Spine SurgeryContemporary

[Pages:8]CoSntpeimnpeorSauryrgery

VOLUME 21 NUMBER 10 OCTOBER 2020

Regional Anesthesia for Posterior Spinal Surgical Approaches

Won Hyung A. Ryu, MD, MSc, Neal A. Mehta, MD, and John E. O'Toole, MD, MS

LEARNING OBJECTIVES: After participating in this CME activity, the spine surgeon should be better able to: 1. Describe regional anesthetic techniques

available for posterior spine surgery. 2. Evaluate the strengths and limitations of

various regional anesthetic agents. 3. Explain the basic techniques of regional

anesthesia as used in spine surgery.

Key Words: Regional anesthesia, Spine surgery, Posterior approach

T here has been growing interest in examining the available anesthetic techniques for spine surgery.

Dr. Ryu is a Spine Fellow, Department of Neurological Surgery, Dr. Mehta is Assistant Professor, Department of Anesthesiology, and Dr. O'Toole is Professor, Department of Neurological Surgery, Rush University, 1725 W. Harrison St, Ste 855, Chicago, IL; E-mail: john_otoole@rush.edu.

Drs. Ryu and Mehta and all faculty and staff in a position to control the content of this CME activity, and their spouses/life partners (if any), have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations relevant to this CME activity.

Dr. O'Toole has disclosed that he is a consultant to Globus Medical and RTI Surgical and a stockholder in Theracell.

Lippincott CME Institute has identified and resolved all conflicts of interest concerning this educational activity.

Historically, general anesthesia (GA) with endotracheal intubation has been the standard for most spinal procedures. However, due to morbidity associated with GA, various regional anesthetic (RA) techniques have been studied for select patient populations. With the recent emphasis on reducing opioid dependence, and in developing Enhanced Recovery After Surgery (ERAS) protocols for spine surgery, it is important for surgeons to become familiar with the scientific evidence behind RA. The requirements of the optimal anesthetic technique are quick onset, reversibility, maintenance of hemodynamic stability, sustained postoperative analgesia, and minimal nausea or emesis.

The purpose of this review is to examine 3 types of RA for spine surgery, including spinal anesthesia (SA), epidural anesthesia (EA), and paraspinal interfascial anesthesia. Specifically, procedural techniques, evidence in the literature, and potential complications of each type of RA have been discussed in detail.

SPINAL ANESTHESIA

The use of SA has been described since the late 19th century with the injection of cocaine into the intrathecal space for pain control.1 Early reports of serious complications such as paraplegia lead to limited clinical application. However, with the development of newer anesthetic

agents, extensive research has been done on the utility and safety of spinal blocks for various specialties including obstetrics, general surgery, and orthopedic surgery. In particular, RA for lower extremity surgery is associated with lower pulmonary complications, intraoperative blood loss, perioperative cardiac complications, and postoperative delirium compared with GA.2 In the context of lumbar spine procedures, the use of SA has been documented in the past 2 decades with several clinical trials.

Technique for Spinal Anesthesia

SA can be performed with the patient in the sitting or lateral decubitus position under conscious sedation, and landmarking the interspinous space between L3 and L4, L4 and L5, or L5 and S1 by palpation. Once the patient is prepped and draped in a sterile fashion, the planned injection site is infiltrated with 2 to 3 mL 1% lidocaine before inserting a 25-gauge spinal needle via introducer needle. Following the angle of the spinous process, the needle is angled approximately 15 degrees cranially traversing the subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, and dura mater before entering the subarachnoid space. The return of cerebrospinal fluid (CSF) confirms appropriate needle placement.

Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This activity expires on September 30, 2022.

Contemporary Spine Surgery

VOLUME 21 NUMBER 10

Editor-in-Chief

Kern Singh, MD Professor Department of Orthopaedic Surgery Co-Director Minimally Invasive Spine Institute at Rush Rush University Medical Center Chicago, Illinois

Contributing Editor

Alpesh A. Patel, MD Professor Department of Orthopaedic Surgery Northwestern University Feinberg School of Medicine Director, Northwestern Orthopaedic Spine Surgery Chicago, Illinois

Editorial Board

Jonathan N. Grauer, MD Yale-New Haven Hospital Spine Center New Haven, CT

Wellington K. Hsu, MD Northwestern University Feinberg School of Medicine Chicago, Illinois

Ken Ishii, MD, PhD Keio University School of Medicine Tokyo, Japan

Yu-Po Lee, MD University of California, San Diego School of Medicine San Diego, California

John O'Toole, MD Rush University Medical Center Chicago, Illinois

Frank M. Phillips, MD Rush University Medical Center Chicago, Illinois

Sheeraz Qureshi, MD, MBA Weill Cornell Medical School New York, New York

Alexander R. Vaccaro, MD, PhD Rothman Institute and Sidney Kimmel Medical College at Thomas Jefferson University Philadelphia, Pennsylvania

Michael Y. Wang, MD University of Miami Miller School of Medicine Miami, Florida

Founding Editor

Gunnar B.J. Andersson, MD, PhD Chairman Emeritus Department of Orthopedic Surgery Rush University Medical Center Chicago, Illinois

A syringe containing a local anesthetic (LA) agent (with or without additives) is then attached to the spinal needle, CSF is briefly aspirated into the syringe to confirm intrathecal placement, and LA is injected into the subarachnoid space at a rate of less than 0.5 mL/s. The common types of LA used are bupivacaine, tetracaine, and ropivacaine with the option of additives (ie, opioid and 2-adrenoreceptor agonist). Once the spinal needle is removed, adjustments in patient positioning (ie, Trendelenburg position vs prone) can be used to manipulate the spread of the spinal block within the intrathecal space. Other variables that impact the spread of the spinal block are the baricity, volume, dosage, needle angulation, and LA injection rate.

Evidence in Literature

There are several level 1 and level 2 evidence studies on the use of SA for spine surgery.3 Attari et al4 performed a randomized controlled trial (RCT) comparing SA versus GA in patients undergoing lumbar discectomy. The authors found that patients who received SA required a significantly lower amount of postoperative opioids. A similar finding was reported by Jellish et al5 with lower postoperative pain severity, analgesic requirement, and nausea.5 In a large, case-controlled study, McLain et al6 also found a reduction in operating time, postoperative

urinary retention, and earlier ambulation and hospital discharge in patients who received SA for 1- to 2-level lumbar laminectomies. Although benefits of SA have been shown in the literature, others found higher surgeon satisfaction with GA as the main anesthetic modality.7 The authors hypothesized this difference in satisfaction is attributable to the inability to accurately assess postoperative neurologic status as a result of SA-associated motor blockade.7

Aside from analyzing the clinical utility of SA, studies have also examined cost-effectiveness of SA compared with GA. Morris et al8 reported the direct cost of lumbar laminectomy or discectomy with GA was nearly 10% higher, with the operating room (OR) cost (OR support staff, surgical supplies, sterilization, and drugs) accounting for the biggest difference. Furthermore, SA improved perioperative patient flow with average reduction in anesthetic time and time spent in a postanesthesia care unit by 60 minutes. The cost-benefit of SA is further substantiated by Agarwal et al,9 who documented a 39% difference in total cost between SA ($7534) and RA ($13,206, P < 0.001). The savings were associated with shorter anesthetic time and hospitalization.

Complications

SA using newer LA agents is well tolerated in most patients; however, there

This continuing education activity is intended for orthopaedic and neurologic surgeons and other physicians with an interest in spine surgery.

Contemporary Spine Surgery (ISSN 1527-4268) is published monthly by Wolters Kluwer Health, Inc., at 14700 Citicorp Drive, Bldg 3, Hagerstown, MD 21742. Customer Service: Phone (800) 638-3030, Fax (301) 223-2400, or E-mail customerservice@ . Visit our website at .

Copyright ? 2020 Wolters Kluwer Health, Inc. All rights reserved. Priority postage paid at Hagerstown, MD, and at additional mailing offices. POSTMASTER: Send address changes to Contemporary Spine Surgery, Subscription Dept., Wolters Kluwer Health, P.O. Box 1610, Hagerstown, MD 21742.

Publisher: John Ewers

Suscription rates: Individual: US $522; international $683. Institutional: US $1142, international $1402. In-training: US resident $169 with no CME, international $193. Single Copies $118. Registration Number: 895524239.

COPYING: Contents of Contemporary Spine Surgery are protected by copyright. Reproduction, photocopying, and storage or transmission by magnetic or electronic means are strictly prohibited. Violation of copyright will result in legal action, including civil and/or criminal penalties. Permission to reproduce copies must be secured in writing; at the newsletter website (), select the article, and click "Request Permission" under "Article Tools" or e-mail customercare@. Reprints: For commercial reprints and all quantities of 500 or more, e-mail reprintsolutions@. For quantities of 500 or under, e-mail reprints@, call 1-866-9036951, or fax 1-410-528-4434.

PAID SUBSCRIBERS: Current issue and archives are available FREE online at .

Contemporary Spine Surgery is independent and not affiliated with any organization, vendor, or company. Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A mention of the products or services does not constitute endorsement. All comments are for general guidance only; professional counsel should be sought for specific situations.

2

OCTOBER 2020

Contemporary Spine Surgery

are numerous procedural challenges and serious complications that should be considered. During the procedure, hemodynamic and respiratory status should be monitored especially for hypotension, bradycardia, and on rare occasion respiratory depression. Depending on the severity of hemodynamic instability, treatment with IV fluids, vasopressors, and/or atropine may be required.

Specific to the procedure, documented minor postoperative complications include nausea, vomiting, shivering, pruritis, transient hearing loss, postpuncture headache, and urinary retention. Major complications include direct trauma to the neural structures, spinal hematoma, meningitis, abscess, and spinal cord ischemia.10 Although direct trauma to the neural tissue is rare, anatomical variability including caudally located conus medullaris, or congenital dysraphisms, may increase the risk of iatrogenic neural injury.

Postprocedural hematoma is most commonly located in the epidural space--associated with the epidural venous plexus. For patients experiencing progressive neurologic deficit, early diagnosis is essential, as the timing of decompression is known to impact their recovery.11 Although most patients experience at least some recovery after hematoma evacuation, up to 25% fail to regain their baseline function.11 Multiple hypotheses on the pathophysiology of spinal cord ischemia associated with SA have been proposed. These include (1) increased CSF pressure leading to decreased spinal cord perfusion pressure, (2) direct vascular injury, (3) vascular spasm, and (4) development of a mass lesion such as hematoma.10 Lastly, continuous SA via a microcatheter has been associated with cauda equina syndrome due to abnormal pooling of LA that can be neurotoxic and lead to permanent neural injury.12

EPIDURAL ANESTHESIA

EA has a long-standing history since its inception over 100 years ago similar to that of SA. In particular, since the introduction of a catheter for continuous infusion, EA has been frequently used in various surgical and medical specialties. This mode of regional anesthesia is particularly common for procedures involving the lower extremities, pelvis, and abdomen. The utility of EA in spine surgery has been explored in the adult and pediatric population as either an intraoperative anesthetic modality or for postoperative pain management.3,13

Technique for Epidural Anesthesia

The procedure can be performed with the patient in the sitting or lateral decubitus position under conscious sedation. The interspinous space between L3 and L4 or L4 and L5 levels is landmarked by palpation. Once the patient is prepped and draped in a sterile fashion, the planned injection site is localized before inserting a 17-gauge epidural or Tuohy needle. The Tuohy needle with a curved tip allows easier placement of the epidural catheter. Similar to that of the SA technique, the needle is angled approximately 15 degrees cranially traversing the subcutaneous tissue, supraspinous ligament, interspinous ligament, and ligamentum flavum before entering the epidural space. For patients with limited lumbar range of motion, the

paramedian approach may be used, as it provides a larger entry zone between the lamina. The key difference in the paramedian approach is reduced resistance while advancing the needle, as it does not traverse the supraspinous and interspinous ligaments. There are numerous techniques to identify the epidural space including loss of resistance to air, loss of resistance to saline, hanging drop technique, and ultrasound-guided. Using the loss of resistance to saline technique, the epidural needle is connected to a syringe with saline. With gentle constant pressure, the needle is advanced until the plunger of the syringe loses resistance.

A growing body of evidence suggests improved safety and efficacy in using ultrasound for EA placement14; however, this technique is limited in current clinical practice and may only be beneficial in a select patient population. Once the epidural space is identified, an epidural catheter is threaded approximately 4 to 5 cm into the space, followed by a "test dose" of 1.5% lidocaine containing epinephrine to assess for unanticipated intravascular catheter placement. LA is then administered via epidural catheter until the desired level of blockade is achieved.

Evidence in Literature

There are many level 1 studies evaluating EA in spine surgery. Demirel et al15 conducted an RCT comparing EA versus GA in patients undergoing lumbar discectomy. The authors reported that patients receiving 15 to 20 mL of 0.5% isobaric bupivacaine and 100-?g fentanyl via epidural catheter experienced lower postoperative pain, nausea, and shorter PACU (postanesthesia care unit) stays. The intraoperative hemodynamic status was comparable between the 2 groups, but the EA group required less intraoperative IV analgesia. Four additional RCTs compared standard GA versus combined single-injection EA plus GA in lumbar decompression.16-19 In 3 of the RCTs, the authors documented similar benefits of EA with the reduction of postoperative pain and opioid requirement up to 24 hours after surgery. In contrast, Aglio et al18 reported that the decrease in postoperative pain severity did not translate to a decrease in the total amount of opioid use during the first 2 days after surgery. Another trial examined combination EA with methylprednisolone and bupivacaine showing a decrease in postoperative pain and opioid consumption.20 Aside from impact of EA on pain, 2 of the trials reported significantly lower rates of blood loss, which was hypothesized to be associated with fewer episodes of intraoperative hypertension.15,16

Complications

Although the complication profile of the EA technique has been extensively investigated, there remains variability in the incidence of these events ranging from 1 per 1000 to 1 per 6000 procedures.21 The major complications of interest are epidural hematoma, epidural abscess, and neural injury. The incidence of epidural hematoma is reported to be 18.5 per 100,000 in a national in-patient database.22 The development of symptoms varies in terms of timing with less than 10% of patients experiencing symptoms during needle insertion, whereas 56% of

3

Contemporary Spine Surgery

VOLUME 21 NUMBER 10

patients became symptomatic after catheter removal.11 The average time of symptom onset was approximately 24 hours after catheter removal.

The most common symptoms in patients with epidural hematoma are a combination of back pain at the epidural insertion site along with sensory and motor deficits. The key predictors of neurologic recovery after development of hematoma are the severity of the deficit and timing of surgical decompression.11 Specifically, patients who underwent hematoma evacuation more than 12 hours after symptom onset had 4.5 times greater odds of experiencing a persistent deficit. Unlike the acuity of epidural hematoma, patients who developed epidural abscess experienced symptoms approximately 160 hours after the procedure, with pain being the most common symptom.11 Although the majority of patients experienced an improvement in symptoms, approximately 10% of patients with an epidural abscess had persistent symptoms. Perioperative anticoagulation should always be considered when placing and removing epidural catheters.

PARASPINAL INTERFASCIAL ANESTHESIA

Application of paraspinal interfascial plane anesthesia for spine procedures has recently gained interest with a growing number of case reports and early clinical trials underway. Although the concept of interfascial blocks in other surgical specialties has been previously described, increased availability of ultrasound imaging has allowed for further development of this RA technique with increased safety and reproducibility.23 For patients undergoing spinal procedures, paraspinal interfascial blocks have been used both in the context of posterior cervical and thoracolumbar procedures. The use of interfascial blocks in the posterior cervical spine has been discussed only in case reports. Specifically, patients undergoing cervical laminoplasty had a preoperative injection of LA between the multifidus and the longissimus or the semispinalis cervicis muscles.24,25 For the purpose of this review, the erector spinae plane block (ESPB) in the thoracolumbar region will be discussed in detail as it has been most commonly studied for perioperative analgesia in spine surgery.

Technique for Erector Spinae Plane Block

The ESPB can be performed with the patient in sitting, lateral decubitus, or prone position under conscious sedation. A unilateral or bilateral ESPB can be performed depending on the surgical procedure and approach. For example, a unilateral ESPB can be done only on the side of the planned incision for minimally invasive surgical decompression while a bilateral ESPB may be performed before bilateral posterior instrumentation. Once the patient's skin is prepped and draped around the planned surgical level, an ultrasound probe is used to identify key landmarks. First, with the probe in longitudinal parasagittal orientation, the hyperechoic transverse process is identified approximately 3 cm lateral to the spinous process. The erector spinae muscle can be visualized immediately superficial to the transverse process. Once the skin is localized, an echogenic 18-gauge needle is inserted 1 to 2 levels cranial to the index

Fig. 1 Ultrasound visualization of ESPB. Hyperechoic 18-gauge needle (arrow) is inserted approximately 3 cm lateral to the spinous process. The trajectory of the needle is parasagittal inplane aiming at the index transverse process (circle). Once the position is confirmed, LA is injected into the interfacial space below the erector spinae muscle (rectangle) with the fluid spread visualized as expanding hypoechoic space (triangle).

level and aimed caudally in-plane toward the targeted transverse process. The needle is then advanced, under ultrasound visualization, until contact with the transverse process is made. The needle is withdrawn 1 mm and 2 to 3 mL of 0.9% saline is injected for hydrodissection of the fascial plane.

Effective achievement of fascial dissection off the transverse process can be observed as an expanding hypoechoic volume of fluid just superficial to the transverse process, causing elevation of the erector spinae muscle on ultrasound imaging (Figure 1). Once this interfascial plane is expanded and confirmed, the LA agent is injected. At our institution, 30 mL of 0.5% bupivacaine/1:200,000 epinephrine is injected unilaterally (or 30-mL 0.25% bupivacaine/1:200,000 epinephrine per side bilaterally) with observed LA spread in both the cranial and caudad directions. The option to thread a catheter into the interfascial plane and administer LA via a continuous infusion has been described in the literature as well using the above technique. The needle is then removed, and the procedure repeated on the contralateral side if the bilateral ESPB is indicated.

Evidence in Literature

The use of ESPB was first described by Forero et al26 in 2016 in a case report of 4 patients with either chronic thoracic neuropathic pain from rib fractures or acute postoperative pain from thoracic surgery. In these patients, injecting an LA agent (0.5% ropivacaine or 0.25% to 0.5% bupivacaine) below the erector spinae muscle leads to the resolution of the pain along with multilevel dermatomal sensory block.26 Supplementing their clinical case reports, the authors performed cadaveric studies examining the spread of methylene blue dye injected in the interfascial space. Using anatomic dissection and radiographic analysis, they found longitudinal and ventrolateral spread of the dye into the paravertebral space where the ventral and dorsal rami are located. Indeed, the proposed mechanism of

4

OCTOBER 2020

Contemporary Spine Surgery

action on the ventral and dorsal rami seems to correspond well with the observed clinical effect.

Since 2016, there has been a steady increase in the number of ESPB studies, including investigations in spine surgery.27 Some of these reports have highlighted variability in the spread of the injectate and raised the importance of standardizing the ESPB technique including the type of LA, the volume of injection, and injection pressure.28,29 Specific to the management of postoperative pain after spine surgery, the ESPB has been shown to reduce patient-reported severity of pain and the amount of opioid use.30-33 Yayik et al33 published an RCT comparing ESPB versus standard care in patients undergoing open lumbar laminectomy. They reported that the ESPB group had significantly lower postoperative pain scores during rest and activity along with lower opioid consumption at all time points during the first 24 hours after surgery. Furthermore, time from the completion of surgery to the first analgesic use was significantly longer in the ESPB group (174.17 vs 325.17, P < 0.001).33

Similar benefits associated with ESPB were reported by Ueshima et al30 in their case-controlled study of patients undergoing lumbar decompression. Both of these studies reported no difference in postoperative nausea and vomiting between the intervention and control groups. Furthermore, they did not specify any procedural-related complications associated with the ESPB. Breebaart et al34 published a protocol for a prospective randomized double-blind trial to assess the utility of the bilateral ESPB in patients undergoing posterior lumbar interbody fusion. This trial was scheduled to be completed in February 2020, but results have not yet been published. Alternatives to the ESPB include the thoracolumbar interfascial plane (TLIP) block that injects LA between the multifidus and longissimus muscles.35 Similar to the ESPB, the mechanism of action is targeted to the dorsal rami in achieving dermatomal sensory block. Ueshima et al35 published their prospective randomized double-blind trial comparing TLIP to sham injection of normal saline. They found a significant reduction in fentanyl use and pain severity during the first 48 hours after open lumbar decompression. Furthermore, the intervention group reported lower rates of nausea and vomiting during the postoperative period.

Complications

One of the proposed benefits of the ESPB is the safety of the technique, given that the injection is made away from vital structures such as major blood vessels and the spinal cord. Although complications of the ESPB when administered for patients undergoing spine surgery have not been reported, case reports of complications of the ESPB have been published in other patient populations. These included pneumothorax in the thoracic ESPB, transient lower extremity weakness in the lumbar ESPB, and priapism.36 However, given that the ESPB is performed superficial to the transverse process, this bony structure decreases the risk of the needle passing into vital structures when compared with other more invasive paraspinal blocks such as the paravertebral block (PVB). Moreover, the

ESPB requires only a single injection on each side to cover numerous vertebral levels whereas the PVB requires multiple injections, thus further reducing risk profile. As future research studies continue to focus on the ESPB for spine surgery, the risk versus benefit of this paraspinal interfascial block will become clearer.

CONCLUSION

There is a growing body of evidence on the utility and safety of RA for posterior spine procedures. Although SA and EA have some risk for significant complications, the incidence of these complications is very low. Both SA and EA lead to a significant reduction in postoperative pain severity and opioid use. However, drawbacks such as hypotension, difficulty of placement, and risk to vital structures limit their use. Paraspinal interfascial anesthesia, in particular the ESPB, is a newer image-guided technique that may offer perioperative analgesic benefits with a lower risk profile and wider applicability for various spine surgeries; however, future prospective studies are needed.

REFERENCES

1. Marx GF. The first spinal anesthesia. Who deserves the laurels? Reg Anesth. 1994;19(6):429-430.

2. Memtsoudis SG, Cozowicz C, Bekeris J, et al. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on AnaesthesiaRelated Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. Br J Anaesth. 2019;123(3):269-287.

3. De Rojas JO, Syre P, Welch WC. Regional anesthesia versus general anesthesia for surgery on the lumbar spine: a review of the modern literature. Clin Neurol Neurosurg. 2014;119:39-43.

4. Attari MA, Mirhosseini SA, Honarmand A, et al. Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: a randomized clinical trial. J Res Med Scie. 2011;16(4):524-529.

5. Jellish WS, Thalji Z, Stevenson K, et al. A prospective randomized study comparing short- and intermediate-term perioperative outcome variables after spinal or general anesthesia for lumbar disk and laminectomy surgery. Anesth Analg. 1996;83(3):559-564.

6. McLain RF, Kalfas I, Bell GR, et al. Comparison of spinal and general anesthesia in lumbar laminectomy surgery: a case-controlled analysis of 400 patients. J Neurosurg Spine. 2005;2(1):17-22.

7. Sadrolsadat SH, Mahdavi AR, Moharari RS, et al. A prospective randomized trial comparing the technique of spinal and general anesthesia for lumbar disk surgery: a study of 100 cases. Surg Neurol. 2009;71(1): 60-65.

8. Morris MT, Morris J, Wallace C, et al. An analysis of the costeffectiveness of spinal versus general anesthesia for lumbar spine surgery in various hospital settings. Global Spine J. 2019;9(4):368-374.

9. Agarwal P, Pierce J, Welch WC. Cost analysis of spinal versus general anesthesia for lumbar diskectomy and laminectomy spine surgery. World Neurosurg. 2016;89:266-271.

10. Neal JM, Kopp SL, Pasternak JJ, et al. Anatomy and pathophysiology of spinal cord injury associated with regional anesthesia and pain medicine: 2015 update. Reg Anesth Pain Med. 2015;40(5):506-525.

11. Bos EME, Haumann J, de Quelerij M, et al. Haematoma and abscess after neuraxial anaesthesia: a review of 647 cases. Br J Anaesth. 2018;120(4):693-704.

12. Moore JM. Continuous spinal anesthesia. Am J Ther. 2009;16(4):289294.

13. Guay J, Suresh S, Kopp S, et al. Postoperative epidural analgesia versus systemic analgesia for thoraco-lumbar spine surgery in children. Cochrane Database Syst Rev. 2019;1(1):CD012819.

5

Contemporary Spine Surgery

VOLUME 21 NUMBER 10

14. Perlas A, Chaparro LE, Chin KJ. Lumbar neuraxial ultrasound for spinal and epidural anesthesia: a systematic review and meta-analysis. Reg Anesth Pain Med. 2016;41(2):251-260.

15. Demirel CB, Kalayci M, Ozkocak I, et al. A prospective randomized study comparing perioperative outcome variables after epidural or general anesthesia for lumbar disc surgery. J Neurosurg Anesthesiol. 2003; 15(3):185-192.

16. Khajavi MR, Asadian MA, Imani F, et al. 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. 2013; 4:105.

17. Thepsoparn M, Sereeyotin J, Pannangpetch P. Effects of combined lower thoracic epidural/general anesthesia on pain control in patients undergoing elective lumbar spine surgery: a randomized controlled trial. Spine (Phila Pa 1976). 2018;43(20):1381-1385.

18. Aglio LS, Abd-El-Barr MM, Orhurhu V, et al. Preemptive analgesia for postoperative pain relief in thoracolumbosacral spine operations: a double-blind, placebo-controlled randomized trial. J Neurosurg Spine. 2018;29(6):647-653.

19. Sekar C, Rajasekaran S, Kannan R, et al. Preemptive analgesia for postoperative pain relief in lumbosacral spine surgeries: a randomized controlled trial. Spine J. 2004;4(3):261-264.

20. Jirarattanaphochai K, Jung S, Thienthong S, Peridural methylprednisolone and wound infiltration with bupivacaine for postoperative pain control after posterior lumbar spine surgery: a randomized doubleblinded placebo-controlled trial. Spine (Phila Pa 1976). 2007;32(6): 609-617.

21. Bos EME, Hollmann MW, Lirk P. Safety and efficacy of epidural analgesia. Curr Opin Anaesthesiol. 2017;30(6):736-742.

22. Rosero EB, Joshi GP. Nationwide incidence of serious complications of epidural analgesia in the United States. Acta Anaesthesiol Scand. 2016; 60(6):810-820.

23. Elsharkawy H, Pawa A, Mariano ER. Interfascial plane blocks: back to basics. Reg Anesth Pain Med. 2018;43(4):341-346.

24. Ohgoshi Y, Kubo EN. Inter-semispinal plane block for cervical spine surgery. J Clin Anesth. 2018;46:94-95.

25. Ueshima H, Otake H. Blocking of multiple posterior branches of cervical nerves using a cervical interfascial plane block. J Clin Anesth. 2017;38:5.

26. Forero M, Adhikary SD, Lopez H, et al. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-627.

27. Kot P, Rodriguez P, Granell M, et al. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019;72(3):209-220.

28. Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018;43(6):567-571.

29. De Cassai A, Tonetti T. Local anesthetic spread during erector spinae plane block. J Clin Anesth. 2018;48:60-61.

30. Ueshima H, Inagaki M, Toyone T, et al. Efficacy of the erector spinae plane block for lumbar spinal surgery: a retrospective study. Asian Spine J. 2019;13(2):254-257.

31. Chin KJ, Lewis S. Opioid-free analgesia for posterior spinal fusion surgery using erector spinae plane (ESP) blocks in a multimodal anesthetic regimen. Spine (Phila Pa 1976). 2019;44(6):E379-E383.

32. Melvin JP, Schrot RJ, Chu GM, et al. Low thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: a case series. Can J Anaesth. 2018;65(9):1057-1065.

33. Yayik AM, Cesur S, Ozturk F, et al. Postoperative analgesic efficacy of the ultrasound-guided erector spinae plane block in patients undergoing lumbar spinal decompression surgery: a randomized controlled study. World Neurosurg. 2019;126:e779-e785.

34. Breebaart MB, Van Aken D, De Fr? O, et al. A prospective randomized double-blind trial of the efficacy of a bilateral lumbar erector spinae block on the 24h morphine consumption after posterior lumbar interbody fusion surgery. Trials. 2019;20(1):441.

35. Ueshima H, Hara E, Otake H. Thoracolumbar interfascial plane block provides effective perioperative pain relief for patients undergoing lumbar spinal surgery: a prospective, randomized and double blinded trial. J Clin Anesth. 2019;58:12-17.

36. Tulgar S, Ahiskalioglu A, De Cassai A, et al. Efficacy of bilateral erector spinae plane block in the management of pain: current insights. J Pain Res. 2019;12:2597-2613.

6

OCTOBER 2020

Contemporary Spine Surgery

Visit

n Sign up for electronic TOCs to be delivered to your inbox

n Access CME tests online n View on any device

without installing an app

7-Q741

7

Contemporary Spine Surgery

VOLUME 21 NUMBER 10

CME Quiz

To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. Select the best answer and use a blue or black pen to completely fill in the corresponding box on the enclosed answer form. Please indicate any name and address changes directly on the answer form. If your name and address do not appear on the answer form, please print that information in the blank space at the top left of the page. Make a photocopy of the completed answer form for your own files and mail the original answer form to Wolters Kluwer Health, Continuing Education Department, P.O. Box 1543, Hagerstown, MD 21741-9914 by September 30, 2022. Only two entries will be consi dered for credit. For more information, call (800) 638-3030.

Online quiz instructions: To take the quiz online, log on to your account at , and click on the "CME" tab at the top of the page. Then click on "Access the CME activity

for this newsletter," which will take you to the log-in page for . Enter your username and password. Follow the instructions on the site. You may print your official certificate immediately. Please note: Lippincott CME Institute, Inc., will not mail certificates to online participants. Online quizzes expire on the due date.

The American Association of Neurological Surgeons (AANS) manually tracks AMA PRA Category 1 CreditsTM earned from neurosurgery activities not sponsored or joint-sponsored by the AANS. As a service to AANS members, Lippincott CME Institute will continue to provide the AANS a monthly listing of their participants and the CME credits they earned so that AANS members do not have to send their individual certificates to the AANS for tracking.

Credits related to activities on orthopaedics may be applied to American Board of Orthopaedic Surgery Maintenance of Certification. Please confirm credit for specific activity with the Board at .

1. Which of the following is a common anesthetic agent used in regional anesthesia? A. Bupivacaine B. Ropivacaine C. Lidocaine D. All of the above

2. Which one of the following is the main bony landmark used to identify with ultrasound for the ESPB? A. Spinous process B. Lamina C. Transverse process D. Spinous process and lamina

3. Which one of the following describes where the needle is inserted relative to the midline for the ESPB? A. 1 cm lateral to the midline B. 2 cm lateral to the midline C. 3 cm lateral to the midline D. At the midline

4. Which one of the following describes how to adjust the spread of LA in spinal blocks? A. Baricity of anesthetic agent B. Dose of anesthetic agent C. Volume of anesthetic agent D. All of the above

5. Which one of the following is one of the strengths of GA for spine surgery as compared with RA, according to the literature? A. Reduced intraoperative blood loss B. Greater intraoperative hemodynamic stability C. Higher surgeon satisfaction D. Lower postoperative nausea

6. Which one of the following is a major complication associated with SA and EA? A. Epidural hematoma B. Hearing loss C. Postpuncture headache D. Urinary retention

7. Which one of the following describes how RA for spine surgery leads to health care cost savings compared with GA? A. Shorter OR time B. Lower operative complication rates C. Shorter hospitalization D. It is not cost-effective compared with GA

8. Which one of the following is a proposed strength of ESPB compared with other RA techniques? A. Lower risk of major complications B. Greater number of level 1 evidence for efficacy over GA C. Cost savings D. Both lower risk of major adverse events and cost savings

9. Which of the following describes the most likely mechanism of action for ESPB in achieving sensory block for posterior spine surgery? A. Anesthetic effect placed on dorsal rami B. Anesthetic effect placed on ventral rami C. Anesthetic effect on spinal cord D. All of the above

10. In setting of epidural hematoma, which one of the following predicts neurologic recovery? A. Timing of surgical decompression B. Severity of neurologic deficit C. Comorbid conditions D. Both timing of decompression and severity of neurologic deficit

8

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download