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Rajjoub R, Ghaith AK, El-Hajj VG, Rios-Zermano J, De Biase G, Atallah E, Tfaily A, Saad H, Akinduro OO, Elmi-Terander A, Abode-Iyamah K. Comparative outcomes of awake spine surgery under spinal versus general anesthesia: a comprehensive systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:985-1000. [PMID: 38110776 DOI: 10.1007/s00586-023-08071-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Awake surgery, under spinal anesthesia (SA), is an alternative to surgery under general anesthesia (GA), in neurological and spine surgery. In the literature, there seem to be some evidence supporting benefits associated with the use of this anesthetic modality, as compared to GA. Currently, there is a notable lack of updated and comprehensive review addressing the complications associated with both awake SA and GA in spine surgery. We hence aimed to perform a systematic review of the literature and meta-analysis on the topic. METHODS A systematic search was conducted to identify studies that assessed SA in spine surgery from database inception to April 14, 2023, in PubMed, Medline, Embase, and Cochrane databases. Outcomes of interest included estimated blood loss, length of hospital stay, operative time, and overall complications. Meta-analysis was conducted using random effects models. RESULTS In total, 38 studies that assessed 7820 patients were included. The majority of the operations that were treated with SA were single-level lumbar cases. Awake patients had significantly shorter lengths of hospital stay (Mean difference (MD): - 0.40 days; 95% CI - 0.64 to - 0.17) and operative time (MD: - 19.17 min; 95% CI - 29.68 to - 8.65) compared to patients under GA. The overall complication rate was significantly higher in patients under GA than SA (RR, 0.59 [95% CI 0.47-0.74]). Patients under GA had significantly higher rates of postoperative nausea/vomiting RR, 0.60 [95% CI 0.39-0.90]) and urinary retention (RR, 0.61 [95% CI 0.37-0.99]). CONCLUSIONS Patients undergoing awake spine surgery under SA had significantly shorter operations and hospital stays, and fewer rates of postoperative nausea and urinary retention as compared to GA. In summary, awake spine surgery offers a valid alternative to GA and added benefits in terms of postsurgical complications, while being associated with relatively low morbidity.
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Affiliation(s)
- Rami Rajjoub
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Victor Gabriel El-Hajj
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Gaetano De Biase
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Ali Tfaily
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Kingsley Abode-Iyamah
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Olmos M, Patel J, Kanter M, Karimi H, Kryzanski J. Evaluating the potential impact of spinal anesthesia use in lumbar surgery on global healthcare cost and climate change. BRAIN & SPINE 2023; 3:101754. [PMID: 37383465 PMCID: PMC10293309 DOI: 10.1016/j.bas.2023.101754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/17/2023] [Accepted: 05/02/2023] [Indexed: 06/30/2023]
Abstract
Introduction Despite recent evidence demonstrating its safety and efficacy, spinal anesthesia remains a seldom-utilized anesthetic modality in lumbar surgical procedures. In addition, numerous clinical advantages, such as reduced cost, blood loss, operative time, and inpatient length of stay have been consistently demonstrated with spinal anesthesia over general anesthesia. Research question In this report we aim to examine the differences between spinal anesthesia and general anesthesia with regard to accessibility and climate impact and determine whether wider adoption of spinal anesthesia would have a meaningful impact on the global population. Materials and Methods: The climate impact of spinal fusions performed under spinal and general anesthesia were obtained from recent studies published in the literature. Cost of spinal fusions was obtained from an unpublished study performed at our institution. Volume of spinal fusions performed in several countries were ascertained from published reports. Data on cost and carbon emissions were extrapolated based on volume of spinal fusions in each of the nations. Results In the U.S., use of spinal anesthesia for lumbar fusions would have resulted in savings of 343 million dollars in 2015. A similar reduction in cost was seen with each country studied. Additionally, spinal anesthesia was associated with 12,352 kg carbon dioxide equivalents (CO2e) while general anesthesia produced 942,872 kg CO2e. Similar reduction in carbon emissions was seen with each country studied. Discussion and conclusion Spinal anesthesia is safe and effective for both simple and complex spine surgeries, it reduces carbon emissions, permits lower operative times, and decreases cost.
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Affiliation(s)
| | | | | | | | - James Kryzanski
- Corresponding author. Department of Neurosurgery, Tufts Medical Center, 800 Washington St. Boston, MA, 02111, USA.
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Abstract
» Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints. » ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia. » The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Kaustubh Ahuja
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Garg B, Ahuja K, Khanna P, Sharan AD. Regional Anesthesia for Spine Surgery. Clin Spine Surg 2021; 34:163-170. [PMID: 33044273 DOI: 10.1097/bsd.0000000000001096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 09/10/2020] [Indexed: 12/15/2022]
Abstract
Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. In this narrative review we discuss the characteristics of regional anesthesia including its types, indications, contraindications, benefits, and potential complications along with new modalities of regional analgesia.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi
| | - Kaustubh Ahuja
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
| | - Puneet Khanna
- Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
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Ahmed Jonayed S, Alam MS, Al Mamun Choudhury A, Akter S, Chakraborty S. Efficacy, safety, and reliability of surgery on the lumbar spine under general versus spinal anesthesia- an analysis of 64 cases. J Clin Orthop Trauma 2021; 16:176-181. [PMID: 33717954 PMCID: PMC7920005 DOI: 10.1016/j.jcot.2020.12.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 12/06/2020] [Accepted: 12/29/2020] [Indexed: 01/17/2023] Open
Abstract
QUASI-EXPERIMENTAL DESIGN PURPOSE Compare intra and postoperative parameters, surgeons' satisfaction, and cost-effectiveness between general anesthesia (GA) and spinal anesthesia (SA) on patients undergoing surgery in the lumbar spine surgery. OVERVIEW OF LITERATURE Surgery on the lumbar spine is the commonest surgical procedure among all spinal surgical practices. Both the GA and SA are shown to be suitable techniques for performing the surgery safely. GA is used most frequently. But, SA became increasingly more popular because it allows the patient to self-position thereby reducing various complications associated with GA in a prone position. METHODS A total of 64 patients from June 2016 to July 2019 who underwent either discectomy, laminectomy, or lamino-foraminotomy for herniated lumbar disc or canal stenosis in 1 or 2 levels were included. During the study period, 32 patients were non-randomly selected for each of the GA and SA groups. The heart rate (HR), mean arterial pressure (MAP), blood loss, total anesthetic time, surgeons' satisfaction, analgesic requirements, cost of the procedure, and hospital stay were recorded and compared. RESULTS In the context of demographic characteristics, baseline HR, or MAP, no significant differences were noted between SA and GA groups. Mean anesthetic time, mean PACU time, mean doses of analgesic requirement, cost of anesthesia, and the surgeon's satisfaction was significantly lower in the SA Group (P < 0.05). The blood loss, duration of operation, and hospital stay were not significant too. No major Intra and postoperative complications were reported nor were significant differences found in either series. CONCLUSION Safety and efficacy of SA in comparison to GA were similar for the patients undergoing surgery on the lumbar spine. Notable advantages of SA include shorter anesthesia duration, fewer drug requirements, relative cost-effectiveness, and fewer complications rate. Successful surgery can be performed using either anesthesia type.
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Affiliation(s)
- Sharif Ahmed Jonayed
- National Institute of Traumatology & Orthopaedic Rehabilitation, (NITOR), Dhaka, Bangladesh,Corresponding author. National Institute of Traumatology & orthopaedic rehabilitation, (NITOR), House#23, Road#06, Dhanmondi Residential Area, Dhaka, 1209, Bangladesh.
| | - Md Shah Alam
- Dhaka Medical College Hospital, Dhaka, Bangladesh
| | | | - Sohely Akter
- Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Shubhendu Chakraborty
- National Institute of Traumatology & Orthopaedic Rehabilitation, (NITOR), Dhaka, Bangladesh
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Parrish JM, Jenkins NW, Brundage TS, Hrynewycz NM, Podnar J, Buvanendran A, Singh K. Outpatient Minimally Invasive Lumbar Fusion Using Multimodal Analgesic Management in the Ambulatory Surgery Setting. Int J Spine Surg 2020; 14:970-981. [PMID: 33560257 DOI: 10.14444/7146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol. METHODS Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics. RESULTS Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures. CONCLUSIONS The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain. LEVEL OF EVIDENCE 4. CLINICAL RELEVANCE The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.
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Affiliation(s)
- James M Parrish
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nathaniel W Jenkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Thomas S Brundage
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nadia M Hrynewycz
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jeffrey Podnar
- Department of Anesthesiology, Midwest Anesthesia Partners LLC, Naperville, Illinois
| | | | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Bhatia A, Buvanendran A. Anesthesia and postoperative pain control-multimodal anesthesia protocol. JOURNAL OF SPINE SURGERY 2019; 5:S160-S165. [PMID: 31656870 DOI: 10.21037/jss.2019.09.33] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Multimodal analgesia (MMA) involves the use of additive or synergistic combinations of analgesics to achieve clinically required analgesia while minimizing significant side effects associated with higher dose of a single equianalgesic medication such as an opioid analgesic. MMA generally involves optimizing non-opioid pharmacologic and non-pharmacologic interventions and reserving opioid use to treat breakthrough pain. Patients receiving medications via MMA protocols are likely to have lower opioid consumption compared to those managed using primarily IV opioid patient-controlled analgesia. MMA pain management strategies have become important components of enhanced recovery after surgery (ERAS) protocols in an effort to optimize care by standardizing analgesic medications in the perioperative setting while minimizing adverse effects and improving quality and patient outcomes. Successful implementation of a MMA requires the input and cooperation of all of the stakeholders including the caregivers as well as the patients. Health system benefits can also be realized from the implementation of an effective MMA, as fewer opioid related side effects can improve patient recovery and lead to faster discharge and improved utilization of resources.
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Affiliation(s)
- Alisha Bhatia
- Rush University Medical Center, Department of Anesthesiology, Chicago, Illinois, USA
| | - Asokumar Buvanendran
- Rush University Medical Center, Department of Anesthesiology, Chicago, Illinois, USA
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Ren DJ, Lin YY, Du P, Zhang ZC, Wang XN, Li F. Percutaneous Endoscopic Lumbar Discectomy on L5-S1: Comparison of Modified Knee-Chest and Prone Position in Terms of Foraminal Height and Puncture Time. Chin Med J (Engl) 2018; 131:2605-2607. [PMID: 30381595 PMCID: PMC6213843 DOI: 10.4103/0366-6999.244122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Da-Jiang Ren
- Department of Orthopaedic, PLA Army General Hospital, Beijing 100700, China
| | - Yi-Yun Lin
- Department of Orthopaedic, PLA Army General Hospital, Beijing 100700, China
| | - Pei Du
- Department of Orthopaedic, PLA Army General Hospital, Beijing 100700, China
| | - Zhi-Cheng Zhang
- Department of Orthopaedic, PLA Army General Hospital, Beijing 100700, China
| | - Xiao-Na Wang
- Department of Orthopaedic, PLA Army General Hospital, Beijing 100700, China
| | - Fang Li
- Department of Orthopaedic, PLA Army General Hospital, Beijing 100700, China
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Kahveci K, Doger C, Ornek D, Gokcinar D, Aydemir S, Ozay R. Perioperative outcome and cost-effectiveness of spinal versus general anesthesia for lumbar spine surgery. Neurol Neurochir Pol 2014; 48:167-73. [PMID: 24981180 DOI: 10.1016/j.pjnns.2014.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 05/23/2014] [Accepted: 05/26/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIM General anesthesia (GA) is the most commonly used anesthetic technique for spinal surgery. This study aimed to compare spinal anesthesia (SA) and GA in patients undergoing spinal surgery, in terms of perioperative outcome and cost effectiveness. MATERIALS AND METHODS The study included 80 patients with ASA (American Society of Anesthesiologists) physical status I-II. The patients were randomized to receive SA (n = 40) or GA (n = 40). Heart rate (HR), mean arterial blood pressure (MABP), blood loss, duration of surgery, duration of anesthesia, surgeon satisfaction, and duration in the post-anesthesia care unit (PACU) were recorded. Postoperative analgesic requirement, nausea and vomiting (PONV), perioperative hemodynamic variables, and anesthetic costs were determined. RESULTS HR and MABP were significantly higher in the GA group than in the SA group at the end of surgery and at PACU admission. Duration of anesthesia, surgeon satisfaction, postoperative analgesic requirement, and anesthetic costs were significantly higher in the GA group. Mean blood loss was lower in the SA group than in the GA group, but the difference was not significant. Duration of surgery, duration in the PACU, perioperative hemodynamic variables, and complications were similar in both groups. CONCLUSIONS SA could be considered a reliable alternative to GA in patients undergoing lumber spine surgery, as it is clinically as effective as GA, but more cost effective.
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Affiliation(s)
- Kadriye Kahveci
- Department of Anesthesiology and Reanimation, Ulus State Hospital, Ankara, Turkey.
| | - Cihan Doger
- Department of Anesthesiology and Reanimation, Ankara Ataturk Training and Research Hospital, Ankara, Turkey.
| | - Dilsen Ornek
- Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey.
| | - Derya Gokcinar
- Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey.
| | - Semih Aydemir
- Department of Anesthesiology and Reanimation, Ataturk Pulmonology Training and Research Hospital, Ankara, Turkey.
| | - Rafet Ozay
- Department of Neurosurgery, Diskapi Training and Research Hospital, Ankara, Turkey.
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Şahin AS, Türker G, Bekar A, Bilgin H, Korfalı G. A comparison of spinal anesthesia characteristics following intrathecal bupivacaine or levobupivacaine in lumbar disc surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 23:695-700. [PMID: 24212478 DOI: 10.1007/s00586-013-3082-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 10/24/2013] [Accepted: 10/26/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE While bupivacaine is the most frequently used local anesthetic for spinal anesthesia, use of levobupivacaine in clinical practice has advanced recently. The aim of our study was to compare the clinical and anesthetic effects of isobaric bupivacaine and isobaric levobupivacaine when administered intrathecally in patients undergoing lumbar disc surgery. METHODS ASA I-III, 60 patients were enrolled in this study. Only patients with unilateral single-level (L4-5) lumbar disc hernia were selected and operated in each group and all were operated by the same surgeon. Patients were randomized into two groups, as group B (n = 30): 15 mg 0.5% isobaric bupivacaine, or group L (n = 30): 15 mg 0.5% isobaric levobupivacaine received intrathecally. The level of sensory block dermatome, degree of motor block, intraoperative sensory and motor block characteristics, and postoperative recovery times of spinal anesthesia were evaluated. The satisfaction scores of the surgeon and patients, intraoperative hemodynamic changes, intraoperative and postoperative complications were recorded. RESULTS The maximum level of sensory blockade was significantly higher in the levobupivacaine group (group L 7 ± 1.63, group B 8.6 ± 1.76 thoracic dermatome, p < 0.05). There was no significant difference in the onset time of sensory (group L 6 ± 3 min, group B 9 ± 4 min) and motor (in group L 7 ± 3 min, in group B 10 ± 4 min) blockade (p > 0.05). There was no significant difference between the groups regarding duration of operation (group L 49 ± 7.3 min, group B 52 ± 8.1, p > 0.05). Recovery times of sensory (175 ± 57 min) and motor (216 ± 59 min) blockade were significantly shorter in the levobupivacaine group (p < 0.05). Mobilization was also earlier in the levobupivacaine group (339 ± 90 min, p < 0.05). Patients' satisfaction and intraoperative, postoperative complications were similar between the two groups. CONCLUSIONS Our results showed that block recovery time was shorter in the levobupivacaine group, this may be a disadvantage for longer operative procedures. But with proper patient selection this can be eliminated. Recovery time was shorter in levobupivacaine group. Therefore, postoperative neurological examination can be done earlier. In addition, early mobilization can be an advantage for postoperative recovery.
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Affiliation(s)
- Ayça Sultan Şahin
- Department of Anesthesiology and Reanimation, Uludag University Faculty of Medicine, Bursa, Turkey,
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Park KB, Son B, Hwang DY, Jeon Y. Spinal anesthetic management for discectomy in a patient with amyotrophic lateral sclerosis -A case report-. Korean J Anesthesiol 2013; 63:547-9. [PMID: 23277817 PMCID: PMC3531535 DOI: 10.4097/kjae.2012.63.6.547] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 02/27/2012] [Accepted: 02/27/2012] [Indexed: 11/23/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS), also referred to as Lou Gehrig's disease, is a degenerative disorder of motor neuron system of the spinal cord and the cortical neuron. Patients with ALS present a unique challenge to the anesthesiologist. Respiratory muscle weakness, for instance, can result in trouble with proper breathing after general anesthesia. We report a case of spinal anesthesia for discectomy in a patient with ALS.
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Affiliation(s)
- Ki-Bum Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kyungpook National University, Daegu, Korea
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