Acute Adult Spine: Introduction and Scope of the Problem

Introduction
Growth and innovation in the spine industry is rapidly increasing. The evolution of operative techniques and instrumentation systems, the discovery and refinement of bone graft substitutes and fusion-enhancing substances, and the development of innovative treatments for back pain have revolutionized spine care. The growth in the utilization of spinal instrumentation alone is projected to be in excess of 15% annually over the next five years. (1) More procedures than ever before are being performed on the spine. Approximately 258,000 spinal fusion procedures were performed in the United States in 1999. (2) There is an increasing body of research today focusing on spine-related concepts, both surgical and non-surgical, reflecting the increasing concern for spinal conditions by consumers, healthcare professionals, and payers.

It is essential that nurses caring for this growing population of patients be knowledgeable about spinal conditions, surgical procedures, expected outcomes, potential complications, and the care and monitoring needs unique to the spine patient. This guideline was developed to provide the reader with a basic understanding of the concepts involved in the care of adult patients with spinal conditions. Anatomy, common pathophysiologic conditions, and diagnostic tests are reviewed. Surgical and non-surgical treatment options are presented, as well as the unique behavioral issues involved in spine care. Specific nursing care issues related to the pre-and post-op care of spinal patients are discussed. Functional outcomes for spine patients, economics of spine care, and emerging trends are outlined. Finally, the nursing management of potential complications of spine surgery and nursing literature are reviewed, with a summary of the evidence-based knowledge on the nursing care of patients with spinal conditions.

Scope of the Problem

Prevalence of Back Pain
Many epidemiological studies and meta-analyses have identified that back pain affects most people at some time in their lives. (3-8) Back pain prevalence tends to peak during the middle years (40-60 years) and declines in the elderly. (5, 9) Some recent data suggest back pain to be more prevalent in young people in their teens and early twenties than originally thought. (10) Back pain tends to be chronic. Individuals with back pain are likely to continue to have recurrent episodes of back pain over time. (11-13)

Heavy labor occupations rank high among the identified predictors of back pain. (13-15) Interestingly, the prevalence of back pain in lower income countries, where heavy labor is endemic, remains less than the prevalence in industrialized, higher income countries. However, the appropriateness of survey tools and cultural differences may affect these findings. (16) Low educational status and lower income are also significantly associated with increased prevalence of back pain and worse outcomes. (17-18)

Impact of Spinal Conditions
In the United States, nearly 12,000 visits to physician offices and over 2 million emergency department visits were made for back pain in 1998. (19) Total hospitalizations for back and neck conditions in 1998 were 500,183 and 166,777 respectively. (20). Thirty-two out of 1,000 people experience activity limitations due to chronic back conditions, with slightly higher incidence in females than males. (18). According to Bureau of Labor Statistics Data (2002) the 2000 incidence rate for back injuries involving time away from work was 12.7 per 10,000 full-time workers for finance, insurance, and real estate, 43.2 for manufacturing, 44.7 for private industry, 70 for construction, and 82.1 for transportation and public utilities. From 1999 to 2000, the number of cases involving lost work time from back pain increased. The median time lost from work for back pain was 6 days (nearly 21 percent of these workers missed 31 days or more). Over 400,000 occupational injuries involving time away from work were attributed to the back. The trunk (including back) was the body part most affected by disabling work incidents in nearly every category of industry. (21)

The human impact of chronic low back pain can be as devastating as the economic impact. Depression and chronic low back pain can be closely related. In a study exploring the relationship of self-efficacy with disability in a population of 126 chronic pain patients (without prior history of depression), 68% of the study participants scored sufficiently high on a depression scale to warrant further depressive work up. (22) Females with chronic low back pain were found to be more depressed than males with chronic low back pain in a study evaluating Perceived Body Space (PBS) (a measure of distortion of self-image) and self-esteem in a population of males and females. (23)