Spine Specialists On-Call: Complex Cervical Spine Surgery and Anesthesia - Considerations Before and During Surgery

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Each year thousands of patients undergo cervical spine surgery to treat disorders ranging from degenerative disc disease to spinal deformity. Similar to other types of surgery, cervical spine surgery requires careful preoperative planning to minimize the patient's risk for complication. In this interview, Doctor Jean-Jacques Abitbol answers questions about patient risk assessment and care before and during cervical spine surgery. Surgical LampsBefore the operation begins, the patient is positioned onto the operating table and in the case of cervical surgery, facial positioning is especially important.SpU: Dr. Abitbol, is there a particular type of patient at higher risk for complication during cervical spine surgery?

Dr. Abitbol: Of particular concern are elderly patients and patients of any age with cervical rheumatoid arthritis, spinal stenosis, narrowing of the spinal canal - also called myelopathy, and spinal instability. Elderly patients are included as they may have a co-existing disease such as diabetes or heart disease that would put them at higher risk during any surgical procedure. Of course, we wouldn't want to exclude young patients, as they too sometimes have a co-existing disorder such as asthma.

SpU: You mentioned several cervical disorders that may increase the risks - why are these of concern?

Dr. Abitbol: Before the operation begins, the patient is positioned onto the operating table and in the case of cervical surgery, facial positioning is especially important. Another aspect of patient preparation is the administration of anesthesia and oxygen throughout the procedure. This necessitates the insertion of a breathing tube into the patient's airway - a procedure called intubation. Here again the condition of the patient's neck is a consideration as some cervical disorders cause the neck to be stiff or difficult to manipulate and, in certain situations, it simply isn't advisable to move the neck at all.

SpU: What steps are taken to prevent risk of complication?

Dr. Abitbol: Prior to spine surgery, the patient obtains medical clearance to verify their general state of health and readiness for surgery. Usually, the patient's primary care physician provides the general medical clearance. Elderly patients and patients with co-existing diseases, such as diabetes or heart disease require additional medical clearance usually from the treating specialist.

The spine surgeon performs a preoperative physical evaluation of the patient's cervical range of motion and orders necessary imaging studies such as x-rays, MRI or CT Scan. Combined with the patient's medical history and clearance, this information provides the spine surgeon and surgical team with valuable facts about the patient's health to assist with preoperative planning.

SpU: How are the imaging studies used by the surgical team?

Dr. Abitbol: In advance of the surgery, the spine surgeon and anesthesiologist review the preoperative imaging studies - such as an MRI to obtain crucial information about the patient's cervical spine. Of particular interest is a cervical condition that would make it unsafe to turn or move the patient's neck. Some types of breathing tubes and intubation methods require the patient's neck to be movable enabling it to be properly manipulated to receive the breathing tube.

SpU: What is the anesthesiologist's role?

Dr. Abitbol: Critical to the success of the surgical procedure is sustaining the patient's ability to breathe. This is accomplished by keeping the patient's airway open artificially - by means of a tube. Oxygen and other gases necessary for general anesthesia are administered through the tube into the patient's lungs. The anesthesiologist is the medical doctor who administers and controls the level of sedation and monitors the patient's vital signs before and during surgery.

SpU: Would you tell us more about intubation?

Dr. Abitbol: The traditional type of intubation involves the use of an endotracheal tube or simply ETT. An endotracheal tube is inserted into the trachea. The trachea begins near the middle of the neck and extends downward into the upper chest area where the lungs are located. A special inflatable tube cuff holds the tube in the correct position. The tube cuff also protects the airway against foreign matter such as secretions or blood.

A drawback to ETT is insertion requires the patient's neck to be hyper-extended (pulled back). The act of hyper-extending the neck straightens the pathway down the throat into the trachea. Of course, hyper-extending the neck would be undesirable in a patient with cervical rheumatoid arthritis, spinal cord compression or instability.

SpU: Are there alternatives to ETT?

Dr. Abitbol: Yes there are alternatives. Fiberoptic endotracheal intubation, laryngeal mask airway (LMA), and nasotracheal intubation (through the nose into the trachea) can be used when the patient's neck is not stable and cannot be safely manipulated.

SpU: Is the breathing tube removed as soon as the surgery is completed?

Dr. Abitbol: Not always. Removing the breathing tube is called extubation. The timing of extubation is an important consideration. This decision is based on many factors that include issues such as the complexity and extent of the surgery, operative time, patient's co-existing diseases, blood loss/transfusions, and complications that occurred during or immediately after the surgery. Some select patients may require postoperative care in an intensive care setting.

SpU: What steps are taken to prevent complications from developing after surgery?

Dr. Abitbol: Patients are monitored very closely both during surgery and afterward in such a way as to anticipate any complication that may begin to develop. The entire preoperative planning process is an essential tool we have to identify which patients are at risk - or higher risk for complication. The goal is to provide our patients with a safe surgery that rewards them with a successful outcome.

SpU: Thank you Dr. Abitbol. We appreciate your time and especially your expertise on this topic.

Dr. Abitbol: You are welcome.

Updated on: 12/13/17
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Pain Management Center
Lali Sekhon, MD, PhD, FAANS, FRACS, FACS
Dr. Abitbol provides an excellent overview of some of the important aspects of anaesthesia for patients undergoing cervical spine surgery. All patients contemplating cervical spine surgery should be aware of these aspects and any questions should be directed to their anaesthesiologist or surgeon. Apart from the anaesthesia and breathing tubes, it is important for patients to realize that they will also have lines put into their arms and bladder to allow for the administration of fluids and drugs as well as for monitoring of vital signs, drainage of urine, and other bodily functions.
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