Protocol for Lumbar Spinal Fusion and Instrumentation

Vietnam - photo by JoAnn Sturman

Scott Sturman, M.D.

Lumbar Spinal Fusion with Instrumentation cases are performed under general anesthesia, but protocols utilizing multimodal therapy and developed for total joint surgery can be applied to more effectively treat pain in the post operative period.

Preoperative Celebrex (200mg vs. 400mg) and pregabalin (300mg in pre op then 150mg po BID during hospitalization --- cut dose in half for patients >70).  Oxycontin 10mg for patients <70.  


1 gm IV acetaminophen intraoperatively by anesthesia.  For patients receiving IV acetaminophen post op in conjunction with oral analgesics containing acetaminophen, care must be taken not to exceed 4 gm per day.

The administration of a long acting narcotic IV or IM in OR prior to arrival in PACU.  Hydromorphone or meperidine with vistaril are preferred.  IM doses suggested: hydromorphone 2-4 mg and meperidine 75-100 mg.  Individually adjust dose for patient's condition.

IV ketamine 100mg intraoperatively at discretion of anesthesiologist.

Infiltration of the wound area with bupivacaine at the conclusion of surgery.
 
Intrathecal narcotics only for select patient, i.e., patients dependent on high dose narcotics with difficult pain control issues.  This therapy is not to be used for routine patients due to problems with urinary retention and the possibility of interfering with the post op neurological exam.

Most pain control problems occur within the first 24 hours following surgery.  By post op day #1, most of these patients have acceptable pain control.  The use of a standardized protocol using multimodal RX should address pain control concerns immediately after surgery.  

 Tiger's Nest, Bhutan - photo by Tom Yanagi, M.D.

Subcostal TAP Block for Laparoscopic Peritoneal Dialysis Catheter Placement of Revision

Bird of New Zealand - photo by Tom Yanagi, M.D.

Scott Sturman, M.D.

At times one would prefer to avoid general anesthesia for laparoscopic dialysis catheter placement.  Bilateral subcostal TAP blocks with IV sedation offer another option for dealing with these chronically ill patients.

The patient was a 120 kg 30 year old male with ESRD, hypertention, and diabetes who presented for CAPD catheter revision.  The surgical plan was to use low pressure insufflation and exteriorize the catheter, clear the obstructed ports, and replace it.

The patient received fentanyl 100ug and midazolam 2mg IV.  Bilateral subcostal TAP blocks using 30 cc of 1.5% lidocaine on each side were placed under ultrasound guidance.  Lidocaine was chosen for its rapidity of onset, but mepivacaine 2% may be a suitable choice for its longer post operative analgesia.

A propofol infusion was begun.  The surgeon injected lidocaine at the port sites.  The patient tolerated the pneumoperitoneum without requiring additional narcotics or changing the propofol infusion rate.  There was a slight reaction when the trochars were placed, but otherwise the procedure proceeded uneventfully.  In all the patient received only the preblock medication and 158 mg of propofol for the entire case.

An excellent video presented by Dr. Brandon Winchester describes both the posterior and subcostal TAP blocks.  The video is 45 minutes long, but the description of the TAP blocks are found in minutes 15-35.

Cairns, Australia - photo by Tom Yanagi, M.D.