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Anesthesia For Spinal Surgery


       Dr.Alaka Purohit
        Associate professor

 DEPARTMENT OF ANAESTHESIOLOGY
     S.M.S. MEDICAL COLLEGE
              JAIPUR
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 may
   occur.
Anaesthetic considerations (contd)


 Renaland Liver function
 assessment
Suggested preoperative investigations
          before major spinal surgery
              Minimum investigations               Optional investigations
Airway        x-rays Cervical spine lateral view
               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 achieved without any neck movement
        (manual in-line stabilization or a hard collar)
    Fiber-optic laryngoscopy:
       Fixed flexion deformities: involving upper T-spine/c-spine
       Pts wearing stabilization devices such as halo vests
       Anatomical reasons: micrognathia, limited mouth opening
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.
Emergence
                     Fully awake,telling name
                     Responding to commands
                     Able to manage his/her own airway
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
   Check breath sounds bilaterally
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)

Monitor disconnects are hard to avoid;carefully manage.
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
                                   kinking of the vertebral artery
   L-spine excessive lordosis may lead to neurologic injury
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 of
   SSEP intraoperatively
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 visualization
• Methods : Proper positioning
              Positive pressure ventilation
              Administration of hypotensive drugs
                  sodium nitropruside      B - Blockers
                   Nitroglycerine          Propofol
                   Trimethaphan            Inhalational
                   Adenosine             (Halothane/ isofluran)
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
          Cerebrovascular disease
          Uncontrolled glaucoma
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

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Anesthetic considerations for spinal surgery

  • 1. Anesthesia For Spinal Surgery Dr.Alaka Purohit Associate professor DEPARTMENT OF ANAESTHESIOLOGY S.M.S. MEDICAL COLLEGE JAIPUR
  • 2. Anesthesia For Spinal Surgery •Spinal conditions requiring spinal surgery •Surgical procedures •Anesthetic considerations •Unique challenges for spinal surgery
  • 3. General Indications for Spine Surgery  Neurologic dysfunction (compression)  Structural instability  Pathologic lesions  Deformity  Pain
  • 4. Spinal conditions requiring spinal surgery Intervertebral disc lesions Spondylolisthesis
  • 5. Spinal conditions requiring spinal surgery Spinal stenosis Scoliosis Kyphosis Spinal tumor
  • 6. Surgical procedures Laminotomy Laminectomy Discectomy
  • 7. Surgical procedures Instrumentation Fusion and Fixation
  • 8. 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.
  • 9. Anesthetic considerations (cont) RESPIRATORY SYSTEM: •Any existing ventilatory impairment •Any signs of pulmonary infection, asthma etc •spine deformities eg. Scoliosis kyphosis ankylosis etc.
  • 10. Anesthetic considerations (cont) Cardiovascular System Besides routine examination: B.P, heart sounds, History: Hypertension Diabetes mellitus Congestive heart failure Coronary artery disease
  • 11. 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 may occur.
  • 12. Anaesthetic considerations (contd)  Renaland Liver function assessment
  • 13. Suggested preoperative investigations before major spinal surgery Minimum investigations Optional investigations Airway x-rays Cervical spine lateral view 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)
  • 14. Anaesthesia technique Premedication:  Consideration of immense pain in patients with degenerative diseases – opiods  premedication sparingly used in patients with difficult airways or ventilatory impairment.
  • 15. 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
  • 16. 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 achieved without any neck movement (manual in-line stabilization or a hard collar) Fiber-optic laryngoscopy: Fixed flexion deformities: involving upper T-spine/c-spine Pts wearing stabilization devices such as halo vests Anatomical reasons: micrognathia, limited mouth opening
  • 17. Algorithm for decision making when intubating a pt for proposed surgery involving the upper T or cervical spine
  • 18. 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. Emergence Fully awake,telling name Responding to commands Able to manage his/her own airway
  • 19. Unique challenges for spinal surgery Positioning Intra-operative monitoring Spinal cord injury Post-operative visual loss (POVL)
  • 20. Positioning  Prone position : most spinal procedures  Supine position with head traction in anterior approach to cervical spine  Sitting or lateral decubitus position : occasionlly
  • 21. Positioning Prone position for thoracic and dorsal-spine procedure
  • 22. Positioning Prone position for C-spine procedure
  • 23. 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  Check breath sounds bilaterally
  • 24. 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) Monitor disconnects are hard to avoid;carefully manage.
  • 25. 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 kinking of the vertebral artery L-spine excessive lordosis may lead to neurologic injury
  • 26. Spine Surgery- Monitoring  Routine  Arterial line  CVP/ PA catheter  Neurophysiologic: . Wake up test . SSEP . MEP . EMG
  • 27. 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
  • 28. 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
  • 29. 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 of SSEP intraoperatively
  • 30. Indications for SSEP’s  Spinal instrumentation  Scoliosis correction  Spinal cord operations
  • 31. 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
  • 32. 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
  • 33. MEPs ( Muscle evoke potentials) Motor cortex stimulated by electrical or magnetic means Neurogenic responses: peripheral N or spinal cord Myogenic responses
  • 34. 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.
  • 35. 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
  • 36. 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.
  • 37. Spinal cord injury Risk factors: • Length and type of surgical procedure • Spinal cord perfusion pressure • Underlying spinal pathology • Pressure on neural tissue during surgery
  • 38. Spine surgery: Conditions of Increased Risk  Spinal distraction  Sub laminar wiring  Induced hypotension  Inadvertent cord compression  Certain instrumentation (Luque rods)  Ligation of segmental arteries
  • 39. 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
  • 40. Methods of Reducing Blood Loss and Limiting Homologous Transfusions  Proper positioning to reduce intraabdominal pressure  Surgical hemostasis  Deliberate hemodilution (?)  Preoperative donation of autologous blood
  • 41. Controlled Hypotensive Anaesthesia • Definition: It is the elective lowering of arterial B.P. • Advantage : Minimization of surgical blood loss Better wound visualization • Methods : Proper positioning Positive pressure ventilation Administration of hypotensive drugs sodium nitropruside B - Blockers Nitroglycerine Propofol Trimethaphan Inhalational Adenosine (Halothane/ isofluran)
  • 42. 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.
  • 43. 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 Cerebrovascular disease Uncontrolled glaucoma
  • 44. 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
  • 45. 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)
  • 46. Injuries: Eye  Corneal abrasions  Orbital edema  Postoperative visual loss ( POVL)
  • 47. 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%).
  • 48. 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