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Ní Eochagáin A, Singleton BN, Moorthy A, Buggy DJ. Regional and neuraxial anaesthesia techniques for spinal surgery: a scoping review. Br J Anaesth 2022; 129:598-611. [PMID: 35817613 DOI: 10.1016/j.bja.2022.05.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/02/2022] [Accepted: 05/25/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Whilst general anaesthesia is commonly used to undertake spine surgery, the use of neuraxial and peripheral regional anaesthesia techniques for intraoperative and postoperative analgesia is an evolving practice. Variations in practice have meant that it is difficult to know which modalities achieve optimal outcomes for patients undergoing spinal surgery. Our objective was to identify available evidence on the use of regional and neuraxial anaesthesia techniques for adult patients undergoing spinal surgery. METHODS This study was conducted using a framework for scoping reviews. This included a search of six databases searching for articles published since January 1980. We included studies that involved adult patients undergoing spinal surgery with regional or neuraxial techniques used as the primary anaesthesia method or as part of an analgesic strategy. RESULTS Seventy-eight articles were selected for final review. All original papers were included, including case reports, case series, clinical trials, or conference publications. We found that general anaesthesia remains the most common anaesthesia technique for this patient cohort. However, regional anaesthesia, especially non-neuraxial techniques such as fascial plane blocks, is an emerging practice and may have a role in terms of improving postoperative pain relief, quality of recovery, and patient satisfaction. In comparison with neuraxial techniques, the popularity of fascial plane blocks for spinal surgery has significantly increased since 2017. CONCLUSIONS Regional and neuraxial anaesthesia techniques have been used both to provide analgesia and anaesthesia for patients undergoing spinal surgery. Outcome metrics for the success of these techniques vary widely and more frequently use physiological outcome metrics more than patient-centred ones.
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Affiliation(s)
- Aisling Ní Eochagáin
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Barry N Singleton
- Department of Anaesthesiology, Cork University Hospital, Cork, Ireland
| | - Aneurin Moorthy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research Consortium, Cleveland, OH, USA; EuroPeriscope: The ESA-IC Onco-Anaesthesiology Research Group, Rue des Comédiens, Brussels, Belgium
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Debono B, Wainwright TW, Wang MY, Sigmundsson FG, Yang MMH, Smid-Nanninga H, Bonnal A, Le Huec JC, Fawcett WJ, Ljungqvist O, Lonjon G, de Boer HD. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J 2021; 21:729-752. [PMID: 33444664 DOI: 10.1016/j.spinee.2021.01.001] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/02/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery. PURPOSE This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program. STUDY DESIGN This is a review article. METHODS Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature. RESULTS Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented. CONCLUSION Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.
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Affiliation(s)
- Bertrand Debono
- Paris-Versailles Spine Center (Centre Francilien du Dos), Paris, France; Ramsay Santé-Hôpital Privé de Versailles, Versailles, France.
| | - Thomas W Wainwright
- Research Institute, Bournemouth University, Bournemouth, UK; The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Bournemouth, UK
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Freyr G Sigmundsson
- Department of Orthopedic Surgery, Örebro University Hospital, Södra Grev Rosengatan, Örebro, Sweden
| | - Michael M H Yang
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Aurélien Bonnal
- Department of Anesthesiology, Clinique St-Jean- Sud de France, Santécité Group. St Jean de Vedas, Montpellier Metropole, France
| | - Jean-Charles Le Huec
- Department of Orthopedic Surgery - Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Orthosud, Clinique St-Jean- Sud de France, SantéCité Group. St Jean de Vedas, Montpellier Metropole, France
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, the Netherlands
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Goel P, Jain S, Bajpai M, Khanna P, Jain V, Yadav DK. Does caudal analgesia increase the rates of urethrocutaneous fistula formation after hypospadias repair? Systematic review and meta-analysis. Indian J Urol 2019; 35:222-229. [PMID: 31367075 PMCID: PMC6639986 DOI: 10.4103/iju.iju_252_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/21/2016] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Caudal block analgesia is administered to lower the requirements of systemic and inhaled anesthetic drugs during hypospadias surgery. However, recent reports, all clustered in a short time-span have generated controversial and mutually opposing results while evaluating caudal block as an independent risk factor for urethroplasty-related complications after hypospadias repair. There is no consensus statement on the role of caudal block analgesia in formation of urethrocutaneous fistula (UCF) after hypospadias surgery. We performed a systematic review and meta-analysis of the studies evaluating the relative rates of UCF formation after hypospadias surgery in patients who were administered caudal block analgesia versus in those who were not. METHODS Electronic searches were performed using PubMed, PubMed Central, Google Scholar, Ovid, and the Cochrane library. Statistical analysis was performed using a fixed-effect model, odds ratios, risk ratios (RR), and heterogeneity (I2) were calculated. Funnel plot was used to assess for publication bias. RESULTS Seven studies with 1706 patients were included. Caudal block analgesia is associated with a significantly higher risk of UCF formation (RR: 1.81; 95% confidence interval [CI]: 1.30-2.53), (P = 0.0004) and other urethroplasty-related complications (RR 2.01; 95% CI: 1.48-2.74), (P < 0.00001) after hypospadias surgery. Funnel plots indicate some publication bias. CONCLUSIONS In patients undergoing hypospadias repair, administration of caudal analgesia is associated with a higher risk of UCF formation and other urethroplasty-related complications.
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Affiliation(s)
- Prabudh Goel
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shikha Jain
- Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Minu Bajpai
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Puneet Khanna
- Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishesh Jain
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Kumar Yadav
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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Atalan HK, Gucyetmez B, Donmez R, Kargi A, Polat KY. Advantages of Epidural Analgesia on Pulmonary Functions in Liver Transplant Donors. Transplant Proc 2018; 49:1351-1356. [PMID: 28736006 DOI: 10.1016/j.transproceed.2017.03.087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/07/2017] [Accepted: 03/30/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Epidural analgesia (EA) has positive effects on anesthetic requirement, blood loss, postoperative analgesia, and pulmonary function tests (PFTs). The purpose of the present study was to investigate the effect of EA on postoperative PFTs in liver transplant donors (LTDs). METHODS In the present study, 66 LTDs were classified as total intravenous anesthesia (TIVA) and TIVA+EA groups. Patient's age, sex, body mass index, induction and maintenance dose of propofol (IDP and MDP), operation duration, forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, visual analog scale (VAS), atelectasis scores, and lengths of intensive care unit (ICU) and hospital stays were recorded. RESULTS In the TIVA+EA group, IPD, MPD, delta-FEV1 delta-FVC, VAS for all time, atelectasis score and length of hospital stay were significantly lower than in the TIVA group (P < .001 for all). Whereas VAS at the end of the operation was negatively correlated with delta-FEV1 and delta-FVC (r2 = 0.26 P < .001; r2 = 0.41 P < .001; respectively), it was positively correlated with atelectasis score and length of ICU stay (r2 = 0.49, P < .001; and r2 = 0.41, P < .001; respectively). Atelectasis score was positively correlated with length of ICU stay (r2 = 0.86, P < .001). CONCLUSIONS Reduced anesthetic requirement, better postoperative analgesia, reduced atelectasis score, and preserved PFTs can be provided with the use of EA in LTDs. Positive effects of EA on anesthesia requirement, pain management and pulmonary function are associated with outcomes.
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Affiliation(s)
- H K Atalan
- Department of Anesthesiology, Ataşehir Memorial Hospital, Istanbul, Turkey
| | - B Gucyetmez
- Department of Anesthesiology, Acibadem University School of Medicine, Istanbul, Turkey.
| | - R Donmez
- Department of Transplantation, Ataşehir Memorial Hospital, Istanbul, Turkey
| | - A Kargi
- Department of Transplantation, Ataşehir Memorial Hospital, Istanbul, Turkey
| | - K Y Polat
- Department of Transplantation, Ataşehir Memorial Hospital, Istanbul, Turkey
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Abstract
Blood management strategies are integral to successful outcomes in many types of orthopaedic surgery. These strategies minimize blood loss and transfusion requirements, ultimately decreasing complications, improving outcomes, and potentially eliminating risks associated with allogeneic transfusion. Practices to achieve these goals include preoperative evaluation and optimization of hemoglobin, the use of pharmacologic agents or anesthetic methods, intraoperative techniques to improve hemostasis and cell salvage, and the use of predonated autologous blood. Guidelines can also help manage allogeneic transfusions in the perioperative period. Although the literature on blood management has focused primarily on arthroplasty and adult spine surgery, pediatric spinal fusion for scoliosis involves a large group of patients with a specific set of risk factors for transfusion and distinct perioperative considerations. A thorough understanding of blood management techniques will improve surgical planning, limit transfusion-associated risks, maintain hemostasis, and optimize outcomes in this pediatric population.
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Saavedra-Belaunde JA, Soto-Aviles O, Jorge J, Escudero K, Vazquez-Cruz M, Perez-Brayfield M. Can regional anesthesia have an effect on surgical outcomes in patients undergoing distal hypospadia surgery? J Pediatr Urol 2017; 13:45.e1-45.e4. [PMID: 27956108 DOI: 10.1016/j.jpurol.2016.09.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/24/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Caudal and penile blocks are the most popular regional anesthetic techniques used in infants and children undergoing urological surgery. A recent report has suggested that penile venous pooling resulting from caudal blocks could affect surgical outcomes after hypospadias operations. OBJECTIVE The aim was to report our experience in patients with distal hypospadias undergoing repair with caudal versus penile block. STUDY DESIGN A retrospective clinical database was constructed for patients who underwent distal hypospadias repair by a single surgeon (M.P.B.) at our sponsoring institutions for the time period 2008-2013 (n = 192). Collected data included hypospadias classification (glanular, coronal, subcoronal), chordee status, perioperative anesthesia (caudal vs. penile), and assessment of postoperative complications (fistula and meatal stenosis). RESULTS Risk ratio (RR) analysis for all distal hypospadias cases revealed that there is a higher risk of developing complications in patients who underwent caudal anesthesia than in patients who underwent penile block RR for a complication was 3.70 (95% CI 1.05-13.03; p < 0.04) (Figure). DISCUSSION Similar to other papers in the literature, we found that patients who underwent caudal anesthesia had more complications than those who underwent penile block. The limitations of this study include not adjusting the results according to the severity of hypospadias. CONCLUSION The main goal of this study was accomplished by demonstrating that, in our series, caudal anesthesia is associated with a higher risk of fistula formation after undergoing distal hypospadias repair than penile block.
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Affiliation(s)
| | - Omar Soto-Aviles
- Department of Urology, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | - Juan Jorge
- Department of Urology, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | | | | | - Marcos Perez-Brayfield
- Department of Urology, University of Puerto Rico School of Medicine, San Juan, PR, USA; HIMA San Pablo, Bayamon, PR, USA
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Atalan HK, Gucyetmez B, Donmez R, Berktas M, Kargi A, Erturer A, Sozenoglu İR, Denizalti TB, Polat KY. The effects of high lumbar epidural analgesia on postoperative pulmonary function tests in liver transplant donor patients. Intensive Care Med Exp 2015. [PMCID: PMC4797765 DOI: 10.1186/2197-425x-3-s1-a693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Moghimi MH, Leonard DA, Cho CH, Schoenfeld AJ, Phan P, Harris MB, Bono CM. Virtually bloodless posterior midline exposure of the lumbar spine using the "para-midline" fatty plane. 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 2015; 25:956-62. [PMID: 26582166 DOI: 10.1007/s00586-015-4319-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/01/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The authors have developed a "para-midline" approach to the posterior lumbar spine using a virtually avascular surgical plane not previously described in the literature. It was their purpose to document consistent MRI presence of this plane and to prospectively evaluate its clinical use in terms of blood loss. METHODS Fifty consecutive patients undergoing primary lumbar surgery on 1-3 levels were prospectively enrolled from September 2014 to May 2015. The para-midline approach was used in all cases. The deep lumbar fascia is longitudinally incised on either side of the spinous processes instead of directly in the midline, which reveals the para-midline fatty plane. Blood loss during the approach and overall blood loss were recorded for all patients. MRIs from each patient were reviewed by an experienced neuroradiologist to determine the presence of the para-midline fatty plane. RESULTS There was no recorded blood loss during the approach for all procedures. The average overall blood loss was 60 cc (20-200 cc). No patient required a transfusion intraoperatively or postoperatively. The fatty para-midline plane was noted on preoperative MRI at all operated levels in all patients. The average width of this plane was 6.5 mm (2-17 mm). CONCLUSIONS The para-midline approach for lumbar surgery is associated with less blood loss than traditional, subperiosteal exposure techniques. The fatty interval through which this approach is made is universally present and identifiable on MRI. The authors offer this approach as a means of decreasing the risks associated with blood loss and transfusion with posterior lumbar surgery.
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Affiliation(s)
- Michael H Moghimi
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Dana A Leonard
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Charles H Cho
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Andrew J Schoenfeld
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Philippe Phan
- The Ottawa Hospital Civic Campus, University of Ottawa, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Mitchel B Harris
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Christopher M Bono
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Kawano H, Manabe S, Matsumoto T, Hamaguchi E, Kinoshita M, Tada F, Oshita S. Comparison of intraoperative blood loss during spinal surgery using either remifentanil or fentanyl as an adjuvant to general anesthesia. BMC Anesthesiol 2013; 13:46. [PMID: 24304964 PMCID: PMC3880217 DOI: 10.1186/1471-2253-13-46] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 11/21/2013] [Indexed: 11/27/2022] Open
Abstract
Background Remifentanil enhances intraoperative hemodynamic stability, suggesting that it may decrease intraoperative blood loss when included as an adjuvant to general anesthesia. This retrospective study compared intraoperative blood loss during spinal surgery in patients administered either remifentanil or fentanyl as an opioid adjuvant. Methods We reviewed clinical and surgical data from 64 consecutive laminoplasty or laminectomy patients treated at National Hospital Organization Zentsuji Hospital between April 2010 and March 2011. Patients received either remifentanil (n = 35) or fentanyl (n = 29) as an opioid analgesic during general anesthesia. In addition to intraoperative blood loss, indices of hemodynamic stability, including heart rate as well as systolic, mean, and diastolic blood pressure (BP), were compared over the entire perioperative period between remifentanil and fentanyl groups. Results The remifentanil group exhibited significantly lower intraoperative arterial BP than the fentanyl group. Intraoperative blood loss was also significantly lower in the remifentanil group (125 ± 67 mL vs. 165 ± 82 mL, P = 0.035). Conclusions Intraoperative blood loss during spinal surgery was decreased in patients who received remifentanil as an opioid adjuvant, possibly because of lower intraoperative BP. A larger-scale prospective randomized controlled trial is warranted to confirm our results and to test whether remifentanil can decrease intraoperative blood loss during other surgical procedures.
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Affiliation(s)
- Hiroaki Kawano
- Department of Anesthesiology and Clinical Research, National Hospital Organization Zentsuji Hospital, Zentsuji, Japan.
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Schroeder KM, Zahed C, Andrei AC, Han S, Ford MP, Zdeblick TA. Epidural anesthesia as a novel anesthetic technique for anterior lumbar interbody fusion. J Clin Anesth 2011; 23:521-6. [DOI: 10.1016/j.jclinane.2011.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 01/27/2011] [Accepted: 01/31/2011] [Indexed: 11/29/2022]
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Sadrolsadat SH, Mahdavi AR, Moharari RS, Khajavi MR, Khashayar P, Najafi A, Amirjamshidi A. A prospective randomized trial comparing the technique of spinal and general anesthesia for lumbar disk surgery: a study of 100 cases. ACTA ACUST UNITED AC 2009; 71:60-5; discussion 65. [PMID: 19084683 DOI: 10.1016/j.surneu.2008.08.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2008] [Accepted: 08/05/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND General anesthesia and regional anesthesia have both been shown to be suitable techniques for patients undergoing lower thoracic and lumbar spine surgery; however, GA is the most frequently used method. The purpose of this study was to conduct an acceptable RCT to compare the intraoperative parameters and postoperative outcome after SA and GA in patients undergoing elective lumbar disk surgery. METHODS Patients undergoing laminectomy for herniated lumbar disk during the years 2005 and 2007 were enrolled. They were randomly selected to undergo GA and SA. The variables recorded during the operation were the patients' HR, MAP, amount of blood loss, and surgeons' satisfaction with the operating conditions. The severity of pain, nausea, vomiting, and length of stay in the hospital were recorded in the postoperative course. RESULTS The mean blood loss was less in the group undergoing GA; however, the difference was not statistically significant. The surgeon's satisfaction was reported to be higher in the GA group. No major intraoperative complication was reported in either series. During the recovery period, hypertension was reported to happen more frequently in the patients undergoing GA; and postoperative nausea and vomiting were more frequent among patients recovering from SA. CONCLUSION Contrary to previous studies, the findings of the present study revealed that SA has no advantages over GA. Moreover, it was showed that GA can reduce the related risks and complications in several aspects.
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Guay J. The effect of neuraxial blocks on surgical blood loss and blood transfusion requirements: a meta-analysis. J Clin Anesth 2006; 18:124-8. [PMID: 16563330 DOI: 10.1016/j.jclinane.2005.08.013] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2005] [Accepted: 08/15/2005] [Indexed: 12/20/2022]
Abstract
PURPOSE The aim of this study was to evaluate the effect of neuraxial blocks on surgical blood losses and on the number of patients requiring blood transfusion. METHODS A search of the American National Library of Medicine's PubMed up to November 12, 2004, was performed. Twenty-four studies could be kept for analysis. RESULTS Regional anesthesia reduced the number of transfused patients for total hip replacement (P = 0.0009) and spinal fusion (P = 0.04). A reduction of measured blood loss that did not lead to a reduction in the number of transfused patients was also found for fractured hip surgery (P < 0.0001), lumbar disk surgery (P = 0.01), peripheral vascular surgery (P = 0.03), retropubic prostatectomy (P = 0.02), cesarean section (P < 0.0001), and bowel surgery (P = 0.0008). In summary neuraxial blocks have a clear and definite effect on surgical blood loss, but this effect do not usually lead to a reduction in the number of transfused patients except for patients undergoing total hip replacement and spinal fusion.
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Affiliation(s)
- Joanne Guay
- Department of Anesthesia, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada H1T 2M4.
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13
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Papadopoulos EC, Girardi FP, Sama A, Pappou IP, Urban MK, Cammisa FP. Lumbar microdiscectomy under epidural anesthesia: a comparison study. Spine J 2006; 6:561-4. [PMID: 16934728 DOI: 10.1016/j.spinee.2005.12.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2005] [Revised: 11/08/2005] [Accepted: 12/10/2005] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar microdiscectomy is most commonly performed under general anesthesia, which can be associated with several perioperative morbidities including nausea, vomiting, atelectasis, pulmonary aspiration, and prolonged post-anesthesia recovery. It is possible that fewer complications may occur if the procedure is performed under epidural anesthesia. PURPOSE To investigate the safety and efficacy of epidural anesthesia in elective lumbar microdiscectomies. STUDY DESIGN A prospective study evaluating the relative morbidities associated with epidural anesthesia and general anesthesia for lumbar microdiscectomy. PATIENT SAMPLE Forty-three patients scheduled for primary lumbar microdiscectomy. Two cohorts were formed and were studied separately; one observational of all the 43 patients, and a second cohort of 17 patients who agreed to enter in the randomized trial. OUTCOME MEASURES The clinical outcome was determined by the presence of postoperative pain, the absence of anesthesia-related complications, and the overall postoperative recovery. METHODS This was a prospective study. With institutional review board approval, 43 consecutive patients were enrolled in the study. However, only 17 patients agreed to be randomized to receive either general or epidural anesthesia for the procedure; the remaining 26 patients selected the type of anesthesia of their preference. Recorded data for all patients included: age; total surgical time; occurrence of nausea, vomiting, atelectasis, or cardiopulmonary complication; ability to arise out of bed on the day of surgery; and the total number of inpatient hospital days. Postoperative pain and satisfaction were assessed only in the randomized cohort. RESULTS There were a total of 43 patients, with a mean age of 38.1 years. The patients undergoing epidural anesthesia were marginally older than those undergoing general anesthesia. The epidural and general anesthetic groups were not different with respect to surgical time, pain assessed with a linear visual analogue scale, hospital stay, or the likelihood of arising out of bed on the day of surgery. There were no major cardiopulmonary complications in either group. Patients with epidural anesthesia had significantly less nausea and vomiting. CONCLUSIONS Epidural anesthesia as an alternative to general anesthesia has shown less postoperative nausea and vomiting in lumbar microdiscectomy. Nevertheless, given the small number of patients, this study should be considered as preliminary, showing small differences in minor potential complications.
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Affiliation(s)
- Elias C Papadopoulos
- Spine Surgery, Spine Service, Hospital for Special Surgery, New York, NY 10021, USA
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Yoshimoto H, Nagashima K, Sato S, Hyakumachi T, Yanagibashi Y, Masuda T. A prospective evaluation of anesthesia for posterior lumbar spine fusion: the effectiveness of preoperative epidural anesthesia with morphine. Spine (Phila Pa 1976) 2005; 30:863-9. [PMID: 15834327 DOI: 10.1097/01.brs.0000158879.26544.69] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, randomized, single-blinded study. OBJECTIVES To prospectively compare the anesthesia for posterior lumbar spinal fusion between the age- and gender-matched groups with and without preoperative epidural anesthesia with morphine. SUMMARY OF BACKGROUND DATA To reduce the blood loss, hypotensive anesthesia is frequently used in the spinal fusion. However, in spite of administration of the hypotensive agents, inadequate analgesia during operation often causes unfavorable and unexpected elevation of blood pressure resulting in excessive bleeding. As well, intractable wound pain sometimes occurs after spinal fusion due to inadequate analgesia during surgery. METHODS Forty cases of posterior lumbar spinal fusion were investigated prospectively. Twenty patients underwent preoperative epidural anesthesia with morphine and sedation by continuous intravenous administration of propofol but without administration of any kind of anesthetics, including intraoperative and/or postoperative epidural anesthesia (Group E). Another 20 patients underwent inhalation general anesthesia with sevoflurane and intermittent intravenous administration of fentanyl without any regional block (Group F). In these groups, dynamics and average mean blood pressure during surgery, blood loss during surgery, postoperative requirement of analgesics, the visual analogue scale, and accuracy of neurologic evaluation immediately after surgery were analyzed. RESULTS The average mean blood pressure during surgery was significantly lower in Group E than Group F: 57.1 mm Hg and 72.8 mm Hg, respectively. In addition, the dynamics of blood pressure were more stable in Group E than Group F. The blood loss during surgery was significantly less in Group E than in Group F: 546 g and 631 g, respectively. The patients of Group E required analgesics after surgery less frequently, and the rating on the visual analogue scale was significantly lower in Group F on the first, second, and third days after surgery. It was difficult to evaluate the neurologic status accurately in 5 patients of Group F because of the inadequate emergence immediately after surgery. There were no patients in Group E whose neurologic status was unclear because of the paralysis caused by epidural anesthesia. CONCLUSIONS To combine preoperative epidural anesthesia with other anesthetic procedure for spinal fusion contributes to maintain more stable hypotension during surgery. As a result, it will be possible to lessen the bleeding during surgery. In addition, the postoperative pain was easily controlled with administration of fewer analgesic agents in patients who underwent the epidural anesthesia. The effectiveness of pre-emptive analgesia should be emphasized to diminish the postoperative pain.
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Block JE. Severe blood loss during spinal reconstructive procedures: The potential usefulness of topical hemostatic agents. Med Hypotheses 2005; 65:617-21. [PMID: 15967590 DOI: 10.1016/j.mehy.2005.02.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Accepted: 02/10/2005] [Indexed: 11/26/2022]
Abstract
Complex spinal reconstructive procedures are invariably associated with excessive intraoperative blood loss that significantly increases the risk of severe perioperative complications. In some cases, excessive hemorrhage is equivalent to estimated total blood volume. Unfortunately, widely exposed bony surfaces are not amenable to standard hemostatic maneuvers utilized during soft tissue surgery. This article evaluates the clinical effectiveness of several approaches to blood management in this setting, and hypothesizes that underappreciated topical hemostatic agents may provide benefit by reducing the need for autologous predonation, banked donor blood or antifibrinolytic agents. Topical agents combining collagen, thrombin and fibrin have demonstrated initial promise by inducing platelet aggregation and initiating the clotting cascade when applied directly to bleeding bony sites. Clinical studies are clearly warranted.
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Szpalski M, Gunzburg R, Sztern B. An overview of blood-sparing techniques used in spine surgery during the perioperative period. 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 2004; 13 Suppl 1:S18-27. [PMID: 15480823 PMCID: PMC3592191 DOI: 10.1007/s00586-004-0752-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2004] [Accepted: 05/07/2004] [Indexed: 11/29/2022]
Abstract
The problems linked to blood loss and blood-sparing techniques in spine surgery have been less studied than in other fields of orthopedics, such as joint-replacement procedures. Decreasing bleeding is not only important for keeping the patient's hemodynamic equilibrium but also for allowing a better view of the surgical field. In spine surgery the latter aspect is especially important because of the vicinity of major and highly fragile neurologic structures. The techniques and agents used for hemostasis and blood sparing in spinal procedures are mostly similar to those used elsewhere in surgery. Their use is modulated by the specific aspects of spinal approach and its relation to the contents of the spinal canal. Blood-sparing techniques can be divided into two categories based on their goals: either they are aimed at decreasing the bleeding itself, or they are aimed at decreasing the need for homologous transfusion. Various hemodynamic techniques, as well as systemic and local drugs and agents, can be used separately or in combination, and their use in the field of spine surgery is reported. The level of evidence for the efficacy of many of those methods in surgery as a whole is limited, and there is a lack of evidence for most of them in spine surgery. However, several blood-saving procedures and drugs, as well as promising new agents, appear to be efficient, although their efficacy has yet to be assessed by proper randomized controlled trials.
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Affiliation(s)
- Marek Szpalski
- Department of Orthopedic Surgery, IRIS South Teaching Hospitals, 142 rue Marconi, 1190 Brussels, Belgium.
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Abstract
The spectrum of spinal surgery in adult life is considerable. Anaesthesia for major spinal surgery, such as spinal stabilization following trauma or neoplastic disease, or for correction of scoliosis, presents a number of challenges. The type of patients who would have been declined surgery 20 yr ago for medical reasons, are now being offered extensive procedures. They commonly have preoperative co-morbid conditions such as serious cardiovascular and respiratory impairment. Airway management may be difficult. Surgery imposes further stresses of significant blood loss, prolonged anaesthesia, and problematical postoperative pain management. The perioperative management of these patients is discussed. The advent of techniques to monitor spinal cord function has reduced postoperative neurological morbidity in these patients. The anaesthetist has an important role in facilitating these methods of monitoring.
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Affiliation(s)
- D A Raw
- University Department Anaesthesia, The Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
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Abstract
Spinal anaesthesia for spinal surgery is becoming increasingly more popular because this anaesthetic technique allows the patient to self-position and avoid neurological injury that may occur with prone positioning under general anaesthesia. Spinal anaesthesia reduces intraoperative surgical blood loss, improves perioperative haemodynamic stability and reduces pain in the immediate postoperative period. This leads to a reduced need for analgesics and a reduction in the incidence of nausea and vomiting in the postoperative setting. Spinal anaesthesia for lumbar spine surgery also decreases the incidence of lower extremity thrombo-embolic complications and does not increase the occurrence of problems with micturition. These benefits increase the patient's satisfaction, and they expedite discharge of the patient from the hospital. Combination anaesthetic techniques, using both subarachnoid and epidural dosing schemes, may be beneficial for improving postoperative pain control and add further to the benefit of spinal anaesthesia for lumbar spine surgical procedures.
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Affiliation(s)
- W Scott Jellish
- Department of Anesthesiology and Neurosurgery, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA.
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Kakiuchi M. Dose-dependent inversion of the effect of prostaglandin E1 on intraosseous pressure: adequate dose for reducing blood loss during operation on bone. J Orthop Sci 2000; 5:283-7. [PMID: 10982670 DOI: 10.1007/s007760050164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Tibial intraosseous pressure and blood flow, along with arterial pressure, were measured in anesthetized rabbits before and during intravenous infusion of prostaglandin E1 at doses of 0, 100, 300, 1000, and 2000 ng/kg per min. The mean arterial pressure decreased dose-dependently. The intra-osseous pressure increased during infusion at doses of 300 and 1000 ng/kg per min, but decreased during infusion at the dose of 2000 ng/kg per min. Bone blood flow increased during infusion only at a dose of 1000 ng/kg per min. Calculated vascular and arteriolar resistances in bone decreased dose-dependently during infusion at doses of up to 1000 ng/kg per min, but no change was seen when the dose was increased from 1000 to 2000 ng/kg per min. These findings indicated that: (1) there was a turning point in the effect of prostaglandin E1 at a certain dose between 1000 and 2000 ng/kg per min, at which the arterioles in bone were fully dilated; (2) at a dose of 1000 ng/kg per min or lower, responsive dilatation in the arterioles of bone under mild arterial hypotension increased the influx of blood into the bone, thereby increasing the intraosseous pressure; and (3) at doses higher than 1000 ng/kg per min, dose-dependent arterial hypotension without further dilatation in the arterioles of bone decreased the influx of blood.
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Affiliation(s)
- M Kakiuchi
- Department of Orthopaedic Surgery, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka 543-0035, Japan
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Urmey WF. Combined regional and general anesthesia for orthopedic spine fusion surgery. ACTA ACUST UNITED AC 2000. [DOI: 10.1053/trap.2000.7029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lentschener C, Cottin P, Bouaziz H, Mercier FJ, Wolf M, Aljabi Y, Boyer-Neumann C, Benhamou D. Reduction of blood loss and transfusion requirement by aprotinin in posterior lumbar spine fusion. Anesth Analg 1999; 89:590-7. [PMID: 10475286 DOI: 10.1097/00000539-199909000-00009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Aprotinin reduces blood loss in many orthopedic procedures. In posterior lumbar spine fusion, blood loss results primarily from large vein bleeding and also occurs after the wound is closed. Seventy-two patients undergoing posterior lumbar spine fusion were randomly assigned to large-dose aprotinin therapy or placebo. All patients donated three units of packed red blood cells (RBCs) preoperatively. Postoperative blood loss was harvested from the surgical wound in patients undergoing two- and/or three-level fusion for reinfusion. The target hematocrit for RBC transfusion was 26% if tolerated. Total (intraoperative and 24 h postoperative) blood loss, transfusion requirements, and percentage of transfused patients per treatment group were significantly smaller in the aprotinin group than in the placebo group (1935 +/- 873 vs 2809 +/- 973 mL per patient [P = 0.007]; 42 vs 95 packed RBCs per group [P = 0.001]; 40% vs 81% per group [P = 0.02]). Hematological assessments showed an identically significant (a) intraoperative increase in both thrombin-antithrombin III complexes (TAT) and in activated factor XII (XIIa) and (b) decrease in activated factor VII (VIIa), indicating a similar significant effect on coagulation in patients of both groups (P = 0.9 for intergroup comparisons of postoperative VIIa, XIIa, and TAT). Intraoperative activation of fibrinolysis was significantly less pronounced in the aprotinin group than in the placebo group (P < 0.0001 for intergroup comparison of postoperative D-dimer levels). No adverse drug effects (circulatory disturbances, deep venous thrombosis, alteration of serum creatinine) were detected. Although administered intraoperatively, aprotinin treatment dramatically reduced intraoperative and 24-h postoperative blood loss and autologous transfusion requirements but did not change homologous transfusion in posterior lumbar spine fusion. IMPLICATIONS In our study, aprotinin therapy significantly decreased autologous, but not homologous, transfusion requirements in posterior lumbar spine fusion.
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Affiliation(s)
- C Lentschener
- Department of Anesthesiology, Hôpital Antoine-Béclère, Université Paris-Sud, Clamart, France.
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