Spinal for lumbar spine surgery?

[B-Bone]

Anybody out there routinely doing spinals for lumbar surgery? I had a patient ask about it today. I've never done it, and honestly never heard of it or even considered it. A few of my partners have done it once or twice, but nobody around here is really doing it. I can think of several disadvantages of spinal, but there are apparently papers out there indicating it's not that rare. Thoughts?

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[excalibur]

Have heard of it or read about it. Never done it, and don't know anyone offhand who has done it

 

[sevoflurane]

We place a catheter above the dura after hardware is in. Once the surgeon is almost done closing, we bolus some marcaine and fentanyl and then pull it. Works pretty well... but it's mainly for post-op pain. I've never done a spinal for a fusion, and don't know I'd want to do one either... cuz they are getting an ETT 100% of the time.

 

[IlDestriero]

We used to do intrathecal morphine for some of our spinal fusions and big ortho procedures. Now we just give some methadone.

 

[B-Bone]

To be clear, I'm talking about a spinal like local anesthetic with the patient awake or sedated, not for post-op pain control. Like doing a knee under spinal.

 

[Pooh & Annie]

Hypobaric SAB or single shot epidural both work. Pt selection is important too (ie. is it someone who will lay still when you ask). You won't be converting to a GA if they're moving on you.

 

[nimbus]

I have never seen or performed this myself, but Petter Lindstrom, a neurosurgeon and Ingrid Bergman's former husband liked to do his lamis this way.

Ironically the exceptionally anxious patients who ask for something like this are the ones who really need GA.

 

[Idiopathic]

it just doesnt make any sense. too much potential for complication, it isnt like you would be doing complicated spines this way, likely just single level laminectomies - why not put those patients to sleep?

what could possibly be gained by doing this except to say that you do it?

 

[pjl]

A partner did this last year for a patient with very low nervousness factor, but high dissatisfaction after GA, nausea, hangover, all the usual. Patient did fine...until they vomited. Still ended up fine, but wasn't a good situation, and I don't forsee any circumstance where I would chose that technique.

 

[Oggg]

There was a surgeon who was afraid of GA, got a spinal for his laminectomy. Seems doable for short procedures. We sedate heavily for spinal cord stimulators in the probe position, right? That being said, I haven't done it and don't want to do it. But it's been done and can be done. I'd rather tube them -- tell them it can't be done, it's painful, can't breathe, neck gets cranked, vomit, you can feel vibrations from hammering, sedation will make you more nauseous than GA, etc.

 

[BLADEMDA]

Spinal/SAB is fine for a single level Diskectomy. I would not do an SAB for a Lumbar Fusion.
Chief of Surgery had his single level lumbar disc done awake under SAB without any issues.

 

[Pooh & Annie]

I wouldn't do it for a fusion either. Too much potential for blood loss/hemodynamic issues, possible EP monitoring, etc... I've only done them for quick lamis.

 

[DET0897]

Do a couple of these a month. Usually single level lami's. Patient selection is huge here and if there is any doubt, just do GA. Fast and trustworthy surgeon. Kneeling table instead of Jackson as well.

I have asked every one of the patients afterward if they would do it the same way next time. So far, 100% have said yes.

 

[loveumms]

Agree with above posters - would do it for a lami but not a fusion. Must have the right patient and even more importantly, the right surgeon.

We did it for a elderly lady with severe pulmonary hypertension a few weeks ago. GA was not an option for her and it worked beautifully. A little bit of ketafol and she did great.

 

[aneftp]

Done it 2 times in my career.

Both times simple 1-2 level lami and patients all had history of severe nausea and vomiting.

Didn't give patient any narcotics. Gave them headphones so they could listen to their music.

Patients did fine.

 

[bedrock]

Hi,
PMR-Pain doc here. Lots of elderly patients in my neck of the woods. Not infrequently, I'll have an 80 something patent with severe one-level lumbar stenosis that doesn't respond to several epidurals, and the patient is sedated and non-functional on minimal doses of pain meds.

However our local surgeons routinely refuse to do these cases citing the risk of surgery, particularly anesthesia. Am I missing something, or should these patients be offered a quick one-level laminectomy under a spinal, etc?

 

[nimbus]

Hi,
PMR-Pain doc here. Lots of elderly patients in my neck of the woods. Not infrequently, I'll have an 80 something patent with severe one-level lumbar stenosis that doesn't respond to several epidurals, and the patient is sedated and non-functional on minimal doses of pain meds.

However our local surgeons routinely refuse to do these cases citing the risk of surgery, particularly anesthesia. Am I missing something, or should these patients be offered a quick one-level laminectomy under a spinal, etc?

No. Surgeons like to operate. If they refuse, they usually have good reason. The risks are real and even without complications the outcomes may not be good. Surgery is not a cure all.

 

[bedrock]

No. Surgeons like to operate. If they refuse, they usually have good reason. The risks are real and even without complications the outcomes may not be good. Surgery is not a cure all.

Thanks for the reply.

Believe me as a pain physician, I try to prevent surgery whenever possible. No one knows better than me that surgery is not a cure all.

However, private practice surgeons have a very good idea of what their common procedures pay, and a single level laminectomy on a medicare patient pays very little.

Spine surgeons don't make big money unless a surgical case involves hardware. They get much more excited about scheduling a L4-L5 PLIF than a L4-L5 lami.

Unfortunately at least every other a month, I see patient that is 85, had a stent placed 5 years ago, and has controlled hypertension. They also have severe one or two level lumbar stenosis, and have failed PT, meds, and multiple epidural steroid injections for their severe lumbar stenosis with claudication.

Our local surgeons won't lift a finger to help them and so I have been referring them to the closest university medical center which is 90 min away, and from what I hear back, most of these patients get their laminectomy. So I'm wondering how much of this situation comes from my local spine surgeons vs our local anesthesia group. Someone is pussing out and punting these cases.

Again I'm not talking patients with severe pulmonary disease, CHF, renal failure etc.
Just 85 guys, or 85 yr old guys with a 5 year old cardaic stent.

My question is really this. What comorbid conditions would prevent anesthesia from doing a spinal epidural as anesthesia for a single level laminectomy on an elderly patient?

 

[Spinach Dip]

Must have the right patient....

+1,000,000



Even as someone WITH a history of post-op nausea, I would opt for a GA in an instant. No one's cutting MY back open under spinal.

I guess I'm the wrong patient.

 

[Idiopathic]

What comorbid conditions would prevent anesthesia from doing a spinal epidural as anesthesia for a single level laminectomy on an elderly patient?

common sense?

never having done one?

prone room air general as backup plan?

 

[Planktonmd]

My question is really this. What comorbid conditions would prevent anesthesia from doing a spinal epidural as anesthesia for a single level laminectomy on an elderly patient?

Well...
It's absolutely feasible and I have done it many times in the past for certain indications.
But it requires a very careful patient selection and surgeon selection.
Also the majority of anesthesiologists in practice right now have never done it and as a result might not feel comfortable doing it.
On the other hand... you must understand that the fear of general anesthesia is very frequently based on urban legends not science.
In the hands of an experienced anesthesiologist a general anesthetic is by far the safest most predictable technique to do any surgery.
I truly think that the best anesthetic for the patient is the one the anesthesiologist is most comfortable with.

 

[urge]

Anybody out there routinely doing spinals for lumbar surgery? I had a patient ask about it today. I've never done it, and honestly never heard of it or even considered it. A few of my partners have done it once or twice, but nobody around here is really doing it. I can think of several disadvantages of spinal, but there are apparently papers out there indicating it's not that rare. Thoughts?

I talked to a Cleveland Clinic attending a few years back. Apparently spinals are very common there for short back surgery. I have never done it myself, but if you have the right patient and the right surgeon, I don't see why not.

 

[bedrock]

That was helpful. Thanks.