The good news is that even if you have back pain you are generally an excellent candidate for spinal and epidural anesthesia. In fact, epidural steroid injections are often used in the treatment of back pain. Because epidural and spinal anesthesia offer significant benefits including decreased blood loss, improved surgical conditions, better post-operative pain control and decreased risk of potentially dangerous blood clots, pre-existing back pain should not be considered a contraindication for surgery.
You may experience back pain after spinal or epidural anesthesia, but this is not from aggravation of disc disease. One cause of post-operative back pain in ambulatory surgery is called TNS (transient neurologic symptoms). While the cause of TNS is not precisely clear, you may expect full resolution within a few days and excellent relief with anti-inflammatory drugs. Some people may experience short-term aggravation of back pain from preoperative discontinuation of non-steroidal anti-inflammatory drugs (NSAIDs, such as Celebrex, Mobic, Ibuprofen, Naproxen) prior to surgery, which improves when these medications are resumed after surgery. Lastly, careful positioning and padding during your surgery limits the risk of postoperative back pain.
If you have a history of alcohol and substance abuse your surgical anesthetic and postoperative care can be designed to minimize the likelihood of problems. There are many things to consider in planning the type of anesthetic for any given surgery. To begin with, open and honest communication between yourself and your anesthesiologist beforehand will minimize any potential problems afterwards.
Substance abuse presents unique challenges to your anesthesiology team. Depending on the surgery, different forms of anesthesia may be employed. The simplest would be a pure local anesthetic technique. This can be done for minor surgical procedures such as carpal tunnel releases and removal of hardware. If the surgery involves an extremity or joint, a regional anesthetic technique can be employed. Examples include spinals for total hip and knee replacements, ACL repairs, and knee arthroscopies. Ankle blocks may be used for bunion and other foot surgeries, while brachial plexus blocks are used for hand, arm, and shoulder surgeries. In each case, minimal use of sedatives and opiates can be employed. The last option is general anesthesia, which is usually necessary for spinal surgery and more complex joint surgery.
The unique problem facing individuals with a history of addiction undergoing surgery is whether relapse can or will occur. Because most patients in the perioperative period will require painkillers or sedatives at some point during their hospitalization, this is a legitimate concern. Fortunately, for the vast majority of these patients, the use of these medications in this particular setting does not lead to reoccurrence of their addiction.
Some patients are concerned that the use of benzodiazepines (a class of drugs that include Versed, Valium and Ativan) will be problematic. These medications are often used preoperatively to alleviate anxiety about going into the operating room, and for sedation during the placement of local and regional anesthetic techniques. There are no studies to suggest that the use of these medications will cause patients with a history of alcohol dependency to relapse or develop a problem in the future with this class of medications.
For patients with a history of substance abuse, the opiates used to treat pain in the postoperative setting may also cause concern. For these patients, the judicious use of these medications, often in consultation with a chronic pain specialist, will reduce the likelihood of relapse while still adequately treating postoperative pain. In addition, careful observation after discharge with limited prescriptions for pain medications (i.e. a 1-2 week supply), along with a definitive follow up plan will also lessen the possibility for problems afterwards.
Many people who come for surgery have allergies and it is extremely important that you inform your anesthesiologist of these. Your anesthesiologist (and the other doctors involved in your care) need to know not only what you might be allergic to, but also what type of reaction you had to that substance. Patients can be allergic to a variety of substances such as environmental particles, drugs (including anesthetics, antibiotics, pain medicines, etc.), latex, and foods or food components (eggs/milk, fruits, etc...). It is important to note all of these on your preoperative form and to inform your health care team. Almost everyone you meet at HSS from physician's assistants and nurses to your surgeons, anesthesiologists and internists will ask you about allergies. You will even be given a wristband that indicates what drugs or substances you are allergic to.
Since not all reactions to medicines or other substances are true allergic reactions, it is important to specify exactly what happened as a result of a previous exposure. If you do not know what the reaction was, it is ok, still include that substance as a possible cause of allergy.
Some people have allergies specifically to anesthetic agents. These can range from typical allergic reactions that cause skin rashes, hives, breathing problems and/or anaphylaxis to a very rare condition called malignant hyperthermia. It is especially important that your anesthesiologist know of any history of these types of reactions. Your anesthesiologist can find safe, alternative ways of giving you anesthesia without using those substances that have caused problems in the past. For your safety, your anesthesiologist may even recommend preoperative testing by an allergist to confirm true drug allergies.
If you do have an allergic reaction in the hospital, it can be treated. However, the safest way to avoid these types of problems is by avoiding exposure. This is why your reporting of previous allergic reactions is so important.
The anesthesiologists at HSS are very knowledgeable about the issues surrounding pain medications and surgery. In general, we are able to keep you safe and comfortable regardless of the medications you are taking for pain preoperatively. If you are taking large doses of pain medication before your surgery, if you have any implanted pain devices (a spinal cord stimulator or implanted opiate pump), or if you have reflex sympathetic dystrophy (RSD or CRPS) you should contact the Department of Musculoskeletal and Interventional Pain Management at 212.606.1865 or the Department of Anesthesiology, Critical Care and Pain Management at 212.606.1036 for a preoperative consultation with a chronic pain specialist here. This is very important, as it will allow us to develop a specialized care plan for your postoperative pain treatment. At HSS we have a dedicated Acute Pain Service to address pain issues postoperatively. Often, the Department of Musculoskeletal and Interventional Pain Management is consulted for management of your pain when you have been taking large doses of pain medications before your surgery.
In general, if you are taking pain medications preoperatively, you should continue your pain medications right up until the time of surgery.
Sleep apnea is a relatively common disorder seen in our patients undergoing surgery. Although many patients with sleep apnea are admitted with the diagnosis, some patients are only diagnosed in the operating room by the anesthesiologist from the pattern of their breathing.
If you know that you have sleep apnea, please alert your surgeon, anesthesiologist, and the hospital staff. Special home equipment for sleep apnea such as nasal CPAP should be brought to the hospital the day of surgery. As a precautionary measure, patients with sleep apnea are usually observed in the recovery room overnight to ensure that opiates (narcotics) or other pain killers prescribed to control pain after surgery do not interfere with respiration. The recovery room allows for constant monitoring of your breathing (which is not possible in a regular hospital room). If you have any further concerns regarding sleep apnea and anesthesia, please contact the Department of Anesthesiology, Critical Care and Pain Management at 212.606.1036.