What is the recommended preoperative workup for spinal surgery clearance in a 65-year-old woman with a history of smoking?

Preoperative Workup for Spinal Surgery Clearance in a 65-Year-Old Woman Who Smokes

A 65-year-old female smoker preparing for spinal surgery should undergo smoking cessation at least 4 weeks before surgery, comprehensive cardiopulmonary assessment, and routine preoperative screening with special attention to potential smoking-related complications.

Smoking Cessation Recommendations

• Smoking cessation should be initiated at least 4-8 weeks before surgery to reduce respiratory and wound-healing complications 1
• Intense counseling and nicotine replacement therapy are most effective for preoperative smoking cessation 1
• Smoking significantly increases risk of:
  • Postoperative infections and poor wound healing
  • Increased blood loss (approximately 328 mL more per pack per day) 2
  • Higher transfusion requirements (odds ratio 13.8) 2
  • Pseudoarthrosis (failed fusion) 3
  • 90-day readmission after spine surgery (odds ratio 1.05) 4

Caution: Be aware that smoking recidivism rates are high (60% within 3 months) after spine surgery, even in patients who successfully quit preoperatively 5

Cardiovascular Assessment

1. Risk stratification based on age and smoking status:

   • At 65 years with smoking history, patient has at least two risk factors for cardiovascular complications 1

2. Recommended cardiac workup:

   • 12-lead ECG
   • Assessment for heart block, bundle-branch block, atrial arrhythmias, or LV hypertrophy with repolarization abnormalities (which would require further evaluation) 1
   • Evaluate for undiagnosed hypertension 1
   • Consider functional capacity assessment
   • For patients with known or suspected CAD, consider additional cardiac testing based on risk factors

3. Beta-blocker considerations:

   • Do not initiate beta-blockers acutely before surgery
   • Continue beta-blockers if patient is already on them chronically 1

Pulmonary Assessment

1. Pulmonary function evaluation:

   • Smoking history necessitates assessment for chronic obstructive pulmonary disease
   • Consider pulmonary function tests, especially if patient has respiratory symptoms
   • Evaluate for reactive airways disease or asthma, which would affect anesthetic management 1

2. Optimization strategies:

   • Consider preoperative pulmonary rehabilitation if significant lung disease is present
   • Ensure appropriate bronchodilator therapy is optimized

Laboratory and Additional Testing

1. Basic laboratory tests:

   • Complete blood count (assess for anemia, which is common in surgical patients and may be exacerbated by smoking) 1
   • Basic metabolic panel
   • Coagulation studies (PT/INR, PTT)
   • Urinalysis

2. Specific considerations for smokers:

   • Assess for polycythemia (which can occur with chronic smoking)
   • Consider arterial blood gas if significant pulmonary disease is present

Anesthesia Considerations

1. Regional anesthesia evaluation:

   • Consider regional anesthesia options when planning anesthetic approach 1
   • Extra consideration should be given to processed EEG monitoring during general anesthesia for smokers 1

2. PONV prophylaxis:

   • Plan for additional PONV prophylaxis for smokers 1

Postoperative Planning

1. Pain management:

   • Anticipate potentially increased postoperative analgesic requirements 1
   • Consider early acute pain service referral for complex pain management 1

2. Monitoring for complications:

   • Increased vigilance for respiratory complications
   • Monitor for increased bleeding risk
   • Watch for signs of poor wound healing or infection

Key Pitfalls to Avoid

1. Delaying surgery for smoking cessation if less than 24 hours before procedure - this may increase risk of withdrawal without providing benefits 1

2. Failing to identify and address modifiable risk factors beyond smoking (alcohol use, anemia, malnutrition) 1

3. Overlooking the increased risk of blood loss and transfusion requirements in smokers undergoing spine surgery 2

4. Not discussing the impact of smoking on fusion success rates with the patient 3