Thoracic Epidural Anesthesia For Lumbar Spine Decompressive Surgery In An Elderly Patient

摘要

We present a case of an elderly patient with a significant medical history, who underwent elective lumbar decompressive surgery, three months after sustaining a myocardial infarction. After a collobarative pre-surgical assesment by the neurosurgery and anesthesiology teams, epidural anesthesia was performed. A thoracic epidural catheter was inserted pre-operatively. The patient underwent successful L4-5 synovial cyst removal, and subsequent relief of pain. Epidural anesthesia is a viable alternative to general anesthesia for lumbar surgery, is safe and may offer several benefits, particularly in patients with multiple cormorbidities. Introduction Despite reports of neuraxial anesthesia as a safe and effective alternative, general anesthesia remains the most commonly used anesthetic technique for lumbar spine surgery.1 However, epidural anesthesia may offer significant advantages when compared to general anesthesia. Patients with significant medical problems may benefit from the positive effects of neuraxial anesthesia on the cardiovascular, pulmonary and neurologic systems. Reduction of blood loss and improved surgical conditions, avoidance of nerve injury (due to patient self positioning), verbal communication between surgeon and patient, reduction of postoperative mortality, improved analgesia, decreased side effects from analgesics and more stable intraoperative and postoperative hemodynamics are cited as potential key advantages.1,2 Thoracic epidural anesthesia may improve coronary perfusion, myocardial oxygen balance and may reduce cardiac events.3 In this case report, we demonstrate the successful application of epidural anesthesia for lumbar spine decompressive surgery in a patient with severe three vessel coronary artery disease.We received written permission from the patient to publish this case report. Case A 91-year-old ASA 3, 69 inch, 75 kg male presented for lumbar decompressive surgery due to severe spinal stenosis causing debilitating back and leg pain. His past medical history was significant for an inferior ST elevation myocardial infarction three months prior to the surgery, three vessel coronary artery disease, hypertension, noninsulin dependent diabetes mellitus, peripheral arterial disease, hyperlipidemia, stroke, paroxysmal atrial fibrillation, bladder cancer, prostate cancer, microcytic anemia and benign prostatic hypertrophy. At the time of the myocardial infarction, the patient underwent coronary catheterization and medical therapy to include aspirin therpay and beta blockade, were recommended. The patient was then seen in the neurosurgery clinic for sciatica, a few weeks later. An MRI revealed a synovial cyst at the L4-L5 lumbar region. After consultation with neurosurgery a day earlier, we placed a thoracic epidural catheter pre-operatively on the day of surgery. The catheter was uneventfully placed at the T10-T11 interspace using an 18 gauge 3.5” Tuohy needle. In the operating room, the patient was placed in the left lateral decubitus position and standard ASA montiors were placed. Oxygen was delivered by face mask and ventilation was measured by capnography. An epidural infusion containing 0.125% bupivacaine and fentanyl (5 mcg/ml) was initiated at 10ml per hour, after an intial test dose of 3 of ml 1.5% lidocaine with epinephrine, followed by a bolus of 1% lidocaine 6 ml through the epidural catheter.A low dose propofol infusion was used for sedation. A sensory level check was performed using the pinprick method, prior to surgical incision. Bradycardia and hypotension were treated with intermittent boluses of ephedrine throughout the case. He was responsive to verbal and physical stimuli and denied pain. After the completion of the surgical procedure, the patient was taken to the recovery unit and the epidural catheter was removed per surgeons request for physical examnations. The following day, the patient was ambulating, epidural blockade had resolved and his pain was controlled with oral medica