Anaesthesia for spine surgery

1. ANAESTHESIA FOR SPINE
SURGERY
BASSEY, A. E.

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
CHECK BREATH SOUNDS BILATERALLY

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
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32. REFERENCES
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