RU2835746C1 - Method of conduction anaesthesia in lumbar spine surgeries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, traumatology and orthopaedics, and can be used for conduction anaesthesia in operations on lumbar spine. Anaesthetic is introduced in the surgical area paravertebrally from both sides under ultrasonic navigation into the area lig. intertransversarium. Injection needle is delivered in the direction to the transverse process of the vertebra related to the overlying spinal motion segment into the area lig. intertransversarium through m. multifidus and m. longissimus thoracis and 20 ml of 0.2% ropivacaine solution is introduced on each side. Then the needle is moved backwards in the interfascial space m. multifidus and m. longissimus thoracis and another 20 ml of 0.2% ropivacaine mixed with dexamethasone 4 mg in volume of 1 ml on each side is introduced.

EFFECT: method enables to minimize tissue injuries and reduce the risk of possible infectious-inflammatory complications by performing two types of regional anaesthesia through one skin puncture, reduces risk of postoperative delirium, cognitive disorders of patients, as well as development of nausea and vomiting in early postoperative period due to possibility of expansion of area of action and intensification of effect of anaesthesia of area of operation, which reduces consumption of inhalation anaesthetics during mechanical ventilation during operation.

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Description

The proposed invention relates to surgery, traumatology and orthopedics and is intended for conduction anesthesia during operations on the lumbar spine.

The need to control postoperative pain syndrome and search for ways to minimize it is due to the fact that its presence contributes to the development of complications from the cardiovascular and respiratory systems (myocardial infarction, heart rhythm disturbances, increased blood pressure, pulmonary edema, hypoxemia) Polupan A.A., Birg T.M., Oshorov A.Y., Savin L.A. Correction of arterial hypertension in the postoperative period in patients with neurosurgical patients. Anesteziologiya i reanimatologiya. 2017; 62(3): 190-4. The presence of severe pain syndrome in the early postoperative period reduces the possibility of early activation, increasing the risks of thromboembolic complications, impaired urodynamics and intestinal patency.

One of the most important tasks of anesthesia in the postoperative period is the interruption of the afferent flow of nociceptive stimuli from peripheral pain receptors in organs and tissues to segmental structures of the central nervous system. This task can be successfully solved using various methods of conduction anesthesia. In operations on the lumbar spine, they can also be used as anesthesia for the wound in the intra- and postoperative period.

Taking into account the peculiarities of surgical interventions for degenerative-dystrophic diseases of the spine, its inherent duration, special patient positioning, the “gold standard” remains the use of combined endotracheal anesthesia, which, while providing adequate anesthesia, the proper level of sedation, relaxation, also has a number of negative consequences, often manifested in postoperative cognitive dysfunction, postoperative delirium, nausea and vomiting.

Due to the problem of adequate pain relief for the patient, various methods of using combined anesthesia in spinal surgeries are being developed.

A method of infiltration of the anesthetic directly into the surgical area is known (Byvaltsev Vadim Anatolyevich, Kalinin A.A., Belykh E.G., Goloborodko V.Yu., Borisov V.E. Analysis of the effectiveness of local use of bupivacaine with epinephrine in performing multilevel decompressive and stabilizing interventions on the lumbosacral spine // Anesthesiology and resuscitation. 2018. No. 1), in which local infiltration anesthesia of the paraspinal muscles, subcutaneous fat and skin is performed before suturing the wound with a 0.5% solution of bupivacaine with epinephrine 1:200,000 with a volume of 30 ml. The disadvantage of this method is the large dose of anesthetic administered, short-term analgesic effect, the impossibility of prolonging it, the lack of targeted administration of anesthetic, as well as registered complications in the form of intermuscular hematomas with cases of infection.

A method of combined general anesthesia based on epidural anesthesia is known, including a combination of epidural anesthesia with naropin and intravenous anesthesia with propofol against the background of artificial lung ventilation (ALV). In this case, anesthetic management includes catheterization of the epidural space and installation of a catheter according to the standard technique 3-4 segments above the level of bone pathology using disposable kits. After a test dose, a 1% solution of naropin is administered epidurally, based on the calculated dosage of 10 mg / segment. Then, tracheal intubation and artificial lung ventilation are performed in the normoventilation mode (IPPV with DO = 6-8 ml / kg, MOD = 80-100 ml / kg and FiO2 - 50%). Propofol (5-6 mg / kg / hour) is used for sedation, myoplegia is maintained by atracurium infusion (0.5-0.6 mg / kg / hour). In the postoperative period, prolonged epidural analgesia (PEA) is performed by administering a 0.2% solution of naropin through a dispenser at a rate of 10-12 ml per hour for 2-3 days (Luk'yanov Dmitry Sergeevich, Shevchenko V.P., Rerikh V.V. Epidural anesthesia as a component of anesthetic protection during operations on the lumbar spine // Surgery of the spine. 2004. No. 3). However, this method has a number of limitations and complications. The method of performing surgical intervention on the lumbar spine requires placing the patient in a forced position lying on his stomach in the knee-elbow position, which is a limiting factor in the use of this method due to possible respiratory problems. Also, given the need for surgical treatment of the lumbar spine in older patients, due to the presence of pronounced degenerative-dystrophic changes in the spine, performing epidural anesthesia becomes a technically complex procedure, entailing such iatrogenic complications as damage to the dura mater, the formation of an epidural hematoma, the development of a high block (respiratory paralysis, cardiac arrest).

A method of thoracolumbar interfascial plane block (TLIP block) using ultrasound navigation in spine surgery is known (Kumar A, Sinha C, Kumar A, Bhadani UK. Ultrasound-guided thoracolumbar interfascial plane block for spine surgery. Saudi J Anaesth. 2017 Apr-Jun; 11(2):248-249. doi: 10.4103/1658-354X.203052. PMID: 28442976; PMCID: PMC5389256). Initially, tracheal intubation and mechanical ventilation are performed in the normoventilation mode (IPPV with DO = 6-8 ml / kg, MOD = 80-100 ml / kg and FiO2 - 50%). Propofol (2 mg / kg / hour) and fentanyl (2 mg / kg / hour) are used for sedation, muscle relaxation is provided by vecuronium (0.08 mg / kg / hour). Further anesthesia is carried out with a gas mixture of isoflurane and nitrous oxide. Next, after placing the patient in the prone position, m. multifidus and m. longissimus thoracis are visualized using a high-frequency linear sensor, after which, under ultrasound navigation using an echogenic needle (22-G, 8 cm, Sonoplex, Pajunk, Germany) inserted in the latero-medial direction through the abdomen of m. multifidus in the direction of m.longissimus thoracis, 20 ml of 0.2% ropivacaine solution is introduced into their interfascial space after an aspiration test (should be negative). The blockade is carried out on the opposite side in a similar manner. The disadvantage of this method is that the intermuscular nerve endings are blocked by introducing an anesthetic into the interfascial space in the area of surgical intervention, which provides limited anesthesia - only in the area of anesthetic administration, which is insufficient, given that direct surgical intervention is carried out on deeper anatomical structures (facet joint, interarch space, intervertebral disc) in order to prolong anesthesia, as well as to create the effect of "impregnation" of the muscles to expand the area of action of the anesthetic, it is necessary to introduce a large volume of solution, which can lead to a toxic dose, especially if this is done on both sides.

The closest analogue of the proposed invention is a method for the same purpose, in which, in the prone position, using a high-frequency linear sensor, a 20G needle of increased echogenicity for regional anesthesia is inserted in the sagittal plane in the craniocaudal direction to the transverse process of the Th12 vertebra. After the tip of the needle passes the hyperechoic internal fascia of m. erector spinae and the tip of the needle comes into contact with the periosteum of the transverse process of the vertebra, hydrodissection is performed with a physiological solution (NaCl 0.9%), detachment of the internal fascia of m. erector spinae from the periosteum of the transverse process of the vertebra and lig. intertransversarium is observed, after which 20 ml of 0.5 ropivacaine solution (100 mg) are introduced. A similar manipulation is performed on the opposite side. This method provides a bilateral blockade of the spinal nerves, which blocks pain impulses from the anatomical structures located at the level of the main surgical intervention, but does not provide analgesia to the skin, subcutaneous fat and muscles along the surgical approach (Erector spinae plane block improves postoperative recovery after laminectomy and discectomy surgery: a retrospective cohort study // van den Broek et al. BMC Anesthesiology (2023) 23:308).

Disclosure of invention

The objective of the invention is the further development of conduction anesthesia for operations on the lumbar spine.

The technical result of the proposed method is a reduction in postoperative complications in the form of delirium, cognitive and inflammatory changes.

The technical result is achieved by anesthetizing all anatomical structures during the surgical approach and reducing the volume of inhalation anesthetics and narcotic analgesics used during surgical intervention.

In the proposed method, bilateral administration of an analgesic solution is performed at two “levels” of surgical intervention:

- at the level of direct intervention in the area of lig. intertransversarium in the zone of the overlying vertebral motor segment;

- at the level of surgical access, in the area of the interfascial space of m. multifidus and m. longissimus thoracis, which provides a wider area of anesthesia of the skin, subcutaneous fat and muscles along the surgical access on each side.

Delivery of the anesthetic substance to two anatomical zones (lig. intertransversarium, interfascial space of m. multifidus and m. longissimus thoracis) is performed through one skin puncture, which ensures the implementation of two types of regional anesthesia in one session, which minimizes tissue trauma and reduces the risk of possible infectious and inflammatory complications. Insertion of the needle in the direction of the transverse process of the vertebra related to the overlying spinal motor segment also prevents the risk of infectious and inflammatory complications and does not violate the anatomy of the tissues at the site of direct surgical intervention.

The combination of two types of regional anesthesia makes it possible to expand the zone of action and enhance the effect of anesthesia in the surgical area, which reduces the consumption of inhalation anesthetics during mechanical ventilation during surgery, which in turn reduces the risk of postoperative delirium, cognitive impairment of patients, as well as the development of nausea and vomiting in the early postoperative period.

Unlike the closest analogue, in which the anesthetic is delivered only to the lig. intertransversarium area, thereby blocking pain impulses from the anatomical structures located at the level of the main surgical intervention - the facet joint, the intervertebral disc, in the proposed method, a combination of regional anesthesia of the lig. intertransversarium with the introduction of an analgesic solution into the interfascial space of m. multifidus and m. longissimus thoracis provides a wider area of anesthesia of the skin, subcutaneous fat and muscles along the surgical approach on each side.

The method is carried out as follows.

For conduction anesthesia in a patient undergoing surgery on the lumbar spine, the anesthetic is administered in the surgical intervention area paravertebrally on both sides under ultrasound navigation in the lig. intertransversarium area. In this case, the injection needle is inserted in the direction of the transverse process of the vertebra related to the overlying vertebral motor segment in the lig. intertransversarium area through m. multifidus and m. longissimus thoracis and 20 ml of 0.2% ropivacaine solution are administered on each side. Then, with a reverse movement, the needle is positioned in the interfascial space of m. multifidus and m. longissimus thoracis. Another 20 ml of 0.2% ropivacaine solution are administered in a mixture with dexamethasone 4 mg in a volume of 1 ml.

The method is illustrated by the following clinical examples.

Example 1: Patient: “F”, 47 years old.

Was in the plastic surgery department of the Clinical hospital No. 1 from 04/15/2024 to 04/22/2024 with the diagnosis:

M99.5 Degenerative-dystrophic changes in the lumbosacral spine, degenerative instability L5-S1, stenosis of the spinal canal L5-S1, secondary radicular syndrome.

Complaints: pain in the lumbar region radiating to the back of the right thigh, lower leg, and heel of the right foot.

Medical history: considers himself ill for 15 years, when after a fall during sports (alpine skiing) he felt acute pain in the lumbar region, did not seek medical help, the pain syndrome was relieved on its own. Later, the patient began to note episodes of pain in the lumbar region with a frequency of 1-2 times a year, relieved on its own against the background of decreased physical activity. In January 2024, the patient noted the appearance of acute pain in the lumbar region radiating to the right buttock, the back of the right thigh, in connection with which he sought medical help at his place of residence, the recommended conservative therapy - without a pronounced positive effect. In this regard, the patient was recommended to undergo an MRI examination of the lumbar spine, during which stenosis of the L5-S1 spinal canal was detected, surgical treatment was recommended.

Due to persistent severe pain in the back of the right thigh and lower leg, the patient sought advisory help at Sechenov University Clinical Hospital No. 1. A control MRI scan of the lumbosacral spine was recommended, which revealed: MRI signs of osteochondrosis, spondyloarthrosis, spinal canal stenosis at the L5-S1 level, protrusions of intervertebral discs at the L3-L4, L4-L5 level; impaired statics of the lumbar spine. Based on the patient's medical history, complaints, and instrumental examination data, the following clinical diagnosis was established: Degenerative-dystrophic changes in the lumbosacral spine, degenerative instability L5-S1, spinal canal stenosis L5-S1, secondary radicular syndrome. Surgical treatment is recommended.

The patient was hospitalized in the plastic surgery department of the City Clinical Hospital No. 1 for planned surgical treatment.

04/16/2024 Facetectomy L5-S1 on the right, discectomy L5-S1, decompression, fusion L5-S1 with Capstone cage, minimally invasive TPF L5-S1 with Legacy Longitude system.

The duration of the operation is 2 hours 25 minutes.

Premedication is standard. Induction was performed with propofol 2 mg/kg + Fentanyl 200 mcg.

Tracheal intubation with non-depolarizing muscle relaxants (Rocuronium 0.6 mg/kg, mechanical ventilation up to 6 ml/kg, MOD 7 l/min, FiO2 50%, O2:air ratio=1 l/min:1 l/min + Sevorane 0.8-0.5 MAC

A mixture was prepared from 80 ml of 0.2% ropivacaine solution (160 mg) in 4 syringes with a volume of 20 ml each, of which 2 syringes contained dexamethasone at 4 mg in a volume of 1 ml in each syringe.

Anesthesia was administered under ultrasound guidance in the prone position. The anesthetic was injected into the surgical area paravertebrally on both sides using ultrasound navigation. The injection needle was inserted toward the transverse process of the vertebra belonging to the overlying spinal motion segment into the lig. intertransversarium region through m. multifidus and m. longissimus thoracis, and 20 ml of 0.2% ropivacaine solution was injected on each side. Then, with a reverse movement, the needle was positioned in the interfascial space of m. multifidus and m. longissimus thoracis. Another 20 ml of 0.2% ropivacaine solution mixed with dexamethasone 4 mg in a volume of 1 ml were injected. The surgery was started 20 minutes after the anesthesia was administered. The course of anesthesia is smooth, hemodynamics are stable, 130/70-110/80 HR 78-80 bpm. Fentanyl administration was required only for intubation, no more fentanyl was added, while the MAC values of Sevoran were at the level of 0.6-0.7.

Extubation immediately after applying the bandage, turning the patient onto his back. Consciousness is clear, contact is possible, there is no nausea, pain in the area of the postoperative wound is absent. The immediate postoperative period is uneventful - nausea, vomiting, dizziness were not observed, delirium was not noted at night. A day later, the patient noted a slight pain syndrome in the area of the operation (VAS-1), no anesthesia was required. Cognitive impairment was not noted. According to the patient, the absence of pain in the area of the operation was noted until the morning of the next day.

The patient was fully activated and able to move around the ward independently 24 hours after the surgery. The patient was discharged from the department in a satisfactory condition under the supervision of doctors at the place of residence on the 6th day after the surgery.

Example 2

Patient "K", 72 years old, in the plastic surgery department of the Clinical Hospital No. 1 from 03/05/2024 to 03/15/2024.

Diagnosis: Degenerative-dystrophic changes in the lumbosacral spine, absolute stenosis of the spinal canal L3-L4, L4-L5, lower distal paraparesis, secondary radicular syndrome.

Complaints: pain in the lumbar region radiating to the right buttock, along the anterior surface of the right shin, increasing when walking, a feeling of numbness in the 3rd to 5th toes of the right foot, weakness of the muscles of the right leg.

Anamnesis: considers herself ill for 30 years, when she first noticed the appearance of pain in the lumbar region, she did not seek medical help, independent conservative therapy with a positive effect. Subsequently, the patient began to note repeated episodes of exacerbation of pain syndrome in the lumbar region, a feeling of numbness in the 3-5 toes of the right foot, in connection with which she repeatedly sought medical help, the recommended conservative therapy - with a temporary positive effect. In 2020, the patient noted the appearance of urine leakage, in connection with which in 2023 an operation was performed to strengthen the pelvic floor muscles - without effect. Since 2023, the patient began to note muscle weakness in the right leg, expressed in episodes of falls, the acquisition of a permanent nature of pain in the lumbar region, since June 2023 - the need to strain during bowel movements. Recommended conservative therapy - without a pronounced positive effect. Currently, due to the persistence of the above complaints, progression of muscle weakness in the right lower limb, the patient independently sought advisory help at the Clinical Hospital No. 1 of Sechenov University, an MRI examination of the lumbosacral spine was recommended, which revealed: a circular herniated disc of the L3-L4 vertebrae and small dorsal bulging of the intervertebral disc of the L4-L5 vertebrae with signs of neural impact of the roots of the equine tail; dorsal bulging of the intervertebral discs of the L1-L3, L5-S1 vertebrae; diffuse degenerative-dystrophic changes in the lumbosacral spine; spondylosis, deforming spondyloarthrosis; secondary relative narrowing of the lumen of the foraminal spaces, signs of absolute stenosis of the spinal canal at the level of the L3-L4 segment of the vertebrae, moderate stenosis of the spinal canal at the level of the intervertebral disc of the L4-L5 vertebrae. Based on the anamnesis, complaints of the patient, and data from instrumental studies, the following clinical diagnosis was established: degenerative-dystrophic changes in the lumbosacral spine, absolute stenosis of the spinal canal L3-L4, L4-L5, lower distal paraparesis, secondary radicular syndrome. Surgical treatment was recommended. The patient was hospitalized in the plastic surgery department for surgical treatment.

The following surgery was performed: Facetectomy L3-L4, L4-L5 on the right, discectomy L3-L4, L4-L5, decompression, spondylodesis L3-L5 with Capstone cages, minimally invasive TPF L3-L5 with the Legacy Longitude system.

Duration of the operation is 4 hours 30 minutes.

Premedication is standard. Induction was performed with propofol 2 mg/kg + Fentanyl 100 mcg.

Tracheal intubation with non-depolarizing muscle relaxants (Rocuronium 0.6 mg/kg, mechanical ventilation up to 6 ml/kg/min, MOD 7 l/min, FiO2 50%, O2:air ratio = 1 l/min:1 l/min + Sevorane 0.6-0.5 MAC.

A mixture was prepared from 80 ml of 0.2% ropivacaine solution (160 mg) in 4 syringes with a volume of 20 ml each, of which 2 syringes contained dexamethasone at 4 mg in a volume of 1 ml in each syringe.

Anesthesia was administered under ultrasound guidance in the prone position. The anesthetic was injected into the surgical area paravertebrally on both sides using ultrasound navigation. The injection needle was inserted toward the transverse process of the vertebra belonging to the overlying spinal motion segment into the lig. intertransversarium region through m. multifidus and m. longissimus thoracis, and 20 ml of 0.2% ropivacaine solution was injected on each side. Then, with a reverse movement, the needle was positioned in the interfascial space of m. multifidus and m. longissimus thoracis. Another 20 ml of 0.2% ropivacaine solution mixed with dexamethasone 4 mg in a volume of 1 ml were injected. The surgery was started 20 minutes after the anesthesia was administered. The course of anesthesia is smooth, hemodynamics are stable, 110/70-100/60 heart rate 69-72 beats per minute. Fentanyl was administered only for intubation and installation of the transpedicular fixation system (300 mcg in total); no more fentanyl was used due to the lack of response to pain stimuli, while the MAC values of Sevoran were at the level of 0.5-0.6. Extubation 10 minutes after applying the bandage, turning the patient onto her back. Consciousness is clear, pain in the area of the postoperative wound according to VAS is 2 points. The immediate postoperative period is uneventful - nausea, vomiting, dizziness were not observed, delirium was not noted at night. A day later, the patient's pain syndrome was estimated at 2 points according to VAS, no anesthesia was required, the patient is activated in the volume of independent movement around the ward. Conclusion: the postoperative period proceeded without any peculiarities or complications. Planned conservative therapy was performed.

Wound healing by primary intention. The patient was discharged for outpatient follow-up care in a satisfactory condition on the 5th day after the operation.

A total of 10 surgeries were performed using combined regional anesthesia of the erector spinae muscle and thoracolumbar interfascial blockade under ultrasound navigation in patients of various age categories. The results are characterized by a decrease in the total doses of the narcotic analgesic - Fentanyl, a decrease in the dose of the inhalation anesthetic - Sevorane, the absence of complaints of pain in the postoperative period (according to VAS 0-1), the absence of postoperative delirium, nausea and vomiting, rapid activation and rehabilitation of the patient, the absence of infectious and inflammatory complications from the postoperative wound.

Thus, the proposed method allows to reduce the toxic effect of inhalation anesthetics and narcotic analgesics used during anesthesia, which is expressed in a decrease in the risk of developing postoperative delirium and cognitive impairment, as well as the risk of infectious and inflammatory processes, especially in elderly patients.

Claims (1)

A method of conduction anesthesia in operations on the lumbar spine, including the introduction of anesthetic in the area of surgical intervention paravertebrally on both sides under ultrasound navigation in the area of lig. intertransversarium, characterized in that the injection needle is inserted in the direction of the transverse process of the vertebra related to the overlying vertebral motor segment in the area of lig. intertransversarium through m. multifidus and m. longissimus thoracis and 20 ml of 0.2% ropivacaine solution is injected on each side, then with a reverse movement the needle is placed in the interfascial space of m. multifidus and m. longissimus thoracis and another 20 ml of 0.2% ropivacaine solution mixed with dexamethasone 4 mg in a volume of 1 ml is injected on each side.