Lumbar Decompression Under Spinal Enhanced Recovery Pathway

Patient Selection

Lumbar laminectomy, discectomy
TLIF

Exclusions:
BMI>30. 
Moderate to Severe OSA
Poorly controlled pulmonary disease, needs baseline RA sat >95%. 
Poorly controlled cardiac disease.  Only mild to no valvular stenosis. 
High risk for aspiration (well controlled gerd ok, no severe reflux or high risk disease (achalasia, ascites ect). 
Psychiatric issues precluding sedation, in other words the patient needs to be on board with sedation.

Preop

• Acetaminophen 1000mg  
• Gabapentin 600mg (Hold for CKD with GFR<60, Age>70)
• Celebrex 400mg (Hold for CKD with GFR<60, Age>70, Hx CAD or GI bleed and TLIFs)

IntraOp

Pre procedure sedation

Midazolam per anesthesiologist (ideally<2mg)
Fentanyl per anesthesiologist – (ideally <100mcg)

Lumbar Spinal – Ideally 1 space above or below decompression

15mg isobaric bupivacaine (3cc 0.5% bupivacaine – preservative free)
10-25mcg fentanyl

Sedation

Propofol titrated to Ramsay Scale of 2-3. (25-50mcg/kg/min)
Ketamine 2mcg/kg/min 
Try to limit opiates
Alternate options: (dexmedatomidine gtt, fentanyl/midazolam)

BP support

Phenylephrine gtt vs ephedrine to maintain MAP 65mmHg or 80% baseline.
Consider fluid bolus if foley has been placed

Nausea prophylaxis

Dexamethasone 4mg IV x 1 (Hold for patients with DM)
Zofran 4mg IV x 1

Surgical infiltration 

Infiltration of 10mL of liposomal bupivacaine (20mL of 1.3% liposomal
bupivacaine diluted with 20mL of normal saline to a total volume of 40mL) to each percutaneous screw tract.

For inadequate analgesia after 2 hours- re-inject 1cc 0.5% bupivacaine with 24g pencil tip spinal needle on the field.

Postop

Avoid PCA
APAP 1g Q4h ATC
Gabapentin 300mg PO TID
Celebrex 200mg PO BID (non fusion patients)
Oxycodone 5mg PO Q3h prn moderate pain
Hydromorphone 0.2-0.4mg IV Q3h prn severe pain unresponsive to oral analgesics (avoid IV opiates if possible)
Zofran 4mg IV Q6h prn N/V
Check bladder scan volume if unable to urinate in PACU, straight cath if necessary

PT day of surgery