The spinal fusion.

Big time back surgery. By the time a patient comes to our OR, they have usually exhausted all their other options. They’ve been to physical therapy; they’ve had the epidural steroid injections; they’ve tried the alternative therapies (chiropracter, acupuncture); and they’re on all kinds of analgesics and muscle relaxants, to no avail.

They’ve been X-rayed, scanned, probed, injected, twitched, and stretched. They’ve had it!

Their surgery may be an anterior approach, a posterior approach, or both, depending upon the location and nature of the lesion. They may need bone grafting. If they have scoliosis (lateral curvature of the spine), they may need rods inserted and then torqued for straightening. If they have a cervical lesion, they may need special tongs inserted into their skull during surgery in order to position their head precisely immobile.

This type of surgery can be challenging to the anesthesia provider. Large bore IVs, possibly an arterial line or central line. Possible difficult intubation if neck mobility is limited. Positioning issues are of tantamount priority before surgery starts, as these cases can and do last HOURS and HOURS. All pressure points must be checked and padded, and neutral anatomic angles of all joints are mandatory.

These patients must be kept warm and well-hydrated. Large blood loss, not uncommon, must be replaced. All organs must be adequately perfused.

Anesthesia can be delivered by either using a standard “balanced” technique of inhalation, narcotics, and muscle relaxation, or via TIVA (total IV anesthesia) when evoked potentials are being monitored. What are evoked potentials and why TIVA? During spinal surgery, the integrity of the spinal cord can be altered, so sensory and/or motor pathways are monitored via little electrical stimuli to make sure that everything is intact. TIVA is the preferred anesthetic when a balanced technique would alter or slow the electrical pathways.

These patients have interfaced with the medical system for quite a while by the time we see them; many are in chronic pain, and usually have varying levels of emotional and inner resources left to tap on.  Spinal surgery often offers them their last hope of improvement and feeling better, with no promises being made! Taking care of this patient population is an engaging process for the anethetist, and especially rewarding when the end results are positive.