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Boddeti U, Polavarapu H, Patel S, Choudhary A, Langbein J, Nusraty S, Vatsa S, Brahmbhatt P, Mitha R. Current Status of Awake Spine Surgery: A Bibliometric Analysis. World Neurosurg 2024:S1878-8750(24)00749-6. [PMID: 38719075 DOI: 10.1016/j.wneu.2024.04.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Spine surgery accounts for a large proportion of neurosurgical procedures, with approximately 313 million spine surgeries conducted annually worldwide. Considering delayed recovery and postoperative complications that are commonly reported, there has been a recent shift toward minimally invasive spine procedures conducted under local anesthesia. Despite proven success, there exists a limited body of literature on the use of awake surgery in spinal procedures. METHODS A bibliometric analysis was conducted to map the current landscape of work in this field. 190 articles were identified from the Web of Science (Clarivate, NY) database. A comprehensive bibliometric analysis was performed on a narrowed list of the most relevant articles using Bibliometrix, an R-based programming tool. RESULTS There has been a rise in academic papers published on the topic of awake spine surgery since 2016, with an increase in publication count by approximately 18% annually and each article cited approximately ten times on average to date. The year 2022 saw an uptick in publications, with 9 throughout the entire year. The most impactful article, with a total of 95 citations, was published by Sairyo et al.1 Thematic analysis revealed that the terms "lumbar spine" and "stenosis" are well-developed topics in the literature, whereas the topics of "complications," "fusion," and "cost-analysis" are less well-developed topics. CONCLUSIONS This study provides a comprehensive overview of the most-cited articles in the field of awake spine surgery. Specifically, it identifies areas that are well represented in the literature and those which are underrepresented and should be areas of continued future research.
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Affiliation(s)
- Ujwal Boddeti
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Hanish Polavarapu
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shrey Patel
- Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Aditi Choudhary
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jenna Langbein
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sabrina Nusraty
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sonika Vatsa
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Priya Brahmbhatt
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Rida Mitha
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Karimi H, Patel J, Olmos M, Kanter M, Hernandez NS, Silver RE, Liu P, Riesenburger RI, Kryzanski J. Spinal Anesthesia Reduces Perioperative Polypharmacy and Opioid Burden in Patients Over 65 Who Undergo Transforaminal Lumbar Interbody Fusion. World Neurosurg 2024; 185:e758-e766. [PMID: 38432509 DOI: 10.1016/j.wneu.2024.02.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Polypharmacy and opioid administration are thought to increase the risk of postoperative cognitive dysfunction and delirium in elderly patients. Spinal anesthesia (SA) holds potential to reduce perioperative polypharmacy in spine surgery. As more geriatric patients undergo spine surgery, understanding how SA can reduce polypharmacy and opioid administration is warranted. We aim to compare the perioperative polypharmacy and dose of administered opioids in patients ≥65 years who undergo transforaminal lumbar interbody fusion (TLIF) under SA versus general anesthesia (GA). METHODS A retrospective analysis of 200 patients receiving a single-surgeon TLIF procedure at a single academic center (2014-2021) was performed. Patients underwent the procedure with SA (n = 120) or GA (n = 80). Demographic, procedural, and medication data were extracted from the medical record. Opioid consumption was quantified as morphine milligram equivalents (MME). Statistical analyses included χ2 or Student's t-test. RESULTS Patients receiving SA were administered 7.45 medications on average versus 12.7 for GA patients (P < 0.001). Average perioperative opioid consumption was 5.17 MME and 20.2 MME in SA and GA patients, respectively (P < 0.001). The number of patients receiving antiemetics and opioids remained comparable postoperatively, with a mean of 32.2 MME in the GA group versus 27.5 MME in the SA group (P = 0.14). Antiemetics were administered less often as a prophylactic in the SA group (32%) versus 86% in the GA group (P < 0.001). CONCLUSIONS SA reduces perioperative polypharmacy in patients ≥65 years undergoing TLIF procedures. Further research is necessary to determine if this reduction correlates to a decrease the incidence of postoperative cognitive dysfunction and delirium.
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Affiliation(s)
- Helen Karimi
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA.
| | - Jainith Patel
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nicholas S Hernandez
- Department of Neurosurgery, University of California San Diego, La Jolla, California, USA
| | - Rachel E Silver
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA; Energy Metabolism Research Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts, USA
| | - Penny Liu
- Department of Anesthesiology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
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Drossopoulos PN, Sharma A, Ononogbu-Uche FC, Tabarestani TQ, Bartlett AM, Wang TY, Huie D, Gottfried O, Blitz J, Erickson M, Lad SP, Bullock WM, Shaffrey CI, Abd-El-Barr MM. Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management. J Clin Med 2024; 13:2410. [PMID: 38673683 PMCID: PMC11051300 DOI: 10.3390/jcm13082410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/05/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
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.
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Affiliation(s)
- Peter N. Drossopoulos
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - Arnav Sharma
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - Favour C. Ononogbu-Uche
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - Troy Q. Tabarestani
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - Alyssa M. Bartlett
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - Timothy Y. Wang
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - David Huie
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - Oren Gottfried
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - Jeanna Blitz
- Department of Anesthesiology, Duke University, Durham, NC 27710, USA (W.M.B.)
| | - Melissa Erickson
- Division of Spine, Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Shivanand P. Lad
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - W. Michael Bullock
- Department of Anesthesiology, Duke University, Durham, NC 27710, USA (W.M.B.)
| | - Christopher I. Shaffrey
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
| | - Muhammad M. Abd-El-Barr
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.S.); (T.Q.T.); (C.I.S.)
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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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Patel J, Karimi H, Olmos M, Wiepert L, Kanter M, Hernandez NS, Frerich JM, Riesenburger RI, Kryzanski J. The Relationship of Spinal Anesthesia Dosing Based on Thecal Sac Area to Anesthetic Failure in Lumbar Surgery. Neurosurgery 2024:00006123-990000000-01036. [PMID: 38299846 DOI: 10.1227/neu.0000000000002847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/12/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Greater thecal sac volumes are associated with an increased risk of spinal anesthesia (SA) failure. The thecal sac cross-sectional area accurately predicts thecal sac volume. The thecal sac area may be used to adjust the dose and prevent anesthetic failure. We aim to assess the rate of SA failure in a prospective cohort of lumbar surgery patients who receive an individualized dose of bupivacaine based on preoperative measurement of their thecal sac area. METHODS A total of 80 patients prospectively received lumbar spine surgery under SA at a single academic center (2022-2023). Before surgery, the cross-sectional area of the thecal sac was measured at the planned level of SA injection using T2-weighted MRI. Patients with an area <175 mm2, equal to or between 175 and 225 mm2, and >225 mm2 received an SA injection of 15, 20, or 25 mg of 0.5% isobaric bupivacaine, respectively. Instances of anesthetic failure and adverse outcomes were noted. Incidence of SA failure was compared with a retrospectively obtained control cohort of 250 patients (2019-2022) who received the standard 15 mg of bupivacaine. RESULTS No patients in the individualized dose cohort experienced failure of SA compared with 14 patients (5.6%) who experienced failure in the control cohort (P = .0259). The average thecal sac area was 187.49 mm2, and a total 28 patients received 15 mg of bupivacaine, 42 patients received 20 mg of bupivacaine, and 10 patients received 25 mg of bupivacaine. None of the patients experienced any adverse outcomes associated with SA. Patients in the individualized dose cohort and control cohort were comparable and had a similar distribution of lumbar procedures and comorbidities. CONCLUSION Adjusting the dose of SA according to thecal sac area significantly reduces the rate of SA failure in patients undergoing lumbar spine surgery.
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Affiliation(s)
- Jainith Patel
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Helen Karimi
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Liana Wiepert
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nicholas S Hernandez
- Department of Neurosurgery, University of California San Diego, La Jolla, California, USA
| | - Jason M Frerich
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
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6
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Olmos M, Kanter M, Karimi H, Patel J, Riesenburger R, Kryzanski J. Correlation of thecal sac cross sectional area to total volume. J Clin Neurosci 2024; 119:157-163. [PMID: 38086293 DOI: 10.1016/j.jocn.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Spinal anesthesia (SA) has been increasingly utilized in lumbar surgery due to its various advantages over general anesthesia (GA), however failure of the first dose requiring intraoperative conversion to GA occurs in as many as 3.6% of SA patients. Some studies have reported that a larger thecal sac volume may dilute the anesthetic and play a role in first dose failure. Unfortunately, easy determination of thecal sac volume has not been reported in the literature. Thus, we sought to determine whether cross-sectional area obtained from MRI accurately predicts the volume of the thecal sac. METHODS We conducted a retrospective review of 80 patients who underwent lumbar surgery with spinal anesthesia. T1 and T2-weighted MRI sequences were used to measure thecal sac area at each level between L1-S1. The volume of the thecal sac was calculated using HorosTM. A statistical model was derived relating the area at each level to the thecal sac volume. Of the 80 patients, 20% were reserved and utilized to test the accuracy of the statistical model. RESULTS The area of the thecal sac positively correlated with volume at each lumbar level. The area of the thecal sac at the L4-L5 level most accurately represented total thecal sac volume (R2 = 0.588, RMSE = 2.76). CONCLUSION Cross-sectional area of the L4-L5 spinal level obtained from MRI sequences may be utilized as a proxy for thecal sac volume.
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Affiliation(s)
- Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Helen Karimi
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Jainith Patel
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Ron Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA.
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Hernandez NS, Begashaw B, Riesenburger RI, Kryzanski JT, Liu P. Spinal anesthesia in elective lumbar spinal surgery. Anesth Pain Med (Seoul) 2023; 18:349-356. [PMID: 37919919 PMCID: PMC10635856 DOI: 10.17085/apm.23031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 11/04/2023] Open
Abstract
Spinal anesthesia (SA) is gaining recognition as a safe and efficacious regional alternative to general anesthesia for elective lumbar surgery. However, unfamiliarity with management issues related to its use has limited the adoption of awake spine surgery, despite its benefits. Few centers in the United States routinely offer SA for elective lumbar surgery, and a comprehensive workflow to standardize SA for lumbar surgery is lacking. In this article, we examine recent literature on the use of SA in lumbar surgery, review the experience of our institution with SA in lumbar surgery, and provide a cohesive outline to streamline the implementation of SA from the perspective of the anesthesiologist. We review the critical features of SA in contemporary lumbar surgery, including selection of patients, methods of SA, intraoperative sedation, and management of several important technical considerations. We aimed to flatten the learning curve to improve the availability and accessibility of the technique for eligible patients.
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Affiliation(s)
| | - Benayas Begashaw
- Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
| | | | | | - Penny Liu
- Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
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Salven D, Sykes D, Erickson M, Than K, Grossi P, Crutcher C, Berger M, Bullock WM, Gadsden J, Abd-El-Barr M. Regional anesthesia in spine surgery: A narrative review. JOURNAL OF SPINE PRACTICE (JSP) 2023:40-50. [DOI: 10.18502/jsp.v2i2.13223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Background: Regional anesthesia, which refers to the use of anesthetics to provide analgesia to a specific body part or nervous innervation territory, has become increasingly popular in the field of spine surgery. With the application of these techniques, it has been postulated that patients will require less systemic analgesia, intraoperatively and postoperatively. The authors of this narrative review discuss the common regional anesthetic modalities applied to spine surgery, in addition to patient selection criteria, success in patients with multiple comorbid illnesses, and its adoption by surgeons.
Materials and Methods: An advanced search was performed in the PubMed database to obtain Englishlanguage articles discussing regional anesthesia, awake spine surgery, and postoperative complications. Articles were screened for relevance, and 47 articles were incorporated into this narrative review.
Results: Classic neuraxial and paraspinal techniques have allowed surgeons to perform posterior decompression, fusion, and revision procedures. Transversus abdominus plane and quadratus lumborum blocks have enabled better pain control in patients undergoing surgeries requiring anterior or lateral approaches. Documented benefits of regional anesthesia include shorter operative time, improved pain control and hemodynamic stability, as well as decreased cost and length of stay. Several case series have demonstrated the success of these techniques in highly comorbid patients.
Conclusion: Regional anesthesia provides an exciting opportunity to make surgical treatment possible for spine patients with significant comorbidities. Although additional randomized controlled trials are necessary to further refine patient selection criteria, current data demonstrates its safety and efficacy in the operating room.
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Kanter M, Hernandez NS, Olmos M, Karimi H, Riesenburger RI, Kryzanski JT. Intraoperative Triggered Electromyography for Pedicle Screw Placement Under Spinal Anesthesia: A Preliminary Report. Oper Neurosurg (Hagerstown) 2023; 24:651-655. [PMID: 36745975 DOI: 10.1227/ons.0000000000000640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 12/01/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Triggered electromyography (tEMG) is an intraoperative neuromonitoring technique used to assess pedicle screw placement during instrumented fusion procedures. Although spinal anesthesia is a safe alternative to general anesthesia in patients undergoing lumbar fusion, its use may potentially block conduction of triggered action potentials or may require higher threshold currents to elicit myotomal responses when using tEMG. Given the broad utilization of tEMG for confirmation of pedicle screw placement, adoption of spinal anesthesia may be hindered by limited studies of its use alongside tEMG. OBJECTIVE To investigate whether spinal anesthesia affects the efficacy of tEMG, we compare the baseline spinal nerve thresholds during lumbar fusion procedures under general vs spinal anesthesia. METHODS Twenty-three consecutive patients (12 general and 11 spinal) undergoing single-level transforaminal lumbar interbody fusion were included in the study. Baseline nerve threshold was determined through direct stimulation of the spinal nerve using tEMG. RESULTS Baseline spinal nerve threshold did not differ between the general and spinal anesthesia cohorts (3.25 ± 1.14 vs 3.64 ± 2.16 mA, respectively; P = .949). General and spinal anesthesia cohorts did not differ by age, body mass index, American Society of Anesthesiologists score status, or surgical indication. CONCLUSION We report that tEMG for pedicle screw placement can be safely and effectively used in procedures under spinal anesthesia. The baseline nerve threshold required to illicit a myotomal response did not differ between patients under general or spinal anesthesia. This preliminary finding suggests that spinal anesthetic blockade does not contraindicate the use of tEMG for neuromonitoring during pedicle screw placement.
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Affiliation(s)
- Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nicholas S Hernandez
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Helen Karimi
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - James T Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
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10
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Wang AY, Olmos M, Ahsan T, Kanter M, Liu P, Balonov K, Riesenburger RI, Kryzanski J. A Second Prone Dose Algorithm for Patients Undergoing Spinal Anesthesia During Thoracolumbar Surgeries. Oper Neurosurg (Hagerstown) 2023; 24:283-290. [PMID: 36701492 PMCID: PMC10158911 DOI: 10.1227/ons.0000000000000497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/06/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Spinal anesthesia is safe and effective in lumbar surgeries, with numerous advantages over general anesthesia (GA). Nevertheless, 1 major concern preventing the widespread adoption of this anesthetic modality in spine surgeries is the potential for intraprocedural anesthetic failure, resulting in the need to convert to GA intraoperatively. OBJECTIVE To present a novel additional prone dose algorithm for when a first spinal dose fails to achieve the necessary effect. METHODS A total of 422 consecutive patients undergoing simple and complex thoracolumbar surgeries under spinal anesthesia were prospectively enrolled into our database. Data were retrospectively collected through extraction of electronic health records. RESULTS Sixteen of 422 required a second prone dose, of whom 1 refused and was converted to GA preoperatively. After 15 were given a prone dose, only 2 required preoperative conversion to GA. There were no instances of intraoperative conversion to GA. The success rate for spinal anesthesia without the need for conversion rose from 96.4% to 99.5%. In patients who required a second prone dose, there were no instances of spinal headache, deep vein thrombosis, pneumonia, urinary tract infection, urinary retention, readmission within 30 days, acute pain service consult, return to operating room, durotomy, or cerebrospinal fluid on puncture. CONCLUSION Use of an additional prone dose algorithm was able to achieve a 99.5% success rate, and those who received this second dose did not experience any complications or negative operative disadvantages. Further research is needed to investigate which patients are at increased risk of inadequate analgesia with spinal anesthesia.
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Affiliation(s)
- Andy Y. Wang
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Tameem Ahsan
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Penny Liu
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Konstantin Balonov
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ron I. Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
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Muacevic A, Adler JR, Akhtar Khan S, Hussain M, Ahmed U. Degenerative Lumbar Spine Surgeries Under Regional Anesthesia in a Developing Country: An Initial Case Series. Cureus 2023; 15:e34065. [PMID: 36843830 PMCID: PMC9943688 DOI: 10.7759/cureus.34065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction Current evidence from developed countries on lumbar spine surgeries under regional anesthesia reports it to be superior to general anesthesia (GA) in terms of decreased anesthesia time, operative time, intraoperative complications such as bleeding, postoperative complications, length of hospital stay, and overall cost. We report the first case series from Pakistan on lumbar spine surgeries under regional anesthesia. Methods We utilized spinal anesthesia (SA) for lumbar spine surgeries of 45 patients in a tertiary-care hospital in Karachi, Pakistan. The surgeries were performed as day-care procedures. The preoperative assessments included MRI findings, visual analogue scale (VAS), pre-operative limb powers, and straight leg raise (SLR). Other assessments included total SA time, total surgical time, time of stay in the post-anesthesia care unit (PACU), complications, and total hospital cost. SPSS v26 was used to calculate means and standard deviations. Results We found the total SA time to be about 45 to 60 minutes in most patients (95.6%). The total surgical time was 30 to 45 minutes for most patients. The average time of stay in the PACU was three to four hours. The VAS scores were significantly improved postoperatively with 46.7% (n=21) of patients with a score of 3, 46.7% (n=21) with a score of 2, and 6.7% (n=3) with a score of 1. 71.1% (n=32) patients had day-care surgery, 22.2% (n=10) stayed in the hospital for one day, and 6.7% (n=3) patients stayed for more than one day. Most patients (88.9%, n=40) had no complications, whereas only 11.1% (n=5) complained of PDPH. The total hospital cost was also lesser than procedures under GA. Conclusion We conclude that SA is well tolerated and has favorable outcomes in terms of cost-effectiveness, anesthesia time, surgical time, and hospital stay; therefore, SA should be considered for a greater number of lumbar spine surgeries, especially in low-middle income countries.
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Hernandez NS, Wang AY, Kanter M, Olmos M, Ahsan T, Liu P, Balonov K, Riesenburger RI, Kryzanski J. Assessing the impact of spinal versus general anesthesia on postoperative urinary retention in elective spinal surgery patients. Clin Neurol Neurosurg 2022; 222:107454. [PMID: 36201900 DOI: 10.1016/j.clineuro.2022.107454] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Postoperative urinary retention (POUR) is a common and vexing complication in elective spine surgery. Efficacious prevention strategies are still lacking, and existing studies focus primarily on identifying risk factors. Spinal anesthesia has become an attractive alternative to general anesthesia in elective lumbar surgery, with the potential of having a differential impact on POUR. METHODS 422 spinal anesthesia procedures were prospectively collected between 2017 and 2021 and compared to 416 general anesthesia procedures retrospectively collected between 2014 and 2017, at a single academic center by the same senior neurosurgeon. The main outcome was POUR, defined as the need for straight bladder catheterization or indwelling bladder catheter placement after surgery due to failure to void. A power calculation was performed prior to data collection. RESULTS The general anesthesia group had a higher rate of POUR (9.1 %) compared with the spinal anesthesia group (4.3 %), p = 0.005. At baseline, the spinal anesthesia cohort had an older average age and fewer patients with a history of previous spine surgery. Other comorbid conditions were comparable between the groups. For perioperative characteristics, spinal anesthesia patients had higher ASA scores, shorter operative times, shorter lengths of hospital stay, less operative levels, and zero use of intraoperative bladder catheterization. Acute pain service consult was similar between the groups. A multivariable logistic regression revealed that spinal anesthesia was associated with a significantly lower rate of urinary retention in the spinal anesthesia group (p = 0.0130), after adjusting for potentially confounding factors. Other statistically significant risk factors for POUR included diabetes, (p = 0.003), BPH (p = 0.014), operative time (p = 4.94e-06), and ASA score (p = 0.005). CONCLUSIONS We collect and analyze one of the largest available cohorts of patients undergoing simple and complex surgeries under spinal and general anesthesia, finding that spinal anesthesia is independently associated with a lower incidence of POUR compared to general anesthesia, even when adjusted for potentially confounding risk factors. Further prospective trials are needed to explore this finding.
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Affiliation(s)
| | - Andy Y Wang
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Tameem Ahsan
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Penny Liu
- Department of Anesthesia, Tufts Medical Center, Boston, MA, USA
| | | | | | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA.
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Wang AY, Liu P, Balonov K, Riesenburger R, Kryzanski J. Use of Spinal Anesthesia in Lower Thoracic Spine Surgery: A Case Series. Oper Neurosurg (Hagerstown) 2022; 23:298-303. [PMID: 36106935 PMCID: PMC10586860 DOI: 10.1227/ons.0000000000000325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Spinal anesthesia is a safe and effective alternative to general anesthesia for patients undergoing lumbar spine surgery, and numerous reports have demonstrated its advantages. To the best of our knowledge, no group has specifically reported on the use of spinal anesthesia in thoracic-level spine surgeries because there is a hypothetical risk of injuring the conus medullaris at these levels. With the advantages of spinal anesthesia and the desire for many elderly patients to avoid general anesthesia, our group has uniquely explored the use of this modality on select patients with thoracic pathology requiring surgical intervention. OBJECTIVE To investigate the feasibility of performing thoracic-level spinal surgeries under spinal anesthesia and report our experience with 3 patients. METHODS A retrospective chart review of medical records was undertaken, involving clinical notes, operative notes, and anesthesia records. RESULTS Three spinal stenosis patients underwent thoracic laminectomy under spinal anesthesia. Two surgeries were performed at the T11-T12 level and 1 at the T12-L1 level. The average age was 82 years, average American Society of Anesthesiologists score was 3.3, and 1 identified as female. Two cases used hyperbaric 0.75% bupivacaine dissolved in dextrose, and 1 used isobaric 0.5% bupivacaine dissolved in water. CONCLUSION Spinal anesthesia is feasible for thoracic-level spine procedures, even in elderly patients with comorbidities. We describe our cases and technique for safely achieving a thoracic level of analgesia, as well as discuss recommendations, adverse events, and considerations for the use of spinal anesthesia during lower thoracic-level spine operations.
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Affiliation(s)
- Andy Y. Wang
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
| | - Penny Liu
- Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Konstantin Balonov
- Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ron Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
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Wang AY, Ahsan T, Kosarchuk JJ, Liu P, Riesenburger RI, Kryzanski J. Assessing the Environmental Carbon Footprint of Spinal versus General Anesthesia in Single-Level Transforaminal Lumbar Interbody Fusions. World Neurosurg 2022; 163:e199-e206. [PMID: 35342029 DOI: 10.1016/j.wneu.2022.03.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/21/2022] [Accepted: 03/21/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The U.S. health care sector produces approximately 10% of national greenhouse gas emissions, paradoxically harming human health. Neurosurgery is a resource-intensive specialty that likely contributes significantly, yet literature assessing this impact is absent. We investigate the difference in carbon emissions between spinal versus general anesthesia in lumbar spine surgery. METHODS A total of 100 patients underwent a single-level transforaminal lumbar interbody fusion (TLIF) from a single surgeon; 50 received spinal anesthesia and 50 received general anesthesia. Data were extracted from patient records. Amounts of anesthetics were calculated from intraoperative records and converted to carbon dioxide equivalents (CO2e). RESULTS The median CO2e for general anesthesia was 4725 g versus 70 g for spinal anesthesia (P = 7.07e-18). The mean CO2e for general anesthesia was 22,707 g versus 63 g for spinal anesthesia. Desflurane use led to outsized carbon emissions. Carbon footprint comparisons are made with familiar units such as miles driven by a car, and are provided for a single TLIF, 50 TLIFs (single surgeon's cases in a year), and 488,000 TLIFs (annual spinal fusions in the United States). CONCLUSION This is one of the first known comparative carbon footprint studies performed in neurosurgical literature. We highlight the dramatic carbon footprint reduction associated with using spinal anesthesia and reflect a single neurosurgeon's change in practice from using only general anesthesia to incorporating the use of spinal anesthesia. Within general anesthesia patients, desflurane use was particularly harmful to the environment. We hope that our study will pave the way toward future research aimed at uncovering and reducing neurosurgery's environmental impact.
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Affiliation(s)
- Andy Y Wang
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Tameem Ahsan
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jacob J Kosarchuk
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Penny Liu
- Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA.
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Yang MJ, Riesenburger RI, Kryzanski JT. The use of intra-operative navigation during complex lumbar spine surgery under spinal anesthesia. Clin Neurol Neurosurg 2022; 215:107186. [DOI: 10.1016/j.clineuro.2022.107186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 11/03/2022]
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Keenan C, Wang AY, Balonov K, Kryzanski J. Postoperative vasovagal cardiac arrest after spinal anesthesia for lumbar spine surgery. Surg Neurol Int 2022; 13:42. [PMID: 35242408 PMCID: PMC8888311 DOI: 10.25259/sni_25_2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/13/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Spinal anesthesia is being increasingly recognized as a favorable alternative to general anesthesia. However, there are still several considerations for its safe and effective use.
Case Description:
A 62-year-old male received spinal anesthesia during an uneventful L3-L5 decompressive laminectomy. However, he subsequently experienced a brief episode of pulseless electrical activity in the post-anesthesia care unit, and was successfully resuscitated without further sequelae. This was attributed to a vasovagal episode, with his notable prior history of experiencing vasovagal syncope with lightheadedness and fainting at the sight of blood.
Conclusion:
Patients with a history of vasovagal syncope may be predisposed to experiencing brief potentiated episodes of severe bradycardia and even cardiac arrest following spinal anesthesia.
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Affiliation(s)
- Caitlin Keenan
- Department of Neurosurgery, Tufts Medical Center, Washington, Boston, United States
| | - Andy Y. Wang
- Department of Neurosurgery, Tufts Medical Center, Washington, Boston, United States
| | - Konstantin Balonov
- Department of Anesthesiology, Tufts Medical Center, Washington, Boston, United States
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Washington, Boston, United States
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