Abstract
Cervical spine surgery (CSS) presents several challenges for the anesthesiologist, and potential complications may be severe; lesions are often permanent and very disabling, as shown by closed claims databases.
As for every kind of surgery, a careful preoperative assessment of the physical status of the patient is needed. In particular for the elderly, comorbidities and chronic therapies are frequent and often interfere with anesthetics or increase the rate of complications.
However, for CSS due to several peculiar features it is necessary a special care. The spine could be stiff or unstable, making the airway management risky and difficult. The surgical field is closely near the airway, increasing the risks of displacement of the endotracheal tube (ETT) or development of postoperative edema or hematoma which could lead to obstructive complications. The patient positioning, especially for posterior cervical spine surgery (PCSS), always needs a great attention for the smaller details, due to the actual possibility of eyes, nerves and skin injury. Cardiovascular instability could result from preexisting or intraoperative spinal cord injuries (SCI), or be the consequence of wrong positioning or fluid management. Moreover, deliberate or inadvertent hypotension can cause or worsen the SCI, especially when a preoperative cord compression or microvascular impairment (e.g. for diabetes or arterial hypertension) are present. In order to minimize SCI or root injury an intraoperative neurophysiologic monitoring (IONM) may be adopted, making crucial the choice of a proper anesthetic technique and the close cooperation with the surgeon and the neurophysiologist.
During the postoperative clinical surveillance is mandatory for the early detection of neurological deterioration, airway obstruction, severe pain or delirium. Some adverse events need to be recognized as soon as possible to perform an efficient therapy. The occurrence of a spinal hematoma could compress the spinal cord, with neurological impairment. The airway could be rapidly compromised for the possible development of a cervical hematoma or the worsening of pharyngeal edema and/or tongue swelling. The adopted strategy for the postoperative pain control could interfere with the haemostatic mechanism if non-steroideal drugs are administered. Impairment in swallowing function or laryngopharingeal sensitivity could cause an aspiration pneumonia, particularly when postoperative nausea and vomiting (PONV) is present.
Anesthetic Management and Prevention of Complications
Preoperative Assessment
The preoperative conditions of the patients scheduled for CSS, and consequently the anesthetic technique chosen, may heavily affect the risks and the outcome of the procedure.
General indications about the most common and important coexisting diseases will be illustrated, underlining some peculiar aspects that need to be evaluated in this kind of surgery.
The most used method for the preoperative risk assessment is the stratification resulting from the American Society of Anesthesiologists Physical Status Classification System (ASA class). ASA score could be also used, together with the burden of the proposed surgical procedure, in order to properly assign the patients to an outpatient protocol, when allowed. With respect to the past, recent studies show that patients ASA III can be treated as outpatients without significant increase in perioperative complications while ASA IV patients are generally addressed for an inpatient treatment.
However, most authors are now focusing their attention on the single comorbidities and on their grade of stabilization, rather than on the ASA class.
A careful evaluation is needed for patients suffering from diabetes, cardiovascular diseases and/or chronic obstructive pulmonary disease (COPD). Also, patients with already diagnosed or suspected Obstructive Sleep Apnea (OSA) deserve special attentions, in particular if a fast-track treatment is proposed. Untreated or poorly stabilized situations should suggest delaying the surgery or deciding for an inpatient treatment [1].
Obesity, with a body mass index (BMI) ≥ 35 kg/m2 and two major comorbidities or a BMI ≥ 40 kg/m2, represents a serious challenge for the surgeon and the anesthesiologist while undergoing CSS. Most of the possible complications are worsened and more frequent in the obese patient, including mistakes in the level of intervention, wound infection, position related injuries [2].
For diabetic patients, it’s greatly advisable to assess the level of control of the disease, based on the history, the number of experienced hospital admission for hypo-hyperglycemia, and so on. It’s also important to assess the level of compliance of the patient with his disease. Commonly, a good compliance consists in his ability to perform blood glucose test and to detect the early symptoms of hypoglycemia by himself.
Patients using insulin often take a combined therapy with a basal component (a single dose of long-acting insulin) and a postprandial correction with a short acting insulin. Usually, if the patient didn’t experience preprandial hypoglycemia in the previous months, it is safe and advisable to administer 75–100% of basal-dose long-acting insulin the morning of surgery. However, the first target is to avoid hypoglicemia, so it’s advisable to control blood glucose levels and to be ready to administer 5–10% glucose solutions i.v. perioperatively when needed.
Oral antidiabetics should not be assumed on the day of surgery, and avoided until normal alimentation is resumed.
The preoperative evaluation of glycosylated haemoglobin A1c (HbA1c) could help to identify patients with poor control of the disease. Levels of HbA1c lower than 7%, representing the ideal therapeutic target according to the American Diabetes Association Guidelines [3], were found associated with a significantly lower rate of postoperative infections [4]. A recent study showed that poorly controlled diabetic patients had a mean hospital stay 5 days longer than normal stay, while well controlled diabetic patients only 1 day longer [5]. Poorly controlled glucose levels are associated with worse mean outcome in diabetic and non-diabetic patients [6]. Some non-diabetic patients may have undiagnosed high levels of HbA1c, that is associated with a higher risk of complications undergoing spine surgery. Therefore, it could be advisable to include the HbA1c as a routine preoperative test for elective spine surgery [7]. Diabetic patients are more often burdened with ischemic complications due to the potential presence of microangiopathy, particularly in case of hypotension or hypovolemia.
Patients affected by coronary artery disease (CAD) should be carefully investigated, particularly when instability or recent modifications in the appearance of symptoms are present. Adverse cardiac events following CSS are not uncommon (4/1000) and their rate increases significantly in older patients (>65 y.o.) with greater comorbidities, particularly cardiovascular diseases [8].
Important studies suggest that Congestive Heart Failure (CHF) is actually the most important risk factor for perioperative morbidity and mortality [9]. CHF leading to a NYHA class (New York Heart Association) higher than II, recommends an inpatient treatment.
There is general agreement to continue chronic cardiovascular medications for cardiac patients until the morning of surgery. However, possibly some antihypertensive drugs could be remodulated: recent reviews suggest a short preoperative suspension for all the antagonists of renin-angiotensin-aldosterone system. These drugs have been involved in increasing the rate of significant hypotension episodes after the induction of anesthesia or during neuraxial blocks, and of postoperative development of acute renal failure [10].
The perioperative continuation of antiplatelet drugs should be carefully considered. While it’s commonly accepted, in the presence of a bleeding risk, to suspend the therapy in primary prevention, many reports suggest that the antiplatelet withdrawal during secondary prevention for ischemic diseases may lead to serious complications [11]. When surgery is performed in an area where the development of a hematoma could lead to severe complications (e.g. the anterior region of the neck), or in closed spaces as the spinal canal, the risk of bleeding should be carefully evaluated. When a double antiplatelet therapy is indicated, elective surgery should be postponed. The average increase in bleeding risk in non-cardiac surgery is about 20% with aspirin or clopidogrel alone [12]. The risk rises up to 50% over the basic risk when aspirin and clopidogrel are used together [13]. In such particular situations, a multidisciplinary approach involving surgeon, anesthesiologist and cardiologist or neurologist is advisable to customize clinical decisions [14].
COPD is a frequent condition, especially among the older patients, and is often associated with obesity and higher rates of postoperative bronchopulmonary complications [15]. If general anesthesia or deep sedation are needed for elective surgery, when a severe or poorly compensated COPD is present, with increase in bronchial secretions and clinically relevant bronchial reactivity, a preparation with aerosol therapy and a short course of antibiotics is advised [16]. In addition, in the compliant patient smoke banning at least 6–8 weeks before surgery has significantly lowered the rate of bronchopulmonary complications and improved surgical wound healing and bone fusion [17]. If possible, local anesthesia and Monitored Anesthesia Care should be preferred in patients with COPD. However, if tracheal intubation is mandatory, the early weaning from invasive ventilation and the adoption of lung-protective ventilation protocols help prevent pulmonary complications [18, 19].
In particular in the elderly, smokers and obese patients, OSA is not uncommon and is often underdiagnosed. The frequent association of anatomical abnormalities in the upper airway could advice a careful evaluation for suspected difficult intubation, and the availability of all emergency airway equipment [20]. In the last years, quite simple questionnaires with the aim to detect patients with suspected OSA have been proposed, compared with others and validated [21].
Patients with already diagnosed and treated OSA can be managed in OP or DS setting if they are able and skilled in the use of their own Continuous Positive Air Pressure (CPAP) device (possibly bringing their own device at the admission to the hospital). Patients with suspected OSA and without comorbidities, with a low risk emerging from clinical evaluation and from the questionnaire results, could be treated in OP or DS setting only if the postoperative pain can easily be controlled without opioids. In patients with high risk for suspected OSA, when other comorbidities are present or when postoperative opioid use is very likely, it is safer to decide in any case for an inpatient treatment [22].
Airway Assessment
As in every kind of surgery, a proper airway evaluation is mandatory before the induction of anesthesia, even if recent surveys show a poor accuracy of the clinical prediction of a difficult direct laryngoscopy (DL) [23].
A simple definition of “difficult airway” could be: a clinical situation in which a meanly skilled anesthesiologist experiences difficulty with facemask ventilation and/or with tracheal intubation [24].
The presence of one or more of the common findings that could hinder an easy direct laryngoscopy or facial mask ventilation must be detected, in order to establish a proper behavior (Table 4.1). All other things being equal, when a patient is scheduled for cervical spine surgery, and mostly if the stability of the spine could be impaired, a more cautious approach is needed. A collective evaluation with the surgeon regarding the preoperative neurological status, the spine stability and the intervention proposed is surely the best approach to choose the more suitable behavior and even to avoid legal issues [25]. Moreover, if an awaken intubation is finally chosen, the psychological compliance of the patients should be appraised, and however a proper information to the patient must be given.
Thanks to the improvement of electronics and glass fiber technology, many devices has been proposed in the last few years to overcome difficult intubation (Fig. 4.1). These devices have been compared with the classical MacIntosh laryngoscope and also with the fiberoptic bronchoscope or laryngoscope for their efficacy in improving visualization and in reducing neck movements and mechanical stress of cervical spine [26, 27].
Videolaryngoscopy in a “difficult airway” using a Glidescope®
Awake fiberoptic intubation can be performed using topic anesthesia with a conscious sedation in order to minimize coughing and neck movements. This has been the favorite technique for most practitioners in patients scheduled for general anesthesia with anticipated difficult intubation [28]. However, awake fiberoptic intubation is not without risks. In a closed claims analysis 12 cases of failed awake intubations, for technical causes or for lack of patient cooperation, or development of airway obstruction for the sedation or edema, resulted in death or brain damage in 9 cases (75%) [29]. When awake intubation is advised and mouth opening is not too limited, awake videolaryngoscopy, being faster and simpler than fiberoptic bronchoscopy, should probably be considered [30].
Intraoperative Neurological Monitoring
Iatrogenic injury to the spinal cord and peripheral nerves could occur during CSS, caused from wrong positioning, surgical or anesthetic maneuvers or poor hemodynamic control; some lesions are often permanent and very disabling [31]. The blood supply to the medulla is granted from the anterior and posterior spinal arteries. The anterior spinal artery feeds approximately the two thirds of the cord mainly in the anterior and central area and the flow is centrifugal. The posterior spinal arteries feed the posterior part of the gray matter of the posterior horns and the more external portion of the anterior-lateral and posterior white matter, and its flow is centripetal. With the exception of the posterior half of the posterior horns, supplied only from the posterior spinal artery, the two systems have a discrete grade of overlapping. Unfortunately, the real efficiency of the interconnections is generally poor and not truly compensatory in case of obstruction of one of the two systems. Moreover, blood supply of the spinal cord is not homogeneous; the cervical tract is more vascularized with a good supply from both anterior and posterior systems, while thoracic and lumbosacral tract have respectively a weaker anterior and posterior flow [32].
In order to early detect neurologic modifications during spinal surgery various neurophysiologic techniques have been proposed and used. Somatosensory-evoked potentials (SSEPs) were the first to be studied and adopted. The registration of cortical or subcortical potentials after administration of peripheral stimuli and the evaluation of variations in amplitude and latency of the responses, helps in detecting possible functional impairment of the posterior afferent pathways. Typically, the stimulating electrode are applied over the median nerve in the arm or over the posterior tibial nerve distally to the knee. The stimulation site is chosen depending of the site of surgery; when CSS is proposed the median nerve is generally used, while for surgery distal to the cervical segment the tibial nerve is stimulated [33].
Moreover, the technique in most cases gives indirect information about the functional situation of the anterior regions of medulla.
However, a recent review suggests that SSEPs changes during CSS are highly specific but not very sensitive in predicting poor outcomes after surgery [34]. Also for the anatomical and functional reasons described above, SSEPs may fail to detect spinal cord injury in the anterior-lateral area involving only the descending motor pathways without impairment of the posterior columns and gray matter.
TcMEPs monitoring was introduced to overcome these false negative records. The electrical or magnetic stimulation of the precentral motor cortex with the peripheric recording under the surgery level of the muscular response can help to assess the integrity of the anterior descending pathways.
Moreover, during CSS, TcMEPs and SSEPs seem to have different patterns of sensitivity: while TcMEPs are more useful to detect hypotension and cord hypoperfusion related injuries, SSEPs may be more helpful in preventing brachial plexus injuries [35].
Literature highly recommends continuous recording of both SSEPs and MEPs for the high sensitivity and specificity of the responses they can give when used together, allowing the recovery of situations otherwise probably with very poor outcome. Despite the lack of large studies, recently multimodal approaches have been proposed, involving clinical and radiological data with electrophysiologic findings, with the aim to predict surgical outcome. When pedicle screws are used, the intraoperative EMG is also recommended [36, 37].
Special anesthetic care is needed when monitoring of somatosensory-evoked potentials (SSEPs) and/or motor-evoked potentials (MEPs ) is planned, in order to detect intraoperative functional impairment of the spinal pathways. Anesthetic agents can heavily affect the quality of the monitoring, particularly for cortical SSEPs for cortical direct depression. Moreover, general anesthesia causes also a depression of intrinsic spinal cord activity, which is more evident when nitrous oxide or halogenated agents are used. Even if the use of trains of stimuli rather than single stimuli tends to overcome this poor excitability, the depressive effects is however significant.
Hence, the simultaneous monitoring of a cortical and a subcortical site of SSEPs may help, when necessary, in the interpretation of a decrease in cortical SSEPs amplitude and/or increase in latency, because the subcortical response is far less impaired from the anesthetic effect. Generally, the first choice should be a Totally IntraVenous Anesthesia (TIVA), because of the impact of inhalational anestetics on evoked potentials even at low concentrations. Propofol suppresses the activity of the anterior horn cells, but significantly less than halogenated anesthetics [38]. Also intravenous drugs should be chosen carefully: benzodiazepines and barbiturates produce CMEPs depression at lower doses than those affecting the SSEPs and this effect lasts for several minutes. Ketamine, instead, has shown an increase in cortex magnetic excitability, leading to larger CMEPs amplitude [39]. Recent studies showed that dexmedetomidine when used during a TIVA at a clinical dose may affect some IONM parameters and without any advantage [40].
Opioids are an important component of anesthesia for evoked potentials monitoring: they produce only minimal changes in spinal or subcortical SSEP recordings, and only a mild decrease in amplitude and increase in latency for cortical SSEPs and myogenic responses from MEPs [41].
Recently it has been noted that remifentanil, when used at higher doses, can affect SSEPs monitoring, acting particularly on the amplitude of signals [42].
Spinal MEPs (stimulating cranially to the level of surgery) or pedicle screw testing during spinal instrumentation (EMG recording) are virtually insensitive to anesthetic agents, while could be hindered from muscle relaxant drugs. Most anesthesiologists prefer to use even a little dose of rocuronium (i.e. about 0.3 mg/kg) to facilitate tracheal intubation and normally the residual neuromuscular blockade at the beginning of surgery has little impact on the quality of tEMG. When necessary, small doses of sugammadex (i.e. about 1–2 mg/kg) can be administered to achieve a better TOF response and abolish the interference with IONM [43].
In any case, due to the complex pattern of interference between anesthesia and intraoperative neurophysiologic monitoring, a continuous exchange of information among all the practitioners involved can improve the interpretation of data and the outcome of the patient [41, 44].
Patient Positioning and Related Complications
Positioning in CSS is potentially challenging. A study on 75 patients undergoing CSS with IONM showed a sudden worsening during positioning of trans cranial MEPs in three cases and both MEPs and SEPs in two cases. Despite the immediate adjustment of the position and the stabilization of an adequate blood pressure, in one case evoked potentials remained depressed during surgery and the patient presented delayed neurological impairment in the postoperative (tetraparesis), but fortunately with a complete recovery after 2 weeks. The other four patients gradually showed improvement of evoked potentials after re-positioning with no neurological deficits at the end of surgery [45]. A recent series of 103 cases showed a 10.7% incidence of IONM significative changes during head positioning for CSS in cervical myelopathy, with complete or partial signal restoration after repositioning in 10 cases and poor signal improving in 1 case. Only in this patient a postoperative deficit was observed [46].
Neurological impairment, mostly transient, is reported even after non-cervical surgery particularly in the elderly patients in which unsuspected cervical stenosis are often present. This suggests always cautious positioning of the head and possibly, in any case of supposed spinal cord compression, a proper maintenance of mean arterial blood pressure that may have potential benefit in improving the blood supply to ischemic areas [32].
Peripheral nerve injury is a rare complication after surgery generally caused from bad patient positioning with an overall rate ranging from 0.03 to 0.1% [47]. The complication seems more frequent in patients with some comorbidities such as diabetes mellitus, alcohol dependence and vascular disease, and particularly in the elderly and in the extreme ranges of body mass index [2]. Literature data are poor and missing in randomized trials about the matter; no guidelines are available to address the correct positioning in any kind of surgery; only some advices have been proposed based on expert opinions, case reports and consensus surveys. The abduction of the arm seems to be more tolerated in the prone rather than in the supine position, though it’s advised not to exceed 90° [47]. In the supine position with the arm abducted the ulnar nerve is better protected with the forearm in supine or neutral position; when the arm is tucked beside the trunk the forearm should be in neutral position and in any case pressure on the ulnar groove at the elbow and on the radial spiral groove of the humerus must be avoided. Flexion of the elbow may increase the rate of ulnar impairment, while excessive extension beyond the range preoperatively assessed as comfortable may stretch the median nerve. During surgery the position of the upper extremities should be periodically reassessed. Gel or foam padding are advised but they must be used carefully from experienced staff. A wrong use of padding can even increase rather than decrease the rate of postoperative neuropathy [48]. Fortunately, these nerve lesions are more often incomplete and deficits and symptoms tend to heal spontaneously, even if sometimes after weeks or months [49].
One of the most devastating complications in non-ocular surgery is the Peri-Operative Visual Loss (POVL), in some cases caused from wrong position. POVL is rare if considered in the whole population of surgical patients, ranging from 1:60,000 to 1:125,000, but is more frequent after spine surgery (3.09:10,000); only cardiac surgery has a higher risk of POVL (8.64:10,000). The causes of POVL are mainly two: the Central Retinal Artery Occlusion (CRAO) and the Ischemic Optic nerve Neuropathy (ION). The CRAO leads to the ischemia of the entire retina, while the less severe obstruction of a branch of the artery (BRAO) causes an impaired function only in a sector. While during cardiac surgery the more common mechanism involved is the arterial microembolism, during spine surgery the complication derives mainly from an improper head position, leading to mono or bilateral ocular compression [50]. The mechanisms underlying the development of ION are not completely known, but the pathogenesis seems to be multifactorial [50]. The occurrence of ION seems to be strictly correlated with surgery duration. In a survey of 83 ION after spine surgery the majority of cases (94%) occurred for 6 h anesthetic duration or longer, while only one case was associated with surgery lasting less than 4 h [51]. Other risk factors for ION were detected such as obesity, male sex, Wilson frame use, greater estimated blood loss, and decreased percent colloid administration. Recently, a task force of the ASA has proposed some practical advices for POVL prevention in spine surgery [52]. For the prevention of CRAO and other ocular damage direct pressure on the eye should be avoided, the eyes of prone-positioned patients should be assessed regularly and documented [52]. ION is less rare than CRAO, accounting for about 89% of cases of POVL after spinal surgery. The pathogenesis of ION is not clear. The most popular theory involves the elevation of venous pressure and the development of interstitial edema leading to deformation and obstruction of the vessels feeding the optical nerve. All the factors able to increase the venous pressure in the head, such as the prone position with abdominal compression in obese patients or the head position lower than the heart, or to decrease the oncotic pressure, such as a significant blood loss with consequent hypoalbuminemia and the inadequate administration of colloids, could predispose to ION [53].
Other complications deriving from improper positioning should be prevented using gel or foam-made dedicated devices or even normal pillows assembled with the active contribution of the surgeons, the nurses and the anesthesiologist. The final result must ensure the distribution of the pressures as more as possible over larger extensions of tissues, avoiding excessive and localized compressions, and excessive stretching or flexion of elbows, shoulders and neck. Abdomen compression should be avoided to facilitate intermittent positive pressure ventilation and limit barotrauma. Moreover, the reduction of the intrathoracic mean pressure leads to improvement of venous return and helps in lowering surgical bleeding. This is particularly important in CSS, where a deliberate arterial hypotension must be generally avoided to ensure a proper blood perfusion to the spinal cord. As discussed above, the head and the face should be frequently controlled (Fig. 4.2) to avoid harmful compressions on the eyes and ears (Fig. 4.3).
A head-rest for prone positioning. The mirror allows eye and face control
Nasotracheal intubation for ACSS at C3 level. The eyes are protected by a shell-shaped device
Prophylaxis of Surgical Site Infection
Surgical site infection (SSI) is a dreadful and costly complication in spinal surgery. One retrospective study regarding 90 patients undergoing PCSS showed no infections in upper cervical surgery (all infected patients were operated at C3 level or below) while underlines the use of a rigid collar in the postoperative as an important risk factor for infections of the wound in subaxial cervical surgery [54]. Other known risk factors were investigated, such as smoke with an odds ratio (OR) = 2.10 and perioperative steroids (OR = 3.42), but neither resulted statistically significant. A larger series of 318 patients undergoing posterior cervical decompression, showed an incidence of 1.6% for SSI needing reoperation (five cases) with a statistically significant correlation between postoperative infection and the number of levels decompressed [55]. In a retrospective study on 1615 lumbar spine fusions (1568 patients), the overall rate of infection was 2.2%. Risk factors detected were diabetes (×6), smoke (×2) and positive history of spinal surgery (×3.7). Moreover, risk increased with the number of levels fused [56]. A recent study in a series of 264 patients undergoing posterior cervical decompression and fusion showed a significant correlation between the incidence of SSI and the variability of glycemic levels in the postoperative [57], and the importance of the optimization of glycemia is also highlighted by the recent guidelines for SSI prevention indicating with strong level of recommendation a blood glucose target value less than 200 mg/dl in the perioperative [58]. Besides the other indications, the guidelines suggest a particular attention to the maintenance of normothermia and the optimization of tissue oxygen delivery, not only by increasing the fraction of inspired oxygen (FIO2) in the perioperative but also optimizing blood volume and oncotic pressure.
Literature data support the efficacy of perioperative antibiotic prophylaxis in all the orthopedic spinal procedures with or without instrumentation, with a grade A in the strength or recommendation [59]. The standard recommended agent is cefazolin 2 g i.v. for adult patients (3 g in patients weighting over 120 kg, 30 mg/kg for pediatric patients), administered within 60 min before skin incision (Table 4.2). Clindamycin or vancomycin should be used as alternative agents in patients with β-lactam allergy. If organizational SSI surveillance shows that gram-negative organisms are associated with infections or if there is risk of gram-negative contamination of the surgical site, as for the transoral approach [60], clindamycin or vancomycin should be used in addition to cefazolin if the patient is not β-lactam allergic, or to aztreonam, gentamicin, or single-dose fluoroquinolone if the patient is β-lactam allergic. In patients who are known to be colonized with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin should be added to cefazolin. For agents requiring a slow infusion over 1–2 h, as fluoroquinolones or vancomycin, the administration should begin within 120 min before skin incision. For patients with renal or hepatic impairment, the dose often does not need to be modified when given as a single preoperative administration before surgical incision. In order to maintain an adequate blood and tissue drug concentration, intraoperative redosing is recommended when the duration of the procedure exceeds two half-lives of the drug or there is excessive blood loss [61].
In clean non-instrumented procedures there is large consensus on discontinuing antibiotic prophylaxis in the postoperative. For instrumented spinal surgery, a 72-h antibiotic administration was associated with significantly less incidence of SSI than observed after a single preoperative dose (3.6 vs. 7.1%) [62].
Local antibiotics used as powder on the surgical site or to irrigate the wound are generally not recommended because their usefulness is uncertain and may select resistant bacteria even becoming harmful [58, 63].
Deep Venous Thrombosis and Pulmonary Embolism Prevention
DVT complicates CSS meanly with a rate ranging from 0.5 to 4%, with a higher incidence after posterior fixation (1.3%) than after ACSS or posterior decompression (<0.5%), with a higher risk in male sex, pulmonary disorders, surgery in teaching-hospital. Despite this low rate of occurrence, when DVT is present the hospital stay increases by 7- to 10-fold over normal, and mortality rates increase by 10- to 50-fold [64,65,66]. In a prospective clinical trial in patients undergoing CSS, mechanical prophylaxis with intermittent pneumatic compression was equally effective as unfractionated heparin or low molecular weight heparin for the prevention of DVT and PE, but avoided the risk of postoperative hemorrhage [67].
The 9th edition of the Antithrombotic Therapy and Prevention of Thrombosis Guidelines from the American College of Chest Physicians suggests mechanical prophylaxis, preferably with IPC, over no prophylaxis or pharmacological prophylaxis. For patients undergoing spinal surgery at high risk for Venous ThromboEmbolism (VTE), including those with malignant disease or those undergoing surgery with a combined anterior-posterior approach, the guidelines suggest adding pharmacologic prophylaxis to mechanical prophylaxis once adequate hemostasis is established and the risk of bleeding decreases [68].
Postoperative Pain Management
Pain after spine surgery is often more severe than in other surgical settings. Skin incision involves more frequently multiple adjacent dermatomes and painful anatomical structures are often involved as periosteum, ligaments, facet joints, muscular fascial tissue. Among the deep somatic structures, periosteum seems to be one of the most painful tissues having the lowest pain threshold nerve fibers [69]. Complex mechanisms of peripheral and central sensitization of pain receptors and spinal cord pathways are also involved in explaining the resistance to treatment and the tendency to persist even after days. In addition, patients scheduled for spine surgery are often under preoperative chronic pain therapy. In some patients, a large use of opioids in the preoperative creates serious therapeutic challenges in the postoperative, making pain less responsive to incremental doses of opioids [70].
When minimally invasive techniques are adopted, pain could be milder for the generally small skin incisions and the reduced damage for muscles and deep tissues. However, among the postoperative “side effect” of surgery, pain represents one of the most common causes of hospital re-admission or delayed discharge, especially when an outpatient (OP) or day surgery (DS) treatment is planned [71]. Nowadays, the multimodal approach to pain therapy is considered the best model of treatment, leading to reduce the doses of the single drugs used and minimize the potential side effects. The multimodal or balanced treatment consists in combining, since the preoperative period, opioid and non-opioid analgesics with additive or synergistic actions sometimes with nonpharmacologic approaches [72].
Other techniques can be adopted together with drug therapy to help to decrease postoperative pain. Skin and tissues infiltration with a long-acting local anesthetic added with epinephrine before the surgical incision is a common practice, reducing intraoperative bleeding and analgesics requirement, at least in the earlier postoperative period, reducing the hospital stay and also the occurrence of PONV [73]. Continuous postoperative wound infiltration with local anesthetics through microcatheters of various length is also available, but not so widely used, though the efficacy and the slow rate of complications have been demonstrated [74]. In the last years, an overwhelming interest is arising about the use of Erector Spinae Plane Block (ESP Block) in order to provide good perioperative analgesia in spine surgery (Fig. 4.4). The risk/benefit ratio of the technique at a cervical level is still unclear. While the first studies reported very encouraging data [75,76,77], after the findings of a specific cadaver study some Authors warned against the potential occurrence of bilateral phrenic nerve block after a bilateral cervical ESP block [78, 79].
High-thoracic ESP block for posterior CSS. TM trapezius muscle, RM rhomboid muscle, ES erector spinae muscles, TA transverse apophysis of T3, LA local anesthetic spreading cranially and caudally from the site of injection
Due to the wide safety margin and the very rare complications, acetaminophen has a special place in the management of pain after CSS. Acetaminophen alone or in combination with other NSAIDs or weak opiates, can control efficiently a moderate pain or significantly reduce the consumption of other analgesics in the postoperative period. The availability of oral and intravenous (iv) preparations makes it suitable both for perioperative and postoperative use, and also allows to continue the support therapy easily after patient discharge [72].
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and cyclooxygenase-2 inhibitors (COX-2) lead to increased risk of non-union after spine fusion surgery, but this adverse effect seems limited to prolonged use (>14 days) or high doses. The use of ketorolac at a dose of more than 120 mg/day even for few days or the use of more than 300 mg of diclofenac in all significantly affect the risk of non-union [80]. When used at lower doses and for few days, these drugs surely help in postoperative pain treatment.
Opiates still have an important role in the treatment of moderate-to-severe postoperative pain, but because of the important side-effects, it’s advisable to reduce the doses in a multimodal protocol. The association of NSAIDs or celecoxib with a slow-release oxycodone given in the preoperative period, when compared with intravenous morphine, improved outcome in spine surgery, providing earlier recovery of the bowel function [81]. Patients treated preoperatively with opiates for chronic pain could necessitate large opiates doses in the perioperative period. The use of intraoperative ketamine infusion in these patients has significantly lowered opiates consumption even over 6 weeks after spine surgery, particularly after CSS [82]. The clinical benefit in terms of reduction in opiate-related PONV has been higher for CSS than for lumbar surgery, while the ketamine related side-effects such as disturbing dreams and hallucination were more common after lumbar surgery [83, 84].
The gabapentinoids (gabapentin, pregabalin) have also been used in association with other drugs for multimodal postoperative pain treatment, but their role remains uncertain as some studies failed in demonstrating a reduced opioids consumption. Furthermore, the side effects as somnolence and sedation, dizziness, ataxia, and visual blurring could slow the physical and psychological recovery, especially in the elderly [72, 85].
PONV Prevention and Treatment
Even if the topic is quite important in patients undergoing CSS, for the particular discomfort deriving from the association between PONV and the frequently required supine position with limited neck movements, only few studies are reported in the specific field [73]. Postoperative nausea and vomiting affect heavily the grade of satisfaction of the patients and in some patients may increase the risks for other severe complications as pulmonary aspiration. After ambulatory or 1 day surgery PONV represents, after pain, the second cause of hospital readmission or delayed discharge. Several studies have been dedicated to the problem and guidelines have been established to help physicians in clinical decisions [86, 87].
Detecting preoperatively risk factors is crucial to provide a correct PONV prevention for each patient. A simple way to assess the risk of PONV after general anesthesia has been proposed; it’s based on the evaluation of only four characteristics: female gender, history of motion sickness or PONV, non-smoking status, need of postoperative opioids [88]. When none of the risks is present, no prophylaxis is recommended. Higher risk scores suggest prophylaxis with one or more drugs, and/or the adoption of specific anesthetic techniques. When general anesthesia is needed, Totally Intra-Venous Anesthesia (TIVA) is associated with lower PONV incidence than inhalational anesthesia, especially in the first hours after surgery [89].
The protective effects of adequate preoperative and intraoperative hydration against PONV, drowsiness and dizziness, if not contraindicated, is generally accepted [87]. For the same reason, allowing oral intake of clear fluids until 3 h before surgery, may help prevent postoperative nausea while is considered safe for the risk of inhalation [90].
Dexamethasone is a long-acting glucocorticoid with a largely demonstrated activity in reducing PONV [91]. The mechanism of action, probably multifactorial, is still unclear. When administered iv during anesthesia induction at a dose ranging from 0.05 to 0.1 mg/kg, it significantly lowered the rate of PONV in various surgical setting and is considered safe in terms of side effects [92, 93]. Although many authors suggest that rescue medication should not involve dexamethasone, when added to ondansetron or droperidol it has been associated with a significant reduction in established PONV [94].
5-Hydroxytryptamine-3 (5-HT3) receptor antagonists are widely used in the common practice for the prevention of PONV and of the side effects of chemotherapy. Ondansetron is the most famous drug of the family, normally used at a dose of 4 mg iv at the end of surgery. Palonosetron, a 5-HT3 antagonist with a longer half-life and a higher receptor-binding profile, seems very promising especially for the prevention of PDNV. Even if more effective and safer than ondansetron (lack of action on QT interval), the use of palonosetron is still limited [92, 95, 96].
Transdermal scopolamine is effective and the side effects are quite frequent although generally mild and well tolerated [97]. In the elderly, however, the occurrence of confusion or an excessive sedation could be observed, suggesting to remove the patch. The patch is applied the evening before surgery or at least 2 h before the induction of anesthesia, because the onset of the effect is about 2–4 h [98].
D2 receptor antagonists are also used for PONV treatment and prevention. Metoclopramide alone or in association with dexamethasone or other drugs has been studied and its efficacy has been questioned. Recent reviews suggest that metoclopramide 10 mg i.v. is effective in preventing PONV after general anesthesia when given preoperatively [99, 100], but may worsen extrapyramidal symptoms, constipation, visual disturbances [93]. Droperidol is very effective in the prevention of PONV even at very low doses (0.625–1.25 mg iv 5–15 min before the end of anesthesia) with a Number Needed to Treat (NNT) of 5, and highly effective in the prevention of nausea during patient-controlled analgesia with opiates (NNT = 3). In the last years, however, the use of droperidol has been greatly limited after the Black Box Warning issued from the Foods and Drugs Administration in the USA in 2001. Droperidol has been associated with adverse cardiac events as prolongation of QT interval and torsades de pointes. Several authors suggested a revision of that decision, for the lack of evidence supporting the black box warning [101, 102]. The warning is still active, restricting the use of droperidol to the treatment of patients who fail to show an acceptable response to other adequate treatments. Recently amisulpride 5 mg iv administered few minutes before the anesthesia induction was approved for PONV prevention and at a dose of 10 mg iv for PONV treatment, with the recommendation to avoid use in patients with congenital long QT syndrome and in patients taking droperidol. It seems highly effective in PONV prevention and treatment with low side effects [103, 93].
More recent drugs, the Neurokinin-1 receptor antagonists and particularly aprepitant, appear very interesting for the prevention of PONV. Aprepitant, casopitant and rolapitant showed better results when compared in clinical trial with ondansetron in patients at high risk for PONV, even if the reduction in vomiting is more evident than the reduction of nausea [93].
Acupuncture has been proposed as a non-pharmacological tool for PONV prevention and treatment, with lack of side effects when compared with traditional approach. A recent meta-analysis of 14 RCTs that included 1653 patients concluded that the transcutaneous electrical acupoint stimulation is a reasonable modality to be considered into a multimodal approach for PONV prevention with a low incidence of adverse effects [104].
Other Complications
Postoperative Airway Compromise
Airway obstruction complicates ACSS with a rate varying from 1.2 to 6.1%. The situation can rapidly worsen and require emergent reintubation. The obstruction, mainly inspiratory, can cause a pulmonary edema due to the development of a markedly negative intrathoracic pressure. Fortunately, this kind of edema tends to resolve rapidly with the resolution of the obstruction and the oxygenation of the patient [105].
The obstruction is more frequently due to edema of the pharynx, prevertebral tissues and larynx and could be eventually worsened by direct trauma during a difficult intubation. Less common is the development of a hematoma in the wound or the involvement of the recurrent laryngeal nerve, with vocal fold palsy. The occurrence of a hematoma is evaluated between 0.4 and 1.2% in studies involving more than 40,000 patients, with a death reported for mechanical asphyxia [106]. Acute postoperative airway obstruction has been also reported for cervical cage displacement [107]. The obstructive events are more frequent when surgery involves more than three vertebral bodies or high cervical levels (c2–c4), with blood loss >300 ml, surgery lasting more than 5 h or combined anterior plus posterior. The incidence is increased in obese patient, with OSA and other respiratory comorbidities [108, 109]. These considerations could help in detecting the cases that deserve a more cautious clinical monitoring and management. Cases with high risk of postoperative airway obstruction for the characteristics of surgery, especially if other patient-related factors are present, need the admission in an intensive care unit (ICU), better with the head elevated about 30% just as for an intracranial postoperative [108]. Extubation must be delayed for 24–36 h and performed only after a fiberoptic inspection or a cuff leak test [110]. Furthermore, these cases need some hours of observation after extubation; recent studies demonstrated a good specificity but only a moderate sensitivity for the cuff leak test in the prediction of post-extubation airway obstruction [111, 112].
Dysphagia, Laryngeal Palsy and Aspiration
Early dysphagia is more frequent after anterior cervical spine surgery (ACSS), and is more common when a plate is used and in the elderly [113], but it’s not so rare also for posterior approaches. After 2 and 6 weeks from surgery dysphagia was present respectively in 11 and 8% of PCSS vs. 61.5 and 44% of ACSS (p < 0.0001). No difference among the two surgical approaches was observed after 12 weeks with rates nearly 12% [114]. Many different strategies have been proposed to reduce the incidence and the lasting of postoperative dysphagia, mostly regarding surgical aspects such as choosing a thinner plate and avoiding plate prominence, limiting the duration of surgery, limiting retraction [115]. In the anesthetic field, the pressure or the ETT cuff was invoked in worsening an eventual nerve injury due to surgical retraction. In a series of 900 consecutive patients who underwent ACSS with plating, Apfelbaum observed a significant reduction in the incidence of temporary vocal fold paresis from 6.4 to 1.7% (p = 0.002), since when the systematic adjustment of the pressure of the ETT cuff after the positioning or repositioning of the surgical retractors was adopted. The acceptable cuff pressure of 20–30 cm of water is often exceeded when manual inflation of the cuff is adopted using a 10 or 20 ml syringe [116, 117], and the use of surgical retractors for ACSS may further increase the pressure. In this type of surgery it could be advisable to adopt routinely an automatic cuff pressure control device [117], even if the gradual and continuous pressure readjustment may not allow the ETT detaching from the trachea.
Apfelbaum supposed that the majority of the laryngeal nerve injuries during ACSS could derive from an asymmetric vocal fold compression. The ETT is anchored distally from the cuff and proximally from the tape; when trachea is retracted the tube compresses the homolateral vocal fold, with possible injury for the compression on the endolaryngeal segment of the nerve. The cuff deflation distally releases the ETT allowing the passive adjustment towards a “neutral” position between the vocal folds, and the release of compression over the ipsilateral nerve [118].
Many of the factors causing dysphagia and hoarseness are generally involved also in another severe complication after CSS affecting about 0.5% of all procedures: the aspiration pneumonia. However, even if the anterior approach is more commonly associated with risks of laryngeal nerves and esophagus injury, and neck tissues swelling that could predispose to swallowing disorders, unexpectantly aspiration is more frequent after PCSS (about 1 vs. 0.4%). Other risk factors are weight loss, fluid-electrolyte disorders, congestive heart failure, neurological disorders respectively with OR of 8.3, 6.2, 3.1 and 2.1. Moreover, it’s more frequent in the elderly (>65 y.o.) and in patients with comorbidities [119]. When aspiration pneumonia occurs, the overall mortality rate in CSS dramatically increases from the basal 0.07 to 3.44%.
Particularly in the revision cases of ACSS surgeons might prefer a contralateral approach to avoid scar and altered anatomy. For these patients, and however in any patient with suspected laryngeal disfunction, a preoperative otorhinolaryngologist consultation is mandatory to prevent the dramatic event of a bilateral laryngeal nerve damage. For patients with monolateral laryngeal paresis surgery must be performed ipsilateral to the preexisting damage, to avoid acute airway obstruction and/or severe swallowing impairment with pulmonary complications [115].
Postoperative Delirium
Postoperative acute delirium (POD) is the third most common complication after cervical spine surgery, occurring in more 5% of cases. More frequent in patients with preoperative dementia, age over 85 year, history of stroke or transient ischemic attack [120]. Delirium has been observed even in elderly patients when immobilization of cervical spine is indicated with or without surgery. In this setting it’s quite challenging to evaluate and balance the risks of an oversedation against the risks of an insufficient immobilization with cervical orthoses [121]. Practice guideline has been proposed from the American Geriatrics Society for the management of POD in older adults [122]. Special attention should be paid to nonpharmacologic measures for the prevention and treatment of POD, beginning from the information and training of the physicians and other healthcare professionals. Important nonpharmacologic interventions include early mobilization, orientation, physiotherapy, communication and practical actions as returning as soon as possible glasses, hearing aids and dentures. Also protecting the sleep-wake cycles is advisable, for instance avoiding the postoperative in ICU if not mandatory [123].
Anesthesia depth should be monitored in order to avoid excessive depression of electric brain activity; the intraoperative use of Bispectral Index Monitoring has been associated with significantly reduced risk of postoperative delirium and long-term cognitive dysfunction [124]. Pain control is crucial in delirium prevention, preferably with an opioid sparing protocol. Antipsychotic or benzodiazepine medications should not be used for the treatment of older adults with postoperative delirium who are not agitated and threatening substantial harm to self or others. Only if the patient is severely agitated and when any attempt of behavioral measure has failed antipsychotic drugs can be used titrating the lowest effective dose and for the period as short as possible. Benzodiazepines should only be used if strictly indicated, as for the treatment of alcohol or benzodiazepine withdrawal, and however for the shortest possible duration and at the lowest effective dose. Some anticholinergic and antihistaminic drugs and meperidine should be avoided because can increase delirium risk as the drugs that contribute to serotonin syndrome. The prophylactic use of antipsychotic medications or cholinesterase inhibitors to prevent delirium in postoperative patients is not recommended [122].
Intracranial Complications
Remote IntraCranial Hemorrages (RICHs) are rare complications observed after spinal surgery performed at any level [125]. These events may evolve subtly. If they develop during surgery, they can simulate a simple delayed emergence that could be ascribed to persistent anesthetic effect or to cerebral edema due to prolonged prone position [126, 127]. More often the complication appears 10 or more hours postoperatively, with headache, nausea, vomiting; sometimes other symptoms may appear such somnolence, altered consciousness, dysarthria, ataxia, and motor or visual deficits. In a recent review all the eight described cases had intraoperative CSF leakage and postoperative drains with moderate serosanguinous output. RICH may be caused from an excessive CSF loss resulting from incidental or intentional durotomy or dural leakage for the action of a drain. This could cause a caudal prolapse in the cerebellum and encephalus, with traction and lesion of some bridging veins. The positioning of a surgical drain in patients with clear or suspected dural lesion should be carefully considered, and however any change in the neurological status deserves to be investigated with cranial imaging [128]. This kind of hematoma is more frequent in the posterior fossa, but sometimes can develop in the supratentorial region [127].
Another rare cause of intracranial hematoma during spine surgery is the possible penetration in the skull of a pin when a Mayfield clamp (Fig. 4.5) is adopted for the positioning [129].
Positioning of a 3-pin Mayfield clamp for ACSS
References
Bettelli G. Anaesthesia for the elderly outpatient: preoperative assessment and evaluation, anaesthetic technique and postoperative pain management. Curr Opin Anaesthesiol. 2010;23(6):726–31.
Epstein NE. More risks and complications for elective spine surgery in morbidly obese patients. Surg Neurol Int. 2017;26(8):66.
American Diabetes Association. Executive summary: standards of medical care in diabetes. Diabetes Care. 2012;35(Suppl 1):S4–S10.
Joshi GP, Chung F, Vann MA, Ahmad S, Gan TJ, Goulson DT, Merrill DG, Twersky R. Society for Ambulatory Anesthesia. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg. 2010;111(6):1378–87.
Guzman JZ, Skovrlj B, Shin J, Hecht AC, Qureshi SA, Iatridis JC, Cho SK. The impact of diabetes mellitus on patients undergoing degenerative cervical spine surgery. Spine (Phila Pa 1976). 2014;39(20):1656–65.
Nair BG, Neradilek MB, Newman SF, Horibe M. Association between acute phase perioperative glucose parameters and postoperative outcomes in diabetic and non-diabetic patients undergoing non-cardiac surgery. Am J Surg. 2019;218(2):302–10.
Walid MS, Newman BF, Yelverton JC, Nutter JP, Ajjan M, Robinson JS Jr. Prevalence of previously unknown elevation of glycosylated hemoglobin in spine surgery patients and impact on length of stay and total cost. J Hosp Med. 2010;5(1):E10–4.
Fineberg SJ, Oglesby M, Patel AA, Singh K. Incidence and mortality of perioperative cardiac events in cervical spine surgery. Spine (Phila Pa 1976). 2013;38(15):1268–74.
Hammill BG, Curtis LH, Bennett-Guerrero E, O'Connor CM, Jollis JG, Schulman KA, Hernandez AF. Impact of heart failure on patients undergoing major noncardiac surgery. Anesthesiology. 2008 Apr;108(4):559–67.
Auron M, Harte B, Kumar A, Michota F. Renin-angiotensin system antagonists in the perioperative setting: clinical consequences and recommendations for practice. Postgrad Med J. 2011;87(1029):472–81.
Biondi-Zoccai GG, Lotrionte M, Agostoni P, Abbate A, Fusaro M, Burzotta F, Testa L, Sheiban I, Sangiorgi G. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27(22):2667–74.
Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med. 2005;257(5):399–414.
Chassot PG, Marcucci C, Delabays A, Spahn DR. Perioperative antiplatelet therapy. Am Fam Physician. 2010;82(12):1484–9.
Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Developed in collaboration with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Medicine. J Nucl Cardiol. 2015;22(1):162–215.
Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of adverse events in day-case surgery. Br J Anaesth. 1999;83(2):262–70.
Taylor A, DeBoard Z, Gauvin JM. Prevention of postoperative pulmonary complications. Surg Clin North Am. 2015;95(2):237–54.
Verla T, Xu DS, Davis MJ, Reece EM, Kelly M, Nunez M, Winocour SJ, Ropper AE. Failure in Cervical Spinal Fusion and Current Management Modalities. Semin Plast Surg. 2021;35(1):10–3.
Spieth PM, Güldner A, de Abreu MG. Chronic obstructive pulmonary disease. Curr Opin Anaesthesiol. 2012;25(1):24–9.
Algahtani R, Merenda A. Multimorbidity and critical care neurosurgery: minimizing major perioperative cardiopulmonary complications. Neurocrit Care. 2021;34(3):1047–61.
Porhomayon J, El-Solh A, Chhangani S, Nader ND. The management of surgical patients with obstructive sleep apnea. Lung. 2011;189(5):359–67.
Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth. 2010;57(5):423–38.
Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115(5):1060–8.
Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015;70(3):272–81.
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, et al. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251–70.
Durga P, Sahu BP. Neurological deterioration during intubation in cervical spine disorders. Indian J Anaesth. 2014;58(6):684–92.
Brück S, Trautner H, Wolff A, Hain J, Mols G, Pakos P, Roewer N, Lange M. Comparison of the C-MAC(®) and GlideScope(®) videolaryngoscopes in patients with cervical spine disorders and immobilisation. Anaesthesia. 2015;70(2):160–5.
Singleton BN, Morris FK, Yet B, Buggy DJ, Perkins ZB. Effectiveness of intubation devices in patients with cervical spine immobilisation: a systematic review and network meta-analysis. Br J Anaesth. 2021;126(5):1055–66.
Ezri T, Szmuk P, Warters RD, Katz J, Hagberg CA. Difficult airway management practice patterns among anesthesiologists practicing in the United States: have we made any progress? J Clin Anesth. 2003;15(6):418–22.
Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33–9.
Moore A, Schricker T. Awake videolaryngoscopy versus fiberoptic bronchoscopy. Curr Opin Anaesthesiol. 2019 Dec;32(6):764–8.
Hindman BJ, Palecek JP, Posner KL, Traynelis VC, Lee LA, Sawin PD, Tredway TL, Todd MM, Domino KB. Cervical spinal cord, root, and bony spine injuries: a closed claims analysis. Anesthesiology. 2011;114(4):782–95.
Martirosyan NL, Feuerstein JS, Theodore N, Cavalcanti DD, Spetzler RF, Preul MC. Blood supply and vascular reactivity of the spinal cord under normal and pathological conditions. J Neurosurg Spine. 2011;15(3):238–51.
Pajewski TN, Arlet V, Phillips LH. Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon. Eur Spine J. 2007;16(Suppl 2):S115–29.
Reddy RP, Chang R, Rosario BP, Sudadi S, Anetakis KM, Balzer JR, Crammond DJ, Shaw JD, Thirumala PD. What is the predictive value of intraoperative somatosensory evoked potential monitoring for postoperative neurological deficit in cervical spine surgery? A meta-analysis. Spine J. 2021;21(4):555–70.
Li F, Gorji R, Allott G, Modes K, Lunn R, Yang ZJ. The usefulness of intraoperative neurophysiological monitoring in cervical spine surgery: a retrospective analysis of 200 consecutive patients. J Neurosurg Anesthesiol. 2012;24(3):185–90.
Jannelli G, Nouri A, Molliqaj G, Grasso G, Tessitore E. Degenerative cervical myelopathy: review of surgical outcome predictors and need for multimodal approach. World Neurosurg. 2020;140:541–7.
Rajappa D, Khan MM, Masapu D, Manchala R, Rudrappa S, Gopal S, Govindasamy R, Horasuku SK. Multimodal intraoperative neurophysiological monitoring in spine surgeries: the experience at a spine centre through years. Asian Spine J. 2020;15(6):728–38.
Stecker MM. A review of intraoperative monitoring for spinal surgery. Surg Neurol Int. 2012;3(Suppl 3):S174–87.
Di Lazzaro V, Oliviero A, Profice P, Pennisi MA, Pilato F, Zito G, Dileone M, Nicoletti R, Pasqualetti P, Tonali PA. Ketamine increases human motor cortex excitability to transcranial magnetic stimulation. J Physiol. 2003;547(Pt 2):485–96.
Pacreu S, Vilà E, Moltó L, Fernández-Candil J, Fort B, Lin Y, León A. Effect of dexmedetomidine on evoked-potential monitoring in patients undergoing brain stem and supratentorial cranial surgery. Acta Anaesthesiol Scand. 2021;65(8):1043–53.
Sloan TB, Heyer EJ. Anesthesia for intraoperative neurophysiologic monitoring of the spinal cord. J Clin Neurophysiol. 2002;19(5):430–43.
Asouhidou I, Katsaridis V, Vaidis G, Ioannou P, Givissis P, Christodoulou A, Georgiadis G. Somatosensory Evoked Potentials suppression due to remifentanil during spinal operations; a prospective clinical study. Scoliosis. 2010;12(5):8.
Lu IC, Wu SH, Wu CW. Neuromuscular blockade management for intraoperative neural monitoring. Kaohsiung J Med Sci. 2020;36(4):230–5.
Nuwer MR, Schrader LM. Spinal cord monitoring. Handb Clin Neurol. 2019;160:329–44.
Plata Bello J, Pérez-Lorensu PJ, Roldán-Delgado H, Brage L, et al. Role of multimodal intraoperative neurophysiological monitoring during positioning of patient prior to cervical spine surgery. Clin Neurophysiol. 2015;126(6):1264–70.
Delgado-López PD, Montalvo-Afonso A, Araus-Galdós E, Isidro-Mesa F, et al. Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery. Neurocirugia. 2021;S1130-1473(21):00031–2.
Kamel I, Barnette R. Positioning patients for spine surgery: avoiding uncommon position-related complications. World J Orthop. 2014;5(4):425–43.
American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice advisory for the prevention of perioperative peripheral neuropathies: an updated report by the American Society of Anesthesiologists Task Force on prevention of perioperative peripheral neuropathies. Anesthesiology. 2011;114(4):741–54.
Antoniadis G, Kretschmer T, Pedro MT, König RW, Heinen CP, Richter HP. Iatrogenic nerve injuries: prevalence, diagnosis and treatment. Dtsch Arztebl Int. 2014;111(16):273–9.
Roth S. Perioperative visual loss: what do we know, what can we do? Br J Anaesth. 2009;103(Suppl 1):i31–40.
Lee LA, Roth S, Posner KL, Cheney FW, Caplan RA, Newman NJ, Domino KB. The American Society of Anesthesiologists Postoperative Visual Loss Registry: analysis of 93 spine surgery cases with postoperative visual loss. Anesthesiology. 2006;105(4):652–9.
American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Practice advisory for perioperative visual loss associated with spine surgery: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Anesthesiology. 2012;116(2):274–85.
Nickels TJ, Manlapaz MR, Farag E. Perioperative visual loss after spine surgery. World J Orthop. 2014;5(2):100–6.
Barnes M, Liew S. The incidence of infection after posterior cervical spine surgery: a 10 year review. Global Spine J. 2012;2(1):3–6.
Halvorsen CM, Lied B, Harr ME, Rønning P, Sundseth J, Kolstad F, Helseth E. Surgical mortality and complications leading to reoperation in 318 consecutive posterior decompressions for cervical spondylotic myelopathy. Acta Neurol Scand. 2011;123(5):358–65.
Schimmel JJ, Horsting PP, de Kleuver M, Wonders G, van Limbeek J. Risk factors for deep surgical site infections after spinal fusion. Eur Spine J. 2010;19(10):1711–9.
Patel PD, Canseco JA, Wilt Z, Okroj KT, Chang M, Reyes AA, Bowles DR, Kurd MF, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Postoperative glycemic variability and adverse outcomes after posterior cervical fusion. J Am Acad Orthop Surg. 2021;29(13):580–8.
Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91.
Shaffer WO, Baisden JL, Fernand R, Matz PG, North American Spine Society. An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery. Spine J. 2013;13(10):1387–92.
Macki M, Basheer A, Lee I, Kather R, Rubinfeld I, Abdulhak MM. Surgical site infection after transoral versus posterior approach for atlantoaxial fusion: a matched-cohort study. J Neurosurg Spine. 2018 Jan;28(1):33–9.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect. 2013;14(1):73–156.
Maciejczak A, Wolan-Nieroda A, Wałaszek M, Kołpa M, Wolak Z. Antibiotic prophylaxis in spine surgery: a comparison of single-dose and 72-hour protocols. J Hosp Infect. 2019;103(3):303–10.
Vakayil V, Atkinson J, Puram V, Glover JJ, Harmon JV, Statz CL, et al. Intrawound vancomycin application after spinal surgery: a propensity score-matched cohort analysis. J Neurosurg Spine. 2021;5:1–11.
Oglesby M, Fineberg SJ, Patel AA, Pelton MA, Singh K. The incidence and mortality of thromboembolic events in cervical spine surgery. Spine (Phila Pa 1976). 2013;38(9):E521–7.
Sato K, Date H, Michikawa T, Morita M, Hayakawa K, Kaneko S, Fujita N. Preoperative prevalence of deep vein thrombosis in patients scheduled to have surgery for degenerative musculoskeletal disorders. BMC Musculoskelet Disord. 2021;22(1):513.
Wewel JT, Brahimaj BC, Kasliwal MK, Traynelis VC. Perioperative complications with multilevel anterior and posterior cervical decompression and fusion. J Neurosurg Spine. 2019;20:1–6.
Epstein NE. Intermittent pneumatic compression stocking prophylaxis against deep venous thrombosis in anterior cervical spinal surgery: a prospective efficacy study in 200 patients and literature review. Spine (Phila Pa 1976). 2005;30(22):2538–43.
Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S–77S.
Buvanendran A, Thillainathan V. Preoperative and postoperative anesthetic and analgesic techniques for minimally invasive surgery of the spine. Spine (Phila Pa 1976). 2010;35(26 Suppl):S274–80.
Sharma S, Balireddy RK, Vorenkamp KE, Durieux ME. Beyond opioid patient-controlled analgesia: a systematic review of analgesia after major spine surgery. Reg Anesth Pain Med. 2012;37(1):79–98.
Soffin EM, Wetmore DS, Barber LA, Vaishnav AS, Beckman JD, et al. An enhanced recovery after surgery pathway: association with rapid discharge and minimal complications after anterior cervical spine surgery. Neurosurg Focus. 2019;46(4):E9.
Elvir-Lazo OL, White PF. The role of multimodal analgesia in pain management after ambulatory surgery. Curr Opin Anaesthesiol. 2010;23(6):697–703.
Li K, Li H, Luo D, Feng H, Ji C, Yang K, Liu J, Zhang H, Xu H. Efficacy of local infiltration analgesia with ropivacaine for postoperative pain management in cervical laminoplasty: a retrospective study. Sci Rep. 2020;10(1):4217.
Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg. 2006;203(6):914–32.
Goyal A, Kamath S, Kalgudi P, Krishnakumar M. Perioperative analgesia with erector spinae plane block for cervical spine instrumentation surgery. Saudi J Anaesth. 2020;14(2):263–4.
Goyal A, Kalgudi P, Sriganesh K. Ultrasound-guided erector spinae plane block for perioperative analgesia in cervical and thoracic spine surgeries—a case series. Neurol India. 2021;69(2):487–9.
Diwan S, Koh WU, Chin KJ, Nair A. Bilateral high thoracic continuous erector spinae plane blocks for postoperative analgesia in a posterior cervical fusion. Saudi J Anaesth. 2020;14(4):535–7.
Elsharkawy H, Ince I, Hamadnalla H, Drake RL, Tsui BCH. Cervical erector spinae plane block: a cadaver study. Reg Anesth Pain Med. 2020;45(7):552–6.
Kwon AH, Xu JL. Cervical erector spinae plane block: is it feasible for cervical spine surgeries? Reg Anesth Pain Med. 2021;46(6):552–3.
Li Q, Zhang Z, Cai Z. High-dose ketorolac affects adult spinal fusion: a meta-analysis of the effect of perioperative nonsteroidal anti-inflammatory drugs on spinal fusion. Spine (Phila Pa 1976). 2011;36(7):E461–8.
Blumenthal S, Min K, Marquardt M, Borgeat A. Postoperative intravenous morphine consumption, pain scores, and side effects with perioperative oral controlled-release oxycodone after lumbar discectomy. Anesth Analg. 2007;105(1):233–7.
Park PJ, Makhni MC, Cerpa M, Lehman RA, Lenke LG. The role of perioperative ketamine in postoperative pain control following spinal surgery. J Spine Surg. 2020;6(3):591–7.
Yamauchi M, Asano M, Watanabe M, Iwasaki S, Furuse S, Namiki A. Continuous low-dose ketamine improves the analgesic effects of fentanyl patient-controlled analgesia after cervical spine surgery. Anesth Analg. 2008;107(3):1041–4.
Loftus RW, Yeager MP, Clark JA, Brown JR, Abdu WA, Sengupta DK, Beach ML. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology. 2010;113(3):639–46.
Peene L, Le Cacheux P, Sauter AR, Joshi GP, Beloeil H, PROSPECT Working Group Collaborators, European Society of Regional Anaesthesia. Pain management after laminectomy: a systematic review and procedure-specific post-operative pain management (prospect) recommendations. Eur Spine J. 2020; https://doi.org/10.1007/s00586-020-06661-8.
Gan TJ, Meyer TA, Apfel CC, Chung F, Davis PJ, Habib AS, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2007;105(6):1615–28.
Elvir-Lazo OL, White PF, Yumul R, Cruz EH. Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review. F1000Res. 2020;9:F1000 Faculty Rev-983.
Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology. 1999;91(3):693–700.
Apfel CC, Kranke P, Katz MH, Goepfert C, Papenfuss T, et al. Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: a randomized controlled trial of factorial design. Br J Anaesth. 2002;88(5):659–68.
White PF, Eng M. Fast-track anesthetic techniques for ambulatory surgery. Curr Opin Anaesthesiol. 2007;20(6):545–57.
Henzi I, Walder B, Tramèr MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg. 2000;90(1):186–94.
Melton MS, Klein SM, Gan TJ. Management of postdischarge nausea and vomiting after ambulatory surgery. Curr Opin Anaesthesiol. 2011;24(6):612–9.
Weibel S, Rücker G, Eberhart LH, Pace NL, Hartl HM, et al. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis. Cochrane Database Syst Rev. 2020;10(10):CD012859.
Ormel G, Romundstad L, Lambert-Jensen P, Stubhaug A. Dexamethasone has additive effect when combined with ondansetron and droperidol for treatment of established PONV. Acta Anaesthesiol Scand. 2011;55(10):1196–205.
Dogan U, Yavas G, Tekinalp M, Yavas C, Ata OY, Ozdemir K. Evaluation of the acute effect of palonosetron on transmural dispersion of myocardial repolarization. Eur Rev Med Pharmacol Sci. 2012;16(4):462–8.
Tan HS, Dewinter G, Habib AS. The next generation of antiemetics for the management of postoperative nausea and vomiting. Best Pract Res Clin Anaesthesiol. 2020;34(4):759–69.
Antor MA, Uribe AA, Erminy-Falcon N, Werner JG, Candiotti KA, Pergolizzi JV, Bergese SD. The effect of transdermal scopolamine for the prevention of postoperative nausea and vomiting. Front Pharmacol. 2014;9(5):55.
Apfel CC, Zhang K, George E, Shi S, Jalota L, Hornuss C, Fero KE, et al. Transdermal scopolamine for the prevention of postoperative nausea and vomiting: a systematic review and meta-analysis. Clin Ther. 2010;32(12):1987–2002.
De Oliveira GS, Jr Castro-Alves LJ, Chang R, Yaghmour E, McCarthy RJ. Systemic metoclopramide to prevent postoperative nausea and vomiting: a meta-analysis without Fujii's studies. Br J Anaesth. 2012;109(5):688–97.
Masiongale AJ, Garvin JT, Murphy MJ, Hooper VD, Odom-Forren J, Masiongale JI, Looney SW. Reexamining metoclopramide's role in the prevention of postoperative nausea and vomiting: a secondary analysis. AANA J. 2018;86(3):213–9.
Jackson CW, Sheehan AH, Reddan JG. Evidence-based review of the black-box warning for droperidol. Am J Health Syst Pharm. 2007;64(11):1174–86.
Halloran K, Barash PG. Inside the black box: current policies and concerns with the United States Food and Drug Administration's highest drug safety warning system. Curr Opin Anaesthesiol. 2010;23(3):423–7.
Zhang LF, Zhang CF, Tang WX, He L, Liu Y, Tian DD, Ai YQ. Efficacy of amisulpride on postoperative nausea and vomiting: a systematic review and meta-analysis. Eur J Clin Pharmacol. 2020;76(7):903–12.
Chen J, Tu Q, Miao S, Zhou Z, Hu S. Transcutaneous electrical acupoint stimulation for preventing postoperative nausea and vomiting after general anesthesia: a meta-analysis of randomized controlled trials. Int J Surg. 2020;73:57–64.
Willms D, Shure D. Pulmonary edema due to upper airway obstruction in adults. Chest. 1988;94(5):1090–2.
Epstein N. Frequency, recognition, and management of postoperative hematomas following anterior cervical spine surgery: a review. Surg Neurol Int. 2020;21(11):356.
Sokhal N, Chaturvedi A, Rath GP, Bala R. Airway obstruction following cervical spine surgery: a diagnostic dilemma. J Anaesthesiol Clin Pharmacol. 2017;33(2):266–7.
Palumbo MA, Aidlen JP, Daniels AH, Bianco A, Caiati JM. Airway compromise due to laryngopharyngeal edema after anterior cervical spine surgery. J Clin Anesth. 2013;25(1):66–72.
Anastasian ZH, Gaudet JG, Levitt LC, Mergeche JL, Heyer EJ, Berman MF. Factors that correlate with the decision to delay extubation after multilevel prone spine surgery. J Neurosurg Anesthesiol. 2014;26(2):167–71.
Girard TD, Alhazzani W, Kress JP, Ouellette DR, Schmidt GA, et al. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: liberation from mechanical ventilation in critically ill adults. Rehabilitation protocols, ventilator liberation protocols, and cuff leak tests. Am J Respir Crit Care Med. 2017;195(1):120–33.
Kuriyama A, Jackson JL, Kamei J. Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis. Crit Care. 2020;24(1):640.
Schnell D, Planquette B, Berger A, Merceron S, Mayaux J, Strasbach L, Legriel S, Valade S, Darmon M, Meziani F. Cuff leak test for the diagnosis of post-extubation stridor: a multicenter evaluation study. J Intensive Care Med. 2019;34(5):391–6.
Zeng JH, Zhong ZM, Chen JT. Early dysphagia complicating anterior cervical spine surgery: incidence and risk factors. Arch Orthop Trauma Surg. 2013;133(8):1067–71.
Radcliff KE, Koyonos L, Clyde C, Sidhu GS, Fickes M, Hilibrand AS, Albert TJ, Vaccaro AR, Rihn JA. What is the incidence of dysphagia after posterior cervical surgery? Spine (Phila Pa 1976). 2013;38(13):1082–8.
Anderson KK, Arnold PM. Oropharyngeal Dysphagia after anterior cervical spine surgery: a review. Global Spine J. 2013;3(4):273–86.
Khan MU, Khokar R, Qureshi S, Al Zahrani T, Aqil M, Shiraz M. Measurement of endotracheal tube cuff pressure: instrumental versus conventional method. Saudi J Anaesth. 2016;10(4):428–31.
Jain MK, Tripathi CB. Endotracheal tube cuff pressure monitoring during neurosurgery—manual vs. automatic method. J Anaesthesiol Clin Pharmacol. 2011;27(3):358–61.
Apfelbaum RI, Kriskovich MD, Haller JR. On the incidence, cause, and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine (Phila Pa 1976). 2000;25(22):2906–12.
Fineberg SJ, Oglesby M, Patel AA, Singh K. Incidence, risk factors, and mortality associated with aspiration in cervical spine surgery. Spine (Phila Pa 1976). 2013;38(19):E1189–95.
Radcliff K, Ong KL, Lovald S, Lau E, Kurd M. Cervical spine surgery complications and risks in the elderly. Spine (Phila Pa 1976). 2017;42(6):E347–54.
Peck GE, Shipway DJH, Tsang K, Fertleman M. Cervical spine immobilisation in the elderly: a literature review. Br J Neurosurg. 2018;32(3):286–90.
American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015;63(1):142–50.
Peden CJ, Miller TR, Deiner SG, Eckenhoff RG, Fleisher LA, Members of the Perioperative Brain Health Expert Panel. Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team. Br J Anaesth. 2021;126(2):423–32.
Luo C, Zou W. Cerebral monitoring of anaesthesia on reducing cognitive dysfunction and postoperative delirium: a systematic review. J Int Med Res. 2018;46(10):4100–10.
Feng L, Han Y, Wang Y, Li G, Wang G. Remote medulla ablongata ventral acute subarachnoid hemorrhage following cervical spinal surgery: a case report. Int J Surg Case Rep. 2021;80:105675.
Nakazawa K, Yamamoto M, Murai K, Ishikawa S, Uchida T, Makita K. Delayed emergence from anesthesia resulting from cerebellar hemorrhage during cervical spine surgery. Anesth Analg. 2005;100(5):1470–1. table of contents
Chen Z, Zhang X, Jiang Y, Wang S. Delayed emergence from anesthesia resulting from bilateral epidural hemorrhages during cervical spine surgery. J Clin Anesth. 2013;25(3):244–5.
Kaloostian PE, Kim JE, Bydon A, Sciubba DM, Wolinsky JP, Gokaslan ZL, Witham TF. Intracranial hemorrhage after spine surgery. J Neurosurg Spine. 2013;19(3):370–80.
Lee MJ, Lin EL. The use of the three-pronged Mayfield head clamp resulting in an intracranial epidural hematoma in an adult patient. Eur Spine J. 2010;19(Suppl 2):S187–9.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2022 The Author(s), under exclusive license to Springer Nature Switzerland AG
About this chapter
Cite this chapter
Chierichini, A., Rossi, M. (2022). Anesthesia and Perioperative Care in Cervical Spinal Surgery. In: Menchetti, P.P.M. (eds) Cervical Spine. Springer, Cham. https://doi.org/10.1007/978-3-030-94829-0_4
Download citation
DOI: https://doi.org/10.1007/978-3-030-94829-0_4
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-94828-3
Online ISBN: 978-3-030-94829-0
eBook Packages: MedicineMedicine (R0)