|Year : 2020 | Volume
| Issue : 2 | Page : 100-103
Single-shot lumbar epidural and sedation during endoscopic lumbar discectomy: A Case series
Delma DCunha1, PS Balakrishna Achar1, Mrinal Shetty2
1 Department of Anaesthesiology, Father Muller Medical College Hospital, Mangalore, Karnataka, India
2 Department of Orthopaedics, Father Muller Medical College Hospital, Mangalore, Karnataka, India
|Date of Submission||10-Feb-2020|
|Date of Decision||28-Feb-2020|
|Date of Acceptance||09-Mar-2020|
|Date of Web Publication||19-Sep-2020|
Dr. P S Balakrishna Achar
Department of Anaesthesiology, Father Muller Medical College Hospital, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Endoscopic discectomy is a painful surgery yet preferably done under moderate sedation and analgesia as the surgeon requires cooperation and inputs from the patient during the procedure. While prone positioning poses a problem for airway management, light sedation poses a problem for securing the airway if the need arises. Therefore, adequate sedation and analgesia is a challenge for the anesthesiologist. Here, we report the management of four patients who successfully underwent endoscopic discectomy under single-shot lumbar epidural and mild-to-moderate sedation.
Keywords: Endoscopic discectomy, lumbar epidural analgesia, sedation
|How to cite this article:|
DCunha D, Balakrishna Achar P S, Shetty M. Single-shot lumbar epidural and sedation during endoscopic lumbar discectomy: A Case series. Indian Anaesth Forum 2020;21:100-3
|How to cite this URL:|
DCunha D, Balakrishna Achar P S, Shetty M. Single-shot lumbar epidural and sedation during endoscopic lumbar discectomy: A Case series. Indian Anaesth Forum [serial online] 2020 [cited 2021 May 10];21:100-3. Available from: http://www.theiaforum.org/text.asp?2020/21/2/100/295318
| Introduction|| |
Endoscopic discectomy is a surgical procedure that is gaining popularity due to its advanced endoscopic visualization and minimally invasive nature.,, In order to avoid nerve injury, this surgery requires that the patient be able to provide inputs regarding pain, discomfort, or abnormal sensations due to surgical manipulation intraoperatively.,
Clinical case reports state that it is not possible to do these procedures under local anesthesia alone as some patients find it difficult to tolerate the pain during surgery, especially during the process of working channel insertion, foraminoplasty, and herniation discectomy. Therefore, local anesthesia for endoscopic discectomy is still controversial. Epidural anesthesia is another method that has been tried. With opioid supplementation and sedation, graded epidural analgesia can achieve the required sensory blockade while maintaining the motor function of the lower limbs (sensory-motor separation).
| Case Reports|| |
A 50-year-old male weighing 65 kg, American Society of Anesthesiologists (ASA) physical Status I, with L3–L4 disc prolapsed and severe neurogenic claudication pain was scheduled for endoscopic discectomy. Preoperative assessment was performed and revealed no other significant medical history. Surgical history included lumbar posterior stabilization of the L4–L5 spine under general anesthesia 18 months prior [Figure 1]. Magnetic resonance imaging of the spine revealed soft disc herniation in the L3–L4 segment [Figure 2]. The patient was explained about the lumbar epidural analgesia, moderate sedation, spontaneous breathing, and prone positioning to allay anxiety, and written informed consent was obtained. The patient was premedicated with oral ranitidine 150 mg and diazepam 10 mg on the night before the surgery.
|Figure 2: Magnetic resonance imaging of the lumbar spine showing L3–L4 disc herniation|
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In the operation theater, IV line was secured using an 18G cannula on the dorsum of the left hand. Electrocardiogram, noninvasive blood pressure, and peripheral capillary oxygen saturation were monitored, and 30 mcg/kg midazolam and 1 mcg/kg fentanyl were preoperatively administered intravenously. Oxygen was administered through nasal cannula at 5 L/min.
Subsequently, the patient was placed in the left lateral decubitus position. Following asepsis using 2% chlorhexidine, and skin infiltration with 2 ml of 2% lignocaine, an 18G Tuohy needle was inserted toward the L2–L3 level through midline approach. The needle was slowly advanced and the epidural space was found at 5 cm using the loss of resistance technique. A test dose of 3 ml lignocaine (2%) with adrenaline was administered. After ruling out neurological symptoms or hemodynamic instability, 12 ml of block solution (4 ml of 0.5% bupivacaine, 4 ml of 2% lignocaine with adrenaline, and 4 ml of normal saline) was injected into the L2–L3 space with the needle tip directed caudad. The patient was then placed in the supine position and levels of sensory and motor blockade were assessed after 10 min. The patient was hemodynamically stable and had no motor blockade (Bromage 3). Sensory blockade was achieved up to level T10. Subsequently, the patient was placed in the prone position, and dexmedetomidine (0.4 mcg/kg body weight) in a 2 mcg/ml solution was initiated at an infusion rate of 12 ml/h. Dexmedetomidine bolus dose was not given as adequate sedation was achieved with a loading dose of fentanyl and midazolam, and the goal was to avoid deeper plane of sedation at all times of the procedure.
Before starting the procedure, the surgeon injected local anesthetic at the point of needle entry, following which guidewire, dilators, and working channel were inserted under C-arm guidance. Only when the endoscope reached the site of disc herniation, the patient complained of slight pain [Figure 3]. At this point, sedation analgesia top-up of fentanyl (0.5 mcg/kg) and midazolam (30 mcg/kg) was administered IV, and the sedation plane was deepened as per the surgeon's request by increasing the infusion rate of dexmedetomidine to 0.5 mcg/kg/h to achieve appropriate sedation. Over the course of the procedure, dexmedetomidine was titrated and stopped toward the end of the surgery.
|Figure 3: C-arm views showing guidewire and endoscope insertion, respectively|
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Throughout the procedure, the vitals were monitored and maintained stable. Subjective assessment of pain and sedation was done by talking to the patient and objective assessment using the Ramsay Sedation Scale. At no point during the surgery did the patient go into deep plane of sedation (Ramsay Score 6). Rescue airway devices were kept available in case of desaturation or deep sedation. Intraoperatively, the patient was cooperative, obeying commands, comfortable, and was able to interact with the surgeon as required. No further opioid top-up was required. There was no bradycardia, hypotension, or inhibition of spontaneous breathing intraoperatively. The duration of the procedure was 2 h.
A 54-year-old male, smoker, with ASA physical Status II, weighing 60 kg had a L4–L5 and L5–S1 intervertebral disc prolapse (IVDP) and was scheduled for endoscopic discectomy. Monitoring, premedication, sedation and analgesia protocol, and surgical intervention were similar to those for Case 1. Lumbar epidural analgesia was administered at the L3–L4 interlaminar space. As in Case 1, an additional sedation analgesia top-up of fentanyl (0.5 mcg/kg) and midazolam (30 mcg/kg) was administered IV during instrumentation, but the infusion rate of dexmedetomidine was continued at 0.4 mcg/kg/h. The duration of the surgery was 2.5 h.
A 66-year-old female (ASA physical Status II), weighing 85 kg, known hypertensive for the past 8 years (on a combination of ARB and calcium channel blockers), was scheduled for L4–L5 endoscopic discectomy. Monitoring, premedication, sedation and analgesia protocol, and surgical intervention were similar to those for Cases 1 and 2. A single-shot epidural dose of analgesia was administered at the L3–L4 interlaminar space. Throughout the procedure, no additional bolus dose of sedation/analgesia was required. There was no respiratory depression or need for ventilatory assistance throughout the procedure. The procedure lasted about 2 h.
A 39-year-old female, with ASA physical Status I, weighing 76 kg had an L3–L4 IVDP and was scheduled for endoscopic discectomy. Monitoring, premedication, sedation and analgesia protocol, and surgical intervention were similar to those for Cases 1, 2, and 3. A single-shot epidural dose of analgesia was administered at the L2–L3 interlaminar space. As in Cases 1 and 2, an additional sedation analgesia top-up of fentanyl (0.5 mcg/kg) and midazolam (30 mcg/kg) was administered IV during instrumentation, and the infusion rate of dexmedetomidine was increased to 0.5 mcg/kg/h and subsequently tapered and discontinued toward the end of surgery. The duration of the surgery was 2.5 h.
| Discussion|| |
Literature shows that different methods have been effectively tried in the anesthetic management of patients undergoing endoscopic discectomy. In our case, target analgesia was achieved in all four cases using a single shot of lumbar epidural anesthesia and an opioid (fentanyl), and sedation depth was achieved using a combination of low-dose benzodiazepine (midazolam) and dexmedetomidine. The aim was to avoid administering unnecessary or excessive drugs in order to preserve spontaneous breathing of the patients, and also to have patient cooperation according to the surgical requirements.
Similar to our cases, Zhu et al., Wang et al., and Xu T et al. have tried preemptive and epidural anesthesia and have obtained good clinical results for intraoperative pain management during endoscopic discectomy compared to local anesthesia.,,
With deeper planes of sedation, patients stand the risk of respiratory depression. In a report published by Oksar et al., three patients who underwent endoscopic discectomy with local anesthesia infiltration were supplemented with propofol and remifentanil infusion. All three patients developed respiratory depression and required positive pressure ventilation. The authors emphasize that a deeper level of sedation can interfere with the spontaneous breathing of the patient, thereby compromising patient safety. In our case, patients were subjected to mild-to-moderate sedation and did not go into respiratory depression at any point of the procedure.
General anesthesia combined with electromyography monitoring is another method that has been tried effectively by Kitahama et al. Although this can be safe, efficacious, and convenient, patients are subjected to the risks of general anesthesia and require postoperative monitoring until recovery.
The practical advantage of our method was that it provided optimum conditions for surgical intervention, i.e., immobilization, and yet provided adequate sedation, and maintained cooperation by the patient during different steps of the surgery.
| Conclusion|| |
Lumbar epidural analgesia with moderate sedation is helpful in endoscopic discectomy in terms of patient comfort, stable vitals, effective communication between surgeon and patient, and optimal surgical goal.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pan Z, Ha Y, Yi S, Cao K. Efficacy of Transforaminal Endoscopic Spine System (TESSYS) technique in treating lumbar disc herniation. Med Sci Monit 2016;22:530-9.
Gotecha S, Ranade D, Patil SV, Chugh A, Kotecha M, Sharma S, et al
. The role of transforaminal percutaneous endoscopic discectomy in lumbar disc herniations. J Craniovertebr Junction Spine 2016;7:217-23.
Ahn Y. Percutaneous endoscopic decompression for lumbar spinal stenosis. Expert Rev Med Devices 2014;11:605-16.
Ahn SS, Kim SH, Kim DW, Lee BH. Comparison of outcomes of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for young adults: A retrospective matched cohort study. World Neurosurg 2016;86:250-8.
Ahn SS, Kim SH, Kim DW. Learning curve of percutaneous endoscopic lumbar discectomy based on the period (early vs. late) and technique (in-and-out vs. in-and-out-and-in): A retrospective comparative study. J Korean Neurosurg Soc 2015;58:539-46.
Ahn Y. Transforaminal percutaneous endoscopic lumbar discectomy: Technical tips to prevent complications. Expert Rev Med Devices 2012;9:361-6.
Kim SI, Ha KY, Oh IS. Preemptive multimodal analgesia for postoperative pain management after lumbar fusion surgery: A randomized controlled trial. Eur Spine J 2016;25:1614-9.
Kitahama Y, Matsui G, Minami M, Kawaoka T, Otome K, Nakamura M. Posterolateral percutaneous endoscopic discectomy with free-running electromyography monitoring under general anesthesia. Minim Invasive Surg 2017;1:109-14.
Wang SJ, Chen BH, Wang P, Liu CS, Yu JM, Ma XX. The effect of percutaneous endoscopic lumbar discectomy under different anesthesia on pain and immunity of patients with prolapse of lumbar intervertebral disc. Eur Rev Med Pharmacol Sci 2017;21:2793-9.
Xu T, Tian R, Qiao P, Han Z, Shen Q, Jia Y. Application of continuous epidural anesthesia in transforaminal lumbar endoscopic surgery: A prospective randomized controlled trial. J Int Med Res 2019;47:1146-53.
Oksar M, Gumus T, Kanbak O. Sedation monitoring and management during percutaneous endoscopic lumbar discectomy. Case Rep Anesthesiol 2016;2016:3931567.
Zhu Y, Zhao Y, Fan G, Sun S, Zhou Z, Wang D, et al
. Comparison of 3 anesthetic methods for percutaneous transforaminal endoscopic discectomy: A prospective study. Pain Physician 2018;21:E347-53.
[Figure 1], [Figure 2], [Figure 3]