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Advanced Principles- Fall 2018 > Ortho- Spine > Flashcards

Flashcards in Ortho- Spine Deck (18)
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1

Positioning for spine surgery:

anterior approach

  • Used for access to upper thoracic and cervical spine
  • GETA- possibly awake fiberoptic
  • Supine, bilateral arms tucked
  • Good IV access- possibly 2 IVs d/t tucking of arms
  • Possible airway edema
  • EBL is minimal if no vascular surgery
  • SSEP monitoring

2

Positioning for spine surgery:

posterior approach

  • For access to mid thoracic spine and below
  • GETA on stretcher
  • Prone- chest rolls or specialized frame
  • Arms often in superman position
  • Facial edema, eyes
    • check eyes frequently
    • risk for blindness
  • Pad pressure points, groin and breasts
  • SSEP

3

Positioning for spinal surgery:

lateral approach

  • For access to thoracic spine
  • May require one-lung ventilation
    • double lumen ETT, bronchial blocker, lung packed
    • A-line to check ABGs
    • Causes VQ mismatch
  • Axillary chest roll
  • ***some spine surgeries will require position changes to all these positions

4

What is your first consideration with cervical spine surgery?

  • Is the neck stable?
  • Position pts head to comfort while awake
    • avoid sniffing position and cricoid pressure
  • Consider awake fiberoptic intubation
    • If procedure is long with prolonged traction, may want to leave them intubated

5

Anesthetic considerations for cervical spine surgery

  • Requires GA
  • Airway compromise and vascular injury can occur
    • hematoma/carotid artery damage causes rapid blood loss
    • unilateral recurrent nerve damage
  • Post op pain can be controlled with cervical plexus block

6

What approach is usually used for cervical spine surgery?

  • Anterior approach
    • Esophagus and trachea medial
    • sternocleidomastoid and carotid sheath lateral
    • Following discectomy, vertebrae fused with bone, plates, and or screws to prevent dislocation
  • *retraction of trachea extremely stimulating
  • arms tucked- check IVs before tucking
  • Also can be done with posterior approach
    • sitting- risk for air embolism
    • prone- risk for eye damage, fluid overload, and airway edema

7

What is spinal stenosis?

Narrowing of the spinal canal

8

What is scoliosis?

What problems is it associated with?

  • Lateral and rotational curvature of spine
  • Restrictive pulmonary dysfunction
  • chronic hypoxia
  • hypercapnia
  • pulmonary vascular constriction
    • this can eventually lead to right ventricular hypertrophy and cor pulmonale

9

Thoracolumbar spinal surgery:

What are the types of surgery?

position?

What kind of monitoring may be required?

  • Types of thoracolumbar spine surgery
    • discectomy
    • harrington rod
    • fracture stabilization
    • scoliosis correction
    • tumor resection
  • Positioning: prone, maybe anterior or lateral
  • monitoring?
    • SSEP
    • MEPS
    • wake up test

10

What are hemodynamic concerns during thoracolumbar surgery?

Monitoring?

  • Considerable EBL
    • depends on number of segments fused
    • 3-4 units autologous
    • cell saver
  • induced hypotension (MAP 55-60)
  • Aline, CVP, PA cath, foley
  • Risk of VAE

11

Lumbar spine surgery:

What types are there?

positioning?

EBL?

  • Discectomy, laminectomy, fusion
  • Prone position
  • EBL depends on number of segments fused

12

What is SSEP?

  • Helps determine surgical impingement on spinal roots
  • monitors dorsal column pathways of posterior spinal cord (sensory)
  • SSEPs recorded by stimulating peripheral afferent nerves
  • If nerve is intact, electrical potential will transmit to contralateral sensory cortex
  • Recording electrodes are placed on the scalp and on the cervical spine
  • Amplitude, shape, and latencies of the responses are monitored
  • Need to establish a reproducible baseline recording prior to any positioning or surgical manipulations
  • Changes from baseline are most important indictors of neurological dysfunction

13

How does anesthetic gas affect SSEP?

14

What are the anesthetic considerations when monitoring SSEPs?

  • Inhaled anesthetics can alter the evoked responses 
  • VA at 0.5 MAC with 50% N2O decrease amplitude and prolong latency of SSEP
  • IV anesthetics have no affect- TIVA is a good option
  • NMB do not impact SSEP
  • Decrease in SSEP signal despite no change in anesthetic or no surgical changes may mean hypotension- Nerves need blood too!

15

What is MEPS?

  • Motor evoked potentials
  • recorded from muscles following transcranial stimulation of the motor cortex to the peripheral muscles
  • Used to ensure the integrity of the descending motor tracts of the spinal cord
  • sensitive to volatile anesthetics
  • affected by muscle relaxation
    • sometimes ok with only two twitches
    • have bite block in mouth because stimulations can movement
    • communicate with neuro monitoring tech

16

How can blood be conserved during spine surgery?

Autologous donation

cell saver

antifibrinolytics such as tranexaminic acid (TXA)

17

How can post-op pain be controlled after spine surgeries?

  • systemic analgesics (IV, PCA)
  • Epidural analgesic (PCE) and with local
    • 0.05%-1% Bupivicaine with 2-5 mcg/cc fentanyl at 3-10 ml/hr
  • Peripheral nerve blocks with bupivacaine or ropivacaine
  • NSAIDS
  • wound LA infiltration
  • methadone

18

What are some complications of spine surgery?

  • Massive transfusion sequelae
  • VAE
  • vision loss/blindness