Intraoperative Infusion of Precedex to Reduce Length of Stay After Lumbar Spine Fusion

Inflammation is a two-edged sword, one edge essential for healing, the other potentially
delaying recovery. There is evidence that modest attenuation of the initial course of the
inflammatory response (IR) - essentially "banking the fire" of the early IR - may be of
benefit in shortening overall hospital course. Several medications have been
evaluated/utilized intra- and perioperatively to modulate different components of IR,
including local anesthetics, steroids and non-steroidal drugs. Additionally, the pro-and
anti-inflammatory properties of various alpha- and beta-adrenergic agonists and antagonists
have been characterized. Of this last category, dexmedetomidine (DEX), a highly specific
ligand for all the subtypes of the alpha-2 receptor throughout the body, has substantial
potency for sedation, analgesia and a reduction in the stress response in a wide variety of
surgical environments as well as contributing to cardiovascular stability during Coronary
Artery Bypass Graft (CABG) and open craniotomy. Additionally, DEX has been shown to have
quite powerful anti-inflammatory activity in a murine endotoxin model. DEX's
anti-inflammatory activity is likely expressed at G protein-coupled receptors (GPCRs) -
either conformationally similar to, or the actual "native" alpha-2 receptor - on
polymorphonuclear leukocytes, tissue macrophages, mast cells and other immune system cells.
Through these receptors, DEX may attenuate the early phase of IR by limiting immune signaling
or release of inflammatory cytokines, potentially favorably limiting the body's IR to injury.

In this present study, our primary assumption is that an ordinarily exuberant IR would be
invoked by major spine fusion surgery. Continuous administration of intravenous DEX during
and immediately after surgery might sufficiently modulate the IR to shorten hospital stay.
Therefore, in a prospective, randomized, placebo-controlled, double blinded fashion, we plan
to evaluate the potential for a perioperative infusion of DEX to reduce
"time-to-fitness-for-discharge" (generally easier to mark and a more accurate surrogate of
time-to-discharge) in patients undergoing major 3+ level lumbar spinal fusion procedures.
Additionally, cytokine markers, pain scores and additional pain medication requirements
associated with surgery will be measured.

Inclusion Criteria:

- American Society of Anesthesiologists (ASA) Classification I - III

- Scheduled for Open Posterior Lumbar Fusion over 3+ (bony) levels

Exclusion Criteria:

- Allergy to dexmedetomidine

- Cardiac disease with reduced ejection fraction < 30%

- History of cirrhosis, active hepatitis or attenuated hepatic function

- Chronic use of steroids, COX-2 inhibitors, alpha-2 agonists, or statins

- Current anticoagulant therapy

- Patients requiring motor evoked potential (MEP) monitoring

- Positive pregnancy test