Jean M Reeder, RN

M y thoughts were far from the road as I drove away from m y ap- pointment wi th an orthopedic

surgeon. He had recommended a pos- terior spinal fusion to correct m y scoliosis. I was confronted with the real- ity that my busy organized life as a wife and military nurse would be disrupted. Roles would be reversed. I would soon be a patient facing a major surgical proce- dure and lengthy recovery. I anticipated this experience with much anxiety. I t of- fered, however, the potential for personal and professional growth. I focused on this as a coping mechanism and as a means to channel my increasing anxiety.

Fig 1. Preoperative x-ray of author's spine with scoliotic curve.

As a result o f my firsthand surgical ex- perience, I was to f ind my perceptions about nurs ing care altered and m y commitment to caring strengthened.

Scoliosis is a lateral curvature of the spine, either structural or nonstruc- tural. Nonstructural curves demon- strate normal flexibility as seen on standing, supine, and side-bending radiographs. A patient with unequal leg lengths has a nonstructural curve, eas- ily corrected with a shoe lift. Structural curves do not have normal spinal flexi- bility and therefore do not correct when seen on side-bending and supine- bending radiographs. The most common

AORN Journal. January 1981. Val 33. No 1 35

forms of structural scoliosis are idio- pathic, neuromuscular, and congenital. This article will focus on s t ructural scoliosis, since i t is most frequently en- countered.

Idiopathic scoliosis, by far the most common type of scoliosis, is categorized according to the patient’s age when ini- tially diagnosed. These categories a re infantile, juvenile, and adolescent scoli- osis (Table 1). Adolescent scoliosis is the most common in the United States. Since initial school health screening programs began in 1962, more children are being diagnosed and referred for ex- amination.’ Treatment varies in a l l types of idiopathic scoliosis according to the location and severity of the curve and its rate of progression. Treatment can range from observation of the cur- vature, exercise, bracing, and finally, to

Jean M Reeder, RN, CNOR, is a captain in t he Army Nurse Corps. She is OR staff nurse and clinical preceptor for the OR technician course at the US Army Hospital at Fort Carson, Colo. She received a BSN from Arizona State Uni- versity, Tempe.

The author would like to acknowledge Barbara Harrum, RN, and Robert Brockman, Fitzsirnrnons Army Medical Center, Aurora, Colo, and Robert Dingeman, M D , Fort Carson, for their assistance in the preparation of this article.

The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

surgical correction. There are several other classifica-

t ions of scoliosis. Neuromuscular scoliosis is a spinal deformity tha t oc- curs in patients with neuropathic dis- eases such as cerebra l palsy o r poliomyelitis and with myopathic dis- orders such as muscular dystrophy.2 Muscle weakness and paralysis con- tribute to the collapsing spine and to impaired respiratory function. Spinal fusions with internal fixation are usu- ally done to stabilize the spine and pre- vent further pulmonary impairment. Congenital scoliosis results from con- geni ta l ly anomalous ve r t eb ra l de- velopment. The anomalies are classified as: (1) defects of segmentation, such as a posterolateral defect producing lordo- scoliosis, (2) defects of formation, one of which results in hemivertebra, and (3) mixed defects, which a re a combination of any of the previous anomalies. Con- genital scoliotic deformities are mostly progressive, highly predictable, and amenable to treatment. When left un- t r ea t ed , t hey can cause c r ipp l ing deformities and, in severe cases, serious cardiopulmonary problem^.^ Scoliosis is also attributed to less frequently seen causes such as neurofibromatosis , t r a u m a , metabol ic disorders , a n d tumors.

All forms of scoliosis may occur in a n adult. Adult scoliosis is simply a spinal curvature t h a t exists af ter skeletal maturity. Symptomatic adults usually seek treatment between 25 and 30 years of age, but patients in their 50s and 60s have been treated.4 The etiology of adult scoliosis is usually elicited from the patient’s history; most cases are idiopathic.5 Many pa t ien ts can re- member evidence of their deformity since childhood or adolescence.

As a teenager, I recall n1.y right hip was higher than the left, which gave me difficulty when sewing clothes. This wus especially noticeable in the hemlines.

36 AORN Journal , January 1981, V o l 3 3 , No 1

Table 1

Glossary Adolescent scoliosis-spinal curvature presenting at or about the onset of puberty and before maturity.

Adult scoliosis-spinal curvature existing after skeletal maturity.

Body alignment, balance, compensation-the alignment of the midpoint of the occiput over the sacrum in the same vertical plane as the shoulders over hips.

Compensatory curve-a curve, which can be structural, above or below a major curve that tends to maintain normal body alignment.

method-select the upper and lower end vertebrae, erect perpendiculars to their transverse axes. They intersect to form the angle of the curve. If the vertebral end plates are poorly visualized, a line through the bottom or top of the pedicles may be used.

Idiopathic scoliosis-a structural spinal curvature for which no cause is established.

Infantile scoliosis-spinal curvature developing during the first three years of life.

Juvenile scoliosis-spinal curvature developing between skeletal age of three years and the onset of puberty.

Kyphoscoliosis-lateral curvature of the spine associated with either increased posterior curvature or a decrease in posterior

Curve measurement by Cobb

angulation in the sagittal plane in excess of the accepted norm for that region. In the thoracic region, 20" to 40" of kyphosis is considered normal.

Lordoscoliosis-lateral curvature of the spine associated with an increase in anterior curvature or a decrease in posterior angulation in the sagittal plane in excess of normal for that region. In the thoracic spine, where posterior angulation is normally present, less than 20" curvature constitutes lordoscoliosis.

Nonstructural curve-a curve that has no structural component and that corrects or overcorrects on recumbent side-bending roentgenograms.

the convexity of a spinal curvature.

with a lateral curvature that lacks normal flexibility. Radiographically, it is identified in supine, lateral, and side-bending films by the failure to correct fully. Structural curves may be multiple.

Rib hump-the prominence of the ribs on

Structural curve-a segment of the spine

These terms have been defined and compiled by the terminology committee of the Scoliosis Research Society as printed in John H Moe et al, Scoliosis and Other Spinal Deformities (Philadelphia: W B Saunders, 1978) 7.

After noticing a slight curvature, my mother took me, at ten years of age, to an orthopedist. She was reassured that it would notprogress. Duringmy teens, the curve was more noticeable, as was the prominent hip, so she had another eval- uation done. This orthopedist told her not to worry and told her to "stop playing doctor." Ironically, m y mother was a school nurse at the time,

The second most common cause o f adult scoliosis i s neuromuscular dis- ease, primarily pol iomyel i t is , w h i c h was epidemic before polio vaccines were developed in 1955. Congenital scoliosis in adul ts i s ra re l y encountered. Symp-

toms o f adult scoliosis are back pain, curvature progression evidenced by a decrease in h e i g h t or i n c r e a s e in deformity, cardiopulmonary decompen- sation, and cosmetic deformity.

There i s a typ ica l p a t t e r n o f pain. T h e day begins pain free o r with on ly a mild ache and stiffness. As t h e day continues, t he backache and fat igue increase. The ache becomes pain, most of ten located at the apex o f t h e curvature o r j u s t below it. Lying down b r ings some relief. T h e pain i s more pronounced af ter moderate t o heavy phys i ca l exer t ion. As t i m e passes, it becomes more frequent and severe. Minimal exer t ion causes dis-

AORN Journal, January 1981, Vol33, No I 37

he potential for T paralysis is the most feared complication.

comfort. The patient decreases physical activities and strenuous work and mod- ifies his lifestyle to include a daily rest period to ease the pain. Sources of tem- porary relief such as heat, exercise, medication, and manipulation are no longer helpful.

I n my early twenties, I experienced a few episodes o f acute lumbarsacral strain, which lasted from several days to three weeks. They were resolved with bed rest, analgesics, and muscle relaxants. During the past two years, these episodes became more frequent. I used to take pride in my ability to remain scrubbed in on long, arduous cases, but now stand- ing for more than one hour in the operat- ing room caused increased discomfort and radiating pain to my right hip. Squatting and bending, routine body movements for the circulator, became taxing. Working overtime and on-call were almost more than I could tolerate. In the last six months prior to surgery, pain limited m y night’s sleep to five or six hours. My condition was deteriorating.

The first and most important step in a treatment plan for scoliosis is an in- depth evaluation. A history is taken with special attention to the complaint of pain. This includes its character, se- verity, and location as well as t h e specific activities that precipitate or re- lieve the pain. Has the patient modified activities of daily living to cope with the pain? Has the patient changed jobs to accommodate the discomfort? Is there

evidence of increasing deformity such as a prominent rib hump, prominent hip, or decrease in height? Does the scoliosis affect the patient’s cardiac or respiratory functions as evidenced in complaints of fatigue, shortness of breath, or increased heart rate upon ex- ertion?’

In the physical examination, atten- tion is focused on the spinal exam. The exam includes forward and side bend- ing, shoulder and iliac crest levels, leg lengths, waistline asymmetry, and pal- pation of the painful area. A neuro- logical examination assesses the pa- tient’s current status and rules out other possible causes of back pain such as herniated nucleus pulposus and spi- nal cord tumor. Previously spinal radiographs, compared to new radio- graphs, document evidence of curvature progression and changes in the skeletal maturation process. A typical scoliosis radiographic series includes a n anterior/posterior, lateral, supine and side-bending, and hyperextension views. Contrast studies such as mylo- graphy may be done if indicated. The anterior, posterior, and lateral views are usually done with a 14 inch by 36 inch cassette film at a 6 foot distance. The complete history, physical exami- nation, and radiographs enable the or- thopedic surgeon to make an accurate diagnosis and treatment recommenda- tion.8

My first episode o f low back pain was

38 AORN Journal, January 1981, Vol33 , N o 1

treated by an orthopedic surgeon who included an x-ray in his general evalua- tion. He gave me a prescription for mus- cle relaxants and advised me to rest for a few days. A few months later, when I was at officer basic training in the Army, my first comprehensive evaluation for scoliosis was performed. The physician assured me that my curve, which was measured at 30" by the Cobb method, would not progress.

The treatments of adult scoliosis are basically the same as for children. The degree of curvature can be observed over a period of time to see if changes occur. A trial of conservative treatment may be instituted consisting of rest periods, analgesics, physical therapy, and instruction in body mechanics and good posture. Bracing may be used for temporary support during painful episodes, particularly in older patients when surgery might be contraindicated due to medical problems. Such tempo- rary measures will not correct the prob- lems of progressive deformities and in- creasing pain. Surgical intervention is indicated when pain is not responsive to treatment, when curvatures progress to the point ofcosmetic deformity, or when cardiopulmonary functions are de- c r e a ~ e d . ~

For the adult scoliosis patient, deci- sion making is extremely difficult. The prospect of a major surgical procedure coupled with a recuperation of 6 to 12 months is a crisis situation. The patient may be the primary breadwinner, and an absence from work for six months or more could ruin the family financially. Will his job be there when he can return to work? Adults accustomed to being in- dependent will be thrust into total de- pendency for decisions and physical care during their hospitalization. Throughout their convalescence, they will rely on family and friends for some physical care, transportation, and other daily activities. The potential for paral-

ysis is perhaps the most feared compli- cation. Changes in one's sex life are also a concern. Will a back healing from a spinal operation, encased in a body cast, withstand sexual activities? All of these considerations must be explored by the patient and those close to him for him to be comfortable with his decision and to have a positive attitude about surgery.

My decision to have surgery was d ip ficult, even though I knew it was neces- sary. My curve had progressed to 37". I wanted two opinions to confirm the need for surgery. I was very concerned about complications and pain. I have V o n Willabrand's disease, a bleeding disor- der, and remembered the frightening period of postoperative bleeding after a previous operation, even though correc- tive measures were taken to control bleeding. What might happen during a normally bloody spinal fusion? My pain tolerance is low, and I was fearful of postoperative discomfort. I felt guilty that other nurses would work harder and take call more frequently during my absence. My husband, a busy military officer and part-time graduate student, would have to assume responsibility for running our home during and after my hospitalization. But, I was not much f u n at home, and I was becoming less useful at work. I felt like a crippled old woman, a feeling I hated. My decision was made. I accepted my physician's recommenda- tion for a posterior spinal fusion with Harrington instrumentation. Surgery was scheduled at a regional medical cen- ter, the referral center for my own hospi- tal. Surgical treatment and complications.

Russell Hibbs, MD, performed the first spinal fusion to correct scoliosis in 1914. Until the mid-l940s, spinal fu- sions for scoliosis were less than saisfac- tory because of failure of correction and nonunion.1° Paul Harrington, MD, achieved a landmark in corrective spi- nal surgery in 1960 when he introduced

AORN Journal, January 1981, V o l 3 3 , No 1 39

Fig 2. Harrington distraction system. 1. Curved distraction hook driver, 2. Harrington rod cutter, 3. hook clamp, 4. spreader, 5. compression rod clamp, 6. wrench, 7. “C” washer clincher, 8. sacral eyelet, 9. sharp sacral hook, 10. dull sacral hook, 11. “C” washer, 12. blunt distraction hooks, 13. sharp distraction hooks, 14. distraction rod, 15 and 16. threaded compression rods (311 6 and 118) with hex nuts, 17. sacral compression hook, 18. threaded sacral rod with hex nuts, 19. outrigger distraction unit.

Photos courtesy of Fitzsimmons Army Medical Center.

his instrumentation for internal fixa- tion of scoliotic spines.” His technique is the most widely used surgical treat- ment for scoliosis. An anterior approach t o correct severe thoracolumbar curves was reported by A Dwyer from Aus- tralia in 1969 for selected cases of scolio- t ic deformities resulting from cerebral palsy, paralysis, severe lordosis, and pelvic obliquity. l2 Dwyer instrumenta- tion is used most often as a staged pro- cedure in combination with Harrington rods.

Correction of scoliosis using the Har- rington distraction instrumentation is

through a posterior midline approach. The patient is under general anes- thesia, and the legs are wrapped to de- crease venous stasis. The prone patient is carefully positioned to permit max- imum chest and abdominal expansion to decrease bleeding from the paraver- tebral plexus. After the surgical team prepares and drapes the back, the sur- geon makes a straight midline incision extending the predetermined length of the fusion. An intradermal infiltration of epinephrine diluted in saline (1 part in 500,000) may be used to augment hemostasis along the incision line. The

40 AORN Journal, January 1981, Vol33, N o 1

surgeon extends the incision through the fascia, using self-retaining retrac- tors to expose the operating field. Meticulous dissection and hemostasis are maintained throughout the proce- dure. The surgeon strips all soft tissue from the posterior spinal elements, in- cluding muscle, fascia, and ligaments to the facets, with subsequent removal of subperiosteal covering.

Beginning the instrumentation, the surgeon places a distraction hook at the uppermost end of the fusion site, within the vertebral facet joint, on the concave side of the curvature. A blunt hook is then seated beneath the lamina of the distalmost vertebra in the fusion, also on the concave side. When both hooks are in place, the surgeon may use an outrigger distraction device to apply gentle distraction force to the curva- ture.

When the desired correction has been attained, the entire fusion area on the concave side is decorticated with par- ticular attention given to the facets. New autogenous bone is harvested from the iliac crest for placement along the fusion site. The bone i s obtained through a separate incision or by exten- sion of the initial incision, taking care to avoid injury to the superior gluteal ar- tery and nerve and the cluneal nerve. A compression assembly can be used on

the convex side. The surgeon places three hooks proximally and two to three distally on the transverse process. He places a compression rod fitted with an equal number of hooks evenly spaced in the convexity and sets it as the tempo- rary hooks are removed. The hex nuts are tightened to secure the assembly in the proper position.

Finally, the surgeon decorticates the convex side and inlays the entire fusion with cancellous bone strips obtained from the posterior iliac crest. The strips are placed lengthwise along the fusion mass.

The wound is irrigated and bleeding sites cauterized before closure. The sur- geon closes the wound primarily and uses pullout or subcuticular suture to close the skin. A compression dressing is applied and left on for several days.13 The patient, still anesthetized, is re- turned to the supine position and may be placed in a Stryker frame or a Circlebed. When the patient is stable and responds to verbal stimuli, he is transported to the postoperative recov- ery area.

Complications from posterior spinal fusions are significant in number and severity and increase in frequency in adults. Early postoperative complica- tions include hemorrhage, decreased pulmonary function, infections, hook or

Fig 3. Lateralposition used forthoracoabdominalapproach for the Dwyer procedure.

Drawings courtesy of Zirnrner, Inc.

AORN Journal, January 1981, Vol33, No 1 41

Fig 4. Dwyer spinal instrumentation. 1. cancellous screws, 2. collar, 3. staples, 4. ratchet spanner, 5. cable, 6. screwdrivers, 7. screw starter, 8. Hall calibrator, 9. staple introducer, 10. staple starter, 11 . crimper, 12. cable tensioner.

rod dislodgment, neurologic damage, paralysis, and death. Postoperative medical problems are often related to immobilization of the patient. Compli- cations most often seen are atelectasis, ileus, urinary retention and infection, and thr0mboph1ebitis.l~ Late post- operative complications are pseudar- throsis, fracture of the rod, and progres- sive loss of curvature correction result- ing from inadequate fusion length.

The Dwyer technique and other an- terior spinal procedures supplement the Harrington instrumentation for correc- tion of severe spinal deformities, par- ticularly in cerebral palsy, paralysis, and pelvic obliquity. For an anterior fu- sion with the transthoracic and thora- coabdominal approaches, a team of gen-

eral or thoracic surgeons may join the orthopedic surgeon.

General anesthesia via endotracheal tube is used for anterior fusion. Intuba- tion may be somewhat difficult in cases of severe spinal deformities. The patient is placed in a lateral position for a trans- thoracic approach or in a modified lat- eral position for a thoracoabdominal approach. A rib is first removed from above the uppermost vertebra to be in- cluded in the fusion. The surgeon enters the chest cavity and gains access to the abdominal cavity through the costal cartilage. He excises the thoracic and lumbar discs and dissects the vertebral bodies free of tissue in preparation for instrumentation, and removes the end plates. Dwyer’s technique uses a series

42 AORN Journal, January 1981, Val 33, No 1

of cannulated screws, staples, and a cable made of titanium that provide cor- rection to the convexity of a curve. A staple is inserted laterally into each vertebral body included in the fusion length. The staples serve as supports for cancellous screws, which are then in- serted through the staple hole into each vertebral body. The surgeon then intro- duces a cable through the screws and tightens the cable with the tensioner to achieve correction. Crimping the screws prevents cable slippage before the ten- sioner is removed. Intervertebral body fusion is then done with the previously removed rib. If bleeding from segmental veins is correctly controlled, there is less blood loss than in posterior fusion because decortication of bone is not done. Some surgeons awaken the pa- tient momentarily a t this point to ascer- tain that sensory and neurological func- tions are intact after such an extensive dissection and instrumentation. With incisional closure, a chest drainage tube is inserted and attached to a drainage system. The remainder of the incision is then closed. The patient is placed in a regular hospital bed and taken to the recovery area. Dwyer instrumentation is almost always used in conjunction with the Harrington procedure, usually performed two weeks apart.15

Anterior fusions have greater risks than posterior fusions. In addition to the complications that can occur in the posterior fusion, injury to the great ves- sels is more likely, with sudden hypovolemia and death. Paraplegia re- sulting from spinal cord trauma is more frequent as is pneumothorax and he- mothorax.16 Preoperative evaluation and counsel- ing.

Spinal fusion is a major surgical pro- cedure with morbidity and mortality rates approaching 50% in adults." For this reason a complete preoperative evaluation is mandatory to ensure the

patient is in optimal condition for surgery. Preexisting medical conditions should receive special attention and ap- propriate treatment. Preventing com- plications is a primary goal for both medical and nursing care planning.

My history o f Von Willabrand's dis- ease, a coagulation disorder charac- terized by a low factor VIII level, pro- longed bleeding time, and easy bruising, was verif ied. Extensive coagulation s tudies were done a n d sent t o a hematologist for evaluation. Dur ing consultation, he outlined a treatment protocol that would be initiated prior to surgery. He reassured me that new knowledge had been gained since my previous surgical experience and that ex- cessive bleeding would be controlled through daily monitoring of bleeding and coagulation times and through the use o f cryoprecipitate to stimulate prod- uction o f m y o w n fac tor V I I I . T h e hematologist gave me information a t a level I could understand and use. I felt more confident about control of m y bleeding problem.

A detailed history and physical exam is the first step in patient evaluation. Cardiopulmonary assessment is aided by a preoperative radiograph of the chest. Laboratory studies should in- clude a urinalysis and culture, a com- plete blood count, blood chemistries, coagulation studies, platelet count, and electrolytes if indicated. Abnormal re- sults should be corrected when possible. Pulmonary function studies are usually done. Electrocardiograms a re often taken in adults ofer 35 years of age or with a history of cardiac disorder. The patient's blood is typed and crossed for up to eight units of whole blood. Because of the increased risk of hepatitis, more patients are opting to donate their own blood for autogenous transfusions. I do- nated four units of my own blood over a period of five to six weeks prior to surgery.

AORN Jourrrul, Janunry 1981. Vol 33, N o 1 43

Fig 5. Dwyer staples, cannulated screws, and cable in place.

Some patients may benefit from a so- cial work or mental health evaluation to help them deal with family and finan- cial problems. Added stress may impede preoperative learning, preparation, and eventual recovery.18

Preoperative teaching by the unit nurse and counseling by the surgeon should be done in a quiet, unhurried, and private atmosphere. Information should be given in language the patient can understand, with terms defined. The patient and his family should be encouraged to ask questions a t this time. Simple illustrations are helpful to clarify points.

My surgeon reviewed complications knowing I understood what they were. His approach was positive and realistic. He also told me how I would feel the first few days after surgery-“like a Mack truck ran over you.” He briefly outlined the expected postoperative course, which allowed me to set some personalgoals for

progress. Perioperative nursing care.

Initial assessment can be accom- plished by telephone, a t home, a t the physician’s ofice, or a t the patient’s bedside. The perioperative nurse re- views the chart for information to assist in planning for optimum care. A patient interview complements th i s da ta gathering process. Family members frequently seek clarification about the surgical procedure and their role in as- sisting the patient during recovery. The family needs to become familiar with the hospital routines, visiting hours, and waiting areas.

The operating room nurse uses in- formation about the patient in planning perioperative care. Medical history and physical limitations such as hearing deficits contribute to the assessment and influence the plan of action. Educa- tion, culture, and religion may also in- fluence nursing care. The nurse briefs

44 AORN Journal, January 1981, V o l 3 3 , N o I

the patient about the preoperative routine: enema, preparatory shave, antibacterial shower, restriction of foods and liquids after midnight, preop- erative sedation, transportation to surgery, the holding area, and various noises and sensations encountered. It is most important that the patient under- stands the need to verify his identifica- tion frequently and that different per- sons will be asking his name and surgi- cal procedure. A visit t o the recovery room acquaints the patient with the routine there. A practice ride on a Stryker frame or Circlebed orients the patient to the purpose of the bed as well as the sensation of being turned.

Information obtained during the as- sessment is documented and shared with unit nurses and surgical team members. The perioperative nurse then plans the care. The nurse assembles proper instrumentation, sterile sup- plies, and positioning equipment, in- cluding chest rolls, pillows, and axillary pads. Positioning, turning, and use of monitoring devices focus on patient safety and prevention of problems dur- ing surgery.

During surgery, the operating room nurse gives periodic progress reports to the family. Stress is high for the family, and fear of the unknown coupled with hours of no communication can be easily misconstrued. Intraoperative care should be documented and communi- cated to the recovery room staff when the patient is transferred.

My husband appreciated the nurse who came to share the progress o f my surgery. The surgeons did likewise, and he felt relief knowing all went well.

Postoperative evaluation can be done in the recovery area or on the surgical unit. Validation of intraoperative nurs- ing care is obtained by verifying infor- mation given to the patient during the assessment interview regarding the atmosphere and stimuli in the operat-

ing room. Presence or absence of burns, pressure areas, and signs of infection also reflect the nursing care. Negative responses by the patient or evidence of complications resulting from surgery can be used in a positive way by modify- ing care for future patients. Evaluation also points out areas for improvement in operative nursing care. Postoperative care.

Immediate postoperative care is mul- tifocal since many body systems have endured prolonged stress during surgery. Normal postoperative care may be continued overnight in a critical care unit following the initial recovery phase. Harrington rod patients are usually placed in Circlebeds or in Stryker frames for immobilization and ease in turning. Monitoring devices and intravenous fluid lines are retained from 12 to 48 hours depending on the patient’s progress. Occasionally a pa- tient may need mechanical ventilatory assistance.

Significant pain lasts three to four days and is best relieved with regular doses of narcotic injections. Pain a t the donor graft site may persist for several months after surgery. Coughing and deep breathing cause pain, which can be relieved by analgesics. A paralytic ileus is common to spinal fusion patients, and a nasogastric tube may be inserted for the first two to three days after surgery. When bowel sounds are heard, nasogas- tric suction is removed and clear liquids are given. Thereafter the diet is ad- vanced as t01erated.l~

I was kept in the surgical intensive care unit until the morning after m y op- eration. Although I do not remember much, I felt as i f I was reclining on a bed o f nails. I also remember using the re- spirometer; it was terribly painful. I do not recall having a nasogastric tube after surgery. M y mouth felt full o f cotton balls, I was thirsty, and my speech was slurred. The first few days after my op-

AORN Journal, January 1982, Vol33, No I 45

eration are blurred in m y memory. Morphine helped the pain when it was given every four to six hours. Occasion- ally I had to wait out the time for another shot. It was extremely frustrating. Didn’t the nurse realize I needed pain medica- tion when I asked for i t , not 20 minutes later? I resented being told, Yt’s not time yet for your next shot.”

Turning is uncomfortable but made easier when done with more than one person. Pillows in the right places help. The patient should be turned to a prone position several hours a day to prevent pressure areas. This also allows the nurse to inspect the dressing. Frequent skin care is essential. A daily bed bath is refreshing for the patient, and massag- ing the back, legs, and bony promi- nences discourages skin breakdown. After the first few postoperative days, the patient is encouraged to perform simple tasks such as brushing teeth, washing hands, and combing hair. This allows the patient to participate in his care and provides exercise for the arms. Quadriceps setting and arm strengthening exercises may be pre- scribed to maintain muscle strength during immobility.20

Adult scoliosis patients require con- tinual emotional support, particularly during the period of extended bed rest after surgery. It is embarrassing for people who are used to caring for them- selves to be forced to depend on others for their physical needs and personal hygiene. Privacy is nonexistent in most hospitals. The need to cry, snore, or expel gas becomes everyone’s business. Periodic depression is experienced by the patient who is uncomfortable, can- not move, and watches the same walls for an eternity. Without diversionary activities, the patient can easily dwell on unpleasant thoughts.21 Occupational therapy can contribute to recovery by offering the patient a few simple activities such as macrame and stitch-

ery, which are easy to do in a supine position. Visitors and staff are morale boosters, especially if they chat for just a minute.

There were times I felt sorry for myself and cried. Then I would look across the room at Kathy, who was recuperating f rom her third spinal surgery. S h e would never walk. I quickly pulled my- self together, knowing my immobility was temporary. Constant background noise from morning until Late at night made sleeping and reading almost im- possible. Watching television did not re- quire much energy. I tried to keep a jour- nal, but even that took too much effort.

A plaster body cast is applied 7 to 12 days after surgery. It may extend over the shoulders or be an underarm jacket. Casting and ambulation are highlights for the patient who has been bedridden for many days. After prolonged bed rest, patients experience orthostatic hypotension and dizziness. Gradual elevation of the patient’s head is fol- lowed by dangling legs at the bedside and slow walking with two strong people to support the patient in case of fainting.

Being encased inplaster from throat to thigh on a Risser table reminded me o f stories I had read on torture devices. Three cast technicians supervised by the orthopedic resident performed th i s ritual on me. My entire weight was care- fully balanced on a two inch wide length o f steel bar with a crosspiece supporting m y shoulders. M y hips were cinched with muslin straps to the end o f the table to keep me in a pelvic tilt. The cast was applied and carved out at the edges, then three people hoisted m y heavy body, while the fourth quickly yanked out the balancing bar that was wrapped beneath the plaster. I felt burning, momentary pain, and then I stuck to the inside of the cast, which abraded my skin. Everyone warned m e about the cast becoming warm as it dried. Actually, it was so cool,

46 AORN Journal, January 2981, Vol33 , No I

Fig 6. Spinal column with 100°/o correction achieved with Harrington distraction and compression rods and hooks.

I used a blanket for the first time since surgery. But I was glad to have that cast on. The end was in sight.

Physical therapy is a vital part of postoperative care. Atrophy of leg mus- cles, a change in body alignment result- ing from curvature correction, and a shift in center of gravity due to the heavy cast all contribute to initial walk- ing difficulty. The patient is quickly fatigued and short of breath from mini- mal exertion. Physical therapists help the patient gain balance, correct an im- proper gait that might be present, and help him negotiate stairs in a cast. When the patient is able to walk with confidence and is otherwise stable, he is discharged from the hospital.

My physical therapy did not begin until nine days after surgery. I did ankle flexes on my own, but did not know other exercises were available; so m y leg, thigh, and buttock muscles were weak and were quite sore the first few days I walked. My physical therapist walked me in front o f a mirror with a strap around my waist; I felt like a toddler learning to walk. I saw myself pale and visibly fatigued from the effort of walk- ing. I walked like a duck. We worked on that. The next day I went u p the stairs. That required strength in my quadriceps that was not there. Going down was easier, but I felt like Humpty Dumpty about to fa l l . T h e greatest freedom gained in walking was not having to use that damn bedpan again. Discharge planning.

Discharge planning is crucial for the patient and family preparing for con- valescence a t home. Patients are unable to resume normal activities and are likely to overestimate their ability to function with a body cast.22 An informa- tion list for the patient to take home

AORN Journal, January 1981. Vol33 , No 1 47

Fig 7. Postoperative x-ray of the author's spine with Harrington rod in place.

should include the following: (1) signs and symptoms of infection and rod dis- placement; (2) cast or brace care: (3) tips on hairwashing; (4) activity limitations such as lifting, bending, and driving; (5) skin care: (6) exercises; (7) adapting the home environment such as putting pots at accessible levels in the kitchen; (8) resumption of sexual activities: (9) rec- ommendations for leisure activities; and (10) the telephone number of the

surgical unit and physician to use when questions arise. Discharge planning can alleviate problems for the patients and numerous phone calls for the surgeons.

I received little discharge planning other than "don't overdo it." I wrote down several questions and cornered m y orthopedic resident, who was happy to provide answers. Noth ing was said about how quickly I would tire for the first month or on planning activities to conserve energy. Because I a m a nurse, perhaps it was assumed that I knew ev- erything.

Throughout my hospitalization, I kept a journal to record my progress, observa- tions, and feelings. Observations re- newed long forgotten nursing concepts and reinforced beliefs I have about nurs- ing care.

I was a basket case by the time admis- sion day arrived. Nurse and physician patients know too much; they know what to fear. I spent many sleepless nights pondering my fear of losing control i f pain became unbearable. How would I cope if an osteotome slipped and I was paralyzed? My modesty made it difficult for me to accept that someone else would bathe me and give me personal hygiene. I could not imagine having unwashed hair for two weeks. I worried about my reaction to fellow nurses. I f a nurse made a mistake, would I correct her? Would I accept the care even if it were incorrect? Could I tolerate immobility for ten days?

Coping mechanisms came from most expected sources. My husband was em- pathetic from the start as he had a post- erior spinal fusion five years before. He was extremely patient, supportive, and encouraging throughout my ordeal. My operating room supervisor was under- standing and did a lot of listening. Her reassurance that my health was more important than work relieved my guilt. A surgeon friend was also supportive and told me I would be a fool i f I was not apprehensive.

48 AORN Journal, January 1981, V o l 3 3 , No 1

Family plays an important role in any surgical experience. Family members bring a touch of normality to an other- wise alien environment. Sometimes they are left out of decision making and forgotten when changes are made. Staff may see them as barriers in accomplish- ing routine patient care, but family can be helpful in participating in care. Mas- saging sore limbs and helping a t meal- time are ways they can feel useful and give a loving touch. Family should be in- cluded in preoperative counseling and discharge planning so they know what to expect.

My husband‘s visits were so important to me. I laid for hours anticipating his arrival and sometimes cried when he left. He knew me best and could cheer me up with his silly jokes and our special talk. When I came home, he continued to be my caregiver and made convalescence so much easier. Other family members and friends called frequently, and my parents drove f rom Arizona to help us for the first week I was home. My mother said she knew in her mind that all went well, but her heart told her to see for herself.

When family is not around, patients give one another support. A unique socialization process occurs among pa- tients, especially on an open unit. When a new patient arrives all the established ones take note. Introductions are made and surgical problems shared. Helpful hints about certain staff members, the diet kitchen, and janitor soon follow. As patients are wheeled away for diagnos- tic studies, casting, and surgery, everyone shouts “good luck.” If someone is in pain or feeling blue, others help as best as they can. They share stories and are glad when someone goes home. Some patients are much more depen- dent on the nursing staff than others. It follows then that the nurses get to know better those patients that need more care, because they spend more time

with them. Nurses spend eight hours a day with

their patients, and the physicians visit briefly each day. Sometimes they do not make rounds, and the patient misses the momentary encounter with the per- son that has performed the cure.

I n m y case, nursing care and medical care varied in quality as it does in any hospital. For the most part , it was good. I was caught in a dilemma being a nurse and a patient. A s ta f f member jokingly told me on my first day not to cause them any trouble. What a message! Patients are expected to accept all decisions made about their care. They are often unaware that a mistake has been made. A nurse is expected to assume the patient role when hospitalized. Passive acceptance o f im- proper care is difficult when you know something is not being done correctly. I t is your body after all. I asked about my medications and m y lab work. A f ter surgery, I reported signs of inflamma- tion in the heparin locks used for infus- ing the cryoprecipitate. I cringed when the nurses used a clearcolorlessprepara- tion solution when inserting the Foley catheter prior to surgery. Where was the iodophor I thought to myself Later on I helpfully instructed the s ta f f how to best move me to the litter when the day came for casting. I t was important to my self- concept that I be allowed to retain my nursing identity. This caused some con- sternation in the nursing staff. They knew that I did a lot of watching.

This experience helped me grow as a person and as a nurse. I no longer took things for granted such as walking and showering every day. Priorities were re- vised. A spotless kitchen was not so im- portant, I felt a new appreciation for my husband. I learned it was hard for me to be confined for so long and that my emo- tions were more labile than usual.

A s a nurse, my belief in emotional sup- port to the patient was reinforced. I saw how important communications between

AORN Journal, January 1981 ~ Vol33, No 1 49

physicians and nurses and between physicians and patients can be. As health professionals, we say things in passing to patients that they take as gospel. Time becomes very important to patients. I f the physician is late or does not show up at all, they feel a letdown. When a pain shot is promised and does not come for 20 minutes, it seems like forever. I wonder how many nurse's aides have reclined on a bedpan for 15 minutes? Busy profes- sionals who are caught up in their own worlds of rounds, care plans, surgery, and continuing education sometimes forget that the patients' time is just as valuable to them. Take time to talk with patients and listen to what they say.

Now that the worst is over, I a m glad the surgery was done. Back pain is no longer a constant companion, and my only complaints are the heat retained in my body jacket and boredom with wear- ing the same shapeless clothes. I antic- ipate returning to work in a few weeks and to the time several months away when my shell is shed. I a m grateful to have a debilitating condition corrected and to live a fulfilling life once again. 0 Notes

1. Catherine Holt de Toledo, "The patient with scoliosis: The defect: Classification and detection," American Journal of Nursing 79 (September 1979) 1591; Mary J Miller, "Screening program for scoliosis." AORN Journal 27 (April 1978) 1012.

2. John H Moe et al, Scoliosis and Other Spinal Deformities (Philadelphia: W B Saunders, 1978) 23.

3. lbid, 7, 131. 4. lbid, 7. 5. Susan M Swank, "The management of

scoliosis in the adult," Orthopedic Clinics of North America 10 (October 1979) 891; John P Kostuik, "Decision making in adult scoliosis," Spine 4 (November-December 1979) 523.

6. Moe et al, Scoliosis and Other Spinal Defor- mities, 430; Swank, "The management of scoliosis in the adult," 892.

7. J L Briard, D Jegou, J Cauchiox, "Adult lum- bar scoliosis," Spine 4 (November-December 1979) 528; Swank, "The management of scoliosis in the adult,'' 892.

8. lbid, 895-896. 9. Kostuik, "Decision making," 521-522; Briard,

Jegou, Cauchoix. "Adult lumbar scoliosis." 529. 10. Moe et al, Scoliosis and Other Spinal Defor-

mities, 2. 11. Paul R Harrington, "Treatment of scoliosis.

Correction and internal fixation by spinal instrumen- tation." Journal of Bone and Joint Surgery 44A (June 1962) 591; Paul R Harrington. Harrington Spine lnstrumentation and Fusion Technique (War- saw, Ind: Zimmer USA Lit No TR-2201, January

12. Moe et al. Scoliosis and Other Spinal Defor- mities, 5.

13. Harrington, Harrington Spine lnstrumenta- tion, D64-D65; Robert B Winter, "Posterior spinal fusion in scoliosis: Indications, techniques, and re- sults," Orthopedic Clinics of North America 10 (Oc- tober 1979) 788-794.

14. Swank, "The management of scoliosis in the adult ," 902.

15. David S Bradford, "Anterior spinal surgery in the management of scoliosis," Orthopedic Clinics of North America 10 (October 1979) 804-809.

1978) D60-D65.

16. lbid, 810. 17. Swank, "The management of scoliosis in the

adult," 901. 18. Mark L Phippen. "Nursing assessment of

preoperative anxiety," AORNJournal31 (May 1980) 1019.

19. Lyle J Micheli, Margaret A Magin, Roberta Rouvales. "The patient with scoliosis: Surgical man- agement and nursing care." American Journal of Nursing 79 (September 1979) 1603.

20. lbid, 1606. 21. lbid, 1607. 22. Lynn H Schatzinger. Eleanor M Brower,

Clyde L Nash Jr, "The patient with scoliosis: Spinal fusion: Emotional stress and adjustment," American Journal of Nursing 79 (September 1979) 1612.

50 AORN Journal, January 1981, Vol33 , N o 1