are you saying you dont do a spinal for knees?
no spinal for either knees or hips unless surgeon requests but in my experience surgeons care more about amnesia, quick discharge and no post op weakness or prolonged spinal or urinary retention and they definitely care about complaints in clinic (from "i was awake the whole time and i remember hearing the saw" than pain.
I know regional guys love to push spinals and blocks on every patients, and I stick to my bread and butter blocks and lma. It works for me. I do tons of spinals (and myelograms) so its not an issue with procedure...its an issue about logistics and practicality in my practice. i am an independent physician, and I do not work at the same place every day and I do not have group coverage (although thats getting better), so I do things which are going to cause the least issues post op. i absolutely loathe dealing with PDPH in my current setup.
i have worked with CRNAs who in their arrogance and stupidity refused to run gtt with propofol after spinals. didnt even give versed because the patient had a bmi of 37. Patient complained post op that they were awake and were moving and very concerned that their legs were dead.
Surgeon was livid. This was 5 years ago. And this was a "protocol" set up by a regional fellowship trained guy straight from fellowship who had significant academic tunnel vision and I often butt heads with him. As I do more and more anesthetics, I am convinced that medicine is more art than science.
I prefer to treat the whole patient. I would want them to have a good experience undergoing surgery and a huge part of that is amnesia. I have done LMAs on top of spinal with low dose sevo - esp in obese patients, just to facilitate their airway. I know nimbus does this as well.
If they have pain, its easier to sell...like you had surgery...maybe do another supplemental block and give them meds...its ok...its post op surgical pain...it will get better over the week. Anesthesiologists care more about pain...
one of the hospitals I work at - has a lot of athletes, no spinal, no blocks for them for any orthopedic surgery concerning nerve damage and liability. So the point is, In many ways what we practice is an art not just textbook medicine. it has to be tailored to specific facility, situation, patient and surgeon.
I also do not do spinals on fractures on 90 year old patients. I go on linkedin - my feed is filled with "turn lateral do spinal" then "turn supine then do peng and fascia iliaca" then wait "then move and give versed" - patient will be comfortable to move...im like...dude...put the patient to sleep on bed...dont treat them like a pin cushion...propofol/lma/FIB - and maintain hemodynamics...done. sometimes physicians make it into an ego thing.
If spinal vs infinitely better than general for these surgeries then yes my decision would be different but from what i have read and researched, there is no significant difference, so if one technique is easier/ and causes less logistical issues and faster turnover, then i would prefer that
