Perioperative care of the complex spine and scoliosis surgery patient

Abstract

Modern spinal surgery can range from relatively simple ambulatory micro-discectomy to complex front and back approaches to deformity correction and spine fusion. Patients are best served using a multidisciplinary team including surgeons, perioperative medical specialists, ENT surgeons, subspecialty trained anesthesiologists, nursing, and physical therapy.Complications are an intrinsic reality of complex modern spine surgery.Complications are observed more commonly as the complexity of the surgery is increased as well as in patients with preoperative medical comorbidities. The cardiopulmonary complications are the most common necessitating careful preoperative evaluation and optimization. Intra-operative neurologic monitoring has become the standard of care and has benefitted from recent technological advances such as the ability to monitor motor evoked potentials. Specialized anesthetic approaches including total intravenous anesthesia may improve the accuracy and effectiveness of the monitoring. Postoperative vision loss occurs infrequently following complex and prolonged spinal procedures. The most common cause is ischemic optic neuropathy. The etiology of postoperative ION at present is unknown and unpredictable. However, several possible pathogenic factors have been suggested including duration in the prone position, blood loss, anemia, hypotension, abnormal optic nerve blood supply, low cup-to-disc ratio, use of vasopressors, excessive crystalloid infusion, and patient comorbidities; particularly smoking, diabetes, and vascular disease. The ASA practice advisory on POVL recommends the use of both colloids and crystalloids to maintain intravascular volume in spine surgery patients who have substantial blood loss. Since ION occurs in the absence of vascular injury to other critical organs and in cases where neither hypotension or anemia are reported, optic nerve blood supply may be uniquely vulnerable to hemodynamic perturbances in the prone position. Blood management may include preoperative autologous donation. Antifibrinolytic agents have been demonstrated to be a useful adjunct in reducing peri-operative blood loss. Pain management can be a challenging problem for the complex spine patient. Patient controlled intravenous analgesia is associated with higher patient satisfaction. Specialized pain management teams will often provide for better resource and pain management utilization.