Abstract
We aimed to investigate operating conditions, postoperative pain, and overall satisfaction of surgeons using deep neuromuscular blockade (NMB) vs. no NMB in patients undergoing lumbar spinal surgery under general anesthesia. Eighty-three patients undergoing lumbar fusion were randomly assigned to receive deep NMB (n = 43) or no NMB (n = 40). In the deep-NMB group, rocuronium was administered to maintain deep NMB (train-of-four count 0, post-tetanic count 1–2) until the end of surgery. In the no-NMB group, sugammadex 4 mg/kg at train-of-four (TOF) count 0–1 or sugammadex 2 mg/kg at TOF count ≥2 was administered to reverse the NMB 10 min after placing the patient prone. Peak inspiratory airway pressure, plateau airway pressure, lumbar retractor pressure significantly were lower in the deep-NMB group. Degree of surgical field bleeding (0–5), muscle tone (1–3), and satisfaction (1–10) rated by the surgeon were all superior in the deep-NMB group. Pain scores, rescue fentanyl consumption in post-anesthesia care unit (PACU), and postoperative patient-controlled analgesia consumption were significantly lower in the deep-NMB group, and this group had a shorter length of stay in PACU. Compared to no NMB, deep NMB provides better operating conditions, reduced postoperative pain and higher overall satisfaction in lumbar spinal surgery.
Highlights
Since the introduction of sugammadex, which provides more predictable and rapid recovery from deep neuromuscular blockade (NMB) [1,2], questions have emerged regarding the issue of maintaining deep NMB until the very end of surgery [3,4,5]
Previous studies regarding the potential advantages of deep NMB were mainly performed in laparoscopic abdominal/pelvic surgeries [3,5,6,7,8] that require full relaxation of the diaphragm and abdominal muscles, which are very resistant to neuromuscular blocking agents [9,10]
The prone position for spinal surgery during general anesthesia may be associated with increased airway pressure
Summary
Since the introduction of sugammadex, which provides more predictable and rapid recovery from deep neuromuscular blockade (NMB) [1,2], questions have emerged regarding the issue of maintaining deep NMB until the very end of surgery [3,4,5]. Spinal surgery is often performed using no, shallow or moderate NMB in current clinical practice; few reports have investigated the effect of deep NMB on operating conditions. Absent or insufficient NMB may cause detrimental effects during spine surgery, including deterioration of the surgical environment for microscopic procedures due to increased muscle tone and inadvertent patient movement. This can cause an increase in bleeding due to increased intrathoracic and abdominal pressure in a prone position which forces blood from the inferior vena cava into the extradural venous plexus [11]. Increases in peak inspiratory airway pressure related to high muscle tone can lead to increased surgical bleeding [12,13], which can worsen operating condition
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