Anesthesia For Spinal Surgery

•Spinal conditions requiring spinal surgery

•Surgical procedures

•Anesthetic considerations

•Unique challenges for spinal surgery

 General Indications for
Spine Surgery
 Neurologic dysfunction
(compression)
 Structural instability
 Pathologic lesions
 Deformity
 Pain
Spinal conditions requiring spinal surgery
Intervertebral disc lesions
Spondylolisthesis
Spinal conditions requiring spinal surgery
Spinal stenosis
Scoliosis

Kyphosis

Spinal tumor
 Surgical procedures

Laminotomy Laminectomy Discectomy

 Surgical procedures
Instrumentation
Fusion and Fixation
 Anesthetic considerations
Pre-Operative Assessment
Airway Assessment:
. TMD,
. Mouth opening
. Previous difficulty in intubation
. Restriction of neck movement due to disease,
traction or braces
. Stability of the cervical spine

. It is essential to discuss preoperatively

the stability of the spine with the surgeon.
 Anesthetic considerations (cont)

RESPIRATORY SYSTEM:
•Any existing ventilatory impairment
•Any signs of pulmonary infection, asthma etc
•spine deformities eg. Scoliosis
kyphosis
ankylosis etc.
 Anesthetic considerations (cont)

Cardiovascular System
Besides routine examination: B.P, heart sounds,
History:
Hypertension
Diabetes mellitus
Congestive heart failure
Coronary artery disease
 Anaesthetic considerations (cont)

Neurological assessment:
The full neurological assessment should be documented.
1. In pts undergoing c-spine surgery, the anesthesiologist
has a responsibility to avoid further neurological deterioration
during maneuvers such as intubation , positioning and
hypotensive anaesthesia.
2. Muscular dystrophies may involve the bulbar
muscles, increasing the risk of postoperative
aspiration.
3. The level of injury and the time elapsed since the insult
are predictors of the physiological derangements of the
cardiovascular and respiratory systems which occur
perioperatively.In < 3 weeks of the injury, spinal shock
may still be present. After this time, autonomic dysreflexia
 Anaesthetic considerations (contd)

 Renal and Liver function

assessment
 Suggested preoperative investigations
before major spinal surgery
Minimum investigations Optional investigations
Airway x-rays Cervical spine lateralview
with flexion/extension views CT scan

Pulmonary CXR Pulmonary function tests

ABG (bronchodilator reversibility)
Spirometry (FEV1, FVC) Pulmonary diffusion capacity

CVS ECG Dobutamine-stress Echo

Echocardiography Dypiridamole
Thalliuscintigraphy

Blood tests CBC,Blood sugar, electrolytes,

RFT, LFT, B.T,C.T. PT/PTT
Calcium (neoplastic disease)
 Anaesthesia technique

Premedication:
 Consideration of immense pain in
patients with degenerative diseases –
opiods
 premedication sparingly used in
patients with difficult airways or
ventilatory impairment.
 Anaesthesia technique(cont)
Induction:
Choice of induction technique:
i.v. or inhalation ?
Pt’s medical condition
Airway
C-spine stability

Choice of muscle relaxants:

Succinylcholine or NDNMBs ?
Pt’s medical condition
Airway
Risk of aspiration
Intra-operative
monitoring
 Anaesthesia technique (contd)

Intubation: (cervical spine surgery)

Awake or asleep
Awake intubation:
Risk of aspiration
Neuro assessment :
an unstable c-
spine
Presence of a neck
stabilization
device: halo
traction

Direct or fiber-optic
laryngoscopy
Direct laryngoscopy:
Intubation can be
 Algorithm for decision making when intubating a pt for
proposed surgery involving the upper T or cervical spine
 Anaesthesia technique(Contd)
Maintenance
Maintain a stable anesthetic depth
positioning of patient, check
airways
Avoid sudden changes in anesthetic depth or BP
Maintain a constant depth of NMB
Common practice: 0.5 MAC Isoflurane /
Halothane
continuous infusion of propofol
continuous remifentanyl or bolus opioids
Controlled hypotensive anaesthesia
Reversal
patient made supine
Thorough endotracheal and oral
suction Oxygenated with 100% oxygen
I.V.- Neostigmine
Glycopyrolate
Extubation: Fully
awake with full
motor power.
Unique challenges for spinal surgery

Positioning

Intra-operative monitoring

Spinal cord injury

Post-operative visual loss

(POVL)
 Positioning

 Prone position : most spinal

procedures
 Supine position with head traction
in anterior approach to cervical
spine
 Sitting or lateral decubitus
position : occasionlly
 Positioning

Prone position for thoracic and dorsal-spine procedure

 Positioning

Prone position for C-spine procedure

 Prone position
 Induction and intubation in supine position
 Turn prone as a single unit requiring at least four
people
 Neck should be in neutral position
 Head may be turned to the side not exceeding the patients
normal range of motion or face down on a cushioned
holder.
 Arms should be at the sides in a comfortable position with
the elbow flexed ( avoiding excessive abduction at the
shoulder
 Chest should rest on parallel rolls (foams )or special
supports (frame) to facilitate ventilation
 Check oral endotracheal tube, ckt, other attachments
 Anesthetic problems of the prone position

Airway:
ET tube kinking or dislodgement
Edema of upper airway in prolonged cases
Blood Vessels:
Arterial or venous occlusion of the upper extremity
Kinking of femoral vein with marked flexion of the
hips,
abdominal pressure:
epidural venous pressure bleeding (frames
elevates)

Pressure necrosis of the nose, ear, forehead, breasts

(female), and genitalias (males)
 Anesthetic problems of the prone position(contd)
Nerves:
Brachial plexus stretch or compression
Ulnar N compression: pressure to the olecranon
Peroneal N compression: pressure over the head of the fibula
Lateral femoral cutaneous N trauma: pressure over the iliac
crest Head and Neck:
Gross hyperflexion or hyperextension of the neck
External pressure over the eyes: retinal injury
Lack of lubrication or coverage of eyes: corneal
abrasion Headrest may cause pressure injury of
supraorbital N.
Excessive rotation of the neck: brachial plexus
problems
 Spine Surgery- Monitoring
 Routine
 Arterial line
 CVP/ PA catheter
 Neurophysiologic:
. Wake up test
. SSEP
.

MEP
. EMG
 Wake-up test
Lightening anesthesia at an appropriate point during the
procedure and observing the patient’s ability to move to
command. It evaluates the gross functional integrity of
the motor pathway. It was first described in 1973.

Anesthesia requirements:
As easy and as rapid to institute as possible
Reliable but quickly antagonized
Wakening should be smooth
No pain during the test
No recall
 Wake-up test
Anesthetic techniques:
Volatile-based anesthesia
Midazolam-based anesthesia
Propofol-based anesthesia
Remifentanyl-based anesthesia
Disadvantages:
Requires pt’s co-operation
Poses risks to pt: falling from the table and extubation
Requires practice
Prolong the duration of surgery
Provides information at the time of the wake-up only
Does not assess sensory pathways
 SSEP (somato sensory evoked potentials)
1. The most common neurophysiological method for
monitoring the intra-operative spinal functional
integrity

2. The stimulus applied to the peripheral N (tibial or ulnar)

3. The recording electrodes placed: cervical region, scalp,

or epidural space during surgery

4. Baseline data obtained after skin incision

5. Responses are recorded intermittently during surgery

6. A reduction in the amplitude by 50% and an increase

in the latency by 10% are considered significant.

7. SSEP tests only dorsal column function not motor

8. Rarely - post operative neurologic deficit reported despite preservation

Indications for SSEP’s
 Spinal instrumentation
 Scoliosis correction
 Spinal cord operations
 Anesthetics and SSEPs
 Satisfactory monitoring of early cortical SSEPs is
possible with 0.5–1.0 MAC isoflurane, desflurane or
sevoflurane.
 Nitrous oxide potentiates the depressant effect of
volatile anesthetics
 Intravenous anesthetics generally affect SSEPs less
than inhaled anesthetics
 Etomidate and ketamine increases cortical SSEP
amplitude
 Clinically unimportant changes in SSEP latency and
amplitude after the administration of opioids
 Implication for SSEPs Monitoring
 Eliminating N2O from the background anesthetic has been
shown to improve cortical amplitude sufficiently to make
monitoring more reliable
 SSEP latency will take 5–8 min to stabilize after the step
changes in volatile anesthetic concentration
 Adding etomidate, propofol or opioids is preferable to beginning
N2O or increasing volatile anesthetic concentrations when
anesthetic depth is inadequate
 If a volatile anesthetic is nevertheless needed rapidly,
sevoflurane permits faster SSEP recovery after the acute need
for volatile anesthetic has been resolved
 It is critical to avoid sudden changes in volatile anesthetic depth
or bolus administration of intravenous anesthetics during
surgical manipulations that could jeopardize the integrity of the
neural pathways being monitored
 MEPs ( Muscle evoke potentials)
Motor cortex stimulated
by electrical or magnetic
means

Neurogenic responses:
peripheral N or spinal
cord

Myogenic responses
Anaesthetics and MEPS( Muscle evoke potentials)
 Inhalational anesthetics suppress myogenic MEPs in a dose-
dependent manner
 Paired pulses or a train of pulses cannot overcome the
suppressive effects
 N2O appears to be less suppressive than other inhaled agents.
Moderate doses of up to 50% N20 have been used successfully
to supplement other agents during myogenic MEP monitoring.
 Fentanyl, etomidate, and ketamine have little or no effect on
myogenic MEP and are compatible with intra-operative
recording.
 Benzodiazepines, barbiturates, and propofol also produce
marked depression of myogenic MEP. However, successful
recordings have been obtained during propofol anesthesia by
controlling serum propofol concentrations and increasing stimuli
rates.
 Anesthetics and MEPs
 Myogenic MEPs are affected by the level of neuromuscular
blockade
 By adjusting a continuous infusion of muscle relaxant to
maintain one or two twitches in a train of four, reliable MEP
responses have been recorded
 Motor stimulation can elicit movement, and this can
interfere with surgery in the absence of neuromuscular
blockade
 Physiologic factors such as temperature, systemic blood
pressure, PaO2, and PaCO2 can alter SSEPs/MEPs and
must be controlled during intra-operative recordings
 Spinal cord injury
1. Neurological damage during surgery and anesthesia is
not limited to the site of surgery.

2. Paraplegia and quadriplegia have been reported as

a result of poor pt positioning.

3. There are reports of pts with spinal disease who

have suffered neurological damage either at levels
remote from the site of surgery or during surgery
unconnected with their spinal disease.

4. Neurological damage is more likely at or near the

site
of surgery on the spine.
 Spinal cord injury

Risk factors:
• Length and type of surgical procedure
• Spinal cord perfusion pressure
• Underlying spinal pathology
• Pressure on neural tissue during surgery
 Spine surgery: Conditions of
Increased Risk

 Spinal distraction
 Sub laminar wiring
 Induced hypotension
 Inadvertent cord compression
 Certain instrumentation (Luque rods)
 Ligation of segmental arteries
 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
 Methods of Reducing Blood Loss
and Limiting Homologous
Transfusions
 Proper positioning to reduce intraabdominal
pressure
 Surgical hemostasis
 Deliberate hemodilution (?)
 Preoperative donation of autologous blood
 Controlled Hypotensive
Anaesthesia
• Definition: It is the elective lowering of arterial
B.P.
• Advantage : Minimization of surgical blood loss
• Better wound
Methods visualization
: Proper positioning
Positive pressure ventilation
Administration of hypotensive drugs
sodium nitropruside B - Blockers
Nitroglycerine Propofol
Trimethaphan Inhalational
Adenosine (Halothane/
 Controlled Hypotensive Anaesthesia (contd)

 Safe level of hypotension :

-In healthy young individuals mean arterial
pressure as low as 50 to 60 mm of Hg is
tolerated with out complication.
-Chronically hypertensive patients have altered
autoregulation of CBF and reduction of MAP
more than 25% of base line not tolerated.
-Patient with H/o transient ischemic attacks may not
tolerate any decline in cerebral perfusion.
 Controlled Hypotensive Anaesthesia (contd)

 Relative contra indication :Pt having

predisposing illnesses that lesson the margin
of safety for adequate organ perfusion
Severe anaemia
Hypovolemia,
Atherosclerotic
vascular
disease
Renal and Hepatic insufficiency
 Controlled Hypotensive Anaesthesia (contd)

Complications: ( more likely in pt with

anaemia)
Cerebral thrombosis
Hemiplegia
Acute tubular necrosis
Massive hepatic necrosis
Myocardial infarction
Cardiac arrest
Blindness from retinal artery thrombosis
or ischemic optic neuropathy
Controlled Hypotensive Anaesthesia (contd)

Monitoring:
• Intra arterial blood pressure monitoring
• E.C.G. with S.T. segment
• analysis Central venous
• monitoring Measurement of
• urinary output
Monitoring of neurologic function
(rarely)
 Injuries: Eye
 Corneal abrasions
 Orbital edema
 Postoperative visual loss
( POVL)
 Post-operative visual loss (POVL)

•POVL is a rare but devastating complication

•1/1100 after prone spinal surgery

•Causes:
Ischemic optic neuropathy (ION) (81%)
Central retinal artery occlusion (13%)
Unknown diagnosis (6%).
 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
Thank You