Surgical Management of Traumatic L₂-L₃ Spondyloptosis

Article Outline

• ABSTRACT
• Case Presentation
  • Radiological studies
  • Preoperative care in the intensive care unit (ICU)
  • Surgical care
  • Postoperative care
• Discussion
  • Preoperative considerations
  • Intraoperative considerations
  • Postoperative consideration
• Conclusion
• Examination
  • Surgical Management of Traumatic L2-L3 Spondyloptosis
    • Purpose/Goal
    • Behavioral Objectives
    • Questions
• Answer Sheet
  • Surgical Management of Traumatic L2-L3 Spondyloptosis
• Learner Evaluation
  • Surgical Management of Traumatic L2-L3 Spondyloptosis
    • Purpose/Goal
    • Objectives
    • Content
    • Test Questions/Answers
    • Learner Input
• References
• Copyright

ABSTRACT 

Subluxation of a vertebra secondary to an injury (ie, traumatic spondyloptosis) is most commonly seen in the lumbosacral joint. This extremely rare spinal destabilization is caused by congenital defects, degeneration, tumors, infection, or trauma and is accompanied by severe neurologic debilitation.

The patient's neurological function can be preserved when surgical team members have knowledge of spinal injuries, surgical interventions, positioning and its implications, and an awareness of the risks to the patient.

Appropriate interventions can decrease complications, operative revisions, length of stay, morbidity and mortality, and hospital costs. AORN J 89 (April 2009) 657–672. © AORN, Inc, 2009.

Key words:  traumatic spine injury , spine surgery , spondyloptosis , spinal subluxation

Traumatic middle lumbar spondyloptosis is defined as 100% or greater subluxation of a superior vertebra on an inferior vertebra secondary to an injury.¹ The most common site of spondyloptosis is the lumbosacral joint. The anatomic etiology of this type of injury is a pathologic destabilization of the spine caused by congenital defects, degeneration, tumors, infection, or trauma.² Severe neurologic debilitation often accompanies lumbar spondyloptosis.³, ⁴, ⁵ The surgical management of traumatic spondyloptosis focuses on spinal stabilization and neurologic decompression.

This type of injury is extremely rare.⁶ Surgical repair of traumatic lumbar spondyloptosis is intricate and extensive, requiring the surgical team to be knowledgeable about positioning options and their associated implications, spinal instrumentation equipment and procedures, specific surgical risks, and essential components of perioperative management. Nurses who maintain a current knowledge base in the advancing field of spine surgery can help improve patient outcomes and decrease complications and the need for surgical revisions, which will further decrease length of stay, morbidity and mortality, and hospital costs.

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Case Presentation 

Mr A, a 37-year-old Hispanic male, arrived in the emergency department trauma resuscitation area via air ambulance after falling approximately 6 feet off construction scaffolding and landing on metal spikes. On arrival, he reported pain in his left flank, left buttock, and lower back, as well as decreased sensation from his left nipple to his left foot, including numbness to his left thigh. The physician examining him found posterior puncture wounds to his right flank and right perineal area just beside the rectum and gross deformity to the lumbar region of his spine.

The physician reported that the patient demonstrated a Glasgow coma score of 15 on initial neurologic examination and normal muscular strength and sensation to his bilateral upper extremities. The patient demonstrated patchy sensory deficits in both lower extremities, especially his left lateral thigh. He also had decreased sensation in his medial thighs bilaterally and his medial and lateral calves bilaterally. The physician performed a limited motor examination, which revealed the patient had the ability to contract his quadriceps and to dorsiflex and plantar flex his feet bilaterally.

Inspection and palpation of the patient's back during the secondary survey showed boney deformity and pain with palpation to the lumbar spine region. Medical and nursing staff members maintained strict spinal precautions throughout the patient's care by ensuring that spinal alignment was maintained during log-rolling maneuvers and by using a slide board for patient transfer. Before transporting the patient for further studies, the emergency department nursing staff administered an initial dose of antibiotics, verified the need for and provided tetanus prophylaxis, completed a pain assessment, and obtained orders for medications to control the patient's pain.

Radiological studies 

Radiological studies included plain films (Figure 1), computed axial tomography (CT) scans, and magnetic resonance imaging (MRI). The CT scan disclosed an acute complete misalignment of the lumbar spine at the L₂-L₃ level. The L₃ vertebral body was displaced to the left and posterior to the L₂ vertebral body (Figure 2). There was also a comminuted fracture of the right aspect of the vertebral body of L₃, a left transverse process fracture, and a nondisplaced fracture of the tip of the spinous process at L₁. The patient had a displaced fracture of the spinous process at L₂ (Figure 3) and a comminuted fracture of the spinous process of L₅ and L₄ (Figure 4). Continuity of the thecal sac was no longer observed at the L₂-L₃ level.

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• Figure 1. 

  Anterior/posterior x-ray view of the L₂-L₃ injury.

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• Figure 2. 

  Coronal computerized tomography scan of the injury.

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• Figure 3. 

  Sagittal computed tomography scan of injury.

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• Figure 4. 

  Coronal computed tomography scan of injury.

In addition to confirming the CT findings, the MRI revealed the presence of post-traumatic marrow changes involving L₁ through L₃ vertebral bodies, soft tissue edema within the thecal sac at the L₃ level (Figure 5), and a probable impingement of the left L₃ nerve root by a fracture fragment (Figure 6). The only concomitant injuries found were bilateral iliopsoas hematomas and a perirenal hematoma.

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• Figure 5. 

  Sagittal magnetic resonance imaging scan showing soft tissue edema within the thecal sac at the L₃ level.

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• Figure 6. 

  Magnetic resonance imaging scan showing probable impingement of the left L₃ nerve root by a fracture fragment.

Preoperative care in the intensive care unit (ICU) 

Upon completion of the radiographic studies, transport personnel took the patient to the ICU to await neurosurgical intervention. After completion of the initial admission assessment, nurses applied thigh-high elastic stockings and sequential compression devices to the patient's lower extremities. The neurosurgeon wrote orders for the patient to remain in the supine position because of the instability of the patient's spinal fractures. The nurses provided position changes within a very limited context by alternating the bed between flat and the reverse Trendelenburg position every two hours. The nurses educated the patient about his impending surgery (see Patient Education Sheet). They encouraged the patient to perform limited therapy exercises (eg, flexing quadriceps muscles; full range of motion to ankles; and flexion, extension, and rotation of upper extremities. Frequent nursing assessments revealed no neurovascular changes for the patient during his time in the ICU.

Nursing staff members maintained adequate pain control for the patient through repeated pain evaluations and administration of narcotic medications as warranted. The ICU nurses also arranged for an orthotic company to assess and measure the patient preoperatively to ensure that he would have a rigid back brace available postoperatively.

Surgical care 

The neurosurgeon scheduled the patient's procedure on hospital day five. Logistically, it is necessary to wait until day five because of the need to allow edema of surrounding tissues to decrease. In the OR holding area, the circulating nurse greeted the patient. She verified his name, date of birth, allergies, NPO status, and scheduled surgical procedure with the patient. She also confirmed the same information on the patient's chart; confirmed that there was no need for isolation precautions; and confirmed that consents for blood products, anesthesia, and the correct surgery had been appropriately signed and witnessed. The nurse conducted a patient assessment for the presence of prosthetics; contact lenses; and removable dentures, bridges, or other oral appliances. She gave the patient the opportunity to ask questions or voice concerns about his spine surgery, explained what he could expect, and answered his questions.

The nurse performed a complete preoperative assessment that included a comprehensive neurovascular and integumentary system assessment and verification of patent IV access. The patient's neurovascular status was unchanged from that previously described by the ICU staff members before transport to the OR. The integumentary findings included multiple abrasions to both arms and the patient's left lower leg and a puncture wound with a large area of bruising to his left flank. By log-rolling the patient with the assistance of team members to ensure that strict spinal precautions were maintained, the nurse was able to observe that there were no signs of skin breakdown to the sacral or scapular regions. Upon completion of the nursing assessment, the nurse initiated an infusion of vancomycin 1 g IV.

While the circulating nurse completed the patient's admission and assessment, the scrub person and RN first assistant (RNFA) verified the presence of the special implants and hardware as well as all routine equipment needed for this extensive procedure before the arrival of the rest of the surgical team. They performed initial counts of instruments, sharps, and sponges at this time.

After all the surgical team members were present, the circulating nurse initiated the “time out” procedure, requiring that all team members be in agreement with and acknowledge the patient's identification, the correct surgical site, the procedure to be performed, and the correct patient position. The surgical team members verified the correct site by reviewing the lumbar spine radiograph that was taken during the time out procedure.

The neurosurgeon and surgical team agreed on a posterior approach for the intraoperative reduction of the subluxation and needed instrumentation. After anesthesia induction, the anesthesia care provider intubated the patient with an endotracheal tube, secured it in place while the patient remained on the transport stretcher, and verified its accurate placement. The somatosensory evoked potential (SEP) technician placed SEP monitoring leads on the patient. This monitoring causes electrical stimulation of peripheral nerves that allows the surgical team to monitor the functional integrity of the somatosensory pathways occupied within the surgical field.

After the anesthesia care provider had protected the patient's eyes by taping the eyelids closed and taping pads in place over the eyelids, the team members (ie, the anesthesia care provider, circulating nurse, RNFA, scrub person) log-rolled the patient and positioned him on the surgical bed. Special attention was given to pressure areas. Team members placed the patient's head in a foam-lined frame ensuring that his eyes and nose were free of pressure. They placed his arms on padded arm boards and placed positioning donuts at his elbows and wrists. They supported the patient's chest on bilateral cushions, and placed a pillow under his lower legs. After the positioning was completed, the SEP technician confirmed the accurate functioning of the somatosensory monitoring system.

The circulating nurse prepped the patient's lumbosacral area. This included removing hair from the area with clippers; because of preoperative spinal precautions, there was no access to the area previously. The circulating nurse gently scrubbed the area with a chlorhexidine gluconate prep solution. After the surgical prep was completed, the nurse removed pooled solution from under the patient and ensured that the prep solution at the surgical site had dried and that there were no wet areas in contact with the patient's skin.

After draping the surgical site, the neurosurgeon, with the assistance of the RNFA, made an incision from the area of T₁₂ to the patient's sacrum. They noted that the subcutaneous layer was extremely erythematous with numerous hematomas. Electrocautery was used to incise the fascia. With the RNFA providing traction and tissue counter traction, the neurosurgeon meticulously took down the muscle attachments from T₁₁ to the sacrum on both sides with muscle dissection of the spinous processes, laminae, and facets and continued the dissection out to the level of the transverse processes bilaterally. This exposure revealed a clear fracture and retrolisthesis of L₃ to L₂ as well as a significant leftward displacement of L₃ to L₂. The patient's spinous processes from L₂ to L₄ were completely fractured off and the interspinous ligaments sheared. The patient's right L₃ pedicle was completely destroyed and noted to be absent.

The neurosurgeon used rongeurs to remove the jagged edges of the L₂-L₄ spinous processes and a used high speed drill to perform an L₂ and L₃ laminectomy. He noted at that time that the patient's dura was in a clearly right-to-left displacement with a leftward and posteriorly curving thecal sac from L₂ to L₃. With the thecal sac visible at all times, the neurosurgeon used manual manipulation to nominally (ie, satisfactorily) reduce the fracture.

Using fluoroscopy, the neurosurgeon and the RNFA performed the instrumentation portion of the procedure. They placed multiple pedicle screws of varying sizes from T₁₂ through S₁, and applied gentle distraction to L₂-L₃ to achieve good reduction with simple manipulation of the distracter. The thecal sac was free of tensile pressure during the reduction process, and the neurosurgeon noted that the patient's nerve roots were well decompressed and clear. He then fashioned two rods and attached them to the pedicle screws bilaterally. A post-reduction x-ray showed excellent reduction in both anterior/posterior and lateral planes of the fracture subluxation (Figure 7).

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• Figure 7. 

  Anterior/posterior x-ray view after reduction surgery.

The neurosurgeon and the RNFA attached two cross links to connect the two rods. They carefully protected the thecal sac using multiple layers of thrombin-soaked absorbable gelatin sponges before they copiously irrigated the wound with saline irrigation solution containing 1 gm vancomycin. They then decorticated the bone and infused it with platelet-rich plasma. The neurosurgeon placed pieces of bone graft liberally within the wound and along the decorticated margins. He then implanted a bone growth stimulator into the subcutaneous space and placed the leads into the bone mass to facilitate bone fusion. After that, he sprayed platelet-rich and platelet-poor plasma liberally into the wound. The platelet-rich plasma assists with healing and the platelet-poor plasma has anti-infective properties.

While the circulating nurse and scrub person performed instrument and sharps counts and verified that they were correct, the neurosurgeon, with the assistance of the RNFA, completed multiple layered wound closure and applied a sterile dressing. The surgical team returned the patient to the supine position. The circulating nurse assessed the patient for proper body alignment, assessed his immediate postoperative skin condition, resecured the safety belt, and removed the electrosurgical grounding pad while the anesthesia care provider awakened the patient from anesthesia and extubated him. When satisfied that the patient was ready for transport, the surgical team transferred him to an ICU bed and transported him to the ICU.

Postoperative care 

Postoperative orders included vancomycin coverage for 24 hours and medications for pain and nausea. The patient experienced a leukocytosis on postoperative day one, and the neurosurgeon continued the antibiotics for an additional two days. He added enoxaparin to the medication regime on postoperative day two for deep vein thrombosis prophylaxis. With his back brace in place and assisted by physical therapy, the patient began ambulating on postoperative day two. Social services staff members arranged for the patient's placement in a rehabilitation center, and the neurosurgeon discharged him from the hospital on postoperative day six.

The initial neurosurgical visit follow-up revealed progressive improvement in the patient's condition. He had decreased paresthesias and was able to walk independently with the aid of a walker. Seventeen months after his injury, he continued to show progress, ambulating with a cane and, on radiographs, showed excellent ongoing bone fusion of T₁₂-S₁ and stable hardware. He showed no significant deterioration in his neurological examination and had minimal remaining paresthesias.

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Discussion 

The three goals of surgical intervention in patients suffering from traumatic lumbar spondyloptosis are

Complex and extensive spinal surgeries such as that required by the patient in this case presentation can be accompanied by postoperative complications. The surgical team's attention to detail throughout the surgical continuum will allow for better patient outcomes and fewer surgical revisions.

Preoperative considerations 

A thorough preoperative assessment is vital for preventing perioperative complications. Health history findings including hypertension, diabetes, coronary artery disease, and renal failure, as well as poor nutritional status, and tobacco or long term steroid use can all adversely affect the healing process. The surgical team should thoroughly evaluate any coexisting health issues and correct them if possible before surgery. The perioperative nurse should develop an appropriate nursing plan of care (Table 1).

Table 1. Nursing Care Plan for Patients Undergoing Surgical Repair of Traumatic L₂-L₃ Spondyloptosis [applicable PNDS code]

The following are a few of the major physiologic findings that require preoperative intervention to promote wound healing.

A patient's condition does not always allow for correction of the preceding risk factors, but, if possible, they should be assessed and appropriate interventions initiated. A thorough nursing assessment should occur preoperatively for these issues, as well as allergies and verification of the planned surgical intervention. Any new information should be brought to the attention of the surgeon and anesthesia care provider. The nurse should assess the patient's skin condition and identify any physical limitations.

Two crucial preoperative interventions in promoting an uncomplicated recovery are the administration of preoperative antibiotics and appropriate skin preparation. Multiple studies have shown the effectiveness of administering preoperative antibiotics. The usual recommendation is for the preoperative use of a first or second generation cephalosporin, depending on the patients' medication allergy history.⁷, ¹¹, ¹², ¹³, ¹⁴, ¹⁵ As previously noted, the patient in the case study received vancomycin instead of the recommended cephalosporin antibiotics. This decision was based on his severe penicillin allergy and the concern for possible cross-reactivity. Depending on the type of antibiotic, the appropriate time to administer prophylactic antibiotic medications is within one hour before the surgical incision occurs.⁷, ¹¹

Preoperative skin preparation is another important dynamic supporting an infection-free recovery period. Surgical asepsis involves scrubbing the patient's skin with some type of antiseptic solution. Various solutions are available as a preoperative skin scrub solution and include chlorhexidine gluconate, alcohol, and povidone iodine or a combination of these chemicals. Aggressive scrubbing of the surgical site, however, can lead to skin damage and provide an entry site for infection-causing bacteria. Thus, a gentle but thorough technique is required.

Preoperative hair removal also can provide a pathway for bacteria to enter the surgical site. Shaving can cause micro-abrasions and allow bacterial growth to occur. Depilatory creams or electric clipping are alternative options to shaving. When preoperative hair removal is necessary and shaving is the chosen method, it should be performed in the holding area before the scheduled surgical procedure.¹²

Intraoperative considerations 

Nursing responsibilities during the perioperative period are multifaceted and often divided between an RNFA, a circulating nurse, and a scrub person.¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²² Each of these surgical team members has specific duties for which he or she is responsible. Some of these responsibilities include orchestration of the time out procedure, ensuring proper positioning and padding of the patient, maintaining normothermia, monitoring vital signs, maintaining instrumentation including confirmation of appropriate sterilization and verification of the presence of all required tools and equipment, and documentation of the lot and serial numbers of all hardware to be internally implanted during the spinal procedure.

Patient safety is the foremost concern with any surgical intervention. To ensure optimal safety, the standard of care is to have all surgical team members participate in a time out.²³, ²⁴ The circulating nurse begins this process in the holding area by confirming with the patient that the planned procedure is the correct one; that there is an accurate, signed consent for the procedure; and that the laterality of the procedure has been marked and confirmed by the patient. In the OR, the circulating nurse initiates the time out procedure, which verifies that the correct patient is receiving the correct surgical intervention. All surgical team members must confirm that all patient identifiers match and that the area marked for surgery is the appropriate surgical site. In spinal surgery, the specific level(s) of the surgery also must be verified during the time out procedure. This is accomplished by reviewing a radiograph taken just before incision. The circulating nurse's coordination of the communication during the time out process is essential for decreasing errors and adverse events.

Patient safety continues in the holding area where the nurse assesses the patient and reports any findings that are out of the ordinary to the surgical team. He or she can then plan how to provide appropriate nursing care to address these issues. Any positioning concerns can be addressed with the anesthesia care provider and surgeon at this time.

In major spinal instrumentation procedures, factors such as the

predispose the patient to postoperative complications. To decrease the contamination, consideration and implementation of the following measures are necessary:

•staffing the procedure with the least number of personnel who can efficiently complete the surgery;

•ensuring that all needed equipment is in the suite before initiation of the opening incision;

•opening sterile supplies and equipment just before the beginning of the procedure;

•not leaving opened supplies and instruments unattended;

•limiting traffic into and out of the OR, thus reducing air turbulence, which causes disturbance of small particulate matter that could contaminate sterile supplies; and

•ensuring the door to the suite remains closed.²⁵

Depending on the number of spinal levels that must be accessed for instrumentation, incision size is often not a modifiable factor. Many of the precautions to promote the health of the surgical site fall under the responsibilities of the RNFA and include periodic release of the retractors to allow for adequate tissue perfusion, limiting wound exposure by covering the inactive field, and debriding necrotic tissue before wound closure.

Close monitoring of vital signs by the surgical team can ensure the patient is maintained in a state of normothermia during this extensive surgery; this promotes optimal tissue perfusion and wound healing. Temperature is often monitored by the use of a temperature-sensing, indwelling urinary catheter. Measures for maintaining an adequate core temperature include

The amount of time and the positioning required for extensive surgeries such as multi-level spinal surgeries predisposes patients to several complications. A major concern accompanying lengthy surgical procedures is the development of a deep vein thrombus (DVT). This can be a result of prolonged immobility and a slightly dependent position of the limbs. Prone positioning used for a posterior approach can cause compression of the femoral venous system, as can the manipulation of the great vessels during an anterior approach. The use of pneumatic boots combined with compression stockings may be of benefit in combating the development of a DVT.

During extensive spinal surgery, the development of skin breakdown caused by continued pressure to bony prominences or contact points or restriction of the circulation as a result of positioning is a concern. The RNFA and circulating nurse work jointly to pad these areas and provide measures that will promote adequate blood flow and tissue perfusion. Patient positioning is determined according to the type of the surgery planned, the level of the spine to be operated on, and the patient's previous surgical history.¹⁶ For example, a laparotomy is required for an anterior approach to lumbar surgery. Previous abdominal surgeries may complicate this approach, necessitating input from a general surgeon, or previous surgeries may rule out this position option completely.

When planning a posterior approach, the surgeon must take care to maintain low epidural venous pressures, which will aid in controlling blood loss that can be excessive in complicated spinal surgeries.²⁶, ²⁷, ²⁸ The use of padded chest rolls can help to lower venous pressure in the prone patient by freeing the abdomen from pressure. Decreasing bleeding is important for maintaining the patient's hemodynamic stability as well as allowing the best view of the surgical region. Maintaining a clear surgical field is extremely important in spinal surgery because of the location of major and exceedingly fragile neurologic structures.

An additional factor that surgical staff members must be mindful of when the patient is in the prone position is the possible inaccuracy of central venous pressure readings.²⁹ Central venous pressure values may be elevated, indicating adequate ventricular filling and volume status when, in reality, this elevation may be caused by reduced cardiac compliance and compression of some of the major vessels.³⁰

Multilevel spinal surgeries that include internal implantation of hardware require quality assurance communications between the circulating nurse and scrub person. Together, they are responsible for the proper documentation of the lot and serial numbers of every piece of hardware implanted in the patient's spine. Clear two-way communication ensures the accuracy of this essential information and is accomplished by the scrub person reading the lot and serial numbers stamped on each piece of hardware while the circulating nurse documents the information in the record. This is followed immediately by the circulating nurse reading the numbers he or she has transcribed to the scrub person for verification. Upon verification of accurate documentation, the hardware is passed to the surgeon for implantation. This process in conjunction with the other patient-focused interventions mentioned previously combine to ensure the best possible outcome for patients who have suffered multilevel spinal injuries.

Postoperative consideration 

Patients who have undergone extensive spinal surgeries must be observed for postoperative complications. The development of DVT is a major concern. Postoperative patients should be mobilized as soon as possible to restore normal circulatory status to the lower extremities. Mobilization begins with passive range of motion (ROM) exercises on the day of surgery. Depending on the patient's physiologic status, nurses help the patient increase his or her activity level progressively from active ROM of extremities while in bed, to sitting on the side of the bed, to standing with assistance, to ambulating with assistance, to independent ambulation with a walker or cane if needed. The ultimate goal is to have the patient ambulating as soon as possible. The patient must wear his or her back brace when out of the bed. This may be delayed depending on spinal and physiologic stability. The extremities should be assessed regularly for the development of redness, swelling, and pain. Appropriate DVT and pressure ulcer prevention strategies should be implemented.

Respiratory complications may arise from prolonged anesthesia and immobilization, inadequate mobilization of secretions, and decreased respiratory effort secondary to pain. The chances of respiratory complications are greatly increased if the patient has a history of previous respiratory impairment, a history of smoking, or is experiencing uncontrolled pain. Thorough lung assessments combined with good pulmonary toilet and adequate pain control are necessary for prevention of respiratory complications.

Prolonged prone positioning required for spinal instrumentation may also cause injury to the brachial plexus or lateral femoral cutaneous nerves. These injuries are caused by prolonged compression or traction on the nerve. The patient may report symptoms of paresthesia, a burning sensation, numbness, or increased or decreased sensitivity over the affected area. Although the nerve damage can be permanent, symptoms usually subside over time.

Patients who have undergone lower spine surgery may develop an ileus (ie, ceasing of the peristaltic movement of the bowel). This may result from retraction pressure on the bowel nerves during surgery, prolonged anesthesia time, and the use of narcotics. The patient should remain NPO until bowel sounds have returned and he or she is passing flatus. Treatment for an ileus may require placement of a nasogastric tube. Support from IV fluid administration and the use of total parenteral nutrition may be warranted if the patient's ileus is prolonged.

Lastly, the patient should be monitored very closely for any signs of wound infection. Signs of infection include

The presence of any of these signs is an indication of infection and should be addressed immediately. Deep wound infections are more difficult to diagnose because of the lack of outward visible signs. Patients may report severe radicular pain (ie, radiating, referred) to buttocks and legs or muscle spasms. These symptoms are caused by the edema of the infectious process and inflammatory response generating pressure on the nerve roots.

All of the above complications can be detected via changes in laboratory values or radiographic findings. No substitute exists, however, for a thorough nursing assessment when early detection is needed to abate postoperative complications. Prevention and early detection of problems will promote timely and successful recovery for the patient.

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Conclusion 

Returning an individual to his or her maximal level of function after a traumatic event is paramount in the delivery of optimal patient care. Injuries such as mid-lumbar spondyloptosis require added competency in several different areas, including

The responsibility for the positive outcome and recovery of the patient with spinal trauma lies largely in the hands of the surgical team. Meticulous care by the trauma team can promote a more rapid healing process, shorter hospital admissions, and lower health care costs.

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Examination 

Surgical Management of Traumatic L₂-L₃ Spondyloptosis 

Purpose/Goal 

To educate perioperative nurses about the care of the patient undergoing surgical repair of traumatic L₂-L₃ spondyloptosis.

Behavioral Objectives 

After reading the article on surgical management of traumatic L₂-L₃ spondyloptosis, nurses will be able to

Questions 

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Answer Sheet 

Surgical Management of Traumatic L₂-L₃ Spondyloptosis 

Event #09104

Session #1035

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Learner Evaluation 

Surgical Management of Traumatic L₂-L₃ Spondyloptosis 

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This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about the care of the patient undergoing surgical repair of traumatic L₂-L₃ spondyloptosis.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

To what extent

Test Questions/Answers 

To what extent

Learner Input 

What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): ____________________________________________________________________________________________________________________

Author names and addresses: ______________________________________________________________________________________________________________________________________________________________

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References 

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12. Collins I , Wilson-MacDonald J , Chami G , Burgoyne W , et al.   The diagnosis and management of infection following instrumented spinal fusion . Eur Spine J . 2008;17(3):445–450
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13. Rechtine GR , Bono PL , Cahill D , Bolesta MJ , Chrin AM . Postoperative wound infection after instrumentation of thoracic and lumbar fractures . J Orthopedic Trauma . 2001;15(8):566–569
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15. Picada R , Winter RB , Lonstein JE , et al.   Postoperative deep wound infection in adults after posterior lumbosacral spine fusion with instrumentation: incidence and management . J Spinal Disord . 2000;13(1):42–45
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