Lumbar laminectomy/fusion under spinal anesthetic

[nopain1234]

I have a patient who’s a poor candidate for GETA. Really needs the surgery. I don’t see why this wouldn’t be doable yet you don’t hear about it much. Anyone have experience with such?

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[UscGhost]

Prone positioning makes it pretty challenging and quite risky if the patient has any airway issues at all.

Wouldn't work on the beds we use. But there may be surgeons and OR beds that facilitate it more easily. Sounds

 

[nimbus]

No personal experience but what’s old is new again.

During residency our department chairman told me stories about doing decompressive laminectomies under spinal anesthesia with Ingrid Bergman’s ex-husband who was a neurosurgeon. They were doing this in the 1980s. He said it helped that the surgeon was smooth and fast. Patient selection is also very important. A poor candidate for general anesthesia is usually a poor candidate for spinal anesthesia too.


This is what our neurosurgical colleagues are currently reading. Apparently they do instrumented fusions under spinal anesthesia at some institutions.

Neurosurgical Focus Volume 51 Issue 6: Anesthetic and Monitoring Techniques in Awake Spinal Surgery (2021)

"Volume 51 (2021): Issue 6 (Dec 2021): Anesthetic and Monitoring Techniques in Awake Spinal Surgery" published on Dec 2021 by American Association of Neurological Surgeons.

thejns.org

 

[patriot6]

I have a patient who’s a poor candidate for GETA. Really needs the surgery. I don’t see why this wouldn’t be doable yet you don’t hear about it much. Anyone have experience with such?

Nope.

I’m just imaging the **** show of trying to convert to GA with the myriad of instruments laid out upon the patient’s open back.

 

[GassYous]

I have a patient who’s a poor candidate for GETA. Really needs the surgery. I don’t see why this wouldn’t be doable yet you don’t hear about it much. Anyone have experience with such?

Does he though?

 

[DocVapor]

Nope.

I’m just imaging the **** show of trying to convert to GA with the myriad of instruments laid out upon the patient’s open back.

Just put the patient in pins and get set up for an upside down VL. I do it all the time. Easy.

 

[teacher2md]

I have a patient who’s a poor candidate for GETA. Really needs the surgery. I don’t see why this wouldn’t be doable yet you don’t hear about it much. Anyone have experience with such?

Serious question:

What comorbidities could plausibly make a spinal anesthetic safer than GA in this case?

****ty heart? just use less propofol with induction, have some phenelyphrine ready. I would have the same concerns with sudden afterload drop with a spinal.

****ty lungs? You’re really going to limp through a case in prone position with Nasal cannula rather than just securing the airway?

 

[patriot6]

Serious question:

What comorbidities could plausibly make a spinal anesthetic safer than GA in this case?

****ty heart? just use less propofol with induction, have some phenelyphrine ready. I would have the same concerns with sudden afterload drop with a spinal.

****ty lungs? You’re really going to limp through a case in prone position with Nasal cannula rather than just securing the airway?

Exactly. I’d much rather just line them up preop and have all the vasoactive drugs rdy to go, along with a controlled airway.

 

[AKMD_1984]

Yeah…no

 

[Maz777]

I think this is commonly done in other countries. I would never. If you can't tolerate a GA, you can't tolerate a spinal. Why people think that avoiding GA is magically safer is beyond me? Sure, a case done under straight local/no sedation in the supine position might be safer. But a prone case done under spinal/deep sedation = no way that is safer than having a controlled airway. If I could obtain a controlled airway for every case I do, I would die happy.

 

[zizzer]

Agree with the suspicion of the assessment that GA is riskier. Why not share some details?

 

[deleted875186]

I’ve done it. Works well. You can tell if spinal is working before getting into surgery to the point where you would need to convert to GA. What is the spinal wears off?? There is a neurosurgeon with dura in plain view who can simply inject another dose of local.

 

[Maz777]

I’ve done it. Works well. You can tell if spinal is working before getting into surgery to the point where you would need to convert to GA. What is the spinal wears off?? There is a neurosurgeon with dura in plain view who can simply inject another dose of local.

What's your plan if you get a high spinal?

 

[deleted875186]

What's your plan if you get a high spinal?

You’ll know if you get a high spinal before the case starts. If surgeon redoses just give a very small dose. Obviously redosing is like plan D, should only be offering this surgery to a one level decompression, or with surgeon who’s very good and fast.

 

[repititionition]

sounds like the type of approach that should be trialed and optimized on many patients who don’t strictly need this anesthetic before attempting it on one that does

 

[Arch Guillotti]

What comorbidities could plausibly make a spinal anesthetic safer than GA in this case?

yeah what's the clinical scenario?

 

[nimbus]

sounds like the type of approach that should be trialed and optimized on many patients who don’t strictly need this anesthetic before attempting it on one that does

Absolutely. The whole team needs to practice on chip shot cases before trying an unfamiliar technique on a sick patient. The best path may be to refer the patient to a center that has experience with this technique (eg Mayo or UCSF) and see if they accept the patient.

 

[GravelRider]

I have a patient who’s a poor candidate for GETA. Really needs the surgery. I don’t see why this wouldn’t be doable yet you don’t hear about it much. Anyone have experience with such?

What is a poor candidate for GA? The hoops some people jump through to avoid intubation or a general anesthetic is fascinating to me sometimes. I’ve taken over cases where someone has 65 different drips running, bilateral nasal trumpets, and an oral airway…all in an attempt to avoid GA.

 

[nopain1234]

You people are insufferable souls. I feel sorry for you

 

[anaesthetic]

You people are insufferable souls. I feel sorry for you

Isn’t this an SDN rule or something? That all threads eventually lead to “you’re a horrible anesthesiologist, person, etc.”.

 

[nopain1234]

Further, I am ashamed to be one of you

 

[vector2]

You people are insufferable souls. I feel sorry for you

Feel sorry? This is my typical day

7:10- Roll out of bed, splash water on my face, head to work.

7:29- Arrive in time at the OR for my 7:30 cases. Determine each patient needs further lab work. I tell the surgeons we are delayed because patients were late arriving to hospital.

7:37- I'm hungry. Breakfast time.

8:42- I cut my breakfast short after 1 hour to make sure my 2 cases are now going. Stick my head in each room, patients asleep. From the door I hear beeping so I assume they both are alive, flash the thumbs up sign and leave.

8:44- Time to make rounds. I need to check on the RN.I.L.F.'s on 3W, 4E, 5C, and ICU.

10:06- "BEEP, BEEP, BEEP." FUQQ!! Rounds cut short due to pager going off, AGAIN! "Dammit, that's the third time this thing has gone off this month! What am I, the friggin hospitalist?"

10:11- Man, I'm hungry. It's been over an hour and a half since my last food break. I head to the doctor's lounge to grab a coke, some donuts, watch CNBC, and check emails.

11:03- Cut my donut break short to check on my cases. Both rooms are empty. I find out my next case is already in progress in a different room. Pulse Ox is beeping. Patient is alive. I flash the thumbs up from the door and leave.

11:06- Family members ask how the surgery is going. I tell them he is fine. They tell me it's a she. "Whatever. She's doing fine. Gotta run."

11:11- Surgeon wants to know if he can add on an emergency appendectomy. All 3 anesthesiologists already have 1 case in progress each that are being supervised, but we can do it first thing in the morning. Surgeon gets pissed. I tell him to tell the hospital to not be so cheap and give anesthesia more money.

11:13- I head off to finish my "floor rounds." (wink, wink)

11:46- Need to grab a quick lunch before I starve to death!

12:49- I cut lunch short after only an hour so that me and my colleagues can have our daily battle over who gets the short straw and has to stay. Once again we all walk out on the new guy.

12:52- Walking to doctor's parking lot. Feeling stressed. This is now the THIRD day in a row I've had to stay past 11:30am. Will bring this up at the next group meeting.

12:56- Driving away in my Bentley. Surgeon waves to me on his way to clinic. I flash him the finger.
​

 

[chocomorsel]

Further, I am ashamed to be one of you

This made me laugh!

 

[chocomorsel]

Prone positioning makes it pretty challenging and quite risky if the patient has any airway issues at all.

Wouldn't work on the beds we use. But there may be surgeons and OR beds that facilitate it more easily. Sounds

You keep them awake enough for them to communicate with you. Not snowed. Never done it but it certainly can be done with the right patient and surgeon.

 

[Maz777]

You’ll know if you get a high spinal before the case starts. If surgeon redoses just give a very small dose. Obviously redosing is like plan D, should only be offering this surgery to a one level decompression, or with surgeon who’s very good and fast.

No thanks. I'll stick to tried and true GETA. If I need to rely on the surgeon to provide my primary anesthetic, I'll need to re-think my career choice.

 

[PainDrain]

I have done one and two level lumbar lamis under spinal for people who, for various reasons, could not have a GA. One was an elderly guy with a terrible heart/pulm hypertension and he did very well. You just need to set the expectations with the surgeon and patient, use a long acting med and bring the level up just a little a bit.

 

[deleted1147063]

No thanks. I'll stick to tried and true GETA. If I need to rely on the surgeon to provide my primary anesthetic, I'll need to re-think my career choice.

The future is local and regional anesthesia, not GA. So I would expect the surgeons and proceduralists provide more and more of the primary anesthetic as time passes.

This is a dying specialty. So, indeed, students should think long and hard before choosing it as a career.

 

[Maz777]

The future is local and regional anesthesia, not GA. So I would expect the surgeons and proceduralists provide more and more of the primary anesthetic as time passes.

This is a dying specialty. So, indeed, students should think long and hard before choosing it as a career.

If our speciality gets to the point of surgeons being allowed to do their own PNBs and neuraxial procedures, fine by me. Don't need me in that OR then. Can staff it with an "independent" CRNA. I'll staff a different room. Don't call me to rescue when the block is insufficient and you are on the cusp of aborting the case.

 

[UscGhost]

The future is local and regional anesthesia, not GA. So I would expect the surgeons and proceduralists provide more and more of the primary anesthetic as time passes.

This is a dying specialty. So, indeed, students should think long and hard before choosing it as a career.

No chance of that.

The population will only continue to get older, obese and with more comorbities. Not to mention the fact that western culture is far less tolerant of pain and discomfort than other cultures so their willingness to tolerate local just so their surgeon can make a little more money is doubtful.

You will see some procedures done in the office, like vasectomies, basic cysto, some small hand procedures but this is already the case and surgical volumes are still through the roof.

We potentially face more risk on the anesthesia supply side (if we train too many physicians or too many mid levels) than we do from the demand side

 

[deleted875186]

The future is local and regional anesthesia, not GA. So I would expect the surgeons and proceduralists provide more and more of the primary anesthetic as time passes.

This is a dying specialty. So, indeed, students should think long and hard before choosing it as a career.

This is a crazy statement. I suppose it could happen, but I don’t see it as realistic. Even with regional, most patients still want sedation. There is no replacing general anesthesia for the majority of surgeries we do.

 

[deleted1147063]

This is a crazy statement. I suppose it could happen, but I don’t see it as realistic. Even with regional, most patients still want sedation. There is no replacing general anesthesia for the majority of surgeries we do.

I wouldn't say it's crazy, just pessimistic. I'm not saying anesthesia is dying, just anesthesiology as a medical (vs nursing) specialty. And not for those already in it, but for those entering it now.

The more sedation, and the faster and less complex the surgeries, the less needed our specific expertise (vs a CRNA's).

We are also living in a world where the number of colonoscopies may decrease (due to stool DNA testing), which was a big moneymaker for anesthesia. Where surgeons are learning to use exparel and require fewer blocks (another moneymaker). Where many CRNAs are comfortable with spinals and epidurals, especially in the OB population. Where Medicare is cutting reimbursements for anesthesia more than for many other specialties. Where big surgeries, the kind that must be done under GA, have decreasing and/or laughable fees and generally pay much less than many small ones.

A world that has seen an increase of 30%+ in graduating anesthesiologists, let's not mention the CRNA increase. A world that's becoming an employer's market in many parts of the country (just see all the docs working for AMCs, which used to be a no-no for anybody respectable).

We have a backlog for now, due to Covid, which has increased the demand for our services, but, long-term, I doubt that anesthesiologists will keep being paid well. Remember the lessons of EM. Midlevels, midlevels, midlevels!

 

[drmwvr]

What's your plan if you get a high spinal?

I'd never do a spinal for a case like this, but if I did, it would be hypobaric.

 

[patriot6]

I wouldn't say it's crazy, just pessimistic. I'm not saying anesthesia is dying, just anesthesiology as a medical (vs nursing) specialty. And not for those already in it, but for those entering it now.

The more sedation, and the faster and less complex the surgeries, the less needed our specific expertise (vs a CRNA's).

We are also living in a world where the number of colonoscopies may decrease (due to stool DNA testing), which was a big moneymaker for anesthesia. Where surgeons are learning to use exparel and require fewer blocks (another moneymaker). Where many CRNAs are comfortable with spinals and epidurals, especially in the OB population. Where Medicare is cutting reimbursements for anesthesia more than for many other specialties. Where big surgeries, the kind that must be done under GA, have decreasing and/or laughable fees and generally pay much less than many small ones.

A world that has seen an increase of 30%+ in graduating anesthesiologists, let's not mention the CRNA increase. A world that's becoming an employer's market in many parts of the country (just see all the docs working for AMCs, which used to be a no-no for anybody respectable).

We have a backlog for now, due to Covid, which has increased the demand for our services, but, long-term, I doubt that anesthesiologists will keep being paid well. Remember the lessons of EM. Midlevels, midlevels, midlevels!

Call me crazy, but I have little fear of ever being replaced. CV, thoracic, OB, pediatrics, regional. I have sharp, broad skills that I apply on a daily basis across all subspecialties. There may be 1% of CRNAs that can perfrom the full breath of what I can do, at the level I can do it. The vast majority I supervise just want to push some prop and drop an LMA. Anecdotally, I've bailed out quite a few CRNAs in just the past couple of weeks. And I also had one ask me if I wanted them to "push some neo" with chest compressions in progress.

 

[nimbus]

Somewhat tangential to this thread but here is a recent meta-analysis of RCTs comparing GA vs Spinal for hip fractures.

DEFINE_ME

 

[deleted1147063]

Call me crazy, but I have little fear of ever being replaced. CV, thoracic, OB, pediatrics, regional. I have sharp, broad skills that I apply on a daily basis across all subspecialties. There may be 1% of CRNAs that can perfrom the full breath of what I can do, at the level I can do it. The vast majority I supervise just want to push some prop and drop an LMA. Anecdotally, I've bailed out quite a few CRNAs in just the past couple of weeks. And I also had one ask me if I wanted them to "push some neo" with chest compressions in progress.

Not everyone wants to deal with all that. I wouldn't associate OB, CV or thoracic with quality of life.

 

[sevo00]

I wouldn't say it's crazy, just pessimistic. I'm not saying anesthesia is dying, just anesthesiology as a medical (vs nursing) specialty. And not for those already in it, but for those entering it now.

The more sedation, and the faster and less complex the surgeries, the less needed our specific expertise (vs a CRNA's).

We are also living in a world where the number of colonoscopies may decrease (due to stool DNA testing), which was a big moneymaker for anesthesia. Where surgeons are learning to use exparel and require fewer blocks (another moneymaker). Where many CRNAs are comfortable with spinals and epidurals, especially in the OB population. Where Medicare is cutting reimbursements for anesthesia more than for many other specialties. Where big surgeries, the kind that must be done under GA, have decreasing and/or laughable fees and generally pay much less than many small ones.

A world that has seen an increase of 30%+ in graduating anesthesiologists, let's not mention the CRNA increase. A world that's becoming an employer's market in many parts of the country (just see all the docs working for AMCs, which used to be a no-no for anybody respectable).

We have a backlog for now, due to Covid, which has increased the demand for our services, but, long-term, I doubt that anesthesiologists will keep being paid well. Remember the lessons of EM. Midlevels, midlevels, midlevels!

Disagree. It’s been a while since our group has completed our backlogged cases. We are still getting requests from the hospital to staff new out of OR areas and surgeons sending new cases to our preop clinic at an ever increasing rate. Word is out that using CRNAs doesn’t save any money for the actual patient. The demand for MD anesthesia services is far out pacing the supply. The surgeons I work with have no desire to be responsible for the anesthetic. Even for small low risk procedures that they used to do in their office, they now want us involved. And no DNA testing is not replacing colonoscopies. Have you seen the Gastroenterologist market lately?

 

[nimbus]

Not everyone wants to deal with all that. I wouldn't associate OB, CV or thoracic with quality of life.

Job security is doing the cases that nobody else (MD or CRNA) wants to do

 

[deleted1147063]

Disagree. It’s been a while since our group has completed our backlogged cases. We are still getting requests from the hospital to staff new out of OR areas and surgeons sending new cases to our preop clinic at an ever increasing rate. Word is out that using CRNAs doesn’t save any money for the actual patient. The demand for MD anesthesia services is far out pacing the supply. The surgeons I work with have no desire to be responsible for the anesthetic. Even for small low risk procedures that they used to do in their office, they now want us involved. And no DNA testing is not replacing colonoscopies. Have you seen the Gastroenterologist market lately?

I have close gastroenterologist friends who tell me to just get a DNA test yearly, and not bother with a colonoscopy unless it's positive, or I had polyps before. I assume it's just a matter of time till that becomes the standard of care.

Just because anesthesia locums pay 50%+ extra in my neck of woods, right now, I don't assume it will stay like that. Especially if we get a recession.

I still think that the days of solo MD anesthesia are numbered (unless one is OK with working at almost CRNA salaries), at least in my area.

 

[patriot6]

Not everyone wants to deal with all that. I wouldn't associate OB, CV or thoracic with quality of life.

Depends on group structure.

I think my QoL is excellent.

 

[anbuitachi]

I have close gastroenterologist friends who tell me to just get a DNA test yearly, and not bother with a colonoscopy unless it's positive, or I had polyps before. I assume it's just a matter of time till that becomes the standard of care.

Just because anesthesia locums pay 50%+ extra in my neck of woods, right now, I don't assume it will stay like that. Especially if we get a recession.

I still think that the days of solo MD anesthesia are numbered (unless one is OK with working at almost CRNA salaries), at least in my area.

why are you getting so many DNA tests. how many kids do you have...

 

[Dr. Rude]

Job security is doing the cases that nobody else (MD or CRNA) wants to do

For less money.

 

[nimbus]

For less money.

Yes. That too.

 

[deleted1147063]

why are you getting so many DNA tests. how many kids do you have...

I need so many fecal DNA tests because I am FOS.

 

[pgg]

Spinals are commonly done for lumbar spine surgeries in developing countries.

The patients are motivated. They don't have an expectation of general anesthesia. They tend to not be obese.

The main reason for doing the cases this way is because a spinal is a $2 anesthetic. Possibly less.

 

[deleted875186]

Spinals are commonly done for lumbar spine surgeries in developing countries.

The patients are motivated. They don't have an expectation of general anesthesia. They tend to not be obese.

The main reason for doing the cases this way is because a spinal is a $2 anesthetic. Possibly less.

Indeed. It is very nice when it works well. Key is patient and surgeon selection, need to have a good surgeon, one or two level decompression, and a patient that’s ok with mild-mod sedation.

 

[abolt18]

Indeed. It is very nice when it works well. Key is patient and surgeon selection, need to have a good surgeon, one or two level decompression, and a patient that’s ok with mild-mod sedation.

Or zero sedation. I did some anesthesia in Africa during residency. They did a lot of Ortho. We do huge osteotomies to straighten legs under only spinal, on teenagers, without any sedation.

 

[nimbus]

Or zero sedation. I did some anesthesia in Africa during residency. They did a lot of Ortho. We do huge osteotomies to straighten legs under only spinal, on teenagers, without any sedation.

That’s patient selection.