Spinal cerrahi tanımı ile medulla spinalise veya ondan çıkan köklere bası yapan anatomik oluşumlara yönelik cerrahi girişim kastedilmektedir. Spinal cerrahide uygulanacak anestezi tipi genel, epidural ya da spinal anestezi olabilir.
Spinal cerrahide rejyonel anestezinin genel anesteziye göre daha az kan kaybı daha az tromboembolik komplikasyonlara neden olması ve de daha erken barsak motilitesinin geri dönmesi gibi avantajları olduğu bilinmesine karşın prone pozisyonu sık kullanılan bir teknik değildir.
Seydişehir Devlet Hastanesinde Kasım 2012- Eylül 2013 tarihleri arasında spinal cerrahi operasyonu geçiren toplam 84 hastayı retrospektif olarak inceledik. Olguların 21 spinal stenoz, 29 vaka disk hernisi, 34 vakada da kombine veya laminektomi,stabilizasyon operasyonları idi.
84 hastaya (50 kadın, 34 erkek) spinal anestezi uygulandı
Hastaların 33 hasta ASA 1, 48 hasta ASA 2, 5 hasta ASA3 idi
77 YAŞINDA BAYAN HASTA BEL, BACAK AĞRISI, YÜRÜYEMEME ŞİKAYETİ İLE BAŞVURDU. ÖZGEÇMİŞİNDE DM, HT, KOAH 10-15 YILDIR BU ŞİKAYETİ OLAN HASTA POLİKLİNİĞİMİZE BAŞVURDU.
NÖROLOJİK MUAYENESİNDE YÜRÜME ANTALJİK VE FLEKSÖR POSTÜRDE SAĞ ELİNDE BASTON YARDIMI İLE YÜRÜYORDU. LASEQUE TESTİ (-) FGT (-)
MOTOR MUAYENESİNDE BİLATERAL AYAK BAŞPARMAK VE AYAK BİLEĞİ DORSAL FLEKSİYONU 4/5 KAS GÜCÜNDEYDİ. BİLATERAL L4-5 HİPOESTEZİK. AŞİL REFLEKSİ (-/-) YÜRÜME MESAFESİ 20 METRE (NÖROJENİK KLODİKASYO İZLENDİ. URGENCY İNKONTİNANS ANAL TONUS ZAYIFTI.
SAĞ DİZ ARTROPLASTİ OPERASYONU (7 YIL ÖNCE) HİKAYESİ VARDI.
HASTANIN BİOKİMYASAL TETKİKLERİ NORMALDİ. wbc: 5.71, hb:12.7, htc: 37.0, plt: 207 A Rh(-)
HASTAYA ÇEKİLEN PREOP LOMBER MRG VE DİREKT GRAFİLERİNDE LOMBER SPONDİLOZ ZEMİNİNDE L4-5 SPİNAL STENOZ İZLENDİ.
HASTA PREOP KARDİOLOJİ İLE KONSULTE EDİLDİ. MUAYENESİNDE EF %65, HAFİF AY-MY, TA: 170/90 mmhg, EKG SİNDE SOL DAL BLOĞU İLE UYUMLU OLARAK BELİRTİLDİ. PREOP ÖNERİ OLARAK ANTİ HİPERTANSİF(CA KANAL BLOKERİ VE ANJ 2 RESEPTÖR ANTAGONİSTİ) TEDAVİSİNE EK OLARAK CLEXANE 04.1X1 SC ÖNERİLDİ.
GÖĞÜS HASTALIKLARI KONSULTASYONU SONRASI SFT İLE DEĞERLENDİRİLDİĞİNDE (FEV1 %69, PEF %77, FVC % 65, FEF 25-75 %115) PREOP -PREDNOL -ULCURAN -TEOBAG VERİLMESİ ÖNERİLDİ.
ASA 3 İLE OPERASYONA ALINAN HASTA KOMBİNE SPİNAL ANESTEZİ (MARCAİNE 12.5 mg, fentanil 25 MCG) VE SEDASYON(ZOLAMID 1 MG) İLE OPERASYONA ALINDI. OPERASYONA ANESTEZİDEN 15 DAKİKA SONRA SUPİNE POZİSYONDA BAŞLANDI.
OPERASYON SÜRESİ 2.20 SAAT SÜRDÜ. L4-5 STABİLİZASYON VE L4 TOTAL LAMİNEKTOMİ İLE FLAVEKTOMİ VE BİL. FORAMİNOTOMİ YAPILDI. PEROP KOMPLİKASYON GELİŞMEDİ. POSTOP KAN TRANSFÜZYONU YAPILMADI. (PEROP 150 CC KANAMA OLDU.) PEROP TA ORT. 140/80 MMHG, NABIZ 90 DK
Postop.yoğun bakım ünitesine alındı. Operasyonun 3.ssatinde %10 lidokain 2 cc test dozu sonraso 2 cc %10 aritmal ve ½ sodyumbikarbonat uygulandı. Postop analjezi 6 saat aralıklarla uygulanan 8 cc serum fizyolojik volum içinde 1 cc %0.5 markain ve 100 mcg ile sağlandı.
POSTOP 1 GÜN MOBİLİZE OLAN HASTANIN 2. GÜN DRENİ ÇEKİLDİ. POSTOP 3 GÜN TABURCU EDİLDİ.
1.Rejyonel anestezi endikasyonu koyarken operasyon süresi 2.Hastanın durumu göz önüne alınmalıdır. 3. Pozisyona bağlı komplikasyonların daha az gözlenmesi bu operasyonlarda rejyonel anestezinin en büyük avantajı sayılabilir. 4. Tek veya çift seviye laminektomilerde rejyonel anestezi etkin ve güvenli olarak kullanılabilir. 5. Spinal cerrahi deneyim sürenin kısalmasında en büyük etkendir.
Masui. 2012 Aug;61(8):837-9. [Anesthetic management of a morbidly obese patient in prone position for lumbar laminectomy]. Niwa Y1, Shimada N, Negishi Y, Kai M, Inoue S, Takeuchi M. Abstract A 22-year-old man weighing 188.7kg, 170cm tall (body mass index 65.2 kg x m(-2)) with bladder and rectal disturbances due to lumbar disc hernia (L4/5 and L5/S1) was scheduled for L4-5 laminectomy under general anesthesia. Awake fiberoptic intubation was attempted to prevent airway obstruction because we predicted difficult airway. During fiberoptic tracheal intubation, we easily succeeded in the insertion of the fiberscope itself into the trachea, and we succeeded in placing the reinforced tube into the trachea. Fentanyl and sugammadex were calculated with total body weight, but, remifentanil, propofol, and rocuronium were re-calculated with ideal body weight. They were given intravenously. Anesthesia was maintained with sevoflurane (1.5 to 2.0%), the fraction of inspiratory oxygen (about 0.6), remifentanil (0.1 to 0.4 microg x kg(-1) x min(-1)), and fentanyl (100 to 150 microg) as needed. After turning to prone position, severe physiological abnormal signs were not recognized. We concluded that awake fiberoptic intubation was useful and safe; moreover, anesthetic agents were administrated appropriately for morbid obesity. PMID: 22991806 [PubMed - indexed for MEDLINE]
Asian J Endosc Surg. 2013 May;6(2):130-3. doi: 10.1111/ases.12004. Percutaneous endoscopic transforaminal approach to decompress the lateral recess in an elderly patient with spinal canal stenosis, herniated nucleus pulposus and pulmonary comorbidities. Kitahama Y1, Sairyo K, Dezawa A. Abstract A 70-year-old man with severe pulmonary comorbidities was referred to our institution for treatment of a right L5 nerve impingement. He had suffered from spinal canal stenosis and herniated nucleus pulposus (HNP) at the level of L4-L5 for more than a year and had been treated conservatively. However, the pain could not be alleviated, and his primary care physician scheduled posterior decompression surgery. During this procedure, the anesthesiologist refused to induce general anesthesia because of the patient's very poor pulmonary condition. Subsequently, the patient was referred to us. We used a transforaminal approach with percutaneous endoscopic discectomy, with the patient under local anesthesia. First, herniated nucleus pulposus fragments at the disc level were removed. With a trephine drill, the upper part of the L5 pedicle was removed, which allowed for the extraction of dorsally migrated fragments. Following complete removal of the herniated nucleus pulposus fragments, osseous decompression was performed. The osseous endplate of L5 (anterior part of the lateral recess) was removed to enlarge the lateral recess so that decompression of the L5 nerve root was possible. The patient's lower back pain and right leg pain subsided following surgery. Percutaneous endoscopic discectomy is useful for patients with severe comorbidities as it can be done with local anesthesia
Neuroradiol J. 2011 Aug 31;24(4):620-6. Epub 2011 Sep 2. mild( ) Lumbar Decompression for the Treatment of Lumbar Spinal Stenosis. Schomer DF1, Solsberg D, Wong W, Chopko BW. 1 Radiology Imaging Associates; Denver, CO, USA - donschomer@mac.com. Abstract More than 1.2 million people are undergoing treatment for lumbar spinal stenosis (LSS) in the United States. Yet, therapeutic options for these patients are limited to either conservative treatments or highly invasive surgeries. A new image-guided interlaminar decompression procedure, mild( ), offers significant relief for many of these patients by debulking dorsal element hypertrophy while preserving structural stability. mild can be performed without general anesthesia and offers a short recovery period. A meta-analysis of four clinical patient series from multiple institutions in the United States evaluated over 250 patients for safety and clinical efficacy of the mild procedure. Clinical efficacy was evaluated at baseline and at three-month follow-up using validated patient reported outcomes (PRO) instruments including the ten-point Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). Acute safety and patient outcomes was compared to the Spine Patient Outcomes Research Trial (SPORT). No device or procedure-related serious adverse events (SAEs) have been recorded with the mild procedure. Outcome metrics for patients treated with mild demonstrated statistically significant symptomatic improvement over baseline. When compared to open surgery, mild efficacy results compare favorably, and complication rates are much lower. mild is a safe and effective procedure that decompresses LSS in a minimally invasive manner while preserving the structural stability of the spine.
Surg Neurol Int. 2013 Aug 19;4:105. doi: 10.4103/2152-7806.116683. General anesthesia versus combined epidural/general anesthesia for elective lumbar spine disc surgery: A randomized clinical trial comparing the impact of the two methods upon the outcome variables. Khajavi MR, Asadian MA, Imani F, Etezadi F, Moharari RS, Amirjamshidi A.