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
 USEOF 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 INTUBATION TIME
MOTION DIFFICULTY 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 VIGILANCE,
KINKING/DISLODGEMENT REINFORCED ETT
NECK CERVICAL ROTATION- PROPER
COMPROMISED BLD TO POSITIONING
BRAIN

EYES CORNEAL ABRASION, POVL EYES TAPED SHUT.

AVOID EYE
COMPRESSION,
HYPOTENSN
ABDOMEN COMPRESSION- USE SOFT
HYPOVENTILATION, BLD SUPPORTS
LOSS
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-UPTEST
 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
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