Anaesthesia for spine surgery

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

CHECK BREATH SOUNDS BILATERALLY

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

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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.

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