Considerations: Laminectomy

Here are few tips to consider for a Neuroskeletal case. (Laminectomy, Fusion etc) It is not complete but has few tips that may be helpful as a quick review.

Preoperative

1) Assess patient's baseline pain status. Ask if patient is feeling any numbness, tingling or pain to  a certain area and document.

2) If patient is undergoing a cervical fusion or laminectomy. It is very important to make sure patient does not have limited neck extension. Some limitation in neck movement would most likely be seen which may make it a difficult intubation

3) Assess patient's baseline vision status. Lying prone for extended period of time can lead to vision impairment or loss. Even though our goal is to keep pressure off of the eye using a prone pillow, vision loss may occur.

Intraoperative

Induction: For intubation, it is ideal to use fiberoptic to limit extension of neck as all laryngoscopies cause some degree of neck extension. Fast-track LMA can be use to aid in intubation but LMA placement may increase pressure on spinal cord.

Agents: Prior to induction, check to see if neuromonitoring will be performed.
If motor evoked potentials are used, long acting muscle relaxants cannot be used.
If SSEP are being monitored, TIVA may be the best choice. Muscle relaxants may actually help by limiting artifact. Propofol/Remifentanyl drip may provide for best results from SSEP monitoring. Barbiturates are known to increase latency and decrease amplitude; magnesium and alpha 2 antagonists also decrease amplitude.

Propofol, narcotics, midazolam, droperidol, clonidine and precedex result in minimal SSEP changes.

On the other hand, Ketamine and Etomidate both are known to increase amplitude.

Volatile anesthetics will also cause dose dependent increase in latency and decrease in amplitude. N20 is worse than other volatile agents.

Positioning: Prone pillow should be used and pressure points must be assessed frequently. No pressure should be placed on the eyes. Ensure that tubing and monitoring leads are not leaving pressure on patient's body. Maintain proper alignment during transfer and it is safe to disconnect the ETT from the circuit and the monitors for transfer to avoid accidental extubation.

Prior to incision: If no paralytics are used, be sure patient is adequately narcotized for pain to avoid moving with stimulation. BIS monitoring is a good tool is use along with other monitors to ensure adequate depth of anesthesia.

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