Perioperative management in complex spine surgery.

The last two decades have seen a significant increase in the number of spine surgical procedures performed worldwide. This type of surgery includes a wide variety of procedures, from mini-invasive discectomies to multilevel spinal arthrodesis and osteotomies. Moreover, different surgical approaches are described at different spine levels: the anesthesiologist should be aware of the potential benefits and risks for the patients and be prepared for their management. In this narrative review we seek to describe basic concepts of perioperative spine care and address evolving areas in which care is changing. We will discuss preoperative concerns, intraoperative management including airway management, choice of maintenance, intraoperative neuromonitoring and anesthetic effect, blood management and the dynamic topic of anesthetic and analgesic techniques. Finally, we will briefly address the issue of perioperative complications as they relate specifically to spine surgery.

The Role of Regional Anesthesia During the SARS-CoV2 Pandemic: Appraisal of Clinical, Pharmacological and Organizational Aspects.

The severe acute respiratory syndrome coronavirus SARS-CoV2 is spreading over millions of people worldwide, leading to thousands of deaths, even among the healthcare providers. Italy has registered the deaths of 337 physicians and more than 200 nurses as of March 14, 2021. Anesthesiologists are at higher risk as they are the care providers in both ICU and operating rooms.Although the vaccination of healthcare providers has been the prioirity, physicians are still continually exposed to the virus and potentially risk contagion and must thus protect themselves and their patients from the risks of infection while providing the best care to their surgical patients.Regional anesthesia allows for a reduction in airway manipulation, reducing environmental contamination as a result. Furthermore, regional anesthesia reduces the opioid requirements as well as the muscle paralysis due to muscle-relaxants and should be recommended whenever possible in COVID-19 patients. Our aim is to evaluate the advantages and criticisms of regional anesthesia in the management of surgical patients in the pandemic age.

Spinal anaesthesia with Chloroprocaine HCl 1% for elective lower limb procedures of short duration: a prospective, randomised, observer-blind study in adult patients.

BACKGROUND: This prospective, randomised, observer-blinded study has been conducted in patients undergoing procedures of the lower extremities to evaluate the time to complete block resolution of 2-chloroprocaine 1% at three intrathecal doses (30, 40 and 50 mg). METHODS: After informed consent, we enrolled 45 male and female patients, aged 18-65 years, ASA score I-II, BMI 18-32 kg/m2, undergoing elective lower limb procedures lasting ≤40 min and with a requested dermatomeric level of sensory block ≥ T12. The patients were randomised in a 1:1:1 ratio to receive Chloroprocaine HCl 1% at one of the three different intrathecal doses (Group 30 = 30 mg, Group 40 = 40 mg or Group 50 = 50 mg). The progression and regression of both sensory and motor blocks were evaluated blindly. Urine and venous blood samples were collected for pharmacokinetic analysis. RESULTS: Times to regression of spinal blocks were 1.76 ± 0.35 h, 2.13 ± 0.46 h and 2.23 ± 0.38 h, in Group 30, 40 and 50 respectively: the 30 mg dose showed a significantly faster resolution of spinal block than the 40 mg (p = 0.034) and the 50 mg (p = 0.006). Time to readiness for surgery was significantly reduced with the dose of 50 mg when compared to dose of 30 mg (p = 0.0259). CONCLUSIONS: The doses of 50 mg and 40 mg yielded a longer resolution of spinal block than the dose of 30 mg. Nevertheless, the dose of 30 mg resulted in a higher secondary failure rate. TRIAL REGISTRATION: Registration of clinical trial: clinicaltrials.gov ( NCT02481505 ).

Liver and skeletal muscle injury in a 12-year-old female patient after scoliosis correction in prone position: a case report.

We report the case of a 12-year-old female, otherwise healthy patient, who underwent surgery for scoliosis correction in prone position under total intravenous general anesthesia, with CardioQ and sensory-motor-evoked potentials for hemodynamic and neurological monitoring. The patient showed severe intraoperative hypotension, lactic acidosis, and complete abolition of motor-evoked potentials during the positioning of posterior corrective bars. During the postoperative period, the increase in muscle and liver enzymes indicated an abdominal organ damage and confirmed hypoperfusion of the lower limbs. Both side effects were caused by the malposition of the patient on the operating table. The case resolved within the first postoperative week without sequelae.

Non-invasive haemodynamic monitoring with Clearsight in patients undergoing spinal anaesthesia for total hip replacement. A prospective observational cohort study.

BACKGROUND: Patients undergoing elective primary total hip replacement and spinal anesthesia may encounter significant hemodynamic instability Objective: The study is aimed at observing the haemodynamic modifications after spinal anaesthesia during total hip replacement in patients managed to "preload independence" with goal directed fluid therapy (GDFT) and monitored non-invasively with Clearsight. METHODS: Thirty patients, aged 50-80 years, with an American Society of Anaesthesiologists' (ASA) score II-III, undergoing elective primary total hip replacement and spinal anaesthesia were enrolled. Patients were monitored with the EV1000 platform and the Clearsight finger-cuff and managed with a goal directed fluid therapy. RESULTS: The 79% of the population showed preload independence at baseline. After spinal, the 93% did not show a significant mean arterial pressure reduction. In our population, 79% reported a decrease >10% of the stroke volume during surgery, while 66% in the Recovery Room. Patients showed an improvement in mean arterial pressure, systemic vascular resistances indexed (SVRI), stroke volume (SV) and stroke volume indexed (SVI) at spinal resolution compared to baseline. CONCLUSIONS: Our cohort population showed hemodynamic stability throughout the study period, with increased SV and decreased SVRI at spinal resolution compared to basal values. Further randomized prospective studies are advocated in the same setting.

A randomized comparison between Accuro and palpation-guided spinal anesthesia for obese patients undergoing orthopedic surgery.

BACKGROUND: Although obese patients benefit from neuraxial anesthesia, technical difficulties often discourage its use. The current randomized trial compared Accuro, a hand-held, battery-operated ultrasound (US) device, and conventional palpation for spinal anesthesia in obese patients undergoing orthopedic surgery. We hypothesized that Accuro would decrease the number of needle redirections. METHODS: We enrolled 130 men and women with a body mass index ≥30 kg/m2, scheduled for lower limb surgery under spinal block. Patients were randomized either to the Control group (group C: spinal block after palpation of cutaneous landmarks) or to the Accuro group (group A: preprocedural US scan with Accuro to identify the needle insertion point). The procedural time, the number of skin passes and of needle redirections, the occurrence of failure and adverse events were recorded. RESULTS: Ninety-nine patients completed the study. Patients in group Accuro showed a median (IQR) number of redirections of 3 (0-9) and a median (IQR) number of needle passes through the skin of 1 (1-2) versus 6 (1-16) and 1 (1-3), respectively, in group Control (p=0.008, p=0.019). The performance time was 558±232 s in group Accuro versus 348±255 s in group Control (p<0.001). There were no intergroup differences in terms of failed blocks and adverse events. CONCLUSIONS: The use of Accuro reduced the number of needle redirections and passes through the skin when performing spinal anesthesia, but required a longer procedural time. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov registry (NCT03075488).

Stimulating versus non-stimulating catheter for lumbar plexus continuous infusion after total hip replacement.

BACKGROUND: This study was aimed to investigate whether stimulating catheters for continuous lumbar plexus block reduce local anesthetic consumption after hip arthroplasty if compared with traditional non-stimulating catheters. METHODS: Seventy-two ASA I-III, 18-82-year-old, undergoing primary hip replacement (THA) for osteoarthritis with spinal anesthesia were randomized into two groups: Stim group (stimulating catheter, N.=36) and Nonstim group (non-stimulating catheter, N.=36). After surgery, 15 mL of mepivacaine 1% were administered in both groups through the catheter. An electronic pump was connected to deliver ropivacaine 0.2% (3 mL/h, bolus 3 mL, lock out 15 min) for the first 72 h. Patients were given ketorolac 30 mg IV every 8 h, acetaminophen 1g IV every 8 h and oxycodone 10 mg per os for rescue analgesia. Primary outcome was postoperative local anesthetic consumption. Numerical Rating Scale (NRS), complications, both quadriceps and obturator strength measurements, and opioid requirement were also registered. Mixed effect models (random intercept) were built for repeated measures over time. A difference between groups was considered statistically significant if P<0.05. RESULTS: Local anesthetic consumption and NRS were comparable between groups. Patients in the Nonstim group required significant more rescue opioid analgesia compared with the Stim group during the first 36 h (P=0.002). Quadriceps and adductor muscle strength was equally preserved in the two groups. CONCLUSIONS: The study showed comparable local anesthetic consumption, pain scores and muscle strength preservation between the two groups. The stimulating catheter allowed a significant, although underpowered, reduction in opioid consumption.

Morphine sulfate abuse-deterrent formulations for the treatment of chronic pain.

INTRODUCTION: Abuse-deterrent formulations have been developed to reduce inappropriate opioid use. The aim of this paper is to review existing literature about currently available morphine abuse-deterrent formulations. Areas covered: The US FDA has currently attributed an 'abuse-deterrent formulation' label to two different morphine compounds: an agonist/antagonist combination, and a morphine formulation with physical barrier. The combination of morphine sulfate and naltrexone showed bioequivalence with extended release morphine. Naltrexone was found in low levels or non-detectable in most of the patients. If the capsules are tampered, the orally available naltrexone would be released, causing a decreased euphoria expected by the use of morphine. The application of physical and chemical barriers to the active compound aims at preventing manipulation of the opioid tablet. This abuse-deterrent formulation obtained with a physical barrier did not reduce drug liking compared to ER morphine. Expert commentary: Available data from literature suggest that both formulations may offer an alternative with lower abuse potential in the treatment of chronic pain. Nevertheless, current evidence suggests that only a little percentage of abusers may stop abusing drugs as result of reformulation. More post-marketing studies are advocated to evaluate the real impact of abuse-deterrent formulations.

Acute pancreatitis after major spine surgery: a case report and literature review.

BACKGROUND: Acute pancreatitis has been described as potential complication of both abdominal and non-abdominal surgeries. The pathogenetic mechanism underlying acute pancreatitis in spine surgery may include intraoperative hemodynamic instability causing prolonged splanchnic hypoperfusion, as well as mechanical compression of the pancreas due to scoliosis correction, with a higher risk in cases of more extended fusions, especially in young adults with lower body mass index (BMI). CASE PRESENTATION: We report here a case of postoperative acute pancreatitis with benign evolution in a young female patient after the first and second surgery of a two-stage correction of right thoracic idiopathic scoliosis.In December 2017, the patient underwent first-stage T4-L3 posterior arthrodesis with T7-T12 osteotomies and temporary magnetic bar. Intraoperative blood loss required massive transfusion. In the immediate postoperative period, the patient started reporting nausea/vomiting, abdominal pain at pressure, moderate meteorism, abdominal distension, hypoactive bowel sounds, and fever. Laboratory tests indicated a progressive increase in aspartate aminotransferase, alanine aminotransferase, serum amylase, lipase, phospho-creatine kinase, and reactive C-protein. A CT scan showed free abundant abdominal fluid in the hepatic, renal, pancreatic, and pelvic regions. After the diagnosis, a hypolipidic diet was initiated, and good hydration per os was maintained. After gastroenterologic consultation, somatostatin, rifaximin, and ursodehoxycholic acid were initiated and maintained for 8 days. In the following days, laboratory tests showed a slow but consistent decrease in liver and pancreatic enzymes until normalization. In January 2018, the patient underwent second-stage surgery with removal of magnetic bar, definitive posterior fusion, and instrumentation T4-L3. Laboratory tests showed a second, even more significant, increase in the amylase and lipase level and a moderate increase in the reactive C-protein. Therapy was maintained until complete normalization of amylase and lipase levels. CONCLUSIONS: Early recognition of symptoms plays a key role in preventing severe morbidity after scoliosis surgery. When symptoms suggest abdominal complication, pancreatic and liver enzymes are to be evaluated for posing prompt diagnosis. Gastroenterologic consultation and eventual imaging are further steps in differential diagnosis and treatment of this rare complication.

Continuous regional anesthesia: a review of perioperative outcome benefits.

Routine use of regional anesthesia for patients having surgery is supported by general safety and proven effectiveness as a targeted modality in the prevention and treatment of acute pain. Recently, perioperative physicians have become much more interested in improving long-term outcomes after surgery rather than focusing on the well-established short-term benefits of regional anesthesia. This interest has raised important questions regarding the potential influence of regional anesthesia on morbidity and mortality, persistent pain and cancer prognosis. Tissue injury is responsible for the inflammatory reaction and physiologic stress response observed during the perioperative period and can influence a patient's recovery trajectory. Regional anesthesia can modulate the inflammatory response through the direct anti-inflammatory effect of local anesthetics, blocking neural afferents, and blunting sympathetic activation. Moreover, continuous techniques (e.g., epidural and perineural catheters) that provide longer duration and titratable pain relief in the perioperative period may be protective against the development of persistent post-surgical pain by providing effective acute pain management and decreasing exposure to opioids. To maximize the potential for long-term outcome benefits to surgical patients, continuous regional anesthesia techniques are preferred over single injection techniques. Although the data are not yet definitive, some studies have demonstrated better functional recovery after joint replacement and lower rates of cancer recurrence in patients treated with continuous regional anesthesia. Future research studies in regional anesthesia will have to focus on these long-term patient-centered outcomes and may need to incorporate novel study designs and analyses of big data.

Cardiovascular and cerebrovascular risk with nonsteroidal anti-inflammatory drugs and cyclooxygenase 2 inhibitors: latest evidence and clinical implications.

Observational studies and meta-analyses have shown that the administration of nonsteroidal anti-inflammatory drugs (NSAIDs), especially when prescribed at high doses for long periods of time, can potentially increase the risk of cardiovascular diseases. The increased thrombotic risk related to the use of NSAIDs is mainly due to their cyclooxygenase 2 selectivity. The dosage use, the formulation selected and the duration of the therapy are other factors that can significantly impact on the cardiovascular risk. In order to minimize the risk, prescription of the right drug based on the patient's features and the different safety profiles of several NSAIDs that are available on the market is key for their appropriate administration. Despite the baseline cardiovascular and gastrointestinal risk of each patient, monitoring of patients is suggested for increases in blood pressure, development of edema, deterioration of renal function, or gastrointestinal bleeding during long-term treatment with NSAIDs.

The use of vitamin B1 as a perineural adjuvant to middle interscalene block for postoperative analgesia after shoulder surgery.

BACKGROUND: Perineural administration of thiamine, via axonal flow, could strenghthen synthesis of ACh in the dorsal horn inhibitory interneurons, thus potentiating analgesia. The purpose of the present retrospective analysis is therefore to investigate whether adding perineurally 2 mg/Kg of thiamine to 0.75% levobupivacaine in patients undergoing middle interscalene block may prolong the duration of analgesia. METHOD: The hospital records of all ASA status 1-2 patients, undergoing a single-shot interscalene block for arthroscopic rotator cuff repair from January 2011 to May 2012 were retrospectively reviewed. All blocks were performed with 0.75% levobupivacaine or a solution of thiamine hydrochloride and 0.75% levobupivacaine. The local anesthetic solution, postoperative visual analogue score for pain at rest and rescue medication were registered. We calculated the time interval elapsing between block anesthetic mixture injection and the patient's first analgesic requirement, ie time to end of analgesia. Eventual postoperative side effects were also reported. RESULTS: 59 patients received 0.4 ml/Kg of 0.75% levobupivacaine (Group L) and 51 patients received a mixture of 2 mg/Kg of thiamine hydrocloride (maximum dose 200 mg) with 0.4 ml/Kg of 0.75% levobupivacaine (Group B1). Tea was 11.4 ± 3.0 hours in Group L versus 17.6 ± 3.0 hours in Group B1 (p < 0.001). The scores for pain in the two Groups at the time of the first analgesic rescue were comparable. CONCLUSION: The present retrospective analysis suggests that thiamine helps to prolong postoperative analgesia when added to the local anesthetic solution. Further prospective studies are necessary to confirm these preliminary results.Word count: 250.

Goal-Directed Fluid Therapy Based on Stroke Volume Variation in Patients Undergoing Major Spine Surgery in the Prone Position: A Cohort Study.

STUDY DESIGN: A retrospective observational study. OBJECTIVE: The aim of this study was to test whether a goal-directed fluid therapy (GDFT) protocol, based on stroke volume variation (SVV), applied in major spine surgery performed in the prone position, would be effective in reducing peri-operative red blood cells transfusions. SUMMARY OF BACKGROUND DATA: Recent literature shows that optimizing perioperative fluid therapy is associated with lower complication rates and faster recovery. METHODS: Data from 23 patients who underwent posterior spine arthrodesis surgery and whose intraoperative fluid administration were managed with the GDFT protocol were retrospectively collected and compared with data from 23 matched controls who underwent the same surgical procedure in the same timeframe, and who received a liberal intraoperative fluid therapy. RESULTS: Patients in the GDFT group received less units of transfused red blood cells (primary endpoint) in the intra (0 vs. 2.0, P = 0.0 4) and postoperative period (2.0 vs. 4.0, P = 0.003). They also received a lower amount of intraoperative crystalloids, had fewer blood losses, and lower intraoperative peak lactate. In the postoperative period, patients in the GDFT group had fewer pulmonary complications and blood losses from surgical drains, needed less blood product transfusions, had a shorter intensive care unit stay, and a faster return of bowel function. We found no difference in the total length of stay among the two groups. CONCLUSION: Our study shows that application of a GDFT based on SVV in major spine surgery is feasible and can lead to reduced blood losses and transfusions, better postoperative respiratory performance, shorter ICU stay, and faster return of bowel function. LEVEL OF EVIDENCE: 3.

Transversus Abdominis Plane Block for Postoperative Analgesia in Patients Undergoing Total Laparoscopic Hysterectomy: A Randomized, Controlled, Observer-Blinded Trial.

BACKGROUND: In this randomized, controlled, observer-blinded study, we evaluated analgesia provided by transversus abdominis plane (TAP) block after elective total laparoscopic hysterectomy in terms of reduced postoperative morphine consumption as the primary end point. METHODS: Fifty-two patients were randomly divided into 2 groups: patients in group T (TAP, n = 26) received an ultrasound-guided bilateral TAP block with 40 mL of 0.375% levobupivacaine and morphine patient-controlled analgesia, whereas patients in group C (control, n = 26) received morphine patient-controlled analgesia. Secondary outcomes included pain measurements (Numeric Rating Scale from 0 to 10) during the first 24 hours postoperatively, times to postanesthesia care unit discharge, times to surgical ward discharge, incidence of postoperative nausea and vomiting, functional capacity measurements in terms of 2-minute walking test, and first oral solid intake. RESULTS: Demographic and anthropometric variables were similar in the 2 groups. The total dose of morphine consumed by patients during postanesthesia care unit stay was 6 (0-8) mg in group T vs 8 (5.5-8.5) mg in group C (P = 0.154). Postoperative morphine consumption during the first 24 hours was 10.55 ± 10.24 mg in group C vs 10.73 ± 13.45 mg in group T (P = 0.950). The 95% confidence interval of the difference between means of 24-hour morphine consumption was -7.45 to +7.09. The 2 groups were comparable. There were no significant differences in secondary outcome variables between groups. CONCLUSIONS: TAP block did not reduce morphine consumption during the first postoperative 24 hours after elective total laparoscopic hysterectomy.

An update around the evidence base for the lower extremity ultrasound regional block technique.

Ultrasound guidance currently represents the gold standard for regional anesthesia. In particular for lower extremity blocks, despite the heterogeneity and the lack of large randomized controlled trials, current literature shows a modest improvement in block onset and quality compared with other localization techniques. This review aims to present the most recent findings on the application of ultrasound guidance for each single lower extremity approach.

Lidocaine versus ropivacaine for postoperative continuous paravertebral nerve blocks in patients undergoing laparoscopic bowel surgery: a randomized, controlled, double-blinded, pilot study.

BACKGROUND AND OBJECTIVES: Lidocaine could provide many advantages in continuous regional anesthesia techniques, including faster onset, greater titratability, and lower cost than long-acting local anesthetics. This prospective, randomized, double-blinded, pilot study is therefore intended to compare lidocaine to ropivacaine in bilateral continuous paravertebral blocks using a multimodal approach for postoperative pain management following laparoscopic bowel surgery. METHODS: Thirty-five ASA I-III consecutive patients undergoing elective laparoscopic bowel surgery and bilateral thoracic paravertebral continuous blocks were analyzed: bilateral thoracic paravertebral infusions of ropivacaine 0.2% (Group Ropi, n=18) or lidocaine 0.25% (Group Lido, n=17) were started at 7 mL/h in the postanesthesia care unit. For each patient, we collected numerical rating scores (NRS) for pain at rest and during movement at baseline, at postanesthesia care unit discharge, at 24 hours and 48 hours after the end of surgery, as well as hydromorphone patient-controlled analgesia requirements, local anesthetic consumption, side effects, postoperative complications, and functional outcomes. RESULTS: No effect of group distribution on NRS scores for pain at rest or at movement (P=0.823 and P=0.146), nor on hydromorphone (P=0.635) or local anesthetic consumption (P=0.063) was demonstrated at any analyzed time point. Hospital length of stay and spontaneous ambulation were comparable between groups (P=0.636 and P=0.148). In the context of a multimodal approach, the two drugs showed comparable safety profiles. DISCUSSION: Lidocaine 0.25% and ropivacaine 0.2% provided similar analgesic profiles after elective abdominal surgeries, without any difference in terms of functional outcomes. The easier titratability of lidocaine together with its lower cost induced our clinical practice to definitely switch from ropivacaine to lidocaine for postoperative bilateral paravertebral continuous infusions.

Use of ultrasound for lower extremity.

PURPOSE OF REVIEW: To explore the recent advances in the use of ultrasound for lower extremity blocks, including approaches to the lumbar and sacral plexus blocks. RECENT FINDINGS: Procedures of the lower extremity often require blocks of the lumbar and sacral plexuses. The use of ultrasound offers some advantages, including the possibility to directly visualize the distribution of local anesthetics. SUMMARY: Lower extremity blocks under ultrasound guidance often require advanced skills because of the depth of target nerves. This review summarizes the recent advances in the use of ultrasound guidance over traditional techniques.

Is spinal anaesthesia a suitable technique for ultra-short outpatient procedures?

Spinal anaesthesia is an easy and reliable technique. Factors limiting its use in the ambulatory setting include delayed ambulation, risk of urinary retention and pain after block regression. On the contrary, general anaesthesia with fast-acting drugs provides a fast recovery that facilitates an early discharge. Although recovery after spinal anaesthesia has been improved by reducing the dose of the commonly used longacting local anaesthetics, discharge times are still prolonged compared with general anaesthesia. 2-Chloroprocaine is an amino-ester local anaesthetic with a very short half-life and a favourable evolution of spinal block for ultra-short outpatient procedures. Moreover, the preservative free 2-chloroprocaine solution showed a very low risk of urinary retention and transient neurological symptoms when compared with bupivacaine and lidocaine. The aim of this article is to evaluate if the neuraxial administration of short-acting local anaesthetics renders spinal anaesthesia a suitable technique for ultra-short surgical procedures.