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  • Evaluation of risk depends on several factors:
    • Elective versus emergent versus staged surgery
    • One versus several vertebral levels
    • Primary versus repeat procedure
  • ALL cases of spine surgery associated with:
    • Risk of medullary injury
    • Risk of significant blood loss
    • Rare occurrence of significant venous emboli (beware if PFO)
    • Higher prevalence of chronic pain and drug dependence
  • Prone positioning associated with:
    • Cardiovascular instability
    • Positioning injuries: pressure points and nerve damage, rarely rhabdomyolysis
    • Visual loss
    • Difficult access to airway
  • Patients with previous high (above T5) spinal cord injury (See Chapter 32)
    • Abnormal autonomic responses (hypertensive crisis or hypotension and bradycardia)
    • Vasoplegia (relative hypovolemia)
    • Atelectasis from inefficient cough and/or hypoventilation
    • Bladder spasticity
    • Creatinine does not correlate with renal function
    • Intramuscular injections may have delayed absorption


  • Severe scoliosis: assess for MH susceptibility and latex allergy
  • Baseline neurologic status: document any preexisting neurologic deficit, look for symptoms appearing during/exacerbated by neck motion (especially in presence of rheumatoid arthritis or spinal stenosis with cervical myelopathy)
  • Discuss type of neuromonitoring with surgeon and specialized personnel
  • Baseline visual status: document any preexisting visual defect
  • Cardiopulmonary comorbidities and physiological reserve
    • Noninvasive cardiac testing in patients with major AHA/ACC risk factors, or intermediate AHA/ACC risk factors and limited exercise tolerance
    • Risk of blood loss: blood work (Hb/Hct, platelets, PT/PTT, ABO typing), assess vascular access, order blood products if necessary
    • Severe scoliosis with pulmonary HTN: obtain baseline ABG and PFTs, look for cor pulmonale, possible need for postoperative ventilation
    • Anti-hypertensive drugs: no ACEIs and/ARBs the day of surgery; no diuretics the day of surgery if history of orthostatic hypotension
  • Diffuse articular disease
    • Assess ROM in neck and TMJ (high incidence of difficult airway)
    • Assess ROM in limbs (risk of difficult positioning)
  • Chronic pain and drug dependence: consider placement of epidural catheter by surgeon during procedure and specialized pain consultation
  • Anticipate need for ICU after surgery
  • All patients should receive following information:
    • Risk of neurologic injury, importance of neurologic evaluation immediately after surgery (ETT sometimes still in place), rare necessity to perform wake-up test during procedure (patient maintained in prone position)
    • Risk of blood loss, possible necessity to transfuse blood products
    • If prone position: risk of visual loss (see postop complications Chapter 62)
    • If long procedure (>6 hours), especially if prone and/or cervical, possible necessity to maintain sedated after surgery with ETT in place until safe to extubate
    • If awake fiberoptic intubation: give usual information
    • If major surgery in elderly patient: risk of postoperative cognitive dysfunction


Before induction:


  • Prone positioning: make sure specialized table is available with adequate padding
  • Usual GA setup plus two large-bore IV lines, A-line, CVL if patient with limited reserve or if high risk of venous air embolism, Foley
  • Hemodynamic monitoring to guide fluid administration or if high risk of blood loss
  • Have vasopressors, fluid warmers, and blood transfusion sets available. Consider intraoperative blood salvage techniques




  • Awake fiberoptic intubation if limited cervical and/or temporo-mandibular ROM
  • Low-pressure ETT cuffs ...

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