3. Anesthetic Management

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Anesthetic management for BESS/UBE should combine patient safety and comfort with stable conditions for precise endoscopic work. The anesthetic plan is individualized according to the extent and expected duration of surgery, comorbidities, patient positioning, airway characteristics, and the need for neurological assessment. The anesthesiologist and surgeon agree on the strategy in advance.

General and spinal anesthesia

General anesthesia allows control of airway patency and ventilation and is suitable, in particular, for prolonged procedures. Spinal anesthesia may be an alternative for selected lumbar BESS/UBE operations. It provides a sensory and motor block of limited duration.

When spinal anesthesia is used, the possibility of conversion to general anesthesia is anticipated if the block is insufficient or the operation takes longer than expected. The plan must account for limited airway access in the prone position.

Hemostasis and hemodynamics

Clear visualization during BESS/UBE requires meticulous surgical hemostasis, free irrigation fluid outflow, and coordinated hemodynamic management. Tranexamic acid is used when indicated after assessment of contraindications and risks. Controlled hypotension is not a mandatory component of every operation: the anesthesiologist sets blood pressure targets with adequate perfusion of organs and neural structures in mind.

Adjuvants and postoperative analgesia

Postoperative analgesia is planned in advance regardless of the anesthetic technique. Adjuvants to local anesthetics may prolong analgesia but require assessment of adverse effects, the drug's approved route of administration, and the monitoring needed. Opioids and α₂-adrenoceptor agonists are not mandatory additions to every spinal anesthetic. After neuraxial opioid administration, ventilation, oxygenation, and level of consciousness are monitored.

References

1. Kang TH, Kim WJ, Lee JH. Efficacy of the erector spinae plane block with sedation for unilateral biportal endoscopic spine surgery and comparison with other anesthetic methods. Acta Neurochir (Wien). 2023;165(9):2651–2663. doi:10.1007/s00701-023-05643-1.

2. Upfill-Brown A, Olson T, Adejuyigbe B, Shah A, Sheppard W, Park CW, Heo DH, Park DY. Does the use of tranexamic acid intraoperatively reduce postoperative blood loss and complications following biportal endoscopic lumbosacral decompression? J Spine Surg. 2024;10(1):68–79. doi:10.21037/jss-23-129.

3. Saugel B, Fletcher N, Gan TJ, Grocott MPW, Myles PS, Sessler DI; PeriOperative Quality Initiative XI Workgroup Members. PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management. Br J Anaesth. 2024;133(2):264–276. doi:10.1016/j.bja.2024.04.046.

4. Shchegolkov YeE. Comparative characteristics of the effectiveness of spinal anesthesia with intrathecal administration of bupivacaine and its combination with adjuvants. Emergency Medicine. 2024;20(1):51–57. doi:10.22141/2224-0586.20.1.2024.1658.

5. Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration: An Updated Report by the American Society of Anesthesiologists Task Force on Neuraxial Opioids and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2016;124(3):535–552. doi:10.1097/ALN.0000000000000975.

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