Anaesthetic management of a patient undergoing

corrective surgery for Kyphoscoliosis

Dr Madhavi Desai
Associate Professor
 Definitions
• Kyphosis: anterior concavity ( thoracic, sacral)
• Lordosis: anterior convexity ( Lumbar, Cervical)

• Scoliosis: “crooked ”
lateral rotation of the spine greater than 10
degrees
accompanied by vertebral rotation in
thoracolumbar spine

The curve is defined as facing to the right or to the

left, depending on the convexity of the curve
 Classification
Type Causes
Congenital Vertebral, rib anomaly

Idiopathic : 70% Infantile (<3 years)

Juvenile (3 to 10 years)
Adolescent (> 10 years)

Neuromuscular disease Poliomyelitis

Myopathies
Muscular dystrophy
Cerebral Palsy

Traumatic and Koch’s

infective Fractures
Irradiation
Burns
Neoplastic disease

Connective tissue disorders Marfan syndrome, Osteogenesis imperfecta

Neurofibromatosis (von Recklinghausen's disease)
Rheumatoid arthritis
Ankylosing Spondilitis
 Spinous processes rotate toward the
concave side of the curve.

Ribs on the convex side are pushed

posteriorly forming the gibbous

Ribs on the concave side become

prominent anteriorly and crowded
 Measurement of Severity of scoliosis

Why we need to know Cobb’s angle?

Cobb’s angle

• Extent of surgical correction

• Information regarding changes in cardio-

respiratory system
 Why we need to know Cobb’s angle?
Angle of Curvature Significance

<10 Normal curvature

>25 Echocardiographic evidence of increased pulmonary
artery pressures

>40 Surgical intervention

>65 Restrictive lung disease
>100 Symptomatic lung disease, dyspnoea on exertion

Increased risk of death from cor pulmonale and right

ventricular failure

>120 Alveolar hypoventilation

Respiratory Sequelae of Scoliosis

p ati ent
to m atic
p
Asym
isea se
u n g d
i cti vel
Restr

concave side lung volume decreases

considerably than convex lung

As the kyphosis increases, the convex

side lung volume also reduces
 Respiratory changes in Scoliosis

• Lung volumes and pulmonary compliance are inversely related to the

degree of curvature
• VC : severely reduced (often to less than 60% )
• FEV1 < 50% -- Respiratory complications

• FRC and RV : not severely affected

• FVC < 50% ( 30ml/kg): Post-op ventilation

• Alterations in lung volumes are caused by changes in chest wall

compliance and the resting position of the thoracic cage, rather than
parenchymal changes
 Cardiovascular

• Mitral valve prolapse (25% of patients)

• Aortic regurgitation ( Marfan’s)

• Pulmonary Hypertension:
– > 70 degrees : pulmonary hypertension on exercise

– > 110 degrees : mean pulmonary artery hypertension at rest

– Lung compression (Structural change)

– Increased incidence of HPV

– Impaired development of the pulmonary vascular bed : reduction in

the number of functional vascular units per unit lung volume
 Muscular dystrophy
• Duchenne's muscular dystrophy ( X linked recessive- absence of
dystrophin in skeletal muscles)
• Becker's muscular dystrophy

• Profound myopathies : ( Wheelchair bound by age of 10 yrs)

• Cardiomyopathy
• Conduction abnormality

• C/I for Elective surgery: LVEF < 50% with cardiomyopathy and FVC <
25% of predicted
 Muscular dystrophy

• Dysphagia and altered gastric motility

• Obesity
• Rhabdomyolysis and hyperkalemia in response to
succinylcholine
• Not associated with malignant hyperthermia
• Volatile anesthetics (?? Subclinical Rhabdomyolysis) : safe
 Pre-op evaluation

• Airway assessment
• Assessment for positioning
• Respiratory tract infection
• CBC
• Coagulation profile
• PFT
• 2 D Echo
• Electrolyte panel, Renal Function
• X Ray
• ECG
• Bl grouping
• Height Weight
 Pre-op preparation

• Treat respiratory infections

• Physiotherapy consult: Prehabilitation

– Breathing exercises
– Incentive Spirometry
• Build up Hb : Oral iron

Inj Iron carboxymaltose ( Encicarb) 1 gm IV

• Pre-op donation (if planned)
 Pre-op Counseling
• Blood loss: Preop blood donation

• Invasive cardiovascular monitoring

• Postop New Neurological deficit

• Neurophysiological monitoring

• Intraoperative Wake up test

• Duration: 4-12 hrs

• Postoperative analgesic regimes (Intraop Epidural insertion/IV PCA)

• Postop mechanical ventilation( FVC < 50%)

 Induction of anesthesia

• Monitors

• Warming measures : Prewarming

• Peripheral IV, 2 wide bore access

• Anxiolysis : In monitored area

• Difficulties in positioning

• IV induction

• Muscle relaxants

• ETT

• Arterial line

• Central venous cannulation?

 Intra-operative monitoring

• ECG

• Continuous Invasive BP
• EtCO2, Pulse-oximetry

• Urine Output
• Continuous Blood loss assessment of ongoing loss

• Core Temperature
• Neurological monitoring : Independent personnel required

• N-M blockade monitoring ( TOF)

 Prone position

Cardiovascular changes
• ↑Intra-thoracic Pressure-↓ venous return -- ↓Stroke volume --↓ CO

( 20-30%)
• Venous congestion of Spinal-Epidural vessels (IVC compression- Incorrect
positioning)
Respiratory changes

• ↑ FRC and PaO2

• Obese patients : ↑ lung volumes, compliance and oxygenation

Intraocular pressure : ↑ even in absence of Hypotension

 Problems associated with prone positioning
Airway ETT Kinking, dislodgement, Upper airway oedema
Paw

Neck Hyperextension / hyperflexion /cervical rotation :

compromised venous drainaige of brain

Eyes ↑IOP, supraorbital nerve compression. Corneal abrasion

Abdomen Epidural vein congestion , ↑ AWP

Upper limb Brachial plexus stretch : arms out

Ulnar nerve compression: arms at side

Lower limb Flexion of hip: occlusion of femoral vein, DVT,

Pressure lateral to fibula: peroneal nerve,
Pressure on ASIS: lateral femoral cutaneous nerve
 Intraoperative Blood loss
• 30-50ml/ kg Rapid over short duration
• Massive blood loss?/Significant major blood loss

• Replacement of one entire blood volume within 24 h

• Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h

• Transfusion of >4 units of PRBCs in 1 h when on‑going need is foreseeable

• Replacement of 50% of total blood volume (TBV) within 3 h.

Age TBV ml/kg

Neonate 90
Infants, toddler,children 70-80
Adults 60-70
 Intraoperative Blood loss

• Levels of correction
• Duration
• Stages of surgery
• Bone mineral density
• Type of disease

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rte

inin
en

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f ve

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raft
/di
Expected blood loss ml/level no

pla

on

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• AIS= 60-150 ew

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• CP= 100-190 dd
1.

• Paralytic=200-280
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 Intraoperative Blood loss
Management

• Preparation
• Estimation of blood volume
• Anticipation
• Notification to the blood bank
• Timely assessment of ongoing loss
• Maintain normothermia
• Maintenance fluid
• Replacement by colloids, blood products
• Intraop Hb, ABG, Coagulation
• TEG before hemostasis
 Measures to reduce intraoperative blood loss

• Positioning : avoid abdominal compression : Most important

• Surgical hemostasis
• Adequate analgesia

• Deliberate Hypotension using pharmacological agents: Not

recommended
• Pharmacological agents reducing fibrinolysis (Aminocaproic Acid and
Aprotinin) : more effective in re-do surgeries
 Neurological monitoring
• Subjective: Clonus test (Ankle jerk)

Wake-up test
• Objective : Evoked potentials

SSEP

MEP: Neurogenic / Myogenic

Need specialized personnel
 Stagnara’s Wake-up test

• Intraoperative emergence from anaesthesia, N-M blockade

• Detects lower limb motor deficits (not sensory component)

• Patient cooperation needed

• Preinduction counseling and rehersal

• Single observation

Complications
• Accidental extubation

• Disconnections of monitors

• Loss of IV access
• VAE during spontaneous inspiration
 Evoked potentials
Action potentials 1-2 microV

Baseline reading postinduction

Furher Eps compared

Significance: Amplitude by ↓50% and/or latency↑ by 10%

Damage 1/∞Time required to disappear EP

 Factors affecting Eps

• Vascular
Physiological factors
• Perfusion ( Flow, volume, Arterial
BP, vascular tone, occlusion)
• Haematocrit
• Mechanical - Instrumentation,
retraction, dissection, stretching
• Pharmacology- anaesthetic agents
 SSEP MEP

Posterior sensory component of Anterior motor component

spinal cord

Impulse is sent from peripheral nerve Impulse is triggered in brain & monitored
& measured centrally in Spinal cord, Epidural Space or specific
muscle group
N-M blockade recovery not required N-M blockade recovery required

Chances of awareness less Depth of Anaresthesia monitoring

essential

Relatively safe Bite injuries, cognitive deficits, seizures,

scalp burns, cardiac arrythmias etc.
Challenging
 Factors influencing EPs
Agents Amplitude Latency

Volatile anaesthetics ↓ ↑

N2O ↓ ↔

Propofol ↔ ↔

Ketamine ↑ ↔

Midazolam ↓ ↔

Opioids ↔ ↔
 Anaesthesia for IONM

• SSEPs can be performed using inhalational 0.5-0.7 MAC , TIVA not

mandatory, Muscle relaxants allowed

• MEP:
 TIVA with propofol and fentanyl is the preferred technique
 Inhalationals to avoid (or MAC 0.2-0.3)
 Dexmedetomidine is safe
 Muscle relaxants: the train-of-four ratio should be kept at 2/4 twitches
and a T1 response at 10-20% of baseline
Or Avoided for ease of conduct
 Avoid sudden changes in anaesthesia
 Complications

• Surgery: Blood loss, New neurological deficits

• Positioning: VAE, Airway oedema, IONP

• Incorrect Positioning : Bleeding, Neuropathies

• While Neurologic Monitoring: VAE, ETT disconnections

 Post-operative vision loss

Central Retinal artery occlusion

• Direct external pressure
• Emboli
• Decreased ocular perfusion pressure

• Unilateral ,
 Ischemic Optic Neuropathy (< 0.01%)
• Can occur without hypotension
• Altered auto regulation of optic nerve artery in prone position
• Posterior ION > anterior ION
• May manifest 24 hrs after surgery, Bilateral
• Care:
– Careful positioning
– Avoid prolonged prone position ( > 6 hrs)
– Avoid anemia /Decrease blood loss
– Avoid hypotension
– Preoperative counseling
 Reversal and Extubation

• Haemodynamically stable
• Adequate hemostasis
• Normothermia
• N-M blockade recovery
• Postop mechanical ventilation: rarely required
• Neurological assessment
• Role of Methylprednisolole ? (30 mg/kg followed by infusion of
5.4 mg/kg/hr?)
 Postoperative analgesia

• Insertion of epidural catheter

– Under vision by operating surgeon
– At the end of surgical correction
– After neurological testing

• Systemic analgesia:

PCM
– ?NSAIDS/ Ketorolac/ Cox 2 inhibitor

• IV PCA: Opiods
 True/ false

• A preoperative FEV1 < 40% predicts a low risk of pulmonary complications

after scoliosis repair

• Postoperative pulmonary complications are greater in non-idiopathic

compared to idiopathic forms of scoliosis

• Cardiac complications are more common with certain forms of non-

idiopathic scoliosis

• Surgical correction of scoliosis is generally indicated with a Cobb angle

greater than 40-45 degrees