anesthesia for minimally invasive spine surgery
TRANSCRIPT
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Carlos Darcy Alves Bersot-TSA/SBA
MD RESPONSÁVEL PELO CET H.F.LAGOA
Médico Anestesiologista do Hospital Federal da Lagoa - RJ
Médico Anestesiologista do Hospital Universitário Pedro Ernesto-UERJ
Anestesia para procedimentos minimamente
invasivos da coluna vertebral
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Dor Lombar
“It is estimated that 70-90% of people suffer from back problems at some point in their lives.” – Australian Bureau of
Statistics, 2007-08.
“Up to 80% of Australians experience back pain and 10% have significant disability as a result.” – The Medical Journal of
Australia, 2009.
Custo de 100 bilhões por ano
2,5 milhões na United States Air Force
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Quais são as patologias vertebrais e medulares que necessitam de
cirurgia?
A incidência de espondilolistese na população geral é
de cerca de 6%
Espondololistese Hernia discal
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Estenose de canal EscolioseTumor Medular/Vertebral
Quais são as patologias vertebrais e medulares que necessitam de
cirurgia?
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Procedimentos cirúrgicos clássicos
Laminotomia Laminectomia Discectomia
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Fusão Instrumentação
Procedimentos cirúrgicos clássicos
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Quais são os problemas relacionados a cirurgia aberta?
• Dano muscular para espinhal
• Internação prolongada
• Degeneração segmentar
• Falha no tratamento da dor lombar
• Infecção
• Perda sanguínea-Posicionamento
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MISS Aberta
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Maximamente efetiva
Minimamente invasiva
• Cirurgia também chamada de menos invasivas
• Via para muscular
• Uso de Microscopio
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Cirurgia minimamente invasiva da coluna?
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Controle MRI
Pré-operatório Pós-operatório
A articulação facetária contra-lateral
também é preservada
Isso preserva o processo espinhoso
na linha média e os ligamentos.
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• Estenose espinhal
• Hernia de disco
• Espondilolistese
• Trauma
• Escoliose?
Quais são as indicações da MISS?
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Quais são as vantagens reportadas da MISS?
• Menor dano tecidos moles
• Menor perda sanguínea
• Alta hospitalar precoce
• Baixa incidência de infecção
• Melhor resultado estética ?
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Quais as desvantagens reportadas com a MISS?
• Maior tempo de sala
• Aumento uso de fluoroscopia
• Curva de aprendizado longa
• Desfechos a longo prazo:
• Frequência de fusão
• Complicações
• Custo
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Contra-indicação
Extensão de instrumentação previa
Obesidade morbida
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Manejo anestésico
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Anestesia Geral com monitorização
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• Escoliose-DPOC
• Posicionamento
• Ventilação monopulmonar
• Abordagem anterior e posterior-Double lumen CHANGE to simples
• Intubação difícil em cifoescoliose/distorção broncotraqueal
• BNM- Estimulação carinal
• Artéria e veia são advogados
• Risco de sangramento.
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Manejo da Dor
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Papel do cirurgião na analgesia perioperatória
O uso liberal de anestesia local (lidocaína 1% com epinefrina: 20-30 mL) deve ser
uma prática padrão antes de qualquer incisão cirúrgica ser feita
Manejo da Dor
Obesidade, Apneia do Sono, Opióides, Dor crônica
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Qual e a melhor técnica anestésica?
• Avaliacao pre anestésica
• Propofol
• Pros
• Contras
• BNM-IONM-Neurovision
• Opióides, Obesidade, Apneia do Sono,Dor crônica
• Multimodalidade
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1,5 milhões de fraturas osteoporóticas
Envelhecimento da população
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1-Posicionamento
Lesões
Alterações fisiológicas
4-Monitorização neurofisiológica intraoperatória
2-Perda visual pós-operatório (povl)
3-Manejo do sangramento perioperatório
Desafios únicos para cirurgia da coluna vertebral
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1-Posicionamento
Lesões
Alterações fisiológicas
4-Monitorização neurofisiológica intraoperatória
2-Perda visual pós-operatório (povl)
3-Manejo do sangramento perioperatório
Desafios únicos para cirurgia da coluna vertebral
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1-Posicionamento
Lesões
Alterações fisiológicas
4-Monitorização neurofisiológica intraoperatória
2-Perda visual pós-operatório (povl)
Desafios únicos para cirurgia da coluna vertebral
3-Manejo do sangramento perioperatório
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1-Posicionamento
Lesões
Alterações fisiológicas
2-Perda visual pós-operatório (povl)
3-Manejo do sangramento perioperatório
Desafios únicos para cirurgia da coluna vertebral
4-Monitorização neurofisiológica
intraoperatória
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Suprimento sanguíneo
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Conclusão
• Função do anestesiologista
• Grande variedade de procedimentos
• Futuro
• “fast track” e analgesia multimodal
• Atenção aos desafios únicos