A New Neuroanesthetic Protocol of Rendering Specialized Care in Treating Degenerative Lumbar Spine Diseases in High-Risk Patients: Prospective Analysis of the Results

The aim of the study is to assess the effectiveness of a new neuroanesthetic protocol for treating degenerative lumbar spine diseases in high-risk patients.

Materials and Methods. Two groups of patients with a high risk of anesthesia and surgery determined by the authors’ clinical decision support system (CDSS) have been prospectively studied. A new neuroanesthetic protocol was used in the experimental group (EG, n=25), while the control group (CG, n=25) underwent intravenous anesthesia based on propofol and fentanyl. Minimally invasive transforaminal lumbar interbody fusion was performed in all cases. Changes of the intraoperative mean arterial pressure and heart rate, intensity of the local pain syndrome, amount of the opiates used, presence of cognitive disorders, adverse effects of anesthesia, and surgical complications have been compared.

Results. The groups were representative (p>0.05) in terms of the age-gender parameters, anthropological data, comorbid background, involvement in smoking, preoperative characteristics of the lumbar spine, as well as the level of cognitive functions. No statistically significant changes of the mean arterial pressure (p=0.17) were registered in EG patients relative to the CG (p=0.0008). Intraoperative reduction of the heart rate in patients of the CG was not noted (p=0.49) in comparison with the EG (р=0.03). In the postoperative period, the best indicators of cognitive functions on the FAB test (p=0.02) and MoCA test (p=0.03) were revealed in EG. A significantly less amount of perioperative opiates (p=0.005) at a low level of the local pain syndrome was also noted (p=0.01). The intergroup analysis has shown fewer adverse effects of anesthesia in EG compared to CG (p=0.01) with a comparable number of postoperative surgical complications (p=0.42).

Conclusion. A new neuroanesthetic protocol of rendering a specialized care to patients with a high risk of anesthesia and surgery, assessed by the authors-developed CDSS, has resulted in effective elimination of the local postoperative pain syndrome, reduction of perioperative application of opioids, and stabilization of intraoperative indicators of cardiovascular activity. In addition, no postoperative cognitive disorders, anesthetic side-effects, adverse pharmacological consequences of the complex usage of non-steroidal anti-inflammatory drugs, prolonged local anesthetics, alpha-2-agonist, and non-narcotic analgesics have been registered.

1. Al Jammal O.M., Shahrestani S., Delavar A., Brown N.J., Gendreau J.L., Lien B.V., Sahyouni R., Diaz-Aguilar L.D., Shalakhti O.S., Pham M.H. Demographic predictors of treatments and surgical complications of lumbar degenerative diseases: an analysis of over 250,000 patients from the National Inpatient Sample. Medicine (Baltimore) 2022; 101(11): e29065, https://doi.org/10.1097/md.0000000000029065.
2. Remov P.S. Topical issues of surgical treatment for lumbar dorsopathy. Novosti khirurgii 2022; 30(2): 198–206.
3. Wasinpongwanich K., Nopsopon T., Pongpirul K. Surgical treatments for lumbar spine diseases (TLIF vs. other surgical techniques): a systematic review and meta-analysis. Front Surg 2022; 9: 829469, https://doi.org/10.3389/fsurg.2022.829469.
4. Dunn L.K., Durieux M.E., Fernández L.G., Tsang S., Smith-Straesser E.E., Jhaveri H.F., Spanos S.P., Thames M.R., Spencer C.D., Lloyd A., Stuart R., Ye F., Bray J.P., Nemergut E.C., Naik B.I. Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery. J Neurosurg Spine 2018; 28(1): 119–126, https://doi.org/10.3171/2017.5.spine1734.
5. Berardino K., Carroll A.H., Kaneb A., Civilette M.D., Sherman W.F., Kaye A.D. An update on postoperative opioid use and alternative pain control following spine surgery. Orthop Rev (Pavia) 2021; 13(2): 24978, https://doi.org/10.52965/001c.24978.
6. Sayfullin A.P., Aleynik A.Ya., Bokov A.E., Israelyan Yu.A., Mlyavykh S.G. Enhanced recovery after surgery (ERAS) in spine surgery: a systematic review. Russian Journal of Neurosurgery 2022; 24(1): 83–100, https://doi.org/10.17650/1683-3295-2021-24-1-83-100.
7. Cheatle M.D., Compton P.A., Dhingra L., Wasser T.E., O’Brien C.P. Development of the revised opioid risk tool to predict opioid use disorder in patients with chronic nonmalignant pain. J Pain 2019; 20(7): 842–851, https://doi.org/10.1016/j.jpain.2019.01.011.
8. Kurnosov I.A., Gulyaev D.A., Godanyuk D.S., Manukovsky V.A. Predictors of outcomes of surgical treatment of degenerative dystrophic diseases of the spine. Rossijskij nejrohirurgiceskij zurnal im. professora A.L. Polenova 2021; 13(2): 67–71.
9. Minetos P.D., Canseco J.A., Karamian B.A., Bowles D.R., Bhatt A.H., Semenza N.C., Murphy H., Kaye I.D., Woods B.I., Rihn J.A., Kurd M.F., Anderson D.G., Hilibrand A.S., Kepler C.K., Vaccaro A.R., Schroeder G.D. Discharge disposition and clinical outcomes after spine surgery. Am J Med Qual 2022; 37(2): 153–159, https://doi.org/10.1097/01.jmq.0000753240.14141.87.
10. Goloborodko V.Yu., Kalinin A.A., Byvaltsev V.A. Effectiveness of optimization program of neuroanesthesia in surgical treatment of degenerative lumbar spine diseases in patients with high risk factors. Anesteziologiya i reanimatologiya 2021; 2: 74, https://doi.org/10.17116/anaesthesiology202102174.
11. He X., Fei Q., Sun T. Metabolic syndrome increases risk for perioperative outcomes following posterior lumbar interbody fusion. Medicine (Baltimore) 2020; 99(38):e21786, https://doi.org/10.1097/md.0000000000021786.
12. Lubnin A.Yu. Current trends in the development of neuroanesthesiology. Voprosy neirokhirurgii im. N.N. Burdenko 2019; 83(5): 83–91, https://doi.org/10.17116/neiro20198305183.
13. Miller M.M., Allison A., Trost Z., De Ruddere L., Wheelis T., Goubert L., Hirsh A.T. Differential effect of patient weight on pain-related judgements about male and female chronic low back pain patients. J Pain 2018; 19(1): 57–66, https://doi.org/10.1016/j.jpain.2017.09.001.
14. Yarikov A.V., Shpagin M.V., Pavlova E.A., Perlmutter O.A., Fraerman A.P. Principles of organizing multidisciplinary clinics and pain treatment centers (analysis of modern literature and personal experience). Vestnik nevrologii, psihiatrii i nejrohirurgii 2022; 4: 287–303, https://doi.org/10.33920/med-01-2204-06.
15. Khor S., Lavallee D., Cizik A.M., Bellabarba C., Chapman J.R., Howe C.R., Lu D., Mohit A.A., Oskouian R.J., Roh J.R., Shonnard N., Dagal A., Flum D.R. Development and validation of a prediction model for pain and functional outcomes after lumbar spine surgery. JAMA Surg 2018; 153(7): 634–642, https://doi.org/10.1001/jamasurg.2018.0072.
16. Beskrovny A.S., Bessonov L.V., Golyadkina A.A., Dol A.V., Ivanov D.V., Kirillova I.V., Kossovich L.Yu., Sidorenko D.A. Development of a decision support system in traumatology and orthopedics. Biomechanics as a tool for preoperative planning. Russian Journal of Biomechanics 2021; 25(2): 99–112, https://doi.org/10.15593/rjbiomech/2021.2.01.
17. Byvaltsev V.A., Goloborodko V.Yu., Kalinin A.A., Pol’kin M.A., Pestryakov Yu.Ya. Decision support system for selecting the method of neuroanesthesiological care based on preoperative screening of risk factors for adverse outcomes in patients with degenerative spine diseases: software program No.2022613463. Bulletin No.3. March 14, 2022.
18. Byvaltsev V.A., Kalinin A.A., Goloborodko V.Yu., Sorokovikov V.A. Method for anesthetic protection when performing surgical interventions on spine in adult patients. Patent RU2754837C1. 2021.
19. Park C., Cook C.E., Garcia A.N., Gottfried O.N. Discharge destination influences risks of readmission and complications after lumbar spine surgery in severely disabled patients. Clin Neurol Neurosurg 2021; 207: 106801, https://doi.org/10.1016/j.clineuro.2021.106801.
20. Kushioka J., Takenaka S., Makino T., Sakai Y., Kashii M., Iwasaki M., Yoshikawa H., Kaito T. Risk factors for in-hospital mortality after spine surgery: a matched case-control study using a multicenter database. Spine J 2020; 20(3): 321–328, https://doi.org/10.1016/j.spinee.2019.10.008.
21. Ranson W.A., Cheung Z.B., Di Capua J., Lee N.J., Ukogu C., Jacobs S., Vig K.S., Kim J.S., White S.J.W., Cho S.K. Risk factors for perioperative complications in morbidly obese patients undergoing elective posterior lumbar fusion. Global Spine J 2018; 8(8): 795–802, https://doi.org/10.1177/2192568218771363.
22. Son H.J., Jo Y.H., Ahn H.S., You J., Kang C.N. Outcomes of lumbar spinal fusion in super-elderly patients aged 80 years and over: comparison with patients aged 65 years and over, and under 80 years. Medicine (Baltimore) 2021; 100(31): e26812, https://doi.org/10.1097/MD.0000000000026812.
23. Debono B., Wainwright T.W., Wang M.Y., Sigmundsson F.G., Yang M.M.H., Smid-Nanninga H., Bonnal A., Le Huec J.C., Fawcett W.J., Ljungqvist O., Lonjon G., de Boer H.D. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J 2021; 21(5): 729–752, https://doi.org/10.1016/j.spinee.2021.01.001.
24. Byvaltsev V.A., Goloborodko V.Y., Kalinin A.A. Analysis of risk factors for the development of unsatisfactory long-term clinical results of performance of multi-level decompressive-stabilizing interventions on the lumbar spine. Sovremennye problemy nauki i obrazovania 2019; 6. URL: https://science-education.ru/ru/article/view?id=29304.
25. Bae S., Alboog A., Esquivel K.S., Abbasi A., Zhou J., Chui J. Efficacy of perioperative pharmacological and regional pain interventions in adult spine surgery: a network meta-analysis and systematic review of randomised controlled trials. Br J Anaesth 2022; 128(1): 98–117, https://doi.org/10.1016/j.bja.2021.08.034.
26. Naftalovich R., Singal A., Iskander A.J. Enhanced recovery after surgery (ERAS) protocols for spine surgery — review of literature. Anaesthesiol Intensive Ther 2022; 54(1): 71–79, https://doi.org/10.5114/ait.2022.113961.
27. Byvaltsev V.A., Goloborodko V.Y., Kalinin A.A., Shepelev V.V., Pestryakov Y.Y., Riew K.D. A standardized anesthetic/analgetic regimen compared to standard anesthetic/analgetic regimen for patients with high-risk factors undergoing open lumbar spine surgery: a prospective comparative single-center study. Neurosurg Rev 2023; 46(1): 95, https://doi.org/10.1007/s10143-023-02005-4.
28. Maheshwari K., Avitsian R., Sessler D.I., Makarova N., Tanios M., Raza S., Traul D., Rajan S., Manlapaz M., Machado S., Krishnaney A., Machado A., Rosenquist R., Kurz A. Multimodal analgesic regimen for spine surgery: a randomized placebo-controlled trial. Anesthesiology 2020; 132(5): 992–1002, https://doi.org/10.1097/ALN.0000000000003143.
29. Smith J., Probst S., Calandra C., Davis R., Sugimoto K., Nie L., Gan T.J., Bennett-Guerrero E. Enhanced recovery after surgery (ERAS) program for lumbar spine fusion. Perioper Med (Lond) 2019; 8: 4, https://doi.org/10.1186/s13741-019-0114-2.
30. Tucker E.M., Thompson J.A., Muckler V.C. implementation of a multimodal analgesia protocol among outpatient neurosurgical patients undergoing spine surgery to improve patient outcomes. J Perianesth Nurs 2021; 36(1): 8–13, https://doi.org/10.1016/j.jopan.2020.05.010.
31. Meng W., Yang C., Wei X., Wang S., Kang F., Huang X., Li J. Type of anesthesia and quality of recovery in male patients undergoing lumbar surgery: a randomized trial comparing propofol-remifentanil total i.v. anesthesia with sevoflurane anesthesia. BMC Anesthesiol 2021; 21(1): 300, https://doi.org/10.1186/s12871-021-01519-y.
32. Murphy G.S., Avram M.J., Greenberg S.B., Benson J., Bilimoria S., Maher C.E., Teister K., Szokol J.W. Perioperative methadone and ketamine for postoperative pain control in spinal surgical patients: a randomized, double-blind, placebo-controlled trial. Anesthesiology 2021; 134(5): 697–708, https://doi.org/10.1097/aln.0000000000003743.
33. Soffin E.M., Wetmore D.S., Beckman J.D., Sheha E.D., Vaishnav A.S., Albert T.J., Gang C.H., Qureshi S.A. Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study. Neurosurg Focus 2019; 46(4): E8, https://doi.org/10.3171/2019.1.focus18645.
34. Finsterwald M., Muster M., Farshad M., Saporito A., Brada M., Aguirre J.A. Spinal versus general anesthesia for lumbar spine surgery in high risk patients: perioperative hemodynamic stability, complications and costs. J Clin Anesth 2018; 46: 3–7, https://doi.org/10.1016/j.jclinane.2018.01.004.
35. Nabavighadi K., Batista C., Ghoddoussi F., Kumar N., Aiello A., Reeves B., Krishnan S., Ellis T. 2nd. Oral multimodal preemptive analgesia improves postoperative pain control and decreases opioid utilization in spinal fusion patients. J Clin Anesth 2020; 61: 109679, https://doi.org/10.1016/j.jclinane.2019.109679.
36. Chang H.K., Huang M., Wu J.C., Huang W.C., Wang M.Y. Less opioid consumption with enhanced recovery after surgery transforaminal lumbar interbody fusion (TLIF): a comparison to standard minimally-invasive TLIF. Neurospine 2020; 17(1): 228–236, https://doi.org/10.14245/ns.1938422.211.
37. Wang M.Y., Grossman J. Endoscopic minimally invasive transforaminal interbody fusion without general anesthesia: initial clinical experience with 1-year follow-up. Neurosurg Focus 2016; 40(2): E13, https://doi.org/10.3171/2015.11.focus15435.
38. Waelkens P., Alsabbagh E., Sauter A., Joshi G.P., Beloeil H; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain therapy (ESRA). Pain management after complex spine surgery: a systematic review and procedure-specific postoperative pain management recommendations. Eur J Anaesthesiol 2021; 38(9): 985–994, https://doi.org/10.1097/EJA.0000000000001448.
39. Wiljer D., Hakim Z. Developing an artificial intelligence-enabled health care practice: rewiring health care professions for better care. J Med Imaging Radiat Sci 2019; 50(4 Suppl 2): S8–S14, https://doi.org/10.1016/j.jmir.2019.09.010.
40. Kwan J.L., Lo L., Ferguson J., Goldberg H., Diaz-Martinez J.P., Tomlinson G., Grimshaw J.M., Shojania K.G. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ 2020; 370: m3216, https://doi.org/10.1136/bmj.m3216.
41. Kheterpal S., Shanks A., Tremper K.K. Impact of a novel multiparameter decision support system on intraoperative processes of care and postoperative outcomes. Anesthesiology 2018; 128(2): 272–282, https://doi.org/10.1097/aln.0000000000002023.
42. Dewan M., Muthu N., Shelov E., Bonafide C.P., Brady P., Davis D., Kirkendall E.S., Niles D., Sutton R.M., Traynor D., Tegtmeyer K., Nadkarni V., Wolfe H. Performance of a clinical decision support tool to identify PICU patients at high risk for clinical deterioration. Pediatr Crit Care Med 2020; 21(2): 129–135, https://doi.org/10.1097/PCC.0000000000002106.
43. Zhang Y., Ma L., Wang T., Xiao W., Lu S., Kong C., Wang C., Li X., Li Y., Yin C., Yan S., Li Y., Yang K., Chan P; APPLE-MDT Study Working Group. Protocol for evaluation of perioperative risk in patients aged over 75 years: aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT study). BMC Geriatr 2021; 21(1): 14, https://doi.org/10.1186/s12877-020-01956-3.
44. Xue B., Li D., Lu C., King C.R., Wildes T., Avidan M.S., Kannampallil T., Abraham J. Use of machine learning to develop and evaluate models using preoperative and intraoperative data to identify risks of postoperative complications. JAMA Netw Open 2021; 4(3): e212240, https://doi.org/10.1001/jamanetworkopen.2021.2240.
45. Colquhoun D.A., Davis R.P., Tremper T.T., Mace J.J., Gombert J.M., Sheldon W.D., Connolly J.J., Adams J.F., Tremper K.K. Design of a novel multifunction decision support/alerting system for in-patient acute care, ICU and floor (AlertWatch AC). BMC Anesthesiol 2021; 21(1): 196, https://doi.org/10.1186/s12871-021-01411-9.

Kalinin A.A., Goloborodko V.Yu., Pestryakov Yu.Ya., Kundubayev R.A., Biryuchkov M.Yu., Shchegolev A.V., Byvaltsev V.A. A New Neuroanesthetic Protocol of Rendering Specialized Care in Treating Degenerative Lumbar Spine Diseases in High-Risk Patients: Prospective Analysis of the Results. Sovremennye tehnologii v medicine 2024; 16(3): 51, https://doi.org/10.17691/stm2024.16.3.06