Relationship among anesthesia technique, surgical stress, and cognitive dysfunction following spinal surgery: a randomized trial

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OBJECTIVE

Surgical trauma is known to result in systemic inflammatory changes that can lead to postoperative cognitive dysfunction. In the present study, the authors compared the effects of an epidural anesthesia protocol to those of traditional anesthesia with regard to postoperative inflammatory changes, cellular immunity, and cognitive dysfunction.

METHODS

Forty-eight patients, ages 45–60 years, underwent multilevel thoracolumbar decompression and fusion and were randomly assigned to one of two groups: group 1 (27 patients) had combined epidural and general anesthesia, followed by epidural analgesia for 48 hours after surgery, and group 2 (21 patients) had general anesthesia, followed by traditional opioid pain management after surgery. At multiple time points, data on pain control, cognitive function, cellular immunity, and inflammatory markers were collected.

RESULTS

Group 1 patients demonstrated lower pain levels, less systemic inflammation, less cellular immune dysfunction, and less postoperative cognitive dysfunction than group 2 patients.

CONCLUSIONS

The use of combined epidural and general anesthesia followed by postoperative epidural analgesia during the first 48 hours after multilevel thoracolumbar decompression and fusion surgery had a significant positive effect on pain management, cellular immune function, systemic inflammation, and postoperative cognitive function.

Clinical trial registration no.: 115080510080 (http://rosrid.ru)

ABBREVIATIONS BIS = Bispectral Index; FAB = Frontal Assessment Battery; IV = intravenous; MMSE = Mini-Mental State Examination; MoCA = Montreal Cognitive Assessment; NK = natural killer; PCA = patient-controlled analgesia; POCD = postoperative cognitive dysfunction; POD = postoperative day.

Article Information

Correspondence D. Greg Anderson: Thomas Jefferson University/Rothman Institute, Philadelphia, PA. greg.anderson@rothmaninstitute.com.

INCLUDE WHEN CITING Published online September 6, 2019; DOI: 10.3171/2019.4.SPINE184.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    CONSORT flow diagram of study. Prepared using the CONSORT Flow Diagram template (available at http://www.consort-statement.org/).

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    The epidural catheter (left arrow) is shown secured by an occlusive dressing and is located cranial to the surgical incision. The surgical incision (right arrow) has been demarcated by the surgeon using fluoroscopy prior to placement of the epidural catheter.

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    Plasma levels of cytokines are shown at baseline (basal), end of surgery (End-Op), POD 1, and POD 3: IL-1β (A), IL-6 (B), IL-10 (C), and IL-8 (D).

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    CD3+ cells and CD4/CD8 cell ratios are shown at baseline (basal), POD 3, and POD 5. *p < 0.05 for comparison between groups. #p < 0.05 for comparison with baseline.

  • View in gallery

    Scores for the MMSE, MoCA, and FAB are shown for the baseline (basal), POD 1, POD 3, and POD 5 time points.

References

  • 1

    Buvanendran AKroin JSBerger RAHallab NJSaha CNegrescu C: Upregulation of prostaglandin E2 and interleukins in the central nervous system and peripheral tissue during and after surgery in humans. Anesthesiology 104:4034102006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Choi SRampersaud YRChan VWPersaud OKoshkin ATumber P: The addition of epidural local anesthetic to systemic multimodal analgesia following lumbar spinal fusion: a randomized controlled trial. Can J Anaesth 61:3303392014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Cibelli MFidalgo ARTerrando NMa DMonaco CFeldmann M: Role of interleukin-1β in postoperative cognitive dysfunction. Ann Neurol 68:3603682010

  • 4

    Deiner SSilverstein JH: Postoperative delirium and cognitive dysfunction. Br J Anaesth 103 (Suppl 1):i41i462009

  • 5

    Dubois BSlachevsky ALitvan IPillon B: The FAB: a Frontal Assessment Battery at bedside. Neurology 55:162116262000

  • 6

    Fidalgo ARCibelli MWhite JPNagy IMaze MMa D: Systemic inflammation enhances surgery-induced cognitive dysfunction in mice. Neurosci Lett 498:63662011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Folstein MFFolstein SEMcHugh PR: “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:1891981975

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Hirsch JVacas STerrando NYuan MSands LPKramer J: Perioperative cerebrospinal fluid and plasma inflammatory markers after orthopedic surgery. J Neuroinflammation 13:2112016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Hudetz JAGandhi SDIqbal ZPatterson KMPagel PS: Elevated postoperative inflammatory biomarkers are associated with short- and medium-term cognitive dysfunction after coronary artery surgery. J Anesth 25:192011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Iwasaki MEdmondson MSakamoto AMa D: Anesthesia, surgical stress, and “long-term” outcomes. Acta Anaesthesiol Taiwan 53:991042015

  • 11

    Jiang XChen DLou YLi Z: Risk factors for postoperative delirium after spine surgery in middle- and old-aged patients. Aging Clin Exp Res 29:103910442017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Kazmierski JBanys ALatek JBourke JJaszewski R: Cortisol levels and neuropsychiatric diagnosis as markers of postoperative delirium: a prospective cohort study. Crit Care 17:R382013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Li YCXi CHAn YFDong WHZhou M: Perioperative inflammatory response and protein S-100β concentrations—relationship with post-operative cognitive dysfunction in elderly patients. Acta Anaesthesiol Scand 56:5956002012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Mandal SBasu MKirtania JSarbapalli DPal RKar S: Impact of general versus epidural anesthesia on early post-operative cognitive dysfunction following hip and knee surgery. J Emerg Trauma Shock 4:23282011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Monk TGWeldon BCGarvan CWDede DEvan der Aa MTHeilman KM: Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology 108:18302008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Nasreddine ZSPhillips NABédirian VCharbonneau SWhitehead VCollin I: The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 53:6956992005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Peng LXu LOuyang W: Role of peripheral inflammatory markers in postoperative cognitive dysfunction (POCD): a meta-analysis. PLoS One 8:e796242013

  • 18

    Rasmussen LSChristiansen MRasmussen HKristensen PAMoller JT: Do blood concentrations of neurone specific enolase and S-100 beta protein reflect cognitive dysfunction after abdominal surgery? ISPOCD Group. Br J Anaesth 84:2422442000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Rasmussen LSLarsen KHoux PSkovgaard LTHanning CDMoller JT: The assessment of postoperative cognitive function. Acta Anaesthesiol Scand 45:2752892001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Riedel BBrowne KSilbert B: Cerebral protection: inflammation, endothelial dysfunction, and postoperative cognitive dysfunction. Curr Opin Anaesthesiol 27:89972014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Shi LYXu LWan YJ: Relationship between postoperative cognitive dysfunction and the expression of inflammatory cytokines of plasma. Shanghai Medical J 35:1151172012

    • Search Google Scholar
    • Export Citation
  • 22

    Silbert BEvered LScott DA: Cognitive decline in the elderly: is anaesthesia implicated? Best Pract Res Clin Anaesthesiol 25:3793932011

  • 23

    Solenkova AVBondarenko AADzyubanova NALubnin AY: Cognitive status assessment after spinal surgery. Anesteziologiya i Reanimatologiya 4:38422012 (Russian)

    • Search Google Scholar
    • Export Citation
  • 24

    Solenkova AVBondarenko AALubnin AYDzyubanova NA: Postoperative cognitive dysfunction in elderly patients. Anesteziologiya i Reanimatologiya 4:13192012 (Russian)

    • Search Google Scholar
    • Export Citation
  • 25

    Steinmetz JChristensen KBLund TLohse NRasmussen LS: Long-term consequences of postoperative cognitive dysfunction. Anesthesiology 110:5485552009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Terrando NMonaco CMa DFoxwell BMFeldmann MMaze M: Tumor necrosis factor-α triggers a cytokine cascade yielding postoperative cognitive decline. Proc Natl Acad Sci U S A 107:20518205222010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Terrando NYang TRyu JKNewton PTMonaco CFeldmann M: Stimulation of the α7 nicotinic acetylcholine receptor protects against neuroinflammation after tibia fracture and endotoxemia in mice. Mol Med 20:6676752015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Vacas SDegos VFeng XMaze M: The neuroinflammatory response of postoperative cognitive decline. Br Med Bull 106:1611782013

  • 29

    van Harten AEScheeren TWAbsalom AR: A review of postoperative cognitive dysfunction and neuroinflammation associated with cardiac surgery and anaesthesia. Anaesthesia 67:2802932012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Volk TSchenk MVoigt KTohtz SPutzier MKox WJ: Postoperative epidural anesthesia preserves lymphocyte, but not monocyte, immune function after major spine surgery. Anesth Analg 98:108610922004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Zywiel MGPrabhu APerruccio AVGandhi R: The influence of anesthesia and pain management on cognitive dysfunction after joint arthroplasty: a systematic review. Clin Orthop Relat Res 472:145314662014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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