Spine instability

When a patient returns from the operating room following spinal surgery it is important to establish with the surgical team any spine instability as well as the integrity of the dura.

This information is critical should the patient need to be reintubated, vomit, or elevate the head of bed.

There would be no greater catastrophe than for a caregiver to cause a spinal cord injury by incorrectly manipulating a patient who has a spine instability, particularly the cervical spine.

In the patient with an cervical spine instability requiring reintubation there are three options: direct laryngoscopy with in-line immobilization; fiberoptic intubation; or an emergent surgical airway.

Direct laryngoscopy with in-line stabilization (avoiding traction on the spine) is unquestionably challenging for the uninitiated but should be attempted firstin spine instability.

Fiberoptic intubation provides a more optimal view of the airway but requires that the equipment be readily available and that the patient is relatively stable and noncombative.

Emergency surgical airway in spine instability should be reserved for circumstances in which oral intubation has failed. It should be stressed that a patient does not need to be intubated to be ventilated.

If the bedside provider has knowledge of an unstable cervical spine and can adequately oxygenate a patient with a bag valve mask, it may be prudent to do so while obtaining the services of an experienced airway professional that may be more adept at the procedures listed earlier.

In the patient of spine instability who vomits and must lie flat, most commonly due to lumbar spine instability or a dural tear, the patient should be log rolled to protect the airway.

While not uniformly agreed upon, bed rest following durotomy is thought to decrease any potential cerebrospinal fluid (CSF) leak, allow the dural tears to seal, and reduce symptoms (e.g., nausea, vomiting, dizziness).

It is incumbent on the ICU provider to consider this bed-rest protocol in spine instability and if instituted, start appropriate thromboembolic (deep vein thrombosis/pulmonary embolism) prophylaxis measures if the query regarding the presence of a dural tear is affirmative.

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