Intravenous Ketorolac Substantially Reduces Opioid Use and Length of Stay After Lumbar Fusion: A Randomized Controlled Trial.

STUDY DESIGN: A randomized, double-blinded, placebo-controlled trial. OBJECTIVE: To examine the effect of intravenous ketorolac (IV-K) on hospital opioid use compared with IV-placebo (IV-P) and IV acetaminophen (IV-A). SUMMARY OF BACKGROUND DATA: Controlling postoperative pain while minimizing opioid use after lumbar spinal fusion is an important area of study. PATIENTS AND METHODS: Patients aged 18 to 75 years undergoing 1 to 2 level lumbar fusions between April 2016 and December 2019 were included. Patients with chronic opioid use, smokers, and those on systemic glucocorticoids or contraindications to study medications were excluded. A block randomization scheme was used, and study personnel, hospital staff, and subjects were blinded to the assignment. Patients were randomized postoperatively. The IV-K group received 15 mg (age > 65) or 30 mg (age < 65) every six hours (q6h) for 48 hours, IV-A received 1000 mg q6h, and IV-P received normal saline q6h for 48 hours. Demographic and surgical details, opioid use in morphine milliequivalents, opioid-related adverse events, and length of stay (LOS) were recorded. The primary outcome was in-hospital opioid use up to 72 hours. RESULTS: A total of 171 patients were included (58 IV-K, 55 IV-A, and 58 IV-P) in the intent-to-treat (ITT) analysis, with a mean age of 57.1 years. The IV-K group had lower opioid use at 72 hours (173 ± 157 mg) versus IV-A (255 ± 179 mg) and IV-P (299 ± 179 mg; P = 0.000). In terms of opiate use, IV-K was superior to IV-A ( P = 0.025) and IV-P ( P = 0.000) on ITT analysis, although on per-protocol analysis, the difference with IV-A did not reach significance ( P = 0.063). When compared with IV-P, IV-K patients reported significantly lower worst ( P = 0.004), best ( P = 0.001), average ( P = 0.001), and current pain ( P = 0.002) on postoperative day 1, and significantly shorter LOS ( P = 0.009) on ITT analysis. There were no differences in opioid-related adverse events, drain output, clinical outcomes, transfusion rates, or fusion rates. CONCLUSIONS: By reducing opioid use, improving pain control on postoperative day 1, and decreasing LOS without increases in complications or pseudarthrosis, IV-K may be an important component of "enhanced recovery after surgery" protocols.

Erector Spinae Plane Block Reduces Immediate Postoperative Pain and Opioid Demand After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Matched cohort comparison. OBJECTIVE: To determine perioperative outcomes of erector spinae plane (ESP) block for minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). SUMMARY OF BACKGROUND DATA: There is a paucity of data on the impact of lumbar ESP block on perioperative outcomes and its safety in MI-TLIF. MATERIALS AND METHODS: Patients who underwent 1-level MI-TLIF and received the ESP block (group E ) were included. An age and sex-matched control group was selected from a historical cohort that received the standard-of-care (group NE). The primary outcome of this study was 24-hour opioid consumption in morphine milligram equivalents. Secondary outcomes were pain severity measured by a numeric rating scale, opioid-related side effects, and hospital length of stay. Outcomes were compared between the two groups. RESULTS: Ninety-eight and 55 patients were included in the E and NE groups, respectively. There were no significant differences between the two cohorts in patient demographics. Group E had lower 24-hour postoperative opioid consumption ( P = 0.117, not significant), reduced opioid consumption on a postoperative day (POD) 0 ( P = 0.016), and lower first pain scores postsurgery ( P < 0.001). Group E had lower intraoperative opioid requirements ( P < 0.001), and significantly lower average numeric rating scale pain scores on POD 0 ( P = 0.034). Group E reported fewer opioid-related side effects as compared with group NE, although this was not statistically significant. The average highest postoperative pain score within 3 hours postprocedurally was 6.9 and 7.7 in the E and NE cohorts, respectively ( P = 0.029). The median length of stay was comparable between groups with the majority of patients in both groups being discharged on POD 1. CONCLUSIONS: In our retrospective matched cohort, ESP blocks resulted in reduced opioid consumption and decreased pain scores on POD 0 in patients undergoing MI-TLIF. LEVEL OF EVIDENCE: Level 3.

Comparative review of airway anesthesia and sedation methods for awake intubation.

PURPOSE OF REVIEW: Successful awake intubation hinges upon adequate airway anesthesia and sedation for patient comfort. This review will summarize relevant anatomy and regional anesthesia techniques to achieve airway anesthesia, and compare various airway anesthesia and sedation regimens. RECENT FINDINGS: Overall, nerve blocks consistently provided superior airway anesthesia, shorter time to intubation, higher patient comfort, and higher postintubation patient satisfaction. Additionally, ultrasound guidance can further provide benefit by reducing the amount of local anesthetic administered, leading to denser blockade, and proving invaluable in challenging clinical situations. Regarding sedation methods, numerous studies supported the use of dexmedetomidine, with or without the addition of supplemental sedation, such as midazolam, ketamine, or opioids. SUMMARY: Emerging evidence has indicated that nerve blocks for airway anesthesia may be superior to other methods of topicalization. Additionally, dexmedetomidine can be useful, both as monotherapy and with supplemental sedatives, to safely provide anxiolysis for the patient and increase success. However, it is crucial to note that the method of airway anesthesia and sedation regimen should be adapted to each patient and clinical situation, and knowledge of multiple techniques and sedation regimens can best equip anesthesiologists to do so.

Enhanced Recovery after Lumbar Spine Fusion: A Randomized Controlled Trial to Assess the Quality of Patient Recovery.

BACKGROUND: Prospective trials of enhanced recovery after spine surgery are lacking. We tested the hypothesis that an enhanced recovery pathway improves quality of recovery after one- to two-level lumbar fusion. METHODS: A patient- and assessor-blinded trial of 56 patients randomized to enhanced recovery (17 evidence-based pre-, intra-, and postoperative care elements) or usual care was performed. The primary outcome was Quality of Recovery-40 score (40 to 200 points) at postoperative day 3. Twelve points defined the clinically important difference. Secondary outcomes included Quality of Recovery-40 at days 0 to 2, 14, and 56; time to oral intake and discharge from physical therapy; length of stay; numeric pain scores (0 to 10); opioid consumption (morphine equivalents); duration of intravenous patient-controlled analgesia use; complications; and markers of surgical stress (interleukin 6, cortisol, and C-reactive protein). RESULTS: The analysis included 25 enhanced recovery patients and 26 usual care patients. Significantly higher Quality of Recovery-40 scores were found in the enhanced recovery group at postoperative day 3 (179 ± 14 vs. 170 ± 16; P = 0.041) without reaching the clinically important difference. There were no significant differences in recovery scores at days 0 (175 ± 16 vs. 162 ± 22; P = 0.059), 1 (174 ± 18 vs. 164 ± 15; P = 0.050), 2 (174 ± 18 vs. 167 ± 17; P = 0.289), 14 (184 ± 13 vs. 180 ± 12; P = 0.500), and 56 (187 ± 14 vs. 190 ± 8; P = 0.801). In the enhanced recovery group, subscores on the Quality of Recovery-40 comfort dimension were higher (longitudinal mean score difference, 4; 95% CI, 1, 7; P = 0.008); time to oral intake (-3 h; 95% CI, -6, -0.5; P = 0.010); and duration of intravenous patient-controlled analgesia (-11 h; 95% CI, -19, -6; P < 0.001) were shorter; opioid consumption was lower at day 1 (-57 mg; 95% CI, -130, -5; P = 0.030) without adversely affecting pain scores (-2; 95% CI, -3, 0; P = 0.005); and C-reactive protein was lower at day 3 (6.1; 95% CI, 3.8, 15.7 vs. 15.9; 95% CI, 6.6, 19.7; P = 0.037). CONCLUSIONS: Statistically significant gains in early recovery were achieved by an enhanced recovery pathway. However, significant clinical impact was not demonstrated.

Trends in Ambulatory Laminectomy in the USA and Key Factors Associated with Successful Same-Day Discharge: A Retrospective Cohort Study.

BACKGROUND: Laminectomy is commonly used in the treatment of lumbar spine pathology. Laminectomies are increasingly being performed in outpatient settings, but patient safety concerns remain. QUESTIONS/PURPOSES: We aimed to describe trends in outpatient lumbar laminectomy between 2008 and 2016 and to identify factors associated with successful same-day discharge. METHODS: We identified patients who underwent single-level lumbar laminectomy between 2008 and 2016 in the American College of Surgeons' National Surgical Quality Improvement Program database and divided them into two groups according to their admission status, either inpatient or outpatient. Inpatient and outpatient groups were further divided according to actual length of stay (LOS): did not remain in the hospital overnight (LOS = 0) or stayed in the hospital overnight or longer (LOS ≥ 1). We then analyzed patient characteristics and complications for significance and to identify factors associated with successful same-day discharge. RESULTS: We identified 85,769 patients, 41,149 classified as outpatient status and 44,620 as inpatient status. Between 2008 and 2016, the proportion of procedures performed on an outpatient basis increased from 24.1 to 56.74%. Overall, 27.3% of all patients were discharged on the day of surgery, representing 52.8% of outpatients and 3.8% of inpatients. Older age and longer duration of surgery predicted that patients were less likely to have same-day discharge. Patients with a primary diagnosis other than intervertebral disk disorder, Hispanic ethnic background, or an American Society of Anesthesiologists physical status classification of III were less likely to achieve same-day discharge. Patients under the care of orthopedic surgeons (as opposed to neurosurgeons) were more likely to be discharged on the day of surgery. We also found an association between sex and day of discharge, with female patients being less likely to be discharged on the day of surgery. CONCLUSIONS: Laminectomy is increasingly being performed in the outpatient setting. Younger, healthier non-Hispanic male patients undergoing uncomplicated surgery have a higher likelihood of successful same-day discharge.

Hemodynamically significant cardiac arrhythmias during general anesthesia for spine surgery: A case series and literature review.

BACKGROUND CONTEXT: Hemodynamically significant bradycardia and cardiac arrest (CA) are rare under general anesthesia (GA) for spine surgery. Although patient risks are well defined, emerging data implicate surgical, anesthetic and neurologic factors which should be considered in the immediate management and decision to continue or terminate surgery. PURPOSE: To characterize causes and contributors to significant arrhythmias during spine surgery. We also provide an updated literature review to inform spine care teams and aid in the management of intraoperative bradycardia and CA. STUDY DESIGN: Case series and literature review. PATIENT SAMPLE: Six patients who underwent spine surgery from 03/2016 to 01/2020 at a single institution and developed unexpected hemodynamically significant arrhythmia. OUTCOME MEASURES: Our primary outcome was to identify potential risk factors of interest for significant arrhythmia during spine surgery. METHODS: Medical records of patients who underwent spine surgery from 03/2016 to 01/2020 at a single institution and developed unexpected hemodynamically significant arrhythmia during spine surgery were identified from a departmental Quality Assurance Database. We evaluated the presence/absence of patient, surgical, anesthetic and neurologic risk factors and estimated the most likely etiology of the event, immediate and subsequent management, whether surgery was postponed or continued and outcomes. RESULTS: We found a temporal relationship of bradyarrhythmia and CA after somatosensory evoked potential (SSEP) stimulation in 4/6 cases and pharmacy/polypharmacy in 2/6. Surgery was completed in 4/6 patients, and terminated in 2/6 (subsequently completed in both). We found no adverse outcomes in any patients. Our literature review predominately identified case reports for guidance to support decision making. New literaure suggests peripheral nerve blocks and opioid-sparing anesthetic agents should also be considered. CONCLUSIONS: Significant bradycardia and CA during spine surgery does not always require termination of the surgical procedure. Decision making should be undertaken in each case individually, with an updated awareness of potential causes. The study also suggests the need for large prospective studies to adequately assess incidence, risk factors and outcomes.

Effects of a multimodal analgesic pathway with transversus abdominis plane block for lumbar spine fusion: a prospective feasibility trial.

PURPOSE: Lumbar spine fusion with anterior (ALIF) or lateral (LLIF) approach is a moderately painful procedure associated with significant length of hospital stay (LoS) and opioid requirements. We developed an opioid-sparing analgesic pathway of care for ALIF and LLIF, featuring transversus abdominis plane (TAP) block. In this study, we assessed the feasibility of performing the TAP block as an analgesic adjunct for ALIF or LLIF. METHODS: This is a prospective feasibility study of 32 patients. All patients received pre-incisional TAP block, regularly scheduled non-opioid analgesics (gabapentin, acetaminophen, ketorolac), and oral tramadol, as needed. The primary feasibility outcomes were rates of recruitment, adherence and adverse events associated with the TAP block. Secondary outcomes included assessment of TAP block efficacy and duration, numeric rating scale (NRS) pain scores, LoS and opioid consumption. RESULTS: Thirty-three patients were approached for the study, and all were enrolled. One patient did not have surgery. All patients received the intervention. There were no block-related adverse events. PACU NRS scores were significantly lower (1.9 ± 3.0) than at postoperative day 1 (POD1; 3.3 ± 2.5). The TAP block was effective in 31/32 patients, with 1 failed block. Median LoS was 26.8 h (IQR 22.8-49.5 h). Median opioid consumption was 57.5 oral morphine equivalents (IQR 30-74.38). One patient required opioid iv patient-controlled analgesia. CONCLUSIONS: Applying TAP block to spine surgery is a novel pain management strategy. This study demonstrates high patient acceptance and the general safety of the technique. Although lacking a control arm, these results also provide preliminary data supporting efficacy. These slides can be retrieved under Electronic Supplementary Material.

Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study.

OBJECTIVEEnhanced recovery after surgery (ERAS) and multimodal analgesia are established care models that minimize perioperative opioid consumption and promote positive outcomes after spine surgery. Opioid-free anesthesia (OFA) is an emerging technique that may achieve similar goals. The purpose of this study was to evaluate an OFA regimen within an ERAS pathway for lumbar decompressive surgery and to compare perioperative opioid requirements in a matched cohort of patients managed with traditional opioid-containing anesthesia (OCA).METHODSThe authors performed a retrospective analysis of prospectively collected data. They included 36 patients who underwent lumbar decompression under their ERAS pathway for spinal decompression between February and August 2018. Eighteen patients who received OFA were matched in a 1:1 ratio to a cohort managed with a traditional OCA regimen. The primary outcome was total perioperative opioid consumption. Postoperative pain scores (measured using the numerical rating scale [NRS]), opioid consumption (total morphine equivalents), and length of stay (time to readiness for discharge) were compared in the postanesthesia care unit (PACU). The authors also assessed compliance with ERAS process measures and compared compliance during 3 phases of care: pre-, intra-, and postoperative.RESULTSThere was a significant reduction in total perioperative opioid consumption in patients who received OFA (2.43 ± 0.86 oral morphine equivalents [OMEs]; mean ± SEM), compared to patients who received OCA (38.125 ± 6.11 OMEs). There were no significant differences in worst postoperative pain scores (NRS scores 2.55 ± 0.70 vs 2.58 ± 0.73) or opioid consumption (5.28 ± 1.7 vs 4.86 ± 1.5 OMEs) in the PACU between OFA and OCA groups, respectively. There was a clinically significant decrease in time to readiness for discharge from the PACU associated with OFA (37 minutes), although this was not statistically significantly different. The authors found high overall compliance with ERAS process measures (91.4%) but variation in compliance according to phase of care. The highest compliance occurred during the preoperative phase (94.71% ± 2.88%), and the lowest compliance occurred during the postoperative phase of care (85.4% ± 5.7%).CONCLUSIONSOFA within an ERAS pathway for lumbar spinal decompression represents an opportunity to minimize perioperative opioid exposure without adversely affecting pain control or recovery. This study reveals opportunities for patient and provider education to reinforce ERAS and highlights the postoperative phase of care as a time when resources should be focused to increase ERAS adherence.

An enhanced recovery after surgery pathway: association with rapid discharge and minimal complications after anterior cervical spine surgery.

OBJECTIVEEnhanced recovery after surgery (ERAS) pathways are associated with improved outcomes, lower morbidity and complications, and higher patient satisfaction in multiple surgical subspecialties. Despite these gains, there are few data to guide the application of ERAS concepts to spine surgery. The authors report the development and implementation of the first ERAS pathway for patients undergoing anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA).METHODSThis was a retrospective cohort study of prospectively collected data. The authors created a multidisciplinary pathway based on best available evidence for interventions that positively influence outcomes after anterior cervical spine surgery. Patients were followed prospectively up to postoperative day 90. Patient data were collected via electronic medical record review and included demographics, comorbidities, baseline and perioperative opioid use, postoperative complications, and length of hospital stay (LOS). ERAS process measures and compliance with pathway elements were also tracked.RESULTSThirty-three patients were cared for under the pathway (n = 25 ACDF; n = 8 CDA). The median LOS was 416 minutes (interquartile range [IQR] 210-1643 minutes). Eight patients required an extended stay-longer than 23 hours. Reasons for extended admission included pain (n = 4), dyspnea (n = 1), hypoxia (n = 1), hypertension (n = 1), and dysphagia (n = 1). The median LOS for the 8 patients who required extended monitoring prior to discharge was 1585 minutes (IQR 1423-1713 minutes). Overall pathway compliance with included process measures was 85.6%. The median number of ERAS process elements delivered to each patient was 18. There was no strong association between LOS and number of ERAS process elements provided (Pearson's r = -0.20). Twelve percent of the cohort was opioid tolerant on the day of surgery. There were no significant differences between total intraoperatively or postanesthesia care unit-administered opioid, or LOS, between opioid-tolerant and opioid-naïve patients. There were no complications requiring readmission.CONCLUSIONSAn ERAS pathway for anterior cervical spine surgery facilitates safe, prompt discharge. The ERAS pathway was associated with minimal complications, and no readmissions within 90 days of surgery. Pain and respiratory compromise were both linked with extended LOS in this cohort. Further prospective studies are needed to confirm the potential benefits of ERAS for anterior cervical spine surgery, including longer-term complications, cost, and functional outcomes.

An Observational Study of Cerebral Blood Flow Velocity Evaluation in the Prone Position During Posterior Lumbar Surgery.

BACKGROUND: Prone positioning (PP) is necessary for surgical access during posterior spine procedure. However, physiological changes occur in the PP. Typical findings are a decrease in arterial blood pressure and in cardiac output that could potentially lead to an alteration in cerebral perfusion. Therefore, we decided to study cerebral blood flow velocity (CBFV) with transcranial Doppler ultrasonography to evaluate the effect of the PP on cerebral hemodynamics. METHODS: Twenty-two patients undergoing spine surgery in the PP were studied. General anesthesia was induced using 250 µg of fentanyl, 2 mg/kg of propofol, and 0.1 mg/kg of vecuronium, and was maintained with 0.25%-0.5% isoflurane, 50% nitrous oxide in oxygen, continuous infusion of 100 µg/kg/min of propofol, 1.5 µg/kg/h of fentanyl, and 0.15 mg/kg/h of ketamine. Continuous invasive arterial blood pressure, heart rate, electrocardiogram, and end-tidal carbon dioxide were monitored. CBFV with transcranial Doppler in the middle cerebral artery was first measured with the patients under general anesthesia in the supine position. Patients were then placed in the PP and remained in this position throughout surgery. CBFV, end-tidal carbon dioxide, heart rate, and blood pressure were measured continuously for 75 minutes after initiation of PP. This coincided with surgical exposure and minimal blood loss. Data were analyzed every 15 minutes for statistical significant change over time. RESULTS: Mean arterial blood pressure decreased 15 minutes after the installation of the PP and onward, but this decrease was not statistically significant. CBFVsyst (the maximal CBFV during the systolic phase of a cardiac cycle) and CBFVmean (the time averaged value of the maximal velocity envelope over 1 cardiac cycle) did not vary at any time points. CBFVdiast (the CBFV just before the acceleration phase [systole] of the next waveform) was lower at T3 (30 minutes after PP) compared to T1 (value derived averaging the first measure in the PP with the ones at 5 and 10 minutes) (P = .01), and the pulsatility index was higher at T5 (60 minutes after PP) compared to T0 (baseline, patient supine under general anesthesia) (P = .04). Data were analyzed at specific time points (T0 and T1). This value was derived by computing an average of the CBFV values collected at the first measure in the PP and at 5 and 10 minutes thereafter: T2, 15 minutes after PP; T3, 30 minutes after PP; T4, 45 minutes after PP; T5, 60 minutes after PP; and T6, 75 minutes after PP. CONCLUSIONS: Our data on CBFV during PP for spine surgery demonstrate preservation of cerebral perfusion during stable systemic hemodynamic conditions. The present results do not allow us to determine whether the PP would be similarly tolerated with increasing length of surgery, variations in systemic hemodynamics, and in different patient populations.

Design and Implementation of an Enhanced Recovery After Surgery (ERAS) Program for Minimally Invasive Lumbar Decompression Spine Surgery: Initial Experience.

STUDY DESIGN: A retrospective cohort study of prospectively collected data. OBJECTIVE: The aim of this study was to describe the development of and early experience with an evidence-based enhanced recovery after surgery (ERAS) pathway for lumbar decompression. SUMMARY OF BACKGROUND DATA: ERAS protocols have been consistently associated with improved patient experience and outcomes, and reduced cost and length of hospital stay (LoS). Despite successes in other orthopedic subspecialties, ERAS has yet to be established in spine surgery. Here, we report the development of and initial experience with the first comprehensive ERAS pathway for MIS lumbar spine surgery. METHODS: An evidence-based review of the literature was performed to select components of the ERAS pathway. The pathway was applied to 61 consecutive patients presenting for microdiscectomy or lumbar laminotomy/laminectomy between dates. Data collection was performed by review of the electronic medical record. We evaluated compliance with individual ERAS process measures, and adherence to the overall pathway. The primary outcome was LoS. Demographics, comorbidities, perioperative course, prevalence of opioid tolerance, and factors affecting LoS were also documented. RESULTS: The protocol included 15 standard ERAS elements. Overall pathway compliance was 85.03%. Median LoS was 279 minutes [interquartile range (IQR) 195-398 minutes] overall, 298 minutes (IQR 192-811) for lumbar decompression and 285 minutes (IQR 200-372) for microdiscectomy. There was no correlation between surgical subtype or duration and LoS. Overall, 37% of the cohort was opioid-tolerant at the time of surgery. There was no significant effect of baseline opioid use on LoS, or on the total amount of intraoperative or PACU opioid administration. There were four complications (6.5%) resulting in extended LoS (>23 hours). CONCLUSION: This report comprises the first description of a comprehensive, evidence-based ERAS for spine pathway, tailored for lumbar decompression/microdiscectomy resulting in short LoS, minimal complications, and no readmissions within 90 days of surgery. LEVEL OF EVIDENCE: 3.

Evaluation of Postgraduates Following Implementation of a Focus Assessed Transthoracic Echocardiography (FATE) Training Course-A Pilot Study.

At our institution, implementation of a formal training course in Basic Focus Assessed Transthoracic Echocardiography (FATE) was associated with an improvement in anesthesia trainees' ability to obtain transthoracic echocardiography (TTE) images. Total image acquisition scores improved by a median (Q1, Q3) 9.1 (2.9,14.7) percentage points from pre-to post-hands-on FATE course (n=20; p=0.001). Participants who returned for a subsequent assessment 5 months following the course demonstrated a median (Q1, Q3) 18.0 (9.1,22.1) percentage point improvement from their pre-course total image acquisition scores (n=11; p=0.002). This pilot study established the feasibility of our program and results suggest that the basic FATE course can be used to teach trainees TTE quickly, effectively, and with significant retention.

Emergent reintubation following elective cervical surgery: A case series.

AIM: To review cases of emergent reintubation after cervical surgery. METHODS: Patients who were emergently intubated in the post-operative period following cervical surgery were identified. The patients' prospectively documented demographic parameters, medical history and clinical symptoms were ascertained. Pre-operative radiographs were examined for the extent of their pathology. The details of the operative procedure were discerned. RESULTS: Eight hundred and eighty patients received anterior- or combined anterior-posterior cervical surgery from 2008-2013. Nine patients (1.02%) required emergent reintubation. The interval between extubation to reintubation was 6.2 h [1-12]. Patients were kept intubated after reintubation for 2.3 d [2-3]. Seven patients displayed moderate postoperative edema. One patient was diagnosed with a compressive hematoma which was subsequently evacuated in the OR. Another patient was diagnosed with a pulmonary effusion and treated with diuretics. One patient received a late debridement for an infected hematoma. Six patients reported residual symptoms and three patients made a complete recovery. CONCLUSION: Respiratory compromise is a rare but potentially life threatening complication following cervical surgery. Patients at increased risk should be monitored closely for extended periods of time post-operatively. If the airway is restored adequately in a timely manner through emergent re-intubation, the outcome of the patients is generally favorable.

Aortic perforation during lateral lumbar interbody fusion.

STUDY DESIGN: A case report. OBJECTIVE: To report a unique case of aortic perforation during lateral lumbar interbody fusion (LLIF). SUMMARY OF BACKGROUND DATA: Among the reported advantages of this minimally invasive transpsoas procedure is the avoidance of an anterior intraperitoneal approach to the lumbar spine, thus avoiding visceral and vascular injuries typically associated with the latter. METHODS: We report a single case of aortic perforation during LLIF, which occurred in the setting of an incidental endplate and anterior vertebral cortex violation. RESULTS: During the implantation of an interbody prosthetic device at the L3-L4 level, the proximal aspect of the implant broke which caused cage misplacement. During the attempt to advance the well-fixed cage, distal violation of the endplate and anterior cortex of the L3 vertebra was noted, concomitant with immediate loss of blood pressure. A presumptive diagnosis of injury to a major vascular structure was quickly made, along with the decision to proceed with emergency laparotomy to repair a through-and-through laceration of the aortic terminus. After successful suture repair of the aortic lesions, the patient was kept intubated, and transferred to the intensive care unit in stable condition. CONCLUSIONS: The distal endplate and anterior vertebral cortex violation can result in the formation of an anterior bony spur in close proximity to the major abdominal vascular structures, and despite the avoidance of an anterior approach to the lumbar spine, surgery-related injury to major abdominal vessels can occur during LLIF. Aortic perforation is a rare, yet potentially lethal intraoperative complication of LLIF, which requires emergency laparatomy and vascular suture repair.

Cervical spine disease is a risk factor for persistent phrenic nerve paresis following interscalene nerve block.

The use of interscalene blocks (ISBs) for shoulder surgery improves postoperative pain control, reduces recovery room times, and reduces overall hospital stays. The most common and potentially disabling adverse effect associated with ISBs is phrenic nerve paresis. Fortunately, persistent phrenic nerve paresis (PPNP) is rare. There are only 4 case reports of PPNP in the English literature. At our institution, we identified 9 cases of PPNP over a 9-year period, representing an incidence of 1 (0.048%) in 2069. In conducting a case-control series, we found that symptomatic cervical spine disease is a risk factor for the development of PPNP. Patients with PPNP had a significantly higher incidence of cervical spine disease (85.7%) compared with the control group (30.9%), P < 0.01. Persistent phrenic nerve paresis remains a perplexing complication of ISB, and many questions remain unanswered. Our data identify an important risk factor that can aid in the risk stratification of patients undergoing ISB.

Comparative utility of centrally versus peripherally transduced venous pressure monitoring in the perioperative period in spine surgery patients.

STUDY OBJECTIVE: To compare central venous pressure (CVP) with peripheral venous pressure (PVP) monitoring during the intraoperative and postoperative periods in patients undergoing spine surgery. DESIGN: Prospective observational study. SETTING: University-affiliated teaching hospital. PATIENTS: 35 ASA physical status 1, 2, and 3 patients. INTERVENTIONS: A peripheral catheter in the forearm or hand and a central catheter into the internal jugular vein were placed for PVP and CVP monitoring, respectively. MEASUREMENTS: CVP and PVP values were collected simultaneously and recorded electronically at 5-minute intervals throughout surgery and in the recovery room. The number of attempts for catheter placement, ease of use, maintenance, and interpretation were recorded. Patient comfort, frequency of complications, and cost were analyzed. MAIN RESULTS: The correlation coefficient between CVP and PVP was 0.650 in the operating room (P < 0.0001) and 0.388 in the recovery room (P < 0.0001). There was no difference between groups in number of attempts to place either catheter, maintenance, and interpretation with respect to PVP and CVP monitoring in the operating room. In the recovery room, the nurses reported a higher level of difficulty in interpretation of PVP than CVP, but no differences were noted in ease of maintenance. There were no complications related to either central or peripheral catheter placement. Patient comfort and cost efficiency were higher with a peripheral than a central catheter. CONCLUSION: During clinically relevant conditions, there was limited correlation between PVP and CVP in the prone position during surgery and postoperatively in the recovery room.

Pulmonary injury in patients undergoing complex spine surgery.

BACKGROUND CONTEXT: Previous reports have shown that 15% of patients who undergo sequential anterior, then posterior, surgical corrections for spinal deformities demonstrate evidence of acute lung injury. By analyzing the bronchoalveolar lavage (BAL) fluid from these patients for evidence of acute inflammation, we might gain some insight into the etiology of this acute lung injury. PURPOSE: To elucidate the etiology of acute lung injury after corrective surgery for adult spinal deformities. STUDY DESIGN/SETTING: Fifteen adult patients with scoliosis scheduled for elective sequential anterior then posterior corrective (A/P) spinal deformity surgery. PATIENT SAMPLE: Consecutive adult patients with scoliosis scheduled for elective corrective surgery with the author (OBA). OUTCOME MEASURES: Patients were assessed for postoperative respiratory complications by oxygen requirements, continued mechanical ventilation, and radiological evidence of diffuse bilateral interstitial or alveolar infiltrates. An acute pulmonary inflammatory response included the presence of inflammatory cells and elevated cytokines in BAL fluid. METHODS: BAL were performed after induction of anesthesia but before surgery, at the completion of surgery, and on the morning after surgery with the patient still intubated. BAL fluid was analyzed for inflammatory cells and cytokine interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) levels. Patients were assessed postoperatively for increased pulmonary vascular resistance, radiological evidence of diffuse bilateral alveolar infiltrates, and the requirement for ventilatory support beyond the first postoperative day (POD1). RESULTS: The cell counts of BAL fluid demonstrated significant increases in neutrophils, lymphocytes, and lipid laden macrophages (LLMAC) with surgery. The concentration of the cytokines IL-6 and TNF-alpha also increased with surgery. The elevations in BAL inflammatory cells and cytokine levels correlated positively with increased pulmonary vascular resistance and the requirement for mechanical ventilation. CONCLUSIONS: After A/P spine fusions, patients have evidence of an acute inflammatory pulmonary injury. Several etiologies exist for this finding, including blood and fluid infusions, direct trauma to the lung, a systemic inflammatory response, and the embolization of fat and bone-marrow debris. The presence of LLMAC in the lungs of these patients and the finding that the patient with the requirement for the longest ventilatory support also had the highest BAL LLMAC count, suggest that the embolization of fat and bone debris released from the spine during surgery may be at least partially responsible for the lung injury. Further studies on the mechanism of lung injury during this procedure are warranted.

Guidelines for regional anesthesia fellowship training.

BACKGROUND: The number of regional anesthesia fellowships has grown over the past 2 decades. There currently exist no guidelines for what constitutes ideal regional anesthesia fellowship training. METHODS: Regional anesthesia fellowship program directors and other advocates of regional anesthesia were invited to participate in a collaborative project to establish a standardized curriculum for regional anesthesia fellowships. Guidelines were created based on the existing template of Accreditation Council of Graduate Medical Education program requirements for residency education in anesthesiology. The resulting draft guidelines were distributed at a meeting of the program directors, who were then asked to forward all comments and relevant training material from their respective institutions to a coordinating institution. RESULTS: All received materials were reviewed, and selected components were collated into a consensus document, which was then reviewed, modified, and eventually approved by the program directors over a 2-year series of meetings. The program directors agreed to adopt the guidelines as their fellowship curriculum and to evaluate their effectiveness in 2 years' time. CONCLUSIONS: The intent of these initial guidelines is to improve the quality and consistency of regional anesthesia fellowship training. The creation process also led to an affirmation of the directors' commitment to continued dialogue for the purpose of facilitating the exchange of ideas among programs.