The current state of the evidence for the use of drains in spinal surgery: systematic review.

PURPOSE: Search for evidence pertaining to the effectiveness of drains used in spinal surgeries. METHOD: PubMed and EMBASE databases were searched for articles pertaining to the use of drains in all types of spinal surgery. The bibliographies of relevant studies were searched for additional papers that met the initial inclusion criteria. Level I and II studies were scored according to guidelines in the Cochrane Collaboration Back Review Group. We utilised the Population, Intervention, Comparison, Outcomes and Study design (PICOS) method to define our study eligibility criteria. RESULTS: Nineteen papers were identified: four level I studies, eight level III studies and seven level IV studies. The four level I, involving the randomization of patients into 'drain' and 'non-drain' groups, identified a total of 363 patients. Seven of the eight level III retrospective studies concluded that the use of drains did not reduce complications. Two of the seven level IV studies agreed with this conclusion. The remaining five level IV studies reported the benefits of lumbar drainage following dural tears. CONCLUSIONS: There is a paucity of published literature on the use of drains following spinal surgery. This is the first study to assess the evidence for the benefits of drains post-operatively in spinal surgery. The identified studies have shown that drains do not reduce the incidence of complications in anterior cervical discectomy and fusion, one and two level posterior cervical fusions, lumbar laminectomies, lumbar decompressions or discectomies and posterior spinal fusion for adolescent scoliosis. Further level I and II studies are needed.

Actuator pin fracture in magnetically controlled growing rods: two cases.

BACKGROUND CONTEXT: Magnetically controlled growing rods (MCGRs) are used in the management of early-onset scoliosis (EOS). Each MCGR contains a telescopic actuator that serves as the distraction element when stimulated by an external remote controller (ERC), permitting non-invasive lengthening in the outpatient clinic. PURPOSE: This report highlights a subtle cause of MCGR failure. We present the first two reported cases of lengthening pin fracture in patients with dual-MCGR constructs. STUDY DESIGN: We present two cases of patients with EOS treated with dual-construct MAGEC (MAGnetic Expansion Control, Ellipse Technologies Inc, Aliso Viejo, CA, USA) MCGRs. METHODS: A 12-year-old boy presented describing a "popping" sensation in his thoracic spine and resultant grating 36 months following MCGR insertion. RESULTS: A plain radiograph revealed a subtle fracture of the lengthening pin within the actuator of the right MCGR. Following identification of this case of implant failure, we reviewed the most recent radiographs of all nine of our patients treated with this MCGR in our institution, resulting in the discovery of bilateral MCGR lengthening pin fractures in an otherwise asymptomatic 11-year-old girl. CONCLUSIONS: Clinicians should have a high index of suspicion of structural implant failure when presented with histories similar to those reported in our first case, or following unsuccessful distraction of MCGRs. In such cases new radiographs should be taken, and all previous images should be reviewed for evidence of this phenomenon. Centers that document MCGR lengthening with ultrasound should obtain plain radiographs every 6 months to evaluate the structural integrity of the implant.

Lessons from surgery and anaesthesia: evaluation of non-technical skills in interventional radiology.

In the medical profession, surgery and anaesthesia are leading the way in identifying human errors that negatively affect patient safety. Evidence suggests that the implementation of non-technical skills assessments reduces such errors. Interventional Radiology is a procedural based speciality and therefore may also benefit from formal assessment of non-technical skills. This literature review supports the use of standardised assessment tools used in surgery and anaesthesia. Using the Downing framework of internal validity, the tools demonstrated good internal consistency but a spectrum of inter-rater variability, which can be partially improved with training. At present, a formal Interventional Radiology non-technical skills assessment tool is probably not suitable to be a stand-alone 'high stakes' assessment, but may be a useful adjunct to the existing array of workplace-based assessments.

Is dissection the only way to learn anatomy? Thoughts from students at a non-dissecting based medical school.

Anatomical teaching has been centred around dissection for centuries. Generations of doctors have been initiated into the medical profession by cutting into their first cadavers. With the number of donor cadavers available decreasing and medical student numbers increasing, the emphasis placed on dissection has changed dramatically over the past 15 years. However, a solid appreciation of human anatomy is still a necessary part of understanding pathology and treatments. Therefore in light of these changes we ask, is dissection the only option? Or are there other options which students can undertake to develop anatomical knowledge?

The effects of environmental and compositional manipulations on the longevity of Tessari-made foam for sclerotherapy.

BACKGROUND: Tessari-made foam sclerotherapy is performed around the world in a variety of clinics differing in methods, equipment, temperatures, and altitudes. We investigated how the following factors affected the foam's longevity: silicone vs nonsilicone syringes, volume of foam made, ratio of gas to sclerosant, use of air vs 50:50 mixture of carbon dioxide and oxygen, temperature, altitude, and 10 consecutive reuses of the syringes. METHODS: Sclerosant foam was made by the Tessari double-syringe technique. To calculate the longevity, the time was taken for half of the original volume of sclerosant to settle. Half-lives were compared with use of silicone and silicone-free syringes to make the foam. We investigated how the volume (5 mL vs 2 mL) and different ratios affected the foam by observing the half-life of 4:1, 3.5:1, and 3:1 ratios of gas to sclerosant. Air and a 50:50 mixture of carbon dioxide and oxygen were both used as the gas in changing the ratio and volume to see which produced better foam. These experiments were conducted at room (23.9°C) and refrigerator (3°C) temperatures with a constant pressure. The different ratio, volume, and silicone vs nonsilicone syringe experiments were all repeated at 9314, 7460, 4575, and 2326 feet above sea level in addition to the baseline experiment, which took place at 236 feet above sea level. To test how consecutive uses of syringes affected the foam, we made consecutive batches of foam reusing each pair of syringes 10 times; this was repeated five times with silicone syringes and twice with nonsilicone syringes. RESULTS: Switching to nonsilicone syringes can increase longevity by 70%. A larger volume of foam and a 3:1 ratio produced longer half-lives at all temperatures and altitudes. The lower (3°C) temperature increased the longevity of foam in all instances, as did the use of air. A high altitude (low pressure) had a detrimental effect on the foam's longevity. Ten consecutive syringe uses had no significant impact on the foam's half-life (silicone syringe mean between first five and last five uses, P = .95). CONCLUSIONS: The optimum conditions for making foam are nonsilicone syringes, larger volumes, a 3:1 air to sclerosant ratio, and low temperatures. Silicone syringes can be reused until friction becomes a burden. Temperature has a bigger effect than altitude on longevity of the foam. Making foam in larger volumes would allow the foam to last longer. To compensate for high altitudes (low pressures), decreasing the temperature will increase the foam's longevity.

Modified Tessari Tourbillon technique for making foam sclerotherapy with silicone-free syringes.

The longevity of foam made using sodium tetradecyl sulphate and gas (air or a CO2:O2 mixture) is increased significantly if silicone-free syringes are used over the normal syringes containing silicone oil lubrication. However, the plungers in silicone-free syringes start sticking after several passages when making foam for sclerotherapy, preventing the smooth injection of the resulting foam. We describe a three syringe technique which allows foam to be made using the Tessari Tourbillon 'three-way stopcock' principle between two syringes, but with the foam ending up in a third syringe which has not undergone multiple passages of the plunger. This allows a smoother injection of the resultant foam, which is particularly useful when injecting small diameter veins under ultrasound control.