Pre-Operative Assessment, Diagnostic Tests and Patient Education
Pre-Operative Assessment
When the patient has been determined to be an appropriate candidate for surgery,
and has elected to proceed with surgical intervention, the pre-operative assessment
phase begins. The purpose of pre-operative evaluation is to reduce the morbidity
of surgery, increase quality of intra-operative care, reduce costs associated
with surgery, and return the patient to optimal functioning as soon as possible.
(111)
Many surgeons feel that minimal baseline pre-operative assessment should include hematologic studies (complete blood count), electrolytes, and urinalysis. For complex spinal cases, older patients, and patients with concurrent disease, type and screen (or type and crossmatch), coagulation tests, chest x-ray, electrocardiography, and pulmonary function tests are indicated. (112)
While most surgeons have standard pre-operative evaluation preferences, the ideal pre-operative testing and evaluation process is guided by the patient's history, physical examination, and type of procedure to be performed. For anesthesia risk purposes, surgical procedures have been classified as A, B, or C. (111)
Class A procedures are considered minimally invasive, and associated with low risk related to the anesthetic.
Class B procedures are moderately invasive and present intermediate risk. Patients undergoing Class B procedures may require invasive monitoring, blood transfusion, or monitoring in the intensive care unit post-operatively.
Class C procedures are highly invasive and commonly necessitate blood administration, invasive monitoring, and post-operative care in a critical care unit.
Generally, the more invasive the surgical procedure the greater the requirement for pre-operative evaluation. Hepatitis or HIV status may be assessed for patients with a history of high risk behaviors. (111) Autologous blood donation should be planned when appropriate.
Pre-Operative Diagnostic Tests
Pre-operatively, as the patient's pain generator is being determined, many tests
may be utilized, including plain radiographs, MRI, CT (with or without myelography),
electrodiagnostic studies, and bone scan. In some instances, when vascular causes
of pain must be ruled out, the patient may undergo arterial blood flow studies.
If a metabolic or neoplastic process is suspected, blood tests such as complete
blood count, sedimentation rate, c-reactive protein, serum protein electrophoresis
with immunofixation, calcium, alkaline phosphatase, and chemistry profile may
be ordered. (113) Additionally, chest radiographs, mammogram, bone scan, PET
scan, as well as CT scans of the chest and abdomen/pelvis may be evaluated.
If compromise of the patient's nutritional status is suspected, pre-operative evaluation of pre-albumin, total protein and albumin is done (in addition to evaluation of the patient's total lymphocyte count) to determine need for nutritional supplementation. (114-117)
In the post-operative phase, most spinal surgery patients will require monitoring of complete blood count, electrolytes, and O2 saturation. If the patient's nutritional status is compromised, total protein, pre-albumin, and albumin levels should be monitored. For instrumented fusions, a post-operative radiograph should be obtained prior to discharge to verify spinal alignment and placement of hardware.
Pre-Operative Patient Education
As hospital lengths of stay shorten and inpatient acuities increase, structured
hospital time devoted to teaching is decreasing. It is therefore imperative
that pre-operative teaching occurs prior to admission.
Ideally, the educational process begins in the physician's office, and is often reinforced through the patient's contacts with the hospital pre-admission process. Some institutions offer intensive pre-operative classes for patients and their families, covering spinal pathophysiological processes, an overview of the basics of the surgical procedure, and anticipatory information on the peri-operative experience, including post-operative monitoring, hospital routines, equipment, pain control techniques, and progression of activity. Opportunity may be provided during this time to begin discharge planning. It is helpful if the case manager or discharge planner is available to interact with the patient and family during this time.
Formal teaching programs available prior to admission for surgery have beneficial effects. In a randomized study evaluating the impact of pre-operative structured education versus post-admission unstructured education in women undergoing abdominal surgery, the group receiving structured pre-operative education experienced higher levels of satisfaction and scored significantly higher on the Recovery Inventory than those receiving unstructured post-admission pre-operative education. (118)
The Recovery Inventory is an instrument that measures post-operative appetite, strength and energy, stomach and bowel conditions, ability to urinate, ability to do things for self, ability to move around and feel comfortable the major part of the day, amount and intensity of pain, and interest in surroundings. In our institution, the hospital length of stay for patients participating in a comprehensive pre-operative class for patients and family members was 3.5 days, compared to 4.3 days for patients not attending class.
Innovative teaching strategies for spinal surgery patients have been studied, including interactive video programs. (119-121) In a randomized multi-center study evaluating teaching materials for patients with spinal conditions (120, 121), information on the patient's diagnosis was provided in booklet form alone, or booklet with interactive videodisc. The combination of booklet with videodisc was more effective in improving knowledge scores for patients who scored the lowest on pretest, and for patients with herniated discs, reduced the surgery rate without diminishing outcomes. Patients also reported that videodisc materials in combination with a booklet were easy to understand.
Length of stay was not reduced for a convenience sample of spinal surgery patients receiving structured pre-op teaching (119). Patients unavailable for teaching were used as controls. In the same study, a new computer-assisted instruction (CAI) tool was piloted. Use of the CAI was evaluated using SF-36 scores. The health concept of bodily pain improved with use of the CAI. The authors recommended more study on the impact of the use of CAI for pre-op spine patients.