RESUMO
This study characterized the incidence of airway misplacement of nasogastric (NG) tubes in surgical patients, and the benefit of using a manometer to discriminate gastric placement from airway placement of NG tubes. Subjects included adult patients scheduled for abdominal surgery. After tracheal intubation, a 16 Fr. NG tube was inserted blindly through the nostril, and its position was assessed using the auscultation (10-ml air insufflation) or manometer (attached to NG tubes) techniques. Briefly, a biphasic pressure change synchronous with airway pressure during mechanical ventilation indicated airway misplacement. The presence of a notable pressure change while compressing the epigastric area indicated a gastric placement. A surgeon made the final confirmation of NG tube placement within the stomach using manual palpation of the tube immediately after laparotomy. The first-attempt success rate was 82.7 % in 104 patients. There were 29 misplacements of 130 attempted insertions (oral cavity, n = 23; trachea, n = 3; distal esophagus, n = 3). The incidence of airway misplacement was 2.9 % (3 of 104 cases). For confirmation of gastric placement, the auscultation technique had a sensitivity of 100.0 % and a specificity of 79.3 %. In contrast, the manometer technique had a sensitivity of 100.0 % and a specificity of 100.0 % in the discrimination of gastric placement from airway placement of NG tubes. Airway misplacement of NG tubes is not uncommon in surgical patients, and the manometer technique may be a reliable and safe method to discriminate gastric placement from airway placement of NG tubes.
Assuntos
Auscultação/métodos , Insuflação/métodos , Intubação Gastrointestinal/efeitos adversos , Manometria/métodos , Erros Médicos/estatística & dados numéricos , Adulto , Idoso , Esôfago , Feminino , Humanos , Incidência , Intubação Intratraqueal/efeitos adversos , Laparotomia , Masculino , Erros Médicos/prevenção & controle , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Respiração Artificial , TraqueiaRESUMO
PURPOSE: The treatment of spinal infection remains a challenge for spinal surgeons because of the variable presentations and complicated course. The diagnostic and therapeutic value of percutaneous endoscopic lavage and drainage (PELD) has been proved in some recent studies. The purpose of this study is to evaluate the efficacy of PELD in patients with advanced infectious spondylitis which may traditionally require open surgery. METHODS: We retrospectively reviewed the medical records of 21 patients who underwent PELD to treat their advanced lumbar infectious spondylitis. Patients with severe infection resulting in significant neurological deficit and mechanical instability were excluded from the PELD procedure, which was only used on selected patients with less severe disease. The 21 patients were categorized into three groups based on their past history, clinical presentation, and imaging studies: those with paraspinal abscesses, postoperative recurrent infection, and multilevel infection. Clinical outcomes were assessed by careful physical examination, Odom's criteria, regular serologic testing, and imaging studies to determine whether continued conservative treatment or surgical intervention was necessary. RESULTS: Causative bacteria were identified in 19 (90.5%) of 21 biopsy specimens. Appropriate parenteral antibiotics for the predominant pathogen isolated from the infected tissue biopsy cultures were prescribed for the patients. All patients reported satisfactory recovery and relief of back pain, except three with multilevel infections who underwent anterior debridement and fusion within 2 weeks after treatment with PELD. The overall infection control rate was 86%. One patient with epidural abscess and spondylolytic spondylolisthesis of the L5-S1 received instrumented fusion surgery due to mechanical instability 5 months later. No surgery-related major complications were found, except 2 patients who had transient paraesthesia in the affected lumbar segment. CONCLUSIONS: PELD was successful in obtaining a bacteriologic diagnosis, relieving the patient's symptoms, and assisting in eradication of lumbar infectious spondylitis. The indications of this minimally invasive procedure could be extended to treat patients suffering from spinal infections with paraspinal abscesses and postoperative recurrent infection. Patients with multilevel infection may have trivial benefits from PELD due to poor infection control and mechanical instability of the affected segments.
Assuntos
Desbridamento/métodos , Drenagem/métodos , Endoscopia/métodos , Vértebras Lombares/cirurgia , Espondilite/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Terapia Combinada , Feminino , Seguimentos , Humanos , Vértebras Lombares/microbiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Espondilite/diagnóstico , Espondilite/tratamento farmacológico , Espondilite/microbiologia , Irrigação Terapêutica , Resultado do TratamentoRESUMO
BACKGROUND: Spinal infections remain a challenge for clinicians because of their variable presentation and complicated course. Common management approaches include conservative administration of antibiotics or aggressive surgical debridement. The purpose of this study was to evaluate the efficacy of percutaneous endoscopic debridement with dilute betadine solution irrigation (PEDI) for treating patients with lumbar infectious spondylitis. METHODS: From January 2005 to July 2010, a total of 32 patients undergoing PEDI were retrospectively enrolled in this study. The surgical indications of the enrolled patients included single-level infectious spondylodiscitis, postoperative infectious spondylodiscitis, advanced infection with epidural abscess, psoas muscle abscess, pre-vertebral or para-vertebral abscess, multilevel infectious spondylitis, and recurrent infection after anterior debridement and fusion. Clinical outcomes were assessed by careful physical examination, Macnab criteria, regular serologic testing, and imaging studies to determine whether continued antibiotics treatment or surgical intervention was required. RESULTS: Causative bacteria were identified in 28 (87.5%) of 32 biopsy specimens. Appropriate parenteral antibiotics for the predominant pathogen isolated from infected tissue biopsy cultures were prescribed to patients. Twenty-seven (84.4%) patients reported satisfactory relief of their back pain after PEDI. Twenty-six (81.3%) patients recovered uneventfully after PEDI and sequential antibiotic therapy. No surgery-related major complications were found, except 3 patients with transient paresthesia in the affected lumbar segment. CONCLUSIONS: PEDI was successful in obtaining a bacteriologic diagnosis, relieving the patient's symptoms, and assisting in the eradication of lumbar infectious spondylitis. This procedure could be an effective alternative for patients who have a poor response to conservative treatment before a major open surgery.
Assuntos
Desbridamento/métodos , Endoscopia , Vértebras Lombares/cirurgia , Espondilite/cirurgia , Centros de Atenção Terciária/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Antifúngicos/uso terapêutico , Candidíase/tratamento farmacológico , Candidíase/microbiologia , Candidíase/cirurgia , Terapia Combinada , Endoscopia/métodos , Abscesso Epidural/microbiologia , Abscesso Epidural/cirurgia , Feminino , Fluoroscopia , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Infecções por Bactérias Gram-Negativas/microbiologia , Infecções por Bactérias Gram-Negativas/cirurgia , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Infecções por Bactérias Gram-Positivas/microbiologia , Infecções por Bactérias Gram-Positivas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Parestesia/epidemiologia , Satisfação do Paciente , Complicações Pós-Operatórias/epidemiologia , Radiografia Intervencionista , Estudos Retrospectivos , Espondilite/tratamento farmacológico , Espondilite/microbiologiaRESUMO
STUDY DESIGN: A retrospective study. OBJECTIVE: To evaluate the efficacy and safety of percutaneous vertebroplasty (PV) for treating patients with symptomatic osteoporotic vertebral compression fractures (VCFs) adjacent to lumbar instrumented circumferential fusion. SUMMARY OF BACKGROUND DATA: Few studies have investigated adjacent VCFs and their management after spinal fusion surgery for degenerative lumbar disease. PATIENTS AND METHODS: From January 2005 to July 2011, a total of 23 patients with lumbar instrumented circumferential fusion suffered from adjacent symptomatic osteoporotic VCFs. All of these patients received PV using polymethylmethacrylate bone cement augmentation in our institute. Radiography and magnetic resonance imaging were used for imaging studies. The visual analog scale and modified Brodsky criteria were used to compare clinical outcomes before and after surgery. The minimum follow-up period was 18 months (range, 18-45 mo). RESULTS: One level PV was performed in 18 patients and 2 levels were performed in 5 patients. The patients' visual analog scale scores improved by an average of 54.3 points after the procedure. Twenty patients returned to their preinjury activities of daily living. Lumbar lordosis was increased from 28.9 degrees before PV to 36.2 degrees after PV. The average restoration of the fractured vertebral body height was 14.0%. No surgery-related complications occurred except asymptomatic cement leakage in 4 patients. CONCLUSIONS: PV is a minimally invasive and effective procedure to treat patients with symptomatic osteoporotic VCFs adjacent to lumbar instrumented circumferential fusion.
Assuntos
Fraturas por Compressão/etiologia , Fraturas por Compressão/terapia , Fraturas por Osteoporose/etiologia , Fraturas por Osteoporose/terapia , Fraturas da Coluna Vertebral/etiologia , Fraturas da Coluna Vertebral/terapia , Fusão Vertebral/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas por Compressão/diagnóstico , Humanos , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Fraturas por Osteoporose/diagnóstico , Estudos Retrospectivos , Fraturas da Coluna Vertebral/diagnóstico , Resultado do Tratamento , VertebroplastiaRESUMO
PURPOSE: The Trachway intubating stylet (Trachway(®)), when used by experienced anesthesiologists, has been shown to be effective for difficult airway management. We evaluated the efficacy of this intubating stylet for tracheal intubation in a manikin when used by experienced laryngoscopists with little experience using this device. METHODS: Thirty-eight nurse anesthesiologists intubated the trachea of a manikin (Laerdal Airway Management Trainer) with a Trachway intubating stylet or a Macintosh laryngoscope in easy and difficult laryngoscopy scenarios. The duration of the intubation attempts, success rates, dental trauma, and ease of use (0 = very easy; 10 = very difficult) were recorded. The primary endpoint was the duration of the successful tracheal intubation attempt in the difficult laryngoscopy scenario. Data are presented as means (SD). RESULTS: Both devices resulted in similar tracheal intubation performance in the easy laryngoscopy scenario. However, the Trachway intubating stylet provided shorter intubation times (20.8 ± 5.6 vs. 25.5 ± 7.3 s; p = 0.003) and easier intubations (2.4 ± 1.6 vs. 5.7 ± 1.8; p < 0.001) compared with the Macintosh laryngoscope in the difficult laryngoscopy scenario. All tracheal intubations were successful and no dental trauma was observed when using the Trachway intubating stylet. CONCLUSION: We concluded that the Trachway intubating stylet, when used by novices, is effective in both easy and difficult laryngoscopy scenarios. In difficult laryngoscopy scenarios, this device provided faster, easier, and less traumatic intubation than the Macintosh laryngoscope.
Assuntos
Laringoscópios , Laringoscopia/instrumentação , Adulto , Manuseio das Vias Aéreas , Anestesiologia/educação , Competência Clínica , Determinação de Ponto Final , Desenho de Equipamento , Humanos , Intubação Intratraqueal/instrumentação , Manequins , Enfermeiros AnestesistasRESUMO
BACKGROUND: Percutaneous vertebroplasty (PV) with polymethylmethacrylate is widely used to treat osteoporotic vertebral compression fracture and satisfactory clinical outcomes have been reported in the literature. However, recurrent or persistent back pain after PV is not uncommon. Sometimes, the pain may result from pathogenesis within the previously treated vertebra. In this study, we evaluated the efficacy and safety of repeat PV for treating patients with recurrent back pain caused by the previously cemented vertebrae. METHODS: We retrospectively reviewed the medical records of 18 patients who underwent repeat PV to treat symptomatic cemented vertebrae. Patients were categorized into 3 groups based on clinical presentation and imaging studies: those with refracture (RF), residual vacuum (RV), and osteonecrosis (ON) along the bone-cement interface. A bipedicle approach was used for repeat PV in all patients. The visual analogue scale (VAS) and modified Brodsky criteria were used to evaluate clinical outcomes before and after surgery. The Kruskal-Wallis test, Wilcoxon signed-rank test, and Spearman correlation analyses were used to analyze patient surgical prognosis and radiologic findings. RESULTS: Nine patients were diagnosed with RF, 5 with RV, and 4 with ON. The average VAS score was 77.1 (range, 62-90) before repeat PV (80.1, 72.4, and 76.3 for the RF, RV, and ON groups, respectively) and 34.4 (range, 25-45) after repeat PV treatment (33.1, 36.8, and 34.3 for the RF, RV, and ON groups, respectively). The VAS score significantly decreased in all 3 groups. The vertebral body height was significantly restored by a mean of 13.9% across all groups (17.8%, 12.7%, and 6.8% in the RF, RV, and ON groups, respectively). Fifteen patients recovered from vertebral compression fracture and regained their preinjury activities of daily living. No surgery-related complications occurred except asymptomatic cement leakage in 5 patients. CONCLUSIONS: The results of this research demonstrate that repeat PV may be an effective method for relieving recurrent or persistent pain in patients with symptomatic cemented vertebrae, allowing them to regain functional activity.
Assuntos
Dor nas Costas/etiologia , Cementoplastia , Dor Pós-Operatória/etiologia , Fusão Vertebral , Idoso , Idoso de 80 Anos ou mais , Dor nas Costas/epidemiologia , Cimentos Ósseos/uso terapêutico , Cementoplastia/estatística & dados numéricos , Síndrome Pós-Laminectomia/cirurgia , Feminino , Humanos , Masculino , Osteonecrose/epidemiologia , Osteonecrose/etiologia , Medição da Dor , Dor Pós-Operatória/epidemiologia , Polimetil Metacrilato , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fraturas da Coluna Vertebral/cirurgiaRESUMO
PURPOSE: The ProSeal™ laryngeal mask airway (PLMA™) may be difficult to insert because of its large soft cuff, even when using a dedicated introducer tool. The purpose of this study was to investigate whether introduction of a stylet (Flexi-Slip™) in the drainage tube improved insertion characteristics compared with the standard introducer. METHODS: In this randomized controlled trial, 160 adults were allocated randomly to either the Introducer group (n = 80) or to the Flexi-Slip stylet group (n = 80). In the Introducer group, the PLMA was inserted with an introducer as described in the manufacturer's instructions. In the Flexi-Slip stylet group, a Flexi-Slip stylet was inserted into the drainage tube of the PLMA and bent to form a near 90° angle at the junction of the cuff and the airway tube. The primary outcome measurement was the success rate at first attempt. Insertion time, visible blood staining, and complications were also noted. RESULTS: Success at first attempt was more frequent with the Flexi-Slip stylet than with the introducer (100% vs 86%, respectively; P = 0.001). Overall time (mean ± standard deviation) taken for successful placement was shorter with the Flexi-Slip stylet than with the introducer (19.9 ± 5.6 sec vs 28.4 ± 15.2 sec, respectively; P < 0.001). The incidences of blood staining and postoperative sore throat were lower in the Flexi-Slip stylet group than in the Introducer group (4% vs 15%, respectively; P = 0.015 and 8% vs 23%, respectively; P = 0.008). CONCLUSION: Insertion of the PLMA with a Flexi-Slip stylet has a higher success rate at first attempt, requires less time, and results in fewer airway complications than the introducer technique.
Assuntos
Drenagem/métodos , Intubação Intratraqueal/métodos , Máscaras Laríngeas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Drenagem/instrumentação , Desenho de Equipamento , Feminino , Humanos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/instrumentação , Masculino , Pessoa de Meia-Idade , Faringite/etiologia , Complicações Pós-Operatórias/etiologia , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: Spinal N-methyl-D-aspartate receptors have been demonstrated to play an important role in the facilitation and maintenance of nociception. To avoid adverse effects of blocking N-methyl-D-aspartate receptors in the central nervous system, blocking N-methyl-D-aspartate receptor in peripheral nervous system is an ideal alternative. Transfection of small interfering RNAs (siRNAs) into cells has been revealed to provide potent silencing of specific genes. In this study, the authors examined the effect of subcutaneous injection of siRNA targeting the NR1 subunit of the N-methyl-D-aspartate receptor on silencing NR1 gene expression and subsequently abolishing inflammatory nociception in rats. METHODS: Male Sprague-Dawley rats received intradermal injection of NR1 siRNA and underwent injection of formalin or complete Freund's adjuvant. The flinch response and mechanical hypersensitivity by von Frey filaments were assessed. Then the messenger RNA and protein of NR1 in skin and dorsal root ganglion were analyzed. RESULTS: The results revealed that subcutaneous injection of 1 nmol NR1 siRNA effectively diminished the nociception induced by formalin and complete Freund's adjuvant stimuli and attenuated the level of NR1 messenger RNA and protein in skin and ipsilateral dorsal root ganglion. The antinociception effect and the inhibition of NR1 expression persisted for about 7 days after administration of NR1 siRNA. CONCLUSIONS: The data of this study suggest that NR1 siRNA has potential therapeutic value in the treatment of inflammatory pain induced or maintained by peripheral nociceptor activity and support the potential application of this method to the study of nociceptive processes and target the validation of pain-associated genes.
Assuntos
Técnicas de Silenciamento de Genes/métodos , Mediadores da Inflamação/administração & dosagem , Dor/metabolismo , Dor/prevenção & controle , RNA Interferente Pequeno/administração & dosagem , Receptores de N-Metil-D-Aspartato/deficiência , Animais , Formaldeído , Adjuvante de Freund , Mediadores da Inflamação/fisiologia , Injeções Subcutâneas , Masculino , Dor/genética , Medição da Dor/métodos , RNA Interferente Pequeno/genética , Ratos , Ratos Sprague-Dawley , Receptores de N-Metil-D-Aspartato/genéticaRESUMO
PURPOSE: We hypothesized that optimal laryngeal mask airway (LMA) insertion conditions might be achieved with topical lidocaine and a smaller dose of propofol. In this study, insertion conditions after topical lidocaine 40 mg followed by propofol 2 mg.kg(-1) were compared with propofol 2 mg.kg(-1) or propofol 3 mg.kg(-1) alone. METHODS: Ninety patients were recruited for this randomized prospective double-blind study. One group received four sprays of topical lidocaine (40 mg) over the posterior pharyngeal wall followed by propofol 2 mg.kg(-1) (Group 2PL; n = 30). The other two groups received four sprays of 0.9% normal saline followed by propofol 2 mg.kg(-1) (Group 2P; n = 30) or by propofol 3 mg.kg(-1) (Group 3P; n = 30). The frequency of optimal insertion conditions (successful insertion at the first attempt without adverse responses) and side effects were recorded. RESULTS: The frequency of optimal insertion conditions was greater in Group 2PL (20/30, 67%) and Group 3P (22/30, 73%) than in Group 2P (11/20, 37%) (P = 0.009). In Group 3P, the mean blood pressure was lower than in the other groups prior to LMA-Classic insertion (P = 0.003) but was similar after insertion. The incidence of apnea was greater in Group 3P patients (17/30, 57%) than in Group 2P (2/30, 7%) or Group 2PL patients (1/30, 3%) (P < 0.001). CONCLUSION: Topical lidocaine 40 mg followed by propofol 2 mg.kg(-1) can provide optimal insertion conditions of the LMA-Classic comparable to those of propofol 3 mg.kg(-1), with fewer hemodynamic changes and a lower incidence of apnea.
Assuntos
Anestésicos Locais/farmacologia , Máscaras Laríngeas , Lidocaína/farmacologia , Administração Tópica , Adulto , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Apneia/induzido quimicamente , Pressão Sanguínea/efeitos dos fármacos , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Lidocaína/administração & dosagem , Lidocaína/efeitos adversos , Masculino , Pessoa de Meia-Idade , Propofol/administração & dosagem , Propofol/efeitos adversos , Estudos ProspectivosRESUMO
PURPOSE: The purpose of this study is to evaluate the efficacy of percutaneous endoscopic debridement and drainage (PEDD) in patients with surgical site infection (SSI) following instrumented lumbar fusion. METHODS: We retrospectively reviewed the medical records of 20 patients (6 women and 14 men; average age, 60.1 years) who underwent PEDD at our institute to treat SSI following instrumented lumbar fusion from January 2010 to December 2015. The terminal event, or failure of PEDD treatment, was defined as a shift in treatment methods to open surgery. Risk factors were analyzed to determine their effect on the therapeutic results of PEDD. Clinical outcomes were assessed by careful physical examination, regular serologic testing, and imaging studies to determine whether continued conservative treatment or open surgery was necessary. RESULTS: Causative bacteria was identified in 17 (85%) of the 20 biopsy specimens. Successful infection control through PEDD was identified in 13 patients (65%). Both the visual analog scale and Oswestry disability index significantly improved in these patients. Detection of the causative pathogens was the only risk factor influencing the terminal event in the remaining seven patients (35%). CONCLUSION: In this study, PEDD was an effective treatment approach for obtaining a bacteriological diagnosis, relieving the patient's symptoms, and assisting in eradication of SSI following instrumented lumbar fusion. The use of species-specific antibiotics for the offending pathogens appears to be the most important factor to determine the success rate. The indications of this procedure could be extended to treat patients with SSI after instrumented lumbar fusion.
Assuntos
Desbridamento/métodos , Drenagem/métodos , Endoscopia/métodos , Fusão Vertebral/efeitos adversos , Espondilite/cirurgia , Infecção da Ferida Cirúrgica/cirurgia , Adulto , Idoso , Feminino , Humanos , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Espondilite/diagnóstico , Espondilolistese/cirurgia , Infecção da Ferida Cirúrgica/diagnóstico , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVES: Hemorrhoidectomy usually leads to severe postoperative pain that often causes urinary retention. Topical EMLA cream (lidocaine 2.5% and prilocaine 2.5%) has been used extensively in the clinical setting. This prospective study tested the effectiveness of EMLA cream for postoperative pain control after hemorrhoidectomy. METHODS: Thirty patients admitted for hemorrhoidectomy were enrolled and randomly assigned into either a control group (n = 15) or EMLA group (n = 15). Postoperatively, the control group received approximately 5 g of neomycin ointment, and the EMLA group received approximately 5 g of EMLA. A visual analog scale (VAS) score was recorded on arrival in the postanesthesia recovery unit (PAR), after 2 hours in the PAR, on the first postoperative evening, and on the first postoperative morning. The requested frequency and dosage of meperidine, the first spontaneous voiding time, the frequency of single urinary catheterization, and a patient satisfaction score were also obtained. RESULTS: The VAS score and frequency and dosage of meperidine injections were significantly lower in the EMLA group than in the control group (P < .01). The voiding time was significantly later in the control group (P = .04). The frequency of single catheterization was significantly lower in the EMLA group than in the control group (P = .03). Patient satisfaction with postoperative pain control was significantly higher in the EMLA group than in the control group (P < .01). No systemic complications were observed. CONCLUSIONS: Topical EMLA cream decreased pain intensity and meperidine requests, reduced the frequency of single catheterizations, and improved patient satisfaction with postoperative pain management after hemorrhoidectomy in adults.
Assuntos
Anestésicos Locais/uso terapêutico , Hemorroidas/cirurgia , Lidocaína/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Prilocaína/uso terapêutico , Adulto , Feminino , Humanos , Combinação Lidocaína e Prilocaína , Masculino , Pessoa de Meia-Idade , Neomicina/uso terapêutico , Pomadas , Medição da Dor , Satisfação do Paciente , Período Pós-Operatório , Estudos ProspectivosRESUMO
During L3-5 instrumented spinal surgery for degenerative spondylolisthesis in a 75-year-old woman, the right L-3 pedicle screw was accidentally pushed into the retroperitoneum and then migrated to the inferior vena cava (IVC). The patient was transferred to the surgical intensive care unit, and after careful discussion with cardiology specialists, a minimally invasive endovascular technique was used to remove the migrating pedicle screw within the IVC and thus salvage this critical case. Pedicle screw instrumentation is an effective procedure, but not risk free. Every detail should be scrutinized during surgery, even instrument construction. A minimally invasive endovascular technique should be considered in this patient population.
Assuntos
Procedimentos Endovasculares , Vértebras Lombares/cirurgia , Parafusos Pediculares , Falha de Prótese , Veia Cava Inferior/cirurgia , Idoso , Descompressão Cirúrgica , Procedimentos Endovasculares/métodos , Feminino , Humanos , Vértebras Lombares/diagnóstico por imagem , Fusão Vertebral/instrumentação , Veia Cava Inferior/diagnóstico por imagemRESUMO
PURPOSE: Sacral insufficiency fractures (SIFs) can cause severe lower back pain and immobility, which have limited therapeutic options. No previous studies have compared clinical outcomes and radiographic findings of sacroplasty with or without balloon assistance for the treatment of SIFs. METHODS: Forty-five patients with SIFs were divided into two groups. One group had 18 patients treated using sacroplasty with balloon assistance, and the other had 27 patients treated without balloon assistance. The operation time and cement injection volume were compared between these two groups. Clinical outcomes were evaluated using visual analog scale (VAS), Oswestry Disability Index (ODI), and Odom's criteria. Cement leakage rate was examined by postoperative radiography and computed tomography. RESULTS: Sacroplasty with balloon assistance was associated with significantly longer operative time ( p = 0.003) and larger cement injection volume ( p = 0.038). Cement leakages were found in 4 of 18 patients (22.2%) with balloon assistance and 15 of 27 patients (55.6%) without balloon assistance, which showed significant difference ( p = 0.027). No significant differences were observed between sacroplasty with and without balloon assistance with regard to clinical outcomes including improvement in VAS, ODI, and Odom's criteria. CONCLUSIONS: Sacroplasty with balloon assistance was shown to achieve greater cement injection with longer operation time and can decrease the risk of cement leakage. Both sacroplasty with and without balloon assistance showed good-to-excellent clinical outcomes for the treatment of SIFs.
Assuntos
Cimentos Ósseos , Fraturas de Estresse/cirurgia , Sacro/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Tomografia Computadorizada por Raios X/métodos , Vertebroplastia/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas de Estresse/diagnóstico , Humanos , Masculino , Sacro/diagnóstico por imagem , Fraturas da Coluna Vertebral/diagnóstico , Resultado do TratamentoRESUMO
AIM: To evaluate the clinical and radiographic results of patients with complicated infectious spondylitis treated with single-stage anterior debridement and reconstruction using tantalum mesh cage (TaMC) followed by immediate instrumentation. METHODS: Single-stage radical debridement and subsequent reconstruction with TaMC instead of autograft or allograft were performed to treat 20 patients with spinal deformity or instability due to complicated infectious spondylitis. Clinical outcomes were assessed by careful physical examination and regular serological tests to determine the infection control. In addition, the visual analog score (VAS), neurologic status, length of vertebral body reconstruction, and the correction of sagittal Cobb angle on radiography were recorded and compared before and after surgery. The conditions of the patients were evaluated based on the modified Brodsky's criteria. RESULTS: The average VAS score significantly decreased after the surgery (from 7.4 ± 0.8 to 3.3 ± 0.8, P < 0.001). The average Cobb angle correction was 14.9 degrees. The neurologic status was significantly improved after the surgery (P = 0.003). One patient experienced refractory infection and underwent additional debridement. Eighteen patients achieved good outcome based on the modified Brodsky's criteria and significant improvement after the surgery (P < 0.001). No implant breakage or TaMC dislodgement was found during at least 24 mo of follow-up. CONCLUSION: Single-stage anterior debridement and reconstruction with TaMC followed by immediate instrumentation could be an alternative method to manage the patients with spinal deformity or instability due to complicated infectious spondylitis.
RESUMO
Instrumented spinal fusion has become one of the most common surgeries for patients with various spinal disorders. Only few studies have reported subsequent vertebral compression fractures (VCFs) after instrumented spinal fusion. The purpose of this study was to evaluate the risk of new VCFs in patients undergoing instrumented spinal fusion.We obtained claims data from the National Health Insurance Research Database of Taiwan and retrospectively reviewed 6949 patients with instrumented spinal fusion as the spinal fusion cohort. Control subjects were individually matched at a ratio of 10:1 with those of the spinal fusion cohort according to age, sex, and the index day. Comorbidities were classified as those existing before the index day, and these included diabetes mellitus, hypertension, osteoporosis, and cerebrovascular accident. The end of the follow-up period for the analyses was marked on the day new VCFs developed, enrolment in the National Health Insurance was terminated, on the day of death, or until the end of 2012. We used the Cox proportion hazards model to analyze the hazard ratio (HR) for developing new VCFs.Patients with instrumented spinal fusion were significantly more likely to develop new VCFs (1.87% vs .25%, HR: 8.56; Pâ<â0.001). Female, elderly, and osteoporotic patients had a high incidence of new VCFs after spinal fusion. The HR for developing new VCFs after instrumented spinal fusion was higher in patients younger than 65 years than in those 65 years or older (HR: 10.61 vs 8.09). Male patients with instrumented spinal fusion also had a higher HR of developing new VCFs than female patients (men, HR: 26.42; women, HR: 7.53).In our retrospective cohort study, patients who had undergone instrumented spinal fusion surgery exhibited an increased risk of developing new VCFs. Particularly, the HR increased in young (age <65 years) and male patients.
Assuntos
Fraturas por Compressão/etiologia , Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Complicações Pós-Operatórias/etiologia , Fraturas da Coluna Vertebral/etiologia , Fusão Vertebral , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Fatores Etários , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas por Osteoporose/etiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Risco , TaiwanRESUMO
BACKGROUND: Complications and failure of vertebroplasty, such as cement dislodgement, cement leakage, or spinal infection, usually result in spinal instability and neural element compression. Combined anterior and posterior approaches are the most common salvage procedure for symptomatic failed vertebroplasty. The purpose of this study is to evaluate the feasibility and efficacy of a single posterior approach technique for the treatment of patients with symptomatic failed vertebroplasty. METHODS: Ten patients with symptomatic failed vertebroplasty underwent circumferential debridement and anterior reconstruction surgery through a single-stage posterior transpedicular approach (PTA) from January 2009 to December 2011 at our institution. The differences of visual analog scale (VAS), neurologic status, and vertebral body reconstruction before and after surgery were recorded. The clinical outcomes of patients were categorized as excellent, good, fair, or poor based on modified Brodsky's criteria. RESULTS: The symptomatic failed vertebroplasty occurred between the T11 and L3 vertebrae with one- or two-level involvement. The average VAS score was 8.3 (range, 7 to 9) before surgery, significantly decreased to 3.2 (range, 2 to 4) after surgery (p < 0.01), and continued to decrease to 2.4 (range, 2 to 3) 1 year later (p < 0.01). The average correction of Cobb's angle after surgery was 17.3° (range, 4° to 35°) (p < 0.01). The mean loss of Cobb's angle correction after 1 year of follow-up was 2.7° (range, 0° to 5°). The average allograft subsidence at 1 year after surgery was 1 mm (range, 0 to 2). The neurologic status of Frankel's scale significantly improved after surgery (p = 0.014) and at 1 year after surgery (p = 0.046). No one experienced severe complications such as deep wound infection or neurologic deterioration. All patients achieved good or excellent outcomes after surgery based on modified Brodsky's criteria (p < 0.01). CONCLUSIONS: Single-stage PTA surgery with circumferential debridement and anterior reconstruction technique provides good clinical outcomes and low complication rate, which can be considered as an alternative method to combined anterior and posterior approaches for patients with symptomatic failed vertebroplasty.
Assuntos
Fixação Interna de Fraturas/métodos , Fraturas por Compressão/cirurgia , Fraturas por Osteoporose/cirurgia , Terapia de Salvação , Fraturas da Coluna Vertebral/cirurgia , Vertebroplastia/métodos , Idoso , Idoso de 80 Anos ou mais , Desbridamento , Descompressão Cirúrgica , Estudos de Viabilidade , Feminino , Fraturas por Compressão/diagnóstico por imagem , Humanos , Vértebras Lombares/lesões , Masculino , Fraturas por Osteoporose/diagnóstico por imagem , Radiografia , Estudos Retrospectivos , Fraturas da Coluna Vertebral/diagnóstico por imagem , Vértebras Torácicas/lesões , Falha de TratamentoRESUMO
Common management approaches for spinal infections include conservative administration of antibiotics and aggressive surgical debridement. Minimally invasive endoscopic treatment has been reported and is gaining widespread attention because of its simplicity and effectiveness. This study retrospectively evaluated the clinical outcomes of bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution in the treatment of patients with lumbar pyogenic spondylitis. From January 2007 to December 2011, a total of 22 patients diagnosed with single-level lumbar pyogenic spondylitis underwent bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution at the authors' institution. Clinical outcomes were assessed by careful physical examination, visual analog scale pain score, modified MacNab criteria functional score, regular serologic testing, and imaging studies to determine whether percutaneous endoscopic debridement and lavage treatment was successful or if surgical intervention was required. Causative bacteria were identified in 19 (86.4%) of 22 biopsy specimens. Eighteen patients had satisfactory relief of back pain and uneventful recovery after this treatment. The success rate was 81.8% (18 of 22). Both visual analog scale and modified MacNab criteria scores improved significantly in successfully treated patients. No major surgical complications were noted, except for 3 patients who had residual or subsequent paresthesia in the affected lumbar segment. Percutaneous endoscopic debridement and lavage is a minimally invasive procedure that can yield a higher bacterial diagnosis, relieve back pain, and help to eradicate lumbar pyogenic spondylitis. It is an effective alternative treatment for patients with spinal infection before extensive open surgery.
Assuntos
Antibacterianos/uso terapêutico , Desbridamento/métodos , Endoscopia/métodos , Vértebras Lombares/cirurgia , Abscesso do Psoas/terapia , Espondilite/terapia , Infecções Estafilocócicas/terapia , Irrigação Terapêutica/métodos , Adulto , Idoso , Dor nas Costas/etiologia , Dor nas Costas/terapia , Feminino , Infecções por Haemophilus/complicações , Infecções por Haemophilus/diagnóstico , Infecções por Haemophilus/terapia , Humanos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/patologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Medição da Dor , Parestesia , Complicações Pós-Operatórias , Infecções por Pseudomonas/complicações , Infecções por Pseudomonas/diagnóstico , Infecções por Pseudomonas/terapia , Abscesso do Psoas/complicações , Abscesso do Psoas/diagnóstico , Radiografia , Estudos Retrospectivos , Espondilite/complicações , Espondilite/diagnóstico , Infecções Estafilocócicas/complicações , Infecções Estafilocócicas/diagnóstico , Infecções Estreptocócicas/complicações , Infecções Estreptocócicas/diagnóstico , Infecções Estreptocócicas/terapia , Resultado do TratamentoRESUMO
Complicated infectious spondylitis is an infrequent infection with severe spinal destruction, and is indicated for combined anterior and posterior surgeries. Staged debridement and subsequent reconstruction is advocated in the literature. The purpose of this study is to evaluate the feasibility and clinical outcome of patients who underwent single-stage combined anterior debridement and fibular allograft implantation followed by supplemental posterior fixation for complicated infectious spondylitis. We retrospectively reviewed the medical records of 20 patients who underwent single-stage combined anterior and posterior surgeries for complicated infectious spondylitis from January 2005 to December 2010. Complicated infectious spondylitis was defined as at least 1 vertebral osteomyelitis with pathological fracture or severe bony destruction and adjacent discitis, based on imaging studies. The severity of the neurological status was evaluated using the Frankel scale. The clinical outcomes were assessed by careful physical examination and regular serological tests to determine the visual analog scale (VAS) score and Macnab criteria. Correction of the sagittal Cobb angle on radiography was also compared before and after surgery. The Wilcoxon signed-rank test was used to analyze patient surgical prognosis and radiological findings. All patients with complicated infectious spondylitis were successfully treated by single-stage combined anterior and posterior surgeries. No patients experienced neurologic deterioration. The average VAS score was 7.8 before surgery and significantly decreased to 2.1 at discharge. Three patients had excellent outcomes and 17 had good outcomes, based on Macnab criteria. The average length of the allograft for reconstruction was 64.0 mm. Kyphotic deformity improved in all patients, with an average correction angle of 13.4°. There was no implant breakage or allograft dislodgement during at least 36 months of follow-up. Single-stage anterior debridement and fibular allograft implantation followed by posterior pedicle screw instrumentation provide immediate stability, satisfactory alignment, and successful infection control. Fibular allograft implantation seems to be a good alternative for anterior reconstruction; it can proceed to bony incorporation and avoids donor site morbidity.
Assuntos
Desbridamento , Fíbula/transplante , Procedimentos Ortopédicos , Espondilite/cirurgia , Adulto , Idoso , Estudos de Viabilidade , Feminino , Humanos , Fixadores Internos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transplante Homólogo , Resultado do TratamentoRESUMO
Airway management in patients with giant neck masses is usually a challenge to anesthesiologists. A giant neck mass could compress the airway and thus impede endotracheal intubation. We encountered a situation where the giant neck masses of a patient pushed the epiglottis posteriorly toward the posterior pharyngeal wall and compressed the laryngeal aperture narrowing after anesthetic induction, causing direct laryngoscopic intubation and sequential fiber-optic intubation failed. The neck masses twisted the aryepiglottic fold tortuously and clogged the laryngeal aperture tightly, making a flexible fiber-optic bronchoscope unable to pass through the laryngeal aperture. Later, we utilized a McCoy laryngoscope alternately to lift the compressed larynx up and away from the posterior pharyngeal wall, creating a passage and completing endotracheal intubation successfully with the aid of a gum elastic bougie. Our case suggested that the tilting tip blade of the McCoy laryngoscope could lever the tongue base up against the tumor mass compression to improve laryngeal views and facilitate endotracheal intubation when a difficult fiber-optic intubation was encountered on a compressed laryngeal aperture.