Intrathecal morphine injection in anterior lumbar and lateral lumbar spine surgery: technical note


doi: 10.21037/jss-20-610.

Affiliations

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Darweesh Al Khawaja.


J Spine Surg.


2021 Jun.

Abstract

Intrathecal morphine (ITM) is routinely used in many surgical specialties as an adjunct to postoperative analgesia. Patients undergoing lumbar spinal surgery commonly experience early postoperative pain. There have been multiple reports of the benefits of ITM in lumbar spine surgery where it has been shown to significantly reduce the need for intravenous opioid analgesia, improve time to mobilization, and shorten length of hospital stay. ITM is yet to become standard of care in Lumbar Spine Surgery likely due to concerns of it causing a cerebrospinal fluid (CSF) leak. In recent times anterior lumbar spine surgery (ALSS) and lateral lumbar spine surgery (LLSS) have increased in popularity although they are still performed in fewer numbers in comparison to the posterior [posterior lumbar interbody fusion (PLIF)] or transformational [transforaminal lumbar interbody fusion (TLIF)] approaches. Although the number of ALSS and LLSS procedures are increasing, to our knowledge there have been no reports of ITM administered via either approach reported in the literature. Herein we describe an intra-operative technique for injection of morphine into the dural sac via the Anterior and Lateral approaches to the lumbar spine. We propose that this technique can be performed easily and quickly with standard surgical equipment that is commonly available. Through use of this technique, patients undergoing spine surgery may benefit from ITM with minimal risk of iatrogenic CSF leak.


Keywords:

Anterior lumbar interbody fusion (ALIF); intrathecal morphine (ITM); lateral lumbar spine surgery (LLSS); opioid analgesia.

Conflict of interest statement

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jss-20-610). The author has no conflicts of interest to declare.

Figures


Figure 1



Figure 1

Administering ITM through the anterior approach. Arrow indicates Spinal needle tip passing through the PLL and dura. L4 and L5 vertebral bodies are labelled. The vessels are held behind the retractor blade. ITM, intrathecal morphine; PLL, posterior longitudinal ligament.


Video 1



Video 1

Injection Technique for anterior lumbar interbody fusion (ALIF). The needle is passed into the intrathecal space and cerebrospinal fluid (CSF) can be seen back flowing through the spinal needle.


Figure 2



Figure 2

View of the anatomy prior to administering ITM via the lateral approach. Arrows indicate L2/L3 posterior annulus and L3 endplate. L2 and L3 vertebral bodies are labelled. Psoas is retracted. ITM, intrathecal morphine.


Figure 3



Figure 3

Confirmation of correct needle position for lateral approach ITM. Arrow indicates 26-gauge spinal needle curved through the disc space and into the dura. CSF is visualised exiting the connector. Sympathetic trunk can be seen traversing the disc space. ITM, intrathecal morphine; CSF, cerebrospinal fluid.

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