The Journal of Spine recently published an article on local anesthesia for minimally invasive endoscopic spine surgery.
Anthony Yeung, MD, founder of Phoenix-based Desert Institute for Spine Care, is the article's lead author along with his partners at DISC. The article covers trends in local anesthesia for endoscopic spine surgery gathered over 10,000 cases. The typical patient receives mild sedation with versed and fentanyl, unless the patient requests no sedation. The anesthesiologist typically administers 1 to 2 cc of fentanyl and versed pre-op as well as titrated during surgery. The physicians also used 1 percent lidocaine for local anesthetic with an average of 10 to 20 cc used, "titrated as needed during surgery."
The patients who requested no sedation were typically the anesthesiologists and other spine surgeons who decided to undergo decompressive surgery but wanted to maintain participation and control of the procedure. The combination of pain relief reported during and immediately after the procedure can predict the results of the decompression.
The lessons outlined in the article include:
1. Surgeons don't need to use neuromonitoring if the patient is awake and lightly sedated.
2. The surgeon can use EMG neuromonitoring to alert them of any peripheral nerve irritation not anesthetized by the local soft tissue injection.
3. "Toxic" annular tear "causes pain out of proportion to the imaging study" and annular tears are not always visualized on MRI.
4. The complexities of the procedure require surgical training and experience, and the article authors suggest non-surgeons without surgical training could put their patients at risk when performing endoscopic spine surgery.
5. Patients are able to report pain relief after the decompression to provide feedback on the procedure.
6. Surgeons may find anomalous nerves that weren't visualized during the traditional translaminar decompression in the MacNab's "hidden zone."
7. Surgeons may visualize a pedunculated synovial cyst from the MRI, and it may not be necessary to remove the cyst at the time of procedure.
8. When patients report pain or difficulty breathing, they may need continuous blood pressure and vital sign monitoring.
9. The surgeons used monitored anesthesia care sedation in conjunction with local anesthesia at the surgical incision to allow communication during the procedure. The anesthesiologist's verbal assurance of the technique can reduce patient anxiety. When patients aren't comfortable during the procedure, surgeons can use additional local anesthetic within safety limits.