Anterior cervical spine recovery

From my experience, most of my co-workers and I groan and dread these anterior cervical spine cases. The majority of them tend to come out bad---you know, screaming/moaning/crying/thrashing. They all seem to require a large amnt of Dilaudid and Valium (or Versed.) I don't know why, I look through their home meds and many of them are chronic po narc users so I guess it's a tolerance issue. Anyways, the benzos seem to help as they tend to have muscle spasms. The few times I have seen these pts now come out bad is when anesthesia given 8-10 mg IM morphine about 30-60 mins before the case ends.

I've seen 2 pts post ACDF have a bleed requiring emergent return to OR. It was very scary as they came quite close to losing their airway due to the bleeding.

I agree with above poster about pain management. The chronic pain patients need to have a Pain Management Consult BEFORE they come out of OR and have drugs on board already.

Otherwise it is an uphill battle getting the pain under control and recovery can extend as long as 2-3 hours more than necessary.

One must be VERY COMFORTABLE in giving large doses of narcotics.

As the other posts stated they can be somewhat of a chalenge with pain control post op as many neck and back patients have been on po pain meds for quite a while. As far as bad outcomes we do not see this as a rule with our patients. Most are very stable. For post-op care airway is always a factor but especially for those patients like these where the surgical site is so close to the airway. For our post op assessment of course you do a full body assessment but extrememty muscle strengths and sensation are important to assess on these patients due to the close proximity of the surgical site to the nerves and spinal cord. you should be assessing their hand grasp strength, leg strength, and dorsi flexion and extension. One of the things you would want to know from the circulator during report is what type of deficits they had pre-op such as weakness, numbness, pain, and or tingling and what extremeties were involved. The other thing to remember is that the patient's symptoms may not be relieved right after surgery due to swelling from the procedure. For those patients that wake up and complain that they still have whatever symptoms they had pre-op it is important to reassure the patient that it may take a while to see results and that this is normal. Hope this helps a little.

I have to say that I've not had any problems with my anterior spine cases -they've all woken up peacefully and remained that way,with pain well controlled - likely due to having an excellent anesthetist - we have a number of those,and,of course,and the one or two that you wouldn't wish on your worst enemy...

We're finding the pts in the best post op pain control are those who've received multi-modal analgesic support preoperatively which,quite often in this PACU, is

-Acetaminophen (usually 975mg)
-Celecoxib (if not contraindicated)
-Gabapentin
-Oxycodone

Someone mentioned it above and I echo it that,since most,if not all,of these pts are narcotic tolerant,it is essential that one develops comfort with giving large doses of narcotic. For example, 4mg Hydromorphone IV in an hour wouldn't be an unusual dose.

My greatest challenges to date have all been pain management of terminally ill cancer pts who've had palliative bone surgery (e.g. pathalogical hip #). Their pain is on an inconceivable level - boy,those are tough. It takes massive amounts of narcotic analgesic to get these folks comfortable again. You do have to suspend your fears while being very observant.

We recover the ACDF patients frequently in our PACU and I agree, most of these patients are chronic pain med users. We find it VERY helpful if they get the "cocktail" PACU Jennifer talked about -- Tylenol, Oxycontin, Celebrex. If we are having trouble managing pain we will also give them their first dose of Vistaril for the muscle spasms.