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Anesthetic management of complex spine surgery in adult patients

a review based on outcome evidence

Alboog, Abdulrahman; Bae, Sandy; Chui, Jason

Current Opinion in Anesthesiology: October 2019 - Volume 32 - Issue 5 - p 600–608
doi: 10.1097/ACO.0000000000000765
NEUROANESTHESIA: Edited by Lingzhong Meng

Purpose of review The aim of this article is to review the evidence regarding the anesthetic management of blood loss, pain control, and position-related complications of adult patients undergoing complex spine procedures.

Recent findings The most recent evidence of the anesthetic management of complex spine surgery was identified with a systematic search and graded. In our review, prophylactic tranexamic acid and optimal prone positioning were shown to be effective blood conservation strategies with minimal risks to the patients. Cell saver was cost-effective in complex surgeries with expected blood loss of greater than 500 ml. As for pain control, most interventions only produced mild analgesic effects, suggesting a multimodal approach is necessary to achieve optimal pain control after spine surgery. Regional techniques and NSAIDs were effective but because of their risks, their usage should be discussed with the surgical team. Further studies are required to assess the effectiveness, cost-effectiveness, and risks associated with combined uses of different analgesic interventions. On the basis of the available evidence, we recommend a combined use of gabapentinoids, ketamine, and opioids to achieve optimal analgesia. Lastly, literature for position-related injuries is heavily relied on case reports and the Anesthesia Closed Claim Study because of their rarity. Therefore, we advocate for a structured team-based approach with checklists to minimize position-related complications.

Summary As the number and complexity of spine procedures are being performed worldwide is increasing, we suggested to bundle the aforementioned effective interventions as part of an ERAS spine protocol to improve the patient outcome of spine surgery.

Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada

Correspondence to Jason Chui, MBChB, MSc, FANZCA, FHKCA, FHKAM, C3-106, University Hospital, 339 Windermere Road, London, ON, Canada N6A 5A5. Tel: +1 519 663 3270x34435; fax: +1 519 663 3161; e-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (

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The number of spine surgeries being performed in North America has exponentially increased in the last two decades [1]. This rapid growth is mainly attributed to the epidemic of chronic low back pain in developed countries, as well as the introduction of minimally invasive surgical technique that allows more complex spine procedures to be performed safely. Along with these changes, more spine surgery patients are morbidly obese, narcotic-dependent, and suffering from other age-related comorbidities. As such, the anesthetic management of spine surgery is often challenged with significant blood loss, difficult pain control, and lengthy operation and its inherited risks of position-related complications. Many institutes have protocolized their perioperative management of patients undergoing spine surgery. However, a widely accepted enhanced recovery after surgery (ERAS) pathway for spine surgery has yet to be developed. Early studies suggested ERAS spine protocol enables faster recovery, increase patient satisfaction, reduction of hospital length of stay and healthcare expenditure [2,3]. One key step of developing a standardized protocol is to identify and bundle effective perioperative interventions, which allow these measures to be consistently implemented in the perioperative patient journey.

The aim of this article is to comprehensively review the current evidence on the three major anesthetic considerations for adult patients undergoing complex spine surgery, namely: blood loss, pain management, and position-related complications. We performed a systematic search in Ovid MEDLINE from 1 January 2009, to 19 April 2019, and retrieved the relevant articles for more detailed review (Appendix I,, and graded the evidence according to the 2011 Oxford Centre for Evidence-Based Medicine Levels of Evidence [4].

Box 1

Box 1

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Major spine surgery is commonly associated with massive blood loss. The risk increases with higher complexity of surgery, such as instrumentation, multiple levels (at least three vertebral levels) and revision operations [5]. A systemic review of major spine surgeries reported that in patients without preventive measures, blood loss can be up to 2.8 l and the transfusion rate can be as high as 81% [6]. A few large databank studies consistently demonstrated an association between transfusion and increased morbidity, mortality, and length of stay (LOS) [5,7]. As such, identifying evidence-based strategies to reduce blood loss is essential to improve the outcomes of complex spine surgery. The major available evidence of blood conservation strategies is summarized and graded in Table 1.

Table 1

Table 1

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Antifibrinolytic agents

Our search identified three antifibrinolytic agents that were commonly investigated for their effect on blood loss and transfusion rate in spine surgery; tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and aprotinin. A systematic review of 2752 patients from 18 randomized controlled studies (RCTs) and 18 non-RCTs compared the effects of TXA to placebo on blood loss in different perioperative periods in spine surgeries [11▪▪]. TXA was effective at reducing intraoperative blood loss [weighted mean difference (WMD): −280 (−350, −210) ml], postoperative blood loss [WMD: −120 (−155, −86) ml], total blood loss [WMD: −311 (−416, −206) ml], and transfusion rate [odds ratio (OR), 0.33 (0.17, 0.65)]. The subgroup analysis found that low-dose TXA (bolus of up to 10 mg/kg followed by up to 10 mg/kg/h) and high-dose TXA (bolus of 10–100 mg/kg followed by infusion greater than 10 mg/kg/h) had no differences in terms of blood loss reduction. There is no large cohort study primarily investigating the thromboembolic risk of TXA in spine surgery, but a recent systematic review showed no difference compared with placebo (4/1075 vs. 7/1081, P = 0.35). The evidence of EACA to reduce blood loss is less convincing. A meta-analysis of 293 patients from four RCTs found EACA reduced the blood transfusion rate compared with placebo (OR 0.46 [0.22, 0.97]), but not reduced blood loss and the amount of blood transfusion [12]. The same metanalysis including 246 patients from 4 RCTs found aprotinin significantly reduced intraoperative blood loss, but not the total blood loss in the perioperative period [12]. However, aprotinin is no longer approved by Food and Drug Administration (FDA) because of possible renal and cardiovascular toxicity.

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Patient positioning

Suboptimal prone positioning can increase intra-abdominal and intra-thoracic pressure, thereby increasing the transmitted venous pressure to inferior vena cava and epidural veins, leading to increased surgical bleeding in spine surgery. A RCT compared the blood loss between jackknife position (a position with less abdominal compression) and prone position (a position with more abdominal compression) in 40 patients undergoing single-level lumbar discectomy [17]. Patients in jackknife position had significantly less blood loss than those in prone position (100 ± 64 vs. 180 ± 100 ml; P = 0.02). The authors also found the amount of blood loss was correlated with the intra-abdominal pressure. In another RCT, 40 patients were randomized either to be positioned in wide or narrow width chest support on a Wilson frame for patients undergoing posterior lumbar spine fusion surgery [18]. The mean blood loss per level was significantly reduced in the wide width chest support group (190 ± 65 ml) compared with the narrow width chest support group (381 ± 236 ml).

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Intraoperative cell salvage

The routine use of cell salvage is not cost-effective and may not reduce blood transfusion in nonmajor spine surgery. It has been estimated cell salvage is only cost-effective in cases of multiple level spine procedures (>3) and expected blood loss of more than 500 ml [19].

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Minimally invasive surgical technique

With the advancement of technology, surgical techniques have changed over time. A systematic review consisting of 602 patients compared blood loss in minimally invasive surgical techniques to open spinal fusion and decompression [22]. Minimally invasive surgical techniques markedly reduced estimated blood loss (median difference: −331[−490, −172] ml), and hospital length of stay (median difference: −1.7 [−3.0, −0.45] day).

The current evidence suggested prophylactic TXA (either low-dose or high-dose) and optimal prone positioning to avoid abdominal/cava compression are effective interventions. Additionally, both interventions are easy to implement clinically with minimal risks and costs. The authors recommended the routine uses of these two interventions in spine surgery to reduce blood loss. The use of minimally invasive surgical technique also demonstrated to impact blood loss and should be discussed with the surgical team when available and feasible. Cell saver is cost effective and can be considered in patients when blood loss is expected greater than 500 ml.

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Among 179 various procedures, complex spine surgery was ranked among the top six most painful procedures [23]. Poor pain control has been shown to be associated with increased risks of wound healing, hospital-acquired infections, length of stay, expenditure, and delayed mobilization. We summarized and graded commonly used analgesic interventions in Table 2.

Table 2

Table 2

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Pharmacological agents


Despite the fact that paracetamol is frequently used in the perioperative period, our review revealed a conflicting result on its effectiveness on pain score and opioid consumption in the first 24 h postoperatively. Two small single centre RCTs showed small but statistically significant reduction in visual analogue score (VAS) scores (median difference: 0.97–1.2) but no reduction in opioid consumption in the first 24 postoperative hours [31,32]. Another small RCT consisting of 56 patients comparing the effectiveness of paracetamol and dexketoprofen to placebo failed to demonstrate any benefit [33].

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Our search identified a number of studies reporting NSAIDs can effectively reduce postoperative pain and opioid consumption in spine surgeries [34]. A metanalysis of 408 from eight studies showed reduction of VAS score at 24 h (SMD: −1.16 [−1.87, −0.45]) [34]. In the subgroup analysis, the authors found selective COX-2 inhibitors were more effective than the nonselective NSAIDs. The major concerns of using NSAIDs during spine surgery are bone nonunion and bleeding. A systematic review including 12895 orthopedic and spine surgery patients found conflicting and low-quality evidence regarding the nonunion risk of NSAIDs [43]. Another systematic review including 2314 patients undergoing general, orthopaedic, and spine surgery did not find the use of NSAIDs increased postoperative bleeding [44]. Overall, although the current evidence suggest NSAIDs are effective analgesic after spine surgery, more studies are required to delineate the risks of nonunion and bleeding. Thus, we recommend a cautious use of NSAIDs and avoid high dose and prolonged usage (3 days after spine surgery).

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Gabapentinoids, either pregabalin or gabapentin, reduced VAS scores and opioid consumption up to 48 h postoperatively, thereby reduced opioid-related side effects, such as nausea, vomiting, and pruritus [35]. There were no significant differences in the occurrence of sedation, dizziness, headache, visual disturbances, somnolence, or urine retention found in the metanalysis [36].

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A meta-analysis of 649 patients from 14 RCTs investigated the effect of ketamine (either bolus (0.2–1 mg/kg) or infusion (1–4 μg/kg/min)) on pain [38]. Ketamine reduced pain score [MD −1.27 (−1.7, −0.84)] and morphine equivalent consumption [median difference: −14.38 (−18.13, −10.62) mg]. No adverse events including unpleasant dreams, dysphoria, hallucinations, post-operative nausea and vomiting, and sedation were associated with the use of ketamine. One recent RCT of 147 chronic opioid-dependent patients suggested that low-dose intraoperative ketamine may produce extended effects on pain and mobilization at 1 year after spine surgery [39].

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Opioids continue to be the cornerstone for postoperative pain management because of their strong potency. A small RCT found tramadol reduced VAS pain score up to 6 h after surgery [median difference: −2.12 (−3.78, −2.46)] and sedation [42]. Methadone is a long-acting, mu-opioid receptor agonist and N-Methyl-D-aspartic Acid receptor antagonist. A RCT involving 120 patients compared the effect of methadone 0.2 mg/kg at the start of surgery to hydromorphone 2 mg at the end of surgery [41]. Methadone reduced VAS pain score [median difference: −1 (−3, 0)] and morphine equivalent consumption [median difference: −8.2 (−12.1, −4.5) mg] at postoperative 24 h.

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Regional anesthesia

Epidural anesthesia

A metanalysis of 938 patients from 17 RCTs comparing the effects of epidural analgesia (infusion, patient-controlled device, or repeated bolus dosing) and intravenous patient-controlled analgesia following spine surgery showed epidural analgesia reduced postoperative VAS score on postoperative day 1 [SMD: −0.94 (−1.56, −0.31)] as well as reduced opioid consumption in the first 24 h [25]. However, the patients receiving epidural analgesia had 15 times higher risk for motor block [relative risk (RR): 15.07 (2.04, 111.34);] that might potentially hamper the postoperative neurological assessment.

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Intrathecal morphine

In a metanalysis of 8 RCTs of 393 patients, intrathecal morphine at various doses from 0.1 mg up to 1 mg reduced in VAS pain score [SMD: −0.47 (−0.69, −0.25)] and morphine equivalent consumption [SMD: −0.93 (−1.32, −0.53) mg] compared with intravenous opioid at postoperative first 24 h [26]. The intrathecal morphine group, however, experienced more pruritus [OR: 4.09 (1.84, 9.11)] and respiratory depression [OR: 3.48 (0.41, 29.32)] but not nausea, vomiting, postdural puncture headache, and sedation.

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Epidural steroid

A metanalysis of 1727 patients from 17 RCTs and cohort studies investigated the effect of epidural steroids administered at closure during lumbar surgery [27]. The VAS pain score at 24 h was reduced [median difference: −0.97 [−0.14, −1.79)] as was the postoperative use of opioid analgesia [median difference: −6.41 (−2.26, −10.56) units]. The study did not report analysis on the risks of delayed healing and infection.

There is growing evidence suggesting the benefit of neuraxial administration of local anesthetic, opioid, or steroid for postoperative pain control in spine surgery. However, these neuraxial techniques are associated with increased complications that may not be favourable for the patient monitoring and recovery.

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Local anesthetic infiltration

Intramuscular injection of local anesthetic reduced VAS pain score at 1 h, prolonged time to first analgesic demand (median difference: 66 (23–108) min] and 24-h opioid usage [median difference: −9.71 (−4.3, −15.07) mg], but no effect on pain score at 24 h [28]. Subcutaneous infiltration of liposomal bupivacaine, a slow-releasing local anesthetic with effect up to 72 h, did neither reduce pain score nor opioid consumption in most clinical studies [29].

Most above-mentioned analgesic interventions produce mild reduction in pain score and opioid consumption. Therefore, it is likely to require multiple analgesic interventions to achieve optimal postoperative pain control. These analgesic methods were previously investigated individually but not in combination, which is most likely used in the clinical setting or as part of the ERAS spine protocol. Further studies are required to evaluate the combined uses of analgesic methods with the consideration of cost-effectiveness and clinical applicability to ERAS spine protocol. On the basis of the literature, we recommend a combined use of gabapentinoids, ketamine, and opioids.

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Despite the best effort, position-related injury frequently occurs, especially for minor skin and soft tissue injuries. Serious injuries, such as postoperative visual loss (POVL), peripheral nerve injury (PNI), spinal cord injury, and rhabdomyolysis were reported sporadically in the literature. Positioning is often not formally taught to surgeons, anesthesiologists, and nurses, and instructions are usually passed down in an apprenticeship manner. The implementation of an ERAS spine protocol creates an opportunity to incorporate a systematic positioning approach to mitigate the position-related complications.

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Postoperative visual loss

The incidence of POVL after spine surgery is around 0.1% [45]. Around 60% of POVL presents within the 24 h postoperatively. The most common cause of POVL after spine surgery was posterior ischemic optic neuropathy (because of systemic hypotension), followed by central retinal artery occlusion and cortical blindness [16▪]. A case–control study from Anesthesia Closed Claim Analysis database suggested male sex, obesity, the use of the Wilson frame, and prolonged surgical time (>6 h) are independent risk factors of POVL, whereas the use of colloids was a protective factor [46]. The recommended strategy for preventing POVL in spine surgery included continuous blood pressure monitoring, avoiding hypovolemia, anemia, and external ocular compression [16▪].

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Peripheral nerve injury

PNI is uncommon after spine surgery with an incidence of 0.07% [47]. However, previous studies investigated the use of somatosensory evoked potential for spinal cord or cerebral injury during neurosurgical procedures incidentally found 2.15% of patients developed abnormal signals because of malpositioning [48▪▪]. This finding suggests nerve insults occur frequently in spine surgery because of malposition, but most insults are mild and not clinically apparent. The recent Anesthesia Closed Claim Study reported 14% of patients with PNI in the database between 1990 to 2013 were after spine surgery [48▪▪]. More than half of patients suffered from permanent injuries. The mechanism of PNI in spine surgery is likely multifactorial [48▪▪]. The current ASA practical advisory on preventing perioperative PNI recommended careful positioning, padding, and periodic assessment [49]. However, most of these recommendations are based on consensus or level 4–5 evidence.

The current evidence of position-related injuries is limited because of the rarity of these complications. We advocate for a structured team approach, a careful selection of equipment, and utilization of checklists to reduce position-related complications [50].

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The increasing number and complexity of spine procedures that are being performed worldwide create demand and opportunity for an ERAS spine protocol. In our review, we found that only TXA and optimal prone positioning are beneficial with minimal risks to the patients. Many analgesic interventions only have mild analgesic effects, suggesting a multimodal approach is necessary to achieve optimal pain control. Thus, we recommend a multimodal approach of using gabapentinoids and ketamine with opioids. Along with these interventions, we suggest to bundle a structured positioning strategy, including a team-based approach with a checklist, to the ERAS protocol to improve the overall outcome of spine surgery.

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We would like to thank Ms Rachel Sandieson (MLIS), Medical Librarian for her assistance with the systematic search in this article, and Dr Katelyn Komsa for reviewing this article. The senior author, Dr. Jason Chui, would like to acknowledge the contribution of Drs. Alboog and Bae, who both contributed equally as principal author in this article.

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Financial support and sponsorship


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Conflicts of interest

There are no conflicts of interest.

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Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest
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      blood loss; complex spine surgery; enhanced recovery; ERAS; pain management; position-related complications

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