• Decompression / Fusion
• Anterior / Posterior
• ACDF = Anterior Cervical Decompression / Fusion
  • ETT towards left, lines on left (surgeons operate on RHS of neck)
  • continuous cuff manometry = detect cervical manipulation causing cuff herniation / extubation
    • use extension tubing, but remember to clamp it (else the cuff will deflate)
  • no PEEP = improve venous drainage
• PCDF = Posterior Cervical Decompression / Fusion
• PLIF = Posterior lumbar interbody fusion
  • generally a longer operation with more blood loss
  • IAL, PCA

• Spinal cord perfusion
  • SCPP = MAP - ISP
  • ISP = intraspinal pressure (cf ICP, intracranial pressure)
  • (ISP/CVP, whichever is higher)
  • ISP can be reduced by spinal drainage of CSF
• Dissection / traction around nerve roots is very stimulating
  • ensure adequate depth of anaesthesia, no movement
• Maintain MAP in haemorrhage
  • Because the spinal cord can't be protected from ischaemia (cf. brain and neuroprotection)

• Instability = trauma, tumour
• Function = kyphoscoliosis
• Infection
• Tumour

• A = airway compromise, up to 2% after C-spine surgery
• C = massive haemorrhage
• D = postoperative visual loss
  • pain (perioperative and chronic)
  • neurological deficit / SCI

• most common = dysphagia

• Airway = 14%

  • retropharyngeal oedema 6%
    • risk = multilevel surgery
  • haematoma 2.4%
  • reintubation
    • 2% single level
    • 5% multilevel

• Chronological

  • 6-12 hours = angioedema
  • 6-24 hours = retropharyngeal haematoma
  • 24-72 hours = pharyngeal oedema
  • 72+ hours = retropharyngeal abscess

Pre-op

• Consider patient co-morbidities
  • cancer, trauma, infection
  • diseases of old age = CAD, COPD
• C = Circulation
  • Patient blood management

Intra-op

• Induction

• A = Airway

  • Reinforced ETT = ⬇risk kinking
    • use for cervical spine surgery

• P = Transfer to OT table

  • plan for disconnection during transfer
    • Fentanyl 500 after intubation
    • use VA
  • Give AB before going prone
  • Leave IAL and SpO2 connected
  • Disconnect everything else (TIVA, ECG, EEG)
  • Stop TIVA pumps on transfer (so that Ce remains accurate)
  • Flip back to supine if any concerns = eg. do not adjust ETT when prone

• P = Positioning

  • unstable fracture
    • cannot be rolled into prone position
    • must be transferred supine onto Jackson, sandwiched, and flipped
  • lumbar = arms outstretched
  • cervical / thoracic = arms by side
  • Mayfield skull clamp = to minimise cervical movement = cervical / upper thoracic
  • Cervical surgery = head away from machine
  • keep pumps at head end

• Maintenance

• B = Ventilation

  • ⬇Vt for ⬆VR, 450 mL, RR 14

• C = Circulation

  • maintain perfusion pressure = SCPP (spinal cord perfusion pressure)
    • bleeding in spinal surgery is usually venous
    • there is NO role for hypotensive techniques
    • maintain SCPP at ALL times
  • patient blood management
  • BP monitoring = IAL
  • IV access = 2 large bore IVC
    • 1 for TIVA
    • 1 connected to extension tubing and syringe = minimise dead space for bolus medications
    • Cervical = ACF is okay because elbows are extended
    • Lumbar = not in ACF because elbow is flexed
    • Caution IAL / IVC on same hand = alternating kink/damp between their positions

• D = Anaesthesia

  • Propofol / Remi TCI
  • NMBA infusion + NMM for cervical spine surgery
  • Gas (Sevo/Des) / Remi
  • Remi for ACDF to prevent coughing
  • NMM = Q1 min TOF
  • monitor for spinal cord ischaemia
    • functional = SSEP / MEP
    • metabolic = CSF analysis
    • physiological = lumbar CSF pressure / paravertebral M oximetry

• D = Analgesia

  • Opioid-sparing techniques = ketamine, lignocaine, dexmedetomidine

• Emergence

  • A = caution AW swelling and safety for extubation
    • Can minimise intraop IVF (dry approach)
    • Or can optimise fluids and maintain Hb (wet approach)
    • Assess difficulty for rapid re-intubation
      • Preop AW assessment
      • Ask surgeon about degree of movement loss (for neck operations)
  • D = rapid emergence for neurological assessment

Post-op

• ICU?
  • Anterior cervical spine surgery = yes
  • others = generally no

Analgesia for complex spine surgery

• PROSPECT EJA 2021
• Paracetamol
• NSAIDs / COX2
• Intraop = ketamine, epidural analgesia(?!)
• Methadone = evidence, but not recommended, prefer short-acting
• Limited evidence
  • LA infiltration
  • IT / Epidural opioids
  • ESP
  • Thoracolumbar interfascial plane block
  • IV lignocaine
  • Dexmedetomidine
  • Gabapentin

https://academic.oup.com/bjaed/article/14/4/147/293508

https://journals.lww.com/ejanaesthesiology/Fulltext/2021/09000/Pain_management_after_complex_spine_surgery__A.10.aspx