Perioperative management and best practices

Chapter 4: Perioperative management and best practices

Ryan Steven D’Souza, Alaa Abd-Elsayed


As evidence grows for the benefits of percutaneous fusion procedures in the treatment of mechanical low back pain, it is important for the proceduralist to pursue appropriate workup and assess for proper patient selection. Poor patient selection and inadequate preoperative workup may lead to suboptimal long-term results and may increase risk for perioperative complications. Although there are no current established guidelines for perioperative workup in patients who are candidates for percutaneous fusion procedures, we recommend adherence to guidelines commonly used for other neuraxial interventions such as spinal cord stimulator placement. This is justified, as a conservative standard is adhered to as evidence and guidelines continue to evolve for percutaneous fusion procedures. In addition, many percutaneous fusion procedures are performed close to the neuraxial space and thus carry similar risks to other neuraxial interventions. In this chapter, we provide a summary of recommendations that should be undertaken in the preoperative, intraoperative, and postoperative period in patients pursuing percutaneous fusion procedures.

Preoperative care

Assessment of clinical indication

First, the clinician should confirm that the patient has an appropriate clinical indication to benefit from a percutaneous fusion procedure. For example, if the patient is offered a percutaneous facet joint fusion procedure, the patient should have one of the following diagnoses: facet joint dysfunction and pain, spinal instability from prior spine surgeries, microinstability of certain spinal segments, or requirement for adjunctive therapy or bridging therapy to an interbody fusion surgery. Clinical indications for other percutaneous fusion procedures are presented elsewhere within this atlas. A thorough assessment of contraindications that would preclude the proceduralist from offering this therapy to the patient should be reviewed, including coagulopathy, current infection, malignancy, and other contraindications.

Another essential component in the preoperative period is for the patient to have an “education” visit, where all questions relevant to the surgery are addressed. In many centers with specialized pain practices, this is often conducted by a nurse or an advanced nurse practitioner. This visit presents an opportunity for the patient to visualize the type of device that would be implanted, discuss alternative or adjunctive treatment, potentially meet with the device company representative, and address any pending questions before the surgery.

Psychiatric screening visit

The biopsychosocial approach to chronic pain management involves a complex interaction between biological, psychological, social, and medicolegal factors. It is well-known that chronic pain and mood disorders often cooccur, as highlighted by studies citing that up to 85% of chronic pain patients are impacted by severe depression.1,2 Furthermore, chronic pain patients who suffer from uncontrolled mood disorder exhibit a poorer prognosis than patients who have chronic pain only.3 Thus it is not uncommon for the proceduralist to obtain a presurgical psychological assessment of patients before offering them advanced interventional options. Presurgical psychosocial health is a major predictor of pain relief, quality of life, and satisfaction after spinal cord stimulator placement.4,5 Thus although a patient may appear to be an ideal candidate for a surgery based on their clinical indication, poorly controlled psychological comorbidities may make them suboptimal candidates. Furthermore, even other psychosocial factors, such as history of drug abuse, alcoholism, personality issues, marital discord, job dissatisfaction, pending litigation, and prior abuse or abandonment, may play a role in a patient’s postsurgical efficacy. Thus a preoperative general psychosocial assessment should include a survey of pain symptoms, demographic data, prior surgeries, employment status, level of education, history of workers’ compensation or other injury litigation, disability payment status, and personality traits.

Imaging studies

Preoperative advanced imaging of the surgical area of interest, utilizing either computed tomography (CT) or magnetic resonance imaging (MRI), is recommended for presurgical planning, to rule out any contraindications or anatomic abnormalities that would preclude the proceduralist from offering percutaneous fusion, and to minimize risk of complications. This imaging should be recent to within 1 to 2 years of the planned procedure. Spine surgeons typically utilize preoperative multiplanar advanced imaging to inform medical decisions and surgical plans before spine fusion surgery that involves pedicle screw instrumentation.6 Similarly, in the neuromodulation space, obtaining preoperative thoracic MRI for thoracic lead placement is the standard of care and has been recommended by consensus committees.7 Thus the authors recommend obtaining either an MRI or CT scan before performing percutaneous fusion procedures.

In addition, osteoporosis has often been considered as a contraindication to spine surgeries that involve instrumentation.8 Studies have demonstrated that patients with substantially lower bone mineral density are at high risk for developing graft subsidence, failure of spinal fusion and implant fixation, and vertebral compression fractures surrounding fusion sites.9,10 Presurgical optimization with bisphosphonates may lead to improved outcomes including increased solid intervertebral fusion, decreased vertebral compression fractures, decreased pedicle screw loosening, and decreased case subsidence.10 Obtaining a presurgical bone density scan, such as a dual-energy x-ray absorptiometry (DEXA) scan, may help inform this decision.


Many percutaneous fusion procedures are in proximity to the neuraxial space and are thus considered as high-to-intermediate risk procedures. Anticoagulation should be held with approval of the prescribing physician for an adequate length of time specific for the anticoagulant medication, before the procedure. Commonly, proceduralists follow anticoagulation practice guidelines as stated by the American Society of Regional Anesthesia and Pain Medicine Consensus committee.11,12 Proceduralists may also choose to follow consensus guidelines that are in place for spinal cord stimulator placement.13 Generally, nonsteroidal antiinflammatory drugs, other antiplatelet agents, and anticoagulants should be discontinued for at least five half-lives. Furthermore, depending on the patient’s bleeding risk, medical comorbidities (e.g., renal or hepatic dysfunction), and the type of anticoagulant, proceduralists may also consider obtaining diagnostic workup that includes hemoglobin, platelet count, prothrombin time, international normalized ratio, and partial thromboplastin time.

In settings where a patient is at high risk for a thromboembolic event, a shared assessment and risk stratification approach between the proceduralist and the provider who prescribes anticoagulation is warranted. High-risk patients who require bridging of anticoagulation therapy may be bridged with low-molecular-weight heparin or heparin. Proceduralists may consider consulting with a vascular medicine service if a thrombophilia specialty service is available to assist in anticoagulation management perioperatively.

Other preoperative recommendations

Optimal glucose control is recommended, and most guidelines advise a hemoglobin A1c level below 8% to 9%.14 Tobacco cessation is also recommended, as continued use may impair surgical healing. Patients who are carriers of methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA) should receive mupirocin nasal ointment and chlorhexidine baths for decolonization.15

Intraoperative care

Infection prevention

Strict sterile precautions are recommended intraoperatively. This entails performing a surgical scrub for 2 to 5 minutes with an antiseptic, wearing a surgical mask, wearing a sterile gown and double gloves, using chlorhexidine gluconate for preoperative skin preparation, placing an iodophor-impregnated drape, removing hair near surgical site with electric clippers, and using laminar flow and high-efficiency particulate air (HEPA) filters in the operating room.15 Administration of prophylactic antibiotics within 1 hour of surgical incision is recommended. Finally, application of a bioocclusive dressing after the surgery that remains in place for 24 to 48 hours is recommended.

Postoperative care

Infection prevention

The key tenet of infection prevention is adherence to the prescribed postoperative antibiotic regimen. Although antibiotic prescription practices vary considerably among providers, recent guidelines for spinal cord stimulator procedures recommend postoperative antibiotics for 24 hours. Given the proximity to the neuraxial space of fusion procedures, the authors also recommend at least 24 hours of postoperative antibiotic therapy.

Furthermore, patients should not shower or remove wound dressings for 48 hours. After that, dressing changes can occur daily. Dressings may be removed before showering, and then incisions should be patted dry and allowed to air dry after showering, with subsequent replacement of dressing. Patients should refrain from completely submerging under water, such as in baths, hot tubs, or swimming pools, for at least 2 weeks. Finally, the patient should monitor for any signs or symptoms that would be concerning for infection such as worsening incisional pain, erythema over the incision, swelling, fever, or pus-like discharge from the incision.

Postoperative resumption of anticoagulation

When resuming antiplatelet and anticoagulation agents after percutaneous fusion, proceduralists should adhere to practice guidelines from the American Society of Regional Anesthesia and Pain Medicine Consensus committee.11,12 Aspirin may be resumed after 24 hours, and clopidogrel may be resumed after 12 to 24 hours. Warfarin may be restarted 6 hours postoperatively. All novel oral anticoagulants (NOACs) should be restarted 24 hours postoperatively. Exceptions to standard care should be individualized and should be made through expert consultation with the vascular medicine service.

Incisional pain control

Patients should employ a multimodal analgesia protocol to assist with incisional pain. The proceduralist may infiltrate the surgical area with local anesthetic. Barring any contraindications, patients may take acetaminophen and nonsteroidal antiinflammatory agents. Ice application over the incisional area may decrease inflammation and pain. Finally, the proceduralist may prescribe a short, 3- to 5-day course of short-acting opioid medication.

Activity restrictions

Activity restrictions may vary institutionally, but certain recommendations are consistent. During the first 2 weeks after fusion, patients should refrain from intense physical activity that could impact the implanted hardware such as weight lifting, biking, running, sexual activity, lifting over 5 pounds, and twisting or bending over 30 degrees. The limited movement prevents migration of the implant and allows the incision to appropriately form scar tissue. During weeks 2 through 6, patients may lift up to 10 pounds in weight, but should continue to refrain from bending and twisting the spine. During weeks 6 to 12, most normal daily activities can be resumed although it is still recommended to refrain from high-impact activities such as horseback riding or riding in all-terrain vehicles.

Follow-up visits

Follow-up visits are crucial to address any adverse effects and to monitor treatment efficacy from the surgical intervention. Traditionally, patients would follow up with the proceduralist at postoperative weeks 10 to 14 for inspection of incisions and removal of any superficial closure materials (e.g., staples). Thereafter routine follow-up is at the discretion of the proceduralist, but may occur at 3 months, 6 months, and 1 year postsurgery to monitor for efficacy of treatment.


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May 21, 2023 | Posted by in PAIN MEDICINE | Comments Off on Perioperative management and best practices

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