Modul Orthopedi 2

Semester 3
Perioperatif dan Neuromonitoring Bedah Tulang Belakang

Pembimbing : Dr. dr. Sudadi, SpAn, KNA, KAR

Departemen Anestesiologi & Terapi Intensif

FKKMK Universitas Gadjah Mada/ RSUP Dr Sardjito
Yogyakarta
2021
General Indications for Spine Surgery
• Neurological dysfunction (compression)
• Structural instability (abnormal displacement)
• Pathologic lesions (such as a tumor or infection)
• Deformity (abnormal alignment)
• Pain (spinal column/discogenic/facetogenic)

Sumber : Morgan (2018), UpToDate

(2021)
• Operations on the spinal column can help correct deformities (eg,
scoliosis), decompress the cord, and fuse the spine if disrupted by
trauma or degenerative conditions.
• Spinal surgery may also be performed to resect a tumor or vascular
malformation or to drain an abscess or hematoma.

Sumber : Morgan (2018)

Preoperative evaluation
• Preoperative evaluation should focus on assessment of the airway and the
respiratory, cardiovascular, musculoskeletal, and neurologic organ
systems.
• Preoperative evaluation should focus on any anatomic abnormalities and
limited neck movements (from disease, traction, “collars,” or other
devices) that might complicate airway management.
• Neurological deficits should be documented.
• Neck mobility should be assessed.
• Patients with unstable cervical spines can be managed with either awake
fiberoptic intubation or intubation after induction with in-line stabilization.
Sumber : Morgan (2018), UpToDate
(2021)
Airway evaluation
• Airway management for patients presenting for spine surgery may
be difficult, particularly when surgery on the upper thoracic or
cervical spine is planned.
• These patients may present with diseases that distort airway
anatomy or restrict neck or jaw movement, such as osteoarthritis,
rheumatoid arthritis, ankylosing spondylitis, neuromuscular
disorders, and previous radiation of the head or neck.
• In addition, these patients may have instability of the cervical spine,
which will affect the choice of intubation technique
Sumber : Morgan (2018), UpToDate
(2021)
Pulmonary evaluation
• Patients scheduled for spine procedures may have conditions that affect
pulmonary function.
• Significant spinal deformity may result in restrictive respiratory physiology, with
decreases in vital capacity and total lung capacity, and in some cases pulmonary
hypertension and cor pulmonale.
• Although rarely required, in addition to routine preoperative respiratory
assessment, pulmonary function testing and arterial blood gas analysis may be
indicated for patients having complex spine procedures, especially for thoracic
spine procedures requiring a thoracotomy and use of a double lumen
endotracheal tube. Results may help predict the effects of one lung ventilation
and thereby help plan the surgical approach.
Sumber :UpToDate
(2021)
Cardiovascular evaluation
• Cardiovascular compromise may be the result of the pathology for
which spine surgery is being performed, such as pulmonary
hypertension in patients with severe kyphoscoliosis.
• In addition, many patients presenting for spine surgery are unable
to exercise and cannot provide functional assessment.
• Preoperative cardiac evaluation should take into account both
patient factors and the invasiveness of the planned surgery

Sumber :UpToDate
(2021)
Musculoskeletal evaluation
• Some patients having spine surgery have coexisting conditions that make
surgical positioning challenging.
• The patient should be asked about range of motion of joints prior to
anesthesia, as limitations may affect decisions about positioning. Skin should be
examined and bruises or signs of injury documented preoperatively
Neuromuscular evaluation
• Existing motor and sensory neurologic deficits should be recognized and
documented prior to surgery.
• Knowledge of existing deficits is essential for accurate surveillance and
diagnosis of new postoperative deficits
Sumber :UpToDate
(2021)
Laboratory evaluation
• Existing comorbidities and invasiveness of the anticipated procedure should
dictate preoperative laboratory evaluation.
• Laboratory testing is usually unnecessary for single-level decompressive
procedures performed in patients with limited comorbid disease.
• We perform a baseline hemoglobin, platelet count, serum creatinine and blood
bank type and screen for surgical procedures that involve more than two
vertebral levels, vertebral fusion and/or instrumentation, or require osteotomies.
• If significant blood loss is expected, consultation with the blood bank may be
required in advance of surgery if the type and screen shows antibodies that will
delay cross match.
Sumber :UpToDate
(2021)
INTRAOPERATIVE MANAGEMENT
• Spinal operations involving multiple levels, fusion, and instrumentation are also
complicated by the potential for large intraoperative blood loss; a red cell salvage
device is often used
• Excessive distraction during spinal instrumentation (Harrington rod or pedicle screw
fixation) can injure the spinal cord.
• Transthoracic approaches to the spine require one-lung ventilation.
Positioning
• Most spine surgical procedures are carried out in the prone position
• The supine position may be used for an anterior approach to the cervical spine,
making anesthetic management easier, but increasing the risk of injury to the
trachea, esophagus, recurrent laryngeal nerve, sympathetic chain, carotid artery, or
jugular vein
Sumber : Morgan (2018)
• Positioning supine to prone  maintain the neck in a neutral position
• On prone position, the head may be turned to the sidedon’t exceeding the
patient’s normal range of motion
• Caution is necessary to avoid corneal abrasions or retinal ischemia from
pressure on either globe, or pressure injuries of the nose, ears, forehead, chin,
breasts, or genitalia
• The arms may be tucked by the sides in a comfortable position or extended
with the elbows flexed (avoiding excessive abduction at the shoulder).
• Airway and facial edema can likewise develop after prolonged “head-down”
positioning. Reintubation, if required, will likely present more difficulty than the
intubation at the start of surgery.
Sumber : Morgan (2018)
• Turning the patient prone is a critical maneuver, sometimes complicated
by hypotension. Abdominal compression, particularly in obese patients,
may impede venous return and contribute to excessive intraoperative
blood loss from engorgement of epidural veins
• Prone positioning with chest rolls that permits the abdomen to hang
freely can mitigate this increase in venous pressure.
• POVL occurs secondary to: (1) Ischemic optic neuropathy (2)
Perioperative glaucoma (3) Cortical hypotension and embolism
Prolonged surgery in a head-down position, major blood loss, relative
hypotension, diabetes, obesity, and smoking all put patients at greater
risk of POVL following spine surgery
Sumber : Morgan (2018)
Monitoring
• When major blood loss is anticipated or the patient has preexisting
cardiac disease, intraarterial pressure monitors should be considered
prior to “positioning” or “turning.”
• Sudden, massive blood loss from injury to the great vessels can occur
intraoperatively with adjacent thoracic or lumbar spine procedures
• Instrumentation of the spine requires the ability to intraoperatively
detect spinal cord injury
• Continuous monitoring of somatosensory evoked potentials and
motor evoked potentials provides alternatives that avoid the need for
intraoperative awakening
Sumber : Morgan (2018)
Monitoring

Standard Monitoring Special Monitoring

• As specified by American • Invasive blood pressure
Society ofAnesthesiologists • Central venous pressure
• ECG, NIBP, Pulse oximetry, • Urine output
Capnometry, Temperature

Sumber :UpToDate
(2021)
Specific monitoring

Somatosensory evoked potential (SSEP)

Motor evoked potential (MEP)

Wake up test

Electro myographic monitoring(EMG)

Sumber :UpToDate
(2021)
Somatosensory Evoked Potentials
Used for monitoring the integrity
of the somatosensory pathway,
specifically the dorsal column
The impulse generates two
responses: orthodromic (visible
as a muscle twitch) and
antidromic (carried by the neural
tract to the somatosensory cortex)
The potentials are evoked by
providing a train of electrical
impulses on peripheral mixed
nerves—commonly median and
ulnar nerves in the upper limb
and posterior tibial and common
peroneal nerves in the lower limb
This antidromic can be measured
along the tract
Sumber :UpToDate
(2021)
Somatosensory Evoked Potentials (cont)
• Stimulus Characteristics
• Stimulus is provided by subdermal electrodes or surface electrodes
• Stimulus intensity kept at a level to produce noticeable twitch in the hand/foot (if not paralyzed) or if
paralyzed, increased progressively from 20 to 100 mA until a good SSEP waveform is elicited

Sumber :UpToDate
(2021)
Somatosensory Evoked Potentials (cont)

• Bolus dosing of hypnotics is not allowed; infusions are preferred

for intravenous and constant dial setting for inhalational agents
• Propofol-based anesthesia is better than inhalational anesthesia;
dexmedetomidine may be added as adjunct. Opioids may be used
liberally
Anesthetic • N2O is contraindicated
Considerations • Body temperature should be maintained constant near euthermia
• Hypotension, hypoxia, anemia, and dyselectrolytemia all influence
SSEPs detrimentally and should be avoided
• Neuromuscular blocking agents are allowed and preferred as
paralysis removes the EMG noise component

Sumber :UpToDate
(2021)
Sumber :UpToDate
(2021)
Motor Evoked Potentials

Opposed to SSEPs, MEPs are

It monitors the corticospinal
conducted in an anterograde
tract, and thus intraoperative
fashion, with stimulation being
deficits in this modality correlate
provided at the cortex and signal
directly with postoperative motor
being captured at level of spinal
deficits
cord and muscles

MEPs are generated by

transcranial electrical or magnetic
stimulation of the cortex, which
produces signals captured at
the spinal cord level and at the
muscle level Sumber :UpToDate
(2021)
Sumber :UpToDate
(2021)
Motor Evoked Potentials (cont)
• Anesthetic Considerations
• Anesthetics have a detrimental effect on this modality
• MEPs are more sensitive to anesthetic agents than SSEPs and the
requirement of exclusion of neuromuscular blocking agents from the
anesthesia protocol

Sumber :UpToDate
(2021)
Spontaneous Electromyography

Spontaneous EMG, as opposed to SSEP and MEP, does not rely on specific stimulation of a neural tract to
observe changes

In essence it may be compared with electroencephalography, such that spontaneous background activity of
muscles gets monitored and any changes point to mechanical, thermal, or metabolic irritation of the neural
tract in real time

Better temporal resolution of this technique compared to evoked potentials makes it an invaluable adjunct to
neurosurgical tract monitoring techniques

Sumber :UpToDate
(2021)
 Spontaneous Electromyography (cont)

Stimulus Characteristics and Response Capture

• Physiological or iatrogenic perturbation of neural tracts at
the operative site
• False-positive discharges occur frequently during
cauterization and cold saline irrigation since electrical
discharges and temperature changes can stimulate
neuronal activity
• The response capture is done using bipolar needle
electrodes (≥5 mm apart) inserted into specific muscles
following the motor distribution of specific parts of the
spinal cord

Sumber :UpToDate
(2021)
Spontaneous Electromyography (cont)
• Waveform Characteristics
• The discharges may be visualized on screen and more often be linked to an
audio output, which provides a real-time feedback to the neurosurgeon
• A single burst of discharge maybe ascribed to a specific maneuver on part of
the neurosurgeon or nearness to a nerve root, but trains of neurotonic
discharges imply constant irritation and maybe indicative of nerve root
damage

Sumber :UpToDate
(2021)
Sumber :UpToDate
(2021)
Spontaneous Electromyography (cont)
• Anesthetic Considerations
• Physiological variables (temperature and blood pressure) and choice of
hypnotic agents have no effect on spontaneous EMG recordings
• Neuromuscular blocking agents need to be excluded from the protocol
• As with MEPs, the discharges may be recorded at partial neuromuscular
blockade (up to 75%)

Sumber :UpToDate
(2021)
Spontaneous Electromyography (cont)
• Limitations and Pitfalls
• False negatives
• Although this modality tests the integrity of the nerve, it is possible for the nerve to be
stimulated, even after transaction, if the stimulation occurs on the distal part of the
transected nerve, thus providing a false impression of continuity
• False positives
• Trains of neurotonic discharges can be elicited by irritation of the nerve root
with sudden temperature changes (warm or cold saline) or with mechanical irritation due
to irrigation, which in themselves are benign
• Overall this modality has a high sensitivity for nerve root damage but low
specificity

Sumber :UpToDate
(2021)
Spontaneous Electromyography (cont)
• Uses
• Any surgery with a risk of damage to a known motor nerve can be
monitored using this technique
• Any of the spinal nerve roots from cranial to sacral may be
monitored for a variety of surgeries such as decompression, deformity
correction, fusion, pedicle screw placement, or tumor resection

Sumber :UpToDate
(2021)
Triggered EMG
• Assessing the fungctional integrity of a nerve or nerve root
• Direct electrical stimulation is also used to acces the health and function of nerve root
• Healty nerve have a stimulation threshold well under 2mA and often under 1 mA
• Assess the placement pedicle screw

Sumber :UpToDate
(2021)
Triggered EMG (cont)
• Anesthetic Considerations
• The same protocol as free-running EMGs is followed
• Neuromuscular block is prohibited

Sumber :UpToDate
(2021)
Terima Kasih