Anaesthetic care for surgical management of adolescent idiopathic scoliosis
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Tags: ../../pages/Orthopaedic surgery, Scoliosis,
Abstract
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(8/11/2022, 10:24:32 PM)
“Adolescent idiopathic scoliosis (AIS) is an abnormal curvature of the spine in the coronal, sagittal, and axial planes that affects 1-3% of adolescents. The diagnosis is made in clinical practice with the Adam’s forward bending test (positive if more than 7). This is confirmed on radiographs when the coronal spinal curvature exceeds a Cobb angle (degree of the most tilted vertebrae on radiograph) of 10° ” Go to annotation (Young et al., 2019, p. 232)
“AIS with a curve greater than 45-50° requires surgical management; as such, deformities are likely to progress and potentially impair cardiorespiratory function and produce increasing back pain” Go to annotation (Young et al., 2019, p. 232)
“Blood loss from PSF is reported as being between 275 and 907 ml. Intraoperative cell salvage is not usually necessary” Go to annotation (Young et al., 2019, p. 234)
“Neurological complications are an uncommon but significant complication of scoliosis correction with an incidence of 0.3% after PSF. A neurophysiologist should monitor somatosensory evoked potential (SSEPs) and motor evoked potential (MEPs) intraoperatively to enable early identification of and intervention for possible neurological injuries. The role of intraoperative neuromonitoring in paediatric spinal surgery has been reviewed recently in this journal. As ../../Knowledge/Medicine/inhaled anaesthetics may interfere with neurophysiological monitoring, anaesthesia is maintained with infusions of propofol, remifentanil, and Ketamine. ../../Knowledge/Medicine/Nitrous oxide in particular causes a more profound depression in amplitude and longer latency in SSEPs and MEPs than the halogenated volatile anaesthetics; however, this effect may be modified by other anaesthetic agents. Nevertheless, all ../../Knowledge/Medicine/volatile anaesthetics and nitrous oxide should be eliminated before initiating neurophysiological monitoring. Although propofol does affect the accuracy of SSEPs and MEPs, equipotent doses of intravenous anaesthetic agents have less effect on these measures than inhalational agents. ../../Knowledge/Medicine/Ketamine can enhance the amplitude of SSEPs and MEPs with spinal stimulation, although it has minimal effect on subcortical, peripheral, and myogenic responses. Although small doses of ../../Knowledge/Medicine/neuromuscular blocking agent (NMBAs) (e.g. rocuronium 0.2-0.4 mg/kg) may be used to facilitate tracheal intubation, these are expected to be metabolised before the start of surgery. Further doses of NMBAs should be avoided after intubation to facilitate neurophysiological monitoring. Opioids, such as remifentanil, do affect SSEPs but not to a clinically significant degree. A ../../Knowledge/Medicine/bispectral index (BIS) monitor or unprocessed EEG information obtained from the neurophysiologist can be used to guide the anaesthetist on depth of anaesthesia when ../../Knowledge/Medicine/total intravenous anaesthesia (TIVA) is used. The evidence to support this in adolescent patients is controversial” Go to annotation (Young et al., 2019, p. 235)
“Anaesthesia in the prone position is associated with a number of complications including
- posterior ischaemic optic neuropathy,
- stroke secondary to arterial occlusion in the neck,
- injury from inhibition of venous drainage, and
- a variety of peripheral neuropathies.” Go to annotation (Young et al., 2019, p. 235)
“Persistent chronic pain with a neuropathic component is common after AIS surgery; it is associated with both preoperative pain and high early postoperative opioid consumption.” (Young et al., 2019, p. 235)
“There is no ideal combination of measures for perioperative management of paediatric patients undergoing AIS surgery. Nevertheless, the current literature does support the following principles: good multimodal analgesia; aggressive prophylaxis and treatment of PONV; careful attention to prevention of infection including maintenance of normothermia; use of TXA to decrease blood loss; and avoidance of drugs that interfere with neuromuscular monitoring. After surgery, the provision of effective analgesia and management of possible adverse effects is key to allow early return of function.” Go to annotation (Young et al., 2019, p. 236)