Neuraxial anesthesia, encompassing both spinal and epidural anesthesia, is typically reserved for surgeries involving the lower abdomen, pelvis, and lower extremities to avoid impairment of the respiratory system. However, neuraxial anesthesia may be used in the cervical spine for specific surgical cases involving the upper torso, neck, or head, especially in the context of the risks associated with general anesthesia or adverse reactions to general anesthesia.
Cervical spine surgeries, including procedures such as decompressions, fusions, and laminectomies, are typically performed under general anesthesia. This approach provides complete unconsciousness, ensuring immobility and optimal surgical conditions. However, general anesthesia is associated with several disadvantages, including prolonged recovery time, hemodynamic instability, and respiratory complications (1). The use of cervical neuraxial anesthesia may offer an alternative that also provides adequate analgesia and muscle relaxation.
One of the main advantages of neuraxial anesthesia in cervical spine surgery is that it can provide strong analgesia and may avoid or reduce perioperative cardiovascular or respiratory complications associated with general anesthesia and ventilation. By maintaining spontaneous respiration and avoiding the need for intubation, neuraxial anesthesia can reduce the risk of airway-related issues, such as laryngospasm or aspiration. This is particularly beneficial in patients with comorbidities, such as chronic obstructive pulmonary disease (COPD), asthma, obstructive sleep apnea, gastroesophageal reflux disease (GERD) or impaired swallowing mechanisms, or patients with prior adverse reactions to general anesthesia (2). In addition, general anesthesia carries the risk of intraoperative hypotension and tachycardia (3).
Several studies have demonstrated successful use of neuraxial anesthesia in cervical spine surgeries. A prospective randomized controlled trial demonstrated that patients undergoing cervical spine surgery under neuraxial anesthesia experienced significantly fewer postoperative complications, including nausea, vomiting, and respiratory depression, compared to those receiving general anesthesia (1). Additionally, these patients reported higher satisfaction levels due to faster recovery and reduced postoperative pain.
Despite its benefits, neuraxial anesthesia in the cervical spine is not without risks. Potential complications include epidural hematoma, infection, and inadvertent high spinal block, which can lead to respiratory arrest. Therefore, it is imperative that the anesthesia provider has extensive experience and expertise in neuraxial techniques and that patients are closely monitored intraoperatively and postoperatively. The decision to use neuraxial anesthesia should be individualized and take into account patient-specific factors such as anatomy, comorbidities, and the extent of the surgical procedure (3). Moreover, neuraxial anesthesia involves the injection of local anesthetics, with or without adjuncts such as opioids, into the epidural or subarachnoid space, leading to a temporary blockade of nerve impulses. For the cervical spine, this approach can be particularly challenging due to the anatomical considerations and the need to achieve an appropriate level of sensory and motor blockade without compromising diaphragmatic function. Proper patient selection and technique are crucial to ensure the safety and efficacy of neuraxial anesthesia in this context. Anesthesiologists must be prepared to quickly provide respiratory support in the case that respiratory compromise occurs.
In conclusion, neuraxial anesthesia in the cervical spine presents an alternative to general anesthesia for certain cases. However, clinicians must be extremely vigilant when using this technique. Ongoing research and clinical trials will further elucidate the optimal protocols and long-term outcomes associated with neuraxial anesthesia in the cervical spine.
References
- Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321(7275):1493. doi:10.1136/bmj.321.7275.1493
- Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg. 2007;104(3):689-702. doi:10.1213/01.ane.0000255040.71600.41
- Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials [published correction appears in Br J Anaesth 2002 Apr;88(4):619]. Br J Anaesth. 2000;84(4):450-455. doi:10.1093/oxfordjournals.bja.a013468