ANESTHESIA AND ANALGESIA . . . Current Researches
550
vni.. 55, No. 4, JULY-AUGUST, 1976
Spinal Anesthesia for Lumbar Disc Surgery: Review of 576 Operations DAVID J. SILVER, M D * REMBRANDT H. DUNSMORE, M D t CHARLES M. DICKSON, M D f Hartford, Connecticuts
Neurologic complications accompanying spinal anesthesia were examined in 576 lumbar disc operations on 507 patients. The single serious complication did not seem attributable to the choice of anesthetic method. Minor neurologic
complications, with the exception of spinal headache, could be explained by surgical manipulation. The authors conclude that spinal anesthesia is safe for surgical operations on the laterally herniated lumbar disc.
N
women), 576 were performed under spinal and 35 under general anesthesia. Patient ages ranged from 15 to 80 (average 43) years. One third were followed for more than 2 years and 55% for over 6 months. A myelogram preceded 77% of the operations. Average hospital stay was 7 days.
complications associated with spinal anesthesia are rare and generally min0r.l-4 Controversy exists, however, over the use of spinal anesthesia for lumbar disc surgery. Vandam and Dripps? suggest that spinal anesthesia may exacerbate existing neurologic disease and recommend against its use for lumbar disc surgery. Others have found spinal anesthesia safe and effective.5-8 Spinal anesthesia has been used at Hartford Hospital for more than 9000 disc operations during a 35-year period. We report here the results of a study of a sample of this patient population. EUROLOGIC
MATERIALS AND METHODS From 918 lumbar disc operations at Hartford Hospital during 1969-70, the charts of 575 patients were selected randomly for study; 68 were eliminated because follow-up study was less than 6 weeks. Of the 611 procedures studied (399 on men and 212 on
General anesthesia was employed in the following situations: (1) a near complete or total myelographic block; (2) inability to accomplish a subarachnoid tap; (3) myelographic demonstration of arachnoiditis; (4) inadvertent production of a “high spinal;” and (5) patient refusal of spinal anesthesia. Approximately 93% of the operations under spinal were at the lowest 2 interspaces (table 1); only 81% of those done under general anesthesia were at the same spaces (table 2). In 58 operations, 2 herniated discs were removed. Each operated
”Chief Resident in Neurosurgery, Hartford Hospital; Instructor in Neurosurgery, Yale University. iAssociate
Clinical Professor, Department of Surgery, University of Connecticut Health Center School of Medicine; Assistant Clinical Professor, Department of Surgery, Yale University School of Medicine; Chief, Department of Neurosurgery, Hartford Hospital. SAttending Anesthesiologist, Hartford Hospital. BDepartments of Neurosurgery and Anesthesia, Hartford Hospital, Hartford, Connecticut. Reprint requests to Dr. Silver, 2800 North Vancouver Avenue, Suite 101, Portland, Oregon 97227. Paper received: 9/23/75 Accepted for publication: 11/13/75
551
Spinal Anesthesia . . . Silver, et a1
tray in a separate envelope marked on the outside with a sterilization indicator.
TABLE 1 Levels of Herniation of Patients Having Spinal Anesthesia Level of herniation
Number
LlrL2 L2-L3 L3-L4 L4-L5 L5-S1
Total
Percentage
2 9 32 328 261
0.3 1.4 5.1 51.9 41.3
632
100.0
TABLE 2 Levels of Herniation of Patients Having General Anesthesia Level of herniation
Number
Ll-L2 L2-L3 L3-L4 L4-L5 L5-S1
Total
Percentage
1 1 5 21 9
2.7 2.7 13.5 56.8 24.3
37
100.0
RESULTS
TABLE 3 Summary of Recurrent Disc Operations Under Spinal ~~~
~~
~~~
Number of recurrences (104)
Number of patients (83)
After the anesthesiologist inserted an IV catheter and checked vital signs, the patient was turned to the lateral position with the affected side down. The anesthesiologist scrubbed briefly, gloved, and painted the back with povidone-iodine solution. After local infiltration with procaine, a 22 or 25 spinal needle was introduced into the subarachnoid space in the midline at a level above the affected disc. A mixture of 10% procaine and 1% tetracaine (usually 8 to 10 mg tetracaine and 40 to 50 mg procaine), diluted to 2.5 to 3 ml with clear cerebrospinal fluid (CSF) was injected over 8 to 10 seconds. After injection, 0.1 to 0.2 ml of CSF was aspirated and reinjected to assure needle position. The patient was placed supine for 5 to 10 minutes, and the progression of anesthetic level carefully monitored. The operation was performed in the lateral position with the affected side up, after further skin infiltration with 1% lidocaine with epinephrine.
1
2
3
4
67
12
3
1
level was counted separately. More than 1’7%of the operations under spinal anesthesia were for recurrent disc herniation (table 3) ; 12 patients underwent 3 operations under spinal, 3 underwent 4, and 1 underwent 5. Neurologic complications were carefully evaluated in an effort to separate surgical trauma from anesthetic damage. Motor or sensory deficit at a level different from that operated on, contralateral pain, or contralateral deficit was classified as a residual probably attributable to anesthesia.
TECHNIC OF ANESTHESIA Anesthetic trays containing glass syringes, spinal needles, and small disposable needles which had been cleaned ultrasonically were wrapped and autoclaved in a central location. Single-dose vials of procaine, tetracaine, and ephedrine were packaged on the
Under spinal anesthesia, 91.6% of patients achieved good-to-excellentresults (table 4 ) . All but 1 of the 8.4% fair and unsatisfactory results were so classified because of residual back pain. One patient, whose preoperative myelogram showed a large defect at U-L5, had a moderate postoperative paresis of ankle flexors and extensors after unilateral exploration at the appropriate level. Reexploration 5 days later under general anesthesia revealed a large centrally herniated lumbosacral disc. The patient recovered to a “fair” status. TABLE 4 Results of Surgery Under Spinal Anesthesia
Excellent* Good+
Fair$ Unsatisf aetorys Total
Number
Percentage
309 219 39 9 576
53.6 38.0 6.8 1.6 100.0
*Totally asymptomatic. ;Mild back pain, unlimited activity. S o m e limitation of activity, or change of job required. $Persistent pain, severely limited activity, worsening of symptoms.
552
ANESTHESIA A N D ANALGESIA . . . Current Researches
TABLE 5 Results of Surgery Under General Anesthesia Excellent':' Goodt Fairx Unsatisfactory$ Total
TABLE 6
Percentage
17 7
48.6 20.0 11.4 20.0 100.0
7 35
4..Tur..i-AucrrsT, 1976
Early Postoperative Complications
Number
4
VOl.. 55. NO.
','Totally asymptomatic.
+Mild back pain, unlimited activity .!:Some limitation of activity. or change of job required.
8 Persistent pain, severely limited activity, worsening o f symptoms.
Patients operated on under general anesthesia achieved 68.6% good-to-excellent results ( table 5 ) . Of 11 patients graded fair or unsatisfactory, 7 had persistent pain and 4 had severe neurologic deficit. Two patients made unsatisfactory recoveries from preoperative paraparesis resulting from central disc herniation. Another sustained a bilateral footdrop after operation and the fourth, a unilaterial footdrop which partially recovered. The patients operated on under spinal anesthesia cannot be compared with those done under general anesthesia since those undergoing general anesthesia were clearly neurologically worse preoperatively. Early complications following operations under spinal anesthesia (table 6) included 11 cases of increased neurologic deficit. Of the 5 patients with motor and sensory deficits, 3 had footdrop following L-5 root retraction, 1 had temporary saddle anesthesia after removal of a large central disc, and 1 suffered weakness of plantar flexion with associated calf dysesthesias after disc removal at the lumbosacral level. I n the group with sensory changes only, 3 complained of persistent dysesthesias in a distribution consistent with the dermatome of the manipulated root and there were 2 cases of numbness of the contralateral thigh, probably from compression of the lateral femoral cutaneous nerve in the lateral operative position. A case of early contralateral postoperative pain was reoperated 2 months later with removal of an extruded fragment on the opposite side at the same level. Other complications were infrequent (table 3 ) . Only 1% of the spinals resulted in spinal headache. There were no wound in-
Spinal ComDlicotionr
(576 rarer1
General
I 3 5 carer) ~
Increased neurologic deficit Motor and sensory change Sensory change only Contralateral pain Urinary retention < 2 days > 2 days Pneumonitis o r atelectasis Phlebitis Spinal headache Aseptic meningitis Discitis Ileus Wound problems Hematoma Infection CSF fistula Trochanteric bursitis
5 5 1
3 1 0
17 1 G 4
2 5 0 0 0 0 0 3
F 1 1 4
2 0 1 5
0 0 0 0
fections. One CSF fistula, following a dural tear, was repaired a t reexploration by reclosure of the luinbodorsal fascia. Trochanteric bursitis, found in 1%, likely resulted from pressure on the bursa in the lateral position. The early neurologic complications associated with general anesthesia included 1 bilateral and 2 unilateral footdrops, and an instance of temporary dysesthesia in the distribution of a retracted S-1 root.
DISCUSSION Operations on the herniated lumbar disc under spinal anesthesia produced results similar to those reported in other series. Several authors claim 90 to 95% good-toexcellent results in cases of typical radicular compression.*-I0 Minor neurologic sequelae of spinal anesthesia have been estimated to occur in 0.5 to 0.8% of patients.ll,l? Since the majority of these relate to the lumbar and sacral dermatomes,I1 it is usually impossible to separate the complications produced by anesthesia from those related to surgical manipulation. Our 1 case of contralateral paresthesia was relieved upon removal of a contralateral recurrent disc.
Spinal Anesthesia . . . Silver, et a1
553
The major reluctance to administer spinal anesthesia for lumbar disc surgery stems from fear of paralysis due to transverse myelitis or chronic progressive adhesive arachnoiditis. These entities are rare serious complications of spinal anesthesia,I2-I4occurring in less than 0.01% of cases. Progressive adhesive arachnoiditis may represent a nonspecific response to an intrathecal irritant. The patients surveyed in this study were, on average, older and had a higher percentage of herniated upper discs than has been found in a summary of 9082 cases from 30 reports in the literature.7 Nearly 15% underwent 2 myelograms, and 17% had 2 or more disc operations under spinal anesthesia. Despite significant exposure to possible insult, chronic progressive adhesive arachnoiditis was not found. Indeed, 1 patient with known arachnoiditis had lysis of adhesions under spinal anesthesia, with clinical improvement. While this procedure is not recommended, our experience is in accord with that of Ditzler and associates,: who reported 10 patients with arachnoiditis to whom spinal anesthesia was administered without harmful effect. Our total experience of 9000 cases has led us to conclude that this feared complication of spinal anesthesia has not appeared more commonly in operations on the laterally herniated disc. Five cases of significant neurologic residual were found in 3168 previously reported lumbar disc operations under spinal anesthesia (table 7 ) . I n Ditzler’s series,s residual deficit related to application of concentrated nupercaine to the cauda equina. In Rosenberg’s case,” progressive weakness developed in association with a deep wound infection and resolved with treatment of the infection. Spangfort’s report‘ gave no information about the origin of the deficit.
Temporary urinary retention, as noted in table 6, was uncommon. Rosenberg and Berner” found urinary retention was more common after disc surgery under general anesthesia than under spinal. This observation has not been confirmed in a large randomly selected sample. Our 1% incidence of postoperative headache was about 10% of that usually associated with spinal anesthesia. We hypothesize that epidural blood serves as a “patch,” and reduces the dural leak. One advantage of spinal anesthesia for the herniated disc may be decreased mortality. In the 4 series (table 7 ) employing spinal anesthesia for disc surgery, the 3 deaths represent a mortality rate of 0.08 percent. This is one-half that found in 15 recent reports of results of nearly 8300 cases of disc surgery.‘ In Hartford Hospital’s 9000 cases of disc surgery under spinal anesthesia, there has been 1 postoperative death, from myocardial infarction, a mortality rate of 0.01 percent. We conclude that proper administration of spinal anesthesia for the herniated lumbar disc is a safe procedure. Serious neurologic complications attributable to the anesthetic method have not been observed more frequently than when using spinal anesthesia for other operations. Low mortality and morbidity coupled with a short average hospital stay indicate to us that this is the anesthesia method of choice for such surgical operations.
ACKNOWLEDGMENT The authors wish to thank Drs. James C. Collias, Norman H. Gahm, William B. Scoville, and Benjamin B. Whitcomb for making available their records of the patients included in this study.
TABLE 7 Summary of Literature on Spinal Anesthesia for Lumbar Disc Surgery Operations
Significant neurologic r e r i d u o i
Morlalify
Ditzler et al” (1959) Rosenberg and Berner‘ (1965) Spangfort’ (1972)
766 128 2274
Subtotal Silver et a1 (1975)
3168 576
5
1
3 0
3744
6 (0.16%)
3 (0.08% )
Grand total
1 1 3
0 0 3
554
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.55, No. 4, JULY-AUGUST, 1976
REFERENCES 1. Dripps RD, Vandam LD: Long-term followup of patients who received 10,098 spinal anesthetics: failure to discover major neurological sequelae. JAMA 156:1486-1491, 1954
A computer-aided analysis of 2504 operations. Acta Orthop Scand Suppl 142:l-95, 1972 8. Scoville WB, Corkill G: Lumbar disc surgery: terhnique of radical removal and early mobilization. J Neurosurg 39:265-269, 1973
2. Vandam LD, Dripps RD: Exacerbation of pre-existing neurologic disease after spinal anesthesia. N Engl J Med 255:843-849, 1956
9. O'Connell J E A : T h e indications for and results of the excision of lumbar intervertebral disc protrusions: review of 500 cases. Ann R Coll Surg Engl 6:403-412, 1950
3. Sadove MS, Levin M J : Neurological complications of spinal anesthesia: a statistical study of more than 10,000 cases. 111 Med J 105:169-174, 1954
10. Slepian A: Lumbar disc surgery: long followup results from three neurosurgeons. NY State J Med 66: 1063-1068, 1966
4, Phillips oC, Ebner H, ~~l~~~ AT, et al: Neurological complications following spinal anesthesis with lidocaine: a prospective review of cases. Anesthesiology 30:284-289, 1969
11. Dripps RD, Eckenhoff JE, Vandam LD: Introduction to Anesthesia: T h e Principles of Safe Practice. Fourth edition. Philadelphia, WB Saunders Company, 1972, p 456
5. Ditder Jw, Dumke PR, Harrington JJ, et al: Should spinal anesthesia be used in surgery for herniated intervertebral disk? Anesth & Analg 38: 118-124, 1959
12. Thorsen G: Neurological complications after spinal anesthesia and results from 2493 follow.up 121:1-272, 1947 cases. Acta Chir Stand suppl
6. Rosenberg MK, Berner G: Spinal anesthesia in lumbar disc surgery: review of 200 cases with a case history. Anesth & Analg 44:419-423, 1965
7. Spangfort EV: The lumbar disc herniation.
13. French J D : Clinical manifestations of lumbar spinal arachnoiditis: report of 13 cases. Surgery 20:718.729, 1946 14. Kennedy F, Effron AS, Perry G: The grave spinal cord paralysis caused by spinal anesthesia. Surg Gynecol Obstet 91:385-397, 1950
BICARBONATE DURING RESUSCITATION. A r t e r i a l pH, PCO, a n d osmolality w e r e measured d u r i n g cardiopulmonary resuscitation in d o g s with o r without i n t r a venous sodium bicarbonate (1 m E q / k g ) . I n t h e first 15 m i n u t e s of resuscitation pH did n o t fall below 7.35 a n d s e r u m osmolality increased significantly when sodium bicarbonate w a s not administered to dogs. When bicarbonate w a s added t o t h e regimen pH increased transiently, PaCO.. increased a n d remained above a w a k e levels a n d s e r u m osmolality w a s elevated. These d a t a confirm t h a t adequate ventilation d u r i n g resuscitation is sufficient to prevent t h e development of acidosis in t h e absence of pre-existing acidosis. PaCO, increased a f t e r bicarbonate despite adequate ventilation. These studies s u g g e s t t h a t bicarbonate should n o t be used d u r i n g cardiopulmonary resuscitation in t h e absence of (1) inadequate alveolar ventilation, ( 2 ) w h e n cardiac a r r e s t is brief a n d preexisting acidosis is unlikely o r ( 3 ) in repeated doses w i t h o u t pH confirmation. C u r r e n t recommendations of t h e National Conference on Cardiopulmonary Resuscitation a r e t o administer bicarbonate 1 m E q / k g twice d u r i n g the e a r l y minutes of resuscitation a n d r e p e a t 0.5 m E q / k g at 10 minute intervals. ( B i s h o p RL, Wcisfeltlt M L : S o d i u m bical,bonatc admiuistmtion d u , i v g cardiac a ) I c s t . Etfcct on alYc?'ial p H , PCOJ and osmolality. J A M A P35:506-509, 1 9 7 6 )
550
vni.. 55, No. 4, JULY-AUGUST, 1976
Spinal Anesthesia for Lumbar Disc Surgery: Review of 576 Operations DAVID J. SILVER, M D * REMBRANDT H. DUNSMORE, M D t CHARLES M. DICKSON, M D f Hartford, Connecticuts
Neurologic complications accompanying spinal anesthesia were examined in 576 lumbar disc operations on 507 patients. The single serious complication did not seem attributable to the choice of anesthetic method. Minor neurologic
complications, with the exception of spinal headache, could be explained by surgical manipulation. The authors conclude that spinal anesthesia is safe for surgical operations on the laterally herniated lumbar disc.
N
women), 576 were performed under spinal and 35 under general anesthesia. Patient ages ranged from 15 to 80 (average 43) years. One third were followed for more than 2 years and 55% for over 6 months. A myelogram preceded 77% of the operations. Average hospital stay was 7 days.
complications associated with spinal anesthesia are rare and generally min0r.l-4 Controversy exists, however, over the use of spinal anesthesia for lumbar disc surgery. Vandam and Dripps? suggest that spinal anesthesia may exacerbate existing neurologic disease and recommend against its use for lumbar disc surgery. Others have found spinal anesthesia safe and effective.5-8 Spinal anesthesia has been used at Hartford Hospital for more than 9000 disc operations during a 35-year period. We report here the results of a study of a sample of this patient population. EUROLOGIC
MATERIALS AND METHODS From 918 lumbar disc operations at Hartford Hospital during 1969-70, the charts of 575 patients were selected randomly for study; 68 were eliminated because follow-up study was less than 6 weeks. Of the 611 procedures studied (399 on men and 212 on
General anesthesia was employed in the following situations: (1) a near complete or total myelographic block; (2) inability to accomplish a subarachnoid tap; (3) myelographic demonstration of arachnoiditis; (4) inadvertent production of a “high spinal;” and (5) patient refusal of spinal anesthesia. Approximately 93% of the operations under spinal were at the lowest 2 interspaces (table 1); only 81% of those done under general anesthesia were at the same spaces (table 2). In 58 operations, 2 herniated discs were removed. Each operated
”Chief Resident in Neurosurgery, Hartford Hospital; Instructor in Neurosurgery, Yale University. iAssociate
Clinical Professor, Department of Surgery, University of Connecticut Health Center School of Medicine; Assistant Clinical Professor, Department of Surgery, Yale University School of Medicine; Chief, Department of Neurosurgery, Hartford Hospital. SAttending Anesthesiologist, Hartford Hospital. BDepartments of Neurosurgery and Anesthesia, Hartford Hospital, Hartford, Connecticut. Reprint requests to Dr. Silver, 2800 North Vancouver Avenue, Suite 101, Portland, Oregon 97227. Paper received: 9/23/75 Accepted for publication: 11/13/75
551
Spinal Anesthesia . . . Silver, et a1
tray in a separate envelope marked on the outside with a sterilization indicator.
TABLE 1 Levels of Herniation of Patients Having Spinal Anesthesia Level of herniation
Number
LlrL2 L2-L3 L3-L4 L4-L5 L5-S1
Total
Percentage
2 9 32 328 261
0.3 1.4 5.1 51.9 41.3
632
100.0
TABLE 2 Levels of Herniation of Patients Having General Anesthesia Level of herniation
Number
Ll-L2 L2-L3 L3-L4 L4-L5 L5-S1
Total
Percentage
1 1 5 21 9
2.7 2.7 13.5 56.8 24.3
37
100.0
RESULTS
TABLE 3 Summary of Recurrent Disc Operations Under Spinal ~~~
~~
~~~
Number of recurrences (104)
Number of patients (83)
After the anesthesiologist inserted an IV catheter and checked vital signs, the patient was turned to the lateral position with the affected side down. The anesthesiologist scrubbed briefly, gloved, and painted the back with povidone-iodine solution. After local infiltration with procaine, a 22 or 25 spinal needle was introduced into the subarachnoid space in the midline at a level above the affected disc. A mixture of 10% procaine and 1% tetracaine (usually 8 to 10 mg tetracaine and 40 to 50 mg procaine), diluted to 2.5 to 3 ml with clear cerebrospinal fluid (CSF) was injected over 8 to 10 seconds. After injection, 0.1 to 0.2 ml of CSF was aspirated and reinjected to assure needle position. The patient was placed supine for 5 to 10 minutes, and the progression of anesthetic level carefully monitored. The operation was performed in the lateral position with the affected side up, after further skin infiltration with 1% lidocaine with epinephrine.
1
2
3
4
67
12
3
1
level was counted separately. More than 1’7%of the operations under spinal anesthesia were for recurrent disc herniation (table 3) ; 12 patients underwent 3 operations under spinal, 3 underwent 4, and 1 underwent 5. Neurologic complications were carefully evaluated in an effort to separate surgical trauma from anesthetic damage. Motor or sensory deficit at a level different from that operated on, contralateral pain, or contralateral deficit was classified as a residual probably attributable to anesthesia.
TECHNIC OF ANESTHESIA Anesthetic trays containing glass syringes, spinal needles, and small disposable needles which had been cleaned ultrasonically were wrapped and autoclaved in a central location. Single-dose vials of procaine, tetracaine, and ephedrine were packaged on the
Under spinal anesthesia, 91.6% of patients achieved good-to-excellentresults (table 4 ) . All but 1 of the 8.4% fair and unsatisfactory results were so classified because of residual back pain. One patient, whose preoperative myelogram showed a large defect at U-L5, had a moderate postoperative paresis of ankle flexors and extensors after unilateral exploration at the appropriate level. Reexploration 5 days later under general anesthesia revealed a large centrally herniated lumbosacral disc. The patient recovered to a “fair” status. TABLE 4 Results of Surgery Under Spinal Anesthesia
Excellent* Good+
Fair$ Unsatisf aetorys Total
Number
Percentage
309 219 39 9 576
53.6 38.0 6.8 1.6 100.0
*Totally asymptomatic. ;Mild back pain, unlimited activity. S o m e limitation of activity, or change of job required. $Persistent pain, severely limited activity, worsening of symptoms.
552
ANESTHESIA A N D ANALGESIA . . . Current Researches
TABLE 5 Results of Surgery Under General Anesthesia Excellent':' Goodt Fairx Unsatisfactory$ Total
TABLE 6
Percentage
17 7
48.6 20.0 11.4 20.0 100.0
7 35
4..Tur..i-AucrrsT, 1976
Early Postoperative Complications
Number
4
VOl.. 55. NO.
','Totally asymptomatic.
+Mild back pain, unlimited activity .!:Some limitation of activity. or change of job required.
8 Persistent pain, severely limited activity, worsening o f symptoms.
Patients operated on under general anesthesia achieved 68.6% good-to-excellent results ( table 5 ) . Of 11 patients graded fair or unsatisfactory, 7 had persistent pain and 4 had severe neurologic deficit. Two patients made unsatisfactory recoveries from preoperative paraparesis resulting from central disc herniation. Another sustained a bilateral footdrop after operation and the fourth, a unilaterial footdrop which partially recovered. The patients operated on under spinal anesthesia cannot be compared with those done under general anesthesia since those undergoing general anesthesia were clearly neurologically worse preoperatively. Early complications following operations under spinal anesthesia (table 6) included 11 cases of increased neurologic deficit. Of the 5 patients with motor and sensory deficits, 3 had footdrop following L-5 root retraction, 1 had temporary saddle anesthesia after removal of a large central disc, and 1 suffered weakness of plantar flexion with associated calf dysesthesias after disc removal at the lumbosacral level. I n the group with sensory changes only, 3 complained of persistent dysesthesias in a distribution consistent with the dermatome of the manipulated root and there were 2 cases of numbness of the contralateral thigh, probably from compression of the lateral femoral cutaneous nerve in the lateral operative position. A case of early contralateral postoperative pain was reoperated 2 months later with removal of an extruded fragment on the opposite side at the same level. Other complications were infrequent (table 3 ) . Only 1% of the spinals resulted in spinal headache. There were no wound in-
Spinal ComDlicotionr
(576 rarer1
General
I 3 5 carer) ~
Increased neurologic deficit Motor and sensory change Sensory change only Contralateral pain Urinary retention < 2 days > 2 days Pneumonitis o r atelectasis Phlebitis Spinal headache Aseptic meningitis Discitis Ileus Wound problems Hematoma Infection CSF fistula Trochanteric bursitis
5 5 1
3 1 0
17 1 G 4
2 5 0 0 0 0 0 3
F 1 1 4
2 0 1 5
0 0 0 0
fections. One CSF fistula, following a dural tear, was repaired a t reexploration by reclosure of the luinbodorsal fascia. Trochanteric bursitis, found in 1%, likely resulted from pressure on the bursa in the lateral position. The early neurologic complications associated with general anesthesia included 1 bilateral and 2 unilateral footdrops, and an instance of temporary dysesthesia in the distribution of a retracted S-1 root.
DISCUSSION Operations on the herniated lumbar disc under spinal anesthesia produced results similar to those reported in other series. Several authors claim 90 to 95% good-toexcellent results in cases of typical radicular compression.*-I0 Minor neurologic sequelae of spinal anesthesia have been estimated to occur in 0.5 to 0.8% of patients.ll,l? Since the majority of these relate to the lumbar and sacral dermatomes,I1 it is usually impossible to separate the complications produced by anesthesia from those related to surgical manipulation. Our 1 case of contralateral paresthesia was relieved upon removal of a contralateral recurrent disc.
Spinal Anesthesia . . . Silver, et a1
553
The major reluctance to administer spinal anesthesia for lumbar disc surgery stems from fear of paralysis due to transverse myelitis or chronic progressive adhesive arachnoiditis. These entities are rare serious complications of spinal anesthesia,I2-I4occurring in less than 0.01% of cases. Progressive adhesive arachnoiditis may represent a nonspecific response to an intrathecal irritant. The patients surveyed in this study were, on average, older and had a higher percentage of herniated upper discs than has been found in a summary of 9082 cases from 30 reports in the literature.7 Nearly 15% underwent 2 myelograms, and 17% had 2 or more disc operations under spinal anesthesia. Despite significant exposure to possible insult, chronic progressive adhesive arachnoiditis was not found. Indeed, 1 patient with known arachnoiditis had lysis of adhesions under spinal anesthesia, with clinical improvement. While this procedure is not recommended, our experience is in accord with that of Ditzler and associates,: who reported 10 patients with arachnoiditis to whom spinal anesthesia was administered without harmful effect. Our total experience of 9000 cases has led us to conclude that this feared complication of spinal anesthesia has not appeared more commonly in operations on the laterally herniated disc. Five cases of significant neurologic residual were found in 3168 previously reported lumbar disc operations under spinal anesthesia (table 7 ) . I n Ditzler’s series,s residual deficit related to application of concentrated nupercaine to the cauda equina. In Rosenberg’s case,” progressive weakness developed in association with a deep wound infection and resolved with treatment of the infection. Spangfort’s report‘ gave no information about the origin of the deficit.
Temporary urinary retention, as noted in table 6, was uncommon. Rosenberg and Berner” found urinary retention was more common after disc surgery under general anesthesia than under spinal. This observation has not been confirmed in a large randomly selected sample. Our 1% incidence of postoperative headache was about 10% of that usually associated with spinal anesthesia. We hypothesize that epidural blood serves as a “patch,” and reduces the dural leak. One advantage of spinal anesthesia for the herniated disc may be decreased mortality. In the 4 series (table 7 ) employing spinal anesthesia for disc surgery, the 3 deaths represent a mortality rate of 0.08 percent. This is one-half that found in 15 recent reports of results of nearly 8300 cases of disc surgery.‘ In Hartford Hospital’s 9000 cases of disc surgery under spinal anesthesia, there has been 1 postoperative death, from myocardial infarction, a mortality rate of 0.01 percent. We conclude that proper administration of spinal anesthesia for the herniated lumbar disc is a safe procedure. Serious neurologic complications attributable to the anesthetic method have not been observed more frequently than when using spinal anesthesia for other operations. Low mortality and morbidity coupled with a short average hospital stay indicate to us that this is the anesthesia method of choice for such surgical operations.
ACKNOWLEDGMENT The authors wish to thank Drs. James C. Collias, Norman H. Gahm, William B. Scoville, and Benjamin B. Whitcomb for making available their records of the patients included in this study.
TABLE 7 Summary of Literature on Spinal Anesthesia for Lumbar Disc Surgery Operations
Significant neurologic r e r i d u o i
Morlalify
Ditzler et al” (1959) Rosenberg and Berner‘ (1965) Spangfort’ (1972)
766 128 2274
Subtotal Silver et a1 (1975)
3168 576
5
1
3 0
3744
6 (0.16%)
3 (0.08% )
Grand total
1 1 3
0 0 3
554
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.55, No. 4, JULY-AUGUST, 1976
REFERENCES 1. Dripps RD, Vandam LD: Long-term followup of patients who received 10,098 spinal anesthetics: failure to discover major neurological sequelae. JAMA 156:1486-1491, 1954
A computer-aided analysis of 2504 operations. Acta Orthop Scand Suppl 142:l-95, 1972 8. Scoville WB, Corkill G: Lumbar disc surgery: terhnique of radical removal and early mobilization. J Neurosurg 39:265-269, 1973
2. Vandam LD, Dripps RD: Exacerbation of pre-existing neurologic disease after spinal anesthesia. N Engl J Med 255:843-849, 1956
9. O'Connell J E A : T h e indications for and results of the excision of lumbar intervertebral disc protrusions: review of 500 cases. Ann R Coll Surg Engl 6:403-412, 1950
3. Sadove MS, Levin M J : Neurological complications of spinal anesthesia: a statistical study of more than 10,000 cases. 111 Med J 105:169-174, 1954
10. Slepian A: Lumbar disc surgery: long followup results from three neurosurgeons. NY State J Med 66: 1063-1068, 1966
4, Phillips oC, Ebner H, ~~l~~~ AT, et al: Neurological complications following spinal anesthesis with lidocaine: a prospective review of cases. Anesthesiology 30:284-289, 1969
11. Dripps RD, Eckenhoff JE, Vandam LD: Introduction to Anesthesia: T h e Principles of Safe Practice. Fourth edition. Philadelphia, WB Saunders Company, 1972, p 456
5. Ditder Jw, Dumke PR, Harrington JJ, et al: Should spinal anesthesia be used in surgery for herniated intervertebral disk? Anesth & Analg 38: 118-124, 1959
12. Thorsen G: Neurological complications after spinal anesthesia and results from 2493 follow.up 121:1-272, 1947 cases. Acta Chir Stand suppl
6. Rosenberg MK, Berner G: Spinal anesthesia in lumbar disc surgery: review of 200 cases with a case history. Anesth & Analg 44:419-423, 1965
7. Spangfort EV: The lumbar disc herniation.
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BICARBONATE DURING RESUSCITATION. A r t e r i a l pH, PCO, a n d osmolality w e r e measured d u r i n g cardiopulmonary resuscitation in d o g s with o r without i n t r a venous sodium bicarbonate (1 m E q / k g ) . I n t h e first 15 m i n u t e s of resuscitation pH did n o t fall below 7.35 a n d s e r u m osmolality increased significantly when sodium bicarbonate w a s not administered to dogs. When bicarbonate w a s added t o t h e regimen pH increased transiently, PaCO.. increased a n d remained above a w a k e levels a n d s e r u m osmolality w a s elevated. These d a t a confirm t h a t adequate ventilation d u r i n g resuscitation is sufficient to prevent t h e development of acidosis in t h e absence of pre-existing acidosis. PaCO, increased a f t e r bicarbonate despite adequate ventilation. These studies s u g g e s t t h a t bicarbonate should n o t be used d u r i n g cardiopulmonary resuscitation in t h e absence of (1) inadequate alveolar ventilation, ( 2 ) w h e n cardiac a r r e s t is brief a n d preexisting acidosis is unlikely o r ( 3 ) in repeated doses w i t h o u t pH confirmation. C u r r e n t recommendations of t h e National Conference on Cardiopulmonary Resuscitation a r e t o administer bicarbonate 1 m E q / k g twice d u r i n g the e a r l y minutes of resuscitation a n d r e p e a t 0.5 m E q / k g at 10 minute intervals. ( B i s h o p RL, Wcisfeltlt M L : S o d i u m bical,bonatc admiuistmtion d u , i v g cardiac a ) I c s t . Etfcct on alYc?'ial p H , PCOJ and osmolality. J A M A P35:506-509, 1 9 7 6 )
