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SNACC Clinical Guidelines and Consensus Statement

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Blacker, Samuel N. MD, FASA*; Vincent, Anita MD; Burbridge, Mark MD; Bustillo, Maria MD§; Hazard, Sprague W. MD; Heller, Benjamin J. MD; Nadler, Jacob W. MD, PhD#; Sullo, Elaine MLS, MAEd**; Lele, Abhijit V. MBBS, MD, MS, FNCS††;  On Behalf of the Society for Neuroscience in Anesthesiology and Critical Care

Author Information
Journal of Neurosurgical Anesthesiology: July 2022 - Volume 34 - Issue 3 - p 257-276
doi: 10.1097/ANA.0000000000000799


It is estimated that upwards of 400,000 patients undergo spinal fusions each year in the United States.1,2 Spinal instrumentation surgeries continue to rise worldwide.3 There has been a 15-fold increase in spine procedures between 2000 and 2007 alone; among this growth, primary lumbar fusion procedures had the largest increase compared with cervical and thoracic spinal fusions.1 Major complex spine surgery (defined as surgery involving 2 or more levels of the spinal column) is associated with in-hospital cardiopulmonary events, stroke and wound complications, prolonged hospitalization, high 30-day hospital readmission rates, and often requires discharge to skilled nursing or rehabilitation facilities.3 A retrospective review of 1,288,496 patients found that mortality for lumbar spine fusion was 0.2%, with over half of the fatalities occurring by postoperative day 9.4 Major complex spine surgery alternatively defined based on associated comorbidities, such as data published from the Spine AdVerse Event Severity (SAVES) system,5 is also associated with increased odds for revision surgery. There is a reported association between deep tissue infection and all-cause mortality.5

The perioperative care of patients undergoing complex spine surgery is a multidisciplinary team effort that incorporates the highest levels of evidence to design standardized patient-centric approaches. Concept and institutional implementation of evidence-based Enhanced Recovery After Surgery (ERAS) clinical pathways aim to incorporate best practice and improve measurable clinical outcomes, including pain, mortality, hospital length of stay, patient satisfaction, and costs.6–9 ERAS pathways have been published to guide the management of patients undergoing different surgery types, including colorectal,10 gynecologic,11 and thoracic surgeries.12 Also, outside of published institutional protocols,9,13–24 the ERAS Society recently published evidence-based ERAS pathway recommendations for lumbar fusion.25 For a specific ERAS pathway, the individual elements of the pathway may not improve measurable outcomes. Rather, the improved outcomes associated with ERAS pathways are likely due to the combination and synergistic effect of all pathway elements and best practices.

A recent systematic review of 22 implemented adult spine surgery pathways26 highlights the variability in outcome measures such as hospital length of stay, opioid consumption, postoperative pain, operative time, patient satisfaction, complication and readmission rates, and overall costs. The most commonly reported outcomes were reduction in hospital length of stay, opioid consumption, and costs. None of the 22 reviewed ERAS pathways were associated with worse outcomes compared with standard pathways.26 Perioperative care encompasses prehospital, preoperative, intraoperative, and postoperative phases.

Although this document was initially intended to address ERAS for spine surgery, based on feedback from the membership of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC), it now aims to provide evidence-based recommendations for the perioperative management of patients undergoing major complex spinal instrumentation surgery. In these guidelines, we have included anesthesia-specific and non–anesthesia-related elements relevant to prehospital, preoperative, intraoperative, and postoperative phases of care, all of which contribute to improved patient outcomes. Perioperative brain health and postoperative delirium reduction are also important but beyond the scope of these guidelines.


In March 2019, all active SNACC members were invited to participate in a task force established to prepare clinical practice guidelines for major complex spine surgery. Eight SNACC members expressed interest in participating; each had clinical experience managing complex spine surgery patients, agreed to the project outline and evidence criteria, and independently examined peer-reviewed studies on complex spine surgery. The completed guideline document was placed on the SNACC Web site for 1 month, and the SNACC membership at large was invited to provide feedback and commentary. In addition, specific feedback was solicited from expert reviewers appointed by SNACC. The authors responded to the feedback from the SNACC membership and expert reviewers, and the final version of these clinical practice guidelines was approved by the SNACC Board of Directors.

Scope of Evidence Reviewed

Anesthesiologists play a vital role in maintaining perioperative anesthetic care standards, reducing practice variability and waste, and improving perioperative outcomes. Due to the heterogeneity and breadth of spine surgery, and to enable a relatively comparative study cohort, we focused on the perioperative management of thoracic and lumbar spine procedures conducted on 2 or more levels. Evaluation of supporting evidence and best practices, when combined, can facilitate the creation of an ERAS pathway for spine surgery patients. When considering perioperative care, we included all relevant care management areas from prehospital to postoperative phases of care. Recommendations are based on best practices, and postoperative outcome measures are stated for areas where data are available.

Literature Review

These clinical practice guidelines present a broad overview of the evidence regarding various components related to overall anesthetic care of patients having major complex spine surgery. The writing group, with the assistance of a medical librarian (E.S.), created a strategy to perform a literature search in the MEDLINE (OVID), Scopus, and Cochrane Library databases using the keywords and relevant MeSH terms (Medical Subject Headings in MEDLINE) listed in the Supplementary Material (Supplemental Digital Content 1: List of MeSH, The search was limited to English-language articles, and search results were limited to studies performed on patients 18 years or older. Studies conducted in children and animals, case reports, book chapters, editorials, letters to the editor, studies including pooled nonspine surgical patients, studies describing only isolated neuromonitoring data, interventional pain therapies, single-level microdiscectomy/laminectomy or minimally invasive procedures, proof of concept studies and device trials were excluded. Studies including isolated cervical spine surgeries were also excluded because cervical spine surgery may differ among concepts, including airway management and perioperative complications, compared with thoracolumbar surgeries. The literature primarily focused on elective surgeries; however, appropriate parallels may be drawn for urgent or emergent procedures.

Three successive levels of the literature review were conducted using a publicly available web-based application ( The Level I screen included a review of article titles and abstracts, and Level II and III screening involved full-text reviews. Each article was independently reviewed by 2 authors responsible for respective sections. Any conflicts that could not be resolved were adjudicated by authors S.N.B. and A.V.L. to determine whether the article should be included in the subsequent level of screening or excluded.

The initial literature search was conducted for articles published between January 1, 2010, and July 31, 2019. A total of 3228 articles were included in the initial Level I review, of which 1315 articles were selected for Level II screening; finally, 675 articles were identified for Level III review (Fig. 1). Sixty-one additional articles meeting inclusion criteria were included following subsequent literature searches during the writing and editing of the manuscript through May 17, 2021, utilizing the same search criteria. The article count listed at the beginning of each section of these guidelines relates to the number (and nature) of spine-related articles identified by the literature search for that particular topic. Other spine and nonspine articles are included in the text for reference and narrative where relevant. The recommendations in these guidelines follow the American College of Cardiology/American Heart Association methodology for assessing the quality of evidence (Supplementary Table 1, Supplemental Digital Content 2,

Flow diagram of the systematic review. The final number of references in the manuscript (n=244), including both spine and nonspine articles, were added after the systematic review was completed to inform the narrative and the clinical practice guidelines.


The evidence related to the perioperative care of patients undergoing major complex spine surgery is summarized in Table 1 and discussed in detail in the following sections.

TABLE 1 - Class of Recommendations and Level of Evidence for Elements to be Considered in Enhanced Recovery Pathway for Patients Undergoing Major Complex Spine Surgery
Phase of Care Details Class of Recommendation Level of Evidence
Scope of the pathway Define complex spine, clarify if applicable to adults or children Class I C-EO
 Preadmission/preoperative assessment Identify significant medical comorbidities, internist consultation Class I C-EO
Dietary consultation for high-risk malnourished patient Class I C-EO
Acute/chronic pain service consultation for high-risk patients Class I C-EO
Counseling for tobacco/substance cessation Class I C-EO
Tobacco cessation, alcohol/substance abuse counseling Class I C-EO
Frailty assessment Class I C-EO
Prehabilitation/preoperative physiotherapy/early rehabilitation Class I C-EO
Identify risk factors for postoperative delirium Class I C-EO
Preadmission (day of surgery) Commercially available carbohydrate drink at least 2 h before procedure start time Class I C-EO
 Anesthesia technique If utilizing volatile agent and IONM, dose <0.5 MAC Class I B-R
If utilizing IONM, avoid abrupt increase in anesthetic dose Class I B-NR
Consider effects of TIVA and volatile effects on IONM Class I B-NR
Informed consent should include IONM risks Class I C-EO
Close communication with IONM team and surgeon Class I C-EO
Dexmedetomidine >0.8 mcg/kg/h may interfere with MEP Class IIa B-R
Padding/secured bite blocks, frequent evaluation of intraoral integrity to prevent intraoral injuries Class IIa C-EO
Lidocaine is likely compatible with IONM Class IIb B-R
Volatile/TIVA/combination Class IIb B-NR
Remifentanil <0.8 mcg/kg/min is compatible with IONM Class IIb B-NR
Avoid NMBD when MEP or EMG are being monitored Class IIb C-EO
 Perioperative analgesia Methadone Class IIa B-R
Wound infiltration Class IIa B-R
Alpha-2 agonists (clonidine/dexmedetomidine) Class IIa B-R
Cyclooxygenase inhibitors Class IIb B-R
Lidocaine infusion Class IIb B-R
Neuraxial (epidural), intrathecal opioids Class IIb B-R
Liposomal bupivacaine Class III (unclear benefit) B-R
Patient-controlled analgesia Class IIb B-R
Acupressure Class IIb B-R
Magnesium Class IIb B-R
Multimodal analgesia regimen Class IIb B-R
Ketamine infusion (bolus 0.1-1 mg/kg+infusion 0.1-0.25 mg/kg/h) intraoperatively and may continue postoperatively Class IIb B-R
Remifentanil infusion as an adjunct without NMBD Class IIb B-R
Remifentanil <0.8 mcg/kg/min for compatibility with IONM Class IIb B-NR
Acetaminophen Class IIb B-NR
Sufentanil/fentanyl infusion Class IIb C-EO
Non-neuraxial blocks Class IIb C-LD
Use of gabapentinoids Class III (no benefit/potential harm) B-R
 Threshold and risk of transfusion, blood conservation Antifibrinolytic therapy (tranexamic acid) Class I A
High-risk group for transfusion Class I B-NR
Serial intraoperative monitoring of hemoglobin/hematocrit Class I C-EO
Amount/rapidity of blood loss, concurrent fluid/acid-base/coagulation profile, systemic perfusion pressure/end-organ function determine perioperative transfusion threshold Class I C-EO
No specific transfusion threshold/transfusion ratio Class IIb B-NR
Preoperative blood donation Class IIb B-NR
Cell salvage Class III (no benefit) A
 Normothermia Core temperature monitoring Class I C-EO
Normothermia (36°C) Class I C-EO
Acceptable techniques (higher ambient room temperature before patient arrival in the operating room, active body surface warmers, and intravenous fluid warmers) Class IIa B-R
 Postoperative nausea and vomiting Multimodal approach to prevent nausea and vomiting Class I B-R
 Mechanical ventilation Use of Jackson surgical table when prone positioning Class I B-R
Higher levels of PEEP (9-12 cm H2O) to prevent atelectasis in prone position Class IIa B-R
Pressure-controlled ventilation Class IIa B-R
Lung protection ventilation (Vt 6-8 mL/kg IBW) Class III (no benefit) B-R
 Fluid management and hemodynamic monitoring Intraoperative invasive/minimally invasive hemodynamic monitoring techniques consistent with institutional standards Class I C-EO
Goal-directed fluid therapy Class IIa B-NR
Balanced salt solution Class IIa B-NR
Colloids and/or crystalloid use for fluid replacement Class IIa C-EO
Invasive arterial blood pressure monitoring Class IIa C-EO
Arterial waveform-based monitoring Class IIb B-NR
 Blood pressure targets Baseline blood pressure, the presence of neurological deficits, and preexisting end-organ injury may influence intraoperative mean arterial blood pressure targets Class I C-EO
 Positioning-related complications Informed consent should include positioning associated risks Class I C-EO
Every effort made to prevent position-related complications Class I C-EO
Periodic position checks during surgery Class I C-EO
 Antibiotics Intravenous antibiotics within 60 min before incision Class I A
 Glycemic control Serial intraoperative glucose monitoring for diabetic patients Class I C-EO
Maintain glucose <180 mg/dL Class I C-EO
 Venous thromboembolism (VTE) prophylaxis Use of nonchemical VTE prophylaxis intraoperatively and postoperatively until appropriate for chemical VTE prophylaxis Class I C-EO
 Postoperative disposition Preoperative and intraoperative factors may affect postoperative ICU/floor/ward admission Class IIb B-NR
 Infection prevention Remove Foley catheter when clinically appropriate to reduce catheter-associated urinary tract infections Class I C-EO
 Postoperative nutrition Early enteral nutrition Class I C-EO
EMG indicates electromyography; IBW, ideal body weight; ICU, intensive care unit; IONM, intraoperative neurophysiological monitoring; MAC, minimum alveolar concentration; MEP, motor-evoked potential; NMBD, neuromuscular blocking drugs; PEEP, positive end-expiratory pressure; TIVA, total intravenous anesthesia; Vt, tidal volume.

Preadmission and Preoperative Considerations

Articles reviewed (16): 6 meta-analysis/systematic reviews, 5 randomized control trials, 2 prospective observational studies, and 3 retrospective cohort studies.

Patients presenting for complex spine procedures may be at risk for adverse perioperative outcomes due to significant medical comorbidities, frailty,28,29 nutritional deficiencies,28,30 chronic uncontrolled pain, chronic opioid use,31 substance abuse,32 and physiological deconditioning.

Preadmission Assessment and Interventions

Preadmission evaluation has many potential benefits, including risk stratification, frailty assessment, identification of the need for postoperative resources in high-risk patients (eg, intensive care and pain services),31 patient education regarding expectations for pain control and quality of life after the surgery, identification of patients who might benefit from prehabilitation and physiotherapy, and those at risk for postoperative delirium.33–36 Commonly reported frailty assessment tools are the frailty index,37 modified 5-item frailty index,28 frailty-based score,38 the clinical frailty scale,39 the metastatic spinal tumor frailty index,29,40 and the FRAIL scale.34 It is hypothesized that the surgical procedure may improve postoperative frailty if deficits improve.39 Prehabilitation has been shown to be feasible41 with promising results,41–43 and without complications in this patient cohort.42 Protein supplementation may increase muscle mass44 and improve physical performance in frail elderly patients.45 Preoperative physiotherapy has decreased pain and risk of avoidance behavior and improved quality of life and physical activity levels.46 Similarly, early rehabilitation can be safely implemented during the first 3 months after lumbar fusion and may include modifying psychological and motor functions.43

Surgeries of urgent or emergent nature may limit the routine use of preadmission multidisciplinary assessment.


  • Whenever possible, a comprehensive preadmission/preoperative assessment should be performed in patients undergoing complex surgeries to address the following areas (Class I, Level of Evidence C-EO):
    • Identification of significant medical comorbidities and a consultation with an internist/specialist for preoperative optimization. This includes but is not limited to cardiopulmonary workup and anemia screening and management.
    • Dietary consultation in a high-risk malnourished patient.
    • Consultation with acute/chronic pain services for high-risk patients.
    • Counseling for tobacco and other substance cessation.
    • Frailty assessment.
    • Prehabilitation/preoperative physiotherapy/early rehabilitation.
    • Identification of risk factors for postoperative delirium.
  • Nil per os should follow American Society of Anesthesiologists (ASA) guidelines, and patients should consume a commercially available carbohydrate drink at least 2 hours before the planned procedure start time (Class I, Level of Evidence C-EO).

Intraoperative Considerations

Anesthetic Technique

Articles reviewed (25): 1 meta-analysis/systematic review, 13 randomized control trials/prospective studies, 10 retrospective cohort studies, 1 medical society guideline.

Total Intravenous Anesthesia (TIVA)

The potential benefits of TIVA include reduced postoperative nausea and vomiting (PONV) and facilitation of intraoperative neurophysiological monitoring (IONM) such as somatosensory-evoked potential (SSEP), motor-evoked potential (MEP), and electromyography monitoring.47–53 Limitations of TIVA are lower titratalibilty compared with volatile agents, risking intraoperative hypotension and the need for vasoactive support, differential context-sensitive half-lives of propofol, remifentanil/sufentanil/fentanyl and their effect on emergence and extubation times, effects of bolus dosing, and possible effects of high-dose remifentanil (0.8 mcg/kg/min) on SSEPs,54 and cumulative dose on neuromonitoring.55–57

Volatile Anesthesia

The potential benefits of volatile anesthetic agents include predictable emergence and extubation profiles. Limitations include PONV, the dose of minimal alveolar concentration53,58–61 and maximal allowed dose to facilitate specific components of IONM safely,62–65 and the effect of abrupt changes in the dose of volatile anesthetics on IONM.66

Patient Safety Concerns for Patients Undergoing MEP Monitoring

Attempts should be made to prevent MEP-associated non-neurological adverse events such as intraoral injury (including tongue lacerations,67,68 lip, mucosal, mandibular,69 or dental injuries67,68) or endotracheal tube rupture due to high extracranial current densities resulting in contraction of the temporalis muscle and forceful closure of the jaw.70 While the incidence of injuries is low (0.63%),68 some can be devastating and require surgical repair in the form of sutures or grafting. Other reported complications of MEP monitoring include seizures and cardiac arrhythmias.69,71

Strategies to prevent MEP monitoring–related injury include the use of padding or soft bite blocks.70 Though bite blocks must be soft enough to prevent dental trauma (avoid rigid bite blocks), they must also be able to resist the force of the human bite. Careful placement of soft bite blocks ensures that the tongue is displaced medially and no part of the tongue sits between the molars. This may be achieved by placing 2 bite blocks, one on either side, with padding anteriorly to prevent tip-of-the-tongue injuries. Clinicians should be aware that bite blocks may shift during patient positioning or MEP stimulation, resulting in their failure.68 Unsecured bite blocks may fall out of the oropharynx when the patient is in the prone position; hence, the anesthesiologist must confirm the secure placement of bite blocks before prone positioning. In addition, all efforts should be made to secure the bite block in place before the initiation of MEP acquisition. There is no high-quality evidence to endorse any commercially available preformed bite blocks.


  • Low-dose volatile agents (not exceeding 0.5 minimum alveolar concentration) are compatible with SSEP and/or MEP monitoring in patients without preexisting neurological deficits (Class I, Level of Evidence B-R).
  • In patients undergoing IONM, a stable concentration of volatile or intravenous anesthetic should be maintained. Abrupt changes in the dose of intravenous and/or volatile agents can interfere with IONM (Class I, Level of Evidence B-NR).
  • When IONM is performed, the effects of volatile and TIVA agents on IONM modalities should be considered (Class I, Level of Evidence B-NR).
  • Closed-loop communication should always be maintained between anesthesiology, neuromonitoring, and surgical teams. Changes in anesthetic dose or IONM signal intensity, and significant changes in IONM data, should be promptly communicated between team members to ensure monitoring quality and patient safety (Class I, Level of Evidence C-EO).
  • Informed consent must be obtained from the patient/legal next of kin regarding potential adverse events related to IONM (Class I, Level of Evidence C-EO).
  • In patients undergoing MEP monitoring, padding/appropriately sized secured soft bite blocks and frequent evaluation of intraoral integrity can be useful in preventing intraoral injuries (Class IIa, Level of Evidence C-EO).
  • Volatile anesthesia or TIVA, or a combination, may be utilized based on patient considerations when not utilizing IONM (Class IIb Level of Evidence B-NR).
  • Caution must be maintained when using remifentanil as high doses (≥0.8 mcg/kg/min) may affect the amplitude of SSEPs (Class IIb, Level of Evidence B-NR).
  • Neuromuscular blocking medications should be avoided when MEPs or electromyography are being monitored (Class IIb, Level of Evidence, C-EO).


Complex spine surgery patients are at risk of significant postoperative acute and chronic pain and chronic opioid use.72 Analgesia is a critical component of perioperative care.


Articles reviewed (10): 6 meta-analysis/systematic reviews, 4 randomized control trials.

The potential benefits of gabapentinoids include reduction in pain scores and morphine consumption at 12 and 24 hours postoperatively,73–76 reduction in preoperative anxiety,77,78 synergistic effects with clonidine,79 and additive effects with dexamethasone.80 Some studies have reported no clinically relevant analgesic effect from the perioperative use of gabapentinoids, and no effect on prevention of postoperative chronic pain or risk of adverse events.81

Gabapentinoids have been associated with the potential for harm, including the risk of respiratory depression with concomitant use of opioids and other central nervous system depressants, in high-risk patients such as those with chronic obstructive pulmonary disease, and with advanced age (US Food and Drug Administration warning).82 Unclear benefits on acute, subacute, and chronic pain have also been reported when gabapentinoids are included in an multimodal analgesia regimen.81,83


  • The usefulness of routine use of perioperative gabapentinoids in multimodal analgesic regimen is not well-established (Class III, Level of Evidence B-R).


Articles reviewed (13): 1 meta-analysis/systematic review, 12 randomized control trials.

The potential benefits of ketamine include reduction in cumulative morphine equivalent consumption and reduced pain scores at 4, 8, 12, and 24 hours following spine surgery,84 and reduced opioid requirements 6 to 12 months after surgery85–87; these effects are superior when ketamine is combined with methadone compared with methadone alone.88 However, one study found no benefit in postoperative quality of recovery scores in the first 48 hours after ketamine use.83 Ketamine is not generally associated with significant adverse events,84 although there may be a risk of postoperative delirium.89

Ketamine dosing recommendations: bolus dose range of 0.1 to 1 mg/kg after intubation,84,87,90,91 followed by infusion at 0.1 to 0.25 mg/kg/h.85,92,93 Infusion rates <0.1 mg/kg/h have not been shown to effectively reduce postoperative opioid requirements,94 especially in the opioid-naive patients.95


  • To reduce opioid consumption in the immediate postoperative period and considering the potential for long-lasting analgesic effects, an infusion of ketamine in the perioperative period (initiated in the intraoperative period and continued into the postoperative period) may be reasonable (Class IIb, Level of Evidence B-R).


Articles reviewed (2): 2 retrospective cohort studies.

There is conflicting evidence for benefit versus no benefit from acetaminophen use, including on reducing opioid consumption,96 opioid-related side effects, and length of stay.97 Generally, acetaminophen has a favorable risk/benefit profile.


  • The routine administration of perioperative acetaminophen for postoperative pain as a part of a multimodal analgesia regimen is not well-established (Class IIb, Level of Evidence B-NR).

Cyclooxygenase Inhibitors

Articles reviewed (2): 1 randomized control trial, 1 retrospective cohort study.

The effect of a single dose of a cyclooxygenase inhibitor on pain reduction is limited to the postanesthesia care unit.98 Cyclooxygenase inhibitor use is associated with the potential for nonunion or failed spinal fusion in patients who smoke tobacco.99


  • After careful patient selection, cyclooxygenase inhibitors may be considered in the perioperative period to reduce postoperative pain (Class IIb, Level of Evidence B-R).

Intravenous Lidocaine Infusion

Articles reviewed (4): 3 randomized control trials, 1 retrospective cohort study.

The potential benefits of lidocaine infusion include reduction in verbal pain scores and opioid requirements at 48 hours postsurgery,100 with no effect on SSEP or MEP monitoring.101,102 Lidocaine infusion has no effect on hospital length of stay100 or 72-hour pain scores.103

Intravenous lidocaine should be administered as a 1 to 1.5 mg/kg bolus followed by an infusion at 1 to 1.5 mg/kg/h.


  • Lidocaine may be considered in the intraoperative and postoperative periods to reduce verbal pain scores and opioid requirements at 48 hours (Class IIb, Level of Evidence B-R).
  • Lidocaine may be safely used for spine surgery patients during IONM (Class IIb, Level of Evidence B-R).

Opioid Analgesics

In patients undergoing propofol-based TIVA, opioids are commonly administered as an infusion during surgery. The choice of opioid (remifentanil, sufentanil, or fentanyl) may depend upon the length of the procedure, concomitant use of neuromuscular blocking agents, and risk of perioperative pulmonary complications.


Articles reviewed (6): 6 randomized control trials.

Concurrent infusion of remifentanil, sufentanil, or fentanyl facilitates propofol-based TIVA in the absence of neuromuscular blocking agents. Preincisional remifentanil infusion is linked to improved immediate postoperative pain scores.104 Potential limitations of remifentanil include opioid-induced hyperalgesia with high doses,105 and the previously highlighted effects of high-dose remifentanil (0.8 mcg/kg/min) on SSEPs.54 Comparisons of remifentanil to other TIVA adjuncts, such as dexmedetomidine favor dexmedetomidine in reducing postoperative pain scores.106,107 The relationship between the context-sensitive half-life of different opioids in relation to the use of propofol or volatile agents may affect the emergence and extubation times.

Remifentanil infusion maximum dose should be <0.8 mcg/kg/min (see Recommendation #8).54 The addition of intraoperative ketamine infusion may blunt opioid-related hyperalgesia.93,108 Remifentanil infusions of 0.16 to 0.3 mcg/kg/min when used as an adjunct to sevoflurane may not cause hyperalgesia.109


  • Remifentanil may be a reasonable adjunct to facilitate TIVA without a neuromuscular blocking agent (Class IIb, Level of Evidence B-R).
  • To facilitate TIVA without a neuromuscular blocking agent, sufentanil or fentanyl may also be reasonable adjuncts (Class IIb, Level of Evidence C-EO).


Articles reviewed (2): 1 randomized control trial, 1 retrospective cohort study.

The potential benefits of methadone include a reduction in pain scores and postoperative opioid requirements by 50%, lasting for up to 72 hours (dose 0.2 mg/kg).110 Postoperative respiratory depression, hypoxemia, need for reintubation, and cardiac complications such as arrhythmias or prolonged corrected QT interval (dose: 0.14±0.07 mg/kg) are reported.111 Methadone can be administered orally 0.2 to 0.3 mg/kg preinduction or as a single intravenous bolus (0.14 to 0.2 mg/kg) intraoperatively.


  • Methadone can be a useful adjunct to TIVA or inhalational anesthetic regimens to reduce pain and opioid requirements (Class IIa, Level of Evidence B-R).

Neuraxial and Regional Anesthesia

Articles reviewed (16): 14 randomized control trials, 1 prospective observational cohort study, 1 retrospective cohort study.

Epidural Analgesia

The potential benefits of intraoperative and/or postoperative epidural analgesia include increased patient satisfaction with decreased pain, lower opioid requirement, earlier mobility, reduced PONV, predictable neuraxial spread, and reduced inflammatory markers in the postoperative period.112–115 There is no benefit in the reduction of inflammatory biomarkers when an epidural catheter is only used postoperatively.114,116

Spinal Anesthesia/Analgesia

Spinal anesthesia is associated with a reduction in visual pain scores117,118 but has no benefit in reducing the duration of anesthesia, surgeon satisfaction, postoperative analgesic requirements, or anesthetic costs.117,118 The use of spinal anesthesia is limited to shorter case times; published literature is restricted to its use in cases <2 hours duration.117,118

Intrathecal morphine (0.1 mg,119 0.3 mg,120,121 or 0.4 mg122) has been shown to reduce the time to rescue opioids and dose of piritramide patient-controlled analgesia,122 whereas intrathecal hydromorphone (0.5 mg)123 is not associated with a reduction in pain scores and opioid dose in the immediate postoperative period. Both agents were found to be safe. Patients receiving intrathecal opioids must be monitored for respiratory depression in the postoperative period and should be admitted to a care area with the capability for end-tidal carbon dioxide and pulse oximetry monitoring.

Regional Anesthesia

Paravertebral blocks reduce postoperative narcotic medication use (50.1% lower on day 2 and 47.1% lower on day 3) but have no benefit on reducing hospital length of stay.124 Thoracolumbar interfascial plane blocks reduce visual pain scores, fentanyl use, and patient-controlled analgesia doses.125 Erector spinae plane blocks lowered pain scores immediately and 6 hours postsurgery, and improved patient satisfaction scores.126,127 The LUMBES trial is investigating whether bilateral lumbar erector spinae blocks are effective in reducing 24-hour postoperative morphine consumption in patients undergoing lumbar interbody fusion surgery.128


  • To reduce postoperative opioid use and improve patient satisfaction, and with careful patient selection and appropriate postoperative neurological and respiratory monitoring, neuraxial techniques (epidural/spinal), or use of intrathecal opioids may be considered an adjunct (Class IIb, Level of Evidence B-R).
  • The usefulness of non-neuraxial regional anesthesia is not well-established (Class IIb, Level of Evidence C-LD).

Patient-controlled Analgesia and Transdermal Analgesia

Article reviewed (3): 2 randomized control trials, 1 retrospective cohort study.

Patient-controlled analgesia allows patient autonomy. Bolus and maximal hourly doses may have to be individualized; thus, a universal dosing regimen may not be applicable.129–131 Clinicians should account for the effects of demand-only patient-controlled analgesia, basal rate patient-controlled analgesia, and transdermal analgesia regarding effects on respiratory depression and the need for capnography and pulse oximetry. The side effects of transdermal analgesia include nausea/vomiting and erythema.131


  • Patient-controlled analgesia may be considered as part of a postoperative multimodal analgesic regimen (Class IIb, Level of Evidence B-R).

Wound Infiltration

Articles reviewed (7): 3 meta-analysis/systematic reviews, 3 randomized control trials, 1 retrospective cohort study.

Wound infiltration with an initial bolus followed by continuous infusion of ropivacaine is reported to reduce postoperative visual pain scores, medication requirements, length of hospital stay,132,133 and PONV.133 Limitations on the total dose of local anesthetic (safety established with appropriate dosing regimens),134,135 and risks for infection (safe in published literature)136 must be taken into account.

In a systematic review,137 the use of liposomal bupivacaine in spine surgery, including pediatric, small and large spine surgeries, safely decreased opioid requirements, pain scores, and length of stay, although the level of evidence is of a low-quality; studies with moderate-quality evidence did not support the use of liposomal bupivacaine.137 A retrospective study of large spinal fusion surgery patients found no difference in overall opioid consumption and no decrease in hospital length of stay with the use of liposomal bupivacaine.138


  • Wound infiltration with local anesthetic may be considered part of a multimodal pain regimen to reduce postoperative pain, PONV, and length of hospital stay (Class IIa, Level of Evidence B-R).
  • The usefulness of liposomal bupivacaine to reduce pain scores, postoperative opioid use, early mobility, and length of stay is not well-established for major spine surgeries (Class III, Level of Evidence C).


Articles reviewed (1): 1 randomized control trial.

Acupressure may reduce postoperative pain intensity, analgesic consumption, and PONV.139


  • Acupressure point therapy may be considered as an adjunct in a multimodal analgesic regimen (Class IIb, Level of Evidence B-R).


Articles reviewed (1): 1 randomized control trial.

Magnesium has been reported to reduce postoperative analgesic requirements.140 However, this evidence derives from a single study with a small sample size.


  • The usefulness of magnesium as an adjunct is not well-established (Class IIb, Level of Evidence B-R).

Alpha-2 Agonists

Articles reviewed (16): 1 meta-analysis/systematic review, 14 randomized control trials, 1 prospective observational study.

Dexmedetomidine may reduce the dose of hypnotic agents,141,142 reduce heart rate responses to intubation and extubation,143 reduce stress144,145 and inflammatory responses,146 reduce the incidence of PONV,147 postoperative fatigue,144 postoperative pain scores and analgesic consumption,107 act as an adjunct to other analgesics for postoperative pain control,148–150 and facilitate intraoperative wake-up testing.151 Dexmedetomidine has not been found to affect SSEPs.150,152–154 Limitations of dexmedetomidine include bradycardia, hypotension (especially with bolus dosing), and heterogenous effects on MEPs.150,152–154

Dexmedetomidine dosing: initial 0.5 to 1 mcg/kg bolus (caution: bradycardia and hypotension) followed by infusion at 0.3 to 1 µg/kg/h; a dose of 0.8 mcg/kg/h should not be exceeded if MEPs are being monitored.150,152–154 Clonidine is administered in a dose of 150 mg (orally/intravenously).155


  • Alpha-2 agonists (clonidine/dexmedetomidine) can be useful analgesic adjuncts during TIVA or inhalational anesthesia to reduce dosing of other agents and opioids, improve postoperative pain, and to reduce PONV (Class IIa, Level of Evidence B-R).
  • If MEPs are monitored, dexmedetomidine should be used in doses <0.8 mcg/kg/h to prevent interference with MEPs (Class IIa, Level of Evidence B-R).

Multimodal Analgesia Regimens

Articles reviewed (5): 1 randomized control trial, 2 retrospective cohort studies, 1 prospective study, 1 narrative review.

Mixed results for the potential benefit/no benefit for the use of multimodal analgesic regimens have been reported.14,31,83,156,157


  • A multimodal analgesic approach may be considered, but a specific regimen cannot be recommended from the literature (Class IIb, Level of Evidence B-R).

Transfusion Management and Antifibrinolytic Use

Risk Factors for Bleeding and Transfusion

Articles reviewed (4): 4 retrospective cohort studies.

Risk factors for intraoperative blood transfusion are anterior spinal instrumentation and fusion (25% to 29% transfusion rate),158 spine deformity, tumor and trauma, multilevel (>3 levels) surgery,159 prolonged operation times, involvement of the sacrum, and open posterior approaches.160,161 Awareness of risk for bleeding and transfusion allows improved blood product resource utilization in the perioperative period.

Transfusion Thresholds and Risks of Transfusion

Articles reviewed (14): 2 meta-analysis/systematic reviews, 12 retrospective cohort studies.

Potential benefits of restrictive packed red cell transfusion strategies include reduced transfusion requirement, reduced transfusion-related adverse events162 such as morbidity,163,164 infectious complications,165–167 and noninfectious complications, reduction in length of stay,168 and reduced costs.163 Restrictive perioperative transfusion policies have been associated with trends in worsening mortality, contrary to that observed in critical care patients.169

There is an unclear benefit of preoperative blood donation and its impact on the need for homologous blood170,171 or on the effect of cell salvage on transfusion rates and total perioperative units of blood transfused.172 Any benefits of balanced transfusion strategies incorporating plasma-reduced red cell: fresh frozen plasma (1:1) and plasma-reduced red cell: platelets (1:4) are also unclear,173 as are any benefits of restrictive174,175 (8 g/dL) versus liberal (10 g/dL) targeted transfusion strategies.


  • Preparation and allocation of resources for transfusion should be considered for the following high-risk groups: age over 50 years, preoperative anemia, multilevel/revision/tumor/deformity/trauma surgeries, and surgeries involving transpedicular osteotomy (Class I, Level of Evidence B-NR).
  • Hemoglobin and hematocrit values should be monitored frequently (every 1 to 2 h or more often on a case-by-case basis) during complex spine procedures (Class I, Level of Evidence C-EO).
  • Anesthesiologists should consider the amount and rapidity of blood loss, the concurrent fluid/acid-base/coagulation profiles, systemic perfusion pressure, and end-organ function in informing perioperative transfusion thresholds ratios (Class I, Level of Evidence C-EO).
  • No specific recommendation can be made for transfusion thresholds or transfusion ratios (Class IIb, Level of Evidence B-NR).
  • Preoperative blood donation may be considered for selected patients undergoing complex spine procedures (Class IIb, Level of Evidence B-NR).
  • Cell salvage may be considered to reduce red blood cell transfusion requirement in patients undergoing complex spine procedures at risk for blood loss (Class III [No benefit], Level of Evidence A).

Antifibrinolytic Therapy

Articles reviewed (11): 5 meta-analysis/systematic reviews, 5 randomized control trials, 1 retrospective cohort study.

The potential benefits of antifibrinolytic therapy such as tranexamic acid include reduced intraoperative blood loss, transfusion needs, and operative times.176–181

When considering dosing schedules, the following factors should be considered: tranexamic acid is associated with dose-dependent reductions in perioperative blood loss,182 and both low-dose and high-dose tranexamic acid use are beneficial.176,183 A typical high-dose tranexamic acid regimen is a 10 mg/kg bolus followed by a 2 mg/kg/h infusion continued until 5 hours postoperatively.182 A typical low-dose tranexamic acid regimen is a 5 mg/kg bolus followed by a 1 mg/kg/h infusion continued until 5 hours postoperatively.182 Emerging data show uncertain benefit for the use of topical tranexamic acid.180,184,185

There is inconclusive evidence that tranexamic acid increases thromboembolism risk in spine surgery patients.186 Seizure risk (cumulative risk=2.7%, 95% confidence interval: 2.0%-3.3%),187 is mostly described in cardiac surgery, with the use of higher doses, and in patients with renal insufficiency/failure.187


  • Intravenous antifibrinolytics such as tranexamic acid (bolus followed by an infusion) are beneficial in reducing intraoperative blood loss and are indicated in complex spine surgeries (Class I, Level of Evidence A).

Intraoperative Normothermia

Articles reviewed (5): 3 randomized control trials, 2 retrospective cohort studies.

Maintenance of intraoperative normothermia reduces blood loss and the incidence of adverse cardiac events and surgical site infections.188 On the contrary, mild hypothermia (35 to 36.5°C) was associated with reduced acute kidney injury after spine surgery in a large (n=6520) retrospective cohort study.189 There is an unclear benefit regarding the type of warming method to maintain normothermia. Devices include electrically-heated humidifiers,190 specially designed thermal gowns,191 active surface warmers192 underbody forced-air warming blanket versus a resistive heating blanket.


  • Core temperature should be monitored (Class I, Level of Evidence C-EO).
  • Normothermia should be maintained (core temperature of >36°C) in the perioperative period (Class I, Level of Evidence C-EO).
  • Higher ambient temperature before the patient arrives in the operating room, active body surface warmers, and intravenous fluid warmers are reasonable techniques to maintain normothermia (Class IIa, Level of Evidence B-R).


Articles reviewed (6): 1 meta-analysis/systematic review, 4 randomized control trials, 1 retrospective cohort study.

Prevention and/or reduction of PONV is associated with improved patient satisfaction, faster hospital discharge, decrease in hospital resource utilization, and reduced risk of aspiration pneumonia, wound dehiscence, dehydration, electrolyte derangements, postoperative bleeding, and delayed early mobilization contributing to venous thromboembolic events.193 Strategies to reduce PONV include dexamethasone (4 mg, every 8 h),194,195 and use of nonopioid medications such as dexmedetomidine147 and proparacetamol (prodrug of acetaminophen).196 5-HT3 antagonists such as ramosetron combined with dexamethasone have been specifically used for fentanyl patient-controlled analgesia-associated nausea and vomiting.197 Amantadine can reduce intraoperative fentanyl and postoperative morphine requirements, as well as reduce the intensity of PONV.198


  • A multimodal approach to PONV prophylaxis is indicated in all patients undergoing complex spine surgeries (Class I, Level of Evidence B-R).

Mechanical Ventilation

Articles reviewed (8): 7 randomized control trials, 1 retrospective cohort study.

The Jackson surgical table reduces intra-abdominal pressure and increases oxygenation index compared with the general surgical table; these effects are more pronounced in overweight patients.199 However, the Jackson table is associated with elevated peak inspiratory airway pressures.200

Pressure-controlled ventilation (compared with volume-controlled ventilation) has several benefits including lower peak airway pressure,201 improved dynamic compliance,202 higher postoperative partial pressure of oxygen levels,202 reduced postoperative glucose and cortisol levels,202 and reduced intraoperative blood loss.203 Higher positive end-expiratory pressure (9 to 12 cm H2O) is required to maintain compliance and regional ventilation in patients in the prone position.204 No benefit of lung-protective ventilation strategies has been observed on reductions in perioperative inflammatory biomarkers205 or on postoperative pulmonary function and oxygenation.206 However, the use of lung-protective ventilation is not associated with harm.205


  • The Jackson surgical table should be used whenever possible to reduce intra-abdominal pressure and improve intraoperative oxygenation in the prone position (Class I, Level of Evidence B-R).
  • Higher levels of positive end-expiratory pressure (9 to 12 cm H2O) may be required to maintain compliance and regional ventilation in the prone position (Class IIa, Level of Evidence B-R).
  • To lower peak airway pressure, improve oxygenation and reduce the risk of surgical bleeding, pressure-controlled ventilation may be considered rather than volume-controlled ventilation. No evidence was found regarding the impact of the mode of ventilation on length of stay, or quality of recovery after spine surgery (Class IIa, Level of Evidence B-R).
  • Lung-protective ventilation (6 to 8 mL/kg ideal body weight) has not been shown to confer benefit when in a prone position but is not harmful (Class III (No Benefit), Level of Evidence B-R).

Fluid Management and Hemodynamic Monitoring

Articles reviewed (15): 3 randomized control trials, 5 prospective observational studies, 5 retrospective cohort studies, 1 narrative review, 1 practice advisory.


Balanced salt solutions reduce the risk of hyperchloremic metabolic acidosis and respiratory acidosis207 but have unclear benefits on coagulopathy, cardiovascular and renal function,208 ocular pressure,209 as well as on total crystalloid volume use and intensive care unit (ICU) length of stay.210

Colloids Versus Crystalloids

Increased administration of crystalloid to colloid ratio is independently associated with delayed extubation.211,212 Intraoperative infusion of balanced 6% hydroxyethyl starch (130/0.4) may result in clinically insignificant changes in postoperative blood loss and coagulation compared with crystalloid.213 Colloid/crystalloid administration in itself may not affect intraocular pressure.209 Colloids may be reasonable for intraoperative use in patients who have substantial blood loss.214

Goal-directed Fluid Therapy and Hemodynamic Monitoring

Hemodynamic monitoring and goal-directed fluid therapy allow optimization of circulatory volume with potential benefits including reduced risk of intraoperative hypotension,215–217 avoidance of interstitial fluid overload (ie, maintenance of euvolemia), optimized cardiac output,218 reduced intraoperative blood loss, reduced intraoperative blood transfusion rate, lower lactate levels, lower postoperative mechanical ventilation rates, faster return of bowel function, and reduced ICU length of stay.219

Pulse pressure variation, stroke volume variation, plethysmographic variability index, and dynamic arterial elastance220,221 are all reasonable trending targets to maintain stroke volume in patients undergoing major complex spine surgery. The superiority of one hemodynamic monitoring technique over another has not been established.


  • Intraoperative invasive/minimally invasive hemodynamic monitoring techniques consistent with institutional standards may be used in patients undergoing complex spine surgeries (Class I, Level of Evidence C-EO).
  • It is reasonable to use goal-directed fluid therapy for complex spine cases (Class IIa, Level of Evidence B-NR).
  • It is reasonable to use a balanced salt solution, especially in procedures with anticipated significant blood loss and fluid resuscitation (Class IIa, Level of Evidence B-NR).
  • To maintain euvolemia, it is reasonable to include colloids and crystalloids in patients with substantial blood loss (Class IIa, Level of Evidence C-EO).
  • Invasive arterial blood pressure monitoring is reasonable for complex spine surgery (Class IIa, Level of Evidence C-EO).
  • Arterial waveform-based monitoring may be useful to guide intraoperative fluid responsiveness (Class IIb, Level of Evidence B-NR).

Blood Pressure Targets

Articles reviewed (9): 7 randomized control trials, 2 retrospective cohort studies.

Blood pressure targets should be set to harmonize fluid and vasoactive medications to maintain systemic and spinal cord perfusion. No evidence was found regarding blood pressure targets during complex spine procedures. A meta-analysis of spinal cord injuries reported a low level of evidence for a recommended mean arterial pressure target ≥85 mm Hg.222 An ongoing multicenter randomized control trial may inform future recommendations.223

The incidence of acute kidney injury after noncardiac surgery is reported to be between 3.9% and 9.8%.224,225 Major risk factors for acute kidney injury include anemia, decreased glomerular filtration rate, elevated risk surgery, ASA physical status, and expected long duration of anesthesia and surgery.224 In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mm Hg) were associated with acute kidney injury (adjusted odds ratio=1.34, 95% confidence interval: 1.16-1.56). Patients with medium risk demonstrated associations between severe range intraoperative hypotension (mean arterial pressure <50 mm Hg) and acute kidney injury (adjusted odds ratio=2.62, 95% confidence interval: 1.65-4.16), while those with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury.224

Potential benefits of optimizing intraoperative blood pressure include maintenance of spinal cord perfusion, protection against acute kidney injury, and maintenance of ocular perfusion pressure. However, specific blood pressure targets for complex spine surgery are not defined. Controlled hypotension can be achieved using various medications.226–232 According to the 2019 practice advisory update from the ASA Task Force on Perioperative Visual Loss, the North American Neuro-Ophthalmology Society, and the SNACC, deliberate hypotension should only be used on a case-by-case basis.214


  • Information related to baseline blood pressure, the presence of neurological deficits, and preexisting end-organ injury may influence intraoperative mean arterial blood pressure targets which must be individualized to the patient (Class I, Level of Evidence C-EO).

Positioning Associated Risks

Articles reviewed (6): 3 practice advisory/systematic reviews, 3 retrospective cohort studies.

Complications may occur during complex spine surgery in supine, prone, and lateral positions. Reported complications include brachial plexus injuries,233 cardiovascular collapse,234 ophthalmologic injury/perioperative vision loss/acute angle-closure glaucoma,214,235 peripheral nerve injury,235 myocutaneous injury,236,237 chest pressure sores,234 oropharyngeal swelling, macroglossia,234 and dislodgement of the endotracheal tube and accidental extubation.234,235 Careful positioning,214 padding of peripheral nerves, use of barrier protection, avoidance of direct pressure on the eyes (to reduce risk of central retinal artery occlusion),214 and periodic position checks are essential to prevent position-associated complications. Suggested positioning for patients at high risk for perioperative vision loss include ensuring that the head is level with or higher than the heart and maintained in a neutral forward position (ie, without significant neck flexion, extension, lateral flexion, or rotation).214


  • Informed consent must be obtained from the patient/legal next of kin regarding the risks associated with positioning (Class I, Level of Evidence C-EO).
  • Every effort must be made to prevent position-related complications (Class I, Level of Evidence C-EO).
  • Whenever possible, periodic position checks must be performed in patients undergoing major complex spine surgery (Class I, Level of Evidence C-EO).

Surgical Site Infections

Articles reviewed (1): 1 clinical practice guideline.

A clinical practice guideline was developed jointly by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Surgical Infection Society, and the Society for Healthcare Epidemiology of America to provide evidence-based recommendations for antimicrobial prophylaxis during surgery.238 Despite appropriate antibiotic use, it is difficult to achieve a surgical site infection rate of 0%, implying that surgical site infections are multifactorial and likely to represent a composite outcome measure. Risk factors for surgical site infection include prolonged preoperative hospitalization, diabetes, elevated serum glucose (≥125 mg/dL preoperatively or ≥200 mg/dL postoperatively), smoking, alcohol abuse, previous surgical site infection, and obesity. Specific procedure-related risk factors include surgery duration >2 to 5 hours, blood loss >1 L, staged procedures, multilevel fusions, screw/plate placement, and combined anterior-posterior fusion.

General considerations regarding surgical site reduction include: (a) intravenous antibiotic prophylaxis; (b) screening for methicillin-resistant Staphylococcus aureus; (c) optimal timing of administration for different antimicrobial agents (eg, vancomycin infusion should be started as early as 120 min before the surgical incision); (d) individualizing drug choice, initial dose, and redosing depending upon renal clearance; (e) continuous quality improvement with adherence to institutional antibiograms, and; (f) glycemic control, as well as the strategies outlined earlier to reduce intraoperative blood loss.


  • Intravenous antibiotics should be administered within 60 minutes before surgical incision, followed by appropriate redosing during surgery (Class I, Level of Evidence A).
  • The recommended antibiotic regimen is cefazolin (2 or 3 g for those >120 kg) or an equivalent first-generation cephalosporin. If there is evidence that gram-negative organisms are the cause of surgical site infection, consider combining clindamycin or vancomycin with another agent, for example, cefazolin for those not beta-lactam allergic or aztreonam/gentamicin/single-dose fluoroquinolone for those beta-lactam allergic (Class I, Level of Evidence A).

Glycemic Control

Articles reviewed (1): 1 systematic review.

According to the Society for Ambulatory Anesthesia and the Endocrine Society, intraoperative blood glucose levels should be maintained between 100 and 180 mg/dL.239 Intravenous insulin is recommended for glycemic control during major complex surgery in patients with anticipated hemodynamic changes, significant fluid shifts, expected changes in temperature, the requirement for inotropes, or lengthy operative times (>4 h).239


  • Serial intraoperative and postoperative glucose monitoring using an intravenous insulin algorithm may be useful to maintain blood glucose <180 mg/dL in diabetic patients (Class I, Level of Evidence C-EO).

Venous Thromboembolism Prophylaxis

Articles reviewed (3): 3 retrospective cohort studies.

The overall rate of venous thromboembolism after elective spine surgery is 0.5% to 1.1%.240–242 Factors associated with postoperative venous thromboembolism include: (1) preoperative factors such as dependent functional status, paraplegia, quadriplegia, disseminated cancer, inpatient status, hypertension, history of transient ischemic attack, sepsis, and African American race; (2) intraoperative factors such as surgery duration >4 hours, emergency presentation, ASA III or greater, intraoperative blood loss >2000 mL, use of packed red blood cell transfusion, deep surgical site infection; and (3) postoperative factors including postoperative sepsis. The addition of low–molecular-weight heparin decreases the incidence of venous thromboembolism compared with mechanical prophylaxis alone (0% vs. 0.59%),242 with no reported cases of epidural hematoma.242


  • To reduce the incidence of perioperative venous thromboembolic complications, nonchemical prophylaxis in the form of sequential compression devices may be applied before induction of general anesthesia and continued until chemical prophylaxis is promptly initiated in the postoperative period (Class I, Level of Evidence C-EO).

Postoperative Care Considerations

Articles reviewed (3): 3 retrospective cohort studies.

Postoperative Care Location

Various factors may affect the postoperative disposition of patients after complex spine surgery. Every attempt must be made to assess the risk-benefit of postoperative admission to an ICU versus admission to a general floor/ward. Institutional factors, such as resource availability, may influence these practices.

Factors that may influence postoperative admission to an ICU versus general ward/floor care include preoperative cardiopulmonary morbidities,243 higher ASA physical status score,243 long-segment fusion, prone position cases with blood loss in excess of 500 mL (829.3±725.1 vs. 448.1±385.2 mL),243 airway edema, postoperative endotracheal intubation/mechanical ventilation status, length of surgery (256.5±84.9 vs. 200.8±80.5 min),243 at risk for acute pain crisis, need to maintain higher mean arterial pressures, need for vasoactive agents, and frequent nursing neurological monitoring (every 1 to 2 h). The use of ERAS pathways may be associated with reduced ICU admissions, and reduced length of ICU stay after spine surgeries.17,24


  • Preoperative and intraoperative factors may be considered when planning patient admission to the ICU or floor/ward (Class IIb, Level of Evidence B-NR).
  • To reduce the incidence of catheter-associated urinary tract infections, urinary catheters should be promptly removed in the postoperative period and patients monitored with serial postvoid residuals with clear guidelines for catheter reinsertion (Class I, Level of Evidence C-EO).
  • Early enteral nutrition should be encouraged in patients after major complex spine surgery (Class I, Level of Evidence C-EO).

Continued Review of Institutional ERAS Pathways

An essential component of enhanced perioperative care in patients undergoing major complex spine surgery is continuous quality improvement. Mere implementation of a protocol is insufficient to improve outcomes.

Some studies have reported benefits of ERAS pathway implementation, including shorter postoperative length of stay,16,19,20,23 reduced ICU length of stay,16,17,24 improved postoperative pain control, reduced opioid use,13,15 accelerated functional recovery with no increase in complications or need for reoperation/readmission,20 fewer rescue antiemetics,21 higher patient satisfaction scores,16,20 and reduced costs.16,17,23 However, other studies found no decrease in length of stay18,21,22 and no reduction in 30-day readmission rates17 or 30-day complication rates.17–19 It is important to note that most studies published regarding spine ERAS pathways included patients undergoing either 1-level or 2-level surgery rather than complex spine surgeries including >2 levels.244


  • Institutions may form a multidisciplinary team of experts for the following reasons (Class I, Level of Evidence C-EO):
    • Identify performance measures.
    • Study the effects of local institutional ERAS pathway implementation.
    • Disseminate information related to trends in performance measures.
    • Audit compliance with existing ERAS pathways.
    • Identify opportunities for quality improvement.
    • Update protocol based on new evidence.


The heterogeneity among institutions regarding various components relevant to anesthetic care of complex spine surgery patients is evident from the review of the published literature; see Table 1 for a summary of the evidence related to the perioperative care of complex spine surgery patients. Future multi-institutional research should focus on the adherence to anesthetic and nonanesthetic components of perioperative care pathways and their impact on shorter recovery times, reduction in anesthetic costs, ICU admissions, ICU/hospital length of stay, patient satisfaction, and overall cost reductions. Attempts should also be made to investigate the impact of prehabilitation medication reconciliation and comprehensive preoperative assessment in greater detail.


These clinical practice guidelines were developed to provide evidence-based recommendations for the perioperative management of patients undergoing major complex spine surgery. Many of the recommendations in these practice guidelines have moderate to low strength and lack a high level of supporting evidence. Anesthesiologists should consider unique institutional/patient-level characteristics when implementing these guidelines. Ongoing and future multi-institutional studies may allow for stronger recommendations with higher quality evidence. Anesthesiologists should incorporate new evidence into local practices as it becomes available.


1. Rajaee SS, Bae HW, Kanim LE, et al. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine (Phila Pa 1976). 2012;37:67–76. doi:10.1097/BRS.0b013e31820cccfb
2. Sheikh SR, Thompson NR, Benzel E, et al. Can we justify it? Trends in the utilization of spinal fusions and associated reimbursement. Neurosurgery. 2020;86:E193–E202. doi: 10.1093/neuros/nyz400
3. Deyo RA, Mirza SK, Martin BI, et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303:1259–1265. doi:10.1001/jama.2010.338
4. Pumberger M, Chiu YL, Ma Y, et al. Perioperative mortality after lumbar spinal fusion surgery: an analysis of epidemiology and risk factors. Eur Spine J. 2012;21:1633–1639. doi:10.1007/s00586-012-2298-8
5. Bari TJ, Karstensen S, Sorensen MD, et al. Revision surgery and mortality following complex spine surgery: 2-year follow-up in a prospective cohort of 679 patients using the Spine AdVerse Event Severity (SAVES) system. Spine Deform. 2020;8:1341–1351. doi:10.1007/s43390-020-00164-8
6. Ljungqvist O, Young-Fadok T, Demartines N. The history of Enhanced Recovery After Surgery and the ERAS Society. J Laparoendosc Adv Surg Tech A. 2017;27:860–862. doi:10.1089/lap.2017.0350
7. Heathcote S Sr, Duggan K, Rosbrugh J, et al. Enhanced Recovery After Surgery (ERAS) protocols expanded over multiple service lines improves patient care and hospital cost. Am Surg. 2019;85:1044–1050. doi:10.1177/000313481908500951
8. Alboog A, Bae S, Chui J. Anesthetic management of complex spine surgery in adult patients: a review based on outcome evidence. Curr Opin Anaesthesiol. 2019;32:600–608. doi:10.1097/ACO.0000000000000765
9. Angus M, Jackson K, Smurthwaite G, et al. The implementation of Enhanced Recovery After Surgery (ERAS) in complex spinal surgery. J Spine Surg. 2019;5:116–123. doi:10.21037/jss.2019.01.07
10. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS(R)) society recommendations: 2018. World J Surg. 2019;43:659–695. doi:10.1007/s00268-018-4844-y
11. Nelson G, Bakkum-Gamez J, Kalogera E, et al. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) society recommendations-2019 update. Int J Gynecol Cancer. 2019;29:651–668. doi:10.1136/ijgc-2019-000356
12. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS(R)) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019;55:91–115. doi:10.1093/ejcts/ezy301
13. Ali ZS, Flanders TM, Ozturk AK, et al. Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution. J Neurosurg Spine. 2019:1–9. doi:10.3171/2018.9.SPINE18681
14. Bhatia A, Buvanendran A. Anesthesia and postoperative pain control-multimodal anesthesia protocol. J Spine Surg. 2019;5(suppl 2):S160–S165. doi:10.21037/jss.2019.09.33
15. Brusko GD, Kolcun JPG, Heger JA, et al. Reductions in length of stay, narcotics use, and pain following implementation of an Enhanced Recovery After Surgery program for 1- to 3-level lumbar fusion surgery. Neurosurg Focus. 2019;46:E4. doi:10.3171/2019.1.FOCUS18692
16. Carr DA, Saigal R, Zhang F, et al. Enhanced perioperative care and decreased cost and length of stay after elective major spinal surgery. Neurosurg Focus. 2019;46:E5. doi:10.3171/2019.1.FOCUS18630
17. Dagal A, Bellabarba C, Bransford R, et al. Enhanced perioperative care for major spine surgery. Spine (Phila Pa 1976). 2019;44:959–966. doi:10.1097/BRS.0000000000002968
18. Grasu RM, Cata JP, Dang AQ, et al. Implementation of an Enhanced Recovery after Spine Surgery program at a large cancer center: a preliminary analysis. J Neurosurg Spine. 2018;29:588–598. doi:10.3171/2018.4.SPINE171317
19. Garg B, Mehta N, Bansal T, et al. Design and implementation of an Enhanced Recovery After Surgery (ERAS) protocol in elective lumbar spine fusion by posterior approach: a retrospective, comparative study. Spine (Phila Pa 1976). 2021;46:E679–E687. doi:10.1097/BRS.0000000000003869
20. Liu B, Liu S, Wang Y, et al. Enhanced recovery after intraspinal tumor surgery: a single-institutional randomized controlled study. World Neurosurg. 2020;136:e542–e552. doi:10.1016/j.wneu.2020.01.067
21. Smith J, Probst S, Calandra C, et al. Enhanced Recovery After Surgery (ERAS) program for lumbar spine fusion. Perioper Med (Lond). 2019;8:4. doi:10.1186/s13741-019-0114-2
22. Soffin EM, Vaishnav AS, Wetmore DS, et al. Design and implementation of an Enhanced Recovery After Surgery (ERAS) program for minimally invasive lumbar decompression spine surgery: initial experience. Spine (Phila Pa 1976). 2019;44:E561–E570. doi:10.1097/BRS.0000000000002905
23. Staartjes VE, de Wispelaere MP, Schroder ML. Improving recovery after elective degenerative spine surgery: 5-year experience with an Enhanced Recovery After Surgery (ERAS) protocol. Neurosurg Focus. 2019;46:E7. doi:10.3171/2019.1.FOCUS18646
24. Ayrian E, Sugeir SH, Arakelyan A, et al. Impact of a perioperative protocol on length of ICU and hospital stay in complex spine surgery. J Neurosurg Anesthesiol. 2021;33:65–72. doi:10.1097/ANA.0000000000000635
25. Debono B, Wainwright TW, Wang MY, et al. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Spine J. 2021;21:729–752. doi:10.1016/j.spinee.2021.01.001
26. Tong Y, Fernandez L, Bendo JA, et al. Enhanced Recovery After Surgery trends in adult spine surgery: a systematic review. Int J Spine Surg. 2020;14:623–640. doi:10.14444/7083
27. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133:e506–e574. doi:10.1161/CIR.0000000000000311
28. Kang T, Park SY, Lee JS, et al. Predicting postoperative complications in patients undergoing lumbar spinal fusion by using the modified five-item frailty index and nutritional status. Bone Joint J. 2020;102-B:1717–1722. doi:10.1302/0301-620X.102B12.BJJ-2020-0874.R1
29. Moskven E, Bourassa-Moreau E, Charest-Morin R, et al. The impact of frailty and sarcopenia on postoperative outcomes in adult spine surgery. A systematic review of the literature. Spine J. 2018;18:2354–2369. doi:10.1016/j.spinee.2018.07.008
30. Adogwa O, Elsamadicy AA, Mehta AI, et al. Preoperative nutritional status is an independent predictor of 30-day hospital readmission after elective spine surgery. Spine (Phila Pa 1976). 2016;41:1400–1404. doi:10.1097/BRS.0000000000001551
31. Devin CJ, McGirt MJ. Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. J Clin Neurosci. 2015;22:930–938. doi:10.1016/j.jocn.2015.01.003
32. Sanden B, Forsth P, Michaelsson K. Smokers show less improvement than nonsmokers two years after surgery for lumbar spinal stenosis: a study of 4555 patients from the Swedish spine register. Spine (Phila Pa 1976). 2011;36:1059–1064. doi:10.1097/BRS.0b013e3181e92b36
33. Baek W, Kim YM, Lee H. Risk factors of postoperative delirium in older adult spine surgery patients: a meta-analysis. AORN J. 2020;112:650–661. doi:10.1002/aorn.13252
34. Susano MJ, Grasfield RH, Friese M, et al. Brief preoperative screening for frailty and cognitive impairment predicts delirium after spine surgery. Anesthesiology. 2020;133:1184–1191. doi:10.1097/ALN.0000000000003523
35. Wu X, Sun W, Tan M. Incidence and risk factors for postoperative delirium in patients undergoing spine surgery: a systematic review and meta-analysis. Biomed Res Int. 2019;2019:2139834. doi:10.1155/2019/2139834
36. Nazemi AK, Gowd AK, Carmouche JJ, et al. Prevention and management of postoperative delirium in elderly patients following elective spinal surgery. Clin Spine Surg. 2017;30:112–119. doi:10.1097/BSD.0000000000000467
37. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorld Journal. 2001;1:323–336. doi:10.1100/tsw.2001.58
38. Medvedev G, Wang C, Cyriac M, et al. Complications, readmissions, and reoperations in posterior cervical fusion. Spine (Phila Pa 1976). 2016;41:1477–1483. doi:10.1097/BRS.0000000000001564
39. Flexman AM, Street J, Charest-Morin R. The impact of frailty and sarcopenia on patient outcomes after complex spine surgery. Curr Opin Anaesthesiol. 2019;32:609–615. doi:10.1097/ACO.0000000000000759
40. De la Garza Ramos R, Goodwin CR, Jain A, et al. Development of a Metastatic Spinal Tumor Frailty Index (MSTFI) using a nationwide database and its association with inpatient morbidity, mortality, and length of stay after spine surgery. World Neurosurg. 2016;95:548.e4–555.e4. doi:10.1016/j.wneu.2016.08.029
41. Lotzke H, Brisby H, Gutke A, et al. A person-centered prehabilitation program based on cognitive-behavioral physical therapy for patients scheduled for lumbar fusion surgery: a randomized controlled trial. Phys Ther. 2019;99:1069–1088. doi:10.1093/ptj/pzz020
42. Nielsen PR, Jorgensen LD, Dahl B, et al. Prehabilitation and early rehabilitation after spinal surgery: randomized clinical trial. Clin Rehabil. 2010;24:137–148. doi:10.1177/0269215509347432
43. Abbott AD, Tyni-Lenne R, Hedlund R. Early rehabilitation targeting cognition, behavior, and motor function after lumbar fusion: a randomized controlled trial. Spine (Phila Pa 1976). 2010;35:848–857. doi:10.1097/BRS.0b013e3181d1049f
44. Tieland M, Dirks ML, van der Zwaluw N, et al. Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc. 2012;13:713–719. doi:10.1016/j.jamda.2012.05.020
45. Tieland M, van de Rest O, Dirks ML, et al. Protein supplementation improves physical performance in frail elderly people: a randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc. 2012;13:720–726. doi:10.1016/j.jamda.2012.07.005
46. Lindback Y, Tropp H, Enthoven P, et al. PREPARE: presurgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial. Spine J. 2018;18:1347–1355. doi:10.1016/j.spinee.2017.12.009
47. Konstantopoulos K, Makris A, Moustaka A, et al. Sevoflurane versus propofol anesthesia in patients undergoing lumbar spondylodesis: a randomized trial. J Surg Res. 2013;179:72–77. doi:10.1016/j.jss.2012.09.038
48. Lin WL, Lee MS, Wong CS, et al. Effects of intraoperative propofol-based total intravenous anesthesia on postoperative pain in spine surgery: comparison with desflurane anesthesia—a randomised trial. Medicine (Baltimore). 2019;98:e15074. doi:10.1097/MD.0000000000015074
49. Yoo KY, Lee MK, Jeong CW, et al. Anaesthetic requirement and stress hormone responses in patients undergoing lumbar spine surgery: anterior vs. posterior approach. Acta Anaesthesiol Scand. 2009;53:1012–1017. doi:10.1111/j.1399-6576.2009.01993.x
50. Lu CH, Wu ZF, Lin BF, et al. Faster extubation time with more stable hemodynamics during extubation and shorter total surgical suite time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in lengthy lumbar spine surgery. J Neurosurg Spine. 2016;24:268–274. doi:10.3171/2015.4.SPINE141143
51. Mishra L, Pradhan S, Pradhan C. Comparison of propofol based anaesthesia to conventional inhalational general anaesthesia for spine surgery. J Anaesthesiol Clin Pharmacol. 2011;27:59–61.
52. Subramanian A, Wanta BT, Fogelson JL, et al. Time to extubation during propofol anesthesia for spine surgery with sufentanil compared with fentanyl: a retrospective cohort study. Spine (Phila Pa 1976). 2014;39:1758–1764. doi:10.1097/BRS.0000000000000509
53. Chan S, Horng H, Huang S, et al. Drug cost analysis of three anesthetic regimens in prolonged lumbar spinal surgery. J Med Sci. 2009;29:75–80.
54. Asouhidou I, Katsaridis V, Vaidis G, et al. Somatosensory evoked potentials suppression due to remifentanil during spinal operations; a prospective clinical study. Scoliosis. 2010;5:8. doi:10.1186/1748-7161-5-8
55. Ushirozako H, Yoshida G, Kobayashi S, et al. Impact of total propofol dose during spinal surgery: anesthetic fade on transcranial motor evoked potentials. J Neurosurg Spine. 2019:1–9. doi:10.3171/2018.10.SPINE18322
56. Lyon R, Feiner J, Lieberman JA. Progressive suppression of motor evoked potentials during general anesthesia: the phenomenon of “Anesthetic Fade”. J Neurosurg Anesthesiol. 2005;17:13–19.
57. Liu HY, Zeng HY, Cheng H, et al. Comparison of the effects of etomidate and propofol combined with remifentanil and guided by comparable BIS on transcranial electrical motor-evoked potentials during spinal surgery. J Neurosurg Anesthesiol. 2012;24:133–138. doi:10.1097/ANA.0b013e31823dfb2e
58. Liu EH, Wong HK, Chia CP, et al. Effects of isoflurane and propofol on cortical somatosensory evoked potentials during comparable depth of anaesthesia as guided by bispectral index. Br J Anaesth. 2005;94:193–197. doi:10.1093/bja/aei003
59. Lo YL, Dan YF, Tan YE, et al. Intraoperative motor-evoked potential monitoring in scoliosis surgery: comparison of desflurane/nitrous oxide with propofol total intravenous anesthetic regimens. J Neurosurg Anesthesiol. 2006;18:211–214. doi:10.1097/01.ana.0000211007.94269.50
60. Chong CT, Manninen P, Sivanaser V, et al. Direct comparison of the effect of desflurane and sevoflurane on intraoperative motor-evoked potentials monitoring. J Neurosurg Anesthesiol. 2014;26:306–312. doi:10.1097/ANA.0000000000000041
61. Tamkus AA, Rice KS, Kim HL. Differential rates of false-positive findings in transcranial electric motor evoked potential monitoring when using inhalational anesthesia versus total intravenous anesthesia during spine surgeries. Spine J. 2014;14:1440–1446. doi:10.1016/j.spinee.2013.08.037
62. Chen Z. The effects of isoflurane and propofol on intraoperative neurophysiological monitoring during spinal surgery. J Clin Monit Comput. 2004;18:303–308. doi:10.1007/s10877-005-5097-5
63. Boisseau N, Madany M, Staccini P, et al. Comparison of the effects of sevoflurane and propofol on cortical somatosensory evoked potentials. Br J Anaesth. 2002;88:785–789. doi:10.1093/bja/88.6.785
64. Sloan TB, Toleikis JR, Toleikis SC, et al. Intraoperative neurophysiological monitoring during spine surgery with total intravenous anesthesia or balanced anesthesia with 3% desflurane. J Clin Monit Comput. 2015;29:77–85. doi:10.1007/s10877-014-9571-9
65. Pelosi L, Stevenson M, Hobbs GJ, et al. Intraoperative motor evoked potentials to transcranial electrical stimulation during two anaesthetic regimens. Clin Neurophysiol. 2001;112:1076–1087. doi:10.1016/S1388-2457(01)00529-6
66. Wang AC, Than KD, Etame AB, et al. Impact of anesthesia on transcranial electric motor evoked potential monitoring during spine surgery: a review of the literature. Neurosurg Focus. 2009;27:E7. doi:10.3171/2009.8.FOCUS09145
67. Yoshida G, Imagama S, Kawabata S, et al. Adverse events related to transcranial electric stimulation for motor-evoked potential monitoring in high-risk spinal surgery. Spine (Phila Pa 1976). 2019;44:1435–1440. doi:10.1097/BRS.0000000000003115
68. Tamkus A, Rice K. The incidence of bite injuries associated with transcranial motor-evoked potential monitoring. Anesth Analg. 2012;115:663–667. doi:10.1213/ANE.0b013e3182542331
69. MacDonald DB. Safety of intraoperative transcranial electrical stimulation motor evoked potential monitoring. J Clin Neurophysiol. 2002;19:416–429. doi:10.1097/00004691-200210000-00005
70. Legatt AD, Emerson RG, Epstein CM, et al. ACNS guideline: transcranial electrical stimulation motor evoked potential monitoring. J Clin Neurophysiol. 2016;33:42–50. doi:1 0.1097/WNP.0000000000000253
71. Davis SF, Kalarickal P, Strickland T. A report of two cases of lip and tongue bite injury associated with transcranial motor evoked potentials. Am J Electroneurodiagnostic Technol. 2010;50:313–320. doi:10.1080/1086508X.2010.11079785
72. Dunn LK, Yerra S, Fang S, et al. Incidence and risk factors for chronic postoperative opioid use after major spine surgery: a cross-sectional study with longitudinal outcome. Anesth Analg. 2018;127:247–254. doi:10.1213/ANE.0000000000003338
73. Fujita N, Tobe M, Tsukamoto N, et al. A randomized placebo-controlled study of preoperative pregabalin for postoperative analgesia in patients with spinal surgery. J Clin Anesth. 2016;31:149–153. doi:10.1016/j.jclinane.2016.01.010
74. Kim JC, Choi YS, Kim KN, et al. Effective dose of peri-operative oral pregabalin as an adjunct to multimodal analgesic regimen in lumbar spinal fusion surgery. Spine (Phila Pa 1976). 2011;36:428–433. doi:10.1097/BRS.0b013e3181d26708
75. Jiang HL, Huang S, Song J, et al. Preoperative use of pregabalin for acute pain in spine surgery: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2017;96:e6129. doi:10.1097/MD.0000000000006129
76. Peng C, Li C, Qu J, et al. Gabapentin can decrease acute pain and morphine consumption in spinal surgery patients: a meta-analysis of randomized controlled trials. Med (Baltimore). 2017;96:e6463. doi:10.1097/MD.0000000000006463
77. Chauhan V, Yadav R, Chaturvedi A, et al. Effect of pregabalin on preoperative anxiety and postoperative pain in spine surgery: a randomized controlled study. J Neuroanesthesiol Crit Care. 2017;5:8–14. doi: 10.1055/s-0037-1616037
78. Liu B, Liu R, Wang L. A meta-analysis of the preoperative use of gabapentinoids for the treatment of acute postoperative pain following spinal surgery. Medicine. 2017;96:e8031. doi:10.1097/MD.0000000000008031
79. Bala R, Kaur J, Sharma J, et al. Comparative evaluation of pregabalin and clonidine as preemptive analgesics for the attenuation of postoperative pain following thoracolumbar spine surgery. Asian Spine J. 2019;13:967–975. doi:10.31616/asj.2019.0031
80. Choi YS, Shim JK, Song JW, et al. Combination of pregabalin and dexamethasone for postoperative pain and functional outcome in patients undergoing lumbar spinal surgery: a randomized placebo-controlled trial. Clin J Pain. 2013;29:9–14. doi:10.1097/AJP.0b013e318246d1a9
81. Verret M, Lauzier F, Zarychanski R, et al. Perioperative use of gabapentinoids for the management of postoperative acute pain: a systematic review and meta-analysis. Anesthesiology. 2020;133:265–279. doi:10.1097/ALN.0000000000003428
82. US Food & Drug Administration. FDA warns about serious breathing problems with seizure and nerve pain medicines gabapentin (Neurontin, Gralise, Horizant) and pregabalin (Lyrica, Lyrica CR); 2019. Available at: Accessed November 25, 2020.
83. Maheshwari K, Avitsian R, Sessler DI, et al. Multimodal analgesic regimen for spine surgery: a randomized placebo-controlled trial. Anesthesiology. 2020;132:992–1002. doi:10.1097/ALN.0000000000003143
84. Pendi A, Field R, Farhan SD, et al. Perioperative ketamine for analgesia in spine surgery: a meta-analysis of randomized controlled trials. Spine (Phila Pa 1976). 2018;43:E299–E307. doi:10.1097/BRS.0000000000002318
85. Nielsen RV, Fomsgaard JS, Nikolajsen L, et al. Intraoperative S-ketamine for the reduction of opioid consumption and pain one year after spine surgery: a randomized clinical trial of opioid-dependent patients. Eur J Pain. 2019;23:455–460. doi:10.1002/ejp.1317
86. Nielsen RV, Fomsgaard JS, Siegel H, et al. Intraoperative ketamine reduces immediate postoperative opioid consumption after spinal fusion surgery in chronic pain patients with opioid dependency: a randomized, blinded trial. Pain. 2017;158:463–470. doi:10.1097/j.pain.0000000000000782
87. Loftus RW, Yeager MP, Clark JA, et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology. 2010;113:639–646. doi:10.1097/ALN.0b013e3181e90914
88. Pacreu S, Fernandez Candil J, Molto L, et al. The perioperative combination of methadone and ketamine reduces post-operative opioid usage compared with methadone alone. Acta Anaesthesiol Scand. 2012;56:1250–1256. doi:10.1111/j.1399-6576.2012.02743.x
89. Elsamadicy AA, Charalambous LT, Sergesketter AR, et al. Intraoperative ketamine may increase risk of post-operative delirium after complex spinal fusion for adult deformity correction. J Spine Surg. 2019;5:79–87. doi:10.21037/jss.2018.12.10
90. Song JW, Shim JK, Song Y, et al. Effect of ketamine as an adjunct to intravenous patient-controlled analgesia, in patients at high risk of postoperative nausea and vomiting undergoing lumbar spinal surgery. Br J Anaesth. 2013;111:630–635. doi:10.1093/bja/aet192
91. Garg N, Panda NB, Gandhi KA, et al. Comparison of small dose ketamine and dexmedetomidine infusion for postoperative analgesia in spine surgery—a prospective randomized double-blind placebo controlled study. J Neurosurg Anesthesiol. 2016;28:27–31. doi:10.1097/ANA.0000000000000193
92. Kim SH, Kim SI, Ok SY, et al. Opioid sparing effect of low dose ketamine in patients with intravenous patient-controlled analgesia using fentanyl after lumbar spinal fusion surgery. Korean J Anesthesiol. 2013;64:524–528. doi:10.4097/kjae.2013.64.6.524
93. Hadi BA, Al Ramadani R, Daas R, et al. Remifentanil in combination with ketamine versus remifentanil in spinal fusion surgery—a double blind study. Int J Clin Pharmacol Ther. 2010;48:542–548. doi:10.5414/CPP48542
94. Subramaniam K, Akhouri V, Glazer PA, et al. Intra- and postoperative very low dose intravenous ketamine infusion does not increase pain relief after major spine surgery in patients with preoperative narcotic analgesic intake. Pain Med. 2011;12:1276–1283. doi:10.1111/j.1526-4637.2011.01144.x
95. Boenigk K, Echevarria GC, Nisimov E, et al. Low-dose ketamine infusion reduces postoperative hydromorphone requirements in opioid-tolerant patients following spinal fusion: a randomised controlled trial. Eur J Anaesthesiol. 2019;36:8–15. doi:10.1097/EJA.0000000000000877
96. Smith AN, Hoefling VC. A retrospective analysis of intravenous acetaminophen use in spinal surgery patients. Pharm Pract (Granada). 2014;12:417. doi:10.4321/s1886-36552014000300004
97. Morwald EE, Poeran J, Zubizarreta N, et al. Intravenous acetaminophen does not reduce inpatient opioid prescription or opioid-related adverse events among patients undergoing spine surgery. Anesth Analg. 2018;127:1221–1228. doi:10.1213/ANE.0000000000003344
98. Siribumrungwong K, Cheewakidakarn J, Tangtrakulwanich B, et al. Comparing parecoxib and ketorolac as preemptive analgesia in patients undergoing posterior lumbar spinal fusion: a prospective randomized double-blinded placebo-controlled trial. BMC Musculoskelet Disord. 2015;16:59. doi:10.1186/s12891-015-0522-5
99. Reuben SS, Ablett D, Kaye R. High dose nonsteroidal anti-inflammatory drugs compromise spinal fusion. Can J Anaesth. 2005;52:506–512. doi:10.1007/BF03016531
100. Farag E, Ghobrial M, Sessler DI, et al. Effect of perioperative intravenous lidocaine administration on pain, opioid consumption, and quality of life after complex spine surgery. Anesthesiology. 2013;119:932–940. doi:10.1097/ALN.0b013e318297d4a5
101. Urban MK, Fields K, Donegan SW, et al. A randomized crossover study of the effects of lidocaine on motor- and sensory-evoked potentials during spinal surgery. Spine J. 2017;17:1889–1896. doi:10.1016/j.spinee.2017.06.024
102. Sloan TB, Mongan P, Lyda C, et al. Lidocaine infusion adjunct to total intravenous anesthesia reduces the total dose of propofol during intraoperative neurophysiological monitoring. J Clin Monit Comput. 2014;28:139–147. doi:10.1007/s10877-013-9506-x
103. Dewinter G, Moens P, Fieuws S, et al. Systemic lidocaine fails to improve postoperative morphine consumption, postoperative recovery and quality of life in patients undergoing posterior spinal arthrodesis. A double-blind, randomized, placebo-controlled trial. Br J Anaesth. 2017;118:576–585. doi:10.1093/bja/aex038
104. Gerlach K, Uhlig T, Hppe M, et al. Postoperative analgesia after preincisional administration of remifentanil. Minerva Anestesiol. 2003;69:563–569; 569–573.
105. Yeom JH, Kim KH, Chon MS, et al. Remifentanil used as adjuvant in general anesthesia for spinal fusion does not exhibit acute opioid tolerance. Korean J Anesthesiol. 2012;63:103–107. doi:10.4097/kjae.2012.63.2.103
106. Rahimzadeh P, Faiz SH, Alimian M, et al. Remifentanil versus dexmedtomidine for posterior spinal fusion surgery. Med J Islam Repub Iran. 2015;29:215.
107. Hwang W, Lee J, Park J, et al. Dexmedetomidine versus remifentanil in postoperative pain control after spinal surgery: a randomized controlled study. BMC Anesthesiol. 2015;15:21. doi:10.1186/s12871-015-0004-1
108. Onaka M, Yamamoto H. Balanced anesthesia with continuous ketamine reduces adverse effects of remifentanil. Masui. 2008;57:1218–1222.
109. Yeom JH, Kim KH, Chon M, et al. Remifentanil used as adjuvant in general anesthesia for spinal fusion does not exhibit acute opioid tolerance. Korean J Anesthesiol. 2012;63:103–107. doi:10.4097/kjae.2012.63.2.103
110. Gottschalk A, Durieux ME, Nemergut EC. Intraoperative methadone improves postoperative pain control in patients undergoing complex spine surgery. Anesth Analg. 2011;112:218–223. doi:10.1213/ANE.0b013e3181d8a095
111. Dunn LK, Yerra S, Fang S, et al. Safety profile of intraoperative methadone for analgesia after major spine surgery: an observational study of 1478 patients. J Opioid Manag. 2018;14:83–87. doi:10.5055/jom.2018.0435
112. Ezhevskaya AA, Mlyavykh SG, Anderson DG. Effects of continuous epidural anesthesia and postoperative epidural analgesia on pain management and stress response in patients undergoing major spinal surgery. Spine (Phila Pa 1976). 2013;38:1324–1330. doi:10.1097/BRS.0b013e318290ff26
113. Schenk MR, Putzier M, Kugler B, et al. Postoperative analgesia after major spine surgery: patient-controlled epidural analgesia versus patient-controlled intravenous analgesia. Anesth Analg. 2006;103:1311–1317. doi:10.1213/01.ane/0000247966.49492.72
114. Servicl-Kuchler D, Maldini B, Borgeat A, et al. The influence of postoperative epidural analgesia on postoperative pain and stress response after major spine surgery—a randomized controlled double blind study. Acta Clin Croat. 2014;53:176–183.
115. Gottschalk A, Freitag M, Tank S, et al. Quality of postoperative pain using an intraoperatively placed epidural catheter after major lumbar spinal surgery. Anesthesiology. 2004;101:175–180. doi:10.1097/00000542-200407000-00027
116. Volk T, Schenk M, Voigt K, et al. Postoperative epidural anesthesia preserves lymphocyte, but not monocyte, immune function after major spine surgery. Anesth Analg. 2004;98:1086–1092. doi:10.1213/01.ANE.0000104586.12700.3A
117. Kahveci K, Doger C, Ornek D, et al. Perioperative outcome and cost-effectiveness of spinal versus general anesthesia for lumbar spine surgery. Neurol Neurochir Pol. 2014;48:167–173. doi:10.1016/j.pjnns.2014.05.005
118. Attari MA, Mirhosseini SA, Honarmand A, et al. Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: a randomized clinical trial. J Res Med Sci. 2011;16:524–529.
119. De Bie A, Siboni R, Smati MF, et al. Intrathecal morphine injections in lumbar fusion surgery: case-control study. Orthop Traumatol Surg Res. 2020;106:1187–1190. doi:10.1016/j.otsr.2020.02.024
120. Techanivate A, Kiatgungwanglia P, Yingsakmongkol W. Spinal morphine for post-operative analgesia after lumbar laminectomy with fusion. J Med Assoc Thai. 2003;86:262–269.
121. Boezaart AP, Eksteen JA, Spuy GV, et al. Intrathecal morphine. Double-blind evaluation of optimal dosage for analgesia after major lumbar spinal surgery. Spine (Phila Pa 1976). 1999;24:1131–1137. doi:10.1097/00007632-199906010-00013
122. Ziegeler S, Fritsch E, Bauer C, et al. Therapeutic effect of intrathecal morphine after posterior lumbar interbody fusion surgery: a prospective, double-blind, randomized study. Spine (Phila Pa 1976). 2008;33:2379–2386. doi:10.1097/BRS.0b013e3181844ef2
123. Aglio LS, Abd-El-Barr MM, Orhurhu V, et al. Preemptive analgesia for postoperative pain relief in thoracolumbosacral spine operations: a double-blind, placebo-controlled randomized trial. J Neurosurg Spine. 2018;29:647–653. doi:10.3171/2018.5.SPINE171380
124. Elder JB, Hoh DJ, Wang MY. Postoperative continuous paravertebral anesthetic infusion for pain control in lumbar spinal fusion surgery. Spine (Phila Pa 1976). 2008;33:210–218. doi:10.1097/BRS.0b013e318160447a
125. Ueshima H, Hara E, Otake H. Thoracolumbar interfascial plane block provides effective perioperative pain relief for patients undergoing lumbar spinal surgery; a prospective, randomized and double blinded trial. J Clin Anesth. 2019;58:12–17. doi:10.1016/j.jclinane.2019.04.026
126. Singh S, Choudhary NK, Lalin D, et al. Bilateral ultrasound-guided erector spinae plane block for postoperative analgesia in lumbar spine surgery: a randomized control trial. J Neurosurg Anesthesiol. 2020;32:330–334. doi:10.1097/ANA.0000000000000603
127. Yayik AM, Cesur S, Ozturk F, et al. Postoperative analgesic efficacy of the ultrasound-guided erector spinae plane block in patients undergoing lumbar spinal decompression surgery: a randomized controlled study. World Neurosurg. 2019;126:e779–e785. doi:10.1016/j.wneu.2019.02.149
128. Breebaart MB, Van Aken D, De Fre O, et al. A prospective randomized double-blind trial of the efficacy of a bilateral lumbar erector spinae block on the 24h morphine consumption after posterior lumbar inter-body fusion surgery. Trials. 2019;20:441. doi:10.1186/s13063-019-3541-y
129. Lee SH, Baek CW, Kang H, et al. A comparison of 2 intravenous patient-controlled analgesia modes after spinal fusion surgery: constant-rate background infusion versus variable-rate feedback infusion, a randomized controlled trial. Medicine (Baltimore). 2019;98:e14753. doi:10.1097/MD.0000000000014753
130. Day MA, Rich MA, Thorn BE, et al. A placebo-controlled trial of midazolam as an adjunct to morphine patient-controlled analgesia after spinal surgery. J Clin Anesth. 2014;26:300–308. doi:10.1016/j.jclinane.2013.12.011
131. Lindley EM, Milligan K, Farmer R, et al. Patient-controlled transdermal fentanyl versus intravenous morphine pump after spine surgery. Orthopedics. 2015;38:e819–e824. doi:10.3928/01477447-20150902-61
132. Bianconi M, Ferraro L, Ricci R, et al. The pharmacokinetics and efficacy of ropivacaine continuous wound instillation after spine fusion surgery. Anesth Analg. 2004;98:166–172. doi:10.1213/01.ANE.0000093310.47375.44
133. Xu B, Ren L, Tu W, et al. Continuous wound infusion of ropivacaine for the control of pain after thoracolumbar spinal surgery: a randomized clinical trial. Eur Spine J. 2017;26:825–831. doi:10.1007/s00586-015-3979-x
134. Greze J, Vighetti A, Incagnoli P, et al. Does continuous wound infiltration enhance baseline intravenous multimodal analgesia after posterior spinal fusion surgery? A randomized, double-blinded, placebo-controlled study. Eur Spine J. 2017;26:832–839. doi:10.1007/s00586-016-4428-1
135. Liu SS, Richman JM, Thirlby RC, et al. Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg. 2006;203:914–932. doi:10.1016/j.jamcollsurg.2006.08.007
136. Kjærgaard M, Møiniche S, Olsen KS. Wound infiltration with local anesthetics for post-operative pain relief in lumbar spine surgery: a systematic review. Acta Anaesthesiol Scand. 2012;56:282–290. doi:10.1111/j.1399-6576.2011.02629.x
137. Nguyen TH, Iturriaga C, Verma R. Efficacy of liposomal bupivacaine in spine surgery: a systematic review. Spine J. 2021:S1529-9430(21)00085-1. [Epub ahead of print]. doi:10.1016/j.spinee.2021.02.014
138. Chung AS, Crandall D, Revella J, et al. Does local administration of liposomal bupivacaine reduce pain and narcotic consumption in adult spinal deformity surgery? Global Spine J. 2021;11:896–902. doi:10.1177/2192568220931053
139. Chung YC, Chien HC, Chen HH, et al. Acupoint stimulation to improve analgesia quality for lumbar spine surgical patients. Pain Manag Nurs. 2014;15:738–747. doi:10.1016/j.pmn.2013.07.010
140. Levaux C, Bonhomme V, Dewandre PY, et al. Effect of intra-operative magnesium sulphate on pain relief and patient comfort after major lumbar orthopaedic surgery. Anaesthesia. 2003;58:131–135. doi:10.1046/j.1365-2044.2003.02999.x
141. Mariappan R, Ashokkumar H, Kuppuswamy B. Comparing the effects of oral clonidine premedication with intraoperative dexmedetomidine infusion on anesthetic requirement and recovery from anesthesia in patients undergoing major spine surgery. J Neurosurg Anesthesiol. 2014;26:192–197. doi:10.1097/ANA.0b013e3182a2166f
142. Sen S, Chakraborty J, Santra S, et al. The effect of dexmedetomidine infusion on propofol requirement for maintenance of optimum depth of anaesthesia during elective spine surgery. Indian J Anaesth. 2013;57:358–363. doi:10.4103/0019-5049.118558
143. Li BY, Geng ZY, Wang DX. Effect of dexmedetomidine infusion on postoperative recovery for patients undergoing major spinal surgery during propofol anesthesia. Beijing Da Xue Xue Bao Yi Xue Ban. 2016;48:529–533.
144. Bekker A, Haile M, Kline R, et al. The effect of intraoperative infusion of dexmedetomidine on the quality of recovery after major spinal surgery. J Neurosurg Anesthesiol. 2013;25:16–24. doi:10.1097/ANA.0b013e31826318af
145. Kim MH, Lee KY, Bae SJ, et al. Intraoperative dexmedetomidine attenuates stress responses in patients undergoing major spine surgery. Minerva Anestesiol. 2019;85:468–477. doi:10.23736/S0375-9393.18.12992-0
146. Zhou H, Lu J, Shen Y, et al. Effects of dexmedetomidine on CD42a(+)/CD14(+), HLADR(+)/CD14(+) and inflammatory cytokine levels in patients undergoing multilevel spinal fusion. Clin Neurol Neurosurg. 2017;160:54–58. doi:10.1016/j.clineuro.2017.06.012
147. Song Y, Shim JK, Song JW, et al. Dexmedetomidine added to an opioid-based analgesic regimen for the prevention of postoperative nausea and vomiting in highly susceptible patients: a randomised controlled trial. Eur J Anaesthesiol. 2016;33:75–83. doi:10.1097/EJA.0000000000000327
148. Demuro JP, Botros D, Nedeau E, et al. Use of dexmedetomidine for postoperative analgesia in spine patients. J Neurosurg Sci. 2013;57:171–174.
149. Lin S, Dai N, Cheng Z, et al. Effect of dexmedetomidine-etomidate-fentanyl combined anesthesia on somatosensory- and motor-evoked potentials in patients undergoing spinal surgery. Exp Ther Med. 2014;7:1383–1387. doi:10.3892/etm.2014.1555
150. Li Y, Meng L, Peng Y, et al. Effects of dexmedetomidine on motor- and somatosensory-evoked potentials in patients with thoracic spinal cord tumor: a randomized controlled trial. BMC Anesthesiol. 2016;16:51. doi:10.1186/s12871-016-0217-y
151. Chen Z, Dai N, Lin S, et al. Impact of dexmedetomidine on intraoperative wake-up tests in patients undergoing spinal surgery. J Perianesth Nurs. 2018;33:448–452. doi:10.1016/j.jopan.2016.07.009
152. Chen Z, Lin S, Shao W. Effects on somatosensory and motor evoked potentials of senile patients using different doses of dexmedetomidine during spine surgery. Ir J Med Sci. 2015;184:813–818. doi:10.1007/s11845-014-1178-0
153. Bala E, Sessler DI, Nair DR, et al. Motor and somatosensory evoked potentials are well maintained in patients given dexmedetomidine during spine surgery. Anesthesiology. 2008;109:417–425. doi:10.1097/ALN.0b013e318182a467
154. Rozet I, Metzner J, Brown M, et al. Dexmedetomidine does not affect evoked potentials during spine surgery. Anesth Analg. 2015;121:492–501. doi:10.1213/ANE.0000000000000840
155. Reena, Vikram A. Comparative evaluation of clonidine and magnesium sulfate infusions upon intraoperative hemodynamics and anesthetic consumption, and postoperative recovery profile in lumbar spine surgery: a prospective, randomized, placebo controlled, double-blind study. Acta Anaesthesiol Belg. 2017;1:31–38.
156. Mathiesen O, Dahl B, Thomsen BA, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eur Spine J. 2013;22:2089–2096. doi:10.1007/s00586-013-2826-1
157. Wainwright TW, Immins T, Middleton RG. Enhanced Recovery After Surgery (ERAS) and its applicability for major spine surgery. Best Pract Res Clin Anaesthesiol. 2016;30:91–102. doi:10.1016/j.bpa.2015.11.001
158. Ristagno G, Beluffi S, Menasce G, et al. Incidence and cost of perioperative red blood cell transfusion for elective spine fusion in a high-volume center for spine surgery. BMC Anesthesiol. 2018;18:121. doi:10.1186/s12871-018-0591-8
159. Butler JS, Burke JP, Dolan RT, et al. Risk analysis of blood transfusion requirements in emergency and elective spinal surgery. Eur Spine J. 2011;20:753–758. doi:10.1007/s00586-010-1500-0
160. Morcos MW, Jiang F, McIntosh G, et al. Predictors of blood transfusion in posterior lumbar spinal fusion: a Canadian spine Outcome and Research Network Study. Spine (Phila Pa 1976). 2018;43:E35–E39. doi:10.1097/BRS.0000000000002115
161. Lenoir B, Merckx P, Paugam-Burtz C, et al. Individual probability of allogeneic erythrocyte transfusion in elective spine surgery: the predictive model of transfusion in spine surgery. Anesthesiology. 2009;110:1050–1060. doi:10.1097/ALN.0b013e31819df9e0
162. Purvis TE, Goodwin CR, Molina CA, et al. Transfusion of red blood cells stored more than 28 days is associated with increased morbidity following spine surgery. Spine (Phila Pa 1976). 2018;43:947–953. doi:10.1097/BRS.0000000000002464
163. Purvis TE, Goodwin CR, De la Garza-Ramos R, et al. Effect of liberal blood transfusion on clinical outcomes and cost in spine surgery patients. Spine J. 2017;17:1255–1263. doi:10.1016/j.spinee.2017.04.028
164. Fominskiy E, Putzu A, Monaco F, et al. Liberal transfusion strategy improves survival in perioperative but not in critically ill patients. A meta-analysis of randomised trials. Br J Anaesth. 2015;115:511–519. doi:10.1093/bja/aev317
165. Janssen SJ, Braun Y, Wood KB, et al. Allogeneic blood transfusions and postoperative infections after lumbar spine surgery. Spine J. 2015;15:901–909. doi:10.1016/j.spinee.2015.02.010
166. Kato S, Chikuda H, Ohya J, et al. Risk of infectious complications associated with blood transfusion in elective spinal surgery-a propensity score matched analysis. Spine J. 2016;16:55–60. doi:10.1016/j.spinee.2015.10.014
167. Purvis TE, Goodwin CR, Molina CA, et al. Percentage change in hemoglobin level and morbidity in spine surgery patients. J Neurosurg Spine. 2018;28:345–351. doi:10.3171/2017.7.SPINE17301
168. Purvis TE, Wang TY, Sankey EW, et al. Defining usage and clinical outcomes following perioperative fresh frozen plasma and platelet administration in spine surgery patients. Clin Spine Surg. 2019;32:E246–E251. doi:10.1097/BSD.0000000000000815
169. Chong MA, Krishnan R, Cheng D, et al. Should transfusion trigger thresholds differ for critical care versus perioperative patients? A meta-analysis of randomized trials. Crit Care Med. 2018;46:252–263. doi:10.1097/CCM.0000000000002873
170. Cha CW, Deible C, Muzzonigro T, et al. Allogeneic transfusion requirements after autologous donations in posterior lumbar surgeries. Spine (Phila Pa 1976). 2002;27:99–104. doi:10.1097/00007632-200201010-00023
171. Hamdan H, Tobing SDL, Sapardan S. Comparing the usage of autologous blood transfusion with homologous blood transfusion in spine surgery. Med J Indonesia. 2004;13:17–23. doi:10.13181/mji.v13i1.126
172. Cheriyan J, Cheriyan T, Dua A, et al. Efficacy of intraoperative cell salvage in spine surgery: a meta-analysis. J Neurosurg Spine. 2020:1–9. doi:10.3171/2019.12.SPINE19920
173. Rankin D, Zuleta-Alarcon A, Soghomonyan S, et al. Massive blood loss in elective spinal and orthopedic surgery: retrospective review of intraoperative transfusion strategy. J Clin Anesth. 2017;37:69–73. doi:10.1016/j.jclinane.2016.10.017
174. Wass CT, Long TR, Faust RJ, et al. Changes in red blood cell transfusion practice during the past two decades: a retrospective analysis, with the Mayo database, of adult patients undergoing major spine surgery. Transfusion. 2007;47:1022–1027. doi:10.1111/j.1537-2995.2007.01231.x
175. Perez JJ, Yanamadala V, Wright AK, et al. Outcomes surrounding perioperative transfusion rates and hemoglobin Nadir values following complex spine surgery. World Neurosurg. 2019;126:e1287–e1292. doi:10.1016/j.wneu.2019.03.079
176. Hui S, Xu D, Ren Z, et al. Can tranexamic acid conserve blood and save operative time in spinal surgeries? A meta-analysis. Spine J. 2018;18:1325–1337. doi:10.1016/j.spinee.2017.11.017
177. Badeaux J, Hawley D. A systematic review of the effectiveness of intravenous tranexamic acid administration in managing perioperative blood loss in patients undergoing spine surgery. J Perianesth Nurs. 2014;29:459–465. doi:10.1016/j.jopan.2014.06.003
178. Lu VM, Ho YT, Nambiar M, et al. The perioperative efficacy and safety of antifibrinolytics in adult spinal fusion surgery: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2018;43:E949–E958. doi:10.1097/BRS.0000000000002580
179. Berenholtz SM, Pham JC, Garrett-Mayer E, et al. Effect of epsilon aminocaproic acid on red-cell transfusion requirements in major spinal surgery. Spine (Phila Pa 1976). 2009;34:2096–2103. doi:10.1097/BRS.0b013e3181b1fab2
180. Ren Z, Li S, Sheng L, et al. Topical use of tranexamic acid can effectively decrease hidden blood loss during posterior lumbar spinal fusion surgery: a retrospective study. Medicine (Baltimore). 2017;96:e8233. doi:10.1097/MD.0000000000008233
181. Li G, Sun TW, Luo G, et al. Efficacy of antifibrinolytic agents on surgical bleeding and transfusion requirements in spine surgery: a meta-analysis. Eur Spine J. 2017;26:140–154. doi:10.1007/s00586-016-4792-x
182. Kim KT, Kim CK, Kim YC, et al. The effectiveness of low-dose and high-dose tranexamic acid in posterior lumbar interbody fusion: a double-blinded, placebo-controlled randomized study. Eur Spine J. 2017;26:2851–2857. doi:10.1007/s00586-017-5230-4
183. Carabini LM, Moreland NC, Vealey RJ, et al. A randomized controlled trial of low-dose tranexamic acid versus placebo to reduce red blood cell transfusion during complex multilevel spine fusion surgery. World Neurosurg. 2018;110:e572–e579. doi:10.1016/j.wneu.2017.11.070
184. Sudprasert W, Tanaviriyachai T, Choovongkomol K, et al. A randomized controlled trial of topical application of tranexamic acid in patients with thoracolumbar spine trauma undergoing long-segment instrumented posterior spinal fusion. Asian Spine J. 2019;13:146–154. doi:10.31616/asj.2018.0125
185. Hui S, Tao L, Mahmood F, et al. Tranexamic acid in reducing gross hemorrhage and transfusions of spine surgeries (TARGETS): study protocol for a prospective, randomized, double-blind, non-inferiority trial. Trials. 2019;20:125. doi:10.1186/s13063-019-3231-9
186. Yoo JS, Ahn J, Karmarkar SS, et al. The use of tranexamic acid in spine surgery. Ann Transl Med. 2019;7(suppl 5):S172. doi:10.21037/atm.2019.05.36
187. Lin Z, Xiaoyi Z. Tranexamic acid-associated seizures: a meta-analysis. Seizure. 2016;36:70–73. doi:10.1016/j.seizure.2016.02.011
188. Guest JD, Vanni S, Silbert L. Mild hypothermia, blood loss and complications in elective spinal surgery. Spine J. 2004;4:130–137. doi:10.1016/j.spinee.2003.08.027
189. Oh TK, Ryu JH, Sohn HM, et al. Intraoperative hypothermia is associated with reduced acute kidney injury after spine surgery under general anesthesia: a retrospective observational study. J Neurosurg Anesthesiol. 2020;32:63–69. doi:10.1097/ANA.0000000000000552
190. Lee HK, Jang YH, Choi KW, et al. The effect of electrically heated humidifier on the body temperature and blood loss in spinal surgery under general anesthesia. Korean J Anesthesiol. 2011;61:112–116. doi:10.4097/kjae.2011.61.2.112
191. Lee WP, Wu PY, Shih WM, et al. The effectiveness of the newly designed thermal gown on hypothermic patients after spinal surgery. J Clin Nurs. 2015;24:2779–2787. doi:10.1111/jocn.12873
192. Hassani V, Chaichian S, Rahimizadeh A, et al. Comparative study of the effect of warming at various temperatures on biochemical, hematologic, and hemodynamic parameters during spinal fusion surgery under intravenous anesthesia. Anesth Pain Med. 2018;8:e79814. doi:10.5812/aapm.79814
193. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118:85–113. doi:10.1213/ANE.0000000000000002
194. Parthasarathi G, Koshy T, Sinha P, et al. A survey on the effect of multi-dose administration of dexamethasone on postoperative nausea and vomiting following spinal surgery. J Anaesthesiol Clin Pharmacol. 2010;26:247–249.
195. Yang SY, Jun NH, Choi YS, et al. Efficacy of dexamethasone added to ramosetron for preventing postoperative nausea and vomiting in highly susceptible patients following spine surgery. Korean J Anesthesiol. 2012;62:260–265. doi:10.4097/kjae.2012.62.3.260
196. Kim EJ, Shim JK, Soh S, et al. Patient-controlled analgesia with propacetamol-fentanyl mixture for prevention of postoperative nausea and vomiting in high-risk patients undergoing spine surgery: a randomized controlled trial. J Neurosurg Anesthesiol. 2016;28:316–322. doi:10.1097/ANA.0000000000000252
197. Choi YS, Shim JK, Yoon DH, et al. Effect of ramosetron on patient-controlled analgesia related nausea and vomiting after spine surgery in highly susceptible patients: comparison with ondansetron. Spine (Phila Pa 1976). 2008;33:E602–E606. doi:10.1097/BRS.0b013e31817c6bde
198. Bujak-Gizycka B, Kacka K, Suski M, et al. Beneficial effect of amantadine on postoperative pain reduction and consumption of morphine in patients subjected to elective spine surgery. Pain Med. 2012;13:459–465. doi:10.1111/j.1526-4637.2011.01321.x
199. Ni L, Fan Y, Bian J, et al. Effect of body mass on oxygenation and intra-abdominal pressure when using a Jackson surgical table in the prone position during lumbar surgery. Spine. 2018;43:965–970. doi:10.1097/BRS.0000000000002505
200. Nam Y, Yoon AM, Kim YH, et al. The effect on respiratory mechanics when using a Jackson surgical table in the prone position during spinal surgery. Korean J Anesthesiol. 2010;59:323–328. doi:10.4097/kjae.2010.59.5.323
201. Jo YY, Kim JY, Kwak YL, et al. The effect of pressure-controlled ventilation on pulmonary mechanics in the prone position during posterior lumbar spine surgery: a comparison with volume-controlled ventilation. J Neurosurg Anesthesiol. 2012;24:14–18. doi:10.1097/ANA.0b013e31822c6523
202. Purohit S, Gupta D. Comparative analysis of effect of pressure controlled and volume controlled ventilation on respiratory mechanics, haemodynamics and systemic stress response in patients undergoing lumbar spine surgery in prone position. J Neurosurg Anesthesiol. 2018;30:413. doi: 10.1097/ANA.0000000000000531
203. Kang WS, Oh CS, Kwon WK, et al. Effect of mechanical ventilation mode type on intra- and postoperative blood loss in patients undergoing posterior lumbar interbody fusion surgery: a randomized controlled trial. Anesthesiology. 2016;125:115–123. doi:10.1097/ALN.0000000000001131
204. Spaeth J, Daume K, Goebel U, et al. Increasing positive end-expiratory pressure (re-)improves intraoperative respiratory mechanics and lung ventilation after prone positioning. Br J Anaesth. 2016;116:838–846. doi:10.1093/bja/aew115
205. Memtsoudis SG, Bombardieri AM, Ma Y, et al. The effect of low versus high tidal volume ventilation on inflammatory markers in healthy individuals undergoing posterior spine fusion in the prone position: a randomized controlled trial. J Clin Anesth. 2012;24:263–269. doi:10.1016/j.jclinane.2011.08.003
206. Soh S, Shim JK, Ha Y, et al. Ventilation with high or low tidal volume with PEEP does not influence lung function after spinal surgery in prone position: a randomized controlled trial. J Neurosurg Anesthesiol. 2018;30:237–245. doi:10.1097/ANA.0000000000000428
207. Takil A, Eti Z, Irmak P, et al. Early postoperative respiratory acidosis after large intravascular volume infusion of lactated Ringer’s solution during major spine surgery. Anesth Analg. 2002;95:294–298. doi:10.1213/00000539-200208000-00006
208. Song JW, Shim JK, Kim NY, et al. The effect of 0.9% saline versus plasmalyte on coagulation in patients undergoing lumbar spinal surgery; a randomized controlled trial. Int J Surg. 2015;20:128–134. doi:10.1016/j.ijsu.2015.06.065
209. Farag E, Sessler DI, Kovaci B, et al. Effects of crystalloid versus colloid and the alpha-2 agonist brimonidine versus placebo on intraocular pressure during prone spine surgery: a factorial randomized trial. Anesthesiology. 2012;116:807–815. doi:10.1097/ALN.0b013e3182475c10
210. Nahtomi-Shick O, Kostuik JP, Winters BD, et al. Does intraoperative fluid management in spine surgery predict intensive care unit length of stay? J Clin Anesth. 2001;13:208–212. doi:10.1016/S0952-8180(01)00244-6
211. Ramchandran S, Day LM, Line B, et al. The impact of different intraoperative fluid administration strategies on postoperative extubation following multilevel thoracic and lumbar spine surgery: a propensity score matched analysis. Neurosurgery. 2019;85:31–40. doi:10.1093/neuros/nyy226
212. Li F, Gorji R, Tallarico R, et al. Risk factors for delayed extubation in thoracic and lumbar spine surgery: a retrospective analysis of 135 patients. J Anesth. 2014;28:161–166. doi:10.1007/s00540-013-1689-2
213. Jang MS, Han JH, Lee S, et al. Postoperative blood loss and coagulation changes after balanced 6% hydroxyethyl starch 130/0.4 administration during spine surgery: a retrospective study. Clin Spine Surg. 2019;32:E65–E70. doi:10.1097/BSD.0000000000000727
214. Practice advisory for perioperative visual loss associated with spine surgery 2019: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Visual Loss, the North American Neuro-Ophthalmology Society, and the Society for Neuroscience in Anesthesiology and Critical Care. Anesthesiology. 2019;130:12–30. doi:10.1097/ALN.0000000000002503
215. Yang SY, Shim JK, Song Y, et al. Validation of pulse pressure variation and corrected flow time as predictors of fluid responsiveness in patients in the prone position. Br J Anaesth. 2013;110:713–720. doi:10.1093/bja/aes475
216. Kim DH, Shin S, Kim JY, et al. Pulse pressure variation and pleth variability index as predictors of fluid responsiveness in patients undergoing spinal surgery in the prone position. Ther Clin Risk Manag. 2018;14:1175–1183. doi:10.2147/TCRM.S170395
217. Poon KS, Wu KC, Chen CC, et al. Hemodynamic changes during spinal surgery in the prone position. Acta Anaesthesiol Taiwan. 2008;46:57–60. doi:10.1016/S1875-4597(08)60026-0
218. Lobo DN, Macafee DA, Allison SP. How perioperative fluid balance influences postoperative outcomes. Best Pract Res Clin Anaesthesiol. 2006;20:439–455. doi:10.1016/j.bpa.2006.03.004
219. Bacchin MR, Ceria CM, Giannone S, et al. Goal-directed fluid therapy based on stroke volume variation in patients undergoing major spine surgery in the prone position: a cohort study. Spine (Phila Pa 1976). 2016;41:E1131–E1137. doi:10.1097/BRS.0000000000001601
220. Lee CT, Lee TS, Chiu CT, et al. Mini-fluid challenge test predicts stroke volume and arterial pressure fluid responsiveness during spine surgery in prone position: a STARD-compliant diagnostic accuracy study. Medicine (Baltimore). 2020;99:e19031. doi:10.1097/MD.0000000000019031
221. Bar S, Leviel F, Abou Arab O, et al. Dynamic arterial elastance measured by uncalibrated pulse contour analysis predicts arterial-pressure response to a decrease in norepinephrine. Br J Anaesth. 2018;121:534–540. doi:10.1016/j.bja.2018.01.032
222. Yue JK, Tsolinas RE, Burke JF, et al. Vasopressor support in managing acute spinal cord injury: current knowledge. J Neurosurg Sci. 2019;63:308–317. doi:10.23736/S0390-5616.17.04003-6
223. US National Library of Medicine Randomized trial of early hemodynamic management of patients following acute spinal cord injury (TEMPLE); 2020. Available at: Accessed February 14, 2021.
224. Mathis MR, Naik BI, Freundlich RE, et al. Preoperative risk and the association between hypotension and postoperative acute kidney injury. Anesthesiology. 2020;132:461–475. doi:10.1097/ALN.0000000000003063
225. Naik BI, Colquhoun DA, McKinney WE, et al. Incidence and risk factors for acute kidney injury after spine surgery using the RIFLE classification. J Neurosurg Spine. 2014;20:505–511. doi:10.3171/2014.2.SPINE13596
226. Jamaliya RH, Chinnachamy R, Maliwad J, et al. The efficacy and hemodynamic response to Dexmedetomidine as a hypotensive agent in posterior fixation surgery following traumatic spine injury. J Anaesthesiol Clin Pharmacol. 2014;30:203–207. doi:10.4103/0970-9185.130021
227. Nazir O, Wani MA, Ali N, et al. Use of dexmedetomidine and esmolol for hypotension in lumbar spine surgery. Trauma Mon. 2016;21:e22078. doi:10.5812/traumamon.22078
228. Mohamed HS, Asida SM, Salman OH. Dexmedetomidine versus nimodipine for controlled hypotension during spine surgery. Egypt J Anaesth. 2019;29:325–331. doi:10.1016/j.egja.2013.06.002
229. Hwang W, Kim E. The effect of milrinone on induced hypotension in elderly patients during spinal surgery: a randomized controlled trial. Spine J. 2014;14:1532–1537. doi:10.1016/j.spinee.2013.09.028
230. Ghodraty MR, Homaee MM, Farazmehr K, et al. Comparative induction of controlled circulation by magnesium and remifentanil in spine surgery. World J Orthop. 2014;5:51–56. doi:10.5312/wjo.v5.i1.51
231. Kurt F, Derbent A, Demirag K, et al. Old method, new drugs: comparison of the efficacy of sevoflurane, isoflurane, and desflurane in achieving controlled hypotension in spinal surgery. Adv Ther. 2005;22:234–240. doi:10.1007/BF02849932
232. Beaussier M, Paugam C, Deriaz H, et al. Haemodynamic stability during moderate hypotensive anaesthesia for spinal surgery. A comparison between desflurane and isoflurane. Acta Anaesthesiol Scand. 2000;44:1154–1159. doi:10.1034/j.1399-6576.2000.440921.x
233. Uribe JS, Kolla J, Omar H, et al. Brachial plexus injury following spinal surgery. J Neurosurg Spine. 2010;13:552–558. doi:10.3171/2010.4.SPINE09682
234. Kwee MM, Ho YH, Rozen WM. The prone position during surgery and its complications: a systematic review and evidence-based guidelines. Int Surg. 2015;100:292–303. doi:10.9738/INTSURG-D-13-00256.1
235. Shriver MF, Zeer V, Alentado VJ, et al. Lumbar spine surgery positioning complications: a systematic review. Neurosurg Focus. 2015;39:E16. doi:10.3171/2015.7.FOCUS15268
236. DePasse JM, Palumbo MA, Haque M, et al. Complications associated with prone positioning in elective spinal surgery. World J Orthop. 2015;6:351–359. doi:10.5312/wjo.v6.i3.351
237. Kamel I, Barnette R. Positioning patients for spine surgery: avoiding uncommon position-related complications. World J Orthop. 2014;5:425–443. doi:10.5312/wjo.v5.i4.425
238. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195–283. doi:10.2146/ajhp120568
239. Duggan EW, Carlson K, Umpierrez GE. Perioperative hyperglycemia management: an update. Anesthesiology. 2017;126:547–560. doi:10.1097/ALN.0000000000001515
240. Wang TY, Sakamoto JT, Nayar G, et al. Independent predictors of 30-day perioperative deep vein thrombosis in 1346 consecutive patients after spine surgery. World Neurosurg. 2015;84:1605–1612. doi:10.1016/j.wneu.2015.07.008
241. Piper K, Algattas H, DeAndrea-Lazarus IA, et al. Risk factors associated with venous thromboembolism in patients undergoing spine surgery. J Neurosurg Spine. 2017;26:90–96. doi:10.3171/2016.6.SPINE1656
242. Fawi HMT, Saba K, Cunningham A, et al. Venous thromboembolism in adult elective spinal surgery: a tertiary centre review of 2181 patients. Bone Joint J. 2017;99-B:1204–1209. doi:10.1302/0301-620X.99B9.BJJ-2016-1193.R2
243. Kay HF, Chotai S, Wick JB, et al. Preoperative and surgical factors associated with postoperative intensive care unit admission following operative treatment for degenerative lumbar spine disease. Eur Spine J. 2016;25:843–849. doi:10.1007/s00586-015-4175-8
244. Khanna P, Sarkar S, Garg B. Anesthetic considerations in spine surgery: what orthopaedic surgeon should know!. J Clin Orthop Trauma. 2020;11:742–748. doi:10.1016/j.jcot.2020.05.005

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