Neuroaxial in patient with lumbar fusion?

[CaliDreamin4Life]

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Do you guys routinely attempt spinal or epidurals in patients with preexisting lumbar fusions?

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[facted]

Do you guys routinely attempt spinal or epidurals in patients with preexisting lumbar fusions?

Sent from my SM-G935V using SDN mobile

Spinals all the time. Then I thank the surgeon later for marking midline for me.

Epidurals can be dicey as the space can be destroyed during the fusion. I usually avoid that level and warn the patient is a potential patchy block.

 

[PapaDosh]

Spinals all the time. Then I thank the surgeon later for marking midline for me.

Epidurals can be dicey as the space can be destroyed during the fusion. I usually avoid that level and warn the patient is a potential patchy block.

For parturients we had a preop clinic evaluation where the ob/gyn would refer to us early so that we could set the patient to have reasonable expectations. We would usually place the epidural as soon as possible and do frequent checks to make sure they were not patchy. Depending on how many levels they had fused and assuming no revisions you may get a reasonable block. If multilevel fusion and we did not think they would get any block, we do a CSE as they would sometimes get reasonable block. IF still no bueno, patient would either opt for natural vs PCA.

 

[Noyac]

Just had an OB pt last week with a L3-5 fusion requesting an epidural. I did a CSE at L2/3 best guess and all was good. But the spinal was slow to set up and I had to dose the epidural some as well to get her real comfy. She delivered a few hours later just fine.
Luckily we don’t see too many OB pts with fusions. This one was 40 yrs old.

If it’s for a total joint I don’t hesitate to do a spinal.

 

[Mman]

spinals are usually easy in fusion patients. Epidurals are completely hit or miss. You can try to go above or below the fusion but their epidural space might be scarred and the local might not spread well.

 

[Timeoutofmind]

Good stuff in this thread

See my long post there

Neuraxial in patient with Harrington rods

Spinal always ok

Epidural not wise at all

 

[BLADEMDA]

I only do spinals in patients who have had lumbar fusions if the risk/benefit warrants it. That is, if the patient has a lot of medical issues and I believe the spinal will lower his/her perioperative morbidty/mortality then I'll proceed with the spinal. Most of the time I'll recommend/choose GA because these patients tend to have issues with back pain postoperatively.

For an OB C section I'd likely do a Spinal. For an elective Total Knee or Total Hip I'd likely do a GA. Other options besides SAB include peripheral nerve blocks with propofol sedation.

 

[Mman]

Most of the time I'll recommend/choose GA because these patients tend to have issues with back pain postoperatively.

These patients have likely had decades of back pain and you are pretty unlikely to get blamed for that postop.

 

[Noyac]

Agree with Mman.

I would not place an epidural for post op pain control if the dermatomes needed to be covered are the same as the fusion level. But if for instance, the fusion was lumbar and the surgery was abdominal then I’d place a thoracic.

 

[BLADEMDA]

These patients have likely had decades of back pain and you are pretty unlikely to get blamed for that postop.

That's not been my experience and I'll avoid spinals in that subgroup unless the patient is unequivocally in favor of an SAB. I do think a preop clinic discussion makes the final decision of GA vs SAB an easier one come the day of surgery in this population.

 

[BLADEMDA]

A significant number of patients complain of backache following anaesthesia and surgery. Although the frequency of backache is as high as 46% following general anaesthesiavi, the patients relate this to their anaesthesia if they have undergone a central neuraxial block; the myth of invariable injury to the back associated with needlesvii. Backache following previous spinal anaesthetic was the major cause for 13.4% patients refusing spinal anaesthesia in a series of more than 1000 patientsviii.

Symptoms varying from “pricking sensation” at the site of needle insertion, upper or lower back pain or pain radiating to the buttocks and legs are all sometimes reported as backache. 26.6% of more than 100 patients studied by Chan complained of injection site tenderness lasting less than a week, which should be differentiated from classical “backache” that none of them complainedix.

Confounding variables like pre-existing backache; duration of surgery and the patient’s posture during surgery compound the issue. The pain could be of a short duration, lasting from 72 hours to a week or persistent, lasting beyond 3 months.

431 out of 918 pregnant patients surveyed by Shaheen and colleagues had at least one episode of backache during their pregnancy; 96 out of these had experienced backache before they became pregnant. This indicates that about half of these patients would have a preexisting backache if they presented for spinal anaesthesia for Caesarean deliveryx.

Controversy exists over the relationship between anaesthetic technique and the true incidence of postoperative back pain. Regardless of anaesthetic technique, back pain was seen in almost 25% of the patients who underwent surgical operations under general or spinal anaesthesiaxi,xii. Randel and colleagues at the University of Michigan compared the recovery characteristics of three anaesthetic techniques for outpatient orthopaedic surgery. One of the parameters they measured was post operative back pain and they found that epidural followed by spinal and then general anaesthesia had highest incidence of back pain on first post operative day but by the third post operative day the difference of back pain in these three techniques was not statistically significant. No patient in this study required any specific treatment for backachexiii.

REVIEW ARTICLE – The causes, prevention and management of post spinal backache: an overview – Anaesthesia, Pain & Intensive Care


Back Pain From Spinal Block

 

[BLADEMDA]

Ignorance among the lay population is very high and a small % of them will absolutely "blame" your SAB for the back problems:

Spinal anaesthesia | February 2002 (Vol. 12 Issue 11) | Magazine | What Doctors Don't Tell You

Please don't misunderstand my posts on this issue; I'm completely in favor of SAB as the technique of choice for many procedures. But, the patient's attitude and understanding of the anesthetic choice does play a role.

 

[Noyac]

I explain the causes of back pain to my pts and if they voice an understanding then I proceed as planned.

 

[deleted171991]

Ignorance among the lay population is very high and a small % of them will absolutely "blame" your SAB for the back problems:

Spinal anaesthesia | February 2002 (Vol. 12 Issue 11) | Magazine | What Doctors Don't Tell You

Please don't misunderstand my posts on this issue; I'm completely in favor of SAB as the technique of choice for many procedures. But, the patient's attitude and understanding of the anesthetic choice does play a role.

+10. I had parturients vehemently refuse neuraxial blocks because their families were convinced that they were a source of chronic back pain. My current malpractice risks are low, and still I tend to avoid placing blocks (including PNBs) whenever there is some kind of pre-existing disease. Some patients are just uneducated/-able, and all the science in the world can't beat the faith in their own stupidity. Some believe that bad things happens only because of bad doctors.

What can one expect from a population where only 79% know that the Earth revolves around the Sun, and not the other way round? Those 21% are scientific analphabetes, and most intelligent, probability-level, risks-vs-benefits discussions will be useless.