The goal of this academic publication is to inform and educate physicians and their staff about spine care and neurosurgery.
A Word From The Editor
Steven C. Zielinski, MD, CM, FRCSC
Diplomate of the American Board of Neurological Surgery And So It Begins…. Welcome. This is the Second issue of the Texas Spine and Neurosurgery Journal. Our goal is to aid and inform family doctors and community providers as well as their staff. We want to help practitioners treat their patients with spine and neurosurgery issues. If you know of someone who might benefit from a subscription, or if you have a question or topic for review, please contact us at info@txspineonline.com. The territory for the Journal continues to grow, but presently extends from Dallas to the Gulf coast and from Stephenville to Nacogdoches.
Expert Opinion: Unruptured Intracranial Aneurysms
Jonathan White, MD, FAANS, FACS
Professor, Neurological Surgery UT Southwestern Medical Center
Residency Program Director
Birsner Family Professorship in Neurological Surgery
Modern imaging techniques such as high resolution CT and MRI scanning has greatly improved the ability to diagnose intracranial pathology. However, the increased use of these techniques has led to the incidental discovery of asymptomatic findings of unclear significance and risk to the patients. One such finding is the unruptured, asymptomatic intracranial aneurysm.
A cerebral aneurysm is a focal outpouching of the vessel wall, usually at a branch point. The incidence of cerebral aneurysms in the general population maybe as high as 5 to 10%. The most dreaded complication of an intracranial aneurysm is rupture with associated subarachnoid hemorrhage. Prior to the advent of advanced imaging, the majority of aneurysms identified had ruptured or were a second aneurysm in a patient who had an aneurysm at another location rupture. These aneurysms carry a high risk of rupture and lead to a bias that most aneurysms identified should be treated.
As advanced imaging became more widespread, numerous small, unruptured, asymptomatic aneurysms were identified. Initially nearly all of these aneurysms were treated but over time it became clear that the rupture risk of some of these aneurysm was quite low. In 1998 the results of the International Sudy of Unruptured Aneuryusms (ISUIA) was published in the New England journal of medicine (1). This study demonstrated that the rupture risk of incidentally discovered aneurysms is probably less than 1% per year but that the rupture risk was size and location dependent.
The management of these unruptured aneurysm remains complex. Treatment risks for most intracranial aneurysms, whether by open surgery or by endovascular techniques, may be as low as 2-6%. These low treatment risks must be balanced against the relatively low rupture risk of the aneurysms but the significant consequences of such a rupture. In general, young, healthy patients with aneurysm greater than 10 mm will benefit from treatment. Most patients with aneurysms less than 5 mm, particularly those aneurysms located on the proximal intracranial carotid can be managed medically. Aneurysms in between need to be evaluated on an individualized basis depending on size, location and patient variables.
If a decision is made to follow a patient with an aneurysm, recommendations about activity restrictions and life style modifications need to be made. Poorly controlled hypertension and smoking are two of the most modifiable risk factors to reduce future aneurysm rupture. Serial imaging is usually done to insure there is not asymptomatic enlargement of the aneurysm which might be a predictor of future rupture. The majority of patients with a newly diagnosed aneurysm should be referred, at least once, to a neurosurgeon or other endovascular trained subspecialist for a detailed discussion of natural history, treatment risk and lifestyle modifications
The international Study Group of Unruptured Intracranial Aneurysms Investigators (ISUIA). Unruptured Intracranial Aneurysms – Risk of Rupture and Risks of Surgical Intervention. N Engl J Med. 1998; 339:1725-1733.
The Pharmacist’s Corner
Jenessa D. Burney, PharmD
Pre-Screening for Post-Surgical Fall Risk
About one in four people over 65 fall each year, with about half of these falls unreported to providers, often due to fear of losing independence.1. Falls are considered a sentinel event for Joint Commission 2, so this plus unsteadiness in surgical patients of any age is a compelling reason to include a pre-surgical fall risk workup for all patients.
Medications, frailty, home environment and post-surgical expectations all contribute to fall risk. While the BEERS List, STRATIFY, the Morse Fall Scale, and the Hendrich II Fall Risk Model have been developed to predict in- and outpatient risk, these do not take the place of the clinician’s assessment of the following areas:
Frailty: “Decreased physiologic reserve” is in itself the most accurate predictor of adverse events after a fall, even more accurate than the patient’s age. 3 A post-surgical fall can mean discharge to LTC and never returning home, so the physician is wise to use any of several published frailty indexes to show need for—
• pre- and post-surgical physical therapy for strengthening and conditioning
• patient’s room near the nurse’s station, with hourly rounding of staff
• fall precaution training by nursing staff for family/caregivers with the patient in the hospital room, including safe patient transfers and bathroom/shower use
Home Risk: A written safety guide given before surgery can assist with identification and elimination of hazards in the home:
• poor lighting
• electrical cords or oxygen tubing
• loose flooring, especially rugs or carpeting
• stairs (enough said)
• doorways too narrow for a walker or wheelchair
• pets who may get underfoot, and need a collar with a bell to alert the owner to their location.4
Suggest that the guide be given to a caregiver instead of the patient, who may be physically unable or too emotionally overwhelmed to address needed changes in the home.
Subtract meds: Four or more medications in a patient’s regimen is itself a risk factor for falls. Reduce the risk from orthostatic hypotension or acute physiological changes after surgery: 5
• Reduce number and strength of medications as much as possible
• Question patient thoroughly about alcohol as well as OTC use, such as anticholinergic first-generation antihistamines for allergies or sleep. (Suggest change to nasal steroid or melatonin)
• The BEERS List can offer guidance for medications which place an elderly individual most at-risk and ideally are reduced or eliminated in the senior adult population (although this author has found few “baby boomers” who accept the label of “elderly” at age 65, and therefore refuse to reduce or stop medications they have used for years.)
Add meds: Conversely, pre-surgery may be the time to add medications:
• Midodrine or fludrocortisone could be indicated to stabilize pre-existing orthostatic hypotension. 6
• Vitamin D 800-1000 units/day has been suggested to reduce fall risk by improving bone, joint, and nerve health.6
• Supplements such as B complex, Vitamin C, and Vitamin E are often overlooked as important nutritional cofactors for cellular synthesis after surgery.
Fall prevention is important for patients along the whole age spectrum, with intensive healthcare resources currently utilized for this. But institutional resources cannot substitute for pre-surgical education tailored to the needs of the individual patient. Assessment and intervention by providers plus awareness and change by patients is the best way to the best possible outcomes.
1 Bergen G, et al. Falls and fall injuries among adults aged >/= 65 years —United States, 2014. MMWR 2016; 65:993-8.
2 Joint Commission. Sentinel Event Alert. Preventing falls and fall-related injuries in health care facilities. September 28,2015.
3 Tom SE, et al. Frailty and fracture, disability, and falls: a multiple country study from the global longitudinal study of osteoporosis in women. J of Amer Geriatric Society. 2013 Mar 61(3)327-34.
5 Therapeutic Research Center (Pharmacist’s Letter). Fall Prevention in the Elderly: Clinical Resource #330401. Hester SA, et al. April 2017.
6 American Geriatrics Society. Prevention of falls in older persons. Summary of recommendations. 2010.
Surgery and Tobacco Use
Angela Collier LVN
Texas Spine and Neurosurgery
As many medical professional are aware, tobacco use (mainly smoking) is a major cause of preventable diseases. Tobacco use is typically linked to heart disease and cancer but also has negative effects on healing systemically. Specifically for spine surgery, the use of tobacco can lead to slow healing surgical wounds, infection, less favorable outcomes, and delayed bony fusion. The reason behind the delay is that nicotine has harmful effects on the production of bone-forming cells.
Studies have shown that patients that are non-tobacco users or that have stopped prior to or after surgery have a 10 to 15% improvement in their success rate in lumbar fusion versus those patients that have continued to use tobacco products. Approximately 70% of non-tobacco users are able to return to full work activity following a lumbar fusion when compared to only about half the patients that continue to use tobacco are able to return to work. Studies show that the rate of success of cervical fusions is similar for the non-tobacco users but is dramatically different for those that continue to smoke or chew tobacco. The studies show the success rate drops to around 60% for tobacco users that have a cervical fusion.
Due to these findings, some commercial insurance will not pre-authorize spinal procedures. In most cases, spinal surgeries are considered elective and most private practice specialist will want to get pre-authorization before proceeding with an elective procedure. Some commercial insurance plans will have criteria regarding smoking and tobacco use on their plans coverages for spinal procedures stating that the patient would need to refrain from tobacco use for a period of 6 weeks or longer. The criteria will either need to be met along with the other criteria that the plan may have in place for a spinal fusion. Other plans may charge the subscriber an extra fee each month to remove the tobacco clause from the criteria for a procedure.
Although most patients’ have heard the spiel of, “Smoking is not good for you and you should quit”, this is not as easy as it seems for most patients. Any provider can give a patient tools to help assist in the cessation of tobacco use such as contacting the American Lung Association or prescribing medications. Ultimately, it is up to the patient to make that decision to stop.
Students Corner
Think Better, Feel Better How Psychological Motivation Affects Recovery
Bethany A. Gray, Student of Psychology
Recovering from a surgery is a process that varies greatly from person to person, but why? Research suggests that at least part of the reason is due to a patient’s motivation to properly heal.1 Of course, everyone’s body is vastly different in genetic make-up and thus has predispositions to various complications. However, no matter the initial damage or problems that arise after surgery, optimistic determination to heal coupled with a willingness to comply to treatment increases the chances of successful recovery. This has been found to be true in more circumstances than postoperative healing. Motivation and the associated coping strategies are crucial to anyone recovering from addiction2, disordered eating3, and most other non-surgical related injuries.
All patients handle surgical recovery differently, but all of them must bear at least a part of the responsibility in the healing process. While some problems cannot be cured with a good attitude and exercise, such as infections or nausea, others demand an element of grit and resilience if they are to become functional again in a reasonable amount of time. Those willing to work hard in to achieve goals in therapy and to be active in their pain management will fare much better and accomplish more than those who see recovery as a straight line that just happens on its own.
Simply wanting to be better is not sufficient. Otherwise, everyone would make remarkable progress and be back to normal in no time. A change in thinking patterns is essential to making healing an active process. One must also recognize the role they play in their physical well-being and be purposeful in how they care for their bodies after surgery.
Though it is not possible to change a patient’s outlook by simply telling them to think differently, it would benefit both the medical staff and the patient to speak in depth about motivation and the role it will play in their health. Additionally, some simple behavioral recommendations could be advised as well to facilitate a sense of accountability. These include postoperative counseling, making a schedule of attainable goals, attending all rehabilitation sessions, tracking recovery progress, staying social, and redirecting energy to other tasks to keep the mind busy.
References:
Nishimura, Y., Onoe, H., Onoe, K., Morichika, Y., Tsukada, H., & Isa, T. (2011). Neural substrates for the motivational regulation of motor recovery after spinal-cord injury. Plos ONE, 6(9), doi:10.1371/journal.pone.0024854
Kushnir, V., Godinho, A., Hodgins, D. C., Hendershot, C. S., & Cunningham, J. A. (2016). Motivation to quit or reduce gambling: Associations between Self-Determination Theory and the Transtheoretical Model of Change. Journal Of Addictive Diseases, 35(1), 58-65. doi:10.1080/10550887.2016.1107315
Dawson, L., Mullan, B., & Sainsbury, K. (2015). Using the theory of planned behavior to measure motivation for recovery in anorexia nervosa. Appetite (84), 309-315. doi:10.1016/j.appet.2014.10.028
Our History
The “Texas Spine & Neurosurgery Journal” was founded by Dr. Steven Zielinski, a Stanford trained neurosurgeon who believes in giving patients the freedom to control their own healthcare, in partnership with their chosen physician. Texas Spine and Neurosurgery is a patient centered practice that brings first class spine care to local communities and to patients. Texas Spine and Neurosurgery started as a small collaboration with local hospitals and local providers and has grown over several years. Today, we have relationships with a vast array of outstanding hospitals and surgical centers. We coordinate care with the best specialists in different aspects of conservative care throughout Texas. In order to continue these efforts Texas Spine and Neurosurgery is a proud sponsor of the Texas Spine and Neurosurgery Journal. It’s focus is to educate and inform community physicians and family doctors in Texas and beyond about relevant topics in spine and neurosurgery.
If you have questions or comments or wish to contact or refer a patient to Texas Spine and Neurosurgery or one of our Physician contributors please contact us.
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Texas Spine and Neurosurgery and Texas Spine and Neurosurgery Journal
are the property of Steven Zielinski MD PA, DBA Texas Spine and Neurosurgery.
All articles reflect the opinions of the individual authors and are not independently verified for accuracy. The Journal provides no recommendation for therapy of any individual patient but tries to promote the academic discussion of the topics covered.
