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STUDY OBJECTIVE: The aim of this study was to investigate the efficacy of a two-step patient blood management (PBM) program in red blood cell (RBC) transfusion requirements among patients undergoing elective cardiopulmonary bypass (CPB) surgery. DESIGN: Prospective, non-randomized, two-step protocol design. SETTING: Cardiac surgery department of Clinique Pasteur, Toulouse, France. PATIENTS: 897 patients undergoing for elective CPB surgery. INTERVENTIONS: We conducted a two-steps protocol: PBMe and PBMc. PBMe involved a short quality improvement program for health care workers, while PBMc introduced a systematic approach to pre- and postoperative correction of deficiencies, incorporating iron injections, oral vitamins, and erythropoiesis-stimulating agents. MEASUREMENTS: The PBM program's effectiveness was evaluated through comparison with a pre-PBM retrospective cohort after propensity score matching. The primary objective was the proportion of patients requiring RBC transfusions during their hospital stay. Secondary objectives were also analyzed. MAIN RESULTS: After matching, 343 patients were included in each group. Primary outcomes were observed in 35.7% (pre-PBM), 26.7% (PBMe), and 21.1% (PBMc) of patients, resulting in a significant reduction (40.6%) in the overall RBC transfusion rate. Both the PBMe and PBMc groups exhibited significantly lower risks of RBC transfusion compared to the pre-PBM group, with adjusted odds ratios of 0.59 [95% CI 0.44-0.79] and 0.44 [95% CI 0.32-0.60], respectively. Secondary endpoints included reductions in transfusions exceeding 2 units, total RBC units transfused, administration of allogeneic blood products, and total bleeding volume recorded on Day 1. There were no significant differences noted in mortality rates or the duration of hospital stays. CONCLUSIONS: This study suggests that health care education and systematic deficiency correction are associated with reduced RBC transfusion rates in elective CPB surgery. However, further randomized, controlled studies are needed to validate these findings and refine their clinical application.
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PURPOSE OF REVIEW: The purpose of this study was to retrospectively evaluate the use of carmustine wafers (CWs) in the management of high-grade gliomas (HGGs). The data from our monoinstitutional series was compared with studies reported in the literature. Special emphasis was placed on the evaluation of side effects and the analysis of extent of resection and molecular profile as risk factors. RECENT FINDINGS: The implantation of CWs into the resection cavity during HGG treatment to deliver localized chemotherapy, followed by the Stupp protocol, remains debated in a clinical setting, largely due to the lack of appropriate phase III studies. Given the high expense and poorly characterized side effects associated with CW treatment, identification of patients most likely to benefit from this therapy could be clinically relevant. CWs may represent an effective and safe first-line treatment for patients with HGG that exhibit complete tumor resection and harboring a methylated MGMT promoter. Our investigation showed a much larger group of patients exhibiting long-term survival (> = 36 months), strongly supporting a potential survival benefit conferred via CW treatment. The pre-surgical definition of the MGMT promoter status could be of clinical use in identifying "good responders" to CW implantation.
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BACKGROUND: Preoperative diffusion tensor tractography (DTT) has recently been used to aid in the mapping of functional pathways to limit damage associated with resection of low-grade gliomas (LGGs). OBJECTIVE: To assess the predictive capacity of DTT as a biomarker of postoperative motor outcomes in patients with LGGs involving the corticospinal tract (CST). CST parameters obtained using a quantitative fiber tracking approach were used to investigate the reliability of the DTT biomarker by comparing their values in the tumoral (Tcst) and healthy (Hcst) hemispheres. METHODS: Thirty-seven patients with LGGs involving the CST were enrolled. Quantification of structural differences between the Tcst and Hcst were analyzed according to the novel biomarker (NF index), defined as follows: (Hcst NF - Tcst NF)/Hcst NF, where NF represents the number of fibers in each region. Logistic regression analysis was used to examine associations among clinical postoperative outcomes and NF index values, tumoral patterns, and premotor/motor evoked potentials. RESULTS: NF values significantly differed between the Tcst and Hcst. Analysis of the NF index showed that patients with a preoperative NF index <0.22 had a significantly lower risk of developing transient postoperative deficits (area under the curve, 0.92; 95% binomial confidence interval, 0.834-1). Patients with less pronounced differences in NF between the Tcst and Hcst also experienced better clinical outcomes. CONCLUSIONS: The NF index may be a useful biomarker for predicting clinical outcomes in patients with LGGs. Furthermore, the NF index may provide a preoperative estimate of the patient's potential for recovery from possible postsurgical neurologic deficits.
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Neoplasias Encefálicas/patología , Neoplasias Encefálicas/cirugía , Imagen de Difusión Tensora/estadística & datos numéricos , Glioma/patología , Glioma/cirugía , Trastornos del Movimiento/epidemiología , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Neoplasias Encefálicas/epidemiología , Comorbilidad , Diagnóstico Precoz , Femenino , Glioma/epidemiología , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Trastornos del Movimiento/diagnóstico , Trastornos del Movimiento/prevención & control , Clasificación del Tumor , Atención Dirigida al Paciente/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios , Prevalencia , Pronóstico , Reproducibilidad de los Resultados , Estudios Retrospectivos , Factores de Riesgo , Sensibilidad y Especificidad , Sustancia Blanca/diagnóstico por imagen , Sustancia Blanca/patología , Adulto JovenRESUMEN
We describe a technical variation used to enhance intraoperative safety and efficiency in multilevel percutaneous pedicle screw fixation (PPSFs) and mini-open transforaminal lumbar interbody fusion (m-TLIFs). A review of the literature on percutaneous screw insertion techniques and related pitfalls is presented. PPSFs and m-TLIFs are increasingly used techniques in multilevel lumbar degenerative disease. Facetectomy and TLIF are usually performed before inserting ipsilateral pedicle screws. Such techniques can cause unintended violation of the pedicle and injure the dura or neural structures, particularly in multilevel cases. A literature review revealed a lack of intraoperative and fluoroscopic images detailing the technique for multilevel PPSF and m-TLIF(s) performed through tubular, expandable retractors. Thirteen patients with two- to four-level disease underwent multilevel PPSF and m-TLIF (one to four levels). The Kirschner Cage Screw (KCS) technique, consisting of early insertion of K-wires in all pedicles followed by facetectomy and m-TLIF(s) and, finally, screw insertion, was used in order to minimize the risk of dural/neural injuries. Neither CSF (cerebrospinal fluid) leaks nor nerve root injuries nor technique-related complications were encountered with a follow-up ranging from 7 to 38 months (mean 23.6). In conclusion, the KCS technique allows safe identification of the pedicles without opening the canal during m-TLIF(s). Moreover, by visualizing the K-wires inside the retractor, the surgeon can check the pedicle position during facetectomy, and screws can be introduced with a minimal risk of neural or dural injuries. We believe that the proposed technique increases the safety and ease of the procedure, particularly in multilevel cases.
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Vértebras Lumbares/cirugía , Región Lumbosacra/cirugía , Procedimientos Ortopédicos , Tornillos Pediculares , Flujo de Trabajo , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Ortopédicos/efectos adversos , Fusión Vertebral/métodosRESUMEN
PURPOSE: Retro-odontoid pseudotumor, not related to inflammatory or traumatic conditions, is an uncommon pathology. Atlanto-axial instability has been advocated to explain the pathophysiology of retro-odontoid pseudotumor's formation and growth. Despite pseudotumor direct removal through transoral or lateral approach represented the main surgical strategy for a long time, in the last decade several authors highlighted the possibility to treat retro-odontoid pseudotumor by occipito-cervical or C1-C2 fixation without removal of the intracanalar tissue. The goal of this study is to analyze the data collected in a series of patients suffering from cervical myelopathy due to non-inflammatory, degenerative retro-odontoid pannus and treated by posterior C1-C2 fixation. The relevant literature is also reviewed. METHODS: Five patients, not suffering from inflammatory diseases, were treated between 2009 and 2012. Abnormalities of cranio-cervical junction and/or lower cervical spondylotic degeneration were observed in all patients. No evidence of atlanto-axial instability was demonstrated. Clinical and radiological evaluation included pre- and post-operative Nurick score as well as pre- and post-operative X-rays, CT and MRI. In one case, CT scan highlighted an eggshell calcification of the pannus. All patients underwent either a C1-C2 fixation (C1 lateral mass and C2 isthmus-pedicle screws) or occipito-cervical fixation (2 patients) in cases of C0-C1 fusion. RESULTS: Follow-up ranges from 22 to 45 months (mean 32) in four patients. One patient died of surgery-unrelated disease. Nurick score changes suggest a clinical improvement in four cases. Neuro-radiological evaluation shows a progressive but incomplete reduction of thickness of retro-odontoid pseudotumor in one patient, and its disappearance in the other three cases. A second-stage transoral or posterior lateral approach was not required. CONCLUSION: Although the etiopathogenesis of non-inflammatory, i.e., degenerative, retro-odontoid pseudotumor is still controversial, our series (the second largest on degenerative retro-odontoid pannus in the literature) confirms that a posterior approach may be sufficient and transoral surgery is not required.
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Articulación Atlantoaxoidea/cirugía , Vértebras Cervicales/cirugía , Apófisis Odontoides/cirugía , Fusión Vertebral/métodos , Neoplasias de la Columna Vertebral/cirugía , Anciano , Articulación Atlantoaxoidea/diagnóstico por imagen , Vértebras Cervicales/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Apófisis Odontoides/diagnóstico por imagen , Radiografía , Neoplasias de la Columna Vertebral/diagnóstico por imagenRESUMEN
This video demonstrates the minimally invasive surgical technique used in a 56-year-old woman suffering from L-5 spondylolysis and grade 2 L5-S1 spondylolisthesis. The first author used expandable tubular retractors bilaterally to perform neural decompression, mini-open TLIF, spondylolysthesis reduction and L5-S1 pedicle screw fixation. L-5 cement augmentation was performed through cannulated and fenestrated screws to enhance resistance to screw pull-out secondary to reduction maneuvers. Sequential surgical steps related to microsurgery, spondylolysthesis reduction and instrumentation are shown and commented. We submit that in cases of lythic spondylolisthesis a bilateral traversing and exiting nerve roots decompression is a safer option prior to performing the deformity reduction and fixation; the proposed minimally invasive technique may help in reducing surgical morbidity and improving postoperative recovery. The video can be found here: http://youtu.be/G4Qdg-A-Y3M.