Anesthetic management of complex spine surgery in adult patients: a review based on outcome evidence.

The aim of this article is to review the evidence regarding the anesthetic management of blood loss, pain control, and position-related complications of adult patients undergoing complex spine procedures.The most recent evidence of the anesthetic management of complex spine surgery was identified with a systematic search and graded. In our review, prophylactic tranexamic acid and optimal prone positioning were shown to be effective blood conservation strategies with minimal risks to the patients. Cell saver was cost-effective in complex surgeries with expected blood loss of greater than 500 ml. As for pain control, most interventions only produced mild analgesic effects, suggesting a multimodal approach is necessary to achieve optimal pain control after spine surgery. Regional techniques and NSAIDs were effective but because of their risks, their usage should be discussed with the surgical team. Further studies are required to assess the effectiveness, cost-effectiveness, and risks associated with combined uses of different analgesic interventions. On the basis of the available evidence, we recommend a combined use of gabapentinoids, ketamine, and opioids to achieve optimal analgesia. Lastly, literature for position-related injuries is heavily relied on case reports and the Anesthesia Closed Claim Study because of their rarity. Therefore, we advocate for a structured team-based approach with checklists to minimize position-related complications.As the number and complexity of spine procedures are being performed worldwide is increasing, we suggested to bundle the aforementioned effective interventions as part of an ERAS spine protocol to improve the patient outcome of spine surgery.