Perioperative management in complex spine surgery: a narrative review

Posterior Corrective Surgery for Type II Congenital Kyphosis: SRS-Schwab Grade 4 Osteotomy or Vertebral Column Resection?

OBJECTIVE

Surgical decision-making for congenital kyphosis (CK) with failure of anterior segmentation (type II) has been contradictory regarding the trade-off between the pursuit of correction rate and the inherent risk of the osteotomy procedure. This study was designed to compare the clinical and radiographic measurement in type II CK underwent SRS-Schwab Grade 4 osteotomy and vertebral column resection (VCR), the most-adapted osteotomy techniques for CK, and to propose the strategy to select between the two procedures.

METHODS

This retrospective observational comparative study evaluated surgical outcomes in type II CK patients underwent VCR or SRS-Schwab Grade 4 osteotomy at our institution between January 2015 and January 2020. Patients operated with VCR and SRS-Schwab Grade 4 osteotomy were allocated to Group 1 and Group 2 respectively. Radiographic parameters and SRS-22 quality of life metrics were assessed at pre-operation, post-operation, and during follow-up visits for both groups, allowing for a comprehensive comparison of surgical outcomes.

RESULTS

Thirty-one patients (19 patients in Group 1 and 12 patients in Group 2) aged 16.3 ± 10.4 years were recruited. Correction of segmental kyphosis was similar between groups (51.1 ± 17.6° in Group 1 and 48.4 ± 19.8° in Group 2, p = 0.694). Group 1 had significantly longer operation time (365.9 ± 81.2 vs 221.4 ± 78.9, p < 0.001) and more estimated blood loss (975.2 ± 275.8 ml vs 725.9 ± 204.3 mL, p = 0.011). Alert event of intraoperative sensory and motor evoked potential (SEP and MEP) monitoring was observed in 1 patient of Group 2. Both groups had 1 transient post operative neurological deficit respectively.

CONCLUSION

SRS-Schwab Grade 4 osteotomy was suitable for kyphotic mass when its apex is the upper unsegmented vertebrae or the neighboring disc, or when the apical vertebrae with an anterior/posterior (A/P) height ratio of vertebral body higher than 1/3. VCR is suitable when the apex is located within the unsegmented mass with its A/P height ratio lower than 1/3. Proper selection of VCR and SRS-Schwab Grade 4 osteotomy according to our strategy, could provide satisfying radiographic and clinical outcomes in type II CK patients during a minimum of 2 years follow-up. Patients undergoing VCR procedure might have longer operation time, more blood loss and higher incidence of peri- and post-operative complications.

Perioperative Management for Complex Spine Fusion Surgery

Complex spine surgeries performed worldwide continue to increase in number, as do the age and comorbidity of patients undergoing these operations. Perioperative care protocols related to blood management, postoperative pain control, and intraoperative measures to mitigate morbidity may improve clinical workflows and patient outcomes.

Pain management with epidural catheter and epidural analgesia after spinal dorsal instrumentation of lumbar spine

Spinal dorsal instrumentation (SDI) is an established treatment for degenerative spinal diseases. Adequate and immediate postoperative pain control is important for patient recovery and may be compromised by uncertainty about its efficacy and concern about early postoperative surgical complications or adverse events. The aim of the current study was to compare the use of epidural analgesia (EA) with systemic analgesia (SA) as regards pain reduction and early postoperative complications after SDI. Pain management with epidural or systemic analgesia in patients undergoing SDI by posterior approach between January 2019 and July 2020 was evaluated by clinical functional testing, measuring total opioid amounts used, and evaluating numerical rating scale values 24 and 96 hours postoperatively. The following were also monitored: demographic data, number of affected segments, length of hospital stay, inflammatory markers (leukocytes and serum C-reactive protein), early postoperative surgical complication rates, and adverse events. In total 79 patients were included (33 in the EA and 46 in the SA group). The SA group had significantly lower numerical rating scale values at days 1 to 4 after surgery (P ≤ .001) and lower cumulative opioid use than the EA group (P < .001). We found no difference in infection parameters, length of hospital stay or surgery-related complication rates. Our data demonstrate that epidural anesthesia was inferior to an opioid-based SA regime in reducing postoperative pain in patients undergoing spinal surgery. There is no benefit to the use of epidural catheters.

[Anesthesia in spinal surgery]

Over the past 20 years improvements in surgical techniques and perioperative patient care have led to a considerable increase in surgical procedures of the spine worldwide. Therefore, the spectrum was extended from minimally invasive procedures up to complex operations over several segments of the spinal column with high loss of blood and complex perioperative management. This article presents the principal pillars of preoperative, intraoperative and postoperative management relating to spinal surgery. Furthermore, procedure-specific features, such as airway management in cervical spine instability or implementation of intraoperative neuromonitoring are dealt with in detail.