Spine Surgery

DEPARTMENT OF ORTHOPAEDIC AND TRAUMATOLOGY
FACULTY OF MEDICINE | HASANUDDIN UNIVERSITY

MAKASSAR
2017
Spinal surgical procedures have a wide variety and comprise a major
subgroup of orthophaedic surgery.
Thousands of patients undergo spinal surgery every year.
Perioperative management of the spinal cases is directly related with
perioperative morbidity and mortality
Spinal surgery is relatively lasting longer, the probability of intraoperative
bleeding is higher comparing to other surgeries (due to the patients prone
position) and the possibility of severe pain after surgery, are facts should
be aware.
zgl Keskin, Hatice Tre, and Neslihan Uztre. Anaesthesia for Spinal Surgery. Yeditepe Medical Journal. 2015;9(33):842-847
Preoperative assessment is one of the most important stages of
perioperative care.
Whereas, the focus of intraoperative management is minimizing spinal
cord ischaemia and compression on the spinal cord.
These are accomplished by maintenance of Spinal Cord Perfusion Pressure
(SCPP) through control of blood pressure (BP) and minimizing venous
congestion by careful positioning of the patient to prevent compression of
the abdomen.
We need to ensure spinal cord perfusion while producing a bloodless
surgical field. 1
Postoperative complications include
persistent hypotension,
haemorrhage,
urinary retention,
nerve root damage,
cauda equina syndrome (urinary/faecal incontinence,
perineal sensory loss and lower-limb motor weakness),
thromboembolism and
airway complications. 1
General Perioperative Management
Preoperative Management
Preoperative assessment is one of the most important stages of
perioperative care
Careful assessment is made based on the medical history and physical
examination of the patient.
Preoperative considerations; evaluation of all organ systems status
especially respiratory and cardiovascular, nervous system evaluation and
documentation of neurological deficits, possible anatomical abnormalities
leading to airway limitation, examination of the physical status and
planning of premedication is important. 1
Preoperative laboratory tests; full blood count, coagulation profile,
electrolytes, renal and liver functions, ECG and echocardiogram(as
appropriate), imaging studies (chest X ray, cervical spine imaging) should
be performed.
Preparation of blood and blood products and if needed intensive care
organization is important to reduce the risk of intraoperative and
postoperative complications. 1
Assessment of the cardiorespiratory system is crucial. Many disorders
requiring spinal surgery may have cardiac involvement.
Symptomatic patients require more cardiac investigations such as
echocardiography or stress tests.
Disease such as Scoliosis and Rheumatoid Arthritis can cause restrictive
lung disease. For this cases lung spirometry is indicated preoperatively. 1
Patient education (PE) has been used by many institutions to deal with
patient anxiety, pain control, and overall satisfaction.
Several authors have found PE to be beneficial, whereas others found little
or no significant improvement.
In a study of patients undergoing surgery after lumbar disc surgery, less
than half of the patients were satisfied with their preoperative PE.
PE may help them to set realistic goals and meet their expectations.
This, in turn, may positively influence surgical outcome and overall
satisfaction.2
In the orthopedic field, PE has frequently been used in total joint
replacement programs.
To our knowledge, there are no comprehensive data on the effectiveness
of PE in patients undergoing spinal surgery. 2
Intraoperative Management
Spinal surgery is relatively lasting longer, the probability of intraoperative bleeding is
higher comparing to other surgeries (due to the patients prone position) and the
possibility of severe pain after surgery, are facts the anaesthetist should be aware
For all spinal surgery patients standard monitoring is considered.
This comprises of electrocardiography monitoring (ECG), pulse oximetry, end-tidal
CO2 with capnography, non invasive arterial blood pressure, body temperature and
neuromuscular block monitoring.
Optinal monitoring is by additional measurement of central venous pressure
measurement, invasive arterial blood pressure, urinary catheter, bispectral index
(BIS) and somatosensory evoked potentials (SSEP) monitoring.
The focus of intraoperative management is minimizing spinal cord
ischaemia and compression on the spinal cord.
These are accomplished by maintenance of Spinal Cord Perfusion
Pressure (SCPP) through control of blood pressure (BP) and minimizing
venous congestion by careful positioning of the patient to prevent
compression of the abdomen.
We need to ensure spinal cord perfusion while producing a bloodless
surgical field
Special care should be taken for the peripheral nerves (like elbow, ulnar,
lateral femoral cutaneous nerve and the peroneal nerve) that should be
padded to avoid injury.
Concerning the pulmonary function, the most obvious change is the
increase in functional residual capacity (FRC). 1
Because of prolonged surgery and blood loss the risk of hypothermia is
existent.
Hypothermia will impact negatively on spinal cord monitoring, increase
blood loss due to abnormal coagulation, delay the recovery time,
increase the risk of arrhythmia and wound infection.
So temperature monitoring and active warming with forced air
warming devices is essential.
Blood loss in spine surgery has a significant impact on patient
morbidity, length of surgery, and total cost.
In addition to maintaining patients hemodynamics, the control of
blood loss is essential in attaining adequate visualization of the surgical
field.
Decreasing the rate of blood loss, salvaging lost blood, and decreasing
the need for transfusion are three potential areas for intervention.
Acute normovolemic hemodilution is a technique employed to
decrease the need for transfusion.
Techniques to minimize blood transfusion during spine surgery include
avoiding hypothermia,
preoperative supplementation with oral iron,
normovolaemic haemodilution,
good surgical technique and haemostasis,
correct positioning of the patient when prone,
controlled hypotensive anaesthesia (only with adequate cord monitoring),
use of cell saver,
pharmacological agents such as tranexamic acid, intrathecal opiates and
monitored use of coagulation products.
Intraoperative monitoring of spinal cord function is considered a standard
care in spinal surgery. 1
The wake up test
Somatosensory evoked potentials (SSEP)
Motor evoked potentials (MEPs)
Dermatomal responses
Perioperative Management in Spine Disease
Neuromuscular Scoliosis
Patients with neuromuscular diseases frequently develop scoliosis that requires
surgical correction. Usually, spinal deformity is associated with great pelvic obliquity.
Spine fusion in neuromuscular scoliosis aims to balance the trunk in frontal and
sagittal plane, centre the head over the pelvis, and restore anatomical spine
condition.
Patients with neuromuscular scoliosis undergoing posterior spinal fusion are at
higher risk for postoperative complications due to underlying comorbidities such as
decreased pulmonary function, inadequate nutritional status, decreased mobility,
and cognitive impairment.
Neuromuscular Scoliosis
Compared with idiopathic scoliosis, neuromuscular scoliosis
patients requiring spine surgery have a higher risk of adverse
perioperative complications because of underlying
comorbidities.
Comorbidities commonly associated with neuromuscular
scoliosis are decreased pulmonary function, inadequate
nutritional status, decreased mobility, and communication and
cognitive impairment.
Osteoporosis
With the aging US population, there has been an

increasing number of age-related diseases, including
degenerative spine conditions and osteoporosis.
Osteoporosis
Management of spine surgery patients with

osteoporosis is challenging because of the difficulty of
instrumenting and the potential complications,
including nonunion, adjacent level fractures, and failure
of the instrumentation.
Osteoporosis
Management of spine surgery patients with osteoporosis is

challenging because of the difficulty of instrumenting and the
potential complications, including nonunion, adjacent level
fractures, and failure of the instrumentation.
Indication for preoperative treatment before spinal fusion
surgery remains unclear.
Pretreatment with PTH may enable additional bone remodeling
and improve the quality of the fusion mass
Pediatric Spinal Disease
The perioperative corrective spinal surgery is challenging. The

major challenges include the extensive nature of surgery,
associated comorbidities and the need for neurophysiological
monitoring to diagnose any form of intraoperative neurological
insult.
The pre-operative functional status and the intra-operative
events could dictate the requirement for post-operative
mechanical ventilation.
Spine surgeries are performed for varied pathologies, including

congenital or idiopathic defects, malignancy, abscesses,
trauma, arteriovenous malformations (AVMs) or herniated disc.
The paediatric spine is commonly operated for the surgical
correction of scoliosis.
Being a complex spinal deformity, scoliosis has an inherent
potential to involve the cardio-pulmonary system.
A holistic approach needs to be employed while evaluating the

children coming for spinal surgery, with emphasis on the
pulmonary, cardiovascular, andneurological systems.
Functional impairment of these systems can co-exist either as
an association or as a result of the spinal pathology.
The associated neuro-muscular diseases (NMD), airway diffi culty and

impaired nutritional status, must be taken into account.
Preoperative assessment encompasses a detailed history general physical
examination, keeping in view, the associated comorbidities, syndromes.
The battery of preoperative investigations should be tailor made to
diagnose the presence and extent of the organ involvement, in addition to
the routine investigations.
Neurophysiological monitoring of spinal cord integrity is the gold

standard of intraoperative care in spinal surgery.
The current monitoring modalities for preventing intraoperative risk of
spinal cord injury are based on the measurement of somatosensory
(SSEP) and motor evoked (MEP) potentials.
The evoked potentials (EPs), being the electrophysiological responses of
the nervous system to stimulation of either sensory or motor pathways,
are essentially stimulus related and pathway specific monitoring modality.
The postoperative care mandates an effective analgesic and respiratory

therapy.
For favorable surgical outcome it is mandatory to have effective pain
control at rest and during ambulation and should be titrated and
individualized accordingly.
The multimodal analgesic therapy includes, wound infiltration, epidural
catheter placed intraoperative, opioids (intravenous, intrathecal), patient
controlled anesthesia in older children and NSAIDs.
Spine Tumor
Metastatic tumors are the most common (97%) tumors of the spine.
On the other hand, primary tumors of the spine are rare, their real incidence is unknown
In the past years, conventional radiation therapy (RT) was the standard of care for
patients with metastatic spine tumor.
However as surgical techniques and instruments improve, surgical treatment followed
by adjuvant RT is affording a longer survival period and better quality of life than RT
alone.
The benefit of perioperative RT has never been fully investigated, but it is assumed to be
beneficial because in most cases spinal tumor resection does not achieve complete
eradication of the microscopic tumor cells. For this reason, tumor surgery is often
accompanied by perioperative RT
Ankylosing Spondylitis
Ankylosing spondylitis, a disease affecting 0.10.5% of the population, is a
chronic inflammatory spine disorder that presents significant challenges for
the spine surgeon.
Although the most common complaint of such patients is spreading lower
back pain in 8090% of clinical presentations, the majority of complaints are
related to complications of spinal trauma or a progressive spinal deformity.
With regard to spinal deformity, reconstructive surgery in the spondylotic
spine has the potential to cause severe neurological damage because of the
complex dynamic forces involved in deformity correction acting on a both
rigid and brittle spine.
Although a smooth and successful intubation is of paramount
importance in airway management and prior to any surgical
intervention, the risks are significantly increased in patients with
AS.
First, the presence of large anterior cervical osteophytes may
prohibit successful visualization of the larynx and may prevent
endotracheal intubation due to significant mass obstruction.
Proper positioning of a patient with AS in the operating room or the ICU is
imperative not only for the patient with an unstable fracture, but in all AS
patients because of their an increased risk of iatrogenic injury.
During head positioning, the surgeon must take into account the sagittal
alignment of the cervical spine, which may often be significantly kyphotic.
When fractures already exist in these patients, inadequate assessment of
the mass of the head and the extent of cervical kyphosis can have
disastrous effects such as complete spinal cord damage and possible death
In surgeries involving osteotomy or reduction of the cervical spine,
preoperative halo placement and traction have shown success in
improving stability during positioning
The ability to monitor the neurological status of any patient during
positioning or surgical manipulation is extremely important in any
spine surgery
Ehlers-Danlos Syndrome
Ehlers-Danlos Syndrome (EDS, Orphanumber: ORPHA98249) is an
umbrella term for a growing number of heritable connective tissue
disorders, mainly featuring joint hypermobility and instability, skin
texture anomalies and vascular and internal organ fragility.
The overall incidence is 1:10,000 to 1:25,000 with no ethnic
predisposition, resulting in a presumed number of at least 20,000-
50,000 EDS patients in the Northern America
Preoperative history and physical examination, general assessment and subtype
classification, results of previous clinical genetic counseling, and a standardized
bleeding history should be taken, as well as assessment of any intubation
difficulties.
Muscular weakness and signs of aortic or mitral insufficiency should be sought.
A Doppler ultrasound scan might help exclude subclinical cardiac pathology (e.g.
non-progressive aortic root dilatation or hemodynamically relevant valve
insufficiency).
Non-invasive monitoring should be performed whenever possible,
although some patients are prone to bruising and hematoma
formation by repetitive non-invasive blood pressure measurements.
On the other hand, invasive blood pressure monitoring runs the risk
of vascular wall dissection (mainly for EDS subtypes with vascular
fragility); we recommend avoiding invasive measurements
whenever possible in non-emergency surgery in vascular EDS.
Ultrasound might reduce the risk of repeated vascular puncture.
Postural orthostatic tachycardia syndrome (POTS) is sometimes a
feature in EDS, especially those with the hypermobile variant (or
joint hypermobility syndrome).
Preoperative infusion of crystalloid and early use of vasopressors
may be helpful.
Summary
Spinal surgical procedures have a wide variety and comprise a major subgroup of
orthophaedic surgery.
Thousands of patients undergo spinal surgery every year.
Perioperative management of the spinal cases is directly related with
perioperative morbidity and mortality.
Preoperative assessment is one of the most important stages of perioperative
care. Whereas, the focus of intraoperative management is minimizing spinal
cord ischaemia and compression on the spinal cord.
Most spinal surgery is painful and good postoperative analgesia is important.
A multimodal analgesic approach is recommended. A combination of local and
regional anaesthesia, opioids, ketamine and NSAIDs can be used.

Spine Surgery

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DEPARTMENT OF ORTHOPAEDIC AND TRAUMATOLOGY

FACULTY OF MEDICINE | HASANUDDIN UNIVERSITY

With the aging US population, there has been an

Management of spine surgery patients with

Management of spine surgery patients with osteoporosis is

The perioperative corrective spinal surgery is challenging. The

Spine surgeries are performed for varied pathologies, including

A holistic approach needs to be employed while evaluating the

The associated neuro-muscular diseases (NMD), airway diffi culty and

Neurophysiological monitoring of spinal cord integrity is the gold

The postoperative care mandates an effective analgesic and respiratory

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