- Department of Anaesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
DOI:10.4103/2152-7806.116683Copyright: © 2013 Khajavi MR This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Khajavi MR, Asadian MA, Imani F, Etezadi F, Moharari RS, Amirjamshidi A. General anesthesia versus combined epidural/general anesthesia for elective lumbar spine disc surgery: A randomized clinical trial comparing the impact of the two methods upon the outcome variables. Surg Neurol Int 19-Aug-2013;4:105
How to cite this URL: Khajavi MR, Asadian MA, Imani F, Etezadi F, Moharari RS, Amirjamshidi A. General anesthesia versus combined epidural/general anesthesia for elective lumbar spine disc surgery: A randomized clinical trial comparing the impact of the two methods upon the outcome variables. Surg Neurol Int 19-Aug-2013;4:105. Available from: http://sni.wpengine.com/surgicalint_articles/general-anesthesia-versus-combined-epiduralgeneral-anesthesia-for-elective-lumbar-spine-disc-surgery-a-randomized-clinical-trial-comparing-the-impact-of-the-two-methods-upon-the-outcome-variables/
Background:General anesthesia (GA) is the most frequently used technique for lumbar spine disc surgery. The aim of this study was to compare the intraoperative variables and postoperative outcome after GA and combined general/epidural anesthesia (CEG) in patients undergoing elective lumbar spine disk surgery.
Methods:Eighty patients who underwent one or two level of laminectomy/discectomy during a 2 year period were enrolled in this randomized controlled trial (RCT). They were randomly selected to undergo GA or CEG. The data recorded during surgery were: The patients’ heart rate (HR), mean arterial blood pressure (MABP), amount of blood loss, and the medication used during anesthesia. The severity of pain score, total analgesic consumption, and complications were recorded in the postoperative period.
Results:The MABP, HR, blood loss, and anesthetic medication were significantly lower in CEG group in comparison with that of GA group. In the postoperative period, the pain score and total analgesic requirement was lower in the CEG group and less complication were encountered in this group.
Conclusion:The results of this study revealed that CEG have some advantages over GA in reducing the blood loss and anesthetic medication during the operation and it is also more effective in control of pain with fewer complications during the postoperative period.
Keywords: Bupivacaine, combined epidural/general anesthesia, fentanyl, laminectomy, pain
Lumbar laminectomy and discectomy is most commonly performed under general anesthesia (GA). This technique can be accompanied by several perioperative morbidities including blood loss, postoperative pain, nausea, vomiting, and prolonged postanesthesia recovery period.[
Techniques of regional anesthesia (RA) alone or epidural anesthesia (EA), may reduce the amount of blood loss, which is an effect of decreased peripheral venous pressure after RA and may also lower the incidence of pulmonary complications.[
This prospective study was conducted to compare the anesthetic, analgesic, and postoperative side effects of GA versus combined epidural/general anesthesia (CEG) in patients undergoing laminectomy for one or two level disc disease. We hypothesized that the CEG would be more suitable and effective, with less blood loss and less amount of anesthetic medications and it would provide more satisfactory postoperative analgesia after lumbar laminectomy.
After the project was approved by the institutional review board and written-informed consent prepared for the patients being enrolled for elective lumbar laminectomy/discectomy, 80 patients undergoing lumbar one or two level laminectomy/discectomy for the first time were enrolled. The exclusion criteria were, contraindications for EA, that is, patient refusal, local infection, bleeding diathesis. Patients were randomly allocated into GA or CEG groups using sealed envelopes method with 40 patients in each group. A single anesthesiologist handled all the anesthesia procedures. The patients receiving EA were given a single injection of 18 ml bupivacaine 0.25% (45 mg) plus100 μg of fentanyl (2 ml) in 18 ml of distilled water. The injection performed at the same level or one level below of the surgery in sitting position, using18-gauge Tuohy needle. All patients receiving GA were induced with Thiopental (4-5 mg/kg), fentanyl (2 μg/kg), midazolam (0.05 mg/kg), and atracurium (0.5 mg/kg). For maintaining the anesthesia, combination of N2O/O2 Isoflurane and fentanyl 1 μg/kg/hour was used. The percent of Isoflurane was changed on the basis of bispectral index score (BIS) 40-60.[
Hypotension or bradycardia was defined as HR <60, and MABP <65 mmHg and treated with atropine or ephedrine 5 mg IV.
Blood loss was measured in routine manner by calculating the volume of blood suctioned from the surgical field and blood collected by sponges. The volume of blood transfusion was calculated by enumerating the blood bags injected during the operation. The percentile of Isoflurane used for GA was also recorded.
After extubation, the patients were transferred to the postanesthesia care unit (PACU) where an anesthetist and a nurse unaware of the study protocol observed the patients. Pain scores were evaluated by a blinded observer anesthesiologist at the time of arrival in the PACU, and 10, 20, and 30 minutes thereafter using visual analogue scale (VAS) (0-10 cm: 0 = no pain, 10 = the worst pain possible). Postoperative pain score (VAS score), the first time and dosage of analgesic given and total analgesic requirement for the first 24 hours were recorded. Rescue analgesia with injection of morphine 2 mg was given intravenously to a maximum total dose of 10 mg when pain score exceeded 4. Any complication such as nausea, vomiting, and catheter-related bladder discomforts (CRBD) occurring in the PACU were also recorded.
To analyze the effect of different binary values of variants x2 test was used. Simple linear regression test was used for analysis of multiple effective variants. Repeated data were analyzed using repeated measure analysis of variance (ANOVA). All statistical analysis were done using SPSS (version 17 Chicago, IL) and statistical significance was defined as P < 0.05.
Eighty patients were enrolled in this study with rather similar demographic characteristics in both groups [
The mean intraoperative blood loss was significantly lower in the CEG group in comparison with that of GA group (P = 0.002). This significance was present after controlling for other variables (age, sex, weight) in linear regression analysis (b = −121.147, P = 0.047). In addition, less allogeneic blood was transfused in the CGA group than in the GA group (0.12 blood units transfused vs. 0.72 blood units; P = 0.006).
The mean percent of anesthetic agent (Isoflurane) that was used during surgery in the CGA group was significantly lower in comparison with that of the GA group (0.67 ± 0.15 vs. 1.23 ± 0.25 P < 0.001).
During the postoperative period, there were no major cardiopulmonary complications in either group, whereas at PACU admission, tachycardia, hypertension, nausea, vomiting, and CRBD were more frequent in those undergoing GA [
In the PACU, the mean pain scores [
In spinal surgery, GA and various forms of RA, either spinal anesthesia (SA) or EA have been in use for decades as successful alternatives. A good anesthetic technique should have both rapid onset and reversal of effects. It should provide desirable intraoperative hemodynamic conditions and, if possible, contribute to reduced demand for blood transfusion. Moreover, it should permit the earliest possible discharge from the PACU and minimize the common postoperative problems such as pain, analgesics consumption, nausea, and vomiting.[
GA is the method of choice for spinal procedures according to some authors.[
The CEG is an efficient technique that offers many advantages for the patient undergoing lumbar spine surgery.[
Demirel et al. randomized 60 patients undergoing discectomy or laminectomy into two groups, which received either GA or EA. The latter, was considered superior to GA with fewer episodes of hypertension and less blood loss.[
Patients undergoing lumbar laminectomy, usually experience severe pain postoperatively. Several studies have evaluated the use of epidural injections for postoperative analgesia after lumbar laminectomy and found that this technique was superior to IM or IV injection of analgesic medications using patient control analgesia systems.[
Cherng et al.[
CRBD is common in patients awakening from anesthesia who have had urinary catheterization during operation and often complain an urge to void or discomfort in the suprapubic region in the postoperative period.[
Limitations of this study
The main limitation of this study would be the small number of the cases included in this preliminary report and it will be tried to continue on the trial in further research protocols.
Addition of EA can lower the need for the anesthetic agents during CEG and lower the blood loss during lumbar laminectomy and discectomy and the intensity of pain score after these surgeries.
The authors acknowledge the support of the Research and Development Center of Sina Hospital for their technical assistance.
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