The Immune Modulation of Bilateral Paravertebral Block and Propofol in Spine Surgery.
Condition: Immune Suppression
Study type: Interventional

Summary: 
      General anesthesia has an important effect on inflammatory cytokines. Inhalational agents as
      isoflurane and sevoflurane attenuate immune function expressed by neutrophil
      chemoattractant-1 as well as inflammatory enzyme and also they reduce inflammatory cascade.
      Total intravenous anesthesia (TIVA) based on using propofol suppresses the inflammatory
      response caused by surgery to a greater extent because Propofol affects the balance between
      pro-inflammatory and anti-inflammatory cytokines, increasing production of the
      anti-inflammatory cytokine IL-10 and at the same time reducing the increase of IL-6 during
      the perioperative period. It also alters expression of nitric oxide and inhibits neutrophil
      function. TIVA has many advantages such as; fewer side effects, earlier discharge, better
      patient satisfaction, faster recovery, less nausea and vomiting and reduced muscle relaxant
      requirements. Paravertebral block has an important role in the inflammatory and immune
      response. The paravertebral block can decrease perioperative inflammation and prevent immune
      suppression. Also, it can attenuate the cytokine response and reduce acute stress response
      caused by surgery. Decrease inflammation processes, improve surgery result, limit the
      duration of hospital stay, decrease post-operative fatigue and reduce postoperative
      complications.
    

Detailed description: 
      Spine surgery is characterized by an elevation in levels of the inflammatory cytokines such
      as interleukin IL-6, IL-1β, and IL-17. These cytokines promote chemokine production and
      changes in cell phenotype which lead to activation of T and B cells, macrophages,
      neutrophils, and mast cells further amplifying the inflammatory cascade. Different analgesic
      modalities are used for pain management during and after spine surgery as narcotic
      analgesics, nonsteroidal anti-inflammatory drugs, Paracetamol and neuraxial techniques like
      intrathecal drug administration, epidural analgesia and paravertebral block. In this study,
      Paravertebral Block is used as a new and recent analgesic strategy for spine surgery. It has
      the advantage of higher success rate and analgesic efficacy, less risk of neurological
      complications than most other regional anesthetic techniques, less nausea, vomiting, and
      constipation compared with opioid-based analgesic techniques, urinary retention does not
      occur, unlike neuraxial techniques and intense block of both the sympathetic and somatic
      nerves. This study will be conducted with the hypothesis that the addition of paravertebral
      block as an analgesic regimen with total intravenous anesthesia (propofol-based) will have a
      better Immunomodulatory effect in patients undergoing posterior lumbar spine fixation
      surgery.
    

Intervention name(s): Total intravenous anesthesia group; Total intravenous plus block group
Intervention type(s): Drug; Drug
Intervention description(s): Induction of general anesthesia with fentanyl, (1mcg / kg), propofol (1-2 mg / kg), atracurium (0.5 mg / kg), intubation. Anesthesia maintained using Propofol (4-6) mg/kg/h, fentanyl (0.5-1) μg/kg/h. to be modified according to analgesic needs and hemodynamics. 10mg atracurium when the 2nd twitch of train of four appears.; Ultrasound guidance identifies the paravertebral space using a linear high-frequency (10-12 MHz) probe in the transverse plane in the midline, rotate the probe to the longitudinal plane, and scan in a medial-to-lateral direction. Locate the desired segment shift from the cephalad aspect of the sacrum. The transverse scan will show a hyperechoic outline of the vertebral spinous and transverse processes. Use the loss of resistance technique. Bilaterally inject (5ml) bupivacaine 0.5% for each segment. Induction of anesthesia after 30 minutes with fentanyl, (1mcg / kg), propofol (1-2 mg / kg), atracurium (0.5 mg / kg),then prone position.
Intervention MeSH terms: Anesthetics
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Supportive Care