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Anesthesia for Spine Surgery Irene P. Osborn, M.D. Mount Sinai Medical Center New York, NY Lecture Goals Overview of modern concepts in understanding of the spinal cord disease Review controversies in anesthesia for spine surgery Provide strategies for improving patient care Why spine?

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Anesthesia for Spine Surgery

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Anesthesia for spine surgery l.jpg

Anesthesia for Spine Surgery

Irene P. Osborn, M.D.

Mount Sinai Medical Center

New York, NY


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Lecture Goals

  • Overview of modern concepts in understanding of the spinal cord disease

  • Review controversies in anesthesia for spine surgery

  • Provide strategies for improving patient care


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Why spine?

  • 29.9 million people reported musculoskeletal impairments. Back/spine was most frequent, representing 51.7%. Impairment is most prevalent in 45-64 year old group.

AAOS, Musculoskeletal Conditions in the U.S., Feb 1992


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Changing times


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General Indications for Spine Surgery

  • Neurologic dysfunction (compression)

  • Structural instability

  • Pathologic lesions

  • Deformity

  • Pain


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Spinal Cord Anatomy

  • Structure

  • Blood supply

  • Autoregulation?


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Normal C-Spine Films

Lateral view


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Typical Pathologies

  • Disc lesions

  • Spinal canal stenosis

  • Tumors

  • Trauma


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Spinal Cord Injury: Incidence/ Etiology

  • 10, 000 new cases/year in US

  • Males> females

  • Causes:

    MVA- 40-50%

    Falls- 20%

    Recreational activities- 7-15%

    violence


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Cervical Spine Injury

  • Occurs in 10% of head-injured patients

  • Suspect when patient is flaccid, has diaphragmatic breathing, hypotension, bradycardia

  • Minimize head movement during airway management

  • In-line stabilization, rather than in-line traction, during laryngoscopy

Criswell JC, et al: Anaesthesia 1994; 49:900-903


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Suspected Cervical Spine Injury

  • Neck pain

  • Neurologic symptoms, signs

  • Unconscious

  • Mechanism of injury

  • Intoxication

  • Spondylosis, rhumatoid arthritis

  • Significant head injury, facial fractures


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Secondary Injury

  • Activation of biochemical, enzymatic and microvascular

  • Hemorrhagic necrosis, edema, inflammation

  • Vascular stasis, decreased spinal cord blood flow, ischemic cell death


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Anesthetic management – acute SCI

  • Airway evaluation

  • Neurologic evaluation

  • Pulmonary evaluation

  • Cardiac evaluation and resuscitation


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Neurologic DeteriorationAssociated with Airway Management in a Cervical Spine-Injured Patient

Hastings RH, Kelly SD

Anesthesiology vol 78:580, 1993


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Unrecognized C-spine injury

Pt became quadriplegic after mask ventilation, repeated laryngoscopy and eventually cricothyroidotmy

Details

Hastings, Anesthesiology 1993


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Use of the Intubating LMA-Fastrach™ in 254 Patients with Difficult to Manage Airways

Ferson DZ, Rosenblatt WH, Osborn I, Ovassapian A.

Anesthesiology 2001 vol 95:1175


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70 cases

67 under general anesthesia

2 awake/topicalized

1 unconscious

No new neurologic deficits

Patients with Immobilized Cervical Spines

Ferson et al, Anesthesiology 2001


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Cervical spine motion: a fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope.

Turkstra et al.

Anesth Analg 2005; 101: 910–5


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Tracheal intubation in patients with cervical spine immobilization:a comparison of the Airwayscope, LMA CTrach, and theMacintosh laryngoscopes

M. A. Malik, R. Subramaniam, S. Churasia1, C. H. Maharaj, B. H. Harteland J. G. Laffey

BJA 2009


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Cervical Disc: Airway Strategies

  • Talk to patient

  • H/O extremity weakness/tingling

  • Elicited symptoms with movement

  • Neutral position is best


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Conditions associated with risk of cervical spine pathology

  • Down’s syndrome

  • Rheumatoid arthritis

  • Ankylosing spondylitis

  • Psoriatic arthritis

  • Trauma


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On the Incidence, Cause, and Prevention of Recurrent Laryngeal Nerve Palsies During Anterior Cervical Spine Surgery

Apfelbaum RI, et al: Spine Volume 25(22), 15 November 2000, pp 2906-2912


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Factor Leading To Possible Higher Incidence of RLN Injury


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Risk Factors for Postoperative Airway Compromise

  • Duration of surgery

  • Amount of blood transfusion

  • Obesity, airway pressure

  • Operations of greater than 4 cervical levels or involving C2

Epstein NE. J Neurosurg 94:185 2001


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Anesthetic Technique

  • Supine induction

  • Maintenance with any combination of opioids, muscle relaxants, volatile agents

  • Careful prone positioning


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Thorocolumbar Spine Disease

  • Anterior or lateral pathology

  • Multiple spine segments

  • Scoliosis, tumors, traumatic fractures

  • Potential large intraoperative blood loss


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Methods of Reducing Blood Loss and Limiting Homologous Transfusions

  • Proper positioning to reduce intraabdominal pressure

  • Surgical hemostasis

  • Deliberate hemodilution (?)

  • Preoperative donation of autologous blood


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Restriction of diaphragm

by abdominal contents

and weight of pt against thorax

Create restrictive defect

Increased peak inspiratory pressure (barotrauma)

Obstruction of Inf Vena Cava

Decreases preload

Increases perivertebral venous pressure

(prone may improve oxygenation when abdomen hangs free- chest roll or frame)

Prone Position


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Prone Position Surgery

  • Despite induced hypotension, some patients continue to bleed

  • Pressure on the abdominal contents may be transmitted to the inferior vena cava and to the epidural venous system, causing increased bleeding


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Flexed Prone Position

  • Brachial plexus may be stretched

  • Ulnar nerve not properly padded

  • Eye damage from pressure

  • Nose pressure

  • Excessive compression to inferior vena cava (minimized by padding under inf iliac spine and chest rolls)


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“The Effect of Patient Positioning on Intraabdominal Pressure and Blood Loss in Spinal Surgery”

CK Park

Anesth Analg 2000;91:552


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Wilson Frame

  • Maintains flexed position for spinal surgery

  • Intrabdominal pressure may be increased if supporting pads are not properly placed


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Group 1

Blood loss (ml) 878

# of patients transfused = 5

Fluid replacement 2175 ml

Operating time (min) 136

Group 2

Blood loss (ml) 436

# of patients transfused = 1

Fluid replacement 1865 ml

Operating time (min) 134

Blood loss during spinal surgery

Park Anesth Analg 2000;91


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Conclusions

  • IAP and intraoperative blood loss were less in the wide vs. narrow width of the Wilson frame

  • Blood loss per vertebra tended to increase with an increase in IAP in the narrow pad support

Park Anesth Analg 2000;91


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Jackson Table

  • Frame based table

  • Allows abdomen and chest to hang freely

  • May allow 180 degree rotation


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Lumbar spine surgery

  • Preoperative pain/disability

  • Intraoperative positioning

  • Anesthetic technique

  • Blood loss

  • Postoperative pain management


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Support Devices – Head & Neck

  • Surgical pillow/ foam donut, C-shaped face piece, horseshoe head rest, Prone Positioner, Prone View Helmet.

  • Prone Positioner

  • C-Shaped Face Piece

  • Mayfield tongs: most stable; recommended in cervical disc disease

  • Horseshoe Head Rest

  • Mayfield Tongs


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Ischemic Optic Neuropathy

  • Rare but increasing

  • Decreased perfusion

  • Increased venous pressure

  • Increased external pressure

  • Decreased oxygen carrying capacity

Williams, et al. Anesth Analg 1995 80:1018


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Injuries: Eye

  • Corneal abrasions

  • Orbital edema

  • Postoperative visual loss ( POVL)

    • Rare; unclear etiology

    • ASA Closed Claims Project12 : management of anesthesiologists frequently implicated

    • ASA Professional Liability Committee created the POVL Registry 13 in 1999

12 ASA Closed Claims Project http://www.asaclosedclaims.org/

13 American Society of Anesthesiologists Task Force on Perioperative Blindness: Practice advisory for perioperative visual loss associated with spine surgery: a report by the American Society


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POVL Registry

  • Goal: Identify risk factors associated with POVL

  • Retrospective analysis of patients who reported visual loss < 7 days postop

CRAO 11%

Unknown

9%

CARDIAC 9%

VASCULAR 5%

SPINE 72%

PION 60%

AION 20%

ORTHO. 4%

MISC. 10%

Distribution of cases from the

ASA POVL Registry

Distribution of 93 ophthalmic lesions

associated with POVL after spine surgery


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POVL


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ASA Closed Claims Project

Profound visual lossVision loss is usually unilateral. Vision loss is usually total.

Visual loss in spine surgeries

85%Ischemic Optic Neuropathy (ION)

11%Central retinal artery occlusion (CRAO)

4%Other Diagnoses

www.asaclosedclaims.org

Overview

Major Risks

MAC

Medication

Pain Management

Equipment

Visual Loss

Premiums


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ASA Closed Claims Project

Visual loss in spine surgeries

85%Ischemic Optic Neuropathy (ION)

11%Central retinal artery occlusion (CRAO)

4%Other Diagnoses

CRAO can result from pressure on the globe.

www.asaclosedclaims.org

Overview

Major Risks

MAC

Medication

Pain Management

Equipment

Visual Loss

Premiums


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ASA Closed Claims Project

Over two-thirds of cases reported to the POVL Registry were related to spine surgery in the prone position.

Lee LA, et al. The American Society of Anesthesiologist’ Postoperative Visual Loss Registry: Analysis of 93 Spine Surgery Cases with Postoperative Visual Loss. Anesthesiology. 2006 Oct; in press.

www.asaclosedclaims.org

Overview

Major Risks

MAC

Medication

Pain Management

Equipment

Visual Loss

Premiums


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ASA Closed Claims Project

Ischemic optic neuropathy was the most common (89%) cause of visual loss after spine surgery in the prone position.

Lee LA, et al. The American Society of Anesthesiologist’ Postoperative Visual Loss Registry: Analysis of 93 Spine Surgery Cases with Postoperative Visual Loss. Anesthesiology. 2006 Oct; in press.

www.asaclosedclaims.org

Overview

Major Risks

MAC

Medication

Pain Management

Equipment

Visual Loss

Premiums


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ASA Closed Claims Project

In 96% of prone position spine cases, at least one of the following was present:

  • ≥ 1000 ml estimatedblood loss

  • ≥ 6 hours anesthetic duration

Lee LA, et al. The American Society of Anesthesiologist’ Postoperative Visual Loss Registry: Analysis of 93 Spine Surgery Cases with Postoperative Visual Loss. Anesthesiology. 2006 Oct; in press.

www.asaclosedclaims.org

Overview

Major Risks

MAC

Medication

Pain Management

Equipment

Visual Loss

Premiums


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Postoperative Vision Loss- Risk Factors

  • Atherosclerotic disease

  • Hypotension

  • Anemia

  • Excessive blood loss

  • Long duration of surgery

  • Head dependent positioning

Cheng MA Neurosurgery 46:625, 2000


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Cardiovascular Support

  • Maintain MAP above 70 mmHg

  • Fluid management- blood & crystalloid

  • “Pressors” if needed


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Spine Surgery- Monitoring

  • Routine

  • Arterial line

  • CVP/ PA catheter

  • Neurophysiologic


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Monitoring the Spinal Cord

  • SSEP

  • MEP

  • Wake up test

  • EMG


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Indications for SSEP’s

  • Spinal instrumentation

  • Scoliosis correction

  • Spinal cord operations

  • Aortic surgery


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Spine surgery: Times of Increased Risk

  • Spinal distraction

  • Sublaminar wiring

  • Induced hypotension

  • Inadvertent cord compression

  • Certain instrumentation (Lugue rods)

  • Ligation of segmental arteries


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MEP

SSEP

SSEP

MEP

Anatomy of Spinal Tracts

Dorsal /

Posterior

Ventral /

Anterior


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Need For Concurrent MEP & SSEP

“Damage in theterritory of the anterior spinal artery might theoreticallyoccur without causing significant impairment of the dorsal sensorytracts, particularly when the spine is approached from the anteriorside.”

May DM, Jones SJ, Crockard HA. Somatosensory evoked potential monitoring in cervical surgery: identification of pre- and intraoperative risk factors associated with neurological deterioration. J Neurosurg 1996;85:566ミ7


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SSEP


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Loss of SSEP & MEP


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Caveats for MEP monitoring

  • You CAN intubate with non-depolarizing agent (there will be time for it to wear off)

  • When closing, administer NMB to allow decrease of hypnotic agents


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Anesthetic Considerations

  • Patients often on chronic pain medication

  • Hypotension may occur with acute blood loss

    Dexmedetomidine

  • Use perioperatively

  • May decrease narcotic use

  • Hemodynamic stability

  • Patients comfortable postoperatively


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Pain management strategies

  • IV PCA

  • Multimodal therapy

  • Epidural opioids (catheter placed by surgeon)

  • Cooperation with pain service


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Lumbar spine surgery

  • Performed by neurosurgeons and orthopedics

  • Minimally invasive techniques


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The ProSeal laryngeal mask airway in prone patients: a retrospective audit of 245 patients

  • Patients positioned prone for induction

  • Mask ventilation followed prone insertion

  • Digital insertion in 237 pts, GEB technique in 8 pts

  • No complications- ONLY for experienced practitioners!

    Anesth Intensive Care 2007:35


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Caveats for prone LMA’s

  • Have good technique

  • Avoid light anesthesia

  • Position carefully and confirm placement tests

  • Have stretcher available (just in case!)


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Conclusions

  • Understand and appreciate the anatomy and physiology of the spinal cord

  • Communicate with your surgeons

  • Explore new techniques but remember to perfuse and monitor the patient


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