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Akgun MY, Orak Hİ, Akgul MH, Ates O. Efficacy and Advantages of Spinal Anesthesia in Lumbar Disk Surgery. J Neurol Surg A Cent Eur Neurosurg 2024; 85:439-443. [PMID: 38599624 DOI: 10.1055/s-0043-1771267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Quality of life (QoL) may be affected due to various reasons such as low back or leg pains with accompanying neurologic problems. Lumbar disk surgery is one of the most common performed surgeries to relieve those symptoms. Various anesthetic techniques can be used safely to perform lumbar disk surgeries. Properties that make an anesthetic technique good are mainly the quick onset and returning of the effects. This large retrospective study with patients who have undergone lumbar disk surgery under spinal anesthesia aims to evaluate the perioperative and postoperative parameters of the spinal anesthesia and review the literature. METHODS Cases operated under spinal anesthesia between January 2017 and December 2020 were investigated, and 617 patients who underwent simple lumbar disk surgery were included in the study. Demographic characteristics and American Society of Anesthesiologists (ASA) physical status of the patients were recorded. Visual analog scale (VAS) and QoLscores were obtained before and after the operation. RESULTS There were 282 (45.7%) male and 335 (54.3%) female patients with a mean age of 39.48 ± 16.71 years (range: 18-58 years) at symptom onset. The mean operating time was 46.3 minutes (range: 22-68 minutes). Average blood loss was 85 mL (range: 55-125 mL). All the patients were mobilized 6 to 12 hours after surgery. In our patient group, there were both high- and normal-risk groups in terms of the ASA physical status. During the clinical follow-up, a statistically significant improvement was found for the VAS and QoL scores (p < 0.05). CONCLUSIONS In this large retrospective study, our results have confirmed that spinal anesthesia is at least comparable to general anesthesia and even superior to it in some aspects.
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Affiliation(s)
| | - Helin İlkay Orak
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
| | | | - Ozkan Ates
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
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De Biase G, Akinduro OO, Garcia D, Bojaxhi E, Buchanan IA, Gruenbaum SE, Forcht Dagi T, Quinones-Hinojosa A, Abode-Iyamah K. Awake Robotic Minimally Invasive Transforaminal Lumbar Interbody Fusion Under Spinal Anesthesia: A Prospective Study with 1-Year Follow-up. World Neurosurg 2024:S1878-8750(24)01185-9. [PMID: 38986938 DOI: 10.1016/j.wneu.2024.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 07/04/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND We describe our protocol and outcomes of awake robotic minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) under spinal anesthesia. METHODS We conducted a prospective study of 10 consecutive patients undergoing awake robotic single-level MIS-TLIF with the Mazor X robot. We prospectively collected patient-reported outcomes (back and leg pain visual analog scale and Oswestry Disability Index) preoperatively at 1-month and 1-year follow-ups and assessed fusion and screw placement accuracy with a 1-year computed tomography (CT) scan. RESULTS Median age was 61 years (interquartile range [IQR] = 57.7-66). Median body mass index was 27 kg/m2. No intraoperative complications were reported. Most (9/10) patients were discharged home, and 50% discharged on the day of surgery. Median length of stay was 16.5 hours (IQR = 5-35.5). Median follow-up was 12.5 months (IQR = 12-13.5), with 9 patients having at least 12-month follow-up, with CT scans documenting good screw placement (Gertzbein-Robbins grade A) and solid bony fusion. Median preoperative back pain visual analog scale score was 7.8 (IQR = 6.9-8) versus 1.5 (IQR = 0-3.2) at 1-month post operation, P < 0.01, and 0 (IQR = 0-1) at 1-year follow-up, P < 0.01; median preoperative leg pain 8 (IQR = 7.4-8) versus 0 (IQR = 0-1.2) at 1-month post operation, P < 0.01, and 0 (IQR = 0-2) at 1-year follow-up, P < 0.01; median preoperative Oswestry Disability Index 47.5 (IQR = 27.8-57.5) versus 4 (IQR = 0-16) at 1-month postoperation, P < 0.01, and 0 (IQR = 0-7) at 1-year follow-up, P < 0.01. Median preoperative disk height of the index level was 8 mm (IQR = 2.4-9.5) versus 11.4 mm (IQR = 9.2-11.2) postoperatively,P < 0.01. Median preoperative lordosis of the index level was 5 degrees (IQR = 3.4-8.5) versus 10.1 degrees (7.3-12.2) postoperatively, P < 0.01. CONCLUSIONS Our study showed significant improvement in patient-reported outcomes at 1-month and 1-year follow-ups after awake robotic MIS-TLIF, as well as solid bony fusion on CT scans.
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Affiliation(s)
- Gaetano De Biase
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Diogo Garcia
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Elird Bojaxhi
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Ian A Buchanan
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Shaun E Gruenbaum
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
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Kang MS, Son IS, Kim TH, Lee SH, You KH, Lee WM, Hyun JT, Park HJ. Paravertebral Nerve Block for Procedural Pain in Percutaneous Vertebroplasty. Clin J Pain 2024; 40:92-98. [PMID: 37982510 DOI: 10.1097/ajp.0000000000001176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 10/30/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES This study aimed to unidimensionally measure procedural pain at each percutaneous vertebroplasty (PVP) stage and evaluate the effectiveness of paravertebral nerve block (PVNB) in reducing procedural pain. METHODS A retrospective study of prospectively collected data was conducted on 66 patients who underwent PVP for osteoporotic vertebral compression fractures. The patients were divided into 2 groups: group A (fluoroscopic-guided PVNB; 5 cm 3 of 0.75% ropivacaine on each side) and group B (local anesthesia). To investigate procedural pain associated with PVP, the visual analog scale score was assessed at each surgical stage: before the incision (stage 1), transpedicular approach (stage 2), and polymethylmethacrylate cement injection (stage 3). After the procedure, patients were asked about their surgical experience and satisfaction using the Iowa Satisfaction with Anesthesia Scale. Periprocedural complications were also recorded. RESULTS A total of 63 patients (78.65 y of age) were finally enrolled: 30 from group A and 33 from group B. In both groups, a significant ≥2-point increase in procedural pain was observed during PVP compared with that during stage 1 ( P < 0.001). In stages 2 and 3, the pain intensity was significantly lower in group A ( P < 0.001). Upon discharge, the visual analog scale score improved in all groups; however, the Iowa Satisfaction with Anesthesia Scale score was significantly higher in group A ( P < 0.001). There was no difference in periprocedural complications between the two groups ( P = 0.743). CONCLUSION PVP causes significant procedural pain, and PVNB is a potentially effective modality for enhancing patient satisfaction and reducing procedural pain.
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Affiliation(s)
- Min-Seok Kang
- Department of Orthopedic Surgery, Korea University College of Medicine, Anam Hospital
| | - In-Seok Son
- Department of Orthopedic Surgery, Jeju University Medical Center, Jeju, Republic of Korea
| | - Tae-Hoon Kim
- Department of Orthopedic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine
| | - Suk-Ha Lee
- Department of Orthopedic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine
| | - Ki-Han You
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical College, Seoul
| | - Woo-Myung Lee
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical College, Seoul
| | - Jin-Tak Hyun
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical College, Seoul
| | - Hyun-Jin Park
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical College, Seoul
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Yin J, Jiang X, Xu N, Nong L, Jiang Y. Is Full-Endoscopic Transforaminal Lumbar Interbody Fusion Superior to Open Transforaminal Lumbar Interbody Fusion for Single-Level Degenerative Lumbar Spondylolisthesis? A Retrospective Study. J Neurol Surg A Cent Eur Neurosurg 2024; 85:39-47. [PMID: 36481999 DOI: 10.1055/a-1994-7857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In this study, we evaluate the clinical efficacy and safety of full-endoscopic transforaminal lumbar interbody fusion (TLIF) for treatment of single-level lumbar degenerative spondylolisthesis. METHODS Fifty-three patients were divided into two groups according to the surgical techniques: Full endoscopic (Endo)-TLIF (n = 25) and TLIF (n = 28). Clinical efficacy was evaluated pre- and postoperatively. The operation time, operative blood loss, postoperative amount of serum creatine phosphokinase (CPK), postoperative drainage volume, postoperative hospital stay time, total cost, and operative complications were also recorded. RESULTS Compared with the TLIF group, the Endo-TLIF group had similar intraoperative blood loss, less postoperative increased CPK, less postoperative drainage volume, and shorter postoperative hospital stay, but longer operative time and higher total cost. The postoperative visual analog scale (VAS) scores of back and leg pain and Oswestry Disability Index (ODI) scores significantly improved compared with the preoperative scores in both two groups; more significant improvement of postoperative VAS scores of back pain and ODI scores were shown in the Endo-TLIF group at the 1-month follow-up (p < 0.05). No difference was found in the intervertebral fusion rate between the two groups. CONCLUSION The Endo-TLIF has similar clinical effect compared with the TLIF for the treatment of lumbar degenerative spondylolisthesis. It also has many surgical advantages such as less muscle trauma, less postoperative back pain, and fast functional recovery of the patient. However, steep learning curve, longer operative time, and higher total cost may be the disadvantages that limit this technique. Also, the Endo-TLIF treatment of patients with bilateral lateral recess stenosis is considered a relative contraindication.
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Affiliation(s)
- Jianjian Yin
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, People's Republic of China
| | - Xijia Jiang
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, People's Republic of China
| | - Nanwei Xu
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, People's Republic of China
| | - Luming Nong
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, People's Republic of China
| | - Yuqing Jiang
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, People's Republic of China
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Wetmore DS, Dalal S, Shinn D, Shahi P, Vaishnav A, Chandra A, Melissaridou D, Beckman J, Albert TJ, Iyer S, Qureshi SA. Erector Spinae Plane Block Reduces Immediate Postoperative Pain and Opioid Demand After Minimally Invasive Transforaminal Lumbar Interbody Fusion. Spine (Phila Pa 1976) 2024; 49:7-14. [PMID: 36940258 DOI: 10.1097/brs.0000000000004581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/02/2022] [Indexed: 03/22/2023]
Abstract
STUDY DESIGN Matched cohort comparison. OBJECTIVE To determine perioperative outcomes of erector spinae plane (ESP) block for minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). SUMMARY OF BACKGROUND DATA There is a paucity of data on the impact of lumbar ESP block on perioperative outcomes and its safety in MI-TLIF. MATERIALS AND METHODS Patients who underwent 1-level MI-TLIF and received the ESP block (group E ) were included. An age and sex-matched control group was selected from a historical cohort that received the standard-of-care (group NE). The primary outcome of this study was 24-hour opioid consumption in morphine milligram equivalents. Secondary outcomes were pain severity measured by a numeric rating scale, opioid-related side effects, and hospital length of stay. Outcomes were compared between the two groups. RESULTS Ninety-eight and 55 patients were included in the E and NE groups, respectively. There were no significant differences between the two cohorts in patient demographics. Group E had lower 24-hour postoperative opioid consumption ( P = 0.117, not significant), reduced opioid consumption on a postoperative day (POD) 0 ( P = 0.016), and lower first pain scores postsurgery ( P < 0.001). Group E had lower intraoperative opioid requirements ( P < 0.001), and significantly lower average numeric rating scale pain scores on POD 0 ( P = 0.034). Group E reported fewer opioid-related side effects as compared with group NE, although this was not statistically significant. The average highest postoperative pain score within 3 hours postprocedurally was 6.9 and 7.7 in the E and NE cohorts, respectively ( P = 0.029). The median length of stay was comparable between groups with the majority of patients in both groups being discharged on POD 1. CONCLUSIONS In our retrospective matched cohort, ESP blocks resulted in reduced opioid consumption and decreased pain scores on POD 0 in patients undergoing MI-TLIF. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
| | | | - Daniel Shinn
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
| | | | | | | | | | | | | | - Sravisht Iyer
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
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Barsa M, Filyk O. Erector spinae plane block versus local infiltration anaesthesia for transforaminal percutaneous endoscopic discectomy: A prospective randomised controlled trial. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:552-560. [PMID: 37666454 DOI: 10.1016/j.redare.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/20/2022] [Indexed: 09/06/2023]
Abstract
BACKGROUND Around 60%-80% of the population suffers from back pain, making it one of the most common health complaints. Transforaminal percutaneous endoscopic discectomy (TPED) is an effective treatment for low back pain that can be performed using different anaesthesia techniques. Our primary objective was to test the hypothesis that bilateral Erector spinae plane block (ESP) plus sedation is equally effective as traditional local infiltration anaesthesia plus sedation in TPED. MATERIALS AND METHODS Fifty-two patients undergoing TPED were randomly assigned to 2 groups: G1 - intravenous sedation with local infiltration anaesthesia; G2 - intravenous sedation with bilateral ESP. PRIMARY OUTCOME volume of fentanyl and propofol administered during surgery. SECONDARY OUTCOMES adverse events during sedation reported using the World Society of Intravenous Anaesthesia (SIVA) adverse sedation event tool, level of postoperative sedation measured on the Richmond Agitation-Sedation Scale (RASS), intensity of postoperative pain on a visual analogue scale (VAS), mechanical pain threshold (MPT) measured with von Frey monofilaments on both lower extremities, patient satisfaction with analgesia on 5-point Likert scale. RESULTS Volume of fentanyl, propofol, and level of postoperative sedation was significantly lower in G2 (p < 0.001). There was no difference between groups in intensity of pain, patient satisfaction with analgesia, and mechanical pain threshold after surgery. There were no adverse events in G2, but in G1 2 patients presented minimal risk descriptors, 5 presented minor risk descriptors, and 1 presented sentinel risk descriptors that required additional medication or rescue ventilation. CONCLUSIONS The ESP was equal to local infiltration anaesthesia in terms of intensity of pain, mechanical pain threshold after surgery, and patient satisfaction; however, ESP reduced the volume of intraoperative fentanyl and propofol, thereby reducing the adverse effects of sedation.
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Affiliation(s)
- M Barsa
- Anaesthesiologist at Communal Enterprise of Rivne region council "Yuri Semenyuk Rivne regional clinical hospital", Rivne, Ukraine; Danylo Halytsky Lviv National Medical University, Lviv, Ukraine.
| | - O Filyk
- Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
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Bydon M, Nathani KR, Ibrahim S. Optimizing Perioperative Care for Spine Surgery: Exploring the Benefits and Techniques of Regional Anesthesia. World Neurosurg 2023; 180:226-227. [PMID: 37903697 DOI: 10.1016/j.wneu.2023.10.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Affiliation(s)
- Mohamad Bydon
- Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Karim Rizwan Nathani
- Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sufyan Ibrahim
- Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Patel Y, Ramachandran K, Shetty AP, Chelliah S, Subramanian B, Kanna RM, Shanmuganathan R. Comparison Between Relative Efficacy of Erector Spinae Plane Block and Caudal Epidural Block for Postoperative Analgesia in Lumbar Fusion Surgery- A Prospective Randomized Controlled Study. Global Spine J 2023:21925682231203653. [PMID: 37737097 DOI: 10.1177/21925682231203653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
STUDY DESIGN Prospective, randomized controlled double-blinded study. OBJECTIVE To compare the relative efficacy of ultrasound-guided ESPB and CEB for postoperative analgesia after a single-level lumbar fusion surgery and compared it with conventional multimodal analgesia. METHODS 81 patients requiring single-level lumbar fusion surgery were randomly allocated into 3 groups (ESPB group, CEB group, and the control group). Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization, and complications were recorded. RESULTS The total opioid consumption in the first 24 hours was significantly lower in both the block groups than in the control group (103.70 ± 13.34 vs 105 ± 16.01 vs 142.59 ± 40.91mcg; P < .001). The total muscle relaxant consumption was also significantly less in block groups compared to controls (50.93 ± 1.98 vs 52.04 ± 3.47 vs 55.00 ± 5.29 mg; P < .001). The intraoperative blood loss was significantly less in both the block group (327.78 ± 40.03 mL, 380.74 ± 77.80 mL) than the control group (498.89 ± 71.22 mL) (P < .001). Among the block groups, the immediate postoperative pain relief was better in the CEB group, however, the ESPB group had a longer duration of postoperative pain relief. CONCLUSION Both ESPB and CEB produce adequate postoperative analgesia after lumbar fusion however the duration of action was significantly longer in the ESPB group with relatively shorter surgical time and lesser blood loss compared to the CEB group.
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Affiliation(s)
- Yogin Patel
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Karthik Ramachandran
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Sekar Chelliah
- Department of Anesthesia, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Balavenkat Subramanian
- Department of Anesthesia, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
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Goto Y, Inoue T, Shitara S, Oka H, Nozuchi S. Lumboperitoneal Shunt Surgery under Spinal Anesthesia on Idiopathic Normal Pressure Hydrocephalus Patients. Neurol Med Chir (Tokyo) 2023; 63:420-425. [PMID: 37423754 PMCID: PMC10556213 DOI: 10.2176/jns-nmc.2022-0367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/27/2023] [Indexed: 07/11/2023] Open
Abstract
Since the publication of guidelines for managing idiopathic normal pressure hydrocephalus (iNPH) in 2004, an increasing number of patients with iNPH have been undergoing shunt surgery in Japan. However, shunt surgeries for iNPH can be challenging because the procedures are performed on elderly patients. General anesthesia-related risks, such as postoperative pneumonia or delirium, are higher in the elderly. To decrease these risks, we applied spinal anesthesia on a lumboperitoneal shunt (LPS). Herein, we analyzed our methods focusing on the postoperative outcomes. We retrospectively analyzed 79 patients who underwent LPS at our institution with more than one year of follow-up. The patients were divided into two groups based on the anesthetic approach, that is, 1) general anesthesia and 2) spinal anesthesia, and were examined in terms of postoperative complications, delirium, and postoperative hospital stay. In the general anesthesia group, two patients had respiratory complications after the surgery. The postoperative delirium score using the intensive care delirium screening checklist (ICDSC) was 0 (2) (median [interquartile range]), and the length of postoperative hospital stay was 11 (4) days. In the spinal anesthesia group, no patients had respiratory complications. The postoperative mean ICDSC was 0 (1), and the length of postoperative hospital stay was 10 (3) days. Although there was no significant difference regarding postoperative delirium existed, LPS under spinal anesthesia decreased respiratory complications and significantly shortened the postoperative hospital stay. LPS under spinal anesthesia could be an alternative to general anesthesia in elderly patients with iNPH and possibly lessen the general anesthesia-related risks.
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Affiliation(s)
| | - Takuro Inoue
- Department of Neurosurgery, Koto Memorial Hospital
| | | | - Hideki Oka
- Department of Neurosurgery, Saiseikai Shiga Hospital
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Rizzo P, Hann H, Coombs B, Ali AAH, Stretton A, Sikander M. The Hitchhiker's Guide to Spine Awake Surgery. The Oxford SAS Protocol and Early Outcomes. World Neurosurg 2023; 176:e289-e296. [PMID: 37224956 PMCID: PMC10200716 DOI: 10.1016/j.wneu.2023.05.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 05/13/2023] [Accepted: 05/15/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Spine awake surgery (SAS) aims to achieve faster recovery times, better outcomes, and a lesser economic impact on society. Our drive to establish SAS was to improve patient outcomes and health economics during the COVID-19 pandemic. After a systematic review and to the best of our knowledge, SAS, the Oxford Protocol, is the first protocolized pathway that aims to train bespoke teams performing SAS safely, efficiently, and in a standardized repeatable fashion. A pilot study was designed around newly derived protocols and simulated training to determine if SAS is a safe and implementable pathway to improve patient outcomes and health economics. METHODS We assessed a cohort of 10 patients undergoing one-level lumbar discectomies and decompressions, analyzing the related costs, length of stay, complications, pain management, and patient satisfaction. RESULTS The age range of our patients was 46-84 years. Three discectomies and 7 central canal stenosis decompressions were performed. Eight patients were discharged on the same day. All patients gave positive feedback about their experience of SAS. A significant cost saving was made compared to a general anesthesia (GA) overnight stay across the group. No on day cancellations occurred due to lack of bed availability. No patient needed analgesia in the recovery room or needed additional analgesia over and above the SAS e-prescription take home package. CONCLUSIONS Our early experience and journey reinforce our drive to push forward and expand on this process. It aligns with the international literature which highlights this approach as safe, efficient, and economical.
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Affiliation(s)
- Paolo Rizzo
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
| | - Helen Hann
- Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Ben Coombs
- Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Ali Asgar Hatim Ali
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Murtuza Sikander
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Bajaj AI, Yap N, Derman PB, Konakondla S, Kashlan ON, Telfeian AE, Hofstetter CP. Comparative analysis of perioperative characteristics and early outcomes in transforaminal endoscopic lumbar diskectomy: general anesthesia versus conscious sedation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07792-4. [PMID: 37450041 DOI: 10.1007/s00586-023-07792-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE To better understand how anesthesia type impacts patient selection and recovery in TELD, we conducted a multicenter prospective study which evaluates the differences in perioperative characteristics and outcomes between patients who underwent TELD with either general anesthesia (GA) or conscious sedation (CS). METHODS We prospectively collected data from all TELD performed by five neurosurgeons at five different medical centers between February and October of 2022. The study population was dichotomized by anesthesia scheme, creating CS and GA cohorts. This study's primary outcomes were the Oswetry Disability Index (ODI) and the Visual Analog Scale (VAS) for back and leg pain, assessed preoperatively and at 2-week follow-up. RESULTS A total of 52 patients underwent TELD for symptomatic lumbar disk herniation. Twenty-three patients received conscious sedation with local anesthesia, and 29 patients were operated on under general anesthesia. Patients who received CS were significantly older (60.0 vs. 46.7, p < 0.001) and had lower BMI (28.2 vs. 33.4, p = 0.005) than patients under GA. No intraoperative or anesthetic complications occurred in the CS and GA cohorts. Improvement at 2-week follow-up in ODI, VAS-back, and VAS-leg was greater in patients receiving CS relative to patients under GA, but these differences were not statistically significant. CONCLUSION In our multicenter prospective analysis of 52 patients undergoing TELD, we found that patients receiving CS were significantly older and had significantly lower BMI compared to patients under GA. On subgroup analysis, no statistically significant differences were found in the improvement of PROMs between patients in the CS and GA group.
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Affiliation(s)
- Ankush I Bajaj
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Natalie Yap
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Peter B Derman
- Texas Back Institute, 6020 West Parker Rd, Plano, TX, 75093, USA
| | - Sanjay Konakondla
- Department of Neurosurgery, Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA, 17822, USA
| | - Osama N Kashlan
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Daneshi SA, Nabiuni M, Taheri M, Pour Roustaei Ardekani R. Spinal Versus General Anesthesia for Spine Surgery During the COVID-19 Pandemic: A Case Series. Anesth Pain Med 2023; 13:e134783. [PMID: 37601956 PMCID: PMC10439686 DOI: 10.5812/aapm-134783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 08/22/2023] Open
Abstract
Background Hospitals are one of the primary resources for disease transmission, so many guidelines were published, and neurosurgeons were advised to postpone elective spine surgeries during the COVID-19 pandemic. Objectives To avoid pulmonary complications and reduce the risk of spreading the virus and contracting the disease during the COVID-19 era, we operated a group of our patients under spinal anesthesia rather than general anesthesia. Methods We retrospectively analyzed all patients who underwent discectomy surgery for lumbar spinal disc herniation under SA between September 2020 and 2021. Results Sixty-four patients diagnosed with lumbar disc herniation underwent lumbar discectomy with SA. All patients except three were male. The mean age was 44.52 ± 7.95 years (28 to 64 years). The mean procedure time for SA was 10 minutes. The duration of the surgery was 40 to 90 minutes per each level of disc herniation. The mean blood loss was 350 cc (200 to 600 cc). The most common involved level was L4/L5 intervertebral disc (n = 40 patients; 63.5%). The mean recovery time was 20 minutes. Only three patients requested more analgesics for relief of their pain postoperatively. All patients with discectomy were discharged a day after surgery, and in the case of fusion, two days after surgery. All the patients were followed up for six months, showing no recurrence symptoms, good pain relief, satisfaction with the surgery, and no bad memory of the surgery. Conclusions Spinal anesthesia is a good alternative or even the main anesthesia route for patients with lumbar disc herniation. More studies are needed to elucidate the best candidate for SA in patients with lumbar pathology.
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Affiliation(s)
| | - Mohsen Nabiuni
- Department of Neurosurgery, Iran University of Medical Sciences, Tehran, Iran
| | - Morteza Taheri
- Department of Neurosurgery, Iran University of Medical Sciences, Tehran, Iran
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13
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Neurosurgical Anesthesia: Optimizing Outcomes with Agent Selection. Biomedicines 2023; 11:biomedicines11020372. [PMID: 36830909 PMCID: PMC9953550 DOI: 10.3390/biomedicines11020372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023] Open
Abstract
Anesthesia in neurosurgery embodies a vital element in the development of neurosurgical intervention. This undisputed interest has offered surgeons and anesthesiologists an array of anesthetic selections to utilize, though with this allowance comes the equally essential requirement of implementing a maximally appropriate agent. To date, there remains a lack of consensus and official guidance on optimizing anesthetic choice based on operating priorities including hemodynamic parameters (e.g., CPP, ICP, MAP) in addition to the route of procedure and pathology. In this review, the authors detail the development of neuroanesthesia, summarize the advantages and drawbacks of various anesthetic classes and agents, while lastly cohesively organizing the current literature of randomized trials on neuroanesthesia across various procedures.
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14
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Muacevic A, Adler JR, Akhtar Khan S, Hussain M, Ahmed U. Degenerative Lumbar Spine Surgeries Under Regional Anesthesia in a Developing Country: An Initial Case Series. Cureus 2023; 15:e34065. [PMID: 36843830 PMCID: PMC9943688 DOI: 10.7759/cureus.34065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction Current evidence from developed countries on lumbar spine surgeries under regional anesthesia reports it to be superior to general anesthesia (GA) in terms of decreased anesthesia time, operative time, intraoperative complications such as bleeding, postoperative complications, length of hospital stay, and overall cost. We report the first case series from Pakistan on lumbar spine surgeries under regional anesthesia. Methods We utilized spinal anesthesia (SA) for lumbar spine surgeries of 45 patients in a tertiary-care hospital in Karachi, Pakistan. The surgeries were performed as day-care procedures. The preoperative assessments included MRI findings, visual analogue scale (VAS), pre-operative limb powers, and straight leg raise (SLR). Other assessments included total SA time, total surgical time, time of stay in the post-anesthesia care unit (PACU), complications, and total hospital cost. SPSS v26 was used to calculate means and standard deviations. Results We found the total SA time to be about 45 to 60 minutes in most patients (95.6%). The total surgical time was 30 to 45 minutes for most patients. The average time of stay in the PACU was three to four hours. The VAS scores were significantly improved postoperatively with 46.7% (n=21) of patients with a score of 3, 46.7% (n=21) with a score of 2, and 6.7% (n=3) with a score of 1. 71.1% (n=32) patients had day-care surgery, 22.2% (n=10) stayed in the hospital for one day, and 6.7% (n=3) patients stayed for more than one day. Most patients (88.9%, n=40) had no complications, whereas only 11.1% (n=5) complained of PDPH. The total hospital cost was also lesser than procedures under GA. Conclusion We conclude that SA is well tolerated and has favorable outcomes in terms of cost-effectiveness, anesthesia time, surgical time, and hospital stay; therefore, SA should be considered for a greater number of lumbar spine surgeries, especially in low-middle income countries.
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15
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Abstract
Current advancements in spine surgery have led to a recent interest in regional anesthesia for spine surgery. Spinal anesthesia, epidural anesthesia, and their combination are commonly used modalities for regional anesthesia in spine surgeries. The successful use of regional anesthesia has led to the emergence of several new concepts such as awake spinal fusion and outpatient spinal surgery. Regarding analgesic techniques, several new modalities have been described recently such as erector spinae and thoracolumbar interfascial plane blocks. These regional analgesic modalities are aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. This narrative review focuses on the techniques, indications and contraindications, benefits, and complications of regional anesthesia in the context of spine surgery.
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16
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Application of Hydromorphone and Ropivacaine in Ultrasound-Guided Brachial Plexus Block of Children. J Perianesth Nurs 2022; 37:662-668. [DOI: 10.1016/j.jopan.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/31/2021] [Accepted: 11/14/2021] [Indexed: 11/23/2022]
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17
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Yang MJ, Riesenburger RI, Kryzanski JT. The use of intra-operative navigation during complex lumbar spine surgery under spinal anesthesia. Clin Neurol Neurosurg 2022; 215:107186. [DOI: 10.1016/j.clineuro.2022.107186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 11/03/2022]
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18
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Lee JK, Park JH, Hyun SJ, Hodel D, Hausmann ON. Regional Anesthesia for Lumbar Spine Surgery: Can It Be a Standard in the Future? Neurospine 2022; 18:733-740. [PMID: 35000326 PMCID: PMC8752703 DOI: 10.14245/ns.2142584.292] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/30/2021] [Indexed: 12/31/2022] Open
Abstract
This paper is an overview of various features of regional anesthesia (RA) and aims to introduce spine surgeons unfamiliar with RA. RA is commonly used for procedures that involve the lower extremities, perineum, pelvic girdle, or lower abdomen. However, general anesthesia (GA) is preferred and most commonly used for lumbar spine surgery. Spinal anesthesia (SA) and epidural anesthesia (EA) are the most commonly used RA methods, and a combined method of SA and EA (CSE). Compared to GA, RA offers numerous benefits including reduced intraoperative blood loss, arterial and venous thrombosis, pulmonary embolism, perioperative cardiac ischemic incidents, renal failure, hypoxic episodes in the postanesthetic care unit, postoperative morbidity and mortality, and decreased incidence of cognitive dysfunction. In spine surgery, RA is associated with lower pain scores, postoperative nausea and vomiting, positioning injuries, shorter anesthesia time, and higher patient satisfaction. Currently, RA is mostly used in short lumbar spine surgeries. However, recent findings illustrate the possibility of applying RA in spinal tumors and spinal fusion. Various researches reveal that SA is an effective alternative to GA with lower minor complications incidence. Comprehensive insight on RA will promote spine surgery under RA, thereby broadening the horizon of spine surgery under RA.
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Affiliation(s)
- Jae-Koo Lee
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong Hwa Park
- Department of Neurosurgery, Spine Center, Yuil Hospital, Hwasung, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Daniel Hodel
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Oliver N Hausmann
- Neuro- and Spine Center, Hirslanden Klinik St. Anna, Lucerne, Switzerland.,University of Berne, Berne, Switzerland
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Kang SY, Cho HS, Yi J, Kim HS, Jang IT, Kim DH. The Comparison of Fluoroscopy-Guided Epidural Anesthesia with Conscious Sedation and General Anesthesia for Endoscopic Lumbar Decompression Surgery: A Retrospective Analysis. World Neurosurg 2021; 159:e103-e112. [PMID: 34896355 DOI: 10.1016/j.wneu.2021.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND With advances and refinements in endoscopic lumbar spine surgery showing effective and satisfactory results, the need for simple yet effective anesthetic techniques for minimally invasive endoscopic spine surgery has increased. The aim of this study was to compare feasibility and postoperative outcomes of fluoroscopy-guided epidural anesthesia with general anesthesia in patients undergoing endoscopic lumbar decompression surgery (≤3 levels). METHODS Patients who underwent 1-3 levels of endoscopic lumbar decompression surgery under either fluoroscopy-guided epidural or general anesthesia between January 2019 and October 2020 were retrospectively reviewed. Postoperative pain intensity and use of rescue analgesics for up to 48 hours were compared between the epidural and general anesthesia groups. Intraoperative anesthetic data and postoperative recovery profiles were also analyzed. RESULTS Postoperative pain scores were significantly lower in the epidural anesthesia group compared with the general anesthesia group at 10 minutes after recovery room admission (2.1 ± 1.8 vs. 5.7 ± 1.9, P < 0.001), 24 hours postoperatively (3.3 ± 1.0 vs. 5.4 ± 1.8, P < 0.001), and 48 hours postoperatively (3.2 ± 0.6 vs. 4.4 ± 1.4, P < 0.001). The proportion of patients requiring rescue analgesics in the recovery room was significantly lower in the epidural anesthesia group (1.9% vs. 20.5%, P = 0.027). The median 15-item Quality of Recovery score on postoperative day 1 was significantly higher in the epidural anesthesia group (118.0 [113.5-123.0] vs. 82.0 [73.5-111.5], P < 0.001). Occurrence of nausea, vomiting, and voiding difficulty up to 48 hours postoperatively did not differ between groups. CONCLUSIONS Compared with general anesthesia, epidural anesthesia provided better analgesia and recovery characteristics during the early postoperative period in endoscopic lumbar decompression surgery.
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Affiliation(s)
- Seung Youn Kang
- Department of Anesthesiology and Pain Medicine, Nanoori Hospital Gangnam, Seoul, South Korea
| | - Hae Sun Cho
- Department of Anesthesiology and Pain Medicine, Nanoori Hospital Gangnam, Seoul, South Korea
| | - Jihwan Yi
- Department of Anesthesiology and Pain Medicine, Nanoori Hospital Gangnam, Seoul, South Korea
| | - Hyeun Sung Kim
- Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul, South Korea
| | - Il Tae Jang
- Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul, South Korea
| | - Do-Hyeong Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea.
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20
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Khattab MFM, Sykes DAW, Abd-El-Barr MM, Waguia R, Montaser A, Ghamry SE, Elhawary Y. Spine surgery under awake spinal anesthesia: an Egyptian experience during the COVID-19 pandemic. Neurosurg Focus 2021; 51:E6. [PMID: 34852322 DOI: 10.3171/2021.9.focus21456] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite tremendous advancements in biomedical science and surgical technique, spine surgeries are still associated with considerable rates of morbidity and mortality, particularly in the elderly. Multiple novel techniques have been employed in recent years to adequately treat spinal diseases while mitigating the perioperative morbidity associated with traditional spinal surgery. Some of these techniques include minimally invasive methods and novel anesthetic and analgesic methods. In recent years, awake spine surgery with spinal anesthesia has gained attention as an alternative to general anesthesia (GA). In this study, the authors retrospectively reviewed a single-institution Egyptian experience with awake spine surgery using spinal anesthesia during the COVID-19 pandemic. METHODS Overall, 149 patients who were admitted to As-Salam International Hospital in Cairo for lumbar and lower thoracic spine surgeries, between 2019 and 2020, were retrospectively reviewed. Patient demographics and comorbidities were collected and analyzed. Visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were assessed at different time intervals including preoperatively, immediately after surgery, and 1 year postoperatively. Patient satisfaction was queried through a questionnaire assessing patient preference for traditional anesthesia or spinal anesthesia. RESULTS Of the 149 patients who successfully received spine surgery with spinal anesthesia, there were 49 males and 100 females. The cohort age ranged from 22 to 85 years with a mean of 47.5 years. The operative time ranged from 45 to 300 minutes with a mean estimated blood loss (EBL) of 385 ± 156 mL. No major cardiopulmonary or intraoperative complications occurred, and patients were able to eat immediately after surgery. Patients were able to ambulate without an assistive device 6 to 8 hours after surgery. Decompression and fusion patients were discharged on postoperative days 2 and 3, respectively. VAS and ODI scores demonstrated excellent pain relief, which was maintained at the 1-year postoperative follow-up. No 30- or 90-day readmissions were recorded. Of 149 patients, 124 were satisfied with spinal anesthesia and would recommend spinal anesthesia to other patients. The remaining patients were not satisfied with spinal anesthesia but reported being pleased with their postoperative clinical and functional outcomes. One patient was converted to GA due to the duration of the procedure. CONCLUSIONS Patients who received spinal anesthesia for awake spine surgery experienced short stays in the hospital, no readmissions, patient satisfaction, and well-controlled pain. The results of this study have validated the growing body of literature that demonstrates that awake spine surgery with spinal anesthesia is safe and associated with superior outcomes compared with traditional GA. Additionally, the ability to address chronic debilitating conditions, such as spinal conditions, with minimal use of valuable resources, such as ventilators, proved useful during the COVID-19 pandemic and could be a model should other stressors on healthcare systems arise, especially in developing areas of the world.
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Affiliation(s)
| | - David A W Sykes
- 2Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | | | - Romaric Waguia
- 2Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Amr Montaser
- 3Aneaesthesia Department, As-Salam International Hospital, Cairo
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21
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Breton JM, Ludwig CG, Yang MJ, Nail TJ, Riesenburger RI, Liu P, Kryzanski JT. Spinal anesthesia in contemporary and complex lumbar spine surgery: experience with 343 cases. J Neurosurg Spine 2021; 36:534-541. [PMID: 34740182 DOI: 10.3171/2021.7.spine21847] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal anesthesia (SA) is an alternative to general anesthesia (GA) for lumbar spine surgery, including complex instrumented fusion, although there are relatively few outcome data available. The authors discuss their experience using SA in a modern complex lumbar spine surgery practice to describe its utility and implementation. METHODS Data from patients receiving SA for lumbar spine surgery by one surgeon from March 2017 to December 2020 were collected via a retrospective chart review. Cases were divided into nonfusion and fusion procedure categories and analyzed for demographics and baseline medical status; pre-, intra-, and postoperative events; hospital course, including Acute Pain Service (APS) consults; and follow-up visit outcome data. RESULTS A total of 345 consecutive lumbar spine procedures were found, with 343 records complete for analysis, including 181 fusion and 162 nonfusion procedures and spinal levels from T11 through S1. The fusion group was significantly older (mean age 65.9 ± 12.4 vs 59.5 ± 15.4 years, p < 0.001) and had a significantly higher proportion of patients with American Society of Anesthesiologists (ASA) Physical Status Classification class III (p = 0.009) than the nonfusion group. There were no intraoperative conversions to GA, with infrequent need for a second dose of SA preoperatively (2.9%, 10/343) and rare preoperative conversion to GA (0.6%, 2/343) across fusion and nonfusion groups. Rates of complications during hospitalization were comparable to those seen in the literature. The APS was consulted for 2.9% (10/343) of procedures. An algorithm for the integration of SA into a lumbar spine surgery practice, from surgical and anesthetic perspectives, is also offered. CONCLUSIONS SA is a viable, safe, and effective option for lumbar spine surgery across a wide range of age and health statuses, particularly in older patients and those who want to avoid GA. The authors' protocol, based in part on the largest set of data currently available describing complex instrumented fusion surgeries of the lumbar spine completed under SA, presents guidance and best practices to integrate SA into contemporary lumbar spine practices.
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Affiliation(s)
- Jeffrey M Breton
- 1Department of Neurosurgery, Tufts Medical Center, Boston.,2Department of Neurosurgery, Tufts University School of Medicine, Boston; and
| | - Calvin G Ludwig
- 1Department of Neurosurgery, Tufts Medical Center, Boston.,2Department of Neurosurgery, Tufts University School of Medicine, Boston; and
| | - Michael J Yang
- 1Department of Neurosurgery, Tufts Medical Center, Boston
| | - T Jayde Nail
- 1Department of Neurosurgery, Tufts Medical Center, Boston
| | - Ron I Riesenburger
- 1Department of Neurosurgery, Tufts Medical Center, Boston.,2Department of Neurosurgery, Tufts University School of Medicine, Boston; and
| | - Penny Liu
- 3Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts
| | - James T Kryzanski
- 1Department of Neurosurgery, Tufts Medical Center, Boston.,2Department of Neurosurgery, Tufts University School of Medicine, Boston; and
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22
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Bithal PK, Rath GP. Regional Anesthesia Practice in Neurosurgery. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0041-1734402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Parmod K. Bithal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Girija P. Rath
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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23
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Sarkar S, Banerji A, Chattopadhyaya A, Banerjee S. Lumbar spine instrumented fusion surgery under spinal anaesthesia versus general anaesthesia-A retrospective study of 239 cases. J Clin Orthop Trauma 2021; 18:205-208. [PMID: 34026488 PMCID: PMC8122088 DOI: 10.1016/j.jcot.2021.04.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 03/14/2021] [Accepted: 04/26/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Conventionally spinal surgeries are done under general anaesthesia (GA). Plenty of literature is available on lumbar spine non-instrumented surgeries under spinal anaesthesia (SA) but handful of literature is there on lumbar spinal instrumented fusion surgeries under SA. We retrospectively analysed the data of 131 patients operated under SA and 108 patients under GA. Aim of the study was to evaluate the safety, advantages and disadvantages of doing lumbar spine instrumented fusion surgeries under SA.In time of COVID-19 pandemic, aerosol generating procedure like intubation, can be avoided if lumbar spine instrumented fusion surgeries are performed under SA. METHODS 239 patients aged between 20 and 79 years operated from January 2014 to December 2019 were included in this study. Indications for surgery were lumbar canal stenosis, degenerative or lytic spondylolisthesis. They underwent L4-L5 or L5-S1 fusion surgeries either TLIF or pedicle screw fixation postero lateral fusion (PLF) and decompression. Out of 239 patients,131 were operated under SA and 108 patients under GA. Heart rate, mean arterial pressure (MAP), blood loss, operating room time, post-op pain relief and need of analgesics, cost of surgery and anaesthesia related complications were analysed. RESULTS The study found significantly less blood loss (p<.05), less OR time, better post-op analgesia and lesser incidence of nausea and vomiting in SA (8.4%) than GA (29.6%). We observed average 10% cost reduction in SA. This study did not find any prone position related complication in regional anaesthesia but one transient brachial plexus palsy and one post-op shoulder pain in GA group. CONCLUSION SA is a safe alternative to GA for lumbar spine instrumented fusion surgery with significant less blood loss, OR time, better post-op analgesia, average 10% overall cost reduction and no reported prone-position related complications.
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Affiliation(s)
- Saikat Sarkar
- Dept of Spine Surgery, Columbia Asia Hospital, Saltlake, Kolkata, India
- KIMS Hospital, Burdwan, India
- ESKAG Sanjeevani N.Home, Kolkata, India
| | - Aditi Banerji
- KIMS Hospital, Burdwan, India
- ESKAG Sanjeevani N.Home, Kolkata, India
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24
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Garg B, Ahuja K, Khanna P, Sharan AD. Regional Anesthesia for Spine Surgery. Clin Spine Surg 2021; 34:163-170. [PMID: 33044273 DOI: 10.1097/bsd.0000000000001096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 09/10/2020] [Indexed: 12/15/2022]
Abstract
Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. In this narrative review we discuss the characteristics of regional anesthesia including its types, indications, contraindications, benefits, and potential complications along with new modalities of regional analgesia.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi
| | - Kaustubh Ahuja
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
| | - Puneet Khanna
- Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
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25
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Fiani B, Reardon T, Selvage J, Dahan A, El-Farra MH, Endres P, Taka T, Suliman Y, Rose A. Awake spine surgery: An eye-opening movement. Surg Neurol Int 2021; 12:222. [PMID: 34084649 PMCID: PMC8168649 DOI: 10.25259/sni_153_2021] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/24/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Awake surgery is performed in multiple surgical specialties, but historically, awake surgery in the field of neurosurgery was limited to craniotomies. Over the past two decades, spinal surgeons have pushed for techniques that only require regional anesthesia as they may provide reduced financial burdens on patients, faster recovery times, and better outcomes. The list of awake spine surgeries that have been found in the literature include: laminectomies/discectomies, anterior cervical discectomy and fusions (ACDFs), lumbar fusions, and dorsal column (DC) stimulator placement. Methods: An extensive review of the published literature was conducted through PubMed database with articles containing the search term “awake spine surgery.” No date restrictions were used. Results: The search yielded 293 related articles. Cross-checking of articles was conducted to exclude of duplicate articles. The articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic. Findings have shown that lumbar laminectomies performed with local anesthesia have shown shorter operating time, less postoperative nausea, lower incidence of urinary retention and spinal headache, and shorter hospital stays when compared to those performed under general anesthesia. Lumbar fusions with local anesthesia showed similar outcomes as patients reported better postoperative function and fewer side effects of general anesthesia. DC stimulator placement performed with local anesthesia is advantageous as it allows real time patient feedback for surgeons as they directly test affected nerves. However, spontaneous movement during the placement of DC stimulators is associated with higher failure rates when compared to general anesthesia (29.7% vs. 14.9%). Studies have shown that the use of local anesthesia during ACDFs has no significant differences when compared to general anesthesia, and patient’s report better tolerated pain with general anesthesia. Conclusion: The use of awake spine surgery is beneficial for those who cannot undergo general anesthesia. However, it is limited to patients who can tolerate prone positioning with no central airway (i.e., normal BMI with a healthy airway), have no pre-existing mental health conditions (e.g., anxiety), and require a minimally invasive procedure with a short operating time. Future studies should focus on long-term efficacies of these procedures that provide further insight on the indications and limitations of awake spine surgery.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, United States
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, United States
| | - Jacob Selvage
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, United States
| | - Alden Dahan
- School of Medicine, University of California Riverside, Riverside, California, United States
| | - Mohamed H El-Farra
- School of Medicine, University of California Riverside, Riverside, California, United States
| | - Philine Endres
- School of Medicine, University of California Riverside, Riverside, California, United States
| | - Taha Taka
- School of Medicine, University of California Riverside, Riverside, California, United States
| | - Yasmine Suliman
- School of Medicine, University of California Riverside, Riverside, California, United States
| | - Alexander Rose
- School of Medicine, University of New Mexico, Albuquerque, New Mexico, United States
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26
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Soulioti E, Efstathiou G, Papanastasiou J, Igoumenou V, Kostopanagiotou G, Batistaki C. Low-dose epidural anesthesia for percutaneous spinal fusion and kyphoplasty due to metastatic fracture of L2 lumbar vertebrae. J Anaesthesiol Clin Pharmacol 2021; 36:560-562. [PMID: 33840943 PMCID: PMC8022040 DOI: 10.4103/joacp.joacp_157_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 10/28/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Eleftheria Soulioti
- 2 Department of Anesthesiology, Faculty of Medicine, National and Kapodistrian University of Athens, "Attikon" Hospital, Athens, Greece
| | - Georgia Efstathiou
- 2 Department of Anesthesiology, Faculty of Medicine, National and Kapodistrian University of Athens, "Attikon" Hospital, Athens, Greece
| | - John Papanastasiou
- 1 Department of Orthopedics, Faculty of Medicine, National and Kapodistrian University of Athens, "Attikon" Hospital, Athens, Greece
| | - Vasilios Igoumenou
- 1 Department of Orthopedics, Faculty of Medicine, National and Kapodistrian University of Athens, "Attikon" Hospital, Athens, Greece
| | - Georgia Kostopanagiotou
- 2 Department of Anesthesiology, Faculty of Medicine, National and Kapodistrian University of Athens, "Attikon" Hospital, Athens, Greece
| | - Chrysanthi Batistaki
- 2 Department of Anesthesiology, Faculty of Medicine, National and Kapodistrian University of Athens, "Attikon" Hospital, Athens, Greece
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Ahmed Jonayed S, Alam MS, Al Mamun Choudhury A, Akter S, Chakraborty S. Efficacy, safety, and reliability of surgery on the lumbar spine under general versus spinal anesthesia- an analysis of 64 cases. J Clin Orthop Trauma 2021; 16:176-181. [PMID: 33717954 PMCID: PMC7920005 DOI: 10.1016/j.jcot.2020.12.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 12/06/2020] [Accepted: 12/29/2020] [Indexed: 01/17/2023] Open
Abstract
QUASI-EXPERIMENTAL DESIGN PURPOSE Compare intra and postoperative parameters, surgeons' satisfaction, and cost-effectiveness between general anesthesia (GA) and spinal anesthesia (SA) on patients undergoing surgery in the lumbar spine surgery. OVERVIEW OF LITERATURE Surgery on the lumbar spine is the commonest surgical procedure among all spinal surgical practices. Both the GA and SA are shown to be suitable techniques for performing the surgery safely. GA is used most frequently. But, SA became increasingly more popular because it allows the patient to self-position thereby reducing various complications associated with GA in a prone position. METHODS A total of 64 patients from June 2016 to July 2019 who underwent either discectomy, laminectomy, or lamino-foraminotomy for herniated lumbar disc or canal stenosis in 1 or 2 levels were included. During the study period, 32 patients were non-randomly selected for each of the GA and SA groups. The heart rate (HR), mean arterial pressure (MAP), blood loss, total anesthetic time, surgeons' satisfaction, analgesic requirements, cost of the procedure, and hospital stay were recorded and compared. RESULTS In the context of demographic characteristics, baseline HR, or MAP, no significant differences were noted between SA and GA groups. Mean anesthetic time, mean PACU time, mean doses of analgesic requirement, cost of anesthesia, and the surgeon's satisfaction was significantly lower in the SA Group (P < 0.05). The blood loss, duration of operation, and hospital stay were not significant too. No major Intra and postoperative complications were reported nor were significant differences found in either series. CONCLUSION Safety and efficacy of SA in comparison to GA were similar for the patients undergoing surgery on the lumbar spine. Notable advantages of SA include shorter anesthesia duration, fewer drug requirements, relative cost-effectiveness, and fewer complications rate. Successful surgery can be performed using either anesthesia type.
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Affiliation(s)
- Sharif Ahmed Jonayed
- National Institute of Traumatology & Orthopaedic Rehabilitation, (NITOR), Dhaka, Bangladesh,Corresponding author. National Institute of Traumatology & orthopaedic rehabilitation, (NITOR), House#23, Road#06, Dhanmondi Residential Area, Dhaka, 1209, Bangladesh.
| | - Md Shah Alam
- Dhaka Medical College Hospital, Dhaka, Bangladesh
| | | | - Sohely Akter
- Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Shubhendu Chakraborty
- National Institute of Traumatology & Orthopaedic Rehabilitation, (NITOR), Dhaka, Bangladesh
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Hamilton GM, MacMillan Y, Benson P, Memtsoudis S, McCartney CJL. Regional anaesthesia quality indicators for adult patients undergoing non-cardiac surgery: a systematic review. Anaesthesia 2021; 76 Suppl 1:89-99. [PMID: 33426666 DOI: 10.1111/anae.15311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 11/26/2022]
Abstract
Improvement in healthcare delivery depends on the ability to measure outcomes that can direct changes in the system. An overview of quality indicators within the field of regional anaesthesia is lacking. This systematic review aims to synthesise available quality indicators, as per the Donabedian framework, and provide a concise overview of evidence-based quality indicators within regional anaesthesia. A systematic literature search was conducted using the databases MEDLINE, Embase, CINAHL and Cochrane from 2003 to present, and a prespecified search of regional anaesthesia society websites and healthcare quality agencies. The quality indicators relevant to regional anaesthesia were subdivided into peri-operative structure, process and outcome indicators as per the Donabedian framework. The methodological quality of the indicators was determined as per the Oxford Centre for Evidence-Based Medicine's framework. Twenty manuscripts met our inclusion criteria and, in total, 68 unique quality indicators were identified. There were 4 (6%) structure, 12 (18%) process and 52 (76%) outcome indicators. Most of the indicators were related to the safety (57%) and effectiveness (19%) of regional anaesthesia and were general in nature (60%). In addition, most indicators (84%) were based on low levels of evidence. Our study is an important first step towards describing quality indicators for the provision of regional anaesthesia. Future research should focus on the development of structure and process quality indicators and improving the methodological quality and usability of these indicators.
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Affiliation(s)
- G M Hamilton
- Department of Anaesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - Y MacMillan
- Department of Medicine, University of Ottawa, ON, Canada
| | - P Benson
- Department of Medicine, University of Ottawa, ON, Canada
| | - S Memtsoudis
- Department of Anaesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - C J L McCartney
- Department of Anaesthesiology and Pain Medicine, University of Ottawa, ON, Canada
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Sekerak R, Mostafa E, Morris MT, Nessim A, Vira A, Sharan A. Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery. J Clin Orthop Trauma 2020; 13:122-126. [PMID: 33680810 PMCID: PMC7919949 DOI: 10.1016/j.jcot.2020.11.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/23/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Spinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies, discectomies, and microdiscectomies. However, the use of SA in spinal fusion surgery has been very scarcely documented in the current literature. Here we present a comparison of SA to GA in lumbar fusion surgery in terms of perioperative outcomes and cost. METHODS The authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015 to 2018. Data collected included demographics, operative and recovery times, nausea/vomiting, postoperative pain, and opioid requirement. Costs were included in the analysis if they were: 1) non-fixed; 2) incurred in the operating room (OR); and 3) directly related to patient care. All cost data represents net costs and was obtained from the hospital revenue cycle team. Patients were grouped for statistical analysis based on anesthetic modality. RESULTS A total of 29 patients received SA and 46 received GA. Both groups were similar in terms of age, gender, BMI, number of levels operated upon, preoperative diagnosis, and medical comorbidities. The SA group spent less time in the OR (163.86 ± 9.02 vs. 195.63 ± 11.27 min, p < 0.05), PACU (82.00 ± 7.17 vs. 102.98 ± 8.46 min, p < 0.05), and under anesthesia (175.03 ± 9.31 vs. 204.98 ± 10.15 min, p < 0.05) than the GA group. Post-surgery OR time was significantly less with SA than with GA (6.00 ± 1.09 vs. 17.26 ± 3.05 min, p < 0.05); however, pre-surgery OR time was similar between groups (50.17 ± 3.08 vs. 56.17 ± 5.34 min, p = 0.061). The SA group also experienced less maximum postoperative pain (3.31 ± 1.41 out of 10 vs. 5.96 ± 0.84/10, p < 0.05) and required less opioid analgesics (2.38 ± 1.37 vs. 5.39 ± 0.84 doses, p < 0.05). Both groups experienced similar nausea or vomiting rates and adverse events postoperatively. Net operative cost was found to be $812.31 (5.6%) less with SA than with GA, although this difference was not significant (p = 0.225). DISCUSSION/CONCLUSION To our knowledge, SA is almost never used in lumbar fusion, and a cost-effectiveness comparison with GA has not been recorded. In this retrospective study, we demonstrate that the use of SA in lumbar fusion surgery leads to significantly shorter operative and recovery times, less postoperative pain and opioid usage, and slight cost savings over GA. Thus, we conclude that this anesthetic modality represents a safe and cost-effective alternative to GA in lumbar fusion.
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Affiliation(s)
| | - Evan Mostafa
- Albert Einstein College of Medicine, Bronx, NY, USA,Corresponding author. Albert Einstein College of Medicine, 1400 Morris Park Ave, Bronx, NY, 10461, United States.
| | - Matthew T. Morris
- Northwell Health, North Shore University Hospital, Manhasset, NY, USA
| | - Adam Nessim
- Albert Einstein College of Medicine, Bronx, NY, USA
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Awake minimally invasive transforaminal lumbar interbody fusion with a pedicle-based retraction system. Clin Neurol Neurosurg 2020; 200:106313. [PMID: 33139086 DOI: 10.1016/j.clineuro.2020.106313] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Recently there has been increasing interest in the use of regional anesthesia for minimally-invasive transforaminal lumbar interbody fusion (TLIF) and laminectomy, with the goal of reducing the side effects and risks associated with general anesthesia and also to improve patient satisfaction. The goal of this technical note is to describe important perioperative aspects to safely perform an awake spine surgery and to describe a novel technique to preform minimally-invasive TLIF using a pedicle-based retraction system. METHODS We report our patient selection criteria, perioperative anesthesia protocol and surgical technique for awake TLIF with the Maximum Access Surgery (MAS) TLIF Retraction System. We describe an illustrative case of a 66-year-old female that presented with leg pain, lumbar MRI revealed a grade one spondylolisthesis at L4-5 with severe canal stenosis. She underwent a L4-5 Awake MIS TLIF using the MAS TLIF Retraction System. RESULTS The first 10 awake TLIF we performed with the MAS TLIF Retraction System had a mean procedure time of 117.3 min with a standard deviation (SD) of 13, and a mean total OR time of 151 min, SD 14.5. No surgery was converted under general anesthesia. No intraoperative complications were reported. Average length of stay was 1.3 ± 0.46 days. CONCLUSION Awake MAS TLIF is a safe and effective technique, with the advantage of reducing the risk and side effect of general anesthesia and the approach-associated damage to soft tissues and morbidity. The pedicle-based distraction allows easier access to the intervertebral disc space for both disc preparation and cage placement.
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Fiani B, Siddiqi I, Reardon T, Sarhadi K, Newhouse A, Gilliland B, Davati C, Villait A. Thoracic Endoscopic Spine Surgery: A Comprehensive Review. Int J Spine Surg 2020; 14:762-771. [PMID: 33046537 DOI: 10.14444/7109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND From the 1990s, there has been growth in the literature demonstrating the feasibility of minimally invasive approaches for treating diverse spinal disorders. There is still much work to be done in circumnavigating the technical challenges and elucidating relative advantages of endoscopic techniques in spine surgery. In this comprehensive literature review, we discuss the history, advantages, disadvantages, approaches, and technology of, and critically examine peer-reviewed studies specifically addressing, endoscopic thoracic spinal surgery. METHODS Literature review was conducted with the key words "endoscopic," "minimally invasive," and "thoracic spinal surgery," using PubMed, Web of Science, and Google Scholar. RESULTS Review of 241 thorascopic procedures showed a success rate of 98% to 100%, low morbidity, and favorable complication profile. Review of 115 thoracic fixation procedures demonstrated high success rate, and 87% of screw positions were rated "good." Review of 55 full endoscopic uniportal decompressions showed sufficient decompression in most patients. Match pair analysis of 34 patients comparing video-assisted thoracoscopy surgery (VATS) or posterior spinal fusion reported the VATS group had increased operative duration but reduced blood loss. CONCLUSIONS Based on our literature review, there is a high rate of positive outcomes with endoscopic thoracic spine surgery, which reduces tissue dissection, intraoperative blood loss, and epidural fibrosis. However, the technical challenge highlights the importance of further training and innovation in this rapidly evolving field. LEVEL OF EVIDENCE 3. CLINICAL RELEVANCE There is growing evidence demonstrating the success of endoscopic thoracic spinal surgery. Populations that could be helped include the elderly and immunocompromised, who would benefit from decreased hospital stay and enhanced recovery time.
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Affiliation(s)
- Brian Fiani
- Desert Regional Medical Center, Palm Springs, California
| | - Imran Siddiqi
- Western University of Health Sciences College of Osteopathic Medicine, Pomona, California
| | - Taylor Reardon
- University of Pikeville, Kentucky College of Osteopathic Medicine, Pikeville, Kentucky
| | - Kasra Sarhadi
- Miller School of Medicine, University of Miami, Miami, Florida
| | | | | | - Cyrus Davati
- New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York
| | - Akash Villait
- Midwestern University, Arizona College of Osteopathic Medicine, Glendale, Arizona
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Lessing NL, Edwards CC, Dean CL, Waxter OH, Lin C, Curto RA, Brown CH. Spinal Anesthesia for Geriatric Lumbar Spine Surgery: A Comparative Case Series. Int J Spine Surg 2020; 14:713-721. [PMID: 33046538 PMCID: PMC7671447 DOI: 10.14444/7103] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The use of spinal anesthesia (SA) as opposed to general anesthesia (GA) during elective lumbar spine surgery is an emerging technique and represents a potentially modifiable factor to limit perioperative complications. Few studies, however, have compared these anesthetic techniques in an elderly population. The aim of this study is to determine if SA is a safe alternative to GA for lumbar spine surgery in elderly patients. METHODS A retrospective, consecutive case series study was performed. All patients aged 70 years and older who underwent lumbar spine decompression or combined decompression and fusion using either SA or GA during a 2-year period at a single institution were identified. Demographics and perioperative outcomes were compared. RESULTS Of all patients meeting the inclusion criteria, 56 patients (19%) received SA and 239 (81%) received GA. Patients receiving SA were slightly older (median age, 77 years versus 75 years, P = .002), consisted of more men (57% versus 36%, P = .01), and had a lower mean body mass index (28.3 versus 30.1, P = .03). Indications for surgery and type of surgery were similar between groups. On average, operative times with SA were 101 minutes versus 103 minutes with GA (P = .71). After controlling for age, sex, and body mass index, patients receiving SA had decreased estimated blood loss (β = -75 mL; 95% confidence interval [CI], -140.6, -9.4; P = .025) and intraoperative intravenous fluid requirements (β = -205 mL; 95% CI, -389.4, -21.0; P = .029), shorter postanesthesia care unit stays (β = -41 minutes; 95% CI, -64.6, -16.9; P = .001), lower maximum visual analog scale pain scores (β = -0.89 points; 95% CI, -1.6, -0.1; P = .020), and decreased odds of receiving blood transfusion (odds ratio, 0.12; 95% CI, 0.01, 0.62; P = .45); there were no significant differences in operative time, length of stay, nausea, or oral morphine equivalents consumed per day. Complication rates were similar between groups. CONCLUSION Spinal anesthesia is a reasonable, safe alternative to general anesthesia for lumbar spine surgery in elderly patients with degenerative conditions.
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Affiliation(s)
| | | | | | | | - Charles Lin
- Department of Anesthesiology, Mercy Medical Center, Baltimore, Maryland
| | | | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
Regional anesthesia has been an undervalued entity in neuroanesthetic practice. However, in the past few years, owing to the development of more advanced techniques, drugs and the prolific use of ultrasound guidance, the unrecognised potential of these modalities have been highlighted. These techniques confer the advantages of reduced requirements for local anesthetics, improved hemodynamic stability in the intraoperative period, better pain score postoperatively and reduced analgesic requirements in the postoperative period. Reduced analgesic requirement translates into lesser side effects associated with analgesic use. Furthermore, the transition from the traditional blind landmark-based techniques to the ultrasound guidance has increased the reliability and the safety profile. In this review, we highlight the commonly practised blocks in the neuroanesthesiologist's armamentarium and describe their characteristics, along with their individual particularities.
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Affiliation(s)
- Ashutosh Kaushal
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Rudrashish Haldar
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
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Influence of infiltration anaesthesia on perioperative outcomes following lumbar discectomy under surgical pleth index-guided general anaesthesia: A preliminary report from a randomised controlled prospective trial. Adv Med Sci 2020; 65:149-155. [PMID: 31945659 DOI: 10.1016/j.advms.2019.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 08/09/2019] [Accepted: 12/17/2019] [Indexed: 01/29/2023]
Abstract
PURPOSE Severe postoperative pain (SPP) may occur after lumbar discectomy. To prevent SPP and reduce rescue opioid consumption, infiltration anaesthesia (IA) has been combined with general anaesthesia (GA). This study verified how GA combined with IA facilitated intra- and postoperative demand for opioids and affected the incidence of SPP in patients subjected to open lumbar discectomy. MATERIALS/METHODS Ninety-nine patients undergoing lumbar discectomy under GA with Surgical Pleth Index (SPI)-guided fentanyl (FNT) administration were randomly assigned to receive IA combined with either 0.2% bupivacaine (BPV) or 0.2% ropivacaine (RPV) with FNT 50 μg and compared with controls (BF, RF, and C groups, respectively). RESULTS Ninety-four patients were included in the final analysis. Adjusted according to SPI, total intraoperative FNT dosages did not differ between the study groups (p = 0.23). The proportion of patients who reported SPP was the highest in group C (41.9%) than in the RF (12.9%) and BF groups (31.3%) (p < 0.05). Mild pain was experienced by 67.7%, 53.1% and 32.3% of patients from the RF, BF and C groups, respectively (p < 0.01). Morphine requirement was the highest in the control group (7.1 ± 5.9 mg), followed by the RF (2.7 ± 5.3 mg) and BF groups (4 ± 4.9 mg) (p < 0.05). CONCLUSIONS IA using RPV/FNT mixture significantly reduced SPP and postoperative demand for morphine in patients subjected to lumbar discectomy under GA.
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Regional Versus General Anesthesia: Effect of Anesthetic Techniques on Clinical Outcome in Lumbar Spine Surgery: A Prospective Randomized Controlled Trial. J Neurosurg Anesthesiol 2020; 32:29-35. [DOI: 10.1097/ana.0000000000000555] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Zakaria HM, Lipphardt M, Bazydlo M, Xiao S, Schultz L, Chedid M, Abdulhak M, Schwalb JM, Nerenz D, Easton R, Chang V. The Preoperative Risks and Two-Year Sequelae of Postoperative Urinary Retention: Analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC). World Neurosurg 2020; 133:e619-e626. [DOI: 10.1016/j.wneu.2019.09.107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 02/06/2023]
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Comparison of the Economic Outcomes of Neuroaxial and General Anesthesia for Lumbar Spine Operations: A Systematic Review and Meta-Analysis. ARCHIVES OF NEUROSCIENCE 2019. [DOI: 10.5812/ans.89989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Full-Endoscopic Visualized Foraminoplasty and Discectomy Under General Anesthesia in the Treatment of L4-L5 and L5-S1 Disc Herniation. Spine (Phila Pa 1976) 2019; 44:E984-E991. [PMID: 31374002 DOI: 10.1097/brs.0000000000003014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of clinical records. OBJECTIVE The aim of this study is to evaluate the clinical outcomes and neurological complications of full-endoscopic visualized foraminoplasty and discectomy under general anesthesia for the treatment of L4-L5 and L5-S1 disc herniation. SUMMARY OF BACKGROUND DATA Full-endoscopic visualized foraminoplasty and discectomy, which is our newly developed technique, has been used in the treatment of lumbar disc herniation and lumbar spinal stenosis. While the clinical effect, safety, and neurological complications of full-endoscopic visualized foraminoplasty and discectomy under general anesthesia are still uncertain. METHODS Between May 2015 and April 2017, 84 patients with lumbar disc herniation were included, and categorized into L4-L5 group and L5-S1 group according to the discectomy segment. Full-endoscopic visualized foraminoplasty and discectomy was performed under general anesthesia. Operative time, fluoroscopy time, hospitalization time, and complications were recorded. Each patient included was followed for at least 12 months. Visual analog scale score for leg and back pain and Oswestry Disability Index score were evaluated preoperatively and at 3, 6, and 12 months postoperatively. The modified MacNab criteria were also used to evaluate surgical effectiveness. RESULTS The mean operative time, fluoroscopy time, and hospitalization time at L4-L5 and L5-S1 were of no significant difference. The mean visual analog scale and Oswestry Disability Index postoperative scores were significantly improved over the preoperative scores. Intraoperative nerve injury occurred in one case at L4-L5, with a neurological complication rate of 2.1% in L4-L5 group. One case at L4-L5 suffered recurrence 2 weeks after the surgery, resulting in a recurrence rate of 2.1% in L4-L5 group. This recurrence case was treated by a second full-endoscopic visualized foraminoplasty and discectomy under general anesthesia. CONCLUSION Full-endoscopic visualized foraminoplasty and discectomy under general anesthesia is efficient and safe for the treatment of L4-L5 and L5-S1 disc herniation. LEVEL OF EVIDENCE 4.
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Deng H, Coumans JV, Anderson R, Houle TT, Peterfreund RA. Spinal anesthesia for lumbar spine surgery correlates with fewer total medications and less frequent use of vasoactive agents: A single center experience. PLoS One 2019; 14:e0217939. [PMID: 31194777 PMCID: PMC6563985 DOI: 10.1371/journal.pone.0217939] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/21/2019] [Indexed: 11/18/2022] Open
Abstract
STUDY OBJECTIVE Anesthesiologists at our hospital commonly administer spinal anesthesia for routine lumbar spine surgeries. Anecdotal impressions suggested that patients received fewer anesthesia-administered intravenous medications, including vasopressors, during spinal versus general anesthesia. We hypothesized that data review would confirm these impressions. The objective was to test this hypothesis by comparing specific elements of spinal versus general anesthesia for 1-2 level open lumbar spine procedures. DESIGN Retrospective single institutional study. SETTING Academic medical center, operating rooms. PATIENTS Consecutive patients (144 spinal and 619 general anesthesia) identified by automatic structured query of our electronic anesthesia record undergoing lumbar decompression, foraminotomy or microdiscectomy by one surgeon under general or spinal anesthesia. INTERVENTIONS Spinal or general anesthesia. MEASUREMENTS Numbers of medications administered during the case. MAIN RESULTS Anesthesiologists administered in the operating room a total of 10 ± 2 intravenous medications for general anesthetics and 5 ± 2 medications for spinal anesthetics (-5, 95% CI -5 to -4, p<0.001, univariate analysis). Multivariable analysis supported this finding (spinal versus general anesthesia: -4, 95% CI -5 to -4, p<0.001). Spinal anesthesia patients were less likely to receive ephedrine, or phenylephrine (by bolus or by infusion) (all p<0.001, Chi-squared test). Spinal anesthesia patients were also less likely to receive labetolol or esmolol (both p = 0.002, Fishers' Exact test). No neurologic injuries were attributed to, or masked by, spinal anesthesia. Three spinal anesthetics failed. CONCLUSIONS For routine lumbar surgery in our cohort, spinal compared to general anesthesia was associated with significantly fewer drugs administered during a case and less frequent use of vasoactive agents. Safety implications include greater hemodynamic stability with spinal anesthesia along with reduced risks for medication error and transmission of pathogens associated with medication administration.
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Affiliation(s)
- Hao Deng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jean-Valery Coumans
- Department of Neurosurgery, Massachusetts General Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Richard Anderson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Timothy T. Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Robert A. Peterfreund
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail:
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Tonković D, Bandić Pavlović D, Baronica R, Virag I, Miklić Bublić M, Kovač N, Željko D. REGIONAL ANESTHESIA FOR NEUROSURGERY. Acta Clin Croat 2019; 58:48-52. [PMID: 31741559 PMCID: PMC6813468 DOI: 10.20471/acc.2019.58.s1.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
During neurosurgery procedures it is vital to assure optimal cerebral perfusion and oxygenation. Despite physiological autoregulation of brain perfusion, maintaining hemodynamic stability and good oxygenation during anesthesia is vital for success. General anesthesia with mechanical ventilation and current drugs provide excellent hemodynamic condition and it is the first choice for most neurosurgery procedures. However, sometimes it is very hard to avoid brief increase or decrease in blood pressure especially during period of intense pain, or without pain stimulation. This could be detrimental for patients presented with high intracranial pressure and brain edema. Modifying anesthesia depth or treatment with vasoactive drugs usually is needed to overcome such circumstances. On the other hand it is important to wake the patients quickly after anesthesia for neurological exam. That is why regional anesthesia of scalp and spine could show beneficial effects by decreasing pain stimuli and hemodynamic variability with sparing effect of anesthetics drugs. Also regional techniques provide excellent postoperative pain relief, especially after spinal surgery
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Affiliation(s)
| | - Daniela Bandić Pavlović
- 1School of Medicine, University of Zagreb; 2University Hospital Zagreb, Department of Anesthesiology, Reanimatology and Intensive care
| | - Robert Baronica
- 1School of Medicine, University of Zagreb; 2University Hospital Zagreb, Department of Anesthesiology, Reanimatology and Intensive care
| | - Igor Virag
- 1School of Medicine, University of Zagreb; 2University Hospital Zagreb, Department of Anesthesiology, Reanimatology and Intensive care
| | - Martina Miklić Bublić
- 1School of Medicine, University of Zagreb; 2University Hospital Zagreb, Department of Anesthesiology, Reanimatology and Intensive care
| | - Nataša Kovač
- 1School of Medicine, University of Zagreb; 2University Hospital Zagreb, Department of Anesthesiology, Reanimatology and Intensive care
| | - Drvar Željko
- 1School of Medicine, University of Zagreb; 2University Hospital Zagreb, Department of Anesthesiology, Reanimatology and Intensive care
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Morris MT, Morris J, Wallace C, Cho W, Sharan A, Abouelrigal M, Joseph V. An Analysis of the Cost-Effectiveness of Spinal Versus General Anesthesia for Lumbar Spine Surgery in Various Hospital Settings. Global Spine J 2019; 9:368-374. [PMID: 31218193 PMCID: PMC6562207 DOI: 10.1177/2192568218795867] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Retrospective chart review. OBJECTIVE To determine the relative cost-effectiveness of spinal anesthesia and general anesthesia for lumbar laminectomy and microdiscectomy surgery performed in an academic versus private practice hospital setting. METHODS The authors retrospectively reviewed charts of 188 consecutive patients who underwent lumbar laminectomy or microdiscectomy by a single surgeon from 2012 to 2016 at either an academic or a private practice hospital setting. Intraoperative and postoperative outcomes were recorded and direct variable costs were calculated. RESULTS At the academic institution, the direct cost of a lumbar laminectomy or microdiscectomy surgery under general anesthesia was determined to be 9.93% greater than with spinal anesthesia (P = .040). The greatest difference was seen with operating room costs, in which general anesthesia was associated with 18.74% greater costs than spinal anesthesia (P = .016). There was no significant difference in cost at the private practice hospital setting. CONCLUSIONS We conclude that use of spinal anesthesia for lumbar laminectomy leads to less operating room, postanesthesia care unit, and anesthesia times, lower levels of postoperative pain, and no increased rate of other complications compared with general anesthesia at an academic institution as compared to a private practice setting. Spinal anesthesia is 9.93% less expensive than general anesthesia, indicating substantial cost-saving potential. With no sacrifice of patient outcomes and the added benefit of less pain and recovery time, Spinal anesthesia represents a more cost-effective alternative to general anesthesia in lumbar spine surgery in the academic hospital setting.
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Affiliation(s)
| | | | | | - Woojin Cho
- Albert Einstein College of Medicine, Bronx, NY, USA,Montefiore Medical Center, Bronx, NY, USA
| | - Alok Sharan
- WESTMED Spine Center, Yonkers, NY, USA,Alok Sharan, WESTMED Medical Group, Ridge
Hill, 73 Market Street, Yonkers, NY 10710, USA.
| | | | - Vilma Joseph
- Albert Einstein College of Medicine, Bronx, NY, USA,Montefiore Medical Center, Bronx, NY, USA
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Yayik AM, Cesur S, Ozturk F, Ahiskalioglu A, Ay AN, Celik EC, Karaavci NC. Postoperative Analgesic Efficacy of the Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Lumbar Spinal Decompression Surgery: A Randomized Controlled Study. World Neurosurg 2019; 126:e779-e785. [PMID: 30853517 DOI: 10.1016/j.wneu.2019.02.149] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/15/2019] [Accepted: 02/16/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Spinal surgery is a procedure that causes intense and severe pain in the postoperative period. Erector spinae plane (ESP) block can target the dorsal-ventral rami of thoracolumbar nerves, but its effect on lumbar surgery is unclear. The aim of this study was to investigate the effect of the ESP block on postoperative opioid consumption and pain scores in patients undergoing spinal surgery. METHODS Sixty patients undergoing open lumbar decompression surgery were randomly assigned to 2 groups. The ESP Group (n = 30) received ultrasound-guided bilateral ESP block with 0.25% bupivacaine 20 mL. In the Control Group (n = 30), no intervention was performed. Postoperative analgesia was performed intravenously twice a day with 400 mg ibuprofen and patient-controlled analgesia with tramadol. Postoperative visual analogue scale scores, opioid consumption, rescue analgesia, and opioid-related side effects were evaluated. RESULTS Compared with the Control Group, the visual analogue scale scores were statistically lower in the ESP Group during all measurements of time, both at rest and active movement (P < 0.05). Tramadol consumption was lower in the ESP Group compared with the Control Group at all time periods (P < 0.05). Twenty-four hour tramadol consumption in the Control Group was significantly higher compared with the ESP Group (370.33 ± 73.27 mg and 268.33 ± 71.44 mg; P < 0.001, respectively) and the difference was 28%, and time to first analgesic requirement was significantly longer in the ESP Group than in the Control Group. CONCLUSIONS ESP block can be used in multimodal analgesia practice to reduce opioid consumption and relieve acute postoperative pain in patients undergoing open lumbar decompression surgery.
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Affiliation(s)
- Ahmet Murat Yayik
- Department of Anesthesiology and Reanimation, Regional Training and Research Hospital, Erzurum, Turkey.
| | - Sevim Cesur
- Department of Anesthesiology and Reanimation, Regional Training and Research Hospital, Erzurum, Turkey
| | - Figen Ozturk
- Department of Anesthesiology and Reanimation, Regional Training and Research Hospital, Erzurum, Turkey
| | - Ali Ahiskalioglu
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - Ayse Nur Ay
- Department of Anesthesiology and Reanimation, Regional Training and Research Hospital, Erzurum, Turkey
| | - Erkan Cem Celik
- Department of Anesthesiology and Reanimation, Regional Training and Research Hospital, Erzurum, Turkey
| | - Nuh Cagrı Karaavci
- Department of Neurosurgery, Regional Training and Research Hospital, Erzurum, Turkey
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Abstract
STUDY DESIGN This was a retrospective comparative study. OBJECTIVE The main objective of this study was to investigate the effects of epidural anesthesia (EA) versus general anesthesia (GA) in elderly patients undergoing lower lumbar spine fusion surgeries. SUMMARY OF BACKGROUND DATA Lumbar spine surgery can be performed under GA or regional anesthesia. GA is more commonly used in lumbar spine surgery, which renders the patient motionless throughout the procedure and provides a secure airway. Although EA is associated with superior hemodynamic status, reduced duration of operation, less health care cost, and lower rate of surgical complications when compared with GA. Controversy still exists with regard to the optimum choice of anesthesia for major lumbar spine surgery, especially in elderly patients. MATERIALS AND METHODS From September 2016 to August 2017, consecutive patients aged 70 years or older who underwent lower lumbar fusion surgery with EA or GA were enrolled in the study. Recorded data for all patients included: age, sex, medical conditions; surgical time, operation procedure, blood loss; intraoperative hypertension and tachycardia; occurrence of nausea, vomiting, delirium, or cardiopulmonary complications. Postoperative pain and satisfaction were also assessed. RESULTS A total of 89 patients were included. Of these, 42 patients underwent GA and 47 patients underwent EA. The number of patients experiencing hypertension and tachycardia during anesthesia was significantly increased in the GA group when compared with EA. Patients with EA had significantly less delirium, nausea, and vomiting. The average Visual Analog Scale scores were significantly higher in the GA group at 0-8 hours after surgery. Patients underwent EA were more satisfied than patients with GA. CONCLUSIONS There was an association between those who received EA and superior perioperative outcomes. However, some concerns including airway security, operation duration, and obesity, must be carefully evaluated. In addition, it should be noted that this study was retrospective and selection bias may probably exist which may interfere with the results.
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Lumbar Spine Surgeries Under Spinal Anesthesia in High-Risk Patients: A Retrospective Analysis. World Neurosurg 2019; 124:e779-e782. [PMID: 30682512 DOI: 10.1016/j.wneu.2019.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 12/29/2018] [Accepted: 01/02/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine outcomes of spinal anesthesia (SA) in high-risk patients undergoing lumbar spine surgery in whom general anesthesia (GA) was contraindicated. METHODS A retrospective study was conducted in Bansal Hospital, Bhopal, India. SA was achieved with a heavy spinal dose of bupivacaine administered in the sitting position. After assessing sensory level, patients were placed into prone position. Throughout surgery, hemodynamic parameters were monitored. At the end of surgery, patients were placed into supine position and taken out of the operating room for monitoring in the recovery room. Postoperatively, time spent in the postanesthesia care unit, hemodynamic changes, incidence of nausea and vomiting, urinary retention, spinal headache, analgesic use, regression of sensory block, and length of hospital stay were documented. Patient and surgeon satisfaction was also assessed. RESULTS The study included 18 high-risk patients with lumbar spine disease. Twelve patients were classified as American Society of Anesthesiologists IV, and 6 were classified as American Society of Anesthesiologists III. Ten patients underwent microdiscectomy, and 8 patients underwent canal and lateral recess decompression. None of the patients had anesthetic or surgical complications. Postoperative pain relief was excellent. There were no incidences of postoperative vomiting or urinary retention. Only 2 patients (11.11%) developed nausea. Both surgeons and patients reported a high level of satisfaction. SA was 12% cheaper than general anesthesia. CONCLUSIONS SA is a safe, reliable, and satisfactory alternative to general anesthesia in high-risk lumbar spine surgeries. Postoperative morbidity and mortality can be reduced by SA and spinal analgesia techniques. SA allows good perioperative hemodynamic stability. It is also more cost-effective.
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Guay J, Suresh S, Kopp S, Johnson RL. Postoperative epidural analgesia versus systemic analgesia for thoraco-lumbar spine surgery in children. Cochrane Database Syst Rev 2019; 1:CD012819. [PMID: 30650189 PMCID: PMC6360928 DOI: 10.1002/14651858.cd012819.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Spine surgery may be associated with severe acute postoperative pain. Compared with systemic analgesia alone, epidural analgesia may offer better pain control. However, epidural analgesia has sometimes been associated with rare but serious complications. Therefore, it is critical to quantify the real benefits of epidural analgesia over other modes of pain treatment. OBJECTIVES To assess the effectiveness and safety of epidural analgesia compared with systemic analgesia for acute postoperative pain control after thoraco-lumbar spine surgery in children. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature on 14 November 2018, together with the references lists of related reviews and retained trials, and two trials registers. SELECTION CRITERIA We included all randomized controlled trials performed in children undergoing any type of thoraco-lumbar spine surgery comparing epidural analgesia with systemic analgesia for postoperative pain. We applied no language or publication status restriction. DATA COLLECTION AND ANALYSIS We assessed risk of bias of included trials using the Cochrane tool. We analysed data using random-effects models. We rated the quality of the evidence according to the GRADE scale. MAIN RESULTS We included 11 trials (559 participants) in the review, and seven trials (249 participants) in the analysis: 140 participants received epidural analgesia and 109 received systemic analgesia.Most studies included adolescents. Three trials included in the analysis contained some participants older than 18 years. The types of surgery were posterior spinal fusion for idiopathic scoliosis (nine trials), anterior correction for idiopathic scoliosis (one trial), or selective dorsal rhizotomy in children with cerebral palsy (one trial). The mean numbers of vertebrae operated on were between nine and 14.5 and the mean numbers of spinal levels were between three and four and a half. The length of surgery varied between three and six and a half hours.Compared with systemic analgesia, epidural analgesia reduced pain at rest at all time points. At six to eight hours, the mean pain score on a 0 to 10 scale with systemic analgesia was 3.1 (standard deviation 0.7) and with epidural analgesia was -1.32 points (95% confidence interval (CI) -1.83 to -0.82; 4 studies, 116 participants; moderate-quality evidence). At 72 hours, the mean pain score with epidural analgesia was equivalent to a -0.8 point reduction on a 0 to 10 scale (standardized mean difference (SMD) -0.65, 95% CI -1.19 to -0.10; 5 studies, 157 participants; moderate-quality evidence).Return of gastrointestinal functionThere was no difference for nausea and vomiting between groups (risk ratio (RR) 0.87, 95% CI 0.58 to 1.30; 6 studies, 215 participants; low-quality evidence). One study found epidural analgesia with local anaesthetics may have increased the number of participants who had their first flatus within 48 hours (RR 1.63, 95% CI 1.08 to 2.47; 30 participants; very low-quality evidence). Two studies found epidural analgesia with local anaesthetics may have increased the number of participants in whom first bowel movement occurred within 48 hours (RR 11.52, 95% CI 2.36 to 56.26; 60 participants; low-quality evidence). It was uncertain whether epidural analgesia reduced the time to first bowel movement (MD 0.09 days, 95% CI -0.32 to 0.50; 1 study, 60 participants; very low-quality evidence) and time to first liquid ingestion following epidural infusion of an opioid alone or a local anaesthetic plus an opioid (mean difference (MD) -5.02 hours, 95% CI -13.15 to 3.10; 2 studies, 56 participants; very low-quality evidence). Epidural analgesia with local anaesthetics may have increased the risk of having first solid food ingestion within 48 hours (RR 7.00, 95% CI 1.91 to 25.62; 1 study, 30 participants; very low-quality evidence).Secondary outcomesIt was uncertain whether there was a difference in time to ambulate (MD 0.08 days, 95% CI -0.24 to 0.39; 1 study, 60 participants; very low-quality evidence) and hospital length of stay (MD -0.29 days, 95% CI -0.69 to 0.10; 2 studies, 89 participants; very low-quality evidence). Two studies found participants were more satisfied when treated with epidural analgesia (MD 1.62 on a scale from 0 to 10, 95% CI 1.26 to 1.97; 60 participants; very low-quality evidence). It was unclear whether there was a difference in parent satisfaction for epidural analgesia with an opioid alone (MD 0.60, 95% CI -0.81 to 2.01; 1 trial, 27 participants; very low-quality evidence).ComplicationsIt was uncertain whether there was a difference in the risk of complications such as: respiratory depression (risk difference (RD) -0.05, 95% CI -0.16 to 0.05; 4 studies, 126 participants; very low-quality evidence); wound infection (RD 0.01, 95% CI -0.05 to 0.08; 2 trials, 93 participants; very low-quality evidence); epidural abscess (RD 0, 95% CI -0.05 to 0.05; 3 trials, 120 participants; very low-quality evidence); and neurological complications (RD 0.01, 95% CI -0.04 to 0.06; 4 studies, 151 participants; very low-quality evidence). AUTHORS' CONCLUSIONS There is moderate- and low-quality evidence that there may be a small additional reduction in pain up to 72 hours after surgery with epidural analgesia compared with systemic analgesia. Two very small studies showed epidural analgesia with local anaesthetic alone may accelerate the return of gastrointestinal function. The safety of this technique in children undergoing thoraco-lumbar surgery is uncertain due to the very low-quality of the evidence. The study in 'Studies awaiting classification' may alter the conclusions of the review once assessed.
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeQuebecCanada
- University of Quebec in Abitibi‐TemiscamingueTeaching and Research Unit, Health SciencesRouyn‐NorandaQCCanada
- Faculty of Medicine, Laval UniversityDepartment of Anesthesiology and Critical CareQuebec CityQCCanada
| | - Santhanam Suresh
- Ann & Robert H. Lurie Children's Hospital of Chicago Research CenterDepartment of Pediatric Anesthesiology225 E. Chicago AveChicagoILUSA60611
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 1st St SWRochesterMNUSA55901
| | - Rebecca L Johnson
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 1st St SWRochesterMNUSA55901
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Sharma N, Piazza M, Marcotte PJ, Welch W, Ozturk AK, Chen HI, Ali ZS, Schuster J, Malhotra NR. Implications of anesthetic approach, spinal versus general, for the treatment of spinal disc herniation. J Neurosurg Spine 2019; 30:78-82. [PMID: 30497221 DOI: 10.3171/2018.7.spine18460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEHealthcare costs continue to escalate. Approaches to care that have comparable outcomes and complications are increasingly assessed for quality improvement and, when possible, cost containment. Efforts to identify components of care to reduce length of stay (LOS) have been ongoing. Spinal anesthesia (SA), for select lumbar spine procedures, has garnered interest as an alternative to general anesthesia (GA) that might reduce cost and in-hospital LOS and accelerate recovery. While clinical outcomes with SA or GA have been studied extensively, few authors have looked at the cost-analysis in relation to clinical outcomes. The authors' objectives were to compare the clinical perioperative outcomes of patients who received SA and GA, as well as the direct costs associated with each modality of care, and to determine which, in a retrospective analysis, can serve as a dominant procedural approach.METHODSThe authors retrospectively analyzed a homogeneous surgical population of 550 patients who underwent hemilaminotomy for disc herniation and who received either SA (n = 91) or GA (n = 459). All clinical and billing data were obtained via each patient's chart and the hospital's billing database, respectively. Additionally, the authors prospectively assessed patient-reported outcome measures for a subgroup of consecutively treated patients (n = 75) and compared quality-adjusted life year (QALY) gains between the two cohorts. Furthermore, the authors performed a propensity score-matching analysis to compare the two cohorts (n = 180).RESULTSDirect hospital costs for patients receiving SA were 40% higher, in the hundreds of dollars, than for patients who received GA (p < 0.0001). Furthermore, there was a significant difference with regard to LOS (p < 0.0001), where patients receiving SA had a considerably longer hospital LOS (27.6% increase in hours). Patients undergoing SA had more comorbidities (p = 0.0053), specifically diabetes and hypertension. However, metrics of complications, including readmission (p = 0.3038) and emergency department (ED) visits at 30 days (p = 1.0), were no different. Furthermore, in a small pilot group, QALY gains were statistically no different (n = 75, p = 0.6708). Propensity score-matching analysis demonstrated similar results as the univariate analysis: there was no difference between the cohorts regarding 30-day readmission (p = 1.0000); ED within 30 days could not be analyzed as there were no patients in the SA group; and total direct costs and LOS were significantly different between the two cohorts (p < 0.0001 and p = 0.0126, respectively).CONCLUSIONSBoth SA and GA exhibit the qualities of a good anesthetic, and the utilization of these modalities for lumbar spine surgery is safe and effective. However, this work suggests that SA is associated with increased LOS and higher direct costs, although these differences may not be clinically or fiscally meaningful.
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Affiliation(s)
- Nikhil Sharma
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Matthew Piazza
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Paul J Marcotte
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- 2The Penn Spinal Research Group, Philadelphia, Pennsylvania
| | - William Welch
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- 2The Penn Spinal Research Group, Philadelphia, Pennsylvania
| | - Ali K Ozturk
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- 2The Penn Spinal Research Group, Philadelphia, Pennsylvania
| | - H Isaac Chen
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Zarina S Ali
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - James Schuster
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- 2The Penn Spinal Research Group, Philadelphia, Pennsylvania
| | - Neil R Malhotra
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- 2The Penn Spinal Research Group, Philadelphia, Pennsylvania
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Finsterwald M, Muster M, Farshad M, Saporito A, Brada M, Aguirre JA. Spinal versus general anesthesia for lumbar spine surgery in high risk patients: Perioperative hemodynamic stability, complications and costs. J Clin Anesth 2018; 46:3-7. [PMID: 29316474 DOI: 10.1016/j.jclinane.2018.01.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/19/2017] [Accepted: 01/04/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE More stable perioperative hemodynamic conditions, lower costs and a lower perioperative complication rate were reported in young healthy patients undergoing lumbar spine surgery in spinal anesthesia (SA) compared to general anesthesia (GA). However, the benefits of SA in high risk patients (ASA≥II suffering from cardiovascular and/or pulmonary pathologies) undergoing this surgery are unclear. Our objective was to analyze whether SA leads to an improved perioperative hemodynamic stability and to a more cost-effective management compared to GA in high risk patients undergoing this surgery. METHODS In a retrospective analysis 146 ASA II-III patients who underwent lumbar spine surgery in SA were compared with 292 ASA I-III patients who were operated in GA between 2000 and 2014. Hemodynamic effects, hospitalization times, complications, and costs according to the Swiss billing system were assessed. The data extraction was conducted according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative for cohort studies. RESULTS The patients in the SA group were older (75years (±9.6) vs 69 (±11.5), p<0.001), had a lower BMI (25.8kg/m2 (±4.8) vs 27.2 (±4.7), p=0.003) and showed a higher ASA score (3 vs 2, p<0.001). However, SA was associated with significantly better perioperative hemodynamic stability with less need for intraoperative vasopressors (15% vs 57%, p<0.001), volume supplementation (1113ml ±458 vs 1589±644, p<0.001) and transfusions (0% vs 4%, p<0.001). Additionally, the number of hypotension episodes was lower in the SA group (15% vs 47%, p<0.001). Furthermore, the SA group showed a significantly shorter duration of surgery (70min (±1.2) vs 91 (±41), p<0.001), lower postoperative nausea and vomiting (PONV) (4% vs 28%, p<0.001) and pain in the post anesthesia care unit (PACU) (visual analogue scale (VAS) 2.3 (±1.1) vs 0.8 (±0.8), p<0.001), whereas pain after 24h did not differ (VAS 0.9 (±1) vs 0.8 (±1.1), p=ns). The postoperative complication (7% vs 5%, p=0.286) and revision rates (4% vs 5%, p=0.626) were similar in both groups. Total costs (United States Dollars (USD) 6377 (±2332) vs 7018 (±4056), p=0.003) and PACU time were significantly lower in the SA group (35min (±12) vs 109 (±173), p<0.001). CONCLUSIONS Lumbar spine surgery in cardiovascular high risk patients with SA is safe, allows good perioperative hemodynamic stability and might lead to lower health care costs. Further prospective studies are needed to confirm these findings.
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Affiliation(s)
- Michael Finsterwald
- Department of Orthopedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Marco Muster
- Division of Anesthesiology, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Andrea Saporito
- Anesthesiology Department, Bellinzona Regional Hospital, 6500 Bellinzona, Switzerland.
| | - Muriel Brada
- Division of Anesthesiology, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - José A Aguirre
- Division of Anesthesiology, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
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Chan JJI, Thong SY, Tan MGE. Factors affecting postoperative pain and delay in discharge from the post-anaesthesia care unit: A descriptive correlational study. PROCEEDINGS OF SINGAPORE HEALTHCARE 2017. [DOI: 10.1177/2010105817738794] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Pain occurring in the post-anaesthesia care unit (PACU) is common, distressing to patients and remains a management challenge for staff. This study aims to identify the factors affecting pain severity and delay in discharge of patients from the PACU. Methods: Data from 590 consecutive postoperative patients in the PACU was collected over one month in 2012 at the Singapore General Hospital. Patient demographics, surgical, intraoperative anaesthetic and recovery data were collected. The primary outcome measured was postoperative pain score and secondary outcome was a delay in discharge. Univariate and multivariate logistic regression were performed to determine preoperative and intraoperative variables that may be associated with pain and delayed discharge. Results: The majority (67.6%) of patients reported no to mild pain while 32.3% reported moderate to severe pain; 65.4% of patients had delayed discharge and 28.3% of these were a result of uncontrolled pain. Factors associated with moderate to severe postoperative pain included younger age, same day admissions, duration of operation >2 h, abdominal, upper limb and spine surgeries and use of general anaesthesia. Factors associated with delay in discharge included higher body mass index, abdominal, spine and superficial surgeries, use of general anaesthesia, moderate to severe pain score and use of nurse controlled analgesia. Conclusions: This study identifies predictive factors for postoperative pain and delay in discharge from the PACU. Knowledge of these factors may help in better clinical judgment for postoperative pain management and can lead to quality improvement measures for patient management and work flow in the PACU.
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Affiliation(s)
- Jason Ju In Chan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Sze Ying Thong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Michelle Geoh Ean Tan
- Pain Management Centre and Department of Anaesthesiology, Singapore General Hospital, Singapore
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Pierce JT, Kositratna G, Attiah MA, Kallan MJ, Koenigsberg R, Syre P, Wyler D, Marcotte PJ, Kofke WA, Welch WC. Efficiency of spinal anesthesia versus general anesthesia for lumbar spinal surgery: a retrospective analysis of 544 patients. Local Reg Anesth 2017; 10:91-98. [PMID: 29066932 PMCID: PMC5644537 DOI: 10.2147/lra.s141233] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Previous studies have shown varying results in selected outcomes when directly comparing spinal anesthesia to general in lumbar surgery. Some studies have shown reduced surgical time, postoperative pain, time in the postanesthesia care unit (PACU), incidence of urinary retention, postoperative nausea, and more favorable cost-effectiveness with spinal anesthesia. Despite these results, the current literature has also shown contradictory results in between-group comparisons. Materials and methods A retrospective analysis was performed by querying the electronic medical record database for surgeries performed by a single surgeon between 2007 and 2011 using procedural codes 63030 for diskectomy and 63047 for laminectomy: 544 lumbar laminectomy and diskectomy surgeries were identified, with 183 undergoing general anesthesia and 361 undergoing spinal anesthesia (SA). Linear and multivariate regression analyses were performed to identify differences in blood loss, operative time, time from entering the operating room (OR) until incision, time from bandage placement to exiting the OR, total anesthesia time, PACU time, and total hospital stay. Secondary outcomes of interest included incidence of postoperative spinal hematoma and death, incidence of paraparesis, plegia, post-dural puncture headache, and paresthesia, among the SA patients. Results SA was associated with significantly lower operative time, blood loss, total anesthesia time, time from entering the OR until incision, time from bandage placement until exiting the OR, and total duration of hospital stay, but a longer stay in the PACU. The SA group experienced one spinal hematoma, which was evacuated without any long-term neurological deficits, and neither group experienced a death. The SA group had no episodes of paraparesis or plegia, post-dural puncture headaches, or episodes of persistent postoperative paresthesia or weakness. Conclusion SA is effective for use in patients undergoing elective lumbar laminectomy and/or diskectomy spinal surgery, and was shown to be the more expedient anesthetic choice in the perioperative setting.
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Affiliation(s)
| | | | | | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania
| | | | | | - David Wyler
- Department of Anesthesiology and Critical Care, Neurosurgery, Jefferson Hospital of Neuroscience, Thomas Jefferson University, Philadelphia PA, USA
| | | | - W Andrew Kofke
- Department of Neurosurgery.,Department of Anesthesiology and Critical Care
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Lin JDC, Ouanes JPP, Sieber FE. Regional Versus General Anesthesia in the Elderly: New Insights. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0236-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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