What is the anesthetic technique for induction of anterior corpectomy?

Anesthetic Technique for Anterior Corpectomy Induction

For anterior corpectomy procedures, use propofol (2-2.5 mg/kg) for induction combined with a short-acting opioid such as fentanyl (1.5-2.0 mcg/kg), remifentanil infusion, or alfentanil, followed by endotracheal intubation with controlled ventilation. 1, 2

Induction Agents

• Propofol is the standard induction agent due to its rapid onset, quick recovery profile, and reduced postoperative nausea and vomiting compared to other agents 1
• Short-acting opioids should be administered concurrently for analgesia during laryngoscopy and intubation 1, 2
• Avoid nitrous oxide as it increases the risk of postoperative nausea/vomiting and delays return of bowel function 1

Neuromuscular Blockade

• Administer a neuromuscular blocking agent to facilitate intubation, with rocuronium being advantageous as it can be rapidly reversed with sugammadex if airway difficulties arise 1
• Calculate the dose of sugammadex for emergency reversal beforehand and have it immediately available 1
• Neuromuscular monitoring must be used throughout the procedure to ensure adequate blockade during surgery and complete reversal (train-of-four ratio ≥ 0.90) before extubation 1

Airway Management

• Endotracheal intubation with controlled ventilation is mandatory for anterior corpectomy given the surgical positioning requirements, duration of procedure, and need for optimal surgical exposure 1
• Use ideal body weight to size the endotracheal tube 1
• Ensure proper positioning with the head in neutral or slight extension to facilitate the anterior cervical approach 3, 4

Ventilation Strategy

• Implement lung-protective ventilation with tidal volumes of 6-8 mL/kg (based on ideal body weight) and positive end-expiratory pressure (PEEP) of 6-8 cm H₂O to reduce pulmonary complications 1
• Monitor end-tidal CO₂ continuously via capnography 2

Multimodal Analgesia Approach

• Consider thoracic epidural anesthesia (T7-10) for open procedures if the surgical approach involves extensive tissue dissection, as it provides superior analgesia compared to systemic opioids and should be commenced before surgery 1, 5
• For epidural loading, use 15-25 mL of long-acting local anesthetic (bupivacaine 0.5-0.75% or ropivacaine 0.5-0.75%) with onset in 10-30 minutes 5
• Maintain epidural infusion at 5-14 mL/hour of dilute local anesthetic combined with opioid (fentanyl 2-2.5 μg/mL) 5
• Administer multimodal non-opioid analgesics including NSAIDs (ibuprofen 10 mg/kg IV every 8 hours or ketorolac 0.5-1 mg/kg, max 30 mg) and acetaminophen to reduce opioid requirements 1, 2

Monitoring Requirements

• Standard ASA monitoring is mandatory: ECG, pulse oximetry, non-invasive blood pressure, capnography, temperature monitoring, and neuromuscular monitoring 2
• Monitor blood pressure every 5 minutes for at least 15 minutes following epidural loading dose if epidural is used 5
• Maintain normothermia throughout the procedure using warming devices 1

Important Caveats

• Volatile anesthetics (sevoflurane, desflurane) can be used for maintenance and may provide cardioprotective effects, though propofol-based total intravenous anesthesia is equally acceptable 1
• If using volatile agents, desflurane provides faster return of airway reflexes compared to sevoflurane 1
• Avoid long-acting anesthetic agents to facilitate rapid emergence and early neurological assessment, which is critical after spinal cord decompression 1, 2
• For multilevel corpectomies or cases with anticipated longer operative times, consider depth of anesthesia monitoring to prevent awareness while minimizing anesthetic load 1

VTE Prophylaxis

• Initiate venous thromboembolism prophylaxis with sequential compression devices and low molecular weight heparin or unfractionated heparin, continuing throughout hospitalization 1
• If epidural catheter is used, strictly adhere to timing guidelines: withhold LMWH for at least 12 hours before catheter removal and do not restart until at least 4 hours after removal 5