Anesthetic Management of Spine Fusion

  • Mary C. TherouxEmail author
  • Sabina Dicindio
Living reference work entry


Spine fusion in children with cerebral palsy (CP) is a more extensive surgical procedure fusing T1 to the sacrum, unlike in idiopathic scoliosis patients where spine fusion is limited to thoracic and lumbar vertebral segments. Significantly greater blood loss, need for central venous line as well as arterial line in addition to at least two large-bore intravenous catheters, and availability of blood and blood products are to be anticipated. Greater blood loss sustained is both due to the more extensive nature of the surgery and the suboptimal levels of clotting factors present in CP patients. Preoperatively, a plan for timely administration of anticonvulsants both in the immediate postoperative period and thereafter needs to be in place. Hypothermia is a constant threat to CP patients who sustain hypothermia easily and to a greater degree than their normal counterparts. To conserve temperature, in addition to controlling the environmental factors such as the temperature in the operating room and use of forced air warmer unit draped on the patient, pre-warming the CP patients in the preoperative holding room is what we have found to be effective. Neuromonitoring should be employed in CP patients except a select few whose baseline evoked potentials are not recordable. Choice of anesthetic agents will be such that neuromonitoring is facilitated and only minimal and unavoidable degradation of the signals should be tolerated. Carefully chosen anesthetic agents would also allow extubation of the trachea in the majority of patients at the end of the anesthetic or shortly thereafter. In our experience the patients extubated earlier experience an easier recovery period with shorter duration PICU and overall hospital stay.


Cerebral palsy Hypothermia Spine fusion Coagulopathy Tranexamic acid 


  1. Anderson PR, Puno MR, Lovell SL, Swayze CR (1985) Postoperative respiratory complications in non-idiopathic scoliosis. Acta Anaesthesiol Scand 29:186–192CrossRefPubMedGoogle Scholar
  2. Brenn BR, Theroux MC, Dabney KW, Miller F (2004) Clotting parameters and thromboelastography in children with neuromuscular and idiopathic scoliosis undergoing posterior spinal fusion. Spine (Phila Pa 1976) 29:E310–E314CrossRefGoogle Scholar
  3. Dehmer JJ, Adamson WT (2010) Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg 19:286–291CrossRefPubMedGoogle Scholar
  4. Devlin VJ, Schwartz DM (2007) Intraoperative neurophysiologic monitoring during spinal surgery. J Am Acad Orthop Surg 15:549–560CrossRefPubMedGoogle Scholar
  5. Dias RC, Miller F, Dabney K, Lipton G, Temple T (1996) Surgical correction of spinal deformity using a unit rod in children with cerebral palsy. J Pediatr Orthop 16:734–740CrossRefPubMedGoogle Scholar
  6. Dicindio S, Arai L, Mcculloch M, Sadacharam K, Shah SA, Gabos P, Dabney K, Theroux MC (2015) Clinical relevance of echocardiogram in patients with cerebral palsy undergoing posterior spinal fusion. Paediatr Anaesth 25:840–845CrossRefPubMedGoogle Scholar
  7. Dicindio S, Theroux M, Shah S, Miller F, Dabney K, Brislin RP, Schwartz D (2003) Multimodality monitoring of transcranial electric motor and somatosensory-evoked potentials during surgical correction of spinal deformity in patients with cerebral palsy and other neuromuscular disorders. Spine (Phila Pa 1976) 28:1851–1855. discussion 1855–6CrossRefGoogle Scholar
  8. Goobie SM, Meier PM, Sethna NF, Soriano SG, Zurakowski D, Samant S, Pereira LM (2013) Population pharmacokinetics of tranexamic acid in paediatric patients undergoing craniosynostosis surgery. Clin Pharmacokinet 52:267–276CrossRefPubMedGoogle Scholar
  9. Ho AM, Dion PW, Yeung JH, Ng CS, Karmakar MK, Critchley LA, Rainer TH, Cheung CW, Tay BA (2010) Fresh-frozen plasma transfusion strategy in trauma with massive and ongoing bleeding. Common (sense) and sensibility. Resuscitation 81:1079–1081CrossRefPubMedGoogle Scholar
  10. Kakinohana M, Fuchigami T, Nakamura S, Kawabata T, Sugahara K (2002) Propofol reduces spinal motor neuron excitability in humans. Anesth Analg 94:1586–1588. table of contentsPubMedGoogle Scholar
  11. Kalkman CJ, Drummond JC, Ribberink AA (1991) Low concentrations of isoflurane abolish motor evoked responses to transcranial electrical stimulation during nitrous oxide/opioid anesthesia in humans. Anesth Analg 73:410–415CrossRefPubMedGoogle Scholar
  12. Kawaguchi M, Sakamoto T, Inoue S, Kakimoto M, Furuya H, Morimoto T, Sakaki T (2000) Low dose propofol as a supplement to ketamine-based anesthesia during intraoperative monitoring of motor-evoked potentials. Spine (Phila Pa 1976) 25:974–979CrossRefGoogle Scholar
  13. Lotto ML, Banoub M, Schubert A (2004) Effects of anesthetic agents and physiologic changes on intraoperative motor evoked potentials. J Neurosurg Anesthesiol 16:32–42CrossRefPubMedGoogle Scholar
  14. Macdonald DB, Skinner S, Shils J, Yingling C, American Society of Neurophysiological M (2013) Intraoperative motor evoked potential monitoring - a position statement by the American Society of Neurophysiological Monitoring. Clin Neurophysiol 124:2291–2316CrossRefPubMedGoogle Scholar
  15. Nathan N, Tabaraud F, Lacroix F, Moulies D, Viviand X, Lansade A, Terrier G, Feiss P (2003) Influence of propofol concentrations on multipulse transcranial motor evoked potentials. Br J Anaesth 91:493–497CrossRefPubMedGoogle Scholar
  16. Olivant Fisher A, Husain K, Wolfson MR, Hubert TL, Rodriguez E, Shaffer TH, Theroux MC (2012) Hyperoxia during one lung ventilation: inflammatory and oxidative responses. Pediatr Pulmonol 47:979–986CrossRefPubMedGoogle Scholar
  17. Pajewski TN, Arlet V, Phillips LH (2007) Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon. Eur Spine J 16(Suppl 2):S115–S129CrossRefPubMedGoogle Scholar
  18. Pechstein U, Nadstawek J, Zentner J, Schramm J (1998) Isoflurane plus nitrous oxide versus propofol for recording of motor evoked potentials after high frequency repetitive electrical stimulation. Electroencephalogr Clin Neurophysiol 108:175–181CrossRefPubMedGoogle Scholar
  19. Phan HH, Wisner DH (2010) Should we increase the ratio of plasma/platelets to red blood cells in massive transfusion: what is the evidence? Vox Sang 98:395–402CrossRefPubMedGoogle Scholar
  20. Pidcoke HF, Aden JK, Mora AG, Borgman MA, Spinella PC, Dubick MA, Blackbourne LH, Cap AP (2012) Ten-year analysis of transfusion in operation Iraqi freedom and operation enduring freedom: increased plasma and platelet use correlates with improved survival. J Trauma Acute Care Surg 73:S445–S452CrossRefPubMedGoogle Scholar
  21. Reames DL, Smith JS, Fu KM, Polly DW Jr, Ames CP, Berven SH, Perra JH, Glassman SD, Mccarthy RE, Knapp RD Jr, Heary R, Shaffrey CI, Scoliosis Research Society M and Mortality C (2011) Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society morbidity and mortality database. Spine (Phila Pa 1976) 36:1484–1491CrossRefGoogle Scholar
  22. Scheufler KM, Zentner J (2002) Motor-evoked potential facilitation during progressive cortical suppression by propofol. Anesth Analg 94:907–912. table of contentsCrossRefPubMedGoogle Scholar
  23. Schwartz DM, Auerbach JD, Dormans JP, Flynn J, Drummond DS, Bowe JA, Laufer S, Shah SA, Bowen JR, Pizzutillo PD, Jones KJ, Drummond DS (2007) Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am 89:2440–2449PubMedGoogle Scholar
  24. Sethna NF, Zurakowski D, Brustowicz RM, Bacsik J, Sullivan LJ, Shapiro F (2005) Tranexamic acid reduces intraoperative blood loss in pediatric patients undergoing scoliosis surgery. Anesthesiology 102:727–732CrossRefPubMedGoogle Scholar
  25. Shapiro F, Sethna N (2004) Blood loss in pediatric spine surgery. Eur Spine J 13(Suppl 1):S6–17CrossRefPubMedPubMedCentralGoogle Scholar
  26. Shapiro F, Zurakowski D, Sethna NF (2007) Tranexamic acid diminishes intraoperative blood loss and transfusion in spinal fusions for duchenne muscular dystrophy scoliosis. Spine (Phila Pa 1976) 32:2278–2283CrossRefGoogle Scholar
  27. Sloan T, Sloan H, Rogers J (2010) Nitrous oxide and isoflurane are synergistic with respect to amplitude and latency effects on sensory evoked potentials. J Clin Monit Comput 24:113–123CrossRefPubMedGoogle Scholar
  28. Sponseller PD, Shah SA, Abel MF, Sucato D, Newton PO, Shufflebarger H, Lenke LG, Letko L, Betz R, Marks M, Bastrom T (2009) Scoliosis surgery in cerebral palsy: differences between unit rod and custom rods. Spine (Phila Pa 1976) 34:840–844CrossRefGoogle Scholar
  29. Theroux MC, Corddry DH, Tietz AE, Miller F, Peoples JD, Kettrick RG (1997) A study of desmopressin and blood loss during spinal fusion for neuromuscular scoliosis: a randomized, controlled, double-blinded study. Anesthesiology 87:260–267CrossRefPubMedGoogle Scholar
  30. Theroux MC, Fisher AO, Horner LM, Rodriguez ME, Costarino AT, Miller TL, Shaffer TH (2010) Protective ventilation to reduce inflammatory injury from one lung ventilation in a piglet model. Paediatr Anaesth 20:356–364CrossRefPubMedGoogle Scholar
  31. Theroux MC, Olivant A, Lim D, Bernardi JP, Costarino AT, Shaffer TH, Miller TL (2008) Low dose methylprednisolone prophylaxis to reduce inflammation during one-lung ventilation. Paediatr Anaesth 18:857–864CrossRefPubMedGoogle Scholar
  32. Thompson GH, Florentino-Pineda I, Poe-Kochert C, Armstrong DG, Son-Hing J (2008) Role of Amicar in surgery for neuromuscular scoliosis. Spine (Phila Pa 1976) 33:2623–2629CrossRefGoogle Scholar
  33. Tsirikos AI, Chang WN, Dabney KW, Miller F (2003) Comparison of one-stage versus two-stage anteroposterior spinal fusion in pediatric patients with cerebral palsy and neuromuscular scoliosis. Spine (Phila Pa 1976) 28:1300–1305Google Scholar
  34. Verma K, Errico TJ, Vaz KM, Lonner BS (2010) A prospective, randomized, double-blinded single-site control study comparing blood loss prevention of tranexamic acid (TXA) to epsilon aminocaproic acid (EACA) for corrective spinal surgery. BMC Surg 10:13CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Department of Anesthesiology and Perioperative MedicineNemours/Alfred I. duPont Hospital for ChildrenWilmingtonUSA
  2. 2.Department of Pediatrics, Jefferson Medical CollegeThomas Jefferson UniversityPhiladelphiaUSA

Section editors and affiliations

  • Freeman Miller
    • 1
  1. 1.AI DuPont Hospital for ChildrenWilmingtonUSA

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