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Anesthesia for the Patient with Neuroskeletal Disease

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Anesthesia for the Patient with Neuroskeletal Disease Justin Snedaker, SRNA April 24, 2009 Overview Anatomy & Physiology Pathophysiology Pharmacology Anesthetic ... – PowerPoint PPT presentation

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Title: Anesthesia for the Patient with Neuroskeletal Disease


1
Anesthesia for the Patient with Neuroskeletal
Disease
  • Justin Snedaker, SRNA
  • April 24, 2009

2
Overview
  • Anatomy Physiology
  • Pathophysiology
  • Pharmacology
  • Anesthetic Technique Management
  • Management of Complications
  • Case Study
  • Questions

3
Anatomy Physiology

4
Anatomy Physiology
5
Anatomy Physiology
6
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7
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8
Blood Flow to the Spinal Cord
  • Anterior Spinal Artery (1)
  • Anterior 2/3 of spinal cord
  • Posterior Spinal Arteries (2)
  • posterior 1/3 of spinal cord
  • These 3 arteries depend on a network of
    collateral vessels to provide adequate blood
    supply to the spinal cord.

9
Artery of Adamkiewicz arteria radicularis magna
  • Largest most consistent radicular artery
  • Located in the thoracolumbar region (T5-L3)
  • Supplies blood to the ASA (anterior 2/3
    of cord)
  • Responsible for most of the spinal cord blood
    flow beneath its point of entry
  • If obstructed ? Anterior Artery Syndrome

10
Anterior Spinal Artery Syndrome
  • Complex paraplegia
  • Dissociated sensory loss below the level of
    occlusion
  • Sphincter disturbances of bowel and bladder

11
Spinal Cord Blood Flow
  • Autoregulation determines the amount of blood
    flow to the spinal cord just as it does to the
    brain.
  • Autoregulation limits are 50-150 mmHg. Outside
    these limits the spinal cord becomes pressure
    dependent.

12
Spinal Cord Blood Flow
  • Spinal cord blood flow increases when CO2 levels
    are high and decreases when CO2 levels are low.
  • (similar to cerebral blood flow)
  • Injury to the spinal cord alters both
    autoregulation and CO2 responsiveness.

13
Pathophysiology

14
Spinal Cord Injury
  • Trauma ? Partial or Complete transection of the
    cord
  • Transections above C 3-5 Diaphragmatic
    innervention (ventilator required for
    survival)
  • Transections above
  • T 1 Quadraplegia
  • Transections above
  • L4 Paraplegia
  • Most Common C 5-7 T 12 - L 1
  • (least protected / most mobile)

15
Acute Spinal Cord Injury
  • Flacid paralysis
  • Complete loss of reflex and sensory activity
    below level of lesion.
  • Loss of vasomotor tone, CV instability,
    Hypotension, Bradycardia, Venous pooling.
  • Paralytic ileus with distension
  • Hypothermia

16
Degenerative Disc Disease
  • Condition where cushioning inter-vertebral discs
    of the spine deteriorate and press upon nerves.
  • Causes aging, trauma, and wear tear
  • Spinal discs are anatomically altered after
    losing water content and become thinner.

17
Degenerative Disc Disease
  • The outer layer may tear, resulting in expulsion
    of the contents of the inner core of the disc
    through the outer covering, a condition known as
    herniated disc.
  • S/S Loss of flexibility and increased
    stiffness. Pain in neck, back leg ranging from
    mild to excruciating.
  • Occurs in Lumbar Spine 6 xs more frequently than
    the cervical spine. (L
    4-5 L 5 S 1)

18
Key Terms
  • Ankylosis - stiffining or fixation of a joint as
    a result of a disease process, with fibrous or
    bony union across the joint fusion
  • Spondylosis ankylosis of the vertebrae
  • Spondylitis inflammation of one or more of the
    vertebrae

19
Ankylosing Spondylitis
  • A form of chronic joint inflammation (arthritis)
    that most often affects the spine.
  • S/S pain, stiffness, swelling, limited motion
    in low back, middle back, neck, hips, chest wall,
    and heels.
  • Over time, joints in the spine can fuse together
    and cause a fixed, bent-forward posture.
  • People with gene HLA-B27 are at increased risk
  • Affects Males gt Females
  • Onset adolescence - age 40

20

Ankylosing Spondylitis

21

22
Spondylolysis
  • Term used to describe the presence of a "defect"
    or stress fracture in the posterior arch of the
    vertebra.  It occurs at the lumbo-sacral junction
    (L5/S1) in about 85 of cases. 

23
Spondylolisthesis
  • Forward movement of the body of one of the lower
    lumbar vertebrae on the vertebrae below it, or on
    the sacrum.

24
Spinal Stenosis
  • Narrowing of the spinal cord that causes
    compression of the nerve roots resulting in
    persistant pain in the buttocks, limping,
    numbness of lower extremeties decreased
    physical activity.

25
Spinal Stenosis
26
Spinal Stenosis
  • Degenerative aging (around 60), wear and tear,
    prolonged standing, spurs, discs, slipped
    vertebrae, walking, increased metabolic demands
    on spinal nerve roots during walking may exceed
    the available micro-vascular blood flow. (60s)
  • Congenital - (age 30-40) a puzzling condition
    that cannot be predicted or prevented. (Extremely
    rare)

27
Scoliosis
  • Lateral curvature of the spine, usually
    accompanied by rotation.
  • Cobb angle is a method used to measure spinal
    column curvature.
  • gt10 degrees scoliosis
  • gt40-50 degrees surgery is indicated
  • The greater the angle, the greater the
    progression and severity of complications.

28
Scoliosis
  • Neuromuscular Scoliosis - the result of muscle
    imbalance and lack of trunk control. (i.e.
    cerebral palsy, muscular dystrophy, or leg length
    discrepancy)
  • Congenital Scoliosis - the result of asymmetry of
    the vertebrae secondary to congenital anomalies.
    (i.e. hemivertebrae, failure of segmentation)
  • Idiopathic Scoliosis - no definite etiology.
    Diagnosis of exclusion. Most common type
    accounting for 80-85 of cases

29
Scoliosis
  • Increased curvature narrowing of thoracic cage,
    which leads to abnormal CV and Pulm function.
  • Increased curvature causes increased
    co-morbidities
  • Restrictive lung disease, dyspnea on exertion,
    pulmonary hypertension, cor pulmonale and
    alveolar hypoventilation.

30
Pharmacology

31
Spinal Cord Injury Succinylcholine
  • Succinylcholine- Induced Hyperkalemia.
  • Safe to administer Succs within first 48 hours
    after spinal cord injury.
  • Avoid Succs in all spinal cord injuries after 48
    hours

32
Epidural Steroid Injections
  • Methylprednisone 80 mg (smaller amounts in
    diabetics who may be at increased risk for
    formation of epidural abscess) is injected into
    epidural space close to the nerve root.
  • The addition of 3-4 mL of local anesthetic
    (lidocaine) to the injected solution produces
    analgesia, confirming proper drug placement

33
Epidural Steroid Injection

34
Epidural Steroid Injections
  • Few pts get relief from repeated injections if
    first one was unsuccessful.
  • Relief can last from weeks to months - injections
    are repeated every 3-4 months.
  • Little risk of serious complications associated
    with epidural steroid injections
  • Suppression of hypothalamic-pituitary-adrenal
    axis may occur but recovers in 1-3 months.
  • Aseptic meningitis and bacterial meningitis are
    uncommon but real risks.

35
What can steroids do for you?

36
High Dose Steroid Therapy (methylprednisone)
  • Pt with Acute Spinal Cord Injury
  • Pt with severe spine disease undergoing major
    spinal surgery.
  • Recommendation bolus dose of 30 mg/kg over 15
    minutes, followed 45 min. later by 23-hour
    infusion at 5.4 mg/kg/hr, if pharmacological
    treatment is started within 8 hours of injury.
  • If therapy is started 3-8 hours after injury, the
    duration of the methylprednisone therapy should
    be continued for 48 hours
  • Pitfalls Immunosuppression,wound infections
    GI bleeds.

37
Opioids
  • Good pain control over long periods of time with
    minimal tolerance and few side effects.
  • Predictors of poor response with opiods include
    neuropathic pain and phasic pain.
  • Pts with cognitive impairment or high levels of
    psychological distress are more likely to
    experience suboptimal pain control from opioids

38
Tricyclic Antidepressants
  • Useful for chronic pain, producing analgesic
    effect via inhibition of reuptake of serotonin
    and norepinephrine.
  • Not predictably effective.
  • Other benefits include normalization of sleep
    patterns, reduction in anxiety and depression,
    reduction in the perception of pain.

39
Anticonvulsants
  • May have some efficacy in treatment of chronic
    pain syndromes
  • Article on Dr. Novaks desk
  • (this may just be a hoax!)
  • Chronic anticonvulsants lead to an increased
    resistance to non-depolarizing neuromuscular
    relaxants

40
Sodium Channel Blockers
  • Systemic lidocaine , oral mexiletine may produce
    analgesic properties in some patients with
    neuropathic pain

41
Anesthetic Technique Management

42
Considerations for cervical neurosurgical
procedures
  • Respiratory insufficiency
  • Inability to handle oropharyngeal secretions
  • Do not flex or extend head or move it laterally
  • Loss of sympathetic tone (vasodilation
    bradycardia)
  • Stop anti-platelet drugs 10 days before surgery

43
Monitors for cervical neurosurgical procedures
  • Lg bore IV X 1-2, Standard Monitors, Art line,
    Doppler if done in sitting position (VAE), CVP,
    Foley, SSEP.
  • The ideal anesthetic for SSEP Sevo, O2,
    opiates, Roc
  • Iso N20 make SSEP less satisfactory

44
Tecnique for cervical neurosurgical procedures
  • Standard vs fiberoptic laryngoscopy - GETA
  • Standard maintenance, possible SSEP or MEP
  • Emergence leave ETT in place until fully awake,
    following commands, able to manage own airway.
  • Deflate cuff occlude ETT to assess whether pt
    can breath around ETT.
  • Spraying lidocaine 4mL down trachea minimizes
    coughing / bucking. (LTA)
  • Consider an airway exchanger- well tolerated as
    long as it doesnt toch the carina - good for
    immediate re-intubation

45
Considerations for throacolumbar neurosurgical
procedures
  • Chronic pain in back that radiates to legs
  • Motor weakness and atrophy of muscle groups in
    legs.
  • TC 2 U PRBC
  • Stop ASA NSAIDS for gt 2 weeks

46
Technique for throacolumbar neurosurgical
procedures
  • 16-18 ga IV X 1-2
  • Standard monitors, A-line, CVP, Foley, Possibly
    SSEP / MEP
  • GETA, wire-reinforced tube to avoid tube kinking
    / occlusion when pt is prone.
  • Relaxation is only needed while surgeon is
    gaining exposure on pt in posterior approach.
  • Emergence turn pt supine, connect vent,
    re-connect SpO2 monitor!, assess for laryngeal
    edema, can pt breath around ETT?, follow
    commands, suction, adequate TV?

47
Anesthesia Implications for Acute Spinal Cord
Transection
  • Maintain in-line stabilization of neck. Consider
    fiberoptic-guided intubation, especially if
    cervical spine injury is suspected.
  • Prepare for CV instability, position changes,
    mild blood loss, positive-pressure ventilation
    may precipitate hypotension.
  • Guard against hypothermia.
  • Succinylcholine may be administered within the
    first 24 hrs of acute injury.
  • Maintain spinal cord integrity
  • Blood flow (maintain perfusion pressure, normal
    CO2)
  • SSEP, MEP, wake up test

48
Anesthesia Implications for Chronic Spinal Cord
Transection
  • Monitor for autonomic hyperreflexia. Have
    rapid-acting vasodilators available.
  • Bradycardia / absence of compensatory tachycardia
    (cardioaccelerators T1-4).
  • Use nondepolarizing muscle relaxants only.
  • Guard against hypothermia.
  • (tendancy to become poikilothermic)
  • Position carefully (osteoporosis).

49
Preventing post-op paralysis with neurological
monitoring
  • Old standard wake-up test
  • Risks loss of IV lines, loss of ET tubes, and
    loss of spinal fixation devices, air embolism,
    pain, and recall.
  • New standard Evoked Potential Monitoring
  • SSEP
  • MEP

50
Anestheisa MEP
  • Compatible
  • Opioids
  • Etomidate
  • Ketamine
  • Low-dose propofol
  • TIVA is often the most appropriate technique
  • Incompatable
  • Volatile inhalational agents
  • Neuromuscular blockade with loss of gt2 twitches
    in TOF
  • Nitrous Oxide gt50
  • Induction doses of thiopental or midazolam

51
Prone Position
52
Prone Position
  • Maintain alignment of head / neck, support head
    in neutral position w/ pillow or head holding
    device.
  • Avoid hyperextension of arms by tucking them
    against the body or extending them lt90 degrees
    alongside the head on armboards
  • Compression stockings to avoid the pooling of
    blood.
  • Frequently examine eyes, ears, chin, nose,
    shoulders, breasts, and genitalia for areas of
    pressure.

53
Management of Complications

54
Complications of Prone positioning
  • Tube comes out
  • Disaster in the prone pt.
  • Put it back in!
  • Tape the tube so that God himself cannot remove
    it. - Dr.Helsley
  • Secretions follow gravity.Tape will not stick to
    secretions. Robinul is a good idea.
  • Dont allow any traction to be put on the ETT or
    circuit!
  • Airway Obstruction
  • Assure pt can breathe around tube by deflating
    cuff and occluding the end of the tube in a
    spontaneously breathing pt.
  • Do not extubate until pt is wide awake.
  • Post op their airway may be different from
    pre-op.
  • Edema may result in difficult or impossible
    intubation.

55
Post Op Visual Loss -POVL
  • Risk Factors
  • Hypotension
  • Anemia
  • Potentially glaucoma
  • Preventative measures
  • HCT gt 27
  • MAP gt70 mmHg
  • Avoid pressure on globe
  • Keep IV fluid to reasonable level
  • Cuase is essentially unkown, but it has been
    suggested that hypoperfusion combined with edema
    and/or stretching of the optic nerve are
    involved.
  • Long prone cases
  • Large amounts of IV fluid administered

56
Anterior Cervical Spine Surgery

57
Compilications of surgery on anterior cervical
spine
  • Accidental extubation
  • Airway obstruction
  • Laryngeal edema
  • Recurrent laryngeal nerve injury
  • External laryngeal nerve injury
  • Phrenic nerve injury
  • Horners syndrome
  • Carotid artery injury
  • Vertebral artery injury
  • Superior or inferior thyroid artery injury
  • Wound hematoma
  • Throacic duct injury
  • Perforation of esophagus
  • Dural tear
  • Hoarsness

58
Tension Pneumothorax
  • Entrainment of air via surgical wound
  • Unsuspected oropharyngeal laceration during
    tracheal intubation, or bleeding into the neck at
    the surgical site, with progressive compression
    of airway.
  • If vital signs unstable insert 18 ga needle
    mid-clavicular, 2nd intercostal space on
    suspected side to relieve the pneumo.

59
Anterior cervical spineand airway complications
  • 6 of pts have post-op airway complications,
    1/3 of these pts require reintubation.
  • Thats 2/100 that require reintubation!
  • Risk factors predictive of airway compromise
  • Operative time gt5 hrs
  • Multilevel operations that exposed gt3 vertebrae
    including C2, C3,or C4
  • Blood loss gt300 mL

60
Autonomic Hyperreflexia
  • Unbridled sympathetic nervous system reflex
    response below the level of a spinal cord
    transection.
  • Occurs most commonly with spinal cord
    transections at T5 or above.
  • May occur anytime after the resolution of spinal
    shock.
  • Common Triggers are Cutaneous (surgical
    stimulation, decubitus ulcer) Visceral (bladder
    or bowel distension) stimulation below the level
    of injury.

61

62
Autonomic Hyperreflexia
  • The result is severe vasoconstriction below the
    transection.
  • Baroreceptor-mediated reflex bradycardia and
    vasocodilation occur above the transection, along
    with cardiac dysrythmias.
  • Immediate interventions to lower BP are required.

63
Autonomic Hyperreflexia
  • S/S HTN, reflex bradycardia, HA, seizure,
    subarachnoid hemorrhage, pulm edema, nasal
    congestion, vasodilation / flushing above
    transection vasoconstriction / pallor below
    transection.
  • Treatment Remove noxious stimulus, Raise head of
    bed, Administer rapid-acting vasodilator drugs.

64
Regional Anesthesia
  • Spinal / epidural anesthesia in theory are
    excellent techniques for lumbar surgery,
    particularly for removal of lumbar intervertebral
    disc.
  • Seldom used because of the medico-legal concern
    that the regional anesthetic may be blamed for a
    new neurological deficit, if one should occur as
    a result of the surgery.
  • Not suitable for lumbar fusion or removal of
    spinal cord tumor because the duration of the
    operation is unpredictable and often prolonged.

65
Regional anesthesia after major spine surgery
  • Degeneratvie changes increase chance for spinal
    cord ischemia neurologic complications with
    regional anesthesia.
  • Ligamentum flavum injury from prior surgery
    results in adhesions possible obliteration of
    the epidural space or interference with spread of
    local anesthetic (patchy block).

66
Regional anesthesia after major spine surgery
  • Increased incidence of accidental dural puncture
    if epidural space altered by prior surgery (blood
    patch difficult to perform if needed).
  • Prior bone grafting or fusion may prevent midline
    insertion of needle.

67
Case Study and Questions

68
Case Study
  • Pre Op
  • Monitors
  • Induction
  • Maintenance
  • Emergence
  • Post Op
  • 29 yo male pt. 110 kg. 9 days s/p MVA w/ SCI.
    hx asthma, donated one kidney.
  • Planned surgery is a C1-3 Cervical fusion.
    dx occipitoatlantal instability.

69
Question 1
  • A pt with a SCI 6 months ago is scheduled for a
    C5-7 cervical fusion with SSEP. What is the
    muscle relaxant of choice (the best option) for
    this patient?
  • A. Succinylcholine
  • B. Mivacurium
  • C. Vecuronium
  • D. Rocuronium

70
Answer 1
  • A pt with a SCI 6 months ago is scheduled for a
    C5-7 cervical fusion with SSEP. What is the
    muscle relaxant of choice for this patient?
  • A. Succinylcholine
  • B. Mivacurium
  • C. Vecuronium
  • D. Rocuronium

71
Question 2
  • All of the following are potential risk factors
    for POVL (discussed in this presentation) except
    for 2 of the following.
  • A. Obesity
  • B. Long Prone Cases
  • C. Anemia
  • D. Pressure on the globe
  • E. Hypotension
  • F. Glaucoma
  • G. Cataracts

72
Answer 2
  • All of the following are potential risk factors
    for POVL (discussed in this presentation) except
    for 2 of the following.
  • A. Obesity
  • B. Long Prone Cases
  • C. Anemia
  • D. Pressure on the globe
  • E. Hypotension
  • F. Glaucoma
  • G. Cataracts

73
Question 3
  • T or F -The cardiac accelerators are located
    between T1-4 and are part of the para-sympathetic
    (Cranio-sacral) nervous system.

74
Answer 3
  • T or F -The cardiac accelerators are located
    between T1-4 and are part of the para-sympathetic
    (Cranio-sacral) nervous system.
  • FALSE!
  • Cardiac accelerators increase the HR, are located
    T1-4, they are part of the Sympathetic
    (thoraco-lumbar) nervous system.

75
Question 4
  • Paraplegia is the result of which of the
    following injuries?
  • A. Occlusion of the artery of adamkiewicz
  • B. Spinal cord transection at C7
  • C. Spinal cord transection at L2
  • D. A C are both correct
  • E. All of the above are correct

76
Answer 4
  • Paraplegia is the result of which of the
    following injuries?
  • A. Occlusion of the artery of adamkiewicz
  • B. Spinal cord transection at C7-Quadraplegia
  • C. Spinal cord transection at L2
  • D. A C are both correct
  • E. All of the above are correct

77
Question 5
  • T / F - Ankylosing spondylitis affects Males more
    than females.

78
Answer 5
  • TRUE!
  • T / F - Ankylosing spondylitis affects Males more
    than females.

79
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