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S C O L I O S I S S C O L I O S I S Document Transcript

  • Indian Journal of Anaesthesia 2007; 51 (6) : 486-495 Special Article Indian Journal of Anaesthesia, December 2007 Scoliosis and Anaesthetic Considerations Anand H. Kulkarni1 , Ambareesha M2 Summary Scoliosis may be of varied etiology and tends to cause a restrictive ventilatory defect, along with ventilation-perfusion mismatch and hypoxemia. There is also cardiovascular involvement in the form of raised right heart pressures, mitral valve prolapse or congenital heart disease. Thus a careful pre-anaesthetic evaluation and optimization should be done. Intraoperatively temperature and fluid balance, positioning, spinal cord integrity testing and blood conservation techniques are to be kept in mind. Postoperatively, intensive respiratory therapy and pain management are prime concerns. Keywords Scoliosis; Deformity, Spine; Monitoring, Spinal cord; Defect, Restrictive. Introduction Table 1 Etiologic classification of scoliosis Scoliosis is a complex deformity of the spine and 1. Idiopathic (genetic) scoliosis (approximately 70% of all cases of scoliosis; classified by age of onset) anaesthesia for scoliosis surgery can be challenging, with several aspects to be kept in mind simultaneously. A brief 2. Congenital scoliosis (probably not genetic) review is presented to highlight important aspects of the Vertebral pre-anaesthesia evaluation and anaesthesia management. Open- with posterior spinal defect With neurologic deficit (e.g., myelomeningocele) Definition Closed- no posterior element defect Scoliosis is a complex deformity of the spine re- With neurological deficit (e.g., diastematomy sulting in lateral curvature and rotation of the vertebrae elia with spina bifida) as well as a deformity of the rib cage1. There is usually Without neurological deficit (e.g., hemivertebra, secondary involvement of the respiratory, cardiovascu- unilateral unsegmented bar) lar and neurologic systems. Extravertebral (e.g., congenital rib fusions) 3. Neuromuscular scoliosis Classification Neuropathic forms The initial classification was given by Schulthess Lower motor neuron disease (e.g., poliomyelitis) W 2. He classified scoliosis by the region involved. Upper motor neuron disease (e.g., cerebral palsy) 1. Cervico thoracic Others (e.g., syringomyelia) 2. Thoracic Myopathic forms 3. Thoracolumbar Progressive (e.g., muscular dystrophy) Static (e.g., amyotonia congenita) 4. Lumbar Others (e.g., Friedrich’s ataxia, unilateral amalia) 5. Combined double primary 4. Neurofibromatosis (Von Recklinghausen’s disease) The etiologic classification was introduced by the 5. Mesenchymal disorders Terminology Committee of the Scoliosis Research Soci- Congenital (e.g., Marfan’s syndrome, ety in 19693, that is shown in Table 1. Morquio’s disease, amyoplasia congenita, various types of dwarfism) Epidemiology Acquired (e.g., rheumatoid arthritis, Still’s disease) Scoliosis can develop at any age, but tends to be- Others (e.g., Scheurmann’s disease, osteogenesis imperfecta) come clinically evident during periods of rapid somatic 6. Trauma growth. It’s reported prevalence in the general population Vertebral (e.g., fracture, irradiation, surgery) varies from 0.3 – 15.3% 4-6. However the prevalence is Extravertebral (e.g., burns, thoracic surgery) less than 3% for curves more than 10o and less than 0.3% 1. MD, DNB, Assistant Professor, 2. MD, DA, Professor and Head, Dept of Anesthesia, Kasturba Medical College, Mangalore, Correspondence to: Anand H.Kulkarni, C 3-20, KMC Staff Quarters, Lighthouse Hill Road, Mangalore -575003. Karnataka, India. E-mail: kulkarnianandh16@yahoo.co.in Accepted for publication on:20.10.07 486
  • Anand H. Kulkarni et al. Scoliosis and anaesthesia for curves more than 30 o. It is more common in adoles- cents and has a female to male ratio of about 3:1 7. 75 -90% of cases of scoliosis are of the idiopathic type, out of which the adolescent type is most common. Remaining 10 – 25% cases belong to various other eti- ologies1. Measurement of severity The Cobb’s method of measurement, recom- mended by the Terminology Committee of the Scoliosis Research Society, consists of three steps. 1. Locating the superior end vertebra. 2. Locating the inferior end vertebra. 3. Drawing intersecting perpendicular lines from the superior surface of the superior end vertebra and from the inferior surface of the inferior end vertebra. Fig.1 Cobb’s method: measurement of severity. The angle of deviation of these perpendicular lines from straight line is the angle of the curve (Fig1). If the Pre anaesthetic assessment end plates are obscured pedicles can be used instead for I. Airway assessment: Airway difficulties may be quantification 8. The draw back of the Cobb’s method is anticipated when the scoliosis involves the upper that it measures a complex deformity in only two dimen- thoracic or cervical spine. Also devices like halo sions. Nevertheless it maintains a uniform method of traction may interfere with securing the airway. measurement. Some disorders like Duchenne muscular dystrophy Surgery is performed when the Cobb’s angle ex- may lead to tongue hypertrophy. ceeds 50o in the thoracic spine and 40o in the lumbar II. Respiratory system: Assessment of the pulmo- spine. The goal of surgery is to stop the progression of nary system must focus on evidence of pre existing cardiopulmonary disease. If untreated, idiopathic scolio- lung injury or pulmonary disease, pneumonia and sis is often fatal in the fourth or fifth decades of life as a 10 severity of scoliosis . Factors associated with post- result of pulmonary hypertension or respiratory failure9 . operative mechanical ventilation requirements in- The severity of scoliosis and clinical implications are as clude pre-existing neuromuscular disease, severe in Table 2. restrictive pulmonary dysfunction with a vital Table 2 Severity of scoliosis and clinical correlation7 : capacity(VC) of <35% predicted, congenital heart Cobb’s angle Clinical manifestations defects, right ventricular failure,obesity, anterior tho- -1 9 ( degrees) racic spine surgery and blood loss of >30ml.kg . <10 No symptoms Scoliosis results in reduced VC, reduced functional >25 Increase in pulmonary artery pressure residual capacity (FRC), and restrictive pulmonary >40 Consider surgical intervention disease pattern characterized by increased respira- >70 Significant decrease in lung volume tory rate and decreased tidal volume. The severity >100 Dyspnea on exertion of pulmonary impairment is influenced by the scolio- o >120 Alveolar hypoventilation, chronic respiratory sis angle (>70 ), number of vertebra involved (7 or failure. more), cephalad location of the curvature and de- Treatment options: gree of loss seen in the thoracic kyphosis. Pulmo- I. Non surgical – braces, traction, plaster applications nary impairment is manifested by a decreased arte- 9. rial oxygen tension due to pulmonary shunting There II. Surgical- posterior approaches, anterior ap- is significant controversy regarding the degree of proaches, combined/staged procedures 487
  • Indian Journal of Anaesthesia, December 2007 improvement in pulmonary function after scoliosis way obstruction, which may be a result of chronic surgery. One study found that patients with an an- airway inflammation secondary to poor clearance 14 terior component to correction had worse pulmo- of secretions . Significant displacement or rotation nary function testing variables at 3 months but im- of the trachea or main stem bronchi may cause 15 proved function at 2 years. Patients who had poste- mechanical airway obstruction . In severe restric- rior correction only had a trend for improved func- tive defects, there is decrease in inspiratory capac- tion at 3 months but no significant difference from ity and also ineffective ventilatory patterns which 11 the anterior or combined group at 2 years . Scolio- rely on increase in frequency of respiration rather sis surgery is more likely to have immediate pulmo- than increase in tidal volume, which increases the o nary complications if the curvature is >60 . Reduced work of breathing and promotes respiratory muscle VC is the first manifestation of restrictive lung dis- fatigue in response to exercise. They also have a 16 ease. As the disease progresses gas exchange is decreased response to carbon dioxide . When the o affected by ventilation-perfusion mismatch, alveo- Cobb’s angle is 100 patients are at an increased lar hypoventilation, an increased dead space and an risk of developing chronic respiratory failure and increased alveolar- arterial gradient. Prolonged pe- pulmonary hypertension. The pulmonary hyperten- riods of hypoxemia result in pulmonary hyperten- sion is a product of chronic atelectasis, chronic hy- 17 sion, hypercapnia and eventual respiratory failure. poxemia and chronic hypercapnia . Scoliosis of neu- Surgery for scoliosis is performed to slow disease romuscular dysfunction etiology usually starts from 10 progression and prevent complications . Scoliosis early infancy, when the chest wall is very compli- may limit the function of the respiratory muscles ant, and the distortion of the thorax is severe. Also i.e., intercostals may be overstretched or unable to the lung growth is severely impaired. Moreover the stretch due to intercostal space changes, putting potential for complications is higher because of prob- them at a mechanical disadvantage. Moreover, the lems like chronic recurrent aspiration and 7 effectiveness of the muscles may be hampered by pneumonias due to impaired secretion clearance . limiting the ability of the thorax to expand. The dis- Preoperatively respiratory function should be as- tortion of the thoracic cage makes the respiratory sessed by a thorough history, focusing on functional system much less compliant, thus increasing the impairment and effort tolerance, physical examina- work of breathing even when the lungs themselves tion and appropriate investigations. Respiratory func- 12 are healthy . Scoliosis has generally been associ- tion should be optimized by treating any reversible ated with the development of restrictive lung defect cause of pulmonary dysfunction like infection by manifested by a decrease in total lung capacity physiotherapy and bronchodilator therapy as indi- (TLC) on pulmonary function testing. Infantile and cated. Preoperative incentive spirometry is advis- juvenile scoliosis are more likely to be associated able before thoracotomy for anterior approach cor- with true lung hypoplasia because the thoracic de- rections. formity is present during the period of rapid lung III. Cardiovascular system: The cardiovascular 13 growth and development . In adolescent scoliosis, changes associated with scoliosis are less common in contrast, the decrease in TLC is more likely to but more serious than the changes in the respira- reflect the impaired chest wall mechanics that pre- tory system and share a common etiology. The al- 7 vent normal inflation of the lungs . Long standing teration in the cardiovascular system is related pri- hypoinflation and atelectasis leads to further reduc- marily to the changes in the structure of the medi- tion of lung volume. The decreased TLC is often astinum and secondarily to the effects of chronic associated with increased residual volume (RV), respiratory insufficiency on the function of the car- resulting in very high RV /TLC ratio reflecting the diac system. The primary changes are related to dysfunction of expiratory muscles, which do not al- structure of the mediastinum following scoliotic 7 low full exhalation . In severe cases of scoliosis, curves. The effect is a restrictive pericarditis with flow-volume loops may show evidence of lower air- a possible secondary pericardial effusion. Limited 488 View slide
  • Anand H. Kulkarni et al. Scoliosis and anaesthesia cardiac filling decreases any potential increases in Table 3 Suggested preoperative investigations be- 18 cardiac output . In response to exercise, the al- fore major spine surgery9 ready elevated pulmonary artery pressure increases. M i n i mu m Optional Moreover the displacement or compression of the investigations investigations Respiratory  Plain chest X-ray  PFT (bronchodilator heart due to thoracic deformity may not allow an system reversibility) increase in stroke volume necessary during exer- ABG  Pulmonary diffusion  7 capacity cise . Eventually even normal filling can be impaired  Spirometry(FEV1,FVC) and the cardiac output at rest can be impaired. At Cardiovascular ECG  Dobutamine  stress echo this point cardiac reserves are limited and may not system  Echo Dipyridamole/thallium  able to withstand the increased haemodynamic de- scintigraphy mand of major surgery. Echocardiography and stress Blood  Complete blood count  Liver function tests   Clotting profile testing, either physical or pharmacologic, can be  Cross match done to determine the performance of the myocar-  Urea/electrolytes dium. In addition to mechanical impairment of myo- IV. Neurologic system: A detailed neurologic evalua- cardium, there can be cardiovascular pathology sec- tion and documentation is important because of medi- ondary to the chronic insufficiency of the respira- colegal issues. Moreover, patients who have preex- tory system. Pulmonary hypertension is the natural isting neurologic deficits are at an increased risk of 18 evolution from chronic hypoxemia . Other factors developing spinal cord injury during scoliosis surgery. contributing to pulmonary hypertension are that the Prepoerative considerations for patients undergo- number of vascular units per unit volume of lung is ing major reconstructive spinal surgery are summa- 19 lesser than in normal lungs .Also in the compressed rized in Table 4. lung regions, the alveoli become smaller than at re- Table 4 Preoperative considerations for patients sidual volume, leading to blood flow in extra alveo- undergoing major reconstructive spinal surgery22 20 lar vessels which have a higher resistance . Even- Problem C o mme n t tually right ventricular strain and failure will evolve Respiratory from increased work of right sided cardiac output.  Reduction in total lung  Reduction worse with increas capacity and vital -ing deformity. If vital capac Detection of any right ventricular dysfunction should capacity -ity <40% predicted postop be a stronger indication for complete cardiac evalu- -erative ventilation likely. 18 ation . Patients with idiopathic scoliosis also have A further decrease in the vital capacity of up to 40% may been found to have a high incidence of mitral valve occur postoperatively: recov- prolapse (up to 25%). It may indicate a common ery may take up to 2 months. basis for both the entities, namely a collagen disor-  Increasing V/Q mismatch  Hypoxemia more likely 7 der . Moreover the incidence of scoliosis is higher Cardiovascular  Increase in pulmonary  Independent of severity of in patients with congenital heart disease than in nor- vascular resistance scoliosis mal subjects. Hence the patients should be evalu-  Increase in incidence of  High index of suspicion congenital heart disease ated for the presence of congenital heart disease and mitral valve like ventricular or atrial septal defects, patent duc- regurgitation 21 Neurological tus arteriosus, tetralogy of Fallot . Assessment of  Variable preoperative  Careful preoperative docu the cardiovascular system should be done keeping deficit mentation all above in mind. Minimum investigations include Musculoskeletal  Muscular dystrophy  Abnormal response to muscle an electrocardiogram and echocardiography to as- relaxants sess left ventricular function and pulmonary artery  Respiratory impairment  Postoperative ventilation may be required pressures. Dobutamine stress echo may be used to Nutrition assess cardiac function in those with limited effort  Malnourishment  Likely in patients with meta -static carcinoma tolerance9 . The preoperative investigations suggested are as in Table 3. Anaesthesia technique I. Premedication: It is advisable to avoid use of nar- 489 View slide
  • Indian Journal of Anaesthesia, December 2007 cotics or heavy sedation as premedication in pres- capnography, esophageal stethoscope and a tem- ence of pulmonary function impairment. perature probe. Also a urinary catheter should be Bronchodilators may be used as part of optimiza- placed and urine output measured. The prolonged tion of lung function preoperatively.Antisialogogues anaesthesia in unusual positions, combined with sig- may be of value in procedures where a fibre- optic nificant blood loss, haemodynamic effects of tho- intubation is planned or when prone or lateral posi- racic surgery and possible need for deliberate hy- tion is required to minimize secretions and avoid potension mandate an invasive arterial line. Also wetting of the tape securing the endotracheal tube. serial blood gas measurements may be done where In those at risk of aspiration H2 blocking agents or required. CVP values are not reliable in the prone proton pump inhibitors may be administered with or 23 position or with an open chest . without sodium citrate. VI. Positioning: Patient positioning for surgery varies II. Induction: Routine induction by the intravenous depending on the level of spine to be operated upon route is common. Alternatively an inhalational in- and nature of proposed surgery. Repositioning may duction may be used guided by the patient’s condi- be required intraoperatively. Peripheral nerves, eyes, tion. Use of succinylcholine may be associated with genitals and bony points should be padded and pro- a hyperkalemic response in presence of myopathies tected. Intraoperative imaging is often required, thus or denervation. It may also cause malignant hyper- the surgical site should be placed away from the thermia in certain syndromes like King- Denborough, table’s central support area. Prone positioning re- central core disease, adenylate kinase deficiency 20 etc . Therefore it may be prudent to avoid succi- quires an uncompressed abdomen. Anterior ap- nylcholine in these cases and use nondepolarising proaches to thoracic spine are via a thoracotomy neuromuscular blocking agents for intubation. with the patient supported in the lateral position. Anterior approach to the lumbar spine necessitates III. Intubation: Anterior approaches to spine may ne- laparotomy. cessitate the use of a double lumen tube for lung isolation to enable access to the anterior spine. This VII.Malignant hyperthermia: Malignant hyperther- may be difficult in cases where there is involve- mia is a rare pharmacogenetic myopathy affecting 24 ment of upper thoracic or cervical spine by the humans .Affected patients are susceptible to acute scoliosis since distortion of the tracheobronchial tree hyperthermia which may be triggered by potent in- 25 is a common accompaniment. On the other hand a halational anaesthetics or succinyl choline . There single lumen tube may be used, allowing more lim- are several published reports of myopathies associ- ited intraopertive lung retraction, after discussion ated with malignant hyperthermia and several of with the surgeon. In posterior approaches a single these syndromes have skeletal abnormalities includ- 20 lumen tube is used. ing scoliosis .It is critically important to be alert for IV. Maintenance: A stable anaesthetic depth is re- early evidence of malignant hyperthermia like rise quired to enable proper interpretation of somato in body temperature, elevated heart rate, ventricu- sensory evoked potentials (SSEPs) or motor evoked lar arrhythmias or hypercapnia. The key to success- potentials (MEPs). Either a nitrous oxide-narcotic- ful management of malignant hyperthermia is im- inhalation agent technique may be employed or an mediate cessation of triggering agents, 100% oxy- intravenous technique using propofol may be used. gen, cooling, supportive respiratory, cardiovascular Non-depolarizing neuromuscular blocking agents are and acid-base procedures; and drugs like dantrolene 20 used to maintain relaxation. When MEPs are to be which lower free ionized intracellular calcium . recorded it is advisable to use atracurium by con- VIII.Spinal cord monitoring: The cervical and lum- tinuous infusion and maintain a constant depth of bar ganglionic areas of the spinal cord are meta- block by neuromuscular monitoring. Intravenous flu- bolically more active and the number and size of ids should be warmed and a warming mattress de- the cervical and lumbar feeders are greater than vice is preferable. those in the thoracic cord and thus the thoracic cir- V. Intraoperative monitoring: Minimum monitoring culation is described as“water shed”. This critical should include ECG, NIBP, pulse oximetry, zone extends from T4 to T9 where the vascular 490
  • Anand H. Kulkarni et al. Scoliosis and anaesthesia supply is least generous and special care should be aesthetic agents may suppress SSEP signals, cer- 26 taken during surgery .Distraction of the spine, tain patient conditions like neuromuscular degenera- placement of pedicle screws and bony decompres- tion may make SSEPs impossible to obtain; and sion are intraoperative events in which the spinal anterior cord injury may go completely undetected 27 cord or nerves may suffer injury . Above and be- in spite of SSEP monitoring. A wake-up test should low the auto- regulation range, spinal cord blood flow be planned for well in advance and discussed with depends on perfusion pressure. Spinal cord injury the patient in the pre-anaesthesia visit. Because of due to above reasons leads to loss of auto regula- neuromonitoring concerns a predominantly nitrous tion. In this situation hypotension may further com- oxide and narcotic technique is typically used. Small promise spinal cord blood flow and compound the doses of volatile anaesthetics, if used, should be dis- injury. Spinal cord blood flow is also highly sensitive continued an hour before wake-up is anticipated. to PaCO2 alterations during induced hypotension28 . Two or three twitches on a train-of-four are suffi- The risks of spinal cord damage and methods to cient to allow the patient to move his or her toes. minimize the risks are as given in Table 5. The inci- After discontinuation of nitrous oxide and ventila- dence of post operative neurologic injury is estimated tion with 100% oxygen, the patient should be able 29 at 1.84% .SSEPs, MEPs and the “wake-up” tests to follow commands to move their toes within ten are commonly used to help safeguard spinal cord minutes. It is not advisable to reverse neuro muscu- and nerve root function during surgery. lar blockade or narcotics to speed a wake-up test Table 5 Risks of spinal cord damage 22 because this may result in violent movements that can damage instrumentation or hurt the patient. Also Risk related to: the sympathetic discharge accompanying narcotic  Length and type of surgical procedure reversal may further compromise spinal cord blood  Spinal cord perfusion pressure flow. As soon as satisfactory movement is observed,  Underlying spinal pathology anaesthesia is reestablished. A successful wake-up  Pressure on neural tissue during surgery test suggests an intact cortex and spinal cord. Risk minimized by: B . SSEP: They are a type of sensory evoked response.  Careful positioning It provides the ability to monitor functional integrity  Maintaining SCPP of sensory pathways in the anaesthetized patient SCPP = MAP – CSFP undergoing surgical procedures which place the CSFP can be reduced by CSF drainage spinal cord at risk. It is recorded after electrical MAP manipulated by anaesthetist stimulation of a peripheral mixed nerve. Stimulation ?keep systolic blood pressure > 90 mmHg is by surface electrodes placed on the skin above  Drugs the nerve. A square wave stimulus of 50-250 micro Methylprednisolone given less than 8 hours after insult sec duration, strength 20-50 mA, stimulation rate 1- NMDA antagonists (ketamine, magnesium) 6 Hz is commonly used. Sites of stimulation are  Prevention of hematoma formation common peroneal nerve at knee or posterior tibial nerve at ankle. For best results an anaesthetic tech- Careful hemostasis nique that does not markedly depress the SSEP Stop anti-platelet medication preoperatively should be chosen and the physiologic status of the Withhold heparin immediately postoperatively patient should remain constant during periods of (CSFP, cerebrospinal fluid pressure; MAP, mean arterial pressure; 31 NMDA, N-methyl-D-aspartate; SCPP, spinal cord perfusion pres- potential surgical injury .The blood supply to the sure) motor tracts is derived from the anterior spinal ar- tery. It is therefore possible for significant motor A. Wake-up test: It was first described by Vauzelle, 30 deficit to develop post-operatively in patients with Stagnara et al in 1973 . It is a gross test of spinal 32 intact SSEPs throughout surgery . All anaesthetic motor function. It remains the most reliable assess- drugs affect SSEPs. Generally they tend to increase ment of the intact spine for several reasons. An- latency and decrease amplitude. Exceptions are ni- 491
  • Indian Journal of Anaesthesia, December 2007 trous oxide, ketamine and midazolam which do not A. Reducing blood loss affect latency. Etomidate has been reported to in- 1. When patients are placed prone intraabdominal crease amplitude. The use of inhaled agents upto 1 pressure should be minimized. This leads to a re- MAC may not significantly affect SSEP monitor- duced epidural venous pressure and thus the venous ing. Bolus doses of opioids or sedatives or sudden surgical bleed. increase in concentration of anaesthetic agents al- 2. Hypotensive anaesthesia is considered a reason- ter SSEPs. Therefore the best anaesthetic technique ably safe and effective method for reducing blood is one that provides smooth and continuous anaes- loss by up to 58% during spine surgery .Mean 42,43 31 thetic effect avoiding bolus dosing . Physiologic arterial pressure is typically maintained at 60-65mm factors influencing SSEPs include blood pressure, of Hg. Hypotensive anaesthesia can be achieved 44 temperature and blood gas tensions. When mean by the use of inhalational agents , sodium nitroprus- arterial pressure falls to below the lower limit of 45 side , ganglion blocking drugs e.g.trimethaphan , 46 47 auto- regulation there is progressive decrease of calcium channel blockers e.g. nicardipine , beta 33 48 amplitude with no change in latency . Hypother- blockers e.g. propranolol, esmolol, labetalol , nitro- 49 50 mia causes increase in latency and decrease in glycerin , fenoldopam etc. 34 amplitude .Hyperthermia decreases amplitude and 3. Antifibrinolytic agents e.g. aprotinin inhibits plas- 0 35 causes loss of wave at 42 C . Hypoxia decreases min and kallikrein and preserves platelet function . 51 36 amplitude . An amplitude decrease of 50% or a Urban et al found significantly reduced blood loss in latency increase of 10% may suggest a correctable major spine surgeries where aprotinin infusion was 41 problem. It is to be confirmed that capnography; used intraoperatively . pulse oximetry and temperature readings are all constant for the patient. The blood pressure is to be B. Autologous blood transfusion raised in attempt to improve spinal cord perfusion. Autologous blood can be made available to the If hemodilution had been performed it should be patient by 3 methods. reversed. A wake-up test or anatomic manipulation 1. Preoperative autologous blood donation may then be performed based on the surgeon’s dis- (PABD): The patient donates blood 3 -5 weeks cretion37 . before surgery for use intraoperatively. Recombi- C. MEP: The limitations of the wake- up test led in- nant erythropoietin has been used before major sur- vestigators to explore the possibility of monitoring gery to rise hemoglobin levels, to reduce allogenic MEPs38 . Compared to SSEPs, MEPs are markedly blood requirements and facilitate PABD and acute depressed by almost all anaesthetic agents 39.The normovolemic hemodilution (ANH). marked influence of anaesthetic drugs on MEPs de- 2. Acute normovolemic hemodilution (ANH): This mands a rigid anaesthetic protocol. During the MEP is performed immediately before surgery. The re- recording anaesthesia is maintained by minimum moved blood is replaced by the infusion of colloids dose of ketamine or etomidate infusion. An alterna- or crystalloids to achieve normovolemia with re- tive is to use a titrable infusion of droperidol-fenta- duced hematocrit. During surgery blood of a lower nyl40 . hematocrit is lost. The donated blood may be IX. Blood conservation: In extensive spine surgeries retransfused once hemostasis is achieved. -1 41 blood losses are typically 10 to 30 ml.kg . It is 3. Intraoperative cell salvage: Blood lost during desirable to keep allogenic blood transfusion to a surgery is collected using commercially available minimum considering the risks of allogenic transfu- equipment and is then anticoagulated, filtered for sion i.e., hypothermia, impaired coagulation, hyper- clots and debris, centrifuged, resuspended in saline kalemia, hypocalcaemia, transfusion reactions, acute and reinfused to the patient. Clotting factors need lung injury, transmitted infections etc. This is ac- to be replaced using fresh frozen plasma. The tech- complished by techniques to reduce blood loss and nique is unsuitable in the presence of malignancy or by autologous blood transfusion. infection. 492
  • Anand H. Kulkarni et al. Scoliosis and anaesthesia 53 X. Post operative care: The patients undergoing fects . The use of opioids would not interfere with scoliosis surgery frequently have preexisting mor- neurologic assessment. However the effects of a bidity, and surgery imposes several further stresses single intrathecal opioid dose would have a limited like significant blood loss and fluid shifts, prolonged duration of effect. Other techniques like intrapleu- anaesthesia, hypothermia etc. After scoliosis cor- ral infusions of local anaesthetics or opioids or both 45 rection preferably all patients should be cared for in have been used .The use of low dose intravenous an intensive care setting. This is particularly impor- ketamine has demonstrated efficacy with an initial tant in those with pre existing myelopathy, pulmo- dose of 0.25 mg.kg -1, followed by an infusion of 2- nary dysfunction, cardio vascular disease, extensive 2.5 mcg.kg -1.min-1 improves pain scores, decreases spine surgery, airway edema or those who have had nausea, reduces narcotic requirements and is not 10 massive transfusion . Oxygen by mask is given for associated with hallucinations27 . the first few hours after extubation and may be re- quired for longer periods in those with pre existing Conclusion pulmonary dysfunction. Pulmonary complications Scoliosis, which may be of varied etiology, leads to (ARDS, pneumonia, atelectasis, pulmonary embo- respiratory involvement characterized by restrictive lung lism) are the most common post operative compli- disease, ventilation-perfusion maldistribution and hypox- cations, and vigilant monitoring, incentive spirom- emia. Cardiovascular involvement is usually in the form etry and aggressive pulmonary toilet are essential of raised right heart pressures, mitral valve prolapse or for reducing morbidity particularly in those with pre congenital heart disease. Anaesthesia is often needed existing pulmonary disease. Certain other compli- for corrective orthopaedic surgery, which is very chal- cations which could occur after scoliosis surgery lenging. A detailed pre-anaesthetic assessment and opti- are neurologic injury, ileus, pneumothorax, dural mization of the respiratory and cardiovascular systems tears, urinary complications and syndrome of inap- is imperative. Important intraoperative considerations are 8, 27 propriate ADH secretion . monitoring, temperature and fluid balance maintenance, XI. Post operative analgesia: Pain management can positioning, spinal cord integrity monitoring and blood be challenging and pain is of a severe degree in conservation. Post operative intensive care, respiratory more extensive procedures. A multimodal approach care and pain therapy deserve special mention. to analgesia is recommended using a combination References of primary analgesics, opioids and regional tech- 1. Horlocker TT, Wedel DJ. Anesthesia for orthopedic surgery, niques where appropriate. Intravenous opioids by Chapter 40, in Clinical Anesthesia by Barash PG, Cullen BF, infusion or patient controlled analgesia devices is Stoelting RK eds. Fifth edition. Lippincott Williams and the mainstay of analgesia. The side effects like res- Wilkins 2005. piratory depression, nausea–vomiting, sedation and 2. Schulthess W. Die Pathologie and therapie der Ruckgrats. ileus tend to limit their use. Nonsteroidal anti-inflam- Joachimsthal-Hand-Buch der Orthopadischen Chirurgie. Gustav Fischer 1905-1907. matory drugs may be used as adjuncts, but the side effects are increased bleeding, gastritis and renal 3. Goldstein LA, Waugh TR. Classification and terminology of scoliosis. Clin Orthop 1973; 93:10-22. dysfunction. Local anaesthetic agents or opioids or 4. Koukourakis I, Giaourakis G, Kouvidis G, et al. Screening school both have been used by the epidural route, the epi- children for scoliosis on the island of Crete. J Spinal Disord dural catheter being placed intraoperatively by the 52 1997; 10:527-531. surgeon . However epidural anaesthesia with lo- 5. Stirling AJ, Howel D, Millner PA, et al. Late onset idiopathic cal anaesthetic agents makes neurologic assessment scoliosis in children six to fourteen years old: A cross sectional difficult. Also concerns over risk of epidural he- prevalence study. J Bone Joint Surg Am 1996; 78:1330-1336. matoma and infection have hindered its widespread 6. Lonstein JE. Adolescent idiopathic scoliosis. Lancet 1994; use. Intrathecal opioids can be injected with techni- 344:1407-1412. cal ease before wound closure. Studies suggest the 7. Koumbourlis AC. Review: Scoliosis and the respiratory sys- optimum dose of morphine to be 2–5 mcg.kg -1 which tem. Paed Resp Rev 2006; 7:152-160. provides analgesia for 24 hours with few side ef- 8. Freeman BL. The Spine. Chapter 12, in Campbell’s Operative Orthopaedics. 10th Edition, Mosby Publications 2003. 493
  • Indian Journal of Anaesthesia, December 2007 9. Raw DA, Beattie JK, Hunter JM. Review article: Anaesthesia 28. Jacobs HK, Lieponis JV, Bunch WH, etal. The influence of for spinal surgery in adults. British Journal of Anaesthesia halothane and nitroprusside on canine spinal cord hemody- 2003; 91:886-904. namics. Spine 1982; 7:35. 10. Taylor JM, Gropper MA. Critical care challenges in orthope- 29. Lowe T. Morbidity and mortality committee report, Scoliosis dic surgery patients. Crit Care Med 2006; 34:S191-S199. Research Society. Read at 22nd Annual Meeting, Vancouver 11. Vedantam R, Lenke LG, Bridwell KH, et al. A prospective BC, Canada, 1987. evaluation of pulmonary function in patients with adolescent 30. Hall JE, Levine CR, Sudhir KG. Intraoperative awakening to idiopathic scoliosis relative to the surgical approach used for monitor spinal cord function during Harrington instrumenta- spinal arthrodesis. Spine 2000; 25:82-90. tion and spine fusion. J Bone Joint Surg Am 1978; 60:533. 12. Cooper DM, Rojas JV, Mellins RB, et al. Respiratory mechan- 31. Mahla ME, Black S, Cucchiara RF. Neurologic Monitoring, ics in adolescents with idiopathic scoliosis. Am Rev Respir Dis Chapter 38 in Text book of Anesthesia by Miller RD, 6th edi- 1984; 130:16-22. tion. Elsevier Chruchill Livingstone 2005. 13. Day GA, Upadhyay SS, Ho EK, et al. Pulmonary functions in 32. Spielholz NI, Benjamin MV, Engler GL, et al. Somatosensory congenital scoliosis. Spine 1994; 19:1027-31. evoked potentials during decompression and stabilization of 14. Boyer J, Amin N, Taddonio R, et al. Evidence of airway ob- the spine: methods and findings. Spine 1979; 4:500. struction in children with idiopathic scoliosis. Chest 1996; 33. Eng DY, Dong WK, Bledsoe SW, etal. Electrical and pathologic 109:1532-1535. correlates of brain hypoxia during hypotension. Anesthesiol- 15. Borowitz D, Armstrong D, Cemy F. Relief of central airways ogy 1980; 53:S92. obstruction following spinal release in a patient with idiopathic 34. Russ W, Kling D, Loesevitz A, etal. Effect of hypothermia on scoliosis. Peditr Pulmonol 2001; 31:86-88. visual evoked potentials in humans.Anesthesiology 1984; 61:207. 16. Kearon C, Viviani GR, Killian KJ. Factors influencing work 35. Dubois M, Loppola R, Buchsbaum MS, et al. SSEP during capacity in adolescent idiopathic thoracic scoliosis. Am Rev whole body hyperthermia in humans. Electroencephalogr Clin Respir Dis 1993; 148:295-303. Neurophysiol 1981; 52:157. 17. Kafer ER. Respiratory and cardiovascular functions in scolio- 36. Grundy BL, Heros RC, Tung AS, et al. Intraoperative hypoxia sis. Bull Eur Physiopathol Respir 1977; 13:299-321. detected by evoked potential monitoring. Anesth Analg 1981; 18. Tetzlaff JE,Yoon HJ. Scoliosis. Chapter 22 in Clinical Or- 60:437. th oped ic Anesthesia. Tetzlaff JE ed. Butterworth 37. Grundy BL. Intraoperative monitoring of sensory evoked po- Heinemann, 1995. tentials. Anesthesiology 1983; 58:72-87. 19. Davies G, Reid L. Effect of scoliosis on growth of alveoli and 38. Ghaly RF, Stone JL, Levy WJ, et al. The effect of an anes- pulmonary arteries and on the right ventricle. Arch Dis Child thetic induction dose of midazolam on motor evoked poten- 1971; 46:623-632. tials evoked by transcranial magnetic stimulation in the mon- 20. Kafer ER.Review article: Respiratory and cardio vascular func- key. J Neurosurg Anesthesiol 1991; 3:20. tions in scoliosis and the principles of anesthetic management. 39. Drummond JC, Tung HC, Bickford RG. The effects of seda- Anesthesiology 1980; 52:339-351. tive agents on magnetic motor evoked potentials. J Clin 21. Kawakami N, Mimatsu K, Deguchi M, et al. Scoliosis and Neurophysiol 1988; 4:366. congenital heart disease. Spine 1995; 20:1252-1256. 40. Salem MR, Klowden AJ. Anesthesia for Orthopedic Proce- 22. http://www.anaesthesiauk.com/article.aspx?articleid=100377 dures, Chapter 22 in Pediatric Anesthesia, Gregory GA ed, 4th edition. Churchill Livingstone, 2002. 23. Toyota S, Amaki Y. Hemodynamic evaluation of the prone position by transoesophageal echo. J Clin Anesth 1998; 41. Urban MK, Beckman J, Gordon M, et al. The efficacy of 9:32-35. antifibrinolytics in the reduction of blood loss during complex adult reconstructive spine surgery. Spine 2001; 26:1152-1156. 24. Britt BA. Malignant Hyperthermia: A pharmacogenetic dis- ease of skeletal and cardiac muscle. N Engl J Med 1974; 42. Malcolm-Smith NA, MacMaster MJ. The use of induced hy- 74:1140-42. potension to control bleeding during posterior fusion for scolio- sis. J Bone Joint Surg 1983; 65:255-8. 25. Britt BA. Etiology and pathophysiology of malignant hyper- thermia. Fed Proc 1979; 38:44-48. 43. Ulrich PF, Keene JS, Hogan KJ, Roecker EB. Results of hy- potensive anesthesia in operative treatment of thoraco lumbar 26. Dommissee GF. The blood supply of the human spinal cord: A fractures. J Spinal Disord 1990; 3:329-33. critical vascular factor in spinal surgery. J Bone Joint Surg Br 1974; 56:225. 44. Prys-Roberts C, Lloyd JW, Fisher A, et al. Deliberate pro- found hypotension induced with halothane: studies of hemo- 27. Sharrock NE, Beckman JD, Connolly E, Savarese JJ. Anes- dynamics and pulmonary gas exchange. Br J Anaesth 1974; thesia for Orthopedic Surgery, Chapter 61 in Text book of 46:105. Anesthesia by Miller RD. 6 th edition. Elsevier Chruchill Livingstone 2005. 45. Miller ED, Ackerly JA, Vaughan ED, et al. The renin-angio- tensin system during controlled hypotension with sodium ni- 494
  • Anand H. Kulkarni et al. Scoliosis and anaesthesia troprusside. Anesthesiology 1977; 47:257. 51. Haas SS, Ketterl R, Stemberger A, et al. The effect of aprotinin 46. Salem MR. Therapeutic uses of ganglion blocking drugs. Int on platelet function, blood coagulation and blood lactate levels Anesthesiol Clin 1978; 16:171. in total hip replacement: A double blind clinical trail. Adv Exp Med Biol 1984; 167:287-97. 47. Hersey SL, O’Dell NE, Lowe S, et al. Nicardipine versus nitro- prusside for controlled hypotension during spinal surgery in 52. Lowry KJ, Tobias J, Kittle D, et al. Post operative pain control adolescents. Anesth Analg 1997; 84:1239. using epidural catheters after anterior spinal fusion for adoles- cent scoliosis. Spine 2001; 26:1290-3. 48. Fahmy NR, bottros MR, Charehaflieh J, et al. Randomized comparison of labetalol and nitroprusside for induced hypoten- 53. Boezaart AP, Eksteen JA, Spuy GV, et al. Intrathecal mor- sion. J Clin Anesth 1989; 1:409. phine: Double blind evaluation of optimal dosage for analgesia after major lumbar spinal surgery. Spine 1999; 24:1131-7. 49. Yaster M, Simmons RS, Tolo VT, et al. A comparison of nitro- glycerin and nitroprusside for inducing hypotension in chil- 54. Inderbitzi R, Flueckiger K, Ris HB. Pain relief and respiratory dren: A double blind study. Anesthesiology 1986; 65:175-9. mechanics during continuous intrapleural bupivacaine administra- tion after thoracotomy. Thorac Cardiovasc Surg 1992; 40:87-9. 50. Tobias JD. Fenoldopam for controlled hypotension during spinal fusion in children and adolescents. Paediatr Anaesth 2000; 9:261-266. ISACON 2007 Diamond Jubilee Year - 2007 55 th Annual National Conference of Indian Society of Anaesthesiologists Visakhapatnam, 26th - 29th Dec, 2007 (Organised by ISA Visakhapatnam City Branch) Hosted by ISA AP State Branch. Venue : Port Stadium complex, Visakhapatnam REGISTRATION CHARGES CATEGORY UPTO UPTO FROM 30.09.07 30.11.07 01.12.07 (REGULAR) (DELAYED) (INCL. SPOT) Organising Chairperson ISA Members Dr. D. Vijay Kumar Rao Conference Rs. 2000 Rs. 2400 Rs. 3200 H.O.D., C.M.E. Rs. 500 Rs. 600 Rs. 700 Andhra Medical College, Conference + C.M.E. Rs. 2400 Rs. 2900 Rs. 3800 Visakhapatnam. PG Students Mob. : 98491 16069 Conference Rs. 1500 Rs. 1900 Rs. 2300 C.M.E. Rs. 500 Rs. 600 Rs. 700 Conference + C.M.E. Rs. 1900 Rs. 2400 Rs. 2900 Organising Secretary Non-ISA Members Dr. V. Kuchela Babu Conference Rs. 2600 Rs. 3200 Rs. 3900 Dept. of Anaesthesiology, C.M.E. Rs. 700 Rs. 800 Rs. 900 Seven Hills Hospital Conference + C.M.E. Rs. 3200 Rs. 3900 Rs. 4700 Rockdale Layout, Accompanying person Rs. 1200 Rs. 1300 Rs. 1400 Visakhapatnam. Ph. : 0891-2526655, 6529261 (Children above 5 yrs) Mob. : 93931 02444 Overseas Delegates US$ 140 US$ 160 US$ 180 Email : kuchelababu@yahoo.com Overseas Delegates US$ 90 US$ 110 US$ 130 Website : www.isacon2007.com Accompanying person  Registration is mandatory for all participants (irrespective of the type of participation)  Identity badge is mandatory for entering into conference area including trade exhibition  Payment is only to be made by DD or cash, in favour of 'ISACON 2007' Payable at Visakhapatnam.  Certificate from Principal or H.O.D. is mandatory for Post Graduate students 495