Transversus Abdominis Plane Block as Part of a Multimodal Analgesic Regimen in Patients Undergoing Anterior Lumbar Interbody Fusion: A Retrospective Cohort Study.

BACKGROUND: Opioids are a mainstay for pain control in patients undergoing lumbar spine surgery but are associated with a high risk of dependence and significant adverse effects. Efforts continue to be made to utilize non-narcotic agents such as regional nerve block for pain control as part of a multimodal analgesia regimen. Recently, transversus abdominis plane (TAP) blocks have proven beneficial for patients undergoing lumbar fusion procedures. The purpose of this study is to evaluate the efficacy of TAP blocks for postoperative pain control and the effect on opioid consumption and hospital length of stay (LOS) in patients undergoing anterior lumbar interbody fusion (ALIF). METHODS: A retrospective review of patients undergoing elective ALIF included collection of data on demographics, LOS, pain scores using visual analog scale (VAS), opioid consumption using morphine milligram equivalents (MME) from postoperative day (POD) 0 to 5, and any complications. Patients who underwent primary ALIF or ALIF with concomitant posterolateral lumbar fusion were included. RESULTS: A total of 99 patients met inclusion criteria; 47 had a preoperative TAP block and 52 did not. Demographic data and number of levels fused were equally distributed between the groups. The TAP group had significantly lower MME consumption postoperatively during POD 0 to 2 and 0 to 5. VAS pain scores were lower for TAP block patients on POD 3 and 4; otherwise, there was no significant difference. LOS and complication rates were not significantly different. A multiple regression analysis found male sex to be a predictor of increased postoperative MME, while age and TAP block were significant predictors of decreased MME. CONCLUSIONS: The use of TAP block for patients undergoing ALIF was associated with less cumulative MME consumption in the immediate postoperative period. TAP block may be an effective tool for reducing postoperative opioid consumption in patients undergoing ALIF. CLINICAL RELEVANCE: The data in this study provide clinical relevance supporting the use of TAP blocks for patients undergoing ALIF procedures.

Airway Complications After Anterior Cervical Spine Surgery: Etiology and Risk Factors.

STUDY DESIGN: Narrative Review. OBJECTIVE: To provide an overview of etiology and risk factors of airway complications after anterior cervical spine surgery (ACSS). METHODS: A search was performed in PubMed and adapted for use in other databases, including Embase, Cochrane Library, Cochrane Register of Controlled Trials, Health Technology Assessment database, and NHS Economic Evaluation Database. RESULTS: 81 full-text studies were reviewed. A total of 53 papers were included were included in the review and an additional four references were extracted from other references. 39 papers were categorized as etiology and 42 as risk factors. CONCLUSIONS: Most of the literature on airway compromise after ACSS is level III or IV evidence. Currently, there are no systems in place to risk-stratify patients undergoing ACSS regarding airway compromise or guidelines on how to manage patients when these complications do occur. This review focused on theory, primarily etiology and risk factors.

Topical Antibiotic Powder and Nonunion Risk in Surgically Treated Tibial Plateau and Pilon Fractures.

INTRODUCTION: High-energy periarticular tibia fractures are challenging injuries with a significant risk of complications. Postoperative infection rates, although improved, remain unacceptable. Intrawound topical antibiotic (TA) application has been popularized to reduce postoperative infections. Although TA may minimize infections, it remains unclear whether TAs have any impact on the development of nonunion. Recent investigations of TA use in fracture care have questioned its efficacy in vivo and suggested a potentially deleterious effect on fracture healing. This study investigates the impact of TA on nonunion rates in surgically treated high-energy periarticular tibia fractures. METHODS: Retrospective analysis of surgically treated periarticular tibia fractures at a single Level 1 trauma center was conducted. Intervention in question was the clinical effect of intrawound TA powder application at definitive closure. A total of 222 high-energy periarticular tibia fractures were included, 114 with TA use and 108 without. The primary outcome was the occurrence of nonunion, with secondary outcomes being superficial and deep postoperative surgical site infections. RESULTS: Twenty-seven patients (12.1%) were diagnosed with nonunions (14 pilons and 13 plateaus). There was no statistically significant difference in nonunion rates among patients who received topical antibiotics (15.8%) versus the group of patients who did not (8.3%) ( P = 0.23). Odds of developing nonunion was significant for open injuries (odds ratio 6.16, P < 0.001) and patients with a provisional external fixator (odds ratio 8.72, P = 0.03) before definitive fixation. No notable difference in the number of superficial and deep infections was identified between groups. CONCLUSION: The use of TA in high-energy periarticular tibia fractures showed no statistically significant increase in nonunion rates but did not conclusively rule out nonunion as a possible effect of intrawound TA. Additional large-scale multicenter prospective studies are needed to confirm these findings. The current body of literature regarding high-energy periarticular tibia fractures does suggest that TAs lower the risk of postoperative infections, but the nonunion risk remains unclear. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Rapid recovery pathway without epidural catheter analgesia for surgical treatment of adolescent idiopathic scoliosis: a comparative study.

PURPOSE: To assess effectiveness of a rapid recovery pathway (RRP) without epidural catheter analgesia (ECA) or intravenous patient controlled analgesia (PCA) in accelerating recovery and decreasing opioid consumption in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF). METHODS: A retrospective cohort study included collection of demographics, ECA use, IV PCA, postoperative opioid consumption, postoperative pain scores, and reoperation rate. Opioid consumption was calculated using morphine milligram equivalents (MME). Hospital length of stay (HLOS) and first reported ambulation with physical therapy (PT) were also recorded. RESULTS: 53 patients were included, with 18 in the RRP group. Patient characteristics were comparable between the groups, except in ECA use and BMI. The RRP group consumed less total MME from postoperative day (POD) 0 to 2 (mean difference 61.6 MME; 95% CI 37.1-86.1 MME; p < 0.001). In addition, the RRP group had significantly shorter HLOS (2.5 vs 4.0 days; p < 0.001). There were no differences in VAS scores between the two groups. A subset analysis comparing patients who did and did not receive ECA showed that ECA resulted in overall higher inpatient MME and HLOS. A prediction model was developed using multiple regression based on the different medications used for multimodal analgesia (MMA) in the RRP. CONCLUSIONS: An RRP without the use of ECA or IV PCA can provide adequate analgesia in patients with AIS undergoing PSF while lowering inpatient narcotic consumption and accelerating immediate postoperative recovery.

Distal Femoral Replacement and Extensor Mechanism Repair Reinforced With Synthetic Mesh for Distal Femur Fracture With Patellar Ligament Avulsion.

Acute patellar ligament disruption in the setting of a distal femur fracture is an uncommon presentation with a variety of treatment options available to the practitioner. The following case report presents an 85-year-old female with a highly comminuted supracondylar distal femur fracture with intercondylar extension and a soft-tissue avulsion of the patellar ligament insertion discovered intraoperatively. A detailed technique review for acute patellar ligament repair with suture anchors and synthetic mesh reinforcement in the setting of distal femoral replacement is then provided. One-year follow-up revealed an intact extensor mechanism with minimal extensor lag and a painless gait. Surgeons faced with such a unique, complex problem may consider mesh augmentation of an acute patellar ligament repair while performing distal femoral replacement.

Hypoglossal Nerve Palsy After Anterior Cervical Spine Surgery: A Case Report and Literature Review.

CASE: A 37-year-old man was found to have hypoglossal nerve palsy after undergoing anterior cervical spine surgery at C3-C5, an injury that would cause him severe disability and further complications. CONCLUSION: Knowledge of the hypoglossal nerve is crucial for cervical spine surgery even at lower levels (C4-C7), including variations in its course and potential displacement during the induction of anesthesia.

MRI diagnosis of suprascapular neuropathy using spinoglenoid notch distension.

PURPOSE: To assess the use of a spinoglenoid notch distension measurement as a radiographic marker on MRI to aid the diagnosis of suprascapular neuropathy. METHODS: Spinoglenoid notch distension was compared on MRI by blinded independent observers for two patient cohorts: one group with an electromyography/nerve conduction study confirmed diagnosis of suprascapular neuropathy who underwent arthroscopic suprascapular nerve decompression, and a control group of patients aged 18-30 years with a normal shoulder MRI. RESULTS: Sixty suprascapular nerve patients (average age 52 years) were compared to 47 control patients (average age 24 years). Intra-rater and inter-rater reliability showed excellent agreement between reviewers for all measurements. There was a significant difference in the mean spinoglenoid notch distension for the SSN group (m = 8.36, SD = 2.42) compared to the control group (m = 5.7, SD = 1.56); [t(212) = 9.40, p < 0.0001]. CONCLUSION: The spinoglenoid notch distension is significantly increased in patients with suprascapular neuropathy. We hypothesize that hypertrophy of the transverse scapular ligament creates a venous obstruction resulting in varicosities of the suprascapular vein which runs with the nerve under the ligament. This distends the spinoglenoid notch and can be enlarged in cases of suprascapular neuropathy which is evident on MRI.