Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review.

Degenerative spine disease increases in prevalence and may become debilitating as people age. Complex spine surgery may offer relief but becomes riskier with age. Efforts to lessen the physiological impact of surgery through minimally invasive techniques and enhanced recovery programs mitigate risk only after the decision for surgery. Frailty assessments outperform traditional tools of perioperative risk stratification. The extent of frailty predicts complications after spine surgery such as reoperation for infection and 30-day mortality, as well as elements of social cost such as hospital length of stay and discharge to an advanced care facility. Symptoms of spine disease overlap with phenotypic markers of frailty; therefore, different frailty assessment tools may perform differently in patients with degenerative spine disease. Beyond frailty, however, cognitive decline and psychosocial isolation may interact with frailty and affect achievable surgical outcomes. Prehabilitation, which has reduced perioperative risk in colorectal and cardiac surgery, may benefit potential complex spine surgery patients. Typical prehabilitation includes physical exercise, nutrition supplementation, and behavioral measures that may offer symptomatic relief even in the absence of surgery. Nonetheless, the data on the efficacy of prehabilitation for spine surgery remains sparse and barriers to prehabilitation are poorly defined. This narrative review concludes that a frailty assessment-potentially supplemented by an assessment of cognition and psychosocial resources-should be part of shared decision-making for patients considering complex spine surgery. Such an assessment may suffice to prompt interventions that form a prehabilitation program. Formal prehabilitation programs will require further study to better define their place in complex spine care.

Utility of evoked potentials during anterior cerebral artery and anterior communicating artery aneurysm clipping.

Objective: To investigate the optimal combination of somatosensory- and transcranial motor-evoked potential (SSEP/tcMEP) modalities and monitored extremities during clip reconstruction of aneurysms of the anterior cerebral artery (ACA) and its branches. Methods: A retrospective review of 104 cases of surgical clipping of ruptured and unruptured aneurysms was performed. SSEP/tcMEP changes and postoperative motor deficits (PMDs) were assessed from upper and lower extremities (UE/LE) to determine the diagnostic accuracy of each modality separately and in combination. Results: PMDs were reported in 9 of 104 patients; 7 LE and 8 UE (3.6% of 415 extremities). Evoked potential (EP) monitoring failed to predict a PMD in 8 extremities (1.9%). Seven of 8 false negatives had subarachnoid hemorrhage. Sensitivity and specificity in LE were 50% and 97% for tcMEP, 71% and 98% for SSEP, and 83% and 98% for dual-monitoring of both tcMEP/SSEP. Sensitivity and specificity in UE were 38% and 99% for tcMEP, and 50% and 97% for tcMEP/SSEP, respectively. Conclusions: Combined tcMEP/SSEP is more accurate than single-modality monitoring for LE but is relatively insensitive for UE PMDs. Significance: During ACA aneurysm clipping, multiple factors may confound the ability of EP monitoring to predict PMDs, especially brachiofacial hemiparesis caused by perforator insufficiency.

Perioperative Multidisciplinary Delirium Prevention: A Longitudinal Case Report.

Postoperative delirium is associated with accelerated cognitive decline, mortality, and high health care costs. The importance of perioperative risk identification is increasingly recognized but optimal prevention strategies are still evolving. We review the case of an at-risk 79-year-old who had 3 lumbar spine surgeries within a year, 2 of which were complicated by postoperative delirium and one which was not. We discuss how a comprehensive preoperative cognitive assessment successfully informed perioperative decision making, including anesthetic management and postoperative multimodal delirium prevention strategies by geriatric medicine. The case exemplifies how coordinated interdisciplinary team management may reduce postoperative delirium in high-risk individuals.

Blood-Related Toxicity after Traumatic Brain Injury: Potential Targets for Neuroprotection.

Emergency visits, hospitalizations, and deaths due to traumatic brain injury (TBI) have increased significantly over the past few decades. While the primary early brain trauma is highly deleterious to the brain, the secondary injury post-TBI is postulated to significantly impact mortality. The presence of blood, particularly hemoglobin, and its breakdown products and key binding proteins and receptors modulating their clearance may contribute significantly to toxicity. Heme, hemin, and iron, for example, cause membrane lipid peroxidation, generate reactive oxygen species, and sensitize cells to noxious stimuli resulting in edema, cell death, and increased morbidity and mortality. A wide range of other mechanisms such as the immune system play pivotal roles in mediating secondary injury. Effective scavenging of all of these pro-oxidant and pro-inflammatory metabolites as well as controlling maladaptive immune responses is essential for limiting toxicity and secondary injury. Hemoglobin metabolism is mediated by key molecules such as haptoglobin, heme oxygenase, hemopexin, and ferritin. Genetic variability and dysfunction affecting these pathways (e.g., haptoglobin and heme oxygenase expression) have been implicated in the difference in susceptibility of individual patients to toxicity and may be target pathways for potential therapeutic interventions in TBI. Ongoing collaborative efforts are required to decipher the complexities of blood-related toxicity in TBI with an overarching goal of providing effective treatment options to all patients with TBI.

Neurophysiological monitoring and spinal cord integrity.

An integral part of a major spine surgery is the intraoperative neurophysiological monitoring (IONM). By providing continuous functional assessment of specific anatomic structures, IONM allows the rapid detection of neuronal compromise and the opportunity for corrective action before an insult causes permanent neurological damage. Thus, IONM functions not just as a diagnostic tool but may also improve surgical outcomes. Effective clinical application requires a thorough understanding of the scope and limitations of IONM modalities not only by the monitoring team but also by the surgeon and anesthesiologist. Intraoperatively, collaboration and communication between monitorist, surgeon, and anesthesiologist are critical to the effectiveness of IONM. In this study, we review specific monitoring modalities, focusing on the relevant anatomy, physiology, and mechanisms of neuronal injury during major spine surgery. We discuss how these factors interact with anesthetic and surgical management. This review concludes with the current controversies surrounding the evidence in support of IONM and directions of future research.