POSTERIOR LUMBAR FUSION

Question 1

Why do they do a lumbar spinal fusion?

Posterior lumbar spinal fusion may relieve

Answer 1

low-back pain resulting from intervertebral movement. Surgery for segmental
lumbar instability, spondylolisthesis, or iatrogenic instability due to extensive laminectomy or facetectomy.

Question 2

Lumbar fusion Procedures

PAD - BRI

Answer 2

placed in the prone position after induction.
a posterior incision is made to meticulously
dissect the skin, subcutaneous tissue, and muscle laterally from the spine.
Bone graft is usually obtained from the patient’s iliac crest (autograft) or cadaver (allograft) for fusion.
Removal of the outside layer of the transverse processes and facet joints.
Instrumentation occurs by placement of metal rods affixed to the vertebrae to internally splint and apply multilevel correction to the spine.

Question 3

Positioning Complications_

Answer 3

Increased Intra-Abdominal Pressure (decreased FRC and IC), POVL, facial pressure injuries, nerve compression, oropharyngeal edema.

Question 4

Neuro “ monitoring

Answer 4

SSEP monitoring is done in some cases to detect nerve injury/ ischemia

Question 5

Prone positioning : RESP, part best oxygenated?

Answer 5

Resp: West lung zones are inverted. The anterior lung is the best oxygenated in the prone position. If transthoracic approach needed, main-stem intubation will be necessary to allow for deflation of one lung to allow for surgical sitevisualization.
Double lumen tube or bronchial blocker will be used to ensure one lung ventilation.

Question 6

Positioning and positioning devices

Answer 6

_Prone position, arms in “swimmer’s position”

Positioning Devices: Prone OR table (Wilson Frame or Jackson Table)

Question 7

CV: have available:

Answer 7

Type and cross patient’s blood, have 2 units available. Cell saver typically used. Have Blood administration
materials readily available.

Question 8

CV Also, mild

Answer 8

hypotension is sometimes indicated to help limit the amount of bleeding, but keep
in mind that plt dysfunction occurs in moderate/severe hypothermia.

Question 9

Est Deficit: Base off of Every patient is different.
EBL: 250-1000 (worse depending on the number of levels fused and thus more dissection of vascular tissue from spine,
and the presence of instrumentation)

Answer 9

patient needs, not 4:2:1 rule. This needs to be the new way of looking at volume deficit.

Question 10

With planned Spinal Fusions, ERAS type protocols are being used to help

Answer 10

Decrease operativecomplications and speed up recovery.

Question 11

ERAS protocol components (EDE)

Answer 11

Euvolemic state, adequate nutrition until surgery, Decreasing NPO time
Early mobility will help with an adequate fluid volume, decrease chances of third spacing, and decrease need for large fluid volume requirements in surgery.

Question 12

Types of anesthesia and which one is not suitable?

NMB

Answer 12

GETA - Regional not suitable because of the length.

NMB discussed with surgeon.

Question 13

Maintenance by level

Answer 13

2-3 h for single level, +1 h per additional level.Standard maintenance with volatile anesthetics and/or
IV anesthetic agents and opioids can be used with the posterior approach.

Question 14

NMB dosing

Answer 14

Single dose NMB is adequate (Anterior
approach should remain paralyzed until the case is over). When monitoring MEP (SSEP), standard dose of NMB will completely abolish the wave forms.

Question 15

Also, VA’s, when used at

Answer 15

> 0.5 MAC can also interfere with MEP and SSEP (to a lesser extent).

Question 16

After a baseline has been established on the SSEP, the surgeon may request a ______what do you use?

Answer 16

NMB while dissecting the muscle from the spine. (i.e. Rocuronium 20-40 mg).

Question 17

is essential in the procedure to help avoid nerve injury.

Answer 17

Neuromonitoring (EMG nerve root mapping)

Question 18

Therefore, when this neuromonitoring is being performed,

Answer 18

minimal or no paralytic

should be used as they may confound monitoring.

Question 19

Emergence: Move patient and consider this?

Answer 19

moved back to the gurney and then the emergence is initiated. Consider a leak test on the ETT before
extubation to assess for the presence of airway edema. (It may be advisable to leave the patient intubated overnight with
the presence of airway edema.

Question 20

Post-OP Pain and tx

Answer 20

6-10 post-op opioid agonist with longer acting effects such as Hydromorphone 0.2-0.6 mg, prior to full emergence.

Question 21

One post op complications : how it happens and how
to prevent
PTM -NEU

Answer 21

The prone poses a risk for the eyes, especially if hypotensive.
An ischemic insult can result in postoperative
vision loss (POVL).
This is most frequently with long spine cases that require the patient to be prone for long periods oftime.

Ensure adequate padding AROUND the eyes, and not directly Interventions to help prevent visual loss: Reverse Trendelenburg if surgery allows, maintain MAP greater than 70, preoperative planning for adequate padding and positioning techniques
normothermia (prevent vasoconstriction), euglycemia, and Urine output of 0.5 ml/kg minimum.

Question 22

One post op complications of this surgery

Answer 22

POVL)