Case Presentation: A 69-year-old woman presented for an elective multi-level lumbar laminotomy for the treatment of chronic back pain secondary to spinal canal stenosis. Her medical history included hypertension and hypercholesterolemia. She reported a history of depression, which was well controlled on paroxetine. She denied using drugs, stated she quit tobacco decades prior, and reported drinking 1-2 glasses of wine with dinner. Her surgery was uncomplicated. The third day after surgery, however, she complained of worsening back pain and leg weakness. Imaging showed an acute epidural hematoma. She was taken to the operating room for emergent surgical evacuation. The following day she was found delirious, tremulous, and diaphoretic. She was tachycardic and acutely hypertensive. She was observed picking at her bed sheets, stating that there were spiders inside. Her family reported no similar episodes in the past. However, her husband clarified that she drank two bottles of wine, not glasses, every evening. She had also been using 2mg of lorazepam nightly for insomnia. Her last drink and lorazepam were taken on the eve of admission. She was diagnosed with acute alcohol and benzodiazepine withdrawal. Symptom guided therapy was initiated alongside intravenous fluid, vitamin, and electrolyte supplementation. Psychiatry was consulted to guide management. A benzodiazepine-sparing protocol with clonidine and valproic acid was initiated. Opiates, and benzodiazepines were gradually withdrawn. She improved over the next few days and returned home nine days after presentation.
Discussion: A significant number of Americans (6.2%) meet criteria for alcohol use disorder. This proportion, however, might be as high as one-in-five of hospitalized patients. Unhealthy consumption of alcohol negatively affects surgical outcomes, increasing overall morbidity, infections, wound and pulmonary complications, length of stay, as well as intensive care needs. Abrupt cessation of alcohol, mandated during hospitalization, can lead to alcohol withdrawal syndrome (AWS). Although most cases will be mild, some patients will develop serious complications such as delirium tremens or seizures.Screening for alcohol misuse in the preoperative clinic with a validated tool is recommended. Unfortunately, however, evidence to guide preoperative alcohol cessation or postponing procedures is scarce. These decisions require a multidisciplinary approach in which consideration is given to the patient’s preference, risk of complicated withdrawal, urgency of the procedure, etc. Close clinical monitoring during the post-operative period for early signs of withdrawal should be encouraged. The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) is a useful tool to predict complicated AWS in medically ill patients requiring hospitalization. It may also be beneficial for otherwise stable surgical patients to detect those at increased risk
Conclusions: Alcohol use prior to surgery negatively impacts outcomes. Alcohol cessation during hospitalization can lead to AWS, including on occasion delirium tremens or withdrawal seizures. Screening for unhealthy alcohol use during the preoperative assessment is essential to the develop an optimal perioperative plan. If cessation prior to surgery cannot happen, predictive tools should be used to identify those at increased risk for complicated AWS. These patients should be monitored closely to provide the opportunity for early recognition and intervention.