Anterior cervical spine surgery

Anterior cervical spine surgery

Anesthesia type	General (note that there are reports of cervical plexus block, Wang 2017)
Airway	ETT
Lines and access	PIV, possible arterial line
Monitors	Standard, possible invasive BP monitoring, possible neuromonitoring, consider level of consciousness monitor
Primary anesthetic considerations
Preoperative	Neck ROM, preoperative neurologic exam, may need CBC and type & screen if expecting blood loss; consider PO aprepitant if PONV concerns
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)
Postoperative	PACU then inpatient, multimodal pain control
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Fusion after discectomy usually needed for stability. Patients may have cervical radiculopathy, cervical myelopathy (spinal stenosis), disc disease, cervical instability.

Preoperative management

Patient evaluation

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

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

Patient preparation and premedication

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

Regional and neuraxial techniques

• 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

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

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

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

• 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

• 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

Majority of patients appropriate for floor, some surgeons request ICU for monitoring.

Pain management

• 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

• 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

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Anesthesiologist's manual of surgical procedures ISBN978-1-4963-0594-7OCLC888551588

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.