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ANAESTHESIA FOR SPINE
SURGERY
BASSEY, A. E.
OUTLINE
 INTRODUCTION
 BRIEF ANATOMY OF THE SPINE
 INDICATIONS FOR SPINE SURGERY
 TYPES OF PROCEDURES
 PREOPERATIVE EVALUATION
 PREMEDICATION
 INDUCTION AND INTUBATION
 POSITIONING
 MONITORING
 MAINTENANCE
 TRANSFUSION MANAGEMENT
 EMERGENCE AND EXTUBATION
 POSTOP CARE
 COMPLICATIONS
 CONCLUSION
INTRODUCTION
 SPINE SURGERIES ARE A WIDE VARIETY OF
PROCEDURES, THEY PRESENT DIVERSE
CHALLENGES TO THE ANAESTHETIST
 4.6 MILLION INDIVIDUALS IN THE USA WILL
REQUIRE SPINE SURGERY IN THEIR LIFETIME
 SKILFUL ANAESTHETIC MANAGEMENT IS
INDISPENSABLE TO OBTAINING BEST
OUTCOME
BRIEF ANATOMY OF THE SPINE
BRIEF ANATOMY OF THE SPINE
INDICATIONS FOR SPINE SURGERY
 NEUROLOGIC DYSFUNCTION
(COMPRESSION)
 STRUCTURAL INSTABILITY (ABNORMAL
DISPLACEMENT)
 PATHOLOGIC LESIONS (TUMOUR,
INFECTION)
 DEFORMITY (ABNORMAL ALIGNMENT)
 PAIN(DISCOGENIC, FACETOGENIC etc)
INDICATIONS
INDICATIONS
INDICATIONS
TYPES OF PROCEDURES
 OPEN SURGERY
 MINIMAL ACCESS
 THORACOSCOPIC APPROACH
 LAPAROSCOPIC APPROACH
PROCEDURES
PROCEDURES
PREOPERATIVE EVALUATION
 HISTORY
 PATHOLOGY – SITE, NATURE
 PROCEDURE – TYPE, DURATION, APPROACH
 CO-MORBIDITIES – HTN, CCF, CAD, ASTHMA, RTI
 DRUGS – ASPIRIN
 COUNSELLING – COMPLICATIONS, INTRAOP TESTS
 EXAM
 AIRWAY – MOUTH OPENING, MALLAMPATI, NECK
ROM?, PREDICTORS OF DIFFICULT INTUBATION
 PULMONARY – DYSPNOEA, INFECTION, ASTHMA
 CVS – DYSFXN MAY BE DUE TO MEDICAL DX, HIGH
CERVICAL PATHOLOGY
 NEUROLOGIC – FULL EXAM & DOCUMENT DEFICITS
 MSS - SPINE
PREOPERATIVE EVALUATION
 INVESTIGATIONS
 FBC, EUCr, URINALYSIS, CLOTTING PROFILE
 CVS – ECG, ECHO
 PULMONARY – CXR, ABGs, SPIROMETRY (esp. in
elderly, deformities, one-lung ventilation)
 C-SPINE PATHOLOGY – XRAY C-SPINE
PREMEDICATION
 DEPENDENT ON CLINICAL STATUS
 USE OF OPIOIDS IN PATIENTS AT RISK OF
PULMONARY DYSFUNCTION
 HAEMODYNAMIC INSTABILITY
INDUCTION AND INTUBATION
 INDUCTION
 INTRAVENOUS OR INHALATIONAL?
 PT’S CLINICAL CONDITION
 AIRWAY
 C-SPINE STABILITY
 MUSCLE RELAXATION
 CONSIDER INTRAOP MONITORING
INDUCTION AND INTUBATION
 INTUBATION
 AWAKE OR ASLEEP,BOTH SUITABLE. NO
EVIDENCE TO PROVE OTHERWISE. HOWEVER,
WHILE AWAKE – NEURO EXAM POSSIBLE
 DIRECT LARYNGOSCOPY: INTUBATION CAN BE
ACHIEVED WITHOUT ANY NECK MOVEMENT
(MANUAL IN-LINE STABILIZATION OR A HARD
COLLAR)
 FIBER-OPTIC LARYNGOSCOPY: FIXED FLEXION
DEFORMITIES INVOLVING UPPER T-SPINE/C-
SPINE, PTS WEARING STABILIZATION DEVICES
SUCH AS HALO VESTS, LIMITED MOUTH
OPENING
 CONSIDER USE OF WIRE-REINFORCED ETT TO
MINIMISE RISK OF KINKING
 ENSURE PT’s C-SPINE IS STABLE BEFORE ETT
INDUCTION AND INTUBATION
METHODS C-SPINE
MOTION
INTUBATION
DIFFICULTY
TIME
REQUIRED
RIGID COLLAR NIL
INLINE
STABILIZATION
AXIAL
TRACTION
BLIND NASAL
INTUBATION
RETROGRADE
INTUBATION
POSITIONING – PRONE
 COMMONEST POSITION FOR SPINE SURGERY
 INDUCTION AND INTUBATION IN SUPINE POSITION
 TURN PRONE AS A SINGLE UNIT REQUIRING AT
LEAST FOUR PEOPLE
 NECK SHOULD BE IN NEUTRAL POSITION
 HEAD MAY BE TURNED TO THE SIDE NOT
EXCEEDING THE PATIENTS NORMAL RANGE OF
MOTION OR FACE DOWN ON A CUSHIONED
HOLDER.
 ARMS SHOULD BE AT THE SIDES IN A
COMFORTABLE POSITION WITH THE ELBOW
FLEXED (AVOIDING EXCESSIVE ABDUCTION AT THE
SHOULDER)
 CHEST SHOULD REST ON PARALLEL ROLLS (FOAMS)
OR SPECIAL SUPPORTS (FRAME) TO FACILITATE
VENTILATION
 CHECK ORAL ENDOTRACHEAL TUBE, OTHER
ATTACHMENTS
POSITIONING
ORGAN/SYSTEM COMPLICATION COMMENTS
AIRWAY ETT
KINKING/DISLODGEMENT
VIGILANCE,
REINFORCED ETT
NECK CERVICAL ROTATION-
COMPROMISED BLD TO
BRAIN
PROPER
POSITIONING
EYES CORNEAL ABRASION, POVL EYES TAPED SHUT.
AVOID EYE
COMPRESSION,
HYPOTENSN
ABDOMEN COMPRESSION-
HYPOVENTILATION, BLD
LOSS
USE SOFT
SUPPORTS
UPPER LIMBS U NERVE COMPRESSION
LOWER LIMBS DVT, FOOT DROP
PRESSURE SORE FOREHEAD, NOSE, EAR
DETACHED
MONITORS
POSITIONING
 SITTING POSITION : GOOD DRAINAGE,
CLEAR FIELD BUT RISK OFAIR EMBOLISM
MONITORING
 STANDARD
 VITALS, ECG, SpO2, CAPNOMETRY, BLOOD
LOSS, URINE OUTPUT
 SPECIFIC
 SSEP
 MEP
 EMG
 WAKE-UP TEST
 MULTIMODAL
MAINTENANCE
 MAINTAIN A STABLE ANESTHETIC DEPTH
 POSITIONING OF PATIENT, CHECK AIRWAYS
 AVOID SUDDEN CHANGES IN ANESTHETIC
DEPTH OR BP
 MAINTAIN A CONSTANT DEPTH OF NMB
 MAINTENANCE OPTIONS
 0.5 MAC ISOFLURANE / HALOTHANE
 CONTINUOUS INFUSION OF PROPOFOL
 CONTINUOUS REMIFENTANYL OR BOLUS OPIOIDS
 DESFLURANE-REMIFENTANYL
 CONTROLLED HYPOTENSIVE ANAESTHESIA
TRANSFUSION MANAGEMENT
 SIGNIFICANT BLOOD LOSS MAY OCCUR
 EBL IN AP DEFORMITY CORRECTION IS 3 –
5L
 TECHNIQUES TO REDUCE NEED FOR
HOMOLOGOUS BLOOD TRANSFUSION
 PREOPERATIVE AUTOLOGOUS DONATION
 INTRAOPERATIVE BLOOD SALVAGE
 HYPOTENSIVE ANAESTHESIA
 ANTIFIBRINOLYTIC THERAPY
EMERGENCE AND EXTUBATION
 PATIENT MADE SUPINE
 THOROUGH ENDOTRACHEAL AND ORAL
SUCTION
 OXYGENATED WITH 100% OXYGEN
 REVERSAL AGENTS – IV NEOSTIGMINE +
ATROPINE
 LEAVE ETT INSITU TILL PT IS
 FULLY AWAKE
 OBEYS COMMANDS
 ABLE TO PROTECT HIS AIRWAY
 SOME MAY REQUIRE ICU CARE POST OP
POSTOPERATIVE CARE
 MOST SPINE SURGERY IS PAINFUL
 INTRAOP, INSTILL LA + OPIOIDS INTO
EPIDURAL SPACE BEFORE CLOSURE
 POST OP PCA + ORAL/RECTAL ANALGESICS
ARE BENEFICIAL
POSTOPERATIVE COMPLICATIONS
 EARLY
 HYPOVOLAEMIA
 NEUROLOGIC DEFICIT
 DURAL TEAR WITH CSF LEAKAGE
 ATELECTASIS
 PARALYTIC ILEUS
 URINE RETENTION
 DVT
 LATE
 INFECTION
 DEHISCENCE
 SPINAL INSTABILITY
 IMPLANT FAILURE
 EPIDURAL FIBROSIS
CONCLUSION
 PATIENT UNDERGOING SPINE SURGERY
PRESENT DIVERSE CHALLENGE TO THE
ANESTHETIST.
 OPTIMAL MANAGEMENT DEPENDS ON THE
ANESTHESIOLOGIST UNDERSTANDING
THE PATHOLOGIC PROCESS AND THE
RISKS AND DEMANDS OF THE OPERATIVE
PROCEDURE.
THANK YOU
REFERENCES
 URBAN, M K. ANAESTHESIA FOR ORTHOPAEDIC
SURGERY IN MILLER’S ANAESTHESIA (7TH
ED)
(CH. 70). ELSEVIER
 www.theiaforum.org
 Regan JJ, Yuan H, McAfee PC: Laparoscopic fusion of
the lumbar Spine: minimally invasive spine surgery.
A prospective multicentre study evaluating open and
laparoscopic lumbar fusion. Spine 24:402-411, 1999.
 Chiu JC, Clifford TJ, Green span M, Richley
RC,Lohman G,Sison RB : Percutaneous
microdecompressive endoscopic cervical discectomy
with laser thermodiskoplasty Mt Sinai J Med 67: 278-
282,2000.
 Rosenthal D, Dickman CA: Thoracoscopic
microsurgical excision of herniated thoracic discs J
Neurosurg 89: 224-235, 2000.
REFERENCES
 Zeidman, S., Ducker, T. & Raycroft, J.. Trends and
complications in cervical spine surgery: 1989-1993.
Journal of Spinal Disorders, 10(6), 523-526, 1997.
 McNeill, T, & Andersson, G. (1997). Complications of
degenerative lumbar spine surgery. In Bridwell, K. &
DeWald, R. (Eds), The textbook of spinal surgery.
(2nd Ed.) (pp 1669-1678) Philadelphia: Lippincott-
Raven Publishers.
 Shu-Hong Chang, Neil R. Miller. The Incidence of
Vision Loss due to Perioperative Ischemic Optic
Neuropathy Associated With Spine Surgery: The
Johns Hopkins Hospital Experience. Spine. ; 30 (11):
1299-1302, 2005. ©2005 Lippincott Williams &
Wilkins.

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Anaesthesia for spine surgery

  • 2. OUTLINE  INTRODUCTION  BRIEF ANATOMY OF THE SPINE  INDICATIONS FOR SPINE SURGERY  TYPES OF PROCEDURES  PREOPERATIVE EVALUATION  PREMEDICATION  INDUCTION AND INTUBATION  POSITIONING  MONITORING  MAINTENANCE  TRANSFUSION MANAGEMENT  EMERGENCE AND EXTUBATION  POSTOP CARE  COMPLICATIONS  CONCLUSION
  • 3. INTRODUCTION  SPINE SURGERIES ARE A WIDE VARIETY OF PROCEDURES, THEY PRESENT DIVERSE CHALLENGES TO THE ANAESTHETIST  4.6 MILLION INDIVIDUALS IN THE USA WILL REQUIRE SPINE SURGERY IN THEIR LIFETIME  SKILFUL ANAESTHETIC MANAGEMENT IS INDISPENSABLE TO OBTAINING BEST OUTCOME
  • 4. BRIEF ANATOMY OF THE SPINE
  • 5. BRIEF ANATOMY OF THE SPINE
  • 6. INDICATIONS FOR SPINE SURGERY  NEUROLOGIC DYSFUNCTION (COMPRESSION)  STRUCTURAL INSTABILITY (ABNORMAL DISPLACEMENT)  PATHOLOGIC LESIONS (TUMOUR, INFECTION)  DEFORMITY (ABNORMAL ALIGNMENT)  PAIN(DISCOGENIC, FACETOGENIC etc)
  • 10. TYPES OF PROCEDURES  OPEN SURGERY  MINIMAL ACCESS  THORACOSCOPIC APPROACH  LAPAROSCOPIC APPROACH
  • 13. PREOPERATIVE EVALUATION  HISTORY  PATHOLOGY – SITE, NATURE  PROCEDURE – TYPE, DURATION, APPROACH  CO-MORBIDITIES – HTN, CCF, CAD, ASTHMA, RTI  DRUGS – ASPIRIN  COUNSELLING – COMPLICATIONS, INTRAOP TESTS  EXAM  AIRWAY – MOUTH OPENING, MALLAMPATI, NECK ROM?, PREDICTORS OF DIFFICULT INTUBATION  PULMONARY – DYSPNOEA, INFECTION, ASTHMA  CVS – DYSFXN MAY BE DUE TO MEDICAL DX, HIGH CERVICAL PATHOLOGY  NEUROLOGIC – FULL EXAM & DOCUMENT DEFICITS  MSS - SPINE
  • 14. PREOPERATIVE EVALUATION  INVESTIGATIONS  FBC, EUCr, URINALYSIS, CLOTTING PROFILE  CVS – ECG, ECHO  PULMONARY – CXR, ABGs, SPIROMETRY (esp. in elderly, deformities, one-lung ventilation)  C-SPINE PATHOLOGY – XRAY C-SPINE
  • 15. PREMEDICATION  DEPENDENT ON CLINICAL STATUS  USE OF OPIOIDS IN PATIENTS AT RISK OF PULMONARY DYSFUNCTION  HAEMODYNAMIC INSTABILITY
  • 16. INDUCTION AND INTUBATION  INDUCTION  INTRAVENOUS OR INHALATIONAL?  PT’S CLINICAL CONDITION  AIRWAY  C-SPINE STABILITY  MUSCLE RELAXATION  CONSIDER INTRAOP MONITORING
  • 17. INDUCTION AND INTUBATION  INTUBATION  AWAKE OR ASLEEP,BOTH SUITABLE. NO EVIDENCE TO PROVE OTHERWISE. HOWEVER, WHILE AWAKE – NEURO EXAM POSSIBLE  DIRECT LARYNGOSCOPY: INTUBATION CAN BE ACHIEVED WITHOUT ANY NECK MOVEMENT (MANUAL IN-LINE STABILIZATION OR A HARD COLLAR)  FIBER-OPTIC LARYNGOSCOPY: FIXED FLEXION DEFORMITIES INVOLVING UPPER T-SPINE/C- SPINE, PTS WEARING STABILIZATION DEVICES SUCH AS HALO VESTS, LIMITED MOUTH OPENING  CONSIDER USE OF WIRE-REINFORCED ETT TO MINIMISE RISK OF KINKING  ENSURE PT’s C-SPINE IS STABLE BEFORE ETT
  • 18. INDUCTION AND INTUBATION METHODS C-SPINE MOTION INTUBATION DIFFICULTY TIME REQUIRED RIGID COLLAR NIL INLINE STABILIZATION AXIAL TRACTION BLIND NASAL INTUBATION RETROGRADE INTUBATION
  • 19. POSITIONING – PRONE  COMMONEST POSITION FOR SPINE SURGERY  INDUCTION AND INTUBATION IN SUPINE POSITION  TURN PRONE AS A SINGLE UNIT REQUIRING AT LEAST FOUR PEOPLE  NECK SHOULD BE IN NEUTRAL POSITION  HEAD MAY BE TURNED TO THE SIDE NOT EXCEEDING THE PATIENTS NORMAL RANGE OF MOTION OR FACE DOWN ON A CUSHIONED HOLDER.  ARMS SHOULD BE AT THE SIDES IN A COMFORTABLE POSITION WITH THE ELBOW FLEXED (AVOIDING EXCESSIVE ABDUCTION AT THE SHOULDER)  CHEST SHOULD REST ON PARALLEL ROLLS (FOAMS) OR SPECIAL SUPPORTS (FRAME) TO FACILITATE VENTILATION  CHECK ORAL ENDOTRACHEAL TUBE, OTHER ATTACHMENTS
  • 21. ORGAN/SYSTEM COMPLICATION COMMENTS AIRWAY ETT KINKING/DISLODGEMENT VIGILANCE, REINFORCED ETT NECK CERVICAL ROTATION- COMPROMISED BLD TO BRAIN PROPER POSITIONING EYES CORNEAL ABRASION, POVL EYES TAPED SHUT. AVOID EYE COMPRESSION, HYPOTENSN ABDOMEN COMPRESSION- HYPOVENTILATION, BLD LOSS USE SOFT SUPPORTS UPPER LIMBS U NERVE COMPRESSION LOWER LIMBS DVT, FOOT DROP PRESSURE SORE FOREHEAD, NOSE, EAR DETACHED MONITORS
  • 22. POSITIONING  SITTING POSITION : GOOD DRAINAGE, CLEAR FIELD BUT RISK OFAIR EMBOLISM
  • 23. MONITORING  STANDARD  VITALS, ECG, SpO2, CAPNOMETRY, BLOOD LOSS, URINE OUTPUT  SPECIFIC  SSEP  MEP  EMG  WAKE-UP TEST  MULTIMODAL
  • 24. MAINTENANCE  MAINTAIN A STABLE ANESTHETIC DEPTH  POSITIONING OF PATIENT, CHECK AIRWAYS  AVOID SUDDEN CHANGES IN ANESTHETIC DEPTH OR BP  MAINTAIN A CONSTANT DEPTH OF NMB  MAINTENANCE OPTIONS  0.5 MAC ISOFLURANE / HALOTHANE  CONTINUOUS INFUSION OF PROPOFOL  CONTINUOUS REMIFENTANYL OR BOLUS OPIOIDS  DESFLURANE-REMIFENTANYL  CONTROLLED HYPOTENSIVE ANAESTHESIA
  • 25. TRANSFUSION MANAGEMENT  SIGNIFICANT BLOOD LOSS MAY OCCUR  EBL IN AP DEFORMITY CORRECTION IS 3 – 5L  TECHNIQUES TO REDUCE NEED FOR HOMOLOGOUS BLOOD TRANSFUSION  PREOPERATIVE AUTOLOGOUS DONATION  INTRAOPERATIVE BLOOD SALVAGE  HYPOTENSIVE ANAESTHESIA  ANTIFIBRINOLYTIC THERAPY
  • 26. EMERGENCE AND EXTUBATION  PATIENT MADE SUPINE  THOROUGH ENDOTRACHEAL AND ORAL SUCTION  OXYGENATED WITH 100% OXYGEN  REVERSAL AGENTS – IV NEOSTIGMINE + ATROPINE  LEAVE ETT INSITU TILL PT IS  FULLY AWAKE  OBEYS COMMANDS  ABLE TO PROTECT HIS AIRWAY  SOME MAY REQUIRE ICU CARE POST OP
  • 27. POSTOPERATIVE CARE  MOST SPINE SURGERY IS PAINFUL  INTRAOP, INSTILL LA + OPIOIDS INTO EPIDURAL SPACE BEFORE CLOSURE  POST OP PCA + ORAL/RECTAL ANALGESICS ARE BENEFICIAL
  • 28. POSTOPERATIVE COMPLICATIONS  EARLY  HYPOVOLAEMIA  NEUROLOGIC DEFICIT  DURAL TEAR WITH CSF LEAKAGE  ATELECTASIS  PARALYTIC ILEUS  URINE RETENTION  DVT  LATE  INFECTION  DEHISCENCE  SPINAL INSTABILITY  IMPLANT FAILURE  EPIDURAL FIBROSIS
  • 29. CONCLUSION  PATIENT UNDERGOING SPINE SURGERY PRESENT DIVERSE CHALLENGE TO THE ANESTHETIST.  OPTIMAL MANAGEMENT DEPENDS ON THE ANESTHESIOLOGIST UNDERSTANDING THE PATHOLOGIC PROCESS AND THE RISKS AND DEMANDS OF THE OPERATIVE PROCEDURE.
  • 31. REFERENCES  URBAN, M K. ANAESTHESIA FOR ORTHOPAEDIC SURGERY IN MILLER’S ANAESTHESIA (7TH ED) (CH. 70). ELSEVIER  www.theiaforum.org  Regan JJ, Yuan H, McAfee PC: Laparoscopic fusion of the lumbar Spine: minimally invasive spine surgery. A prospective multicentre study evaluating open and laparoscopic lumbar fusion. Spine 24:402-411, 1999.  Chiu JC, Clifford TJ, Green span M, Richley RC,Lohman G,Sison RB : Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiskoplasty Mt Sinai J Med 67: 278- 282,2000.  Rosenthal D, Dickman CA: Thoracoscopic microsurgical excision of herniated thoracic discs J Neurosurg 89: 224-235, 2000.
  • 32. REFERENCES  Zeidman, S., Ducker, T. & Raycroft, J.. Trends and complications in cervical spine surgery: 1989-1993. Journal of Spinal Disorders, 10(6), 523-526, 1997.  McNeill, T, & Andersson, G. (1997). Complications of degenerative lumbar spine surgery. In Bridwell, K. & DeWald, R. (Eds), The textbook of spinal surgery. (2nd Ed.) (pp 1669-1678) Philadelphia: Lippincott- Raven Publishers.  Shu-Hong Chang, Neil R. Miller. The Incidence of Vision Loss due to Perioperative Ischemic Optic Neuropathy Associated With Spine Surgery: The Johns Hopkins Hospital Experience. Spine. ; 30 (11): 1299-1302, 2005. ©2005 Lippincott Williams & Wilkins.