American Society of Regional Anesthesia and Pain Medicine August 2017 - 32

current literature does not conclusively suggest a decrease in blood
loss in neuraxial techniques for lumbar surgery.9
A recent retrospective study of 400 patients performed at
Massachusetts General Hospital suggested a cost reduction with
the use of spinal anesthesia. The median operating room (OR) times
of the general anesthesia cases in this study were longer than
the neuraxial anesthetic cases (175 ± 39 and 158 ± 33 minutes,
respectively) by approximately 20 minutes. Spinal anesthesia was
also associated with a 10.3% lower direct OR cost compared with
general anesthesia.10 While variability exists among institutions, the
results of this review encourage the use of regional anesthesia in
these short (<2 hour) elective lumbar spine surgeries. According
to the Healthcare Cost and Utilization Project (HCUP) Statistical
Briefs, laminectomy was listed as the third most common operating
room procedure in 2012, with 468,200 cases performed that year.11
Clearly, a cost savings for this common surgical procedure could be
substantial if more procedures were performed under a neuraxial
anesthetic.

One prospective study of 100 patients reports that PONV is more
common in patients receiving spinal anesthesia instead of general
anesthesia. In this study, general anesthesia with total intravenous
anesthesia (propofol and alfentanil for maintenance of anesthesia)
was used instead of inhalation agents. As a result, the antiemetic
effect of propofol in the neuraxial anesthetic arms of other studies
was neutralized. This very interesting study reveals that the spinal
anesthetic may not be the cause of reduced nausea and vomiting
but that spinal anesthesia may actually result in more PONV than
general anesthesia.12
CONCLUSIONS
While the majority of elective lumbar spine procedures-such
as discectomy, decompression of spinal stenosis, and fusion
for degenerative instability-are performed under general
anesthesia, the evidence is largely supportive of using spinal or
epidural anesthesia. The benefits are compelling: a spontaneously
ventilating, awake patient with a decreased incidence of
intraoperative hypertension and tachycardia, reduced analgesic
requirement in the
postanesthesia care unit,
less PONV, and a shorter
length of hospital stay.
Under the appropriate
circumstances, neuraxial
anesthesia should be
considered as a reasonable
alternative anesthetic plan
for lumbar surgery.

"Lumbar spine surgery can be performed
under general anesthesia, neuraxial
anesthesia, or local anesthetic infiltration
with monitored anesthesia care."

While intrathecal anesthesia
is most commonly reported
in the literature, a technique
commonly utilized by author
S.B.B. for short duration
procedures utilizes epidural
anesthesia. This technique
involves gentle intravenous
fluid loading (300-500
ml) and epidural catheter insertion two levels above the planned
surgical site. The epidural is then dosed with fentanyl 100 mcg
and lidocaine 2% in 5 mL incremental boluses until an adequate
surgical level is obtained. The patient is kept alert until positioning
is complete, monitored closely for hemodynamic changes, and the
epidural catheter is then removed prior to the surgical incision.
Sedation is titrated to patient comfort and generally consists of
propofol, ketamine, midazolam, and fentanyl.

POTENTIAL RISKS/COMPLICATIONS
With every intervention, there are inherent risks. In the case of
neuraxial anesthesia, surgeons are often apprehensive about
patient movement. Intraoperatively, there is a risk of high spinal
level resulting in apnea in the prone position, failed spinal attempt,
surgical delay, and the possible need to convert to general anesthesia.
Surgeon unfamiliarity with neuraxial anesthesia and anesthesiologist
discomfort with a patient in the prone position without a secure
airway can also preclude a team from offering a spinal or epidural to
a patient having lumbar surgery.4 Most studies to date are supportive
of neuraxial anesthesia for these cases and cite reduced postoperative
analgesic requirements, shorter hospital length of stay, reduced
urinary retention, and reduced hemodynamic fluctuation.

32

REFERENCES
1.

Mixter WJ, Barr JS. Rupture of the intervertebral disk with involvement of the
spinal canal. N Engl J Med. 1934;211:210-215.

2.

Caspar W. A new surgical procedure for lumbar disk herniation causing less
tissue damage through a microsurgical approach. Adv Neurosurg. 1977;4:74-
80.

3.

Kroll D. Lumbar microdiscectomy. Tech Reg Anesth Pain Manag. 2013;17:36-38.

4.

McLain RF, Bell GR, Kalfas I, Tetzlaff JE, Yoon HJ. Complications associated with
lumbar laminectomy: a comparison of spinal versus general anesthesia. Spine.
2004:29:2542-2547.

6.

Sanusi T, Davis J, Nicassio N, Malik I. Endoscopic lumbar discectomy
under local anesthesia may be an alternative to microdiscectomy: a single
centre's experience using the far lateral approach. Clin Neurol Neurosurg.
2015;139:324-327.

7.

Nicassio N, Malik I. Spinal anaesthesia. In: Spinal Surgery, Topics in Spinal
Anaesthesia. Whizar-Lugo V (ed.). Rijeka, Croatia: In Tech;2014. Available
at: https://www.intechopen.com/books/topics-in-spinal-anaesthesia/spinalanaesthesia-in-spinal-surgery. Accessed June 2017.

8.

Chui J, Craen RA. An update on the prone position: continuing professional
development. Can J Anaesth. 2016;63:737-767.

9.

Meng T, Zhong Z, Meng L. Impact of spinal anesthesia vs. general anesthesia on
perioperative outcome in lumbar spine surgery: A systematic review and metaanalysis of randomized, controlled trials. Anaesthesia. 2017;72:391-401.

American Society of Regional Anesthesia and Pain Medicine
2017


https://www.intechopen.com/books/topics-in-spinal-anaesthesia/spinal-anaesthesia-in-spinal-surgery https://www.intechopen.com/books/topics-in-spinal-anaesthesia/spinal-anaesthesia-in-spinal-surgery

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