Preoperative preparation should be used to eliminate psychological concerns and fears about surgery and to build up confidence in overcoming the disease; physiologically, various factors that are not favorable to surgery should be eliminated to enhance tolerance to surgery.
(I) General preparation
In addition to the spinal examination, all patients who are to undergo surgery must undergo a comprehensive and systematic physical examination and necessary laboratory and special tests before surgery. These include routine blood, urine and stool, bleeding time, coagulation time, blood glucose, urine glucose, electrolytes, liver function, kidney function, chest photograph, and electrocardiogram. Pulmonary function was checked in patients with spinal deformity. Routine ultrasound examination of liver, gallbladder, pancreas, spleen and both kidneys are done. To understand the function of each important organ and the presence of potential disease. Other necessary tests such as Stagnara special postural radiographs for congenital scoliosis, CT, MRI, isotope scan, etc. are performed as needed. Ultrasound of the paravertebral, bilateral psoas major and iliac fossa should be done for spinal tuberculosis. Yuan Haifeng, Department of Spinal Orthopedics, General Hospital of Ningxia Medical University
2. The patient and family should be given a detailed explanation of the condition, the purpose and general procedure of the operation, the matters requiring the patient’s cooperation and the problems to be noted before and after the operation, the possible therapeutic results, the risks of the operation, the possible accidents during the operation and the problems that may remain after the operation. In order to obtain the understanding of the patient and family, but need to avoid adverse stimulation, and sign the surgical consent form.
3. The day before the surgery, the patient should clean the whole body and take a shower if possible. Patients undergoing sacrococcygeal surgery should routinely have a cleansing enema. Blood specimens are drawn and sent to the blood bank for blood preparation for use during surgery. Notify the operating room and anesthesia department to prepare for surgery. For patients with excessive emotional stress, give appropriate sedative medication, e.g., 2mg of oral solarelin, before going to sleep to ensure that patients have good rest. After 10 p.m., fasting from food and drink begins.
4. Spinal surgery is a highly demanding procedure to prevent infection and requires systemic prophylactic antibiotic application 1 day before surgery and 30 minutes before surgery. In the case of spinal tuberculosis, regular and strict anti-tuberculosis treatment is required for two weeks before surgery is performed.
5. In the morning of the day of surgery, the patient should have all stools and urine removed. If the estimated duration of surgery is more than 6 hours, a retention urinary catheter is placed to prevent intraoperative overfilling of the bladder. Thirty minutes before surgery, preoperative medication is given as prescribed by the anesthesiologist. Before entering the operating room, remove the denture, watch, earrings, etc., and keep them properly. Bring medical records, various photos, intraoperative antibiotics and other items into the operating room with the patient.
(ii) Pre-operative training
The purpose of preoperative training is to make the patient better adapt to the postoperative situation and reduce the occurrence of postoperative complications.
The patient is not accustomed to defecate and urinate in the prone position. Therefore, difficulty in urination often occurs after surgery, and overfilling of the bladder forces the physician to use catheterization measures, increasing the patient’s pain and the chance of urinary tract infection. Difficulty in passing stool can cause postoperative abdominal distension and constipation. Therefore, patients should learn to defecate and urinate in the prone position within two days before surgery.
Respiratory training can significantly reduce the occurrence of postoperative respiratory complications. Deep breathing and effective coughing in the prone position need to be practiced. When performing deep breathing exercises, the patient should experience the sensation when using the intercostal muscles and diaphragm separately for maximal inspiration and when using both together. In this way, the postoperative patient can breathe adequately using the respiratory muscle strength that minimizes wound pain. An effective cough should be a sudden contraction of the respiratory muscles and the rapid passage of airflow through the airway for the purpose of expelling secretions. The key to training is to enable the patient to overcome the “false cough” of laryngeal vocalization, which can be identified by the sound of the cough. If necessary, the patient can be stimulated to cough by pressing on the trachea in the superior sternal fossa. Patients who are to undergo anterior cervical surgery should be trained to push the larynx to the left or right 3 to 4 times a day and maintain it for a few seconds to reduce postoperative laryngeal discomfort.
3. Physical activity training Appropriate physical activity can increase body metabolism, improve cardiopulmonary function and enhance surgical tolerance in the preoperative period. After surgery, it can promote blood circulation and avoid deep vein thrombosis. It can also enhance the patient’s confidence in recovery. Therefore, patients should be instructed to perform functional exercises of limbs in bed.
For patients who need to perform the “wake-up test” during surgery, teach them to make fist and toe extension and flexion activities according to medical advice. 4.
When posterior spinal surgery is performed prone, the patient should be trained to extend the prone time gradually until he/she can support the patient for more than 2 hours. The physician should determine whether the patient is comfortable in prone position and whether there is any respiratory impairment before surgery. This training is even more necessary if the surgery is performed under local anesthesia.
(iii) Local preparation
Wound infection after spinal surgery often leads to serious consequences. This is due to the fact that spinal surgery mostly involves exposure of the spinal canal and even incision of the dura mater, and infection can spread to the central nervous system. Various spinal internal fixators are foreign bodies, and once the wound is infected, it is not easy to control the infection, and the internal fixator cannot be easily removed, making management very difficult. Therefore, the quality of local skin preparation must be emphasized.
1. Routine skin preparation For those who have been bedridden for a short time and whose skin is not broken, shave the sweat and hair of the skin in the surgically sterilized area 1 day before surgery, brush gently with soapy water 3 times, wipe dry and rub with 75% alcohol for 1 minute, and wrap with a sterile towel. In the morning of the day of surgery, the skin preparation is checked again, and if there is any omission, additional skin preparation should be made. The skin of the surgical area is wiped with 75% alcohol for 1 time and then wrapped with a sterile towel and sent to the operating room. When shaving, if there is any skin cut, disinfect with iodine and cover with sterile gauze.
2. Treatment of skin problems Patients who have been bedridden for a long time, especially those who have undergone cranial traction or slept in a plaster bed, local preparation should be started from 3 days before surgery. The skin surface is often scabbed and closely adhered to the sweat hair. If it is forcibly removed on the day before surgery, more small traumas may be left on the skin, increasing the chance of postoperative infection. It is advisable to use warm soapy water, gently scrub; or use liquid paraffin to soak through the scab, and then gradually peel it off. The hair should be shaved very gently and carefully to avoid damaging the skin.
Patients with pus spots on the skin in the surgical area or with scabs that have not fallen off after skin injury and secretions under the scabs should not undergo elective spine surgery. In cases where there is damage to the skin in the surgical area and emergency surgery is necessary, such as open spinal injuries, the patient is treated as a debridement procedure. The use of antibiotics should not replace skin preparation and aseptic operation, nor should it improve tissue resistance that has been reduced by surgical trauma.
(iv) Special case management
Patients undergoing spinal surgery have a combination of conditions that require special management, with paraplegia and medical conditions being more common. This article only mentions some points to attract the attention of surgeons.
1. paraplegic patients paraplegic patients are bedridden for a long time, heavy psychological burden, less activity, poor appetite, coupled with gastrointestinal tract dysfunction, resulting in inadequate intake and absorption of nutrients, often malnutrition, poor general condition, preoperative patients should be encouraged to eat, and eat more fresh fruit. If necessary, tube feeding or intravenous high nutrition can be used to improve the nutritional status as much as possible, so that patients can successfully pass the negative nitrogen balance period after surgery, ensure the wound healing and reduce the occurrence of postoperative complications.
Water, electrolyte and acid-base imbalance must be completely corrected before surgery. Patients with comorbidities such as decubitus ulcers, respiratory tract infections, and urinary tract infections should be actively treated before surgery (see the content about postoperative complication control).
2. Treatment of diabetic patients Under the influence of anesthesia and surgery, the metabolic disorders of diabetic patients increase accordingly, which can aggravate diabetes, cause hypoglycemia, water and electrolyte disorders, and in severe cases, ketonemia, and make postoperative recovery difficult. In diabetic patients, leukocyte phagocytosis is decreased, and bacteria are more likely to multiply in the organism, making postoperative infection easy to occur and not easily controlled. Therefore, diabetic patients should work out a treatment plan with an internist before surgery, including dietary control and the use of hypoglycemic drugs, especially insulin. It is best to control blood glucose to a level of 8 mmol/L or less. As long as appropriate measures are taken, there is no special risk for surgery in patients with moderate diabetes or less.
3. Treatment of hypertensive patients Because of the poor vascular regulation of these patients, blood pressure fluctuations are likely to occur during anesthesia. During the operation. The trauma surface bleeds a lot, which may lead to excessive blood loss. Postoperative rebound hypertension may occur, which increases the risk of surgery. During the preoperative preparation phase, diastolic blood pressure should be controlled within 90 mm Hg and at least not more than 100 mm Hg. For mild hypertension, antihypertensive drugs can be discontinued 2 weeks before surgery. In patients with severe hypertension, medication should be used until preoperatively. For hypertension-induced impairment of heart, kidney, brain and other organ functions, appropriate treatment should be made. Intraoperative monitoring should be strengthened to complete the surgery safely.
Patients with severe spinal deformity or paraplegia often have respiratory insufficiency and respiratory tract infection, which increase the risk of surgery and postoperative complications. Strengthen respiratory function exercise, avoid smoking for at least 2 weeks, and use effective antibiotics, expectorants, and bronchial antispasmodics. For general anesthesia, inhalation anesthetics should not be used to reduce mucosal irritation to the respiratory tract. Encourage the patient to cough up sputum. If the sputum is sticky and not easy to cough up, do nebulized inhalation twice a day to dilute the sputum, reduce inflammation and facilitate coughing up.
As a surgeon, the most important thing is not to think only about the surgery and ignore the problems that exist. The whole body of the patient should always be considered. If there is a medical problem that needs to be treated, ask for a consultation with an internist to assist in the management.
——————- from Surgery of the Spine, Third Edition, edited by Rao Shucheng and Song Yuming