Comparison of Operating Conditions, Postoperative Pain and Recovery, and Overall Satisfaction of Surgeons with Deep vs. No Neuromuscular Blockade for Spinal Surgery under General Anesthesia: A Prospective Randomized Controlled Trial

Abstract

We aimed to investigate operating conditions, postoperative pain, and overall satisfaction of surgeons using deep neuromuscular blockade (NMB) vs. no NMB in patients undergoing lumbar spinal surgery under general anesthesia. Eighty-three patients undergoing lumbar fusion were randomly assigned to receive deep NMB (n = 43) or no NMB (n = 40). In the deep-NMB group, rocuronium was administered to maintain deep NMB (train-of-four count 0, post-tetanic count 1-2) until the end of surgery. In the no-NMB group, sugammadex 4 mg/kg at train-of-four (TOF) count 0-1 or sugammadex 2 mg/kg at TOF count ≥2 was administered to reverse the NMB 10 min after placing the patient prone. Peak inspiratory airway pressure, plateau airway pressure, lumbar retractor pressure significantly were lower in the deep-NMB group. Degree of surgical field bleeding (0-5), muscle tone (1-3), and satisfaction (1-10) rated by the surgeon were all superior in the deep-NMB group. Pain scores, rescue fentanyl consumption in post-anesthesia care unit (PACU), and postoperative patient-controlled analgesia consumption were significantly lower in the deep-NMB group, and this group had a shorter length of stay in PACU. Compared to no NMB, deep NMB provides better operating conditions, reduced postoperative pain and higher overall satisfaction in lumbar spinal surgery.

Keywords: neuromuscular blockade; neuromuscular monitoring; neurosurgical procedures.

Figure A1

Neuromuscular monitoring with a wrist brace. (A) The forearm was immobilized with a detachable wrist brace (Neoban wrist support, Seoul Brace, Seoul, Korea) that allowed the thumb to move, (B) with the stimulating electrode attached to the passage of the ulnar nerve and the elastic preload positioned at the thumb to monitor the response of the adductor pollicis.

Figure A2

The patient positioning and the study setup including the screen setup for masking groups from surgeons.

Figure A3

The retractor pressure transducer setting. (A) A flat planar pneumatic pressure transducer was placed beneath the lumbar retractor blade (B) then the lumbar retractor blades were retracted until they reached the lateral margin of the bilateral facet joints, and (C) the value of the back muscle retractor pressure (mmHg) was shown via a pressure monitor (red circle).

Figure 1

The pressure transducer used for retractor pressure monitoring was attached to a retractor blade. It was mounted on the middle of the inner surface of the retractor. (a) Medial view. (b) Lateral view.

Figure 2

A flow-chart describing patient recruitment, randomization, and withdrawal. NMB: neuromuscular blockade.

Figure 3

The change over time in (a) train-of-four (TOF) ratio, (b) bispectral index (BIS), (c) mean arterial pressure and (d) heart rate at the main time points during the perioperative period. NMB: neuromuscular blockade. The graphs show the mean value and standard deviation of each variable for each time point during general anesthesia. Time point 1: at baseline (before anesthesia), 2: at intubation, 3: at skin incision, 4: 30 min after skin incision, 5: 60 min after skin incision, 6: 120 min after skin incision, 7: at the end of surgery. * p < 0.001.

Figure 3

The change over time in (a) train-of-four (TOF) ratio, (b) bispectral index (BIS), (c) mean arterial pressure and (d) heart rate at the main time points during the perioperative period. NMB: neuromuscular blockade. The graphs show the mean value and standard deviation of each variable for each time point during general anesthesia. Time point 1: at baseline (before anesthesia), 2: at intubation, 3: at skin incision, 4: 30 min after skin incision, 5: 60 min after skin incision, 6: 120 min after skin incision, 7: at the end of surgery. * p < 0.001.