Anaesthesia for spine surgery
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Spine surgeries present diverse challenges to anaesthetists. The document outlines considerations for anaesthesia including preoperative evaluation and optimization, induction and intubation while maintaining spine stability, positioning prone or sitting, intraoperative monitoring, maintenance with stable anaesthetic depth and blood pressure, transfusion management for blood loss, emergence and extubation when fully awake, postoperative analgesia, and complications prevention and management. Skillful anaesthetic management is key to optimal patient outcomes for various spine procedures.
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)
- 7. INDICATIONS
- 8. INDICATIONS
- 9. INDICATIONS
- 10. TYPES OF PROCEDURES OPEN SURGERY MINIMAL ACCESS THORACOSCOPIC APPROACH LAPAROSCOPIC APPROACH
- 11. PROCEDURES
- 12. PROCEDURES
- 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
- 20. POSITIONING
- 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.
- 30. THANK YOU
- 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.