Post-operative Delirium in Lumbar Degenerative Disease

Study design: The study is a retrospective review of all patients who developed delirium following surgery for lumbar degenerative disease. Purpose: Delirium is an acute decline in cognitive function and attention and represents acute brain failure. Post-operative alterations in attention and consciousness in Spine patients is a pathway to significant morbidity. There is a marked paucity in the literature on delirium in Spine patients in our environment. This reflects tendency to miss the diagnosis and results in avoidable morbidity and mortality. We evaluate the risk factors for delirium in surgery for lumbar degenerative disease in our environment and discuss our methods of evaluation and management. Methods: We reviewed our cases postoperative delirium after lumbar Spine Surgery in order to elucidate the risk factors and management in our environment specifically operative stress, anaesthetic agents and pre-operative presence of psychopathology. Overview of literature: Post- operative delirium is an acute fluctuation of consciousness following major surgery. Pathophysiology reflects imbalance in inflammatory mediators. The incidence is 3.3% in spine patients. Predisposing and precipitating risk factors include modifiable and non-modifiable conditions. Treatment hinges on knowledge of the various types, early recognition, prompt reversal of treatable causes and low- dose anti- psychotic medications Results: There were four cases of post op delirium noted after spine stabilization for lumbar canal stenosis noted between 2014- 2016. Common factors to these cases include prolonged surgery greater than 5-6 h, the use of Pentazocine and post- operative sepsis. There were three cases noted between 2016 till date after our management protocol changed. Common factors in these later cases include prolonged surgery. The earliest symptom in all patients was an alteration of sleep pattern. Haloperidol given promptly is also beneficial in preventing the deteriorating of early symptoms into established delirium. Conclusion: Anticipation and earlier recognition have led to prompt intervention in our more recent cases with avoidance of morbidity specifically prolonged hospital stay, wound sepsis and mortality.

Post-operative delirium is an acute brain failure and it is not innocuous. An appreciation of risk factors and early recognition onset is crucial to prevent morbidity and possible mortality. Better harmonization in the methods of monitoring and scoring cognitive dysfunction in elderly patients for spine surgeries is required. We suggest the use of the CAM-ICU as a quick, validated scoring tool. Treatment hinges on low dose antipsychotic therapy and sedatives and early correction of organic causes. We have found low dose oral Haloperidol is adequate and safe. Proper attention to restoration of normal sleep patterns, fluid and electrolyte balance would be helpful.

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Asian Journal of Biomedical and Pharmaceutical Scineces