View source for Anterior cervical spine surgery

{{Infobox surgical case reference
| anesthesia_type = General (note that there are reports of cervical plexus block, Wang 2017)
| airway = ETT
| lines_access = PIV, possible arterial line
| monitors = Standard, possible invasive BP monitoring, possible neuromonitoring, consider level of consciousness monitor
| considerations_preoperative = Neck ROM, preoperative neurologic exam, may need CBC and type & screen if expecting blood loss; consider PO aprepitant if PONV concerns
| considerations_intraoperative = minimize neck movement during intubation, maintain MAP for spinal cord perfusion, maintenance anesthesia based on local neuromonitoring standards (TIVA vs. lower dose volatile + 50% nitrous + remifentanil infusion)
| considerations_postoperative = PACU then inpatient, multimodal pain control
}}

Fusion after discectomy usually needed for stability. Patients may have cervical radiculopathy, cervical myelopathy (spinal stenosis), disc disease, cervical instability.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Potentially limited neck ROM related to pain, trauma, or mechanical stabilization devices leading to more challenging airway. Potential unstable cervical spine, instrumentation could cause permanent paralysis. Consider awake intubation if high concern for unstable spine or difficult airway. 
|-
|Neurologic
|Possible preexisting motor and/or sensory deficits, particularly in the upper extremities. These symptoms may be exacerbated by head/neck positioning. May have chronic pain.
|-
|Cardiovascular
|Intraoperative bradycardia related to traction on the carotid bulb.
|-
|Pulmonary
|Limited neck ROM related to pain or structural changes can cause difficult laryngoscopy. Recurrent laryngeal nerve potentially at risk of damage intraop.
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|If trauma, assess for respiratory depression, decreased sympathetic tone (decreased BP and HR), presence of other injuries (pulmonary contusion, pneumo- or hemothorax, tracheal injuries, facial injuries)
|}

=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===

* May need CBC and T&S if expecting blood loss

=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===

=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

* Standard premeds (eg PONV prophylaxis, anxiolytics), if chronic disease and elective cases
* Caution with premeds for trauma patients

=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

* Reports of cervical plexus anesthesia; general anesthesia (compared to cervical plexus block) showed increased of the following: intraoperative hemodynamic stability, intraoperative pain control, patient satisfaction, post-op pain medications given, time for surgery, time for recovery (Wang 2017)

== Intraoperative management ==

=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
Standard ASA monitors. Neuromonitoring per surgeon request. PIV 18-20g usually sufficient. Arterial line based on patient comorbidities. If utilizing arterial line, usually align transducer to level of head.

=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
Potentially limited neck ROM related to pain, trauma, or mechanical stabilization devices leading to more challenging airway. Potential unstable cervical spine, instrumentation could cause permanent paralysis. Consider awake intubation if high concern for unstable spine or difficult airway. Consider neuro exam following awake intubation if concern for cervical spine injury. If MEP monitoring, consider succinylcholine or lower dose rocuronium. 

=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
Positioned supine, typically with shoulder roll for exposure and head on a doughnut gel pillow to facilitate neck positioning. Sometimes will have cervical traction. Surgeons may prefer left side approach to minimize injury to recurrent laryngeal nerve.

=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

* Neuromonitoring may be used to detect potential nerve/spinal cord injury. In these cases, surgical teams typically require no paralytic and frequently request TIVA techniques to minimize the affect of anesthetic on neuromonitoring. If local neuromonitoring group allows, consider 50% nitrous oxide with 0.6% isoflurane (or 0.5 MAC sevoflurane) with remifentanil infusion.
*May need to increase MAP goals (eg > 80) to maintain spinal cord perfusion. 

=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

* If patient has a halo device or body jacket, consider waiting until patient is fully awake before removing ETT (as it may be more difficult to re-intubate)
* Airway obstruction from soft tissue occlusion or superior laryngeal nerve damage may occur on extubation; consider testing airway patency by removing air from ETT cuff and observing if patient able to still breath around tube
* If concern for airway issues, consider inserting airway exchange catheter prior to extubation
* If using remifentanil during case, likely will need a longer-acting opioid for pain control after extubation

== Postoperative management ==

=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
Majority of patients appropriate for floor, some surgeons request ICU for monitoring. 

=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

* Intraop with remifentanil
* Postop with IV acetaminophen, IV hydromorphone, fentanyl pushes as needed, consider PCA; consult with surgeon about use of ketorolac or celecoxib

=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

* Neck hematoma
* Airway edema
* Injury to cranial nerves, recurrent laryngeal nerve, and/or superior laryngeal nerve
* Dural tear
*Notes on bone non-union:
**Smoking increases risk of non-union (Reuben)
**NSAIDs (celecoxib, rofecoxib, low dose ketorolac < 110 mg/day) for short term (5-days) post-op paoin control without significant difference in non-union assessed at 1 year (Reuben, retrospective)
**Perioperative steroid (dexamethasone 0.2 mg/kg intraop; 4 post op doses 0.06 mg/kg Q6H for 24 hours) reported to improve short term swallowing function and airway edema, and shorten length of stay, with lower 6-month fusion rates but not at 12 months (Jeyamohan)
*Tension pneumothorax
*Hypotension (could be due to venous pooling, acute drop may be due to vascular injury)
*If in sitting position, risk of venous air embolism
*Esophageal perforation

== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

{| class="wikitable"
|+
!
!Variant 1
!Variant 2
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|Unique considerations
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|Position
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|Surgical time
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|EBL
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|Postoperative disposition
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|Pain management
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|Potential complications
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|}

== References ==
Anesthesiologist's manual of surgical procedures [[ISBN (identifier)|ISBN]][[Special:BookSources/978-1-4963-0594-7|978-1-4963-0594-7]][[OCLC (identifier)|OCLC]]888551588

Jeyamohan SB, Kenning TJ, Petronis KA, Feustel PJ, Drazin D, DiRisio DJ. Effect of steroid use in anterior cervical discectomy and fusion: a randomized controlled trial. J Neurosurg Spine. 2015 Aug;23(2):137-43. doi: 10.3171/2014.12.SPINE14477. Epub 2015 May 1. PMID: 25932600.

Pardo, Manuel, Ronald D Miller (2020). Basics of Anesthesia 9th Edition. Print. p. 2096.

Reuben SS, Ablett D, Kaye R. High dose nonsteroidal anti-inflammatory drugs compromise spinal fusion. Can J Anaesth. 2005 May;52(5):506-12. doi: 10.1007/BF03016531. PMID: 15872130.

Wang H, Ma L, Yang D, Wang T, Wang Q, Zhang L, Ding W. Cervical plexus anesthesia versus general anesthesia for anterior cervical discectomy and fusion surgery: A randomized clinical trial. Medicine (Baltimore). 2017 Feb;96(7):e6119. doi: 10.1097/MD.0000000000006119. PMID: 28207536; PMCID: PMC5319525.
[[Category:Surgical procedures]]