What are the preoperative clearance requirements from a neurology perspective for a patient with a history of seizures undergoing fracture surgery?

Preoperative Neurological Clearance for Patients with Seizure History Undergoing Fracture Surgery

For patients with a history of seizures undergoing fracture surgery, preoperative neurological clearance should focus on seizure control status, medication management, and risk assessment rather than routine neurological consultation or additional testing. 1

Initial Assessment

• Evaluate the patient's seizure history including frequency, timing of most recent seizure, and current antiepileptic drug (AED) regimen 2
• Patients with frequent seizures at baseline (particularly those who had seizures in the immediate preoperative period) have a significantly higher risk of perioperative seizures 2
• The frequency of preoperative seizures and timing of the most recent seizure are both significantly related to the likelihood of experiencing a perioperative seizure 2
• As the number of antiepileptic medications increases, so does the frequency of perioperative seizures, suggesting more complex epilepsy carries higher risk 2

Imaging Considerations

• Head CT without contrast is the preferred initial imaging modality if there are concerns about recent seizures or trauma 3
• MRI is more sensitive for detecting subtle lesions but is generally not required preoperatively unless there are new neurological findings or change in seizure pattern 3
• Dedicated seizure protocols and 3T MRI acquisition should be considered only if there is suspicion of a new epileptogenic focus 3

Medication Management

• Ensure continuation of the patient's regular antiepileptic medications throughout the perioperative period 2
• Avoid missed doses of antiepileptic medications, which is a common cause of breakthrough seizures 2
• For patients on enzyme-inducing AEDs (e.g., phenytoin, carbamazepine), consider potential drug interactions with anesthetic agents 2
• Levetiracetam is preferred if temporary seizure prophylaxis is needed due to better tolerability and fewer drug interactions 1, 4

Risk Stratification

• The overall frequency of perioperative seizures in patients with pre-existing seizure disorders is approximately 3.4% 2
• Neither the type of surgery nor the type of anesthesia (general anesthesia, regional anesthesia, or monitored anesthesia care) significantly affects the frequency of perioperative seizures 2
• Risk factors for increased seizure risk include:
  • History of frequent seizures 2
  • Recent seizures (within weeks before surgery) 2
  • Multiple antiepileptic medications (indicating difficult-to-control epilepsy) 2
  • History of traumatic brain injury with risk factors such as skull fracture or subdural hematoma 3, 5

Specific Recommendations for Orthopedic Surgery

• Non-hemorrhagic surgical procedures, including orthopedic surgery, can be performed early (less than 24 hours) in stabilized patients with a history of traumatic brain injury in the absence of intracranial hypertension 3
• For patients with well-controlled seizures (no seizures in the past year), no additional neurological workup is typically needed 2
• For patients with poorly controlled seizures, consider optimization of antiepileptic regimen before elective procedures 2
• The majority of perioperative seizures in patients with pre-existing seizure disorders are related to the patient's underlying condition rather than the surgical procedure or anesthetic technique 2

Perioperative Monitoring

• Standard monitoring is sufficient for most patients with well-controlled seizures 2
• Consider more intensive monitoring for patients with poorly controlled seizures or those who have had recent seizures 2
• Be prepared to treat breakthrough seizures regardless of the surgical procedure or anesthetic technique 2

Common Pitfalls to Avoid

• Unnecessary delay of surgery for patients with well-controlled seizures 2
• Discontinuation of antiepileptic medications perioperatively 2
• Overreliance on prophylactic antiepileptic drugs for patients without a history of seizures 6
• Failure to recognize potential drug interactions between antiepileptic medications and anesthetic agents 2