PERIOPERATIVE MANAGEMENT OF SPINE SURGERY

1. INTRODUCTION

Spinal surgical procedures have a wide variety and comprise a major subgroup of
orthophaedic surgery. Thousands of patients undergo spinal surgery every year.
Perioperative management of the spinal cases is directly related with perioperative
morbidity and mortality.1

Spinal surgery is relatively lasting longer, the probability of intraoperative

bleeding is higher comparing to other surgeries (due to the patients prone
position) and the possibility of severe pain after surgery, are facts should be
aware. 1

For all spinal surgery patients standard monitoring is considered. This comprises
of electrocardiography monitoring (ECG), pulse oximetry, end-tidal CO2 with
capnography, non invasive arterial blood pressure, body temperature and
neuromuscular block monitoring. Optinal monitoring is by additional
measurement of central venous pressure measurement, invasive arterial blood
pressure, urinary catheter, bispectral index (BIS) and somatosensory evoked
potentials (SSEP) monitoring. 1

Preoperative assessment is one of the most important stages of perioperative care.

Whereas, the focus of intraoperative management is minimizing spinal cord
ischaemia and compression on the spinal cord. These are accomplished by
maintenance of Spinal Cord Perfusion Pressure (SCPP) through control of blood
pressure (BP) and minimizing venous congestion by careful positioning of the
patient to prevent compression of the abdomen. We need to ensure spinal cord
perfusion while producing a bloodless surgical field. 1

Postoperative complications include persistent hypotension, haemorrhage, urinary

retention, nerve root damage, cauda equina syndrome (urinary/faecal
incontinence, perineal sensory loss and lower-limb motor weakness),
thromboembolism and airway complications. 1

zgl Keskin, Hatice Tre, and Neslihan Uztre. Anaesthesia for Spinal Surgery.
Yeditepe Medical Journal. 2015;9(33):842-847

2. GENERAL PERIOPERATIVE MANAGEMENT

a. Preoperative Management
Preoperative assessment is one of the most important stages of
perioperative care in anaesthesia. Careful assessment is made based on the
medical history and physical examination of the patient. Preoperative
considerations; evaluation of all organ systems status especially respiratory
and cardiovascular, nervous system evaluation and documentation of
neurological deficits, possible anatomical abnormalities leading to airway
limitation, examination of the physical status and planning of
premedication is important. 1

Preoperative laboratory tests; full blood count, coagulation profile,

electrolytes, renal and liver functions, ECG and echocardiogram(as
appropriate), imaging studies (chest X ray, cervical spine imaging) should
be performed. The preoperative tests should be according to the ASA
(American Society of Anaesthesi-ologists) recommendation. Preparation
of blood and blood products and if needed intensive care organization is
important to reduce the risk of intraoperative and postoperative
complications. 1

Assessment of the cardiorespiratory system is crucial. Many disorders

requiring spinal surgery may have cardiac involvement. Symptomatic
patients require more cardiac investigations such as echocardiography or
stress tests. Disease such as Scoliosis and Rheumatoid Arthritis can cause
restrictive lung disease. For this cases lung spirometry is indicated
preoperatively. 1
As premedication, to reduce the preoperative anxiety for the night before
operation, alprazolam (oral0.5mg) or diazepam (oral5mg), (0.05-
0.2mg/kg) is highly effective. Midazolam can only be used before the
operation due to its amnestic effect. 1

Before the procedure, we need to get informed consent from the patient.
For Mallampati I-II patients, standard airway management with
endotracheal intubation can be performed. 1

Fiber optic intubation can be used for difficult airway or unstable spinal
injuries. If we decide the fiber optic intubation, appropriate equipment and
skilled staff should be made available. In certain circumstances
(e.g.surgery involving maxillotomy or mandi bulotomy), an elective
tracheostomy may be necessary for postoperative airway management. We
can choose the method of endotracheal intubation after airway and neck
stability assessment. 1

Patient education (PE) has been used by many institutions to deal with
patient anxiety, pain control, and overall satisfaction. Several authors have
found PE to be beneficial, whereas others found little or no significant
improvement. In a study of patients undergoing surgery after lumbar disc
surgery, less than half of the patients were satisfied with their preoperative
PE. PE may help them to set realistic goals and meet their expectations.
This, in turn, may positively influence surgical outcome and overall
satisfaction.2

In the orthopedic field, PE has frequently been used in total joint

replacement programs.To our knowledge, there are no comprehensive data
on the effectiveness of PE in patients undergoing spinal surgery. 2

Preoperative PE pertains to various types of educational interventions that

occur before surgery to prepare patients for the increasing physical and
psychological demands during and after the operation. These provisions
 include health information, skill training for patients on the use of pain
pumps, and provision of psychosocial support to address patients
anxieties, needs, and concerns. A wide range of different approaches have
been described, including group or individualized lectures, printed
information such as a booklet or information sheet, audiovisual
presentation, or a combination of these modalities. Timing of education
also varies (before vs after admission, 1 day vs several days or weeks
before the operation). PE has been implemented to help with various
aspects of patient management, including length of hospitalization,
preoperative anxiety, patient compliance, pain control and analgesic use,
overall satisfaction, physical coping, mobility independence, and discharge
preparation. 2

The implementation of our spine pre-care program has had a positive

impact on patient satisfaction, especially in terms of pain management. PE
represents a viable, efficient, and inexpensive intervention in patients
undergoing spinal surgery. 2

b. Intraoperative Management

Spinal surgery is relatively lasting longer, the probability of intraoperative

bleeding is higher comparing to other surgeries (due to the patients prone
position) and the possibility of severe pain after surgery, are facts the
anaesthetist should be aware. 1

For all spinal surgery patients standard monitoring is considered. This

comprises of electrocardiography monitoring (ECG), pulse oximetry, end-
tidal CO2 with capnography, non invasive arterial blood pressure, body
temperature and neuromuscular block monitoring. Optinal monitoring is
by additional measurement of central venous pressure measurement,
invasive arterial blood pressure, urinary catheter, bispectral index (BIS)
and somatosensory evoked potentials (SSEP) monitoring. 1
 Spine surgery is mostly performed under general anaesthesia with
endotracheal intubation. During the maintenance of anaesthesia, the
anesthetist must pay attention to the airway preservation, by firmly
securing the tube in prone position. It is important to use the appropriate
agents for anaesthetic maintenance to facilitate the spinal cord monitoring.
During the operation, care should be taken to prevent hypothermia,
maintain the blood volume status by being aware of potential blood loss so
that is promptly substituted by blood products and also antibiotic
prophylaxis. 1

The focus of intraoperative management is minimizing spinal cord

ischaemia and compression on the spinal cord. These are accomplished by
maintenance of Spinal Cord Perfusion Pressure (SCPP) through control of
blood pressure (BP) and minimizing venous congestion by careful
positioning of the patient to prevent compression of the abdomen. We need
to ensure spinal cord perfusion while producing a bloodless surgical field. 1

Special care should be taken for the peripheral nerves (like elbow, ulnar,
lateral femoral cutaneous nerve and the peroneal nerve) that should be
padded to avoid injury. Concerning the pulmonary function, the most
obvious change is the increase in functional residual capacity (FRC). 1

Because of prolonged surgery and blood loss the risk of hypothermia is

existent. Hypothermia will impact negatively on spinal cord monitoring,
increase blood loss due to abnormal coagulation, delay the recovery time,
increase the risk of arrhythmia and wound infection. So temperature
monitoring and active warming with forced air warming devices is
essential. 1

Joseph L Laratta. Improving Safety in Spine Surgery: Reducing Perioperative

Blood Loss and Transfusion Requirements. MOJ Orthop Rheumatol 2016; 4(5):
1-5
Blood loss in spine surgery has a significant impact on patient
morbidity, length of surgery, and total cost. In addition to maintaining
patients hemodynamics, the control of blood loss is essential in attaining
adequate visualization of the surgical field. Due to the proximity of
tenuous neurovascular structures, the importance of a dry surgical field
cannot be overemphasized. Realizing this goal requires collaboration
between surgical and anesthetic teams. Although there is no standardized
system for blood sparing, there are a number of techniques and
approaches that can be employed to minimize blood loss perioperatively.

Decreasing the rate of blood loss, salvaging lost blood, and decreasing
the need for transfusion are three potential areas for intervention. Acute
normovolemic hemodilution is a technique employed to decrease the
need for transfusion. Venous blood is collected after anesthetic
induction until a target hematocrit of 30% and lost volume is replaced
with colloids. As a result of decreased blood viscosity, tissue
oxygenation is maintained through a compensatory increase in cardiac
output and venous return.

Moreover, any surgical blood loss contains fewer blood cells per volumetric
unit. The safety and efficacy of acute normovolemic hemodilution has
been well documented in spinal fusion and scoliosis surgery. In
posterior instrumentation and fusion operations of the lumbar spine,
Epstein et al. showed that 76% of patients avoided allogeneic transfusion
with implementation of this technique.

Long before skin incision, patient positioning is the first step in the
reduction of blood loss. Epidural veins are connected to the inferior vena
cava (IVC) by a valve-less system. Positioning the patient on a Jackson
frame table with the abdomen free of compression allows for decreased
IVC pressure and subsequently, a decreased rate of epidural engorgement
and bleeding.
Fast and efficient surgery is an often underestimated component in the
reduction of blood loss. Surgeon comfort with the procedure and
simultaneous operation on multiple areas of the spine allows for decreased
surgical time and total blood loss. Use of bovie electrocautery on high
setting (60/60) and meticulous subperiosteal dissection is paramount.
Intraoperatively, the surgeon has various passive and active local agents
in his armamentarium to achieve hemostasis. Collagen, cellulose, and
gelatin-based products are passive agents that provide a scaffold for the
promotion of platelet aggregation and formation of clot. On the other
hand, active hemostatic agents have biologic activity allowing the de novo
generation of a fibrin clot. These products are typically thrombin or
combination products and have been shown to provide hemostasis within
ten minutes of application.

In terms of high quality literature, intrathecal morphine may have the

greatest effect on the reduction of perioperative bleeding. The mechanism
of action is unclear, but the benefits are obvious. In a prospective
randomized controlled trial (PRCT), Goodarzi et al. showed that a
2g/kg dose of intrathecal morphine led to a 50% reduction in estimated
blood loss (EBL). In a later PRCT expanding on Goodarzi et al. [6]
original work, Gall et al. confirmed the efficacy of intrathecal morphine
with a 65% reduction in EBL (5g/kg dose).

The usefulness of antifibrinolytic drugs on a systemic reduction in blood

loss has been analyzed, as well. Tranexamic acid (TXA) is a synthetic
lysine derivative that inhibits the conversion of plasminogen to plasmin,
thus preventing clot breakdown. In PRCTs, standard dosing of TXA has
been shown to decrease blood loss by 13% and 25% in posterior lumbar
and cervical laminoplasty procedures, respectively. High dose TXA
(loading dose of 100mg/kg with a continuous infusion of 10mg/ kg/hr)
achieves even greater blood sparing. In posterior spinal deformity, Xie et
al. reported a 39.8% reduction in EBL, while Sethna et al. confirmed a 41%
reduction in pediatric scoliosis surgery. A recent meta-analysis of all
PRCTs confirmed the efficacy of TXA with a 67% reduction in
transfusions and an average 202mL decrease in total EBL.

When the resources used to minimize the rate of bleeding are exhausted,
red blood cell salvage may remain effective in reducing transfusion. The
exact role for autotransfusion remains highly debated in the literature,
with some studies showing promise and others questioning the cost-
benefit ratio. However, in a Cochrane review of seventy-five PRCTs
involving cardiac and orthopaedic cases, a 21% absolute risk reduction
of allogeneic transfusion was achieved with the use of cell salvage systems.

Numerous techniques have been described to reduce perioperative blood

loss and allogeneic blood transfusion during major spinal surgery.
Unfortunately, the efficacy of the methods is still largely controversial
and disputed in the literature. No standard protocol exists for the
optimal management of blood loss in spinal surgery. However, judicious
use of a combination of blood-sparing techniques may allow for a safer
surgical experience and improved patient outcomes.

During the operation blood pressure control is important, balancing the

need to ensure spinal cord perfusion with the requirement to produce a
bloodless surgical field. Remifentanil or esmolol infusion have been
widely used for this purpose. Blood loss is usually minimal from simple
procedures, though if large laminectomies and fusions are performed,
cross-matched blood should be available. 1

Standard monitoring is appropriate for simple procedures. However,

invasive blood pressure monitoring, a central venous pressure line and a
urinary catheter should be considered if controlled hypotension is used or
if the procedure is likely to be prolonged and involve large fluid shifts. 1
 Techniques to minimize blood transfusion during spine surgery include
avoiding hypothermia, preoperative supplementation with oral iron,
normovolaemic haemodilution, good surgical technique and haemostasis,
correct positioning of the patient when prone, controlled hypotensive
anaesthesia (only with adequate cord monitoring), use of cell saver,
pharmacological agents such as tranexamic acid, intrathecal opiates and
monitored use of coagulation products. 1

Intraoperative monitoring of spinal cord function is considered a standard

care in spinal surgery. 1

The wake up test

Somatosensory evoked potentials (SSEP)
Motor evoked potentials (MEPs)
Dermatomal responses

The Wake Up Test1

Because wake up test is an old method, today new methods like
SSEP and MEP are preferred. A wake up test is indicated if there is a
sudden, severe deterioration of spinal cord function during surgery. Before
the use of electrical monitoring, it was a method of assessing spinal cord
function during corrective procedures of the spine (1). Volatile agents or
propofol and muscle relaxants are stopped and the patient is allowed to
wake up until they can obey commands (move feet and hands).
Remifentanil can be used, patients can respond to commands but not
experience pain The major advantage is that it assesses anterior spinal cord
function (i.e.motor function).
The hazards of this test include accidental extubation, air embolism
on deep inspiration, and dislodgement of fixators. Its major limitation is that
it assesses spinal cord function only at one specific time (i.e.during the wake
 up test) and not continuously during the procedure. False negatives are
reported.

Somatosensory Evoked Potentials (SSEP) 1

Neurophysiological monitoring of the operative area of spinal cord
uses evoked potentials, both motor (MEP) and somatosensory (SSEP).
SSEP monitoring continuously stimulates a nerve in the lower limbs and
detects a response in cortical or spinal electrodes.
This is a more widespread method of electrical monitoring of the
spinal cord. SSEPs are a measurement of electrical potentials evoked by
stimulation of the sensory system.
The response of constant current stimulation of the median, tibial
and the sural nerve is recorded at the cortex using surface electrodes or a
bipolar electrode placed epidurally by the surgeon. Baseline SSEPs are
recorded in order to exclude neurological dysfunction and also to determine
the feasibility of operative monitoring.
Neurophysiology technicians monitor the latency and amplitude of
the recordings continuously during anaesthesia and surgery. Numerous
anaesthetic agents interfere with the latency and amplitude of the SSEP.

Motor Evoked Potentials1

MEPs may be either evoked EMGs or compound muscle action
potentials (CMAPs). They assess function of the motor cortex and the
descending motor pathways.
Surgical stimulation level and hypothermia also interfere with
SSEP. Volatile agents, hypothermia, hypoxia, hypercarbia, and spinal
ischaemia suppress both SSEPs and MEPs.

c. Postoperative Management
Postoperative complications include persistent hypotension, haemorrhage,
urinary retention, nerve root damage, cauda equina syndrome
(urinary/faecal incontinence, perineal sensory loss and lower-limb motor
weakness), thromboembolism and airway complications. 1

Also the most important complication is the airway obstruction after

extubation, which is potentially life-threatening if the patient has had a
spinal fusion and is encased in a stabilization device. Airway compromise
may result from haematoma formation or neurological deficit. 1

Most spinal surgery is painful and good postoperative analgesia is

important. A multimodal analgesic approach is recommended. A
combination of local and regional anaesthesia, opioids, ketamine and
NSAIDs can be used. Infiltration of the wound at the end of the surgery with
local anaesthetic will provide pain relief in the immediate postoperative
period. Opioids should be supplemented with regular paracetamol and non-
steroidal anti-inflammatory drugs if there are no contraindications to their
use. 1

For scoliosis surgery, this may be supplemented with the use of an epidural
catheter inserted by the surgeon at the end of the procedure. Also local
anaesthetic and opioid drugs can be instilled into the epidural space before
closing. More usually, however a regimen including patient-controlled
analgesia (PCA) combined with regular oral/rectal analgesics is successful.1

The incidence of thromboembolism following spinal surgery is 0.395-

15.5%. ntermittent pneumatic compression boots must be use for
prophylaxis. Use of heparin must be balanced with the risk of increased
bleeding, especially f regional anethesia have been employed (2). The
routine use of compression stockings and sequential compression devices
(SCD) are recommended. 1

After posterior spinal surgery there are some risk factors that can cause
airway complications. These are; an operation time more than 5 hour,
exposing more then three vertebral bodies, prone position, large blood loss
during surgery and transfusion of large volumes of fluid. 1
 Even after the patient has been successfully extubated, might still be at risk
as airway oedema may develop several hours later. We have to follow these
patients in intensive care unit (ICU). 1

Extubation may be problematic and is best performed with the patient

awake and able to support their own airway. If the risk of reintubation is
high, a tracheal tube exchange catheter (e.g. Cook catheter) may be useful. 1

The catheter can be introduced into the tracheal tube and left in situ when
the patient is extubated. Should urgent reintubation be necessary, the new
tracheal tube can be rapidly railroaded over the exchange catheter. However,
prolonged sedation and ventilation should be avoided because this may
mask postoperative neurological deterioration. Great care should be
exercised when moving and transferring patients to prevent dislodgement of
spinal fixation. 1

Mark M. Stecker. A review of intraoperative monitoring for spinal

surgery. Surg Neurol Int. 2012; 3(Suppl 3): S174S187.

Intraoperative neurophysiologic monitoring (IONM) is a valuable technique

for assessing the nervous system. It replaces the neurologic examination
when the patient is under general anesthesia and cannot cooperate with a
face-to-face examination. It allows for assessment of many neural structures
including the neuromuscular junction, peripheral nerve, spinal cord,
brainstem, and cortex during surgery. One goal of this review is to
summarize the techniques used for IONM of the spine. The most commonly
employed techniques during spinal procedures are: (1) transcranial motor
evoked potentials (Tc-MEPs), (2) upper and lower somatosensory sensory
evoked potentials (upper and lower SSEP), (3) pedicle screw simulation,
and (4) spontaneous electromyography (EMG). A number of other
techniques have been used over the years that include direct spinal cord
stimulation and reflex monitoring.
TECHNIQUES

Trancranial motor evoked potentials

Tc-MEPs have been used to perform intraoperative monitoring for more

than 20 years. They have been available on a routine basis since the
approval of the first device designed to producing them by the FDA in 2002.
The Tc-MEP involves applying a train of high-voltage stimuli to electrodes
on the surface of the head to activate motor pathways and produce either a
motor contraction (muscle MEP) or a nerve action potential (D-wave) that
can be recorded.

Basic physiology of Tc-MEPs in the awake patient

In a normal awake patient, electrical stimulation of the cortex/subcortical

white matter with a single electrical pulse produces a number of responses
that can be recorded by an epidural electrode placed over the upper thoracic
spinal cord [Figure 1]. The first of these waves is called the direct or D-
wave and the succeeding waves are termed indirect or I-waves. The D-wave
is the orthodromic nerve action potential that results from stimulating white
matter directly. It involves no synaptic activity. The I-waves represent the
volleys produced by the cortical neurons that were excited by the same
stimulus. These require synaptic activity and are hence strongly suppressed
with general anesthesia. This is important because of the characteristics of
the anterior horn cell which is the final common pathway for all motor
responses. These cells respond optimally not to single stimuli but to
multiple sequential time locked stimuli. Thus, an anterior horn cell will fire
easily in response to a train of stimuli, but will not fire readily with just a
single stimulus.

The clinical importance of the physiology described above is that a single

stimulus applied to the scalp of an awake person may produce a muscle
contraction because of the train of D- and I-waves reaching the anterior horn
cell. However, under general anesthesia, a single stimulus may not be
effective since the I-waves are diminished and the anterior horn cell sees
only the single D-wave. In addition, during general anesthesia, there is a
reduction in spontaneous activity in the interneurons of the spinal cord,
reducing the overall level of excitation reaching the anterior horn cell.
During clinical IONM studies, these problems are overcome by using trains
of stimuli rather than single stimuli [Figure 1]. As the depression of intrinsic
spinal cord activity is greatest with the halogenated anesthetic agents and
nitrous oxide, these agents should generally not be used for the recording of
muscle MEP. Despite the recommendation against certain anesthetics,
muscle MEP responses can be recorded in the presence of low-dose
halogenated agents such as isoflurane, sevoflurane, or desflurane and/or low
concentrations of nitrous oxide. The clinical question relating to the use of
these halogenated agents during monitoring is When there is a change in
the muscle MEP during surgery, can the monitoring team be certain that it
was not due to the effects of anesthesia? This is a complex question
because the effects of the inhalational anesthetic agents on evoked potentials
are not simply related to the end-tidal concentrations of the agents but also
on other factors such as the time over which the anesthetic has been
administered and the presence of prior nervous system injury. It is much
better not to use precious time answering this question when there is an
intraoperative change, and so the use of the halogenated anesthetic and
nitrous oxide should be avoided. The use of total intravenous anesthesia
(TIVA) with propofol is preferred when monitoring muscle MEP because it
suppresses this response to a lesser degree than the inhalational agents.
Other intravenous agents such as ketamine or etomidate may be helpful in
obtaining the muscle MEP. Narcotics do not cause problems with the
muscle MEP although the benzodiazepines may. Since the D-wave is purely
a nerve action potential and does not involve synaptic activity, it is
relatively insensitive to the effects of anesthesia.
Stimulus parameters and trancranial motor evoked potentials

The train stimuli used during TC-MEP range in amplitude from about 75 to
900 V, with maximal currents up to 0.9 A. The stimulation voltage and
current required is markedly dependent on the type of electrode used. The
highest current levels are required if EEG cup electrodes are used. Lower
thresholds are seen with subdermal needle electrodes and corkscrew
electrodes. The duration of each pulse is between 50 and 500 msec. The
longer duration pulses are associated with a lower threshold. The number of
pulses ranges between 3 and 12, with the frequency of the pulses at 150500
Hz.

Safety and complications of trancranial motor evoked potentials

Safety and the prevention of complications are important issues when

discussing motor evoked potentials. Safety is an issue for two major
reasons: first because of the high voltage and high current delivered during
stimulation, there is risk of tissue injury or shock to OR personnel who
inadvertently touch stimulating electrodes during stimulation. The second
risk is that the spread of current can cause direct stimulation of the
trigeminal nerve, causing jaw contractions. The most common complication
of Tc-MEP is tongue bite. It is prevented by placing soft spacers between
the teeth. It is not optimal to use a hard plastic bite block because of the
risk of damage to teeth. One effective approach is to make two large cotton
wads from 4 4's and place them bilaterally between the molars on each
side. Another problem is that the patient may move during the elicitation of
the Tc-MEP. It is important to make sure that the surgeon is aware of this
possibility prior to performing each test so that that patient does not move
during a critical surgical maneuver. In patients at risk for seizures, it is
common to perform the Tc-MEP study provided that the stimulus is not
given very frequently. There is a tiny risk for seizures, and the monitorist
should be vigilant and the surgeons aware of this possibility. If a patient
undergoing Tc-MEP has an implanted defibrillator, it is prudent not to
perform the study unless there is a very high risk of motor injury. In that
case, consultation in advance with a cardiologist is suggested. For patients
with a pacemaker without defibrillator, although the risk of damage or
aberrant firing of the pacemaker is low, the issue should be discussed with a
cardiologist in advance.

Electrode locations for performing trancranial motor evoked potentials

Stimulating electrodes are typically placed over the C1 and C2 locations

(located midway between the traditional C3 and C4 electrode positions and
Cz in the 1020 system) which are near the motor cortex. Other locations
including more lateral placements may optimize stimulation in some
patients. Midline stimulation may be helpful at times for eliciting responses
from the lower extremities. However, even with these placements, the point
of maximal stimulation is not the cortex, but the deep white matter likely in
the corona radiate. This means that although the technique may not be
sensitive to cortical injury, especially if the stimulation level is far above the
threshold, it would still be sensitive to injury to motor pathways in the
brainstem or spinal cord. When there is risk to the cortex, direct stimulation
of the motor cortex using subdural electrodes may provide additional
information.

Muscle MEP

The muscle MEP is the most commonly used Tc-MEP. Recordings are of
high amplitude and can be obtained with a single trial. Thus, they can
provide the surgeon with nearly instantaneous information, unlike the SSEP
which requires prolonged averaging. The problem with the muscle MEP is
that the waveform is complex. Thus, many schemes have been devised to
try to determine when there is a significant change.
 Spontaneous electromyography

The recording of spontaneous EMG activity from a muscle provides

information on the state of the peripheral nerves that innervate that muscle.
Compression or stretch of a nerve as well as hypothermia and ischemia
produce depolarization of the axons resulting in the appearance of
spontaneous action potentials. These action potentials subsequently produce
contractions of muscle fibers that can be recorded by electrodes placed in
the muscle.

Direct spinal cord stimulation

Spinal cord stimulation techniques, originally championed by Owen,

involved stimulating the spinal cord either directly or through a long
intraosseous electrode. Recordings were made from peripheral nerves. This
technique was originally proposed as a means of monitoring motor function
that could be achieved even with total paralysis since only the peripheral
nerve action potential was recorded, and not the muscle response. However,
collision studies have demonstrated that the responses are mainly the result
of conduction along large fiber somatosensory pathways similar to those
used by the SSEP, and hence this technique does not provide additional
information to that already conveyed by the SSEP and MEP.

Ioannis Papanastassiou, Roberta Anderson, Nicole Barber, Cathleen Conover, and

Antonio E. Castellvi. Effects of preoperative education on spinal surgery patients.
SAS J. 2011; 5(4): 120124.

Sbastien Pesenti, Benjamin Blondel, Emilie Peltier, Franck Launay, Stphane

Fuentes, Grard Bollini, Elke Viehweger, and Jean-Luc Jouve. Experience in
Perioperative Management of Patients Undergoing Posterior Spine Fusion for
Neuromuscular Scoliosis. BioMed Research International. 2016: 1-7.

3. PERIOPERATIVE MANAGEMENT IN SPINE DISEASE

a. Neuromuscular Scoliosis

Patients with neuromuscular diseases frequently develop scoliosis that

requires surgical correction. Usually, spinal deformity is associated with
great pelvic obliquity. Spine fusion in neuromuscular scoliosis aims to
balance the trunk in frontal and sagittal plane, centre the head over the
pelvis, and restore anatomical spine condition. Extension into the pelvis is
meant to achieve global correction of both pelvic and spinal deformity.

A lot of instrumentation has been used in these specific deformities but the
use of techniques such as the one described by Luque and Galveston
remains the gold standard with low complication rate related to the
material, short operation time, and good functional results.

Patients with neuromuscular scoliosis undergoing posterior spinal fusion

are at higher risk for postoperative complications due to underlying
comorbidities such as decreased pulmonary function, inadequate
nutritional status, decreased mobility, and cognitive impairment.
Complication rate associated with spinal surgery in neuromuscular
scoliosis ranges from 17% to 74%. Few studies pointed out the relation
between postoperative complications and preoperative nutritional,
digestive, and respiratory preparation of patients.

Neuromuscular scoliosis is complex and still challenging with regard to

the type of spinal deformity and patients general medical condition. This
kind of surgery is often associated with high mechanical complication rate
as hardware fracture, tearing of sacral fixation, loss of lumbar lordosis, and
a significant rate of pseudarthrosis. Thus, interest of Unit Rod is to provide
a segmental fixation, allowing a good distribution of constraints all along
the spine. The Unit Rod is an extremely resistant autostable
instrumentation, avoiding postoperative restraint. It is quick and simple to
use, although it is technically more difficult in patients with hyperlordosis.
It is considerably less expensive than most other systems. The Unit Rod
can achieve good deformity correction with a low loss of correction, as
well as a low prevalence of associated complications and reoperation rate.
In our series, reoperation rate related to implant failure was only at 4.2%.

Correction achieved by Unit Rod was satisfactory in our population, with

Cobb angle correction rate of 61.5% and pelvic obliquity correction rate of
73.5%. These results are comparable to those found in literature, with
Cobb angle correction rates ranging from 54 to 82% and pelvic obliquity
correction rate ranging from 42 to 86.8%, using Luque Galveston or Unit
Rod instrumentation.

As an alternative to LG instrumentation and associated techniques, some

authors have described the use of Cotrel-Dubousset (CD) instrumentation
in neuromuscular scoliosis. Comparison of LG instrumentations in
neuromuscular scoliosis does not reveal differences in terms of
radiological outcome, complications, and patient satisfaction in the
literature. The mean operating time in our series was 277.8 minutes, which
is comparable to those reported by authors using CD instrumentation.

Recently, multilevel instrumentation with all-screw construct has been

described for neuromuscular scoliosis. Resistance to pull-out constraints is
theoretically improved with this kind of instrumentation but specific
mechanical complications have been described, such as surrounding
osteolysis around screws. Another theoretical advantage of Unit Rod
technique can be related to the low price of the implant. As an example, in
France a Unit Rod costs between 200 and 500 euros while each pedicular
screw costs around 150 euros.
Complication rate after surgical correction of neuromuscular scoliosis is
variable according to different authors but remains high. In these different
studies, complication rate ranges from 17 to 74%, Benson et al. reporting
the highest rate with 17 complications in 24 patients, predominantly
infectious and respiratory problems. Our results are consistent with an
overall early complication rate of 50%. Curve magnitude and
nonambulatory status have been described as risk factors of major
postoperative complications.

Among complications, prevalence of wound infections ranges from 8.7%

to 20%. Degree of patients cognitive impairment, denutrition, respiratory
problems, and intraoperative bleeding are associated with an increased
infectious rate. In our series, wound infection was diagnosed in 16.7% of
the population. Six patients were treated using antibiotics alone, and the
other 10 required a reoperation associated with antibiotherapy. In first
intention, wound infections treatment after spinal surgery must be
conservative, and hardware removal must be considered only if infection
persistence is diagnosed after an appropriate treatment.

Respiratory complications are a major concern in these patients, occurring

in 23.5 to 57% of cases. The analysis of our series found respiratory
complications in only 15.6% of the population. This observation may be
the consequence of the respiratory preparation patients underwent before
surgery (noninvasive ventilation and physiotherapy). It has been
previously proved that patients preoperative general status was correlated
to complication rate. Thus, we believe that respiratory preparation is of
major importance in these patients management.

Digestive complications remain relatively rare in the literature. However,

this kind of complications may be serious. In our series, one patient died
from a probable gastric perforation. In the same way, Master et al. reported
major gastrointestinal complications with 2 cast syndrome cases and 1 case
 of concomitant gallbladder hydrops and pancreatitis. Risk factors for
digestive complications are hypotensive anaesthesia, intraoperative
position, and denutrition, especially in cast syndrome occurrence.

Most of late complications were due to hardware failures including 13

pseudarthrosis cases that led to 3 rods breakage and 3 proximal junctional
kyphosis cases. Most studies report one or two cases of rod fracture.
Nectoux et al. did not report reintervention due to major mechanical
complications although 10 asymptomatic cases of windshield wiper effect
occurred in the long term.

Compared with idiopathic scoliosis, neuromuscular scoliosis patients

requiring spine surgery have a higher risk of adverse perioperative
complications because of underlying comorbidities. Comorbidities
commonly associated with neuromuscular scoliosis are decreased
pulmonary function, inadequate nutritional status, decreased mobility, and
communication and cognitive impairment.

b. Osteoporosis

Daniel Lubelski, Theodore J. Choma, Michael P. Steinmetz, James S. Harrop, and

Thomas E. Mroz. Perioperative Medical Management of Spine Surgery Patients
With Osteoporosis. Congress of Neurological Surgeons. 2015; 77 (4): 92-95

With the aging US population, there has been an increasing number of

age-related diseases, including degenerative spine conditions and
osteoporosis. Within the next 2 decades, estimates project that the
percentage of the population older than 65 years of age will increase from
approximately 12% to 20%. Osteoporosis is seen in 26% of women older
than 65 years of age and in 50% of those older than 85.4

Of spine surgery patients older than 50 years of age, 14.5% of men and
51.3% of women have osteoporosis. With an increasing life expectancy,
the prevalence of osteoporosis among spine surgery patients will continue
to increase. 4

Osteoporosis in the aging spine significantly increases the risk of vertebral

compression fractures, as well as difficulty with obtaining sufficient
fixation in instrumented cases. Older patients with degenerative conditions
without compelling surgical indications should be treated conserva-tively.
Those with continued symptoms refractory to conservative management,
with acutely worsening symptoms or with neurological symp-toms, should
be considered for surgery. Many studies have reported that, for certain
indications, spine surgery leads to greater satisfaction and functionality
relative to nonoperative management. However, in the elderly osteoporotic
population, these data become unclear because of the additional
complexity that poor-quality bone introduces to the surgical management.
These older patients require more extensive surgeries to fixate the spine,
are more prone to vertebral fractures, and are more likely to experience
complications from surgery. Elderly patients with osteoporosis have less
dense bone, poor vascularity, limited functional bone marrow, and
osteoblast activity. This corresponds to worsened osteoconductive,
osteoinductive, and osteogenic capacity, which contributes to negative
bone remodeling, non-union, and reduced pull-out strength with pedicle
screw instru-mentation. Accordingly, when surgery is necessary in this
patient population, preoperative risk assessment and medical optimization,
as well as postoperative therapy, become increasingly important. 4
Management of spine surgery patients with osteoporosis is challenging
because of the difficulty of instrumenting and the potential complications,
including nonunion, adjacent level fractures, and failure of the
instrumentation. Treatment of this patient population should involve a
multidisciplinary approach including the spine surgeon, primary care
physician, endocri-nologist, and physical therapist. All patients should
receive calcium and vitamin D. Hormone replacement therapy, includ-ing
estrogen and SERMs, should be considered for elderly female patients
with decreased bone mass. Bisphosphonates or intermittent PTH are
reserved for those with significant bone loss in the spine. All of these latter
treatment decisions should be made in consultation with an
endocrinologist to weigh the potential benefits vs the possible
complications associated with these medications. Last, calcitonin should
be provided for patients who cannot tolerate the hormone therapies or
bisphosphonates, as well as for those with pain from new vertebral
fractures. 4

Indication for preoperative treatment before spinal fusion surgery remains

unclear. Pretreatment with PTH may enable additional bone remodeling
and improve the quality of the fusion mass. Bisphosphonates remain
bound to the skeleton for an extended period, and pretreatment would
 undoubtedly affect remodeling. Although bone remodeling is a vital part
of graft incorporation and fusion, animal studies have shown that the
antiresorption osteoporosis medications are not detrimental to spine fusion.
However, there has only been 1 clinical trial investigating the effect of
bisphosphonates on spine fusion, which showed increased fusion rate but
no difference in clinical outcome. Further clinical data are needed for more
conclusive guidelines. The current evidence suggests that, perioperatively,
osteoporosis treatment should be continued regardless of a recent or
upcoming spine surgery. Physical therapy should be emphasized to
increase strength and balance. However, additional clinical evidence is
needed to understand the relative advantages/disadvantage of
antiresporptive vs anabolic agents, as well as the impact of administration
of these medications before vs after fusion surgery. Future clinical studies
will enable better understanding of the impact of current therapies on
biomechanics and fusion outcomes in this unique and increasingly
prevalent patient population. 4

c. Pediatric Spinal Disease

Sukhminder Jit Singh Bajwa and Ridhima Sharma. Paediatric Spinal Surgery: The
Essentials of Perioperative Management. Glob J Anesth. 2017; 4(1): 004-005.

The perioperative corrective spinal surgery is challenging. The major

challenges include the extensive nature of surgery, associated
comorbidities and the need for neurophysiological monitoring to diagnose
any form of intraoperative neurological insult. The pre-operative
functional status and the intra-operative events could dictate the
requirement for post-operative mechanical ventilation.

Spine surgeries are performed for varied pathologies, including congenital

or idiopathic defects, malignancy, abscesses, trauma, arteriovenous
malformations (AVMs) or herniated disc. The paediatric spine is
commonly operated for the surgical correction of scoliosis. Being a
complex spinal deformity, scoliosis has an inherent potential to involve the
cardio-pulmonary system. The anesthetic management must begin with a
focused pre-operative evaluation. The major intra-operative challenges
include the maintenance of safe positioning, fluid and temperature balance,
blood conservation and spinal cord function monitoring. Adequate
analgesia and ventilation are the primary issues of concern in the
postoperative period.

A holistic approach needs to be employed while evaluating the children

coming for spinal surgery, with emphasis on the pulmonary,
cardiovascular, andneurological systems. Functional impairment of these
systems can co-exist either as an association or as a result of the spinal
pathology. The associated neuro-muscular diseases (NMD), airway diffi
culty and impaired nutritional status, must be taken into account.
Preoperative assessment encompasses a detailed history general physical
examination, keeping in view, the associated comorbidities, syndromes.
The battery of preoperative investigations should be tailor made to
diagnose the presence and extent of the organ involvement, in addition to
the routine investigations.

Neurophysiological monitoring of spinal cord integrity is the gold standard

of intraoperative care in spinal surgery. The current monitoring modalities
for preventing intraoperative risk of spinal cord injury are based on the
measurement of somatosensory (SSEP) and motor evoked (MEP)
potentials. The evoked potentials (EPs), being the electrophysiological
responses of the nervous system to stimulation of either sensory or motor
pathways, are essentially stimulus related and pathway specific monitoring
modality. However, the interference of anesthetic agents with the EPs
poses a major constraint on the reliability of the neurological monitoring.
Most of the anesthetic agents depress the amplitude and increase the
latencies of the EPs.
 The postoperative care mandates an effective analgesic and respiratory
therapy. For favorable surgical outcome it is mandatory to have effective
pain control at rest and during ambulation and should be titrated and
individualized accordingly. The multimodal analgesic therapy includes,
wound infiltration, epidural catheter placed intraoperative, opioids
(intravenous, intrathecal), patient controlled anesthesia in older children
and NSAIDs. Considering the risk involved in surgery, the availability of
high definition unit (HDU) becomes an essential part of postoperative
care. The factors predicting the need for post-operative ventilation include,
prolonged surgery, number of vertebrae involved (>7), major blood loss
(>30ml/ kg), severe cardiorespiratory involvement, obesity, high Cobbs
angle and decreased vital capacity (<35% predicted). Prolonged intensive
care and postoperative ventilation may be required in these children.

Tae-Kyum Kim, Wonik Cho, Sang Min Youn, and Ung-Kyu Chang. The Effect of
Perioperative Radiation Therapy on Spinal Bone Fusion Following Spine Tumor Surgery. J
Korean Neurosurg Soc. 2016; 59 (6) : 597-603

d. Spine Tumor

Metastatic tumors are the most common (97%) tumors of the spine. On the
other hand, primary tumors of the spine are rare, their real incidence is
unknown. Metastatic involvement of the vertebral column can occur in 50% of
patients diagnosed with cancer and can lead to unfavorable neurological
sequelae in 514 of cancer patients. Spine tumor incidence is recently
increasing owing to the increased life span and development of spinal tumor
treatment. It is difficult to perform radical resection in the cases of vertebral
body tumors with cord compression. Over the past few years, spinal tumor
surgery was restricted to dorsal decompression of the spinal cord, and
instrumentation options for stabilization were very limited. In recent years,
surgical techniques for spinal tumors have been progressed. Nowadays, in
addition to simple spinal decompression, complex surgical procedures such
as vertebrectomy, circumferential fusion and multi-level fixation are also
widely performed to increase the stability of vertebral column. For this reason,
it is im- portant to achieve successful bone fusion in spine tumor surgery.

In the past years, conventional radiation therapy (RT) was the standard of care
for patients with metastatic spine tumor. However as surgical techniques
and instruments improve, surgical treatment followed by adjuvant RT is
affording a longer survival period and better quality of life than RT alone.
The benefit of perioperative RT has never been fully investigated, but it is
assumed to be beneficial because in most cases spinal tumor resection does
not achieve complete eradication of the microscopic tumor cells. For this
reason, tumor surgery is often accompanied by perioperative RT. Typically,
in the patients who underwent interbody fusion perioperative irradiation is
known to interfere with bone fusion and to make pseudoarthrosis causing a
late fracture after surgery. The abnormalities observed in the irradiated
tissue include the impairment of vascularization due to the high vulnerability
of small vascular endothelial cells, impairment of cell homeostasis with
cellular apoptosis, and the accumulation of fibrosis. It is well known that
high-dose irradiation delivers deleterious effects to bone tissue, including
osteoradionecrosis, sclerosis, loss of bone mass, and bone fracture, in a
dose- and time-dependent manner. However, studies have been reported that
low-dose irradiation promotes fracture healing through upregulation of
vascular endothelial growth factor. Clinical studies on spinal fusion rate in
perioperative radiation are insufficient.

It is important to achieve successful bone fusion in spine tumor surgery.

When spinal fusion surgery was combined with the perioperative RT, the
bone fusion rate showed a relatively low rate (57%). Statistically the only
factor affecting the spinal fusion was to use autologus bone graft. Type of
 radiation (SRS), time interval between RT after surgery (>1 month) were not
statistically difference but showed high fusion rate compared to the other
groups. Although it has statistically limitation, there have considerable
factors for successful spinal fusion. For the successful bone fusion, some
technical strategies are considered. First, the use of autologus bone graft is
recommended rather than allogenic bone graft. Second, the adoption of SRS
protects bone fusion bed more efficiently than convention RT. Third, when the
postoperative RT is considered, it is best to delay RT from the operation time
for as long as possible.

D. M. Sciubba et al. Perioperative challenges in the surgical management of

ankylosing spondylitis. Neurosurg Focus. 2008; 24 (1): E10

e. Ankylosing Spondylitis

Ankylosing spondylitis, a disease affecting 0.10.5% of the population, is a

chronic inflammatory spine disorder that presents significant challenges for
the spine surgeon. Although the most common complaint of such patients is
spreading lower back pain in 8090% of clinical presentations, the majority
of complaints are related to complications of spinal trauma or a progressive
spinal deformity.

Patients with AS have a high preponderance of spinal instability because of

increased rigidity across multiple spine segments in concert with osteopenia
or osteoporosis. Autofusion across normally mobile segments leads to a spine
that resembles a tubular long bone rather than a dynamic system of multiple
parts. As a result, small forces acting along large long bone lever arms create
greater rotational and translational strain, leading to greater risk of fracture
displacement. Most frequently, patients present with fractures from the
midcervical spine to the cervicothoracic junction (Fig. 1); these patients are
more likely to suffer severe neurological damage than patients with normal
spines who present with fractures, reaching 75% with neurological damage in
some series of cervical fractures. Although conservative treatment with a
halothoracic plaster or jacket can be offered, such management can be
associated with significant complications. As a result, many clinicians
recommend early surgery, particularly in the case of spinal fractures.

With regard to spinal deformity, reconstructive surgery in the spondylotic

spine has the potential to cause severe neurological damage because of the
complex dynamic forces involved in deformity correction acting on a both
rigid and brittle spine. In addition, poor bone quality due to osteoporosis and
osteopenia may lead to poor fixation and dislodgement of instrumentations,
especially with the distinctive condition of the spine that acts more like a
long, tubular bone structure than a system of articulating joints. Although
surgery is commonly recommended for patients with AS who have spinal
fractures or deformities, these patients pose several intraoperative challenges
that may lead to significant complications and death if not recognized and
efficiently managed. The surgeon must therefore be aware of several potential
perioperative complications. In this review, imaging studies, intubation
procedures, intraoperative positioning, and neurological monitoring will be
discussed in relation to the patient with AS.

Although a smooth and successful intubation is of paramount importance in

airway management and prior to any surgical intervention, the risks are
significantly increased in patients with AS. First, the presence of large
anterior cervical osteophytes may prohibit successful visualization of the
larynx and may prevent endotracheal intubation due to significant mass
obstruction.

Proper positioning of a patient with AS in the operating room or the ICU is

imperative not only for the patient with an unstable fracture, but in all AS
patients because of their an increased risk of iatrogenic injury. During head
positioning, the surgeon must take into account the sagittal alignment of the
cervical spine, which may often be significantly kyphotic. When fractures
already exist in these patients, inadequate assessment of the mass of the head
and the extent of cervical kyphosis can have disastrous effects such as
complete spinal cord damage and possible death. Hunter and colleagues
reported on a case in which rotating a patient in traction led to death.

In surgeries involving osteotomy or reduction of the cervical spine,

preoperative halo placement and traction have shown success in improving
stability during positioning. To allow a certain degree of freedom for patients
with AS in the operating room or ICU, a number of adaptations to patient
beds have been developed to accommodate prolonged immobilization. Such
advances have particular relevance for the AS population because they allow
the patient to maintain a more comfortable kyphotic condition with cervical
traction. For instance, the circle electric bed may allow movement that would
otherwise be contraindicated because of associated alteration of traction. This
apparatus allows the patient to be rotated within a circular frame with a fixed
head position relative to the torso throughout all maneuvers, such that sagittal
alignment and traction are maintained. Postoperatively, specialized beds such
as these also facilitate changing from a supine or prone position to an upright
position.

The ability to monitor the neurological status of any patient during

positioning or surgical manipulation is extremely important in any spine
surgery. However, due to the significant spinal instability in patients with AS
and the potential serious complications associated with surgical manipulation,
neurological monitoring in such patients is critical. The Scoliosis Research
Society in 1974 found that aggressive surgeries to correct deformities were
associated with severe postoperative neurological deficits, and thus the
society advised the universal use of intraoperative monitoring. In patients
with AS, this statement is especially relevant. The surgeon must first decide
whether the patient should receive general anesthesia at all. Because of the
potentially hazardous nature of osteotomy procedures, a local anesthetic can
be administered for frequent neurological assessments during deformity
correction. Urist was one of the first to report success with cervical osteotomy
with the patient in the sitting position and with local anesthesia. Such
operations carry a high risk of neurological complications due to the potential
for iatrogenic cervical subluxation and spinal cord compromise, and thus
continual feedback on neurological status provided by the awake patient is
especially important. Nevertheless, performing these complex corrective
spinal procedures on awake patients is a challenging task and is done on a
rare basis.

Operations involving patients with AS have been associated with increased

perioperative blood loss. In some patients with kyphotic deformities, the
presence of a highly curved spine prohibits achievement of a free-hanging
abdomen. Specifically, if the abdomen is not supported, there is increased
pressure applied to the chest with resultant increases in peak inspiratory
pressure and ventilation problems. To compensate, generous additional
padding may be used to relieve the pressure at the cost of increasing
abdominal pressure and causing a resultant increase in central venous
pressure, leading to distention of the epidural venous plexus. Tetzlaff and
colleagues described a procedure involving a patient undergoing
decompression, osteotomy, and fusion at T-12 with blood loss of 17,000 ml
perioperatively. Blood-loss issues can further be complicated by the inability
to visualize the accumulation of an epidural hematoma on radiography or CT
scans. Magnetic resonance imaging is considered the imaging modality of
choice by radiologists for the diagnosis of hemorrhaging in such cases.

The severely rigid yet brittle nature of the spine in patients with AS must not
be underestimated when managing their care in the emergency room,
operating room, or ICU. An increased rate of neurological damage exists in
these patients due to excessive rotation and angulation at fracture sites, a
phenomenon exacerbated by preexisting deformity and associated corrective
maneuvers. Thus the routine management of patients with spinal lesions,
 including effective imaging, intubation, positioning, neurological monitoring,
and deformity correction becomes particularly challenging in patients with
AS. Early recognition of potential pitfalls and complications associated with
the treatment of patients with AS will help to avoid preventable or iatrogenic
injuries.

Thomas Wiesmann, Marco Castori, Fransiska Malfait and Hinnerk Wulf.

Recommendations for anesthesia and perioperative management in patients with
Ehlers-Danlos syndrome(s). Orphanet Journal of Rare Diseases. 2014;9:109

f. Ehlers-Danlos Syndrome
Ehlers-Danlos Syndrome (EDS, Orphanumber: ORPHA98249) is an umbrella
term for a growing number of heritable connective tissue disorders, mainly
featuring joint hypermobility and instability, skin texture anomalies and
vascular and internal organ fragility. The overall incidence is 1:10,000 to
1:25,000 with no ethnic predisposition, resulting in a presumed number of at
least 20,000-50,000 EDS patients in the Northern America. However, the real
frequency is probably underestimated due to the general lack of awareness
among the various disciplines of such a protean condition, especially for the
most atypical presentations. Clinical manifestations range from extremely
mild phenotypes to life-threatening complications. The current Villefranche
nosology recognizes six major subtypes, comprising classic (corresponding to
EDS type I and II of the old Berlin nosology), hypermobile (EDS type III),
vascular (EDS type IV), kyphoscoliotic (type VIA), arthrochalasia (types
VIIA and VIIB) and dermatosparaxis (type VIIC), most of which are linked
to mutations in one of the genes encoding for fibrillar collagen proteins or
enzymes involved in post-translational modification of these proteins.
Recently, several new EDS variants have been defined clinically and
genetically. In addition, there has recently been suggested a possible
connection between hypermobile EDS and the joint hypermobility syndrome,
a relatively neglected rheumatologic condition recognized by specific
diagnostic criteria. However, not all researchers and clinicians agree with this
view, which may be clarified by future molecular studies.

Classic EDS commonly presents with various degrees of skin fragility and
hyperextensibility, defective wound healing, easy bruising and generalized
joint hypermobility. Hypermobile EDS is also characterized by minor but
often-recognizable skin anomalies and chronic musculoskeletal pain.
Vascular EDS features thin, easily bruised, translucent skin, with very
marked fragility of blood vessels. The gastro-intestinal tract and gravid
uterus, and, less commonly, lungs, spleen and liver, are prone to spontaneous
rupture. The natural history and phenotypic spectrum of the other three major
variants and all the emerging ones are less well known, but most share tissue
fragility and its complications with the more common subtypes. Therefore,
carrying out a detailed interview and clinical examination as well as
contacting the local/regional reference center is essential in order to estimate
the individual anesthetic/procedural risks for each patient. Subtype
classification, with particular attention to those variants with increased
vascular fragility (especially vascular EDS), should be obtained before
surgery.

Preoperative history and physical examination, general assessment and

subtype classification, results of previous clinical genetic counseling, and a
standardized bleeding history should be taken, as well as assessment of any
intubation difficulties. It is helpful to contact the EDS specialist in charge to
discuss open questions regarding the specific patient. Skin fragility, with
regard to shear forces or use of medical tapes, should be noted. Laboratory
results are usually within normal range and mostly not helpful for estimating
the bleeding risk. If neuraxial anesthesia is contemplated, scoliosis, previous
spinal surgery and other spine pathology should be ruled out. Ineffectiveness
of local anesthetics, e.g. during dental procedures in the past, or block failure
in previous attempts of local or regional anesthesia should be noted. Muscular
weakness and signs of aortic or mitral insufficiency should be sought. A
Doppler ultrasound scan might help exclude subclinical cardiac pathology
(e.g. non-progressive aortic root dilatation or hemodynamically relevant valve
insufficiency).

Non-invasive monitoring should be performed whenever possible, although

some patients are prone to bruising and hematoma formation by repetitive
non-invasive blood pressure measurements. On the other hand, invasive
blood pressure monitoring runs the risk of vascular wall dissection (mainly
for EDS subtypes with vascular fragility); we recommend avoiding invasive
measurements whenever possible in non-emergency surgery in vascular EDS.
Ultrasound might reduce the risk of repeated vascular puncture.

Patient positioning

Padding should be used to reduce shear forces and external tissue pressure.
The eye should be protected as direct force to the eyeball increases the risk of
retinal detachment and globe rupture, especially in kyphoscoliotic EDS and
brittle cornea syndromes with increased ocular fragility, and in pathological
myopia. One of the authors (TW) has anecdotal knowledge of an iatrogenic
retinal detachment by a surgeons elbow in a patient during surgery on the
contralateral eye. A case report describes a severe stretch injury to the
brachial plexus due to intraoperative hyper abduction. Adhesive tapes and
wound dressing for fixation of devices should be easily removable or avoided
if possible because of the risk of severe skin damage; the history should
specifically address this issue. This issue is of outstanding importance in EDS
with fragile skin such as dermatosparaxis and other subtypes with fragile
skin. Patient handling must be performed with maximal reduction of shear
forces of the skin as even minor shear forces might result in severe
decollement injuries in these patient subgroups. Pre- and postoperative
written documentation of the neurological and visual status might be helpful
with regard to medicolegal issues in operations with need for extreme patient
positioning.
In general, mask ventilation, intubation and laryngeal mask insertion are all
possible, but care is required with mask ventilation to avoid
temporomandibular joint luxation. Repeated intubation attempts may cause
bleeding; smaller endotracheal tubes may reduce mucosal damage. Cuff
pressure should be checked frequently and kept as low as possible. Airway
pressure should be minimised due to the risk of pneumothorax.

Difficult airway management and intubation may occur in many forms of

EDS with temporomandibular dysfunction, premature spondylosis, or
occipitalatlantoaxial instability and should be anticipated with a higher
incidence than in general population. This might result in high risk for
accidental joint dislocation during intubation attempts or in reduced joint
mobility caused by spondylosis resulting in reduced mouth opening.
Subclinical cervical spine instability may be present in patients with
preserved neck flexibility and temporomandibular joint mobility or
occipitoatlantooccipital instability. Care taken here might prevent post-
operative complications, such as neck pain and compression-related
neurological symptoms. Elective fibreoptic intubation should be considered
when difficulties are anticipated.

Circulatory issues

Postural orthostatic tachycardia syndrome (POTS) is sometimes a feature in

EDS, especially those with the hypermobile variant (or joint hypermobility
syndrome). Preoperative infusion of crystalloid and early use of vasopressors
may be helpful. The effects of POTS on perioperative care arent yet known;
adequate postoperative patient monitoring is recommended.

Crossmatching, bleeding prophylaxis and thromboprophylaxis

Crossmatching adequate amounts of RBCs is advised for patients at risk of

bleeding (EDS subtypes with increased vascular fragility, as well as patients
with unknown or positive bleeding history). In elective surgery, autologous
donation should be discussed. Cell-saving might be advisable for major
surgery. For details we refer to the review by Castori et al. Although
laboratory testing usually shows normal values for INR, PTT and other in-
vitro-tests (such as thrombelastometry, e.g. ROTEM), platelet aggregation
abnormalities can be expected in about 26% of patients. New measures of
platelet function such as PFA-100 or Multiplate show normal values and
should not be used routinely. About 90% of EDS patients (all subtypes)
bruise easily. In some classic and dermatosparaxis EDS, and EDS subtypes
with increased vascular fragility, patients are prone to severe bleeding and
hematoma formation. De Paepe and Malfait have given a detailed review of
bleeding disorders in EDS patients. In acute bleeding (especially in vascular
EDS), we recommend an early aggressive hemostatic therapy as well as
intraoperative coagulation tests (in laboratory as well as point-of care, e.g.
ROTEM). Desmopressin (DDAVP) improves the bleeding time and
reduces transfusion requirements although the exact mechanism is unknown.
It increases plasma levels of Factor VIII and von-Willebrand-Factor (vWF).
Some authors recommend its use preoperatively in vascular EDS.

Pharmacology

Ehlers-Danlos syndrome is not associated with abnormalities of

pharmacokinetics or pharmodynamics, but a detailed history might reveal
relevant concurrent disease. General anesthesia can be performed as balanced
anesthesia with volatile anesthetics, nitrous oxide or as total intravenous
anesthesia (TIVA). Depolarizing (Succinylcholine) as well as non-
depolarizing agents are safe. As some EDS patients present with muscular
weakness, monitoring of neuromuscular blockade is advised before
emergence of the anesthesia. In immobilized patients, the avoidance of
depolarizing agents (succinylcholine) is advisable.
 Perioperative emergencies

All PACU and ward nurses should be aware of specific acute situations in
EDS such as vascular dissection (e.g. aortic dissection, peripheral arteries &
veins) caused spontaneously or iatrogenic (especially during angiographic
interventions. Compartment syndromes can be caused by vascular puncture or
rupture due to pressure and shear forces and resulting bleeding. Unstoppable
bleeding from the operation site or organ rupture (vascular EDS) may occur.
Risk of pneumo- (hemo-) thorax must be anticipated during positive pressure
ventilation as well as central venous access. Moreover, spontaneous rupture
or rupture after trivial trauma to the bowel, uterus, esophagus or vagina has
been reported. This risk is greater in the post-operative period, and may occur
at sites remote from the site of surgery. All team members should be aware of
these possibilities in the postoperative period to avoid delayed diagnosis
when unusual symptoms occur. These events are unusual in patients other
than vascular EDS; in this condition, even elective vascular, gastro-intestinal
and other surgery should be avoided whenever possible.

4. SUMMARY

Spinal surgical procedures have a wide variety and comprise a major subgroup of
orthophaedic surgery. Thousands of patients undergo spinal surgery every year.
Perioperative management of the spinal cases is directly related with perioperative
morbidity and mortality.

Preoperative assessment is one of the most important stages of perioperative care.

Whereas, the focus of intraoperative management is minimizing spinal cord
ischaemia and compression on the spinal cord.

Most spinal surgery is painful and good postoperative analgesia is important. A

multimodal analgesic approach is recommended. A combination of local and
regional anaesthesia, opioids, ketamine and NSAIDs can be used.