive antibiotics pre and postoperatively, but should any pathogenic growth occur on the Agar plates, antibiotics would be changed accordingly. Sponges and tapes must be weighed to accurately estimate blood loss. Once counted, they should be placed in a clear plastic bag for easy final sponge count and to prevent them from drying and releasing bacteria into the OR environment.
Sterile dressings are applied at the close of the operation. Drapes are removed, and the back of the Risser cast is placed on the patient. Pillows are placed along the side of the table and bed, and the patient, frame, and jacket are turned as a unit onto the bed. The catheter and drainage bag are again checked for proper functioning. The frame is then removed, and the patient’s skin is checked for pressure points and her general condition assessed. The front of the Risser is then put on and the cast lightly strapped together. The anesthesiologist may not want the front of the Risser applied immediately because it may interfere with monitoring respirations. Accompanied by the anesthesiologist, the patient is transferred to the PAR room where vital signs are immediately checked. In addition to chart data, the anesthesiologist verbally reports replacem e n t a n d e s t i m a t e d blood loss, anesthetic agent used, and pertinent medical history to PAR personnel. Mutual agreement on the patient’s condition must be confirmed before the anesthesiologist leaves the area. The interval of cast changes varies depending on the case and the physi-
Table set up with instruments for Harrington rod insertion.
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cian’s preference. Usually, the patient will return to the plaster room in about two weeks for removal of stitches and application of a new Risser localizer cast. Hip flexion is restricted approximately 45 degrees to prevent excessive strain on the spine during sitting on an elevated level. Generally, the patient will then be permitted to go home, returning in five months for application of an ambulatory Risser body cast. This cast is less constricting and allows the patient more head movement and the joy of sitting. After three months (eight months postsurgery) the patient returns to the plaster room for x-rays and final removal of the cast. This time span is average, varying with physicians. It is a satisfying experience for the OR nurse to know that adherence to the standards described in this article is essential in the care and recovery of the scoliotic adolescent and will help him or her return to a normal, healthy, and ac0 tive life.
Notes 1. R Roaf, L J Hodkinson, Textbook of Orthopaedic Nursing (Oxford: Blackwell Scientific Publications, 1971) 466-475. 2. Roaf, Hodkinson, Textbook. 3. P A Zorab, Scoliosis (London: Heinemann Medical Books Limited, 1969) 17. 4. Roaf, Hodkinson, Textbook. 5 . Roaf, Hodkinson, Textbook. 6. Roaf, Hodkinson, Textbook. 7. Orthopaedic Metallurgy (Warsaw, Ind: Zimmer Manufacturing Company, 1967) 13-19.
Acknowledgment The author gratefully acknowledges the assistance of Clyde L Nash, MD, assistant professor of orthopedics; Mary Daunt, orthopedic assistant; and the Youth Spine Center, University Hospitals of Cleveland, in the preparation of this paper. Photography by Case Western Reserve University medical photography division.
True versus pseudociaudlcation Leg pain that mimics the cramp-like pain due to an insufficient blood supply to the muscles is caused by nerve compression in the ‘‘tail’’ end of the spinal cord, a group of investigators reported at the convention of the American Academy of Orthopaedic Surgeons in San Francisco. Frederick C Feiler, MD, and his coauthors, Donald P Gazibara, MD, and Jerry R Graul, MD, of St Francis Hospital, Colorado Springs, Colo, noted several signs that differentiate true claudication from pseudoclaudication. In true claudication, after about a block of walking, pain usually starts in the large calf muscle and goes upward. The pain is deep and aching, the skin blanches, and there is coldness of feet. Standing still relieves discomfort. In pseudoclaudlcation, a burning-type pain travels down the leg as walking continues. There is no blood vessel involvement, and only sitting or lying down relieves the pain. Causes of pseudoclaudication include congenital narrowing of the spinal canal, degenerative changes (spurs off the spinal vertebra), spinal column deformities, and spinal bone fractures.
Hospital admissions increase The American Hospital Association (AHA) Panel Survey, a monthly survey of 999 community hospitals selected at random, indicated hospital admissions in 1974 increased 4% over 1973. Average length of stay for all patients was reduced to 7.2 days, the lowest recorded by the AHA surgery in 11 years. In 1974, health care recorded a 10.6% increase over 1973. The third largest national industry, it accounted for about 7.7% of the gross national product, a total of $104.2 billion.
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