Does the use of tranexamic acid intraoperatively reduce postoperative blood loss and complications following biportal endoscopic lumbosacral decompression?

Background: Biportal endoscopic spine surgery is an effective minimally invasive technique for treating common lumbar pathologies. We aim to evaluate the impact of intraoperative tranexamic acid (TXA) use on postoperative blood loss in biportal endoscopic decompression surgery. Methods: Patients undergoing biportal endoscopic lumbar discectomies and decompressions either by same day surgery or overnight stay at a single institution beginning in October 2021 were prospectively enrolled. This study was non-randomized, non-blinded with the first cohort of consecutive patients receiving 1 g of intravenous TXA intra-operatively before closure and the second cohort of consecutive patients receiving no TXA. Exclusion criteria included any revision surgery, any surgery for the diagnosis of spinal instability, infection, tumor, or trauma, any contraindication for TXA. Results: Eighty-four patients were included in the study, with 45 (54%) receiving TXA and 39 (46%) not receiving TXA. Median follow-up was 168 days [interquartile range (IQR), 85-368 days]. There were no differences in patient or surgical characteristics between cohorts. Estimated blood loss (EBL) was similar (P=0.20), while post-operative drain output was significantly lower in the TXA cohort (P=0.0028). Single level discectomies had significantly less drain output as compared to 2 level unilateral laminotomy, bilateral decompression (ULBD) cases (P<0.005). Post-operative complications were similar, with low rates of wound complication (1.2%) and transient postoperative weakness (2.4%, P>0.99 for both). Oswestry disability index (ODI), visual analog scale (VAS) back and VAS leg scores decreased significantly; the absolute decrease in scores did not differ between groups (P=0.71, 0.22, 0.86, respectively). Conclusions: Systemic intraoperative TXA administration is associated with a significant decrease in post-operative blood loss in biportal spinal endoscopy, with no impact on the improvement in patient-reported outcomes (PROs) or rate of post-operative complications. Single level biportal discectomies had significantly less postoperative drainage with TXA and may not need drains postoperatively. Larger, randomized studies are necessary to evaluate the cost-effectiveness of TXA use in biportal spinal endoscopy.

Biportal Endoscopic Approach for Lumbar Degenerative Disease in the Ambulatory Outpatient vs Inpatient Setting: A Comparative Study.

BACKGROUND: Biportal spinal endoscopy is increasingly utilized for lumbar disc herniations and lumbar stenosis. The objective was to investigate the safety and effectiveness of the technique in the outpatient vs inpatient setting. METHODS: This is a comparative study of consecutive patients who underwent biportal spinal endoscopy by a single surgeon at a single institution. Demographics, surgical complications, and patient-reported outcomes were prospectively collected and retrospectively analyzed. Statistics were calculated among treatment groups using unpaired t test and χ 2 analysis where appropriate. Statistical significance was determined as P < 0.05. RESULTS: Eighty-four patients were included, 58 (69.0%) as outpatient, 26 (31.0%) as inpatient. Mean follow-up was 7.5 months. Statistically significant differences in age, American Society of Anesthesiologists classification, and Charleston Comorbidity Index scores were reported between cohorts, with younger and healthier patients undergoing outpatient surgery (P < 0.0001). Outpatients were more likely to have discectomies while inpatients were more likely to have decompressions for stenosis. No significant differences in postoperative complications were found between groups.Both cohorts demonstrated significant improvement in visual analog scale (VAS) back and leg pain scores and Oswestry Disability Index scores (P < 0.001). Outpatients had significantly lower postoperative VAS back pain (P = 0.001) and Oswestry Disability Index scores (P = 0.004) at 5-8 weeks compared with inpatients, but there was no significant difference for VAS leg pain scores at all time points between the cohorts. CONCLUSIONS: Early results demonstrate that biportal spinal endoscopy can safely and effectively be performed in both inpatient and outpatient settings. CLINICAL RELEVANCE: Outpatient biportal spinal endoscopy can be performed successfully in well selected patients, which may reduce the financial burden of spine surgery to the U.S. healthcare system.

The Use of Dual Direction Expandable Titanium Cage With Biportal Endoscopic Transforaminal Lumbar Interbody Fusion: A Technical Consideration With Preliminary Results.

OBJECTIVE: Expandable cage technology has emerged for lumbar interbody fusion to restore intervertebral disc space height and alignment through a narrow surgical corridor. The purpose of this study is to present the technique of biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using dual direction expandable cage and provide early clinical results. METHODS: We performed the biportal endoscopic TLIF using a dual direction expandable titanium cage for height restoration and a larger footprint in 10 patients. Clinical parameters including Oswestry Disability Index (ODI), visual analogue scale (VAS), and complications were retrospectively analyzed. Also, we investigated radiologic parameters using preoperative and postoperative x-ray images. RESULTS: We successfully inserted dual direction expandable cages during biportal endoscopic TLIF. There was no significant subsidence or collapse of the expandable cages during the 6-month follow-up period. Lumbar lordosis and disc height were significantly increased after surgery. ODI and VAS scores were significantly improved at 6 months after surgery. CONCLUSION: In this report, we describe the first use of a dual direction expandable interbody TLIF cage that expands in both width and height in biportal endoscopic TLIF surgery. Early clinical and radiographic outcomes of this TLIF technique may be favorable in early 6-month follow-up.

Indications, Contraindications, and Complications of Biportal Endoscopic Decompressive Surgery for the Treatment of Lumbar Stenosis: A Systematic Review.

BACKGROUND: Biportal endoscopic spine surgery is gaining popularity in managing degenerative lumbar diseases and has optimal indications and contraindications. The perioperative complications related to the biportal endoscopic approach affect the postoperative outcomes. Therefore, this study aimed to review the indications, contraindications, and complications of biportal endoscopic decompression for lumbar stenosis. METHODS: For this systematic review, articles on biportal endoscopic decompressive surgery for lumbar stenosis, including central, lateral recess and foraminal stenoses, were searched for and reviewed. Additionally, the complications, indications, and contraindications of biportal endoscopic surgery for lumbar stenosis were reviewed. RESULTS: Forty-one articles were included in this study. The indications for biportal endoscopic decompression are central lumbar stenosis, central stenosis with lipomatosis, lateral recess stenosis, foraminal stenosis, and the far-out syndrome. The contraindications include trauma, infection, tumor, instability, high-grade spondylolisthesis, isthmic spondylolisthesis, and severe scoliosis. Perioperative complications are typically minor; major complications include durotomy, epidural hematoma, incomplete decompression, infection, facet joint injury, neural injury, increased epidural pressure, and postoperative instability. CONCLUSIONS: Favorable indications for a biportal endoscopic approach are central lumbar, lateral recess, foraminal, extraforaminal stenoses, and the Bertolotti syndrome. Incidental durotomy and postoperative epidural hematomas are common complications of biportal endoscopic decompression.

Intermittent and Transient Hypotension-related Anterior Cord Syndrome following Elective Cervical Spine Surgery: A Case Report.

INTRODUCTION: Anterior cord syndrome (ACS) is a type of incomplete spinal cord injury caused by either direct compression of the anterior spinal cord, or by ischemia of the anterior spinal artery. This phenomenon has neither been described transiently nor intraoperatively. CASE REPORT: We describe the case of a 61-year-old male who developed intermittent and transient anterior spinal cord syndrome secondary to hypotension related hypoperfusion of the anterior spinal artery after elective cervical spine surgery. Through close blood pressure monitoring and intensive care unit support, the patient regained full neurological recovery. CONCLUSION: Anterior spinal cord syndrome is a rare condition affecting the anterior 2/3 of the spinal cord, resulting in incomplete paralysis. Blood flow can be disrupted through the anterior spinal artery, either through thrombosis or hypotension. We describe our rare case so that surgeons may recognize this potentially devastating condition.

The combined administration of vancomycin IV, standard prophylactic antibiotics, and vancomycin powder in spinal instrumentation surgery: does the routine use affect infection rates and bacterial resistance?

BACKGROUND: Surgical site infections (SSI) poses significant risk following spinal instrumentation surgery. The 2013 North American Spine Society (NASS) Evidence-Based Clinical Guidelines found that the incidence of SSI in spine surgery ranged from 0.7-10%, with higher rates with medical comorbidities. National guidelines currently recommend first-generation cephalosporins as first line prophylaxis. Due to an increase in MRSA cases in our institution, a combined antibiotic strategy using vancomycin IV, standard prophylactic antibiotics, and vancomycin powder was implemented for all spinal instrumentation surgeries. METHODS: All spinal instrumentation surgeries performed at this institution from 2013-2016 were identified. Chart review was then performed to identify the inclusion and exclusion criteria, demographic data, diagnosis, type of surgery performed, and bacterial culture results. Rates of SSI, as defined by the Center for Disease Control (CDC), were calculated and antibiotic resistance was determined. As control, SSIs were identified and reviewed from 2010, prior to the implementation of the combined strategy. RESULTS: One thousand and seventy four subjects were identified in the combined cohort. Mean age was 52.3 years, 540 males (50.2%), 534 females (49.8%). There were 960 primary surgeries (89.4%), 114 cases revision surgeries (10.6%). Cervical myelopathy (27.9%), lumbar stenosis (16.2%), lumbar spondylolisthesis (14.0%), and scoliosis (pediatric and adult)/deformity (13.7%) were leading diagnoses. The standard prophylactic antibiotic was cefazolin IV in 524 cases (48.8%), gentamicin IV in 526 cases (49.0%), vancomycin powder was used in 72.3% of cases. Four SSI cases out of 1,074 were identified (0.37%), 3 deep and 1 superficial, with no antibiotic resistance. In the control group, there were 11 infections of 892 cases (1.23%). There were significantly lower rates of SSI in the combined group versus control (P=0.05). CONCLUSIONS: The combined antibiotic strategy led to low SSI rates in this retrospective case control study. Limitations of this study include retrospective design and small sample size. A large multicenter randomized clinical trial may provide further insight in the effectiveness of this strategy. Level of evidence 3. Clinical relevance: the combined antibiotic protocol may be considered in institutions with concern for SSI and methicillin resistant infections associated with spinal instrumentation surgeries.

Acute and Rapid Development of Spontaneous Spinal Epidural Hematoma Associated with Combined Aspirin-Dipyridamole Therapy: A Case Report.

CASE: Spontaneous spinal epidural hematoma (SSEH) is a known, although rare, clinical entity that may be challenging to diagnose. This case report describes the rapid development of a large SSEH in an elderly patient on aspirin-dipyridamole combination therapy after she shifted her position in bed. Magnetic resonance imaging obtained 4 hours after the onset of symptoms demonstrated a large spinal epidural hematoma that extended from T4 to L1. CONCLUSION: With early diagnosis, the patient was successfully treated with a laminectomy and evacuation of the hematoma, and there was full neurological recovery.

The effect of suture coated with mesenchymal stem cells and bioactive substrate on tendon repair strength in a rat model.

PURPOSE: Exogenously administered mesenchymal stem cells and bioactive molecules are known to enhance tendon healing. Biomolecules have been successfully delivered using sutures that elute growth factors over time. We sought to evaluate the histologic and biomechanical effect of delivering both cells and bioactive substrates on a suture delivery vehicle in comparison with sutures coated with bioactive substrates alone. METHODS: Bone marrow-derived stem cells were harvested from Sprague-Dawley rat femurs. Experimental cell and substrate-coated, coated suture (CS) group sutures were precoated with intercellular cell adhesion molecule 1 and poly-L-lysine and seeded with labeled bone marrow-derived stem cells. Control (substrate-only [SO] coated) group sutures were coated with intercellular cell adhesion molecule 1 and poly-L-lysine only. Using a matched-paired design, bilateral Sprague-Dawley rat Achilles tendons (n = 105 rats) were transected and randomized to CS or SO repairs. Tendons were harvested at 4, 7, 10, 14, and 28 days and subjected to histologic and mechanical assessment. RESULTS: Labeled cells were present at repair sites at all time points. The CS suture repairs displayed statistically greater strength compared to SO repairs at 7 days (12.6 ± 5.0 N vs 8.6 ± 3.7 N, respectively) and 10 days (21.2 ± 4.9 N vs 16.4 ± 4.8 N, respectively). There was no significant difference between the strength of CS suture repairs compared with SO repairs at 4 days (8.1 ± 5.1 N vs 6.6 ± 2.3 N, respectively), 14 days (22.8 ± 7.3 N vs 25.1 ± 9.7 N, respectively), and 28 days (40.9 ± 12.4 N vs 34.6 ± 15.0 N, respectively). CONCLUSIONS: Bioactive CS sutures enhanced repair strength at 7 to 10 days. There was no significant effect at later stages. CLINICAL RELEVANCE: The strength nadir of a tendon repair occurs in the first 2 weeks after surgery. Bioactive suture repair might provide a clinical advantage by jump-starting the repair process during this strength nadir. Improved early strength might, in turn allow earlier unprotected mobilization.

Influence of stretching and warm-up on Achilles tendon material properties.

BACKGROUND: Controversy exists on stretching and warm-up in injury prevention. We hypothesized that warm up has a greater effect on Achilles tendon biomechanics than static stretching. This study investigated static stretching and warm-up on Achilles tendon biomechanics in recreational athletes, in vivo. MATERIALS AND METHODS: Ten active, healthy subjects, 5 males, 5 females, With a mean age of 22.9 years with no previous Achilles tendon injuries were recruited. Typical stretching and warm-up routines were created. Testing was performed in a randomized cross-over design. A custom-built dynamometer was utilized to perform controlled isometric plantarflexion. A low profile ultrasound probe was utilized to visualize the musculotendinous junction of the medial gastrocnemius. An eight-camera motion capture system was used to capture ankle motion. Custom software calculated Achilles tendon biomechanics. RESULTS: Achilles tendon force production was consistent. No statistically significant differences were detected in stretch, stiffness, and strain between pre-, post-stretching, and post-warm-up interventions. CONCLUSION: Stretching or warm-up alone, and combined did not demonstrate statistically significant differences. Stretching and warm-up may have an equivalent effect on Achilles tendon biomechanics. Prolonged and more intense protocols may be required for changes to occur. CLINICAL RELEVANCE: Stretching and warm-up of the Achilles before exercise are commonly practiced. Investigating the effect of stretching and warm-up may shed light on potential injury prevention.

Stretching for prevention of Achilles tendon injuries: a review of the literature.

Professional and recreational athletes commonly perform pre-exercise stretching to prevent musculoskeletal injuries. Little definitive evidence exists that clearly demonstrates the efficacy of stretching in reducing injury. Achilles tendon injuries are among the most common injuries affecting active individuals in the United States today. Clinicians commonly recommend stretching the Achilles tendon without concrete scientific evidence to support such a claim. Few studies have addressed the effect of stretching in Achilles tendon injuries, and it is unclear if the conclusions made for musculoskeletal injuries can be applied to the Achilles tendon. Biomechanical studies of the Achilles tendon and measurements of the tendon's reflex activity have demonstrated possible mechanisms for the potential benefit of stretching, including load-induced hypertrophy and increased tendon tensile strength. Recent prospective studies have contended that reductions in plantarflexor strength and increases in ankle dorsiflexion range of motion from stretching the Achilles tendon may increase the risk of injury. Studies examining stretching in injury prevention, the biomechanical properties of injuries to the Achilles tendon were compiled and reviewed. Although many theories have been published regarding the potential benefits and limitations of stretching, few studies have been able to definitively demonstrate its utility in injury prevention.