Spinal versus general anesthesia for lumbar spine surgery in high risk patients: Perioperative hemodynamic stability, complications and costs

Efficacy and Advantages of Spinal Anesthesia in Lumbar Disk Surgery

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.

Awake Robotic Minimally Invasive Transforaminal Lumbar Interbody Fusion Under Spinal Anesthesia: A Prospective Study with 1-Year Follow-up

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.

Intrathecal dexamethasone as an adjuvant for spinal anesthesia: a systematic review

INTRODUCTION

Spinal anesthesia is a common anesthetic technique for lower limb and abdominal surgery. Despite its efficacy, its use is limited because of its duration and potential severe side effects, especially in high-risk patients undergoing major surgery. Adjuvants such as dexamethasone offer the potential to prolong the anesthetic effect and reduce the need for local anesthetics while reducing the incidence of serious adverse events. The purpose of this systematic review is to evaluate the efficacy of dexamethasone as an intrathecal adjuvant in prolonging anesthetic duration, delaying pain onset, and minimizing adverse events (PROSPERO registration: CRD42022350218).

EVIDENCE ACQUISITION

We included randomized controlled trials conducted in adult patients undergoing spinal anesthesia for lower limb or abdominal surgery and comparing the performance of dexamethasone with alternative spinal treatments. A comprehensive systematic search was conducted on PubMed/MEDLINE, Scopus, CINAHL, EMBASE, CENTRAL, and Cochrane Library from February to June 2023 without language restriction. Risk of bias was assessed using the Cochrane Risk of Bias Tool (RoB2).

EVIDENCE SYNTHESIS

Ten studies, nine of which were at high risk of bias, were included (N.=685 patients). Overall, intrathecal dexamethasone was associated with a longer duration of sensory block, improvement in the duration or extent of postoperative analgesia, and significant shortening of block onset. The role of dexamethasone in prolonging motor block was not clear. The incidence of adverse events was low. Intrathecal dexamethasone has been shown to be a potentially valuable adjuvant to prolong the duration of sensory block and improve postoperative analgesia without increasing adverse events.

CONCLUSIONS

Given the wide heterogeneity of methodological approaches, further investigation is needed. Considering the limitations of the included studies and awaiting more conclusive evidence, the prudent use of dexamethasone could be recommended in those specific situations where general anesthesia or higher local anesthetics should be avoided.

Background factors for intra-operative hypotension during hip fracture repair surgery in the elderly under spinal anesthesia managed by orthopedic surgeons: A retrospective case-control study

BACKGROUND

Spinal anesthesia is used for femoral trochanteric fracture surgery, but frequently induces hypotension and the causative factors remain unclear. We examined background factors for the use of an intraoperative vasopressor in elderly patients receiving spinal anesthesia for femoral trochanteric fracture surgery.

METHODS

We retrospectively analyzed 203 patients >75 years (mean age, 87.9 years) with femoral trochanteric fractures who underwent short nail fixation under orthopedically managed spinal anesthesia at our hospital between April 2020 and July 2023. Patients were divided into two groups: group A (intraoperative vasopressor) and group B (no vasopressor). The following data were compared: age, sex, height, weight, body mass index, antihypertensive medication, years of experience as a primary surgeon, bupivacaine dose, puncture level, anesthesia time, operation time, hemoglobin level and blood urea nitrogen/creatinine ratio on the day of surgery, brain natriuretic peptide level, left ventricular ejection fraction, and percentage of patients operated on the day of transport.

RESULTS

There were 65 patients in group A and 138 in group B. The average dose of bupivacaine was 11.7 mg. In a univariate analysis, group A was slightly younger (87.0 vs. 88.3 years), had a higher blood urea nitrogen/creatinine ratio (27.1 vs. 24.5), more frequently received β-blockers (14.1% vs. 5.8 %) and diuretic medications (21.9% vs. 11.6 %), and had a higher puncture level. A logistic regression analysis identified younger age (p = 0.02) and diuretic medication (p = 0.001) as independent risk factors in group A. Vasopressor use was more frequent at a higher puncture level in group A (57 % for L2/3, 33 % for L3/4, 15 % for L4/5, 0 % for L5/S).

CONCLUSIONS

Spinal anesthesia-induced hypotension is attributed to volume deficit or extensive sympathetic blockade and may be prevented by avoiding high puncture levels and increasing preoperative fluid supplementation in patients on diuretics. There is currently no consensus on anesthetic dosages.

General anesthesia versus local anesthesia for deep brain stimulation targeting of STN in Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

Subthalamic nucleus deep brain stimulation (STN-DBS) is a viable therapeutic for advanced Parkinson's disease. However, the efficacy and safety of STN-DBS under local anesthesia (LA) versus general anesthesia (GA) remain controversial. This meta-analysis aims to compare them using an expanded sample size.

METHODS

The databases of Embase, Cochrane Library and Medline were systematically searched for eligible cohort studies published between 1967 and 2023. Clinical efficacy was assessed using either Unified Parkinson's Disease Rating Scale (UPDRS) section III scores or levodopa equivalent dosage requirements. Subgroup analyses were performed to assess complications (adverse effects related to stimulation, general neurological and surgical complications, and hardware-related complications).

RESULTS

Fifteen studies, comprising of 13 retrospective cohort studies and 2 prospective cohort studies, involving a total of 943 patients were included in this meta-analysis. The results indicate that there were no significant differences between the 2 groups with regards to improvement in UPDRS III score or postoperative levodopa equivalent dosage requirement. However, subgroup analysis revealed that patients who underwent GA with intraoperative imaging had higher UPDRS III score improvement compared to those who received LA with microelectrode recording (MER) (P = .03). No significant difference was found in the improvement of UPDRS III scores between the GA group and LA group with MER. Additionally, there were no notable differences in the incidence rates of complications between these 2 groups.

CONCLUSIONS

Our meta-analysis indicates that STN-DBS performed under GA or LA have similar clinical outcomes and complications. Therefore, GA may be a suitable option for patients with severe symptoms who cannot tolerate the procedure under LA. Additionally, the GA group with intraoperative imaging showed better clinical outcomes than the LA group with MER. A more compelling conclusion would require larger prospective cohort studies with a substantial patient population and extended long follow-up to validate.

Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.

Thoracic spinal anesthesia with intrathecal sedation for lower back surgery: a retrospective cohort study

Background

Spinal anesthesia (SA) is a good alternative to general anesthesia (GA) for spine surgery. Despite that, a few case series concern the use of thoracic spinal anesthesia for short-duration surgical interventions. In search of an alternative approach to GA and a better opioid-free modality, we aimed to investigate the safety, feasibility, and patient satisfaction of thoracic SA for spine surgery.

Materials and methods

We analyzed retrospectively a cohort of 24 patients operated on for a degenerative and osteoporotic pathology of the lower thoracic and lumbar spine. Data was collected from medical records, including clinical notes, operative and anesthesia records, and patient questionnaires.

Results

Twenty-one surgeries for herniated discs, two for degenerative spinal stenosis, and one for multi-level osteoporotic vertebral body fractures were performed under spinal anesthesia with intrathecal sedation. In all cases, we applied 0.5% isobaric bupivacaine and the following adjuvants: midazolam, clonidine or dexmedetomidine, and dexamethasone. We boosted the anesthesia with local ropivacaine due to inefficient sensory block in two patients. Nobody in the cohort received intravenous opioids, non-steroidal anti-inflammatory drugs, or additional sedation intraoperatively. Postoperative painkillers were upon the patient's request. No significant complications were detected.

Conclusion

Thoracic spinal anesthesia incorporating adjuvants such as midazolam, clonidine or dexmedetomidine, and dexamethasone demonstrates not only efficient conditions for spine surgery, a favorable safety profile, high patient satisfaction, and intrathecal sedation but also effective opioid-free pain management.

Transforaminal endoscopic lumbar foraminotomy for octogenarian patients

Background

Radiculopathy caused by lumbar foraminal stenosis in older people has become more common in the aging general population. However, patients aged ≥80 years rarely undergo conventional open surgery under general anesthesia because of the high risk of peri-operative morbidity and adverse events. Therefore, less invasive surgical alternatives are needed for older or medically handicapped patients. Transforaminal endoscopic lumbar foraminotomy (TELF) under local anesthesia may be helpful in at-risk patients, although only limited information is available regarding the clinical outcomes of this procedure in octogenarians. Therefore, this study aimed to investigate the safety and efficacy of TELF for treating radiculopathy induced by foraminal stenosis in octogenarian patients.

Methods

Overall, 32 consecutive octogenarian patients with lumbar foraminal stenosis underwent TELF between January 2019 and January 2021. The inclusion criterion was unilateral radiculopathy secondary to lumbar foraminal stenosis. The pain focus was confirmed using imaging studies and selective nerve blocks. Full-scale foraminal decompression was performed using a percutaneous transforaminal endoscopic approach under local anesthesia. Surgical outcomes were assessed using the visual analog pain score, Oswestry Disability Index, and modified MacNab criteria.

Results

The pain scores and functional outcomes improved significantly during the 24-month follow-up period, and the rate of clinical improvement was 93.75% in 30 of the 32 patients. None of the patients experienced systemic complications.

Conclusion

TELF under local anesthesia is an effective and safe treatment for foraminal stenosis in octogenarian or medically compromised patients. The mid-term follow-up did not reveal any significant progression in spinal stability. Therefore, this endoscopic procedure can be an effective alternative to aggressive surgery for managing lumbar foraminal stenosis in octogenarian patients with intractable radiculopathy.

Transforaminal Endoscopic Lumbar Lateral Recess Decompression for Octogenarian Patients

The incidence of radiculopathy due to lumbar spinal stenosis has been on the increase in the aging population. However, patients aged ≥ 80 years hesitate to undergo conventional open surgery under general anesthesia because of the risk of postoperative morbidity and adverse events. Therefore, less invasive surgical alternatives are required for the elderly or medically handicapped patients. Transforaminal endoscopic lumbar lateral recess decompression (TELLRD) may be helpful for those patients. This study aimed to demonstrate the efficacy of TELLRD for treating radiculopathy in octogenarian patients. A total of 21 consecutive octogenarian patients with lumbar foraminal stenosis underwent TELLRD between January 2017 and January 2021. The inclusion criterion was unilateral radiculopathy, which stemmed from lumbar lateral recess stenosis. The pain source was verified using imaging studies and selective nerve blocks. Full-scale lateral canal decompression was performed using a percutaneous transforaminal endoscopic approach under local anesthesia. We found the pain scores and functional status improved significantly during the 24-month follow-up period. The clinical improvement rate was 95.24% (20 of 21 patients) with no systemic complication. In conclusion, endoscopic lateral recess decompression via the transforaminal approach is practical for octogenarian patients.

Erector spinae plane block versus local infiltration anaesthesia for transforaminal percutaneous endoscopic discectomy: A prospective randomised controlled trial

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.

Ultrasound predictors of difficult spinal anesthesia: a prospective single-blind observational study

BACKGROUND

Ultrasound showed to improve the precision and efficacy of spinal anesthesia (SA) through the identification of specific structures surrounding the intrathecal space, such as the anterior and posterior complex of dura mater (DM). The aim of this study was to verify the efficacy of ultrasonography in predicting difficult SA trough the analysis of different ultrasound patterns.

METHODS

This prospective single-blind observational study involved 100 patients undergoing orthopedic or urological surgery. A first operator chose by landmarks the intervertebral space where he wanted to perform SA. Then a second operator recorded the visibility of DM complexes at ultrasound. Subsequently, the first operator, blinded to the ultrasound evaluation, performed SA, defined as "difficult" in case of failure, change of intervertebral space, operator exchange, duration >400 seconds or more than 10 needle passes.

RESULTS

The ultrasound visualization of only posterior complex or the failure in visualization of both complexes showed a positive predictive value of 76% and 100%, respectively, towards difficult SA vs. 6% when both complexes were visible; P<0.001. A negative correlation was found between the number of visible complexes and both patients' age and BMI. Landmark-guided evaluation underestimated the intervertebral level in 30% of cases.

CONCLUSIONS

Ultrasound showed a high accuracy in detecting difficult spinal anesthesia and its use should be recommended in the daily clinical practice in order to increase success rate and minimize patient discomfort. The absence of both DM complexes at ultrasound should lead the anesthetist to evaluate other intervertebral levels or consider alternative techniques.

Transforaminal Endoscopic Lumbar Foraminotomy for Juxta-Fusional Foraminal Stenosis

Adjacent segment foraminal stenosis is a significant adverse event of lumbar fusion. Conventional revision surgery with an extended fusion segment may result in considerable surgical morbidity owing to extensive tissue injury. Transforaminal endoscopic lumbar foraminotomy (TELF) is a minimally invasive surgical approach for symptomatic foraminal stenosis. This study aimed to demonstrate the surgical technique and clinical outcomes of TELF for the treatment of juxta-fusional foraminal stenosis. Full-scale foraminal decompression was performed via a transforaminal endoscopic approach under local anesthesia. A total of 22 consecutive patients who had undergone TELF were evaluated. The included patients had unilateral foraminal stenosis at the juxta-fusional level of the previous fusion surgery, intractable lumbar radicular pain despite at least six months of non-operative treatment, and verified pain focus by imaging and selective nerve root block. The visual analog scale and Oswestry Disability Index scores significantly improved after the two-year follow-up period. The modified MacNab criteria were excellent in six patients (27.27%), good in 12 (55.55%), fair in two (9.09%), and poor in two (9.09%), with a 90.91% symptomatic improvement rate. No significant surgical complications were observed. The minimally invasive TELF is effective for juxta-fusional foraminal stenosis.

The Hitchhiker's Guide to Spine Awake Surgery. The Oxford SAS Protocol and Early Outcomes

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.

Current indications for spinal anesthesia-a narrative review

Spinal anesthesia is a commonly performed regional anesthesia technique by most anesthesiologists worldwide. This technique is learned early during training and is relatively easy to master. Despite being an old technique, spinal anesthesia has evolved and developed in various aspects. This review attempts to highlight the current indications of this technique. Understanding the finer aspects and knowledge gaps will help postgraduates and practicing anesthesiologists in designing patient-specific techniques and interventions.

Operative room time comparison between general and spinal anesthesia in total hip arthroplasty: an institutional study

PURPOSE

A relatively high expense with any procedure is total operative time; two components being the time spent anesthetizing the patient and time spent transferring the patient out of the operating room (OR). Both times can be affected by the anesthetic method used. This study compares different operative time intervals for both spinal anesthesia (SA) and general anesthesia (GA), in patients undergoing a primary total hip arthroplasty (THA), to identify the most appropriate and cost-effective anesthetic method.

METHODS

A retrospective chart review was performed at a single institution for primary total hip arthroplasty procedures performed in the year 2019. Primary THAs without complications performed by three orthopedic surgeons were selected. Anesthesia records for 200 patients were used to compare perioperative time intervals; 100 consecutive patients that received SA and 100 consecutive patients that received GA.

RESULTS

The time spent transferring the patient out of the operating room was 8 min for GA and 5 min for SA (p < 0.001). Total operative time for GA was 90 min and 87 min for SA (p = 0.3330). Total pre-operative time averaged 26 min in SA compared to 25 min in GA (p = 0.5874). Non-operative total time (all time components of patient interaction excluding surgery start to surgery finish) was significantly shorter in SA with an average of 52 compared to 56 in GA (p = 0.0151).

CONCLUSION

Time to transfer patient out of the OR and total non-operative time was significantly shorter in patients who received spinal anesthesia. These results and the complications of both general and spinal anesthesia should be taken into consideration when anesthetizing patients undergoing primary THA.

LEVEL OF EVIDENCE

III.

The Effect of Two Different Dexmedetomidine Doses on the Prevention of Nausea and Vomiting in Discectomy Surgery under Spinal Anesthesia

Background

Considering the preventative effect of various medications on such complications after surgery, the present study evaluated the effect of two different dexmedetomidine doses on the prevention of nausea and vomiting in discectomy surgery.

Materials and Methods

The present controlled, double-blind clinical trial was performed on 135 patients that were candidates for discectomy surgery under spinal anesthesia, which were randomly allocated into three groups. Two different dexmedetomidine doses of 0.2 and 0.5 mcg/kg/h were intravenously administered using an infusion pump for 10 min in the first (DEX-0.2 group) and second (DEX-0.5 group) groups, respectively, with the third placebo group being used as a control group. Hemodynamic parameters, the severity of nausea and vomiting, and the incidence of complications were evaluated and recorded up to 24 h after surgery.

Results

The results of the present study revealed that, 20 min after the intervention, the severity of nausea and vomiting in the control group (with the mean of 1.95 ± 1.58) was significantly higher than that of the DEX-0.2 and DEX-0.5 groups with the means of 1.52 ± 1.11 and 1.27 ± 0.99, respectively (P = 0.010). In addition, no significant difference was found between the two dexmedetomidine doses in terms of the severity of nausea and vomiting (P > 0.05).

Conclusion

According to the results of the present study, a low dose of dexmedetomidine may be a more preferable choice as a preventive drug in the incidence of nausea and vomiting in discectomy surgery due to its lower complications, further reduction of nausea and vomiting, and more desirable hemodynamic stability.

Dose Selection of Ropivacaine for Spinal Anesthesia in Elderly Patients with Hip Fracture: An Up-Down Sequential Allocation Study

Objective

The dose selection of ropivacaine for spinal anesthesia in clinical work mainly depends on the experience of the anesthesiologist. In this study, a prospective and modified up-down sequential allocation design was used to provide the optimal dose selection of ropivacaine for spinal anesthesia.

Patients and methods

This study was divided into two stages, and a total of 164 elderly patients with elective hip fractures were included. In stage I, the dose of ropivacaine was selected using the up-down sequential method of height correction, and the 50% effective dose (ED50) and 95% effective dose (ED95) were obtained. A nomogram for predicting satisfactory anesthesia and a formula for predicting the optimal dose was also given in this stage. In stage II, the dose of ropivacaine was calculated by using the optimal dose prediction formula, so as to evaluate the efficacy and safety of the model.

Results

The ED50 and ED95 of the stage I were 7.036 mg (95%CI 6.549–7.585 mg) and 8.709 mg (95%CI 7.902–14.275 mg), respectively. And provided a nomogram predicting satisfactory anesthesia with a C-index of 0.847 (95%CI 0.774–0.92). The optimal dose prediction formula of ropivacaine was calculated, including variables for age, gender, height, and weight. This formula was found to be 90% efficient. It is worth mentioning that the incidence of direct transfer to the ward in the two stages was as high as 86.84% and 93.33%, respectively, and no patients were transferred to the ICU in stage II.

Conclusion

The ED50 and ED95 of ropivacaine were 7.036 mg and 8.709 mg, respectively, and the nomograms are sufficiently accurate to predict satisfactory anesthesia. Beyond that, the dose prediction equation provided in this study has high efficacy and safety, and can guide the dose selection of spinal anesthesia in elderly patients with hip fracture in clinical practice.

Clinical trials registration

ChiCTR2100046982

Regional and neuraxial anaesthesia techniques for spinal surgery: a scoping review

BACKGROUND

Whilst general anaesthesia is commonly used to undertake spine surgery, the use of neuraxial and peripheral regional anaesthesia techniques for intraoperative and postoperative analgesia is an evolving practice. Variations in practice have meant that it is difficult to know which modalities achieve optimal outcomes for patients undergoing spinal surgery. Our objective was to identify available evidence on the use of regional and neuraxial anaesthesia techniques for adult patients undergoing spinal surgery.

METHODS

This study was conducted using a framework for scoping reviews. This included a search of six databases searching for articles published since January 1980. We included studies that involved adult patients undergoing spinal surgery with regional or neuraxial techniques used as the primary anaesthesia method or as part of an analgesic strategy.

RESULTS

Seventy-eight articles were selected for final review. All original papers were included, including case reports, case series, clinical trials, or conference publications. We found that general anaesthesia remains the most common anaesthesia technique for this patient cohort. However, regional anaesthesia, especially non-neuraxial techniques such as fascial plane blocks, is an emerging practice and may have a role in terms of improving postoperative pain relief, quality of recovery, and patient satisfaction. In comparison with neuraxial techniques, the popularity of fascial plane blocks for spinal surgery has significantly increased since 2017.

CONCLUSIONS

Regional and neuraxial anaesthesia techniques have been used both to provide analgesia and anaesthesia for patients undergoing spinal surgery. Outcome metrics for the success of these techniques vary widely and more frequently use physiological outcome metrics more than patient-centred ones.

Perioperative outcomes of general versus spinal anesthesia in the lumbar spine surgery population: A systematic review and meta-analysis of data from 2005 through 2021

STUDY DESIGN

Meta-analysis.

OBJECTIVES

Perform a systematic review and meta-analysis to determine the perioperative utility of general versus spinal anesthesia in the lumbar spine surgery population.

METHODS

PubMed and Embase were queried for manuscripts reporting perioperative outcomes for patients undergoing one to three-level lumbar spine surgery (including decompression, fusion, and decompression with fusion) using either general or spinal anesthesia. Inclusion criteria included studies published from 2005 to 2021, in English, involving primary data from human subjects. Studies were further screened for data on total operative time, blood loss, intraoperative hypotension, pain scores, postoperative nausea and vomiting, time required in post-anesthesia care unit (PACU), PACU pain anesthetic requirement, and length of stay. Risk of bias for each study was assessed using standardized tools (i.e., RoB 2, ROBINS-I, NOS, as appropriate). Potential predictors of outcome were compared using univariate analysis, and variables potentially associated with outcome were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to produce standard mean differences (SMD) or odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

In total, 12 studies totaling 2796 patients met inclusion criteria. 1414 (50.6%) and 1382 (49.4%) patients underwent lumbar spine surgery with general anesthesia and spinal anesthesia, respectively. Patients undergoing spinal anesthesia were statistically more likely to have coronary artery disease and respiratory dysfunction. Total operative time (SMD: 12.62 min, 95% CI -18.65 to -6.59), estimated blood loss (SMD: 0.57 mL, 95% CI -0.68 to -0.46), postoperative nausea and vomiting (OR = 0.20, 95% CI 0.15 to 0.26), time required in PACU (SMD = -0.20 min, 95% CI -0.32 to -0.08), and length of stay (SMD = -0.14 day, 95% CI -0.18 to -0.10), all statistically significantly favored spinal anesthesia over general anesthesia (p < 0.05).

CONCLUSION

In one to three-level lumbar spine surgery, current literature supports spinal anesthesia as a viable alternative to general anesthesia. As this was a heterogeneous patient population, prospective randomized trials are needed to corroborate findings.

Regional Anesthesia for Lumbar Spine Surgery: Can It Be a Standard in the Future?

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.

Spinal anesthesia in contemporary and complex lumbar spine surgery: experience with 343 cases

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.

What Is the Learning Curve for Lumbar Spine Surgery Under Spinal Anesthesia?

BACKGROUND

Spinal anesthesia (SA) is routinely used in obstetrics and orthopedic surgery but has not been widely adopted in lumbar spine surgery (LSS). One perceived barrier is the learning curve for the neurosurgical and anesthesia team associated with managing a patient in the prone position under SA.

METHODS

A retrospective cohort of 34 LSS cases under SA at our institution was examined. Operative time, corrected operative time per level, and complications were analyzed. The learning curve was assessed using a curve-fit regression analysis.

RESULTS

Of patients, 62% were female, with mean (SD) age and body mass index of 60.7 (10.8) years and 29.9 (4.6) kg/m², respectively. The mean (SD) for each time segment was operating room arrival to incision 35.7 (8.1) minutes, total surgical time 100.4 (35.8) minutes, and procedure finish to operating room exit 3.4 (2.5) minutes. When the times were normalized to procedure type and analyzed sequentially, the mean (SD) slope of all trendlines was 0.003 (0.005) with correlation coefficients of R² = 0.0002-0.01, indicating no appreciable learning curve. Normalized postanesthesia care unit time was significantly shorter for overnight stay versus same-day discharge (0.64 vs. 1.36, P = 0.0005).

CONCLUSIONS

Our data demonstrate the lack of a learning curve when SA is implemented in LSS cases by an anesthetic team already familiar with SA techniques for other procedures. Importantly, the surgical team was already familiar with the minimally invasive surgery approaches used in conjunction with SA. This study highlights that the barriers to transitioning to SA for LSS may be fewer than perceived.

The risk factors and predictive nomogram of human albumin infusion during the perioperative period of posterior lumbar interbody fusion: a study based on 2015-2020 data from a local hospital

BACKGROUND

Perioperative hypoalbuminemia of the posterior lumbar interbody fusion (PLIF) can increase the risk of infection of the incision site, and it is challenging to accurately predict perioperative hypoproteinemia. The objective of this study was to create a clinical predictive nomogram and validate its accuracy by finding the independent risk factors for perioperative hypoalbuminemia of PLIF.

METHODS

The patients who underwent PLIF at the Affiliated Hospital of Qingdao University between January 2015 and December 2020 were selected in this study. Besides, variables such as age, gender, BMI, current and past medical history, indications for surgery, surgery-related information, and results of preoperative blood routine tests were also collected from each patient. These patients were divided into injection group and non-injection group according to whether they were injected with human albumin. And they were also divided into training group and validation group, with the ratio of 4:1. Univariate and multivariate logistic regression analyses were performed in the training group to find the independent risk factors. The nomogram was developed based on these independent predictors. In addition, the area under the curve (AUC), the calibration curve and the decision curve analysis (DCA) were drawn in the training and validation groups to evaluate the prediction, calibration and clinical validity of the model. Finally, the nomograms in the training and validation groups and the receiver operating characteristic (ROC) curves of each independent risk factor were drawn to analyze the performance of this model.

RESULTS

A total of 2482 patients who met our criteria were recruited in this study and 256 (10.31%) patients were injected with human albumin perioperatively. There were 1985 people in the training group and 497 in the validation group. Multivariate logistic regression analysis revealed 5 independent risk factors, including old age, accompanying T2DM, level of preoperative albumin, amount of intraoperative blood loss and fusion stage. We drew nomograms. The AUC of the nomograms in the training group and the validation group were 0.807, 95% CI 0.774-0.840 and 0.859, 95% CI 0.797-0.920, respectively. The calibration curve shows consistency between the prediction and observation results. DCA showed a high net benefit from using nomograms to predict the risk of perioperative injection of human albumin. The AUCs of nomograms in the training and the validation groups were significantly higher than those of five independent risk factors mentioned above (P < 0.001), suggesting that the model is strongly predictive.

CONCLUSION

Preoperative low protein, operative stage ≥ 3, a relatively large amount of intraoperative blood loss, old age and history of diabetes were independent predictors of albumin infusion after PLIF. A predictive model for the risk of albumin injection during the perioperative period of PLIF was created using the above 5 predictors, and then validated. The model can be used to assess the risk of albumin injection in patients during the perioperative period of PLIF. The model is highly predictive, so it can be clinically applied to reduce the incidence of perioperative hypoalbuminemia.

Spinal versus general anesthesia for Holmium laser enucleation of the prostate of high-risk patients - A propensity-score-matched-analysis

OBJECTIVE

To compare perioperative management and functional outcome of spinal anesthesia (SpA) to general anesthesia (GA) in high-risk patients treated for lower urinary tract symptoms (LUTS) with Holmium laser enucleation of the prostate (HoLEP).

METHODS

In the current retrospective analysis, a propensity-score-matching of patients treated for LUTS with HoLEP (n=300) in SpA with ASA>2 (n=100), GA with ASA>2 (GA-high-risk) (n=100) or GA with ASA≤2 (GA-low-risk) (n=100) was performed. The impact of anesthesiologic mode on perioperative anesthesiologic outcome, early functional outcome and treatment related adverse events (according to Clavien Dindo), was evaluated.

RESULTS

Hypotensive episodes were significantly less frequent in the SpA-cohort (9%) compared to the GA-high-risk cohort (32%) and the GA low-risk cohort (22%) (each p<0.05 respectively). SpA-patients showed a significantly shorter median time in post anesthesia care unit (PACU-time: 135min; 120-166.5) compared to GA-high-risk patients (186min; 154-189.5), with significant less referrals to Intermediate care unit (ICU) (1% vs. 9 %); (each p<0.05). PACU-time (99min) and ICU referrals (0%) for GA-low-risk were lower than for both other cohorts. Postoperative requirement for analgesics was significantly lower in the SpA-cohort (2%), compared to both GA-cohorts (74% and 61% respectively; p<0.05). No significant difference was found regarding early functional outcome or treatment related adverse events (AE) (p-range:0.201-1.000).

CONCLUSION

For patients undergoing HoLEP, SpA provides greater hemodynamic stability and allows faster overall postoperative recovery with preferable pain management. Yielding a comparable functional outcome, it is a safe and efficient alternative to GA in high-risk patients.

Direct Visualization of the Dural Puncture Site During Lumbar Spine Surgery Performed Under Spinal Anesthesia: A Case Report

Spinal anesthesia (SA) has been utilized for lumbar surgical procedures; however, postdural puncture headache (PDPH) and subdural hemorrhage (SDH) are potential consequences. We present the case of a 76-year-old with progressive neurogenic claudication secondary to lumbar spinal stenosis who received SA for a 2-level lumbar posterior decompression. After decompression, the site of dural puncture from a 24-gauge Sprotte spinal needle was identified. Our intraoperative image demonstrates the submillimeter dural defect that can potentially engender complications as significant as PDPH and/or SDH. We recommend searching for, and preemptively sealing, the dural puncture site when SA is used for lumbar spine surgery.

General Versus Neuraxial Anesthesia for Appendectomy: A Multicenter International Study

BACKGROUND

In resource-limited countries, open appendectomy is still performed under general anesthesia (GA) or neuraxial anesthesia (NA). We sought to compare the postoperative outcomes of appendectomy under NA versus GA.

METHODS

We conducted a post hoc analysis of the International Patterns of Opioid Prescribing (iPOP) multicenter study. All patients ≥ 16 years-old who underwent an open appendectomy between October 2016 and March 2017 in one of the 14 participating hospitals were included. Patients were stratified into two groups: NA-defined as spinal or epidural-and GA. All-cause morbidity, hospital length of stay (LOS), and pain severity were assessed using univariate analysis followed by multivariable logistic regression adjusting for the following preoperative characteristics: age, gender, body mass index (BMI), smoking, history of opioid use, emergency status, and country.

RESULTS

A total of 655 patients were included, 353 of which were in the NA group and 302 in the GA group. The countries operating under NA were Colombia (39%), Thailand (31%), China (23%), and Brazil (7%). Overall, NA patients were younger (mean age (SD): 34.5 (14.4) vs. 40.7 (17.9), p-value < 0.001) and had a lower BMI (mean (SD): 23.5 (3.8) vs. 24.3 (5.2), p-value = 0.040) than GA patients. On multivariable analysis, NA was independently associated with less postoperative complications (OR, 95% CI: 0.30 [0.10-0.94]) and shorter hospital LOS (LOS > 3 days, OR, 95% CI: 0.47 [0.32-0.68]) compared to GA. There was no difference in postoperative pain severity between the two techniques.

CONCLUSIONS

Open appendectomy performed under NA is associated with improved outcomes compared to that performed under GA. Further randomized controlled studies should examine the safety and value of NA in lower abdominal surgery.

Spinal Anesthesia for Geriatric Lumbar Spine Surgery: A Comparative Case Series

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.

Effectiveness Comparison of Dexmedetomidine and Remifentanil for Perioperative Management in Patients Undergoing Endoscopic Sinus Surgery

BACKGROUND

For patients undergoing endoscopic sinus surgery, intranasal injection of epinephrine can cause acute increases in heart rate and blood pressure.

OBJECTIVE

Among the drugs for reducing hyperdynamic effects, dexmedetomidine and remifentanil are expected to blunt the acute hemodynamic responses after intranasal injection of epinephrine. Our study compared a difference in the 2 drugs in their abilities to blunt the hemodynamic responses in intraoperative period and postoperative profile.

METHODS

In this study, the patients were randomly divided into the dexmedetomidine and remifentanil groups. During the intraoperative period, the hemodynamic values were recorded. The surgical condition was assessed by a single surgeon. During the postoperative period, hemodynamic values, sedation scale score, and pain score were recorded.

RESULT

No significant differences in hemodynamic variables were found between the groups before and after intranasal injection of epinephrine. Comparison of the group mean values before endotracheal intubation revealed that the blood pressure values in the remifentanil group were significantly lower than those in the dexmedetomidine group. At 2 minutes after endotracheal intubation, blood pressure and heart rate values in the remifentanil group were significantly lower than those in the dexmedetomidine group. The sedation score was significantly lower in the dexmedetomidine group on arrival and at 30 minutes after arrival at the postanesthetic care unit (P < .001 and P = .001, respectively). At 30 and 60 minutes after the operation, the pain scores were significantly lower in the dexmedetomidine group (P = .015 and P = .001, respectively).

CONCLUSION

Dexmedetomidine had better postoperative sedative and analgesic effects than remifentanil for patients undergoing endoscopic sinus surgery in this study. Remifentanil and dexmedetomidine attenuated acute hemodynamic responses to be within normal ranges after intranasal injection of epinephrine, and no significant differences in terms of hemodynamic variables. Remifentanil was superior to dexmedetomidine in inducing hypotension during endotracheal intubation.

Lengthy complex lumbar fusion surgery in high-risk elderly patient under spinal anesthesia: A case report

•

The longest reported lumbar surgery in an elderly patient under spinal anesthesia.

•

Spinal Anesthesia is a feasible option for lengthy geriatric lumbar surgery.

•

SA affords effective anesthesia with possibly lower physiological stress to some older patients.

•

Spinal Anesthesia may have elongated efficacy in the elderly population.

Introduction

Spinal Anesthesia (SA) continues to be an emerging technique for lumbar fusion surgery in the elderly population. SA is an appealing option in the high-risk geriatric population for several reasons, including the potential for reduced systematic stress, reduced blood loss, and reduced post-operative delirium. The safe limits of spine surgery under SA remain undetermined.

Presentation of case

The following case-study describes an elderly high-risk patient (ASA III) with severe spinal stenosis and degenerative scoliosis who presented with lower back and right leg pain and underwent a 3-level lumbar fusion surgery with spinal anesthesia. The procedure lasted 3 h and 44 min with sufficient anesthesia maintained throughout. The patient experienced minor post-operative complications, but had an excellent clinical outcome at 3-month follow-up.

Discussion

Further research should be conducted to define the temporal limits of SA in elderly patients and the etiology of post-operative complications following lumbar fusion surgery under spinal anesthesia in the geriatric population.

Conclusion

The case reported, herein, demonstrates the feasibility of SA in elderly patients undergoing lengthy complex lumbar surgeries who have been designated “high-risk” patients (ASA > II) and provides support for future investigation into surgical and anesthesia treatment options for geriatric high-risk patients presenting with complex lumbar spine pathologies.

Comparison of Single-Agent Versus 3-Additive Regional Anesthesia for Foot and Ankle Surgery

BACKGROUND

This study compared the results of regional blocks containing a single anesthetic, bupivacaine, with those containing bupivacaine and 3 additives (buprenorphine, clonidine, and dexamethasone) in patients undergoing foot and ankle surgery.

METHODS

Eighty patients undergoing foot and ankle surgery over a 9-month period were prospectively enrolled and randomized to receive a peripheral nerve block containing either a single anesthetic (SA) or one with 3 additives (TA). Patients, surgeons, and anesthesiologists were blinded to the groups. Patients maintained pain diaries and were evaluated at 1 and 12 weeks postoperatively. Fifty-six patients completed the study.

RESULTS

The TA group had a longer duration of analgesic effect than the SA group (average 82 vs 34 hours, P < .05). Forty-eight hours after surgery, 93% of SA blocks, compared with 34% of TA blocks, had completely worn off. The TA group had a longer duration of sensory effects. At 3 months, 10 of 26 (38.5%) TA patients, compared with 3 of 30 (10%) SA patients, reported postoperative neurologic symptoms. Pain scores in both groups were not statistically different at 1 week or 3 months after surgery. Patients in both groups were similarly satisfied with their blocks.

CONCLUSION

Both types of nerve blocks provided equivalent pain control and patient satisfaction in patients undergoing foot and ankle surgery. The 3-additive agent blocks were associated with a longer duration of pain relief and a longer duration of numbness, as well as higher rates of postoperative neurologic symptoms. Longer pain relief may be obtained at the cost of prolonged sensory deficits.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Percutaneous Endoscopic Lumbar Foraminotomy for Foraminal Stenosis with Postlaminectomy Syndrome in Geriatric Patients

INTRODUCTION

Postlaminectomy syndrome (PLS) or failed back surgery syndrome is a condition characterized by persistent pain following a back surgery. Degenerative processes may result in foraminal stenosis development over time, even after a successful surgery. Percutaneous endoscopic lumbar foraminotomy (PELF) offers a minimally invasive means of treating foraminal stenosis after a back surgery. The objective of this study was to evaluate the outcomes of PELF for foraminal stenosis with PLS in geriatric patients.

METHODS

Two-year follow-up data were collected from 21 consecutive patients aged 65 years or older (mean age, 72.4 years) who underwent PELF for foraminal stenosis with PLS. Transforaminal endoscopic foraminal decompression was performed under local anesthesia. Outcomes were assessed using visual analog scale pain score, Oswestry Disability Index, and modified Macnab criteria.

RESULTS

Mean visual analog scale for leg pain improved from 8.48 at baseline to 3.33 at 6 weeks, 2.10 at 1 year, and 2.19 at 2 years after PELF (P < 0.01). Mean Oswestry Disability Index improved from 67.29 at baseline to 30.69 at 6 weeks, 22.50 at 1 year, and 20.81 at 2 years after PELF (P < 0.01). Based on the modified Macnab criteria, excellent or good results were obtained in 81.0% of patients and symptomatic improvements were obtained in 95.2% of patients.

CONCLUSIONS

The transforaminal endoscopic approach can provide a better access angle to achieve a sophisticated foraminal decompression with less facet and dural injury. Therefore, PELF under local anesthesia can be useful for PLS or postoperative foraminal stenosis in elderly patients.

Anesthesia for the patient with a recently diagnosed concussion: think about the brain!

Some patients require emergent, urgent, or elective surgery in the time period immediately following diagnosis of concussion. However, changes in brain homeostatic mechanisms following a concussion and concern for secondary brain injury can complicate the decision as to whether or not a surgery should proceed or be postponed. Given the paucity of available evidence, further evaluation of the use of anesthesia in a patient with concussion is warranted. This article summarizes what is currently known about the relevant pathophysiology of concussion, intraoperative anesthesia considerations, and effects of anesthesia on concussion outcomes in an attempt to help providers understand the risks that may accompany surgery and anesthesia in this patient population. While most contraindications to the use of anesthesia in concussed patients are relative, there are nonetheless pathophysiologic changes associated with a concussion that can increase risk of its use. Understanding these changes and anesthetic implications can help providers optimize outcomes in this patient population.

Spinal anesthesia for lumbar spine surgery correlates with fewer total medications and less frequent use of vasoactive agents: A single center experience

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.

Laser-assisted endoscopic lumbar foraminotomy for failed back surgery syndrome in elderly patients

Elderly patients with failed back surgery syndrome (FBSS) or post-laminectomy foraminal stenosis have a higher risk of perioperative morbidity with extensive revision surgery. Thus, there is a need for safer and less invasive surgical options, such as laser-assisted endoscopic lumbar foraminotomy (ELF). A pin-point laser beam can allow precise tissue ablation and dissection in fibrotic adhesion tissues while preventing normal tissue injury. The present study aimed to describe the surgical technique of laser-assisted ELF and to evaluate the clinical outcomes of elderly patients with FBSS. Two-year follow-up data were collected from 26 consecutive patients aged 65 years or older who were treated with laser-assisted ELF for FBSS. Full-endoscopic foraminal decompression was performed using a side-firing laser and mechanical instruments. The average age of the patients was 70.2 years (range, 65-83 years). The mean visual analog pain score for leg pain improved from 8.58 at baseline to 3.35 at 6 weeks, 2.19 at 1 year, and 2.35 at 2 years after ELF (P < 0.001). The mean Oswestry disability index improved from 65.93 at baseline to 31.41 at 6 weeks, 21.77 at 1 year, and 20.64 at 2 years after ELF (P < 0.001). Based on the modified Macnab criteria, excellent or good results were obtained in 84.6% patients and symptomatic improvements were obtained in 92.3%. Extensive revision surgery in elderly patients might cause significant surgical morbidities. Laser-assisted ELF under local anesthesia could be a safe and effective surgical alternative for such patients at risk.

General anesthesia vs spinal anesthesia for patients undergoing total-hip arthroplasty: A meta-analysis

BACKGROUND

The optimal anesthetic technique remains debated in patients undergoing total-hip arthroplasty (THA). The purpose of this meta-analysis was to test the efficacy of general and spinal anesthesia for patients undergoing THA.

METHODS

In January 2018, we searched PubMed, Embase, Web of Science, Cochrane Database of Systematic Reviews, and the Google database. Data from randomized controlled trials (RCTs) that compared the use of general and spinal anesthesia for patients undergoing THA were retrieved. The primary outcome was to compare the total blood loss. The secondary outcomes were the occurrence of deep venous thrombosis (DVT), the occurrence of nausea, and the length of hospital stay. Software Stata 12.0 was used for meta-analysis.

RESULTS

Five RCTs with 487 THAs were finally included for meta-analysis. There was no significant difference between the general anesthesia and spinal anesthesia in terms of the total blood loss (weighted mean difference [WMD] = -20.72, 95% confidence interval [CI] -84.50 to 43.05, P = .524; I = 87.8%) and the occurrence of DVT (risk ratio (RR) = 0.85, 95% CI 0.24-3.01, P = .805; I = 70.5%). Compared with general anesthesia, spinal anesthesia was a significant reduction in the occurrence of nausea (RR = 3.04, 95% CI 1.69-5.50, P = .000; I = 0.0%) and the length of hospital stay (WMD = 1.00, 95% CI 0.59-1.41, P = .000; I = 94.7%).

CONCLUSION

Spinal anesthesia was superior than general anesthesia in terms of the occurrence of nausea and shorten the length of hospital stay. The quality and number of included studies was limited; thus, a greater number of high-quality RCTs is still needed to further identify the effects of spinal anesthesia on reducing the blood loss after THA.

Emergency inguinal hernioplasties in a tertiary public Hospital in Athens Greece, during the economic crisis

Background

Although the effect of the recent Greek economic crisis and austerity on the population’s health and the health system effectiveness have been discussed a lot recently, data on common surgical conditions affecting large part of the population are missing. Using inguinal hernia as a model we investigated possible changes of citizens’ attitude regarding the time of referral, the perioperative details and the intraoperative findings of the emergency hernioplasties.

Methods

The present retrospective study was conducted by a Department of Surgery in a tertiary public hospital of the Greek capital. We reviewed the records of all hernioplasties performed during two 5-year periods: 2005–2009 and 2012–2016, i.e. before and during the crisis focusing on the emergency ones (either incarcerated or strangulated).

Results

An equal number of hernioplasties was performed in both periods. During the crisis however, an emergency hernioplasty was significantly more probable (HR 1.269, 95% CI 1.108–1.1454, p = 0.001), at a younger age (p = 0.04), mainly in patients younger than 75 years old (p = 0.0013). More patients presented with intestinal ischemia (7 vs 18, p = 0.002), requiring longer hospitalization (5.2 vs 9.6 days, p = 0.04), with higher cost (560 ± 262.4€ vs 2125 ± 1180.8€ p < 0.001). In contrast the percentage of patients with intestinal resection, their hospitalization length and treatment-cost remained unchanged. During the crisis there was a non-significant increase of emergency patients requiring ICU postoperatively (0 vs 4, p = 0.07) and a non-significant 60% increase of emergency operations in migrants/refugees population (3.5% vs 5.8%, p = 0.28). Epidural anesthesia was significantly more frequent during the crisis.

Conclusion

During the crisis: (i) the emergency hernioplasties increased significantly, (ii) more patients (exclusively Greek) presented with intestinal ischemia requiring longer hospitalization and higher treatment cost, (iii) the mean age of the urgently treated patients decreased significantly (iv) regional (epidural) anesthesia was more frequent. Although a direct causal relation could not be proven by the present study most observations can be explained by an increase of the patients who delayed the elective treatment of their hernia, and by a redistribution of the surgical workload towards big central hospitals. This can be prevented by adequately supporting the small district hospitals.

Impact of Epidural Versus General Anesthesia on Major Lumbar Surgery in Elderly Patients

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.

Lumbar Spine Surgeries Under Spinal Anesthesia in High-Risk Patients: A Retrospective Analysis

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.