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Inicio Revista Científica de la Sociedad Española de Enfermería Neurológica (Englis... Clinical case: Patient with spinal cord stimulation who suffered post-surgical p...
Journal Information
Vol. 49. Issue C.
Pages 23-27 (January - June 2019)
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Vol. 49. Issue C.
Pages 23-27 (January - June 2019)
Brief article
DOI: 10.1016/j.sedeng.2019.04.002
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Clinical case: Patient with spinal cord stimulation who suffered post-surgical paraplegia and cerebrospinal fluid leak, the importance of nursing care
Caso clínico: paciente con implante de electrodo medular con paraplejia posquirúrgica y fístula de líquido cefalorraquídeo, importancia de la atención de enfermería
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Victoria Baneira Yáñez
Corresponding author
victoriabaneira@gmail.com

Corresponding author.
, Yordy Emmanuel Batista Batista, María Galego Montero
Unidad de Neurocirugía, Hospital General de Asturias, Oviedo, Spain
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Tables (2)
Table 1. Virginia Henderson's assessment of needs.
Table 2. Nursing care plan.
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Abstract

Chronic neuropathic pain treatment is currently one of the biggest challenges for health care professionals because of its high impact on quality of life. Neurostimulation therapy is shown as a widely-accepted treatment for patients who have completed the pharmacological treatment options with no results.

Objectives

To show the importance of early detection of post-surgical complication in spinal cord stimulation patients with spinal electrode as well as an adaptation and personalisation of nursing care in the event of post-surgical complications.

Method

A case of a woman suffering long-term chronic neuropathic pain following a serious traffic accident and subsequent spinal trauma. A study of a number of possible medical options was undertaken to decide the best outcome for the patient; finally, fitting a spinal electrode implant was decided as the best option, in order to start spinal cord stimulation therapy. Post-surgical paraplegia and cerebrospinal fluid leak were detected and incorrect placement of the electrode was observed on magnetic resonance imaging. A re-intervention was carried out for repositioning.

Results

Nursing care of post-surgical complications, the identification of nursing diagnoses and the ideal adaptation of the initial care plan as well as possible activities and objectives are described.

Conclusions

The importance of the adaptation and personalisation of the nursing care plan for patients with postoperative surgical complications must be highlighted.

Keywords:
Chronic pain
Paraplegia
Neurostimulation
Nursing care
Nursing diagnosis
Cerebrospinal fluid leak
Resumen

El tratamiento del dolor crónico neuropático se encuentra entre uno de los grandes retos para el personal sanitario en la actualidad debido al gran impacto que produce en la calidad de vida de los pacientes. La neuroestimulación profunda se plantea como tratamiento para los pacientes que han agotado las posibilidades de tratamiento farmacológico sin resultados.

Objetivos

Mostrar la importancia de la detección temprana de complicaciones posquirúrgicas en pacientes con implantes de electrodo medular, así como de una adaptación y personalización de los cuidados de enfermería en complicaciones posquirúrgicas.

Método

Se refleja un ejemplo de caso clínico de una mujer con dolor crónico neuropático de larga duración tras traumatismo en accidente de tráfico. Después del estudio de posibles opciones se decide conjuntamente la implantación de un electrodo medular para proceder a la terapia de neuroestimulación profunda. Tras la aparición de paraplejia posquirúrgica y fístula de líquido cefalorraquídeo se detecta una errónea colocación del electrodo y se procede a la realización de una segunda intervención para recolocación.

Resultados

Se describe la actuación de enfermería ante complicaciones posquirúrgicas, identificación de diagnósticos, adaptación del plan de cuidados inicial, así como actividades y objetivos posibles.

Conclusiones

Resaltar la importancia de la adaptación y de la personalización de los cuidados de enfermería en pacientes con complicaciones posquirúrgicas.

Palabras clave:
Dolor crónico
Paraplejia
Neuroestimulación
Cuidados
Diagnósticos de enfermería
Fístula líquido cefalorraquídeo
Full Text
Introduction

Chronic pain in adults is a major cause for medical consultation in Spain, and the World Health Organisation (WHO) considers it a global public health problem. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. It causes a decrease in the perception of life of our patients and their families, not to mention the financial and human costs of its treatment.1 It is estimated that one in five Europeans (19%) suffers chronic pain, and the literature estimates that the prevalence is similar in our country, although slightly lower (17%).2

Drugs are the most common treatment for patients with chronic pain,1 following the scale recommended by the WHO; however, many patients state that they do not bring about a significant reduction in their pain. Spinal cord stimulation (SCS) as treatment for chronic neuropathic pain is a direct consequence of the application of Wall and Melzak's gate control theory and started to be used in the nineteen seventies. SCS is a reversible procedure by which an implantable pulse generator and its cables are placed 2.5cm below the skin, generally in the abdominal area, while the electrodes (Fig. 1) are put into the epidural space indicated. This treatment is indicated for the following cases in particular: postlaminectomy syndrome, regional pain syndrome or peripheral neuropathy. The literature shows that despite the initial high cost this therapy generally provides long term financial benefits because these patients’ demand for health resources reduces substantially.3–5

Figure 1.

Electrode in the dural space.

(0.08MB).

Cerebrospinal fluid fistulas (CSF) are possible complications but are rare following surgical implementation of the epidural electrode; however, their care and treatment remain a challenge. They can occur immediately postoperatively and can cause intracranial hypotension, directly related to post-puncture dural headache. However, spinal injuries during this surgical procedure are very infrequent.5,6

Objective

To demonstrate by applying the NANDA-NIC-NOC nursing process, the importance of the early detection of postoperative complications in patients with spinal electrode implants, and the adaptation and personalisation of nursing care for postoperative complications.

DevelopmentCase description

A 56-year-old woman who experienced a car accident in 1998 and sustained a fracture to her lumbar vertebrae L2 and L3. After consolidation of the fractures the patient started to experience symptoms of paraesthesia-like pain in the big toe of her left foot. Drug treatment was tried for a long period of time exhausting all possibilities without a satisfactory result. The drug regimen that she has followed to date comprises morphine sulphate (MST) 90mg every 12h, fentanyl 200μg if there is breakthrough pain, and another after 15min if it does not subside (she reported requiring rescue therapy of up to 6 tablets), metamizole every 8h, bromazepam 1.5mg, amitriptyline 25mg, alprazolam .25mg, gabapentin 300mg, and extended release venlafaxine 75mg. After interdisciplinary assessment by the neurosurgical team of the General Hospital of Asturias the patient was offered implantation of an epidural electrode to start deep neurostimulation therapy in order to reduce her chronic pain.

After she had been explained the possibilities available and when she had reflected, the patient agreed to undergo the surgical procedure. She underwent a hemilaminectomy above the fracture to implant the intradural electrode in the operating theatre. After the surgical procedure, the patient was transferred to the hospital's post-anaesthetic resuscitation unit (PARU).

In the first 24h the patient reported a loss of strength, pins and needles in both lower limbs and occasional loss of control of sphincters. The nursing staff also recorded the onset of an accumulation of fluid around the surgical wound associated with a possible dural fistula. An emergency lumbar MRI scan was requested to rule out possible complications following the surgical procedure, that showed that the electrode had been placed intradurally and was touching the spine. Therefore, the patient was informed of the need for emergency surgery to reposition the device.

After this second operation and when she had come round in the PARU, the patient came to the ward conscious, oriented and collaborative, with a Glasgow scale score of 15. A total loss of strength in both lower limbs was noted.

Discussion

The nursing care process currently governs nursing activities in most neurosurgical units in Spain. The patient was interviewed when she returned to the neurosurgical unit as part of a nursing assessment tool based on Virginia Henderson's model,7 which is shown in Table 1 along with the proposed nursing diagnoses. At that time the patient required an adaptation of the postoperative patient's care plan, since her new situation following the surgery called for specific activities to prevent pressure ulcers and falls etc. after her loss of lower limb strength, which would not usually be expected post-surgery. Her new care plan is shown in Table 2 and required constant review by nursing staff to adapt it to the patient's new needs throughout her stay in the unit.

Table 1.

Virginia Henderson's assessment of needs.

Needs  Data obtained 
Oxygenation  Maintains eupneic breathing, mucosa with healthy colour 
Nutrition, hydration  Does not need help, independent. Reports eating everything, no dental prosthesis 
Elimination  Occasional relaxation of sphincters, requires help to go to the bathroom, due to loss of strength. Needs monitoring for constipation due to lack of activity and current medication 
Mobility, maintaining posture  Tingling and loss of strength in the lower limbs, requires help. Barthel index: severe dependence 
Sleep, rest  Has problems getting to sleep related to her chronic pain and agitation caused by this new health situation 
Dressing, undressing  Needs help, dependent in relation to the lack of mobility in her lower limbs 
Thermoregulation  No changes 
Hygiene  Requires help for most bodily hygiene activities, although able to wash her face and clean her teeth 
Safety  Anti-fall rails in place, to protect against injury 
Communication  Independent, conscious and oriented on her return to the unit. Glasgow Coma Scale 15. Able to express fears and concerns and ask for help 
Beliefs, values  Independent, does not state any spiritual concerns 
Work, sense of accomplishment  Not working at present and does not mention this as a concern or priority 
Recreation  She says she is not concerned about recreation at the moment, the television is enough entertainment for her 
Table 2.

Nursing care plan.

NANDA  Outcome target (NOC)  Score on admission  Score on discharge to rehabilitation 
0015 Risk for constipation0501 Bowel elimination
• Control of bowel movements 
• Amount of faeces in relation to diet 
00155 Risk for falls1828 Knowledge: fall prevention; 1912 falls
• Staggering 
• Falls 
• Description of correct use of devices 
00004 risk for infection1902 Risk control
• Identify infection risk factors 
• Identify signs and symptoms 
• Hand hygiene 
• Universal precautions 
00108 Bathing: selfcare deficit0301/0305 Selfcare: Bathing/Hygiene
• Enters and exits the bathroom 
• Washes her face, upper and lower parts 
00249 Risk for pressure ulcer1101 Tissue integrity: skin and mucous membranes
• Hydration 
• Skin integrity 
• Skin lesions 
00085 Impaired physical mobility0204 Immobility consequences: Physiological
• Muscle mobility (Lower limbs) 
• Joint mobility (Lower limbs) 
• Maintaining good posture 
Chronic pain2100 Comfort level
• Referred pain 
• Facial expressions of pain 
NANDA  Nursing interventions (NIC)  Activities 
0015 Risk for constipation  0450 Constipation management2380 Medication management (opioids)  • Observe for signs and symptoms of constipation• Encourage increased fluid intake• Instruct on fibre-rich diet• Assess medication 
00155 Risk for falls  6490 Fall prevention6486 Environmental management: safety6654 Surveillance (safety)  • Use rails to prevent falls from the bed• Place objects within the patient's reach 
00004 Risk for infection  6550 Infection protection3660 Wound and incision site care  • Observe for signs and symptoms of systemic and localised infection• Inspect for reddening, extreme heat or drainage into the skin and mucous membranes• Obtain samples for culture 
00108 Bathing: selfcare deficit  1801 Self-care assistance bathing/hygiene  • Help the patient to bathe herself• Provide the necessary help• Establish a routine 
00249 Risk for pressure ulcers  3540 Pressure ulcer prevention3590 Skin surveillance  • Observe for reddening, extreme heat, oedema or drainage into the skin and mucous membranes• Observe skin colour and temperature• Observe for areas of pressure of friction• Instruct about the signs of loss of skin integrity• Observe for dryness or moisture on the skin 
00085 Impaired physical mobility  1806 Self-care assistance: transfer0224 Exercise therapy: joint mobility  • Dress the patient in comfortable clothes• Perform assisted exercises• Determine limitations of joint movement• Help with regular and rhythmic joint movement within the limits of pain 
Chronic pain  2380 Medication management1400 Pain control220 Administration of analgesia  • Administer analgesics and/or complementary drugs when necessary• Assess pain relief measures by ongoing evaluation 

Source: NANDA Internacional,8 Moorhead et al.9 and Bulechek et al.10

The Braden scale was used to assess the risk of pressure ulcers, and the visual analogue scale (VAS) to appropriately monitor her pain throughout her stay. Again, the Glasgow Coma Scale was used daily to detect any changes in the patient's neurological condition.

Conclusions

Nursing care for patients following surgery is crucial for the early identification of complications, therefore correctly applying the nursing care process is vital in our daily care practice. Personalised adaptation of care plans in neurosurgery units is essential, since it enables better monitoring and detection of signs and symptoms of improvement or worsening of the functions of our patients.

We should highlight that the care plan that we present was the initial plan after the patient's return to the operating theatre and was not changed in the few days following her admission to the unit until she was transferred to the rehabilitation unit, where the plan was continued and her progress evaluated.

Acknowledgements

To the entire team from the neurosurgical unit of the General Hospital of Asturias for their support and help throughout this study.

References
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M.P. Jensen, M.A. Day, J. Miró.
Neuromodulatory treatments for chronic pain: efficacy and mechanisms.
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[2]
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Rev Soc Esp Dolor, 21 (2014), pp. 16-22
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Cost benefit analysis of neurostimulation for chronic pain.
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[7]
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[9]
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Please cite this article as: Baneira Yáñez V, Batista Batista YE, Galego Montero M. Caso clínico: paciente con implante de electrodo medular con paraplejia posquirúrgica y fístula de líquido cefalorraquídeo, importancia de la atención de enfermería. Rev Cient Soc Esp Enferm Neurol. 2019;49:23–27.

Copyright © 2019. Sociedad Española de Enfermería Neurológica
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