Impact of spinal anaesthesia vs. general anaesthesia on peri-operative outcome in lumbar spine surgery

Meng, T. et al. (2017) Anaesthesia. 72(3) pp. 391-401

Introduction: The authors systematically reviewed the comparative evidence for the use of spinal anaesthesia versus general anaesthesia for lumbar spinal surgery.

Results: Eight studies with a total of 625 patients were included. These were considered to be at high risk of bias. Compared with general anaesthesia, the risk ratio (95% confidence interval [CI]) with spinal anaesthesia for intraoperative hypertension was 0.31 (0.15 to 0.64), I2 = 0% (p=0.002); for intraoperative tachycardia 0.51 (0.30 to 0.84), I2 = 0% (p=0.009); for analgesic requirement in the post-anaesthesia care unit 0.32 (0.24 to 0.43), I2 = 0% (p<0.0001); and for nausea/vomiting within 24 hours postoperatively 0.29 (0.18 to 0.46), I2 = 12% (p<0.00001). The standardised mean difference (95% CI) for hospital stay was -1.15 (–1.98 to –0.31), I2 = 89% (p=0.007). There was no evidence of a difference in intraoperative hypotension and bradycardia, blood loss, surgical time and analgesic requirement within 24 hours postoperatively or nausea/vomiting in the post-anaesthesia care unit.

Conclusions: The authors conclude that spinal anaesthesia appears to offer advantages over general anaesthesia for lumbar spine surgery.

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Use of ultrasound for spinal anesthesia in a super morbidly obese patient

Morimoto, Y. et al. (2017) Journal of Clinical Anesthesia. 36 pp. 88–89

Heather Spears, Wellcome Images

Image source: Heather Spears – Wellcome Images // CC BY-NC-ND 4.0

Highlights

  • We report the application of ultrasound prescan for spinal anesthesia to morbid obesity patient.
  • The transverse view of the patient’s lumbar spine showed the posterior dura, transverse process, and posterior vertebral body below the thick fat tissue.
  • At this point, spinal anesthesia was successfully performed.
  • Pre-insertion ultrasound guidance for spinal anesthesia was useful in this morbidly obese patient with a BMI of 50.

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Anesthesia Technique and Mortality after Joint Replacement

Perlas, A; Chan, V. W.S; & Beattie, S.  Anesthesia Technique and Mortality after Total Hip or Knee Arthroplasty: A Retrospective, Propensity Score–matched Cohort Study. Anesthesiology  October 2016, Vol.125, 724-731

Abstract
Background: This propensity score–matched cohort study evaluates the effect of anesthetic technique on a 30-day mortality after total hip or knee arthroplasty.

Methods: All patients who had hip or knee arthroplasty between January 1, 2003, and December 31, 2014, were evaluated. The principal exposure was spinal versus general anesthesia. The primary outcome was 30-day mortality. Secondary outcomes were (1) perioperative myocardial infarction; (2) a composite of major adverse cardiac events that includes cardiac arrest, myocardial infarction, or newly diagnosed arrhythmia; (3) pulmonary embolism; (4) major blood loss; (5) hospital length of stay; and (6) operating room procedure time. A propensity score–matched-pair analysis was performed using a nonparsimonious logistic regression model of regional anesthetic use.

Results: We identified 10,868 patients, of whom 8,553 had spinal anesthesia and 2,315 had general anesthesia. Ninety-two percent (n = 2,135) of the patients who had general anesthesia were matched to similar patients who did not have general anesthesia. In the matched cohort, the 30-day mortality rate was 0.19% (n = 4) in the spinal anesthesia group and 0.8% (n = 17) in the general anesthesia group (risk ratio, 0.42; 95% CI, 0.21 to 0.83; P = 0.0045). Spinal anesthesia was also associated with a shorter hospital length of stay (5.7 vs. 6.6 days; P < 0.001).

Conclusions: The results of this observational, propensity score–matched cohort study suggest a strong association between spinal anesthesia and lower 30-day mortality, as well as a shorter hospital length of stay, after elective joint replacement surgery.

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Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research

Johnson, R. L. et al. British Journal of Anaesthesia. (2016) 116 (2): 163-176.

Background: This systematic review evaluated the evidence comparing patient-important outcomes in spinal or epidural vs general anaesthesia for total hip and total knee arthroplasty.

Methods: MEDLINE, Ovid EMBASE, EBSCO CINAHL, Thomson Reuters Web of Science, and the Cochrane Central Register of Controlled Trials from inception until March 2015 were searched. Eligible randomized controlled trials or prospective comparative studies investigating mortality, major morbidity, and patient-experience outcomes directly comparing neuraxial (spinal or epidural) with general anaesthesia for total hip arthroplasty, total knee arthroplasty, or both were included. Independent reviewers working in duplicate extracted study characteristics, validity, and outcomes data. Meta-analysis was conducted using the random-effects model.

Results: We included 29 studies involving 10 488 patients. Compared with general anaesthesia, neuraxial anaesthesia significantly reduced length of stay (weighted mean difference −0.40 days; 95% confidence interval −0.76 to −0.03; P=0.03; I2 73%; 12 studies). No statistically significant differences were found between neuraxial and general anaesthesia for mortality, surgical duration, surgical site or chest infections, nerve palsies, postoperative nausea and vomiting, or thromboembolic disease when antithrombotic prophylaxis was used. Subgroup analyses failed to find statistically significant interactions (P>0.05) based on risk of bias, type of surgery, or type of neuraxial anaesthesia.

Conclusion: Neuraxial anaesthesia for total hip or total knee arthroplasty, or both appears equally effective without increased morbidity when compared with general anaesthesia. There is limited quantitative evidence to suggest that neuraxial anaesthesia is associated with improved perioperative outcomes. Future investigations should compare intermediate and long-term outcome differences to better inform anaesthesiologists, surgeons, and patients on importance of anaesthetic selection.

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Cervical epidural analgesia in current anaesthesia practice: systematic review of its clinical utility and rationale, and technical considerations

Shanthanna, H. et al. British Journal of  Anaesthesia (2016) 116 (2): 192-207.

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Image source: Amin Ashaari

Cervical epidural analgesia (CEA) is an analgesic technique, potentially useful for surgeries involving the upper body. Despite the inherent technical risks and systemic changes, it has been used for various surgeries. There have been no previously published systematic reviews aimed at assessing its clinical utility. This systematic review was performed to explore the perioperative benefits of CEA. The review was also aimed at identifying the rationale of its use, reported surgical indications and the method of use.

We performed a literature search involving PubMed and Embase databases, to identify studies using CEA for surgical indications. Out of 467 potentially relevant articles, 73 articles were selected. Two independent investigators extracted data involving 5 randomized controlled trials, 17 observational comparative trials, and 51 case reports (series). The outcomes studied in most comparative studies were on effects of local anaesthetics and other agents, systemic effects, and feasibility of CEA. In one randomized controlled study, CEA was observed to decrease the resting pain scores after pharyngo-laryngeal surgeries. In a retrospective study, CEA was shown to decrease the cancer recurrence after pharyngeal-hypopharyngeal surgeries.

The limited evidence, small studies, and the chosen outcomes do not allow for any specific recommendations based on the relative benefit or harm of CEA. Considering the potential for significant harm, in the face of better alternatives, its use must have a strong rationale mostly supported by unique patient and surgical demands. Future studies must aim to assess analgesic comparator effectiveness for clinically relevant outcomes.

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