Anesthetic management of complex spine surgery in adult patients: a review based on outcome evidence

Complication Rates Following Adult Spinal Deformity Surgery: Evaluation of the Category of Complication and Chronology

OBJECTIVE

Provide benchmarks for the rates of complications by type and timing.

STUDY DESIGN

Prospective multicenter database.

BACKGROUND

Complication rates following adult spinal deformity (ASD) surgery have been previously reported. However, the interplay between timing and complication type warrants further analysis.

METHODS

The data for this study were sourced from a prospective, multicenter ASD database. The date and type of complication were collected and classified into three severity groups (minor, major, and major leading to reoperation). Only complications occurring before the two-year visit were retained for analysis.

RESULTS

Of the 1260 patients eligible for two-year follow-up, 997 (79.1%) achieved two-year follow-up. The overall complication rate was 67.4% (N=672). 247 patients (24.8%) experienced at least one complication on the day of surgery (including intraoperatively), 359 (36.0%) between postoperative day 1 and six weeks postoperatively, 271 (27.2%) between six weeks and one-year postoperatively, and finally 162 (16.3%) between one year and two years postoperatively. Using Kaplan-Meier survival analysis, the rate of remaining complication-free was estimated at different time points for different severities and types of complications. Stratification by type of complication demonstrated that most of the medical complications occurred within the first 60 days. Surgical complications presented over two distinct timeframes. Operative complications, incision-related complications, and infections occurred early (within 60 d), while implant-related and radiographic complications occurred at a constant rate over the two-year follow-up period. Neurological complications had the highest occurrence within the first 60 days but continued to increase up to the two-year visit.

CONCLUSION

Only one-third of ASD patients remained complication-free by two years, and 2 of 10 patients had a complication requiring a reoperation or revision. An estimation of the timing and type of complications associated with surgical treatment may prove useful for more meaningful patient counseling and aid in assessing the cost-effectiveness of treatment.

LEVEL OF EVIDENCE

3.

Inter-Semispinalis Plane Block Versus General Anesthesia for Postoperative Analgesia in Posterior Cervical Spine Surgery: A Randomized Controlled Trial

Background

Postoperative pain management is crucial for improving patient outcomes following posterior cervical spine surgery. Opioids are effective but carry a risk of respiratory depression. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used but may not provide adequate pain relief and have potential complications. The inter-semispinalis plane (ISPB) block is a novel technique for postoperative analgesia in cervical spine surgery.

Objectives

This study aims to evaluate and compare the efficacy of the ISPB with general anesthesia in terms of analgesia, postoperative Visual Analog Scale (VAS) pain scores, patient-surgeon satisfaction levels, and the occurrence of postoperative complications.

Methods

This double-blind, randomized controlled trial was blinded to both the patient and the assessor. Fifty adult patients (18 - 60 years old) undergoing elective posterior cervical spine surgery were enrolled. The participants were divided into 2 groups: The ISPB group (receiving bilateral ultrasound-guided ISPB at the C5 level) and the control group (receiving general anesthesia only), with each group comprising 25 patients. The study assessed intraoperative fentanyl use, postoperative VAS pain levels, the need for rescue analgesia, and complications.

Results

The ISPB group showed significantly lower intraoperative fentanyl consumption (median 100 vs. 100 - 150 μg, P = 0.022) and lower postoperative pain scores at 1, 8, 12, and 48 hours (P = 0.016, 0.009, 0.005, 0.016). Additionally, the ISPB group required less postoperative pethidine (20% vs. 64%, P = 0.002) and had a longer delay before requesting pethidine (hazard ratio 0.215, P = 0.001). Surgeon satisfaction was significantly higher in the ISPB group (P = 0.003). These results suggest that the ISPB can effectively reduce pain and analgesic requirements.

Conclusions

The ISPB is an effective analgesic technique for posterior cervical spine surgery, reducing opioid consumption, providing better pain control, and enhancing surgeon satisfaction without increasing complications. This approach has the potential to improve postoperative care and patient outcomes in this surgical population.

Enhanced Recovery After Surgery: Exploring the Advances and Strategies

Enhanced recovery after surgery (ERAS) has emerged as a paradigm-shifting approach in perioperative care, aimed at optimizing patient outcomes, accelerating recovery, and minimizing hospital stays. This review delves into the latest advances and strategies within the field of ERAS, encompassing a comprehensive examination of preoperative, intraoperative, and postoperative interventions. By analyzing an array of clinical studies, meta-analyses, and implementation experiences, this review highlights the multifaceted elements contributing to the success of ERAS programs. Key components such as preoperative patient education, minimally invasive surgical techniques, tailored anesthesia protocols, judicious fluid management, optimized pain control, early ambulation, and structured nutritional support are thoroughly explored. Furthermore, the review delves into the intricacies of ERAS implementation across diverse surgical specialties, emphasizing the significance of multidisciplinary collaboration, protocol customization, and sustained quality improvement initiatives. The analysis not only showcases the tangible benefits of ERAS, including reduced complication rates, shortened hospital stays, and enhanced patient satisfaction, but also underscores the challenges and barriers that medical professionals encounter during program adoption. By synthesizing the current state of ERAS research and practice, this review provides clinicians, administrators, and researchers with valuable insights into the evolving landscape of perioperative care, fostering a deeper understanding of ERAS as a holistic approach that transcends traditional surgical pathways.

Analgesic efficacy of inter-semispinal fascial plane block in Patients undergoing Cervical Spine Surgery through Posterior Approach: a randomized controlled trial

BACKGROUND

Posterior cervical spine surgery is commonly performed in elderly patients with significant comorbidities and is considered one of the most painful surgical procedures. Accordingly, perioperative pain management during posterior cervical spine surgery represents a unique challenge for anesthesiologists. Inter-semispinal plane block (ISPB) represents a promising analgesic technique for spine surgery through the blockade of the dorsal rami of the cervical spinal nerves. The present study aimed to investigate the analgesic effect of bilateral ISPB as an opioid-sparing nerve block technique for posterior cervical spine surgeries.

METHODS

This prospective randomized controlled trial enrolled 52 patients planned for cervical spine surgery via the posterior approach. Patients were randomly assigned to one of two groups in a one-to-one ratio, with 26 patients allocated to the block group (ISPB) who received general anesthesia preceded by bilateral ISP using 20 mL 0.25% bupivacaine on each side and the remaining 26 patients allocated to the control group who received general anesthesia only. The primary outcome was total perioperative opioid consumption through two co-primary outcomes, i.e. total amount of fentanyl administered intraoperatively and total morphine consumption during the first 24 hours postoperatively. The secondary outcomes included intraoperative hemodynamic parameters, assessment of numerical rating scores (NRS) during the first 24 hours postoperatively, time to first rescue analgesia and opioid-related side effects.

RESULTS

A significantly lower amount of intraoperative fentanyl was administered in the ISPB group (median, 175 μg; range, 110-220 μg] compared to the control group [median, 290 μg; range 110-350 μg). Patients in the ISPB group consumed significantly lower doses of morphine (median, 7 mg; range, 5-12 mg]) within the first 24 h postoperatively compared to the control group (median, 12 mg; range, 8-21 mg). In addition, NRS values were significantly lower in the ISPB group during the first 12 h postoperatively than in the control group. No significant differences in mean arterial pressure (MAP) or heart rate (HR) were observed between intraoperative time points in the ISPB group. However, a significant increase in MAP was observed during surgery in the control group (p < 0.001). The incidence of opioid side effects such as nausea, vomiting, and sedation was significantly greater in the control group compared to the ISPB group.

CONCLUSIONS

Inter-semispinal plane block (ISPB) represents an effective analgesic technique and reduces opioid consumption in both intra- and postoperative settings. Moreover, the ISPB could significantly decrease opioid-associated side effects.

Application of opioid-free general anesthesia for gynecological laparoscopic surgery under ERAS protocol: a non-inferiority randomized controlled trial

BACKGROUND

Enhanced recovery after surgery (ERAS) is now widely used in various surgical fields including gynecological laparoscopic surgery, but the advantages of opioid-free anesthesia (OFA) in gynecological laparoscopic surgery under ERAS protocol are inexact.

AIMS

This study aims to assess the effectiveness and feasibility of OFA technique versus traditional opioid-based anesthesia (OA) technique in gynecological laparoscopic surgery under ERAS.

METHODS

Adult female patients aged 18 ~ 65 years old undergoing gynecological laparoscopic surgery were randomly divided into OFA group (Group OFA, n = 39) with esketamine and dexmedetomidine or OA group (Group OA, n = 38) with sufentanil and remifentanil. All patients adopted ERAS protocol. The primary outcome was the area under the curve (AUC) of Visual Analogue Scale (VAS) scores (AUC_VAS) postoperatively. Secondary outcomes included intraoperative hemodynamic variables, awakening and orientation recovery times, number of postoperative rescue analgesia required, incidence of postoperative nausea and vomiting (PONV) and Pittsburgh Sleep Quality Index (PSQI) perioperatively.

RESULTS

AUC_VAS was (Group OFA, 16.72 ± 2.50) vs (Group OA, 15.99 ± 2.72) (p = 0.223). No difference was found in the number of rescue analgesia required (p = 0.352). There were no between-group differences in mean arterial pressure (MAP) and heart rate (HR) (p = 0.211 and 0.659, respectively) except MAP at time of surgical incision immediately [(Group OFA, 84.38 ± 11.08) vs. (Group OA, 79.00 ± 8.92), p = 0.022]. Times of awakening and orientation recovery in group OFA (14.54 ± 4.22 and 20.69 ± 4.92, respectively) were both longer than which in group OA (12.63 ± 3.59 and 18.45 ± 4.08, respectively) (p = 0.036 and 0.033, respectively). The incidence of PONV in group OFA (10.1%) was lower than that in group OA (28.9%) significantly (p = 0.027). The postoperative PSQI was lower than the preoperative one in group OFA (p = 0.013).

CONCLUSION

In gynecological laparoscopic surgery under ERAS protocol, OFA technique is non-inferior to OA technique in analgesic effect and intraoperative anesthesia stability. Although awakening and orientation recovery times were prolonged compared to OA, OFA had lower incidence of PONV and improved postoperative sleep quality.

TRIAL REGISTRATION

ChiCTR2100052761, 05/11/2021.

Perioperative management in complex spine surgery: a narrative review

The last two decades have seen a significant increase in the number of spine surgical procedures performed worldwide. This type of surgery includes a wide variety of procedures, from mini-invasive discectomies to multi-level spinal arthrodesis and osteotomies. Moreover, different surgical approaches are described at different spine levels: the anesthesiologist should be aware of the potential benefits and risks for the patients and be prepared for their management. In this narrative review we seek to describe basic concepts of perioperative spine care and address evolving areas in which care is changing. We will discuss preoperative concerns, intraoperative management including airway management, choice of maintenance, intraoperative neuromonitoring and anesthetic effect, blood management and the dynamic topic of anesthetic and analgesic techniques. Finally, we will briefly address the issue of perioperative complications as they relate specifically to spine surgery.

Surgical fixation of pathologic and traumatic spinal fractures using single position surgery technique in lateral decubitus position

STUDY DESIGN

Retrospective Case Series.

OBJECTIVES

This study aims to determine complications, readmission, and revision surgery rates in patients undergoing single position surgery (SPS) for surgical treatment of traumatic and pathologic thoracolumbar fractures.

METHODS

A multi-center review of patients who underwent SPS in the lateral decubitus position (LSPS) for surgical management of traumatic or pathologic thoracolumbar fractures between January 2016 and May 2020 was conducted. Operative time, estimated blood loss (EBL), intraoperative complications, postoperative complications, readmissions, and revision surgeries were collected.

RESULTS

A total of 12 patients with a mean age of 45 years (66.67% male) were included. The majority of patients underwent operative treatment for acute thoracolumbar trauma (66.67%) with a mean injury severity score (ISS) of 16.71. Mean operative time was 175.5 min, mean EBL of 816.67 cc. Five patients experienced a complication, two of which required revision surgery for additional decompression during the initial admission. All ambulatory patients were mobilized on postoperative day 1. The mean hospital length of stay (LOS) was 9.67 days.

CONCLUSION

The results of this case series supports LSPS as a feasible alternative to the traditional combined anterior-posterior approach for surgical treatment of pathologic and thoracolumbar fractures. These results are similar to reductions in operative time, EBL, and LOS seen in the elective spine literature with LSPS.

LEVEL OF EVIDENCE

IV.

The impact of initial surgical management on outcome in patients with severe burns: a 9-year retrospective analysis

PURPOSE

To investigate the prognostic value of the factors related to the initial surgical management of burn wounds in severely burned patients.

METHODS

A total of 189 severely burned adult patients who were admitted to our institute between January 2012 and December 2020 and met the inclusion criteria were recruited. Patients were divided into survival and nonsurvival groups. The patient data included sex, age, total burn surface area (TBSA), burn index (BI), inhalation injury, mechanical ventilation, initial surgical management of the burn wound (including post-injury time before surgery, surgical duration, surgical area, intraoperative fluid replenishment, intraoperative blood loss, and intraoperative urine output), and duration in the burn intensive care unit (BICU). Independent samples t tests, Mann-Whitney U tests, and χ 2 tests were performed on these data. those of which with statistically significant differences were subjected to univariate and multivariate Cox regression analyses to identify independent risk factors affecting the prognosis of severely burned patients. Receiver operating characteristic (ROC) curves were plotted, and the area under the curve (AUC), optimal cut-off value were calculated. Patients were divided into two groups, according to the optimal cut-off value of the independent risk factors. The TBSA, surgical area and survival rates of the two groups during hospitalization were analysed.

RESULTS

The survival group (146 patients) and the nonsurvival group (43 patients) differed significantly in TBSA, burn index, inhalation injury, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, intraoperative blood loss, and duration in the BICU (P<0.05). Univariate Cox regression analysis showed that TBSA, burn index, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, and intraoperative blood loss were risk factors for death in severely burned patients (P<0.05). Multivariate Cox regression analysis showed that the burn index and intraoperative blood loss were independent risk factors for death in severely burned patients (P<0.05). When the intraoperative blood loss during the initial surgical management of burn wounds was used to predict death in 189 severely burned patients, the AUC was 0.637 (95% confidence interval (CI): 0.545-0.730, P=0.006), and the optimal cut-off for intraoperative blood loss was 750 ml. Kaplan-Meier survival analysis showed that the prognosis of the group with intraoperative blood loss ≤750 ml was better than that of the group with intraoperative blood loss >750 ml (P=0.008). Meanwhile, the TBSA and surgical area in the group with intraoperative blood loss ≤750 ml were significantly lower than that of the group with intraoperative blood loss >750 ml (P<0.05).

CONCLUSION

The burn index and intraoperative blood loss during the initial surgical management of burn wounds are independent risk factors affecting the outcome of severely burned patients with good predictive values. During surgery, haemostatic and anaesthetic strategies should be adopted to reduce bleeding, and the bleeding volume should be controlled within 750 ml to improve the outcome.

Application of Controlled Hypotension During Surgery for Spinal Metastasis

With advances in tumor treatment, metastasis to bone is increasing, and surgery has become the only choice for most terminal patients. However, spinal surgery has a high risk and is prone to heavy bleeding. Controlled hypotension during surgery has outstanding advantages in reducing intraoperative bleeding and ensuring a clear field of vision, thus avoiding damage to important nerves and vessels. Antihypertensive drugs should be carefully selected after considering the patient's age, different diseases, etc, and a single or combined regimen can be used. Hypotension also inevitably leads to a decrease in perfusion of important organs, so the threshold of hypotension and the maintenance time of hypotension should be strictly limited, and the monitoring of important organs during the operation is particularly important. Information such as blood perfusion, blood oxygen saturation, cardiac output, and neurophysiological conduction potential changes should be obtained in a timely fashion, which will help to reduce the risk of hypotension. In short, when applying controlled hypotension, it is necessary to choose an appropriate threshold and duration, and appropriate monitoring should be conducted during the operation to ensure the safety of the patient.

The effect of ketorolac on posterior minimally invasive transforaminal lumbar interbody fusion: an interim analysis from a randomized, double-blinded, placebo-controlled trial

BACKGROUND CONTEXT

Postoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses.

PURPOSE

We sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period.

STUDY DESIGN/SETTING

This is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis.

PATIENT SAMPLE

Adults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF).

OUTCOME MEASURES

Six-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index.

METHODS

A double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis.

RESULTS

Two hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p<.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications.

CONCLUSIONS

Short-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.

Complication rate evolution across a 10-year enrollment period of a prospective multicenter database

OBJECTIVE

Adult spinal deformity is a complex pathology that benefits greatly from surgical treatment. Despite continuous innovation, little is known regarding continuous changes in surgical techniques and the complications rate. The objective of the current study was to investigate the evolution of the patient profiles and surgical complications across a single prospective multicenter database.

METHODS

This study is a retrospective review of a prospective, multicenter database of surgically treated patients with adult spinal deformity (thoracic kyphosis > 60°, sagittal vertical axis > 5 cm, pelvic tilt > 25°, or Cobb angle > 20°) with a minimum 2-year follow-up. Patients were stratified into 3 equal groups by date of surgery. The three groups' demographic data, preoperative data, surgical information, and complications were then compared. A moving average of 320 patients was used to visualize and investigate the evolution of the complication across the enrollment period.

RESULTS

A total of 928/1260 (73.7%) patients completed their 2-year follow-up, with an enrollment rate of 7.7 ± 4.1 patients per month. Across the enrollment period (2008-2018) patients became older (mean age increased from 56.7 to 64.3 years) and sicker (median Charlson Comorbidity Index rose from 1.46 to 2.08), with more pure sagittal deformity (type N). Changes in surgical treatment included an increased use of interbody fusion, more anterior column release, and a decrease in the 3-column osteotomy rate, shorter fusion, and more supplemental rods and bone morphogenetic protein use. There was a significant decrease in major complications associated with a reoperation (from 27.4% to 17.1%) driven by a decrease in radiographic failures (from 12.3% to 5.2%), despite a small increase in neurological complications. The overall complication rate has decreased over time, with the lowest rate of any complication (51.8%) during the period from August 2014 to March 2017. Major complications associated with reoperation decreased rapidly in the 2014-2015. Major complications not associated with reoperation had the lowest level (21.0%) between February 2014 and October 2016.

CONCLUSIONS

Despite an increase in complexity of cases, complication rates did not increase and the rate of complications leading to reoperation decreased. These improvements reflect the changes in practice (supplemental rod, proximal junctional kyphosis prophylaxis, bone morphogenetic protein use, anterior correction) to ensure maintenance of status or improved outcomes.

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

A novel checklist for anesthesia in neurosurgical cases

Throughout their training, anesthesiology residents are exposed to a variety of surgical subspecialties, many of which have specific anesthetic considerations. According to the Accreditation Council for Graduate Medical Education requirements, each anesthesiology resident must provide anesthesia for at least twenty intracerebral cases. There are several studies that demonstrate that checklists may reduce deficiencies in pre-induction room setup. We are introducing a novel checklist for neuroanesthesia, which we believe to be helpful for residents during their neuroanesthesiology rotations. Our checklist provides a quick and succinct review of neuroanesthetic challenges prior to case setup by junior residents, covering noteworthy aspects of equipment setup, airway management, induction period, intraoperative concerns, and postoperative considerations. We recommend displaying this checklist on the operating room wall for quick reference.

Single position circumferential fusion improves operative efficiency, reduces complications and length of stay compared with traditional circumferential fusion

BACKGROUND CONTEXT

Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) with percutaneous posterior screw fixation are two techniques used to address degenerative lumbar pathologies. Traditionally, these anterior-posterior (AP) surgeries involve repositioning the patient from the supine or lateral decubitus position to prone for posterior fixation. To reduce operative time (OpTime) and subsequent complications of prolonged anesthesia, single-position lumbar surgery (SPLS) is a novel, minimally invasive alternative performed entirely from the lateral decubitus position.

PURPOSE

Assess the perioperative safety and efficacy of single position AP lumbar fusion surgery (SPLS).

STUDY DESIGN

Multicenter retrospective cohort study.

PATIENT SAMPLE

Three hundred and ninety patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group.

OUTCOME MEASURES

Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, estimated blood loss (EBL), length of stay (LOS), and perioperative complications. Radiographic analysis included lumbar lordosis (LL), pelvic incidence, pelvic tilt, and segmental LL.

METHODS

Patients undergoing primary ALIF and/or LLIF surgery with bilateral percutaneous pedicle screw fixation between L2-S1 were included over a 4-year period. Patients were classified as either traditional repositioned "Flip" surgery or SPLS. Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, EBL, LOS, perioperative complications. Radiographic analysis included LL, pelvic incidence, pelvic tilt, and segmental LL. All measures were compared using independent samples t-tests and chi-squared analyses as appropriate with significance set at p < .05. Propensity matching was completed where demographic differences were found.

RESULTS

Three hundred and ninety patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group. Age, gender, BMI, and CCI were similar between groups. Levels fused (1.47 SPLS vs 1.52 Flip, p = .468) and percent cases including L5-S1 (31% SPLS, 35% Flip, p = .405) were similar between cohorts. SPLS significantly reduced OpTime (103 min vs 306 min, p < .001), EBL (97 vs 313 mL, p < .001), LOS (1.71 vs 4.12 days, p < .001), and fluoroscopy radiation dosage (32 vs 88 mGy, p < .001) compared to Flip. Perioperative complications were similar between cohorts with the exception of postoperative ileus, which was significantly lower in the SPLS group (0% vs 5%, p < .001). There was no significant difference in wound, vascular injury, neurological complications, or Venous Thrombotic Event. There was no significant difference found in 90-day return to operating room (OR).

CONCLUSIONS

SPLS improves operative efficiency in addition to reducing blood loss, LOS and ileus in this large cohort study, while maintaining safety.

Cannulation of the popliteal vein as an intraoperative emergency access in prone position: A case report

Many surgeries have to be performed in the prone position. Access to central vessels is very limited in this position. This requires forward planning with regard to the placement of a central venous catheter. Emergency situations or unexpected intraoperative events in prone position are challenging, as a conventional central venous access is not possible. We describe the cannulation of the popliteal vein in such a case. We report the case of a patient with severe intracerebral hemorrhage who was transferred to our emergency department where his clinical condition rapidly deteriorated. Due to the surgical approach, a prone position was necessary and preoperative central venous cannulation was not possible. We therefore performed an alternative vascular access in prone position using a ultrasound-guided cannulation of the popliteal vein. The cannulation of the popliteal vein described here can be carried out as a quick and easy feasible alternative in emergency situations in prone position. The ultrasound-guided catheter insertion succeeded without any problems and there was no evidence of a deep vein thrombosis after the intervention.

Comparative short-term outcomes of enhanced recovery after surgery (ERAS) program and non-ERAS traditional care in elderly patients undergoing lumbar arthrodesis: a retrospective study

Background

Enhanced recovery after surgery (ERAS) program is an evidence-based improvement over non-ERAS traditional care. The aim of the present study was to analyze the safety, feasibility, and efficacy of an ERAS program in patients over 70 years undergoing lumbar arthrodesis by comparison with non-ERAS traditional care.

Methods

During January 2018 to December 2018, patients enrolled received non-ERAS traditional care, while the ERAS program was implemented from January to December 2019. Demographic characteristics, comorbidities, surgical data and postoperative recovery parameters were collected from all patients. Postoperative pain scores were evaluated by visual analog scales (VAS). The clinical outcomes were length of stay (LOS), postoperative complications and postoperative pain scores. Compliance results were also collected.

Result

A total of 127 patients were enrolled, including 67 patients in the non-ERAS traditional care group and 60 patients in the ERAS group. The demographic characteristics and comorbidities of the two groups showed no significant differences. The LOS of patients treated with ERAS program (13.6 ± 4.0 days) was significantly less than that of patients treated with non-ERAS traditional care (15.6 ± 3.9 days) (p = 0.034). Complication rate was 8.3% in the ERAS group versus 20.9% in the non-ERAS traditional care group (p = 0.048). VAS (back) in the ERAS group was significantly lower on postoperative day (POD) 1 and POD2. Postoperative recovery parameters were improved in the ERAS group. The overall compliance with the ERAS program was 94%.

Conclusions

Based on our results, ERAS program is safer and more effective for elderly patients over 70 undergoing lumbar arthrodesis than non-ERAS traditional care.

Perioperative and Anesthetic Considerations for Patients with Degenerative Spine Disease

The demand for spine surgery has dramatically increased over the last 2 decades. As the population ages and surgical and anesthetic techniques advance, the perioperative care of spine surgery patients poses challenges to anesthesiologists. Perioperative outcomes in terms of a decrease in complication rates and total health care expenditures have directed perioperative care to focus on enhanced recovery after surgery protocols, which many institutions have adopted. The role of anesthesiologists in the care of patients undergoing spine surgery is expanding beyond intraoperative care; consequently, a multidisciplinary approach is the best direction for optimal patient care.

Anesthetic considerations in spine surgery: What orthopaedic surgeon should know!

With clinical innovation and technological advancement, the paradigm of surgical procedures on the spine and spinal cord along with the perioperative management are rapidly evolving. Irrespective of different modes the anesthetic management of spine surgery is challenging in view of significant blood loss, prolong procedure, position-related complications, and complex pain management. The enhanced recovery after surgery (ERAS) for this kind of surgery is yet to be finalized. The aim of this article is to highlight the current evidence-based major perioperative considerations for patients undergoing spine surgery.