I am going in for arthroscopic surgery in October. It is definitely not my first one (I've had three previous), but in all of my prior knee surgeries, I had a general anesthetic. This one, I have the option to choose.

i am wondering if anyone has had both, and can give me an opinion.

I was sort of intrigued with the spinal, b/c I am the type of person that would get a kick out of watching it (assuming they had a screen), or asking questions...but I don't know what happens with that.

Stuff to consider:

I like to watch :p

I AM a puker with anesthesia.

I have had a spinal tap (and the anesthetic that goes with it)...and the spinal headache made me want to DIE (and I am a veteran of migraines). I was incapacitated for almost a week. Would I be at risk of this with the local/spinal anesthetic? B/c, if so...I will take 12 hours of vomit in a second.

If you had a spinal tap for testing, then chances are good that a bigger needle was used to get more fluid out of you. The risk of headache is much greater with the bigger needles than it is with the smaller needles used for spinal anesthesia. That said you can still have a post-dural puncture headache (aka spinal headache). I'm an anesthesiologist and for a simple knee arthroscopy I'd pick general. For something more painful like ACL repair, then spinal can be more comfortable in the recovery period. Plus if you have a repair done you'll be off your feet for a while, so if you get the headache there are fewer workouts to miss ;). I never did many spinal for knees because they patients go home quicker after a smooth general anesthetic.

You may want to consider a femoral nerve block if you're having an ACL repair. They can give great post-op pain control.

brian

Not sure if there is an increased risk of a second spinal headache. Most people are so miserable after the first one that they work really hard never to have another. The risk of headache does decline with age, so being older is better.

I did the spinal for both of mine, and it was great. I was actually talking to the doc as he was showing me the IT bands were fine, no unusual wear, etc, and it totally re-assured me that I was not doing damage to my knees by my exercise. He showed me the actual internal things on the screen, while he was in there. I would do it no there way, and if they said they would have to put me out, I'd find another doc. Good luck....it's VERY interesting, and re-assuring, as I mentioned.

I am going in for arthroscopic surgery in October. It is definitely not my first one (I've had three previous), but in all of my prior knee surgeries, I had a general anesthetic. This one, I have the option to choose.

i am wondering if anyone has had both, and can give me an opinion.

I was sort of intrigued with the spinal, b/c I am the type of person that would get a kick out of watching it (assuming they had a screen), or asking questions...but I don't know what happens with that.

Stuff to consider:

I like to watch :p

I AM a puker with anesthesia.

I have had a spinal tap (and the anesthetic that goes with it)...and the spinal headache made me want to DIE (and I am a veteran of migraines). I was incapacitated for almost a week. Would I be at risk of this with the local/spinal anesthetic? B/c, if so...I will take 12 hours of vomit in a second.

I can tell you as a guy that has had a leak from a spinal tap, get the general and have the dr. tape the sugery. There is no cool factor that is worth the risk of a leaking spinal column. I have had no other experience in my life that even would get mentioned in the same discussion as a spinal headache. It is not even close. I would rather file my teeth than get another spinal headache.

One word of warning when they numb you from the waist down, they numb EVERYTHING from the waist down and feeling returns to your junk way last!!!

Being in the medical field, here's my take: ASK YOUR SURGEON. You don't really want to go outside of his normal routine. Surgeons get used to doing things a certain way and that's when they are at their best. If you start throwing variables into the routine you start introducing more risk. Some surgeons are very comfortable talking to you and showing you what they are doing and answering your questions. Others want you to STFU and let them operate.

If he has no preference, then move on to all the other criteria presented to you.

You must be kidding. All the average surgeon wants is the patient to lie still. They know esentially nothing about the various issues associated with the different anesthetic choices. Further, while one choice might be best for me to do it might be the worst for another anesthesiologist if he doesn't have a lot of experience or comfort with the technique. This is a decision that can only be made between the patient and the anesthesiologist. As the OP is finding out, there are no guarantees (good or bad) with any technique.

Remember that YOU are the customer. Seems the medical field needs to realize that. I've even seen acupuncture used for anesthesia in brain surgery. Do what YOU want after weighting the options. There are plenty of anesthesiologists around.

No offense, but you must not know many surgeons--at least not good ones. Anesthesia is what lets us do what we do safely, and anyone living in blissful ignorance of the physiologic effects of anesthesia, postop pain management, etc. needs to do some reviewing.

Surgeons/anesthesiologists/etc. are all part of a team. When they're communicating and working together it's a MUCH better experience for the patient than when they're not.

I have known plenty of surgeons. Most of them know almost zero about the decision making anesthesiologists make. Many are upset when the anesthesiologist chooses a regional technique because they don't want the patient awake (for fear of what they might hear I presume) or because they think if slows them down, or because they think the patient might have a "bad" experience. Not all are like that but most are. The one exception to that, as a general rule, are the oral surgeons whose residency requires them to take a substantial anesthesia rotation.

I agree it is a team and if the surgeon has any special anesthesia needs or requirements he should bring it up with the anesthesiologist. But, why on earth does the anesthesiologist need to, on each individual patient, communicate with the surgeon before deciding on whether a general or regional technique is best on such a simple, routine procedure?

edit: it is the anesthesiologists job to provide optimum operating conditions for the surgeon as consistent with maximum patient safety. Unless there are some unusual needs for a particular surgery this does not require the anesthesiologist consulting with the surgeon before hand on routine operations.

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Frank,
An original Ironman and the Inventor of PowerCranks

Maybe I've just been incredibly lucky with where I work, but in cases where there's an option the anesthesiologist will generally tell me what they've decided.

The type of anesthesia used also dictates some of the postop planning for pain control, what to look for in terms of complications, etc. I personally can't imagine not thinking about the anesthetic plan when I do a case.

I'll freely admit that there's nothing terribly simple or routine about most of the patients I operate on--most have significant cardiac, pulmonary, or renal issues, so I'll admit to being a bigger stickler about what's going on across the drape than your average ortho/sports surgeon is--or needs to be.

But, there is always an option. Your anesthesiologist(s) may only be informing you when they make a decision that is different from their routine.

And, most ortho patients hardly every have really significant cardiac, pulmonary or renal issues, at least in the eyes of anesthesiologists who see these patients all the time. Check how the anesthesiologist classifies the patient in his/her pre op workup. Unless they are ASA 4 or 5 the anesthesiologist doesn't consider them to be particularly sick.

I can remember one patient I dealt with in this regard. An extremely sick women with tons of problems had end stage rheumatoid arthritis and needed some joint replacements in her hands so she could simply take care of herself. Her "anesthetic problem" was she had SEVERE pulmonary hypertension with essentially zero cardiac reserve. Possibly the only ASA 5 I ever anesthetized who was not an ASA 5E. No one in the department would touch her except me. I proposed to the surgeon the most minimalist intervention possible, a cervical epidural with fentanyl (no local to affect blood flow sympathetics or blood flow) and some local (no epi) by the surgeon. Case went super, without a hitch, and patient got two new joints in one hand (as I remember). We were even able to provide great post op pain relief through that catheter without the need to give her anything that might affect her cardiac dynamics. To show you how sick she was, she died about 3 weeks after the surgery from her heart disease.

In the old days people used to worry about "can the patient survive the anesthesia". Nobody asks that question anymore as they expect everyone to survive and almost all of them do. Hence, anesthesiologists are used to seeing almost everything and handling it well. Your average fractured hip can have all sorts of underlying problems yet these are relatively routine operations for the anesthesiologist.

What most surgeons consider to be "significant" problems are pretty much routine to most anesthesiologists. While it is good for you to be concerned about what is going on above the drape, the surgeon is no longer the "captain of the ship" in this regards and your attention is better spent taking care of your end of this partnership. The anesthesiologist will (or should) let you know if there is something going on that needs your attention.

If your patients are really that sick and you want to consult with the anesthesiologist before the surgery about the plan, you should do so before the operation is ever put on the schedule (as was done with the case above). Otherwise, I suggest you should let the anesthesiologist do his/her job.

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Frank,
An original Ironman and the Inventor of PowerCranks

x2

Was completely awake and alert the whole time, saw everything asked questions it was great experience. It seems like the risks are less than general in the way it was explained to me. One word of warning when they numb you from the waist down, they numb EVERYTHING from the waist down and feeling returns to your junk way last!!!

Where did I say that this communication is happening on the day of surgery? Nor did I say anywhere that I'm dictating what the anesthesiologist will do, or keeping him/her from doing his/her "job." The statement I'm taking issue with is your assertion that surgeons don't know/understand/care what anesthesiologists do.

And doing joint replacements on an ASA 5... There's a reason nobody would touch her. I'm guessing in the last 3 weeks of her life she wasn't doing much with the hand. Even in the absence of retrospect it would be a bad idea to proceed with that case. In fact, you could go so far as to say that doing joint replacements on a debilitated, non-ambulatory patient is downright unethical.

Just to review the ASA classification, a 5 is a "Moribund Patient Who Is Not Expected to Survive Without the Operation," correct? Was she going to die if she didn't get new joints?

I wouldn't advertise that case as something to be proud of. It sounds like you did an unnecessary procedure on a dying woman.

If you throw the ASA 5 thing out there, then either the ASA status was overcalled or the procedure should never have been done. I know that's terrible with respect to her quality of life and all, but the only procedure it sounds like she should have been undergoing was a heart/lung transplant if indicated.

Now I'm sure I don't have all the facts, but if you throw out there that this lady was a 5, something stinks. If I were presented on my boards with a patient who wanted an elective procedure done and you told me she's an ASA 5, I'm quite sure I'd fail that question if I operated on her.

As for your position about what surgeons know about anesthesia, I'm sorry you've had that experience, because that certainly hasn't been mine, nor do I ever want my understanding of anesthesia to be "keep moving the air in and out." But to each his own I suppose.

Perhaps it is different now, but I doubt it.

If I were presented on my boards with a patient who wanted an elective procedure done and you told me she's an ASA 5, I'm quite sure I'd fail that question if I operated on her.

Why would you fail if you could justify your decision? Surgeons don't use that risk system anyhow. for your boards you would be unaware of the risk status that the anesthesiologist assigned to the patient. Your board question would not be "you have an ASA 5 patient . . ." You wouldn't know what an ASA 5 patient meant. They would say "You have a patient with pulmonary hypertension . . ." Your correct answer would be, I believe, "I would present the case to anesthesia and if they thought they could safely proceed then this is what I would do. . ."

You would fail, I believe, if you said. Well, I think she is going to die anyhow so I wouldn't do anything.

A lot has changed since the 80s, apparently. Maybe it's an Army thing, but between my anesthesia rotations and a number of intubations/bronchs/a couple TEEs done in a trauma/critical care environment, I think I know a little more than zero about anesthesia. Anyway, perhaps we should let this complete and utter threadjack end.

For the record I had the GA yesterday and no ill effects except constipated. Oh, and my leg is effing hurting.

Anyway, perhaps we should let this complete and utter threadjack end.

Rock - Although I'm out on a limb here, haven't examined you, haven't seen the MRI, etc., the likelihood of your meniscus having a repairable tear in the face of the degenerative change (arthritis) is pretty darn low. The Baker's cyst, a secondary lesion to the above, is probably also not going to be excised.

So, I'll bet that this will likely be relatively short case and that the "amount" of anesthesia given in a general would be comparatively low with a low level of post-anesthetic issues.

Two things come to mind: first a solid preop discussion with the anesthesiologist about what he/she thinks works well in your situation, and - no less importantly - a postop discussion with the surgeon to quantify the amount of arthritis found and if you should make any changes in your choices of exercise.

I think Dr. Pete's notes above are more centrist opinion than possibly previous posts.

I'm with you on general anesthetics, PUKE MY GUTS OUT. ...

If the spinal headaches are anything like concussion headaches, I would choose puking any day of the week.

4)Spinal taps are administered using a large needle which also increases (10-20% incidence of spinal headaches), where as spinal anesthetics are administered using a special non cutting and dramatically smaller needles, risk of spinal headaches 1-2/300 cases. I personally have had none in a 14 year career.

.that is if a busy OR can support this type of anesthetic.

Sometimes patients can have mild symptoms that persist for years. I had one patient in my chronic pain practice who was complaining of "migraines" for that had been going on for years. They were worse when he was upright and started sometime after a spinal. A blood patch gave him immediate cure. This had been misdiagnosed for years. Only the obvious one's usually get diagnosed.

No tourniquet since the intraarticular local has epi. Possibly have to inflate the tourniquet 1% of the time because of bleeding. My mixture = 30cc 1% lido + epi and 30cc 0.5% ropiv intraarticular. I use 0.5% lido for port infiltration. Usually 2mg midaz + 50 mcg fentanyl for block (in preop) and then the remaining 50 mcg in the OR. That's it - rarely need propofol.