Neuraxial in patient with Harrington rods

[Hoya11]

Our results also demonstrated that a history of spinal surgery did not increase the risk of technical or neurologic complications or affect block success. Previous spinal surgery has often been considered a relative contraindication to the use of neuraxial blockade. Many of these patients experience chronic back pain and are reluctant to undergo epidural or spinal anesthesia, fearing exacerbation of their preexisting back complaints. Several postoperative anatomic changes make needle or catheter placement more difficult and complicated after major spinal surgery. The presence of adhesions or obliteration of the epidural space from scar tissue may increase the incidence of dural puncture or decrease the spread of local anesthetic within the epidural space, producing an incomplete or failed block. Needle placement in an area of the spine that has undergone bone grafting and posterior fusion may not be possible with midline or lateral approaches; needle insertion can be accomplished only at unfused segments.

Neuraxial Blockade in Patients with Preexisting Spinal Steno... : Anesthesia & Analgesia

"hardware in the back" from "prior spinal surgery":

rods to correct scoliosis - does not effect epidural space, rods are lateral to the midline and ligaments and tissues are not involved and are therefore normal. Epidural space in every aspect is normal and untouched. Epidural is possible. Spinal is possible. Now in this case I can see the needle trajectory (paramedian) and advanced skill and technique actually mattering. The midline spine has normal tissues but is twisted and contorted and you have to bully your way in possibly.

lumbar laminectomy - the most posterior elements of the spine, including the ligamentum flavum, have been surgically removed to decompress the spinal canal from the back. Removing these elements makes the spine unstable and you have to laterally fuse the levels (bone or rods whatever). Spinal is not only possible, its much easier. The bones that normally get in your way have been removed. There is a clear path to the CSF for SAB. But NO epidural space. Attempt at epidural at the surgical site almost certainly results in wet tap.

Agree that an epidural placed and used above or below the lumbar laminectomy levels (which is the only possibility for epidural) may be patchy due to altered anatomy at the surgical levels. But id still do it, and most likely it will serve the patient very well.

"Posterior fusion" Does not mean the posterior spinal canal is fused shut with bone, which would block a needle from getting in. Thats the opposite of whats happening. "Posterior fusion" means the surgical entrance is posterior , as opposed to an anterior approach (incision in the belly). "Posterior fusion" means that lateral to midline (usually to the point of the pedicles) on both sides there is fusion. But the posterior MIDLINE is WIDE OPEN. So to say you are going to do a different approach to SAB (paramedian) because of prior surgery doesn't make sense. You could not only take the standard approach to SAB, you could do it with one hand behind your back and upside down. There is literally nothing in your way.

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[Hoya11]

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[BLADEMDA]

"hardware in the back" from "prior spinal surgery":

rods to correct scoliosis - does not effect epidural space, rods are lateral to the midline and ligaments and tissues are not involved and are therefore normal. Epidural space in every aspect is normal and untouched. Epidural is possible. Spinal is possible. Now in this case I can see the needle trajectory (paramedian) and advanced skill and technique actually mattering. The midline spine has normal tissues but is twisted and contorted and you have to bully your way in possibly.

lumbar laminectomy - the most posterior elements of the spine, including the ligamentum flavum, have been surgically removed to decompress the spinal canal from the back. Removing these elements makes the spine unstable and you have to laterally fuse the levels (bone or rods whatever). Spinal is not only possible, its much easier. The bones that normally get in your way have been removed. There is a clear path to the CSF for SAB. But NO epidural space. Attempt at epidural at the surgical site almost certainly results in wet tap.

Agree that an epidural placed and used above or below the lumbar laminectomy levels (which is the only possibility for epidural) may be patchy due to altered anatomy at the surgical levels. But id still do it, and most likely it will serve the patient very well.

"Posterior fusion" Does not mean the posterior spinal canal is fused shut with bone, which would block a needle from getting in. Thats the opposite of whats happening. "Posterior fusion" means the surgical entrance is posterior , as opposed to an anterior approach (incision in the belly). "Posterior fusion" means that lateral to midline (usually to the point of the pedicles) on both sides there is fusion. But the posterior MIDLINE is WIDE OPEN. So to say you are going to do a different approach to SAB (paramedian) because of prior surgery doesn't make sense. You could not only take the standard approach to SAB, you could do it with one hand behind your back and upside down. There is literally nothing in your way.

Again, I like to avoid the area of prior surgery. That's the main reason I choose a different level other than the one where the surgery occurred. Of course, if you choose to stick that level (or levels) that's your decision but this group of patients does tend to have much higher complaints of back pain after surgery. I prefer not to do anything which may promote inflammation or muscle spasm in that area.

I have personally been in the room for hundreds of lumbar fusions; I fully understand the surgical technique involved and the instrumentation used. I would be reluctant to ever have an anterior fusion myself but a posterior lumbar fusion can be beneficial and successful for the right patients.

Posterolateral Gutter Spine Fusion Surgery

 

[BLADEMDA]

Here is the type of lumbar fusion most commonly performed at my institution: PLIF

Posterior Lumbar Interbody Fusion (PLIF) Video

 

[BLADEMDA]

We have one surgeon who prefers the TLIF procedure:

Transforaminal Lumbar Interbody Fusion (TLIF) Video

 

[deleted162650]

I would be reluctant to ever have an anterior fusion myself but a posterior lumbar fusion can be beneficial and successful for the right patients.

I couldn't disagree with you more on this point. ALIF pts do infinitely better than posterior fusion pts that have had their extensor muscles peeled off the spine. The key is having a rockstar vascular surgeon for the exposure and then it's just like doing a big ACDF. How many chronic painer "failed back" pts have seen after ALIF compared to posterior lami/post fusion??

 

[BLADEMDA]

I couldn't disagree with you more on this point. ALIF pts do infinitely better than posterior fusion pts that have had their extensor muscles peeled off the spine. The key is having a rockstar vascular surgeon for the exposure and then it's just like doing a big ACDF. How many chronic painer "failed back" pts have seen after ALIF compared to posterior lami/post fusion??

That's fine. It's my personal preference. I don't want any of my abdominal wall muscles disturbed if at all possible. The success rates of posterior fusions are very high for 1 or 2 level fusions these days.

 

[BLADEMDA]

Minimally Invasive L5-S1 Spinal Fusion with AxiaLIF+

Has anyone seen a few of these minimally invasive spine surgeries? Is this the future for lumbar fusions?

 

[deleted162650]

I think one thing we can all agree on is to do whatever you can to avoid back surgery. Back surgery begets more back surgery. Pretty sure that's in the Old Testament somewhere - Leviticus maybe.

 

[deleted162650]

That's fine. It's my personal preference. I don't want any of my abdominal wall muscles disturbed if at all possible. The success rates of posterior fusions are very high for 1 or 2 level fusions these days.

Not trying to argue here - just genuinely curious: why so dead set on preserving abdominal wall over your back muscles? Tons of pts have adbominal surgery and almost none of them go on to develop debilitating chronic pain. How many back surgery pts go on to develop debilitating chronic pain - enough to support a whole sub specialty of anesthesia.

 

[Arch Guillotti]

The key is having a rockstar vascular surgeon for the exposure and then it's just like doing a big ACDF.

???

I have never seen a vascular surgeon do the approach for an anterior spine case. Always general surgeons. Why do you need a vascular surgeon?

 

[deleted162650]

???

I have never seen a vascular surgeon do the approach for an anterior spine case. Always general surgeons. Why do you need a vascular surgeon?

Well it's probably a regional thing more than anything else but the 2 places I've worked post residency it's always been vascular. There are a few local vascular guys who's practice is probably > 50% ALIF approaches. They are making a killing and they are damn good at it too (like 7 mins for an approach with beautiful exposure). It involves moving some major vessels out of the way (iliacs for the low lumbar and aorta/IVC for high lumbar). The potential for vessel injury is very real and I'm assuming that's why they tend to be the ones to do it around here. In residency the trauma guys did it but we really didn't do that many. I've never seen a straight GS do one.

 

[BLADEMDA]

Not trying to argue here - just genuinely curious: why so dead set on preserving abdominal wall over your back muscles? Tons of pts have adbominal surgery and almost none of them go on to develop debilitating chronic pain. How many back surgery pts go on to develop debilitating chronic pain - enough to support a whole sub specialty of anesthesia.

Spine J. 2015 May 1;15(5):1118-32. doi: 10.1016/j.spinee.2015.02.040. Epub 2015 Feb 26.
Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications.
Bateman DK1, Millhouse PW2, Shahi N2, Kadam AB2, Maltenfort MG2, Koerner JD2, Vaccaro AR2.
Author information

Abstract
BACKGROUND CONTEXT:
The anterior approach to the lumbar spine is increasingly used to accomplish various surgical procedures. However, the incidence and risk factors for complications associated with anterior lumbar spine surgery (ALS) have not been fully elucidated.

PURPOSE:
To identify and document types of complications and complication rates associated with ALS, determine risk factors for these events, and evaluate the effect of measures used to decrease complication rates.

STUDY DESIGN:
Systematic review and meta-analysis.

METHODS:
A systematic review of the English-language literature was conducted for articles published between January 1992 and December 2013. A MEDLINE search was conducted to identify articles reporting complications associated with ALS. For each complication, the data were combined using a generalized linear mixed model with a binomial probability distribution and a random effect based on the study. Predictors used were the type of procedure (open, minimally invasive, or laparoscopic), the approach used (transperitoneal vs. retroperitoneal), use of recombinant bone morphogenetic protein-2, use of preoperative computed tomography angiography (CTA), and the utilization of an access surgeon. Open surgery was used as a reference category.

RESULTS:
Seventy-six articles met final inclusion criteria and reported complication rates in 11,410 patients who underwent arthrodesis and/or arthroplasty via laparoscopic, mini-open, and open techniques. The overall complication rate was 14.1%, with intraoperative and postoperative complication rates of 9.1% and 5.2%, respectively. Only 3% of patients required reoperation or revision procedures. The most common complications reported were venous injury (3.2%), retrograde ejaculation (2.7%), neurologic injury (2%), prosthesis related (2%), postoperative ileus (1.4%), superficial infection (1%), and others (1.3%). Laparoscopic and transperitoneal procedures were associated with higher complication rates, whereas lower complication rates were observed in patients receiving mini-open techniques. Our analysis indicated that the use of recombinant bone morphogenetic protein-2 was associated with increased rates of retrograde ejaculation; however, there may be limitations in interpreting these data. Data regarding the use of preoperative CTA and an access surgeon were limited and demonstrated mixed benefit.

CONCLUSIONS:
Overall complication rates with ALS are relatively low, with the most common complications occurring at a rate of 1% to 3%. Complication rates are related to surgical technique, approach, and implant characteristics. Further randomized controlled trials are needed to validate the use of preventative measures including CTA and the use of an access surgeon.

Copyright © 2015 Elsevier Inc. All rights reserved.

 

[Phyzicz]

As a pain management physician, I routinely, daily, do epidurals at levels of a laminectomy and a fusion. I just use x-ray. And a tiny needle. From the side of the spine.

 

[Timeoutofmind]

As a pain management physician, I routinely, daily, do epidurals at levels of a laminectomy and a fusion. I just use x-ray. And a tiny needle. From the side of the spine.

Do u mean transforaminals?
Apples and oranges.
No bearing on what these guys do in OR/OB.

 

[deleted162650]

My transforaminal labor epidurals all tend to be one-sided.

 

[Phyzicz]

Do u mean transforaminals?
Apples and oranges.
No bearing on what these guys do in OR/OB.

I am aware. There were posts here saying an epidural cannot be done. The correct statement is an interlaminar epidural cannot.

 

[Phyzicz]

My transforaminal labor epidurals all tend to be one-sided.

Should use flouro it will help lol...