- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
Syed Ather Enam
Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
DOI:10.4103/2152-7806.130669Copyright: © 2014 Khan MB 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: Khan MB, Kumar R, Enam SA. Thoracic and lumbar spinal surgery under local anesthesia for patients with multiple comorbidities: A consecutive case series. Surg Neurol Int 16-Apr-2014;5:
How to cite this URL: Khan MB, Kumar R, Enam SA. Thoracic and lumbar spinal surgery under local anesthesia for patients with multiple comorbidities: A consecutive case series. Surg Neurol Int 16-Apr-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/thoracic-and-lumbar-spinal-surgery-under-local-anesthesia-for-patients-with-multiple-comorbidities-a-consecutive-case-series/
Background:Although some patients with symptomatic spinal disease may benefit greatly from surgery, their multiple attendant comorbidities may make general anesthesia risky or contraindicated. However, there is scarce literature describing the efficacy and safety of local anesthesia to perform these operations. Here we report seven patients who successfully underwent spinal surgery utilizing local anesthesia to limit the risks and complications of general anesthesia.
Methods:Seven patients for whom general anesthesia was contraindicated were prospectively followed for a minimum of 3 months following spinal surgery performed under local anesthesia. Pain and functional improvement were assessed utilizing the Visual Analog Scores (VAS) and Oswestry Disability Index (ODI) scores.
Results:Five patients had interlaminar decompressions for stenosis alone, while two patients had laminectomies for debulking of tumors. The mean duration of surgery was 79.8 ± 16.6 min, the mean estimated blood loss was 157.1 ± 53.4 ml, the mean dose of local anesthetic was 1.9 ± 0.7 mg/kg, and the mean length of hospital stay after surgery was 3.2 ± 1.2 days. There were no intraoperative complications. The surgery resulted in improved VAS and ODI scores consistent with significant improvement in pain (P = 0.017) and functionality (P = 0.011).
Conclusions:Performing spinal surgery under local anesthesia is a safe and effective alternative when patient's major comorbidities preclude a general anesthetic. For all the seven patients studied, spinal surgery, performed under a local anesthetic, resulted in a statistically significant reduction in pain and improvement in function.
Keywords: Debulking, interlaminar decompression, local anesthesia, lumbar, multiple comorbidities, spinal surgery, thoracic
Patients with symptomatic degenerative spinal disorders (e.g. disc herniation/stenosis) or metastatic cancers may require spinal surgery consisting of decompressive laminectomies, but cannot tolerate a general anesthetic due to multiple attendant morbidities.[
Performing spinal surgery utilizing a local anesthetic is not a new concept, particularly when performed in healthy patients.[
Our literature search yielded only one study involving 10 patients with American Society of Anesthesiologists (ASA) physical status score of III or higher managed with local anesthesia.[
MATERIALS AND METHODS
This study included seven consecutive patients in whom general anesthesia was contraindicated due to multiple comorbidities (e.g. ASA scores of III or IV) [
Surgical procedures local anesthetic technique
In five patients, bilateral laminotomies with medial facetectomies were performed to decompress central/lateral stenosis and ossified yellow ligament (OYL) under the operating microscope [
Preoperative scans from a patient who underwent laminectomy and tumor excision. (a) axial section and (b) sagittal section showing metastatic involvement of posterior elements of T3 with significant epidural component resulting in marked compression of the cord with contour deformity. Left paravertebral body can also be appreciated with involvement of the transverse process. Involvement of vertebral bodies of T1, T2 and T3 can also be seen
Patients were premedicated with meperidine (50 mg), promethazine (25 mg) and cefuroxime (1.5 g). They were mildly sedated with meperidine (15-35 mg/h continuous infusion) and fentanyl (1-2 mcg/kg/h continuous infusion) allowing for continuous verbal contact throughout the procedure. Ten milliliters of 2% lidocaine with 1:200,000 adrenaline was infiltrated into the skin overlying the incision site and into the deep tissues. During surgery, the patients received additional injections of a local anesthetic if they complained of pain. This was administered only after consultation with the anesthesiologists, making sure that the patients vital signs were stable, and that the total dose did not exceed 7 mg/kg [
Intraoperative monitoring routinely included blood pressures, pulse oximetry, electrocardiogram, and cutaneous temperature probes. Postoperatively, patients had access to patient controlled intravenous analgesia (PCIA) for the duration of their hospital admission (range 2-5 days). They were typically discharged on pregabalin, muscle relaxants, and tramadol hydrochloride for two postoperative weeks.
Outcome assessment and statistical analysis
Outcomes assessment was done 3 months postoperatively. Pain improvement was assessed utilizing Visual Analog Scale (VAS) scores, while functional improvement was gauged with the Oswestry Disability Index (ODI). Data were analyzed using IBM SPSS statistics for Windows version 20 (IBM, Armonk, NY). A Wilcoxon matched pairs test was used to check the statistical significance of change in preoperative and postoperative VAS and ODI scores. A P value of less than 0.05 was considered statistically significant.
All patients showed a statistically significant improvement in VAS scores (decreased from a mean of 6.14-0.71 [P = 0.017]) and ODI scores (decreased from a mean of 77.2-24.3% [P = 0.011]) [
ASA physical status has been shown to correlate with perioperative variables, postoperative complications, and mortality rates with the risks mainly being influenced by ASA class IV (odds ratio = 4.2) and ASA class III (odds ratio = 2.2).[
The operation was generally well tolerated with exception of the discomfort felt during the retraction of paraspinal muscles and manipulation of the dural sac or nerve roots reported to varying extents by almost all patients; this finding has also been previously reported.[
We as well as other authors have observed that most patients found laying still for the duration of surgery (especially after 90 min) difficult.[
Risks of local anesthesia for spinal surgery
Previously, focus was placed on the risks of utilizing local anesthesia for spinal surgery, including toxicity associated with high local anesthetic doses, and venous air embolism. None of our patients suffered from any local anesthesia-related toxicity; this is consistent with other reports in the literature.[
Spinal surgery may be safely performed utilizing a local anesthetic in patients who are not candidates for a general anesthetic due to attendant major comorbidities (e.g. ASA scores of III or IV). In the seven patients presented in this series, spinal surgery performed under local anesthesia resulted in significant improvement in pain and functionality.
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