The number of degenerative lumbar spine diseases is increasing progressively. Lumbar spine surgery has been routinely performed under general anesthesia, but spinal anesthesia may be safe and effective alternative. Among the advantages of spinal anesthesia lower blood loss and length of stay, reducing of postoperative nausea and vomiting (PONV) and cost effect are described. Unfortunately there are no guidelines for choosing of anesthesia type, because such operations have several peculiarities regarding prone position, deliberate hypotension, pain syndrome and specific complications, like postoperative visual loss. The aim of the study was to improve the results of anesthesia management for elective lumbar spine surgery due to degenerative diseases on the base of studying of hemodynamics, pain syndrome, cognitive functions, biochemical stress markers, intraocular pressure and spinal anesthetic distribution in prone position.
254 ASA I-III patients aged 18-75 year old were enrolled into prospective study. Patients were divided randomly into 2 groups. Patients of group SA were operated under spinal anesthesia, patents of group TIVA were operated under intravenous propofol/fentanyl anesthesia. Additionally patients were divided into subgroups StA (obtained standard postoperative analgesia) and MMA (multimodal postoperative analgesia). It was shown that turning of the patient into prone position leads to statistically significant hemodynamic changes. During surgery deliberate hypotension was induced with level of mean blood pressure 60-80 mm Hg. According to our data this level was effective and safe as it had no influence on postoperative neurological recovery and function of kidneys. We performed a series of CT myelograms to assess the distribution of hyperbaric solution in prone position. We revealed that typically the biggest amount of hyperbaric solution is located at the level LI-LII with highest level at ThXI-ThXII. Using of isobaric bupivacaine is suitable for surgery lower than LIII and duration 2 hours and less and allows to start surgery faster as the patient can position himself on his own. Hyperbaric solution allows to increase the level to LI and duration of surgery up to 3 hours. Exposition in supine position should be 5 min. Intraocular pressure increased in prone position in anesthetized and non-anesthetized patients. The most significant changes were found in patients of TIVA group in the dependent eye if the head was rotated 45°. Intraocular pressure of non-anesthetized patients was similar to those of group SA. Among biochemical markers of stress significant changes were found in levels of cortisol and IL-6. Cortisol level was higher in TIVA group on the end of surgery than in SA group. Level of IL-6 was found to be higher 30 min after incision in TIVA group comparing with SA group. When we studied pain syndrome we found that neuropathic component was present in 53,9 ± 4,9 % of patients. In patients with neuropathic component pain syndrome was significantly more severe before surgery and on the 3rd day after surgery. We used our algorithm of multimodal perioperative pain management that included pregabalin, paracetamol, parecoxib and morphine (optionally). This algorithm allowed to decrease requirements for morphine and incidence of PONV and dizziness. Anesthesia type had no influence on postoperative cognitive function. Significant decreasing of the attention was found in patients who received standard analgesia regimen with higher morphine dose instead of MMA. On the base of our investigation the algorithm of choosing of anesthesia type was produced, that included PIHI, level of surgery, estimated time of surgery, level of psychological stress. We applied the algorithm to 30 patients and we found significant difference, comparing to 30 patients with random choosing, in length of stay 7,1 ± 1,4 vs 10,7 ± 1,1 days (р < 0,05), time in intensive care ward 0,3 ± 0,5 vs 1,4 ± 0,9 days (р < 0,05), sympathomimetic requirements 5,1 ± 1,8 % vs 9,8 ± 1,5 % (р < 0,05), time of mobilization on postoperative day 1 18,1 ± 6,2 vs 7,4 ± 3,8 min.
