Spinal Anesthesia with Targeted Sedation based on Bispectral Index Values Compared with General Anesthesia with Masked Bispectral Index Values to Reduce Delirium: The SHARP Randomized Controlled Trial.

BACKGROUND: Reducing depth of anesthesia and anesthetic exposure may help prevent delirium, but trials have been conflicting. Most studies were conducted under general anesthesia or in cognitively impaired patients. It is unclear whether reducing depth of anesthesia beyond levels consistent with general anesthesia reduces delirium in cognitively intact patients. The authors' objective was to determine whether a bundled approach to reduce anesthetic agent exposure as determined by Bispectral Index (BIS) values (spinal anesthesia with targeted sedation based on BIS values) compared with general anesthesia (masked BIS) reduces delirium. METHODS: Important eligibility criteria for this parallel-arm randomized trial were patients 65 yr or greater undergoing lumbar spine fusion. The intervention group received spinal anesthesia with targeted sedation to BIS greater than 60 to 70. The control group received general anesthesia (masked BIS). The primary outcome was delirium using the Confusion Assessment Method daily through postoperative day 3, with blinded assessment. RESULTS: The median age of 217 patients in the analysis was 72 (interquartile range, 69 to 77). The median BIS value in the spinal anesthesia with targeted sedation based on BIS values group was 62 (interquartile range, 53 to 70) and in the general anesthesia with masked BIS values group was 45 (interquartile range, 41 to 50; P < 0.001). Incident delirium was not different in the spinal anesthesia with targeted sedation based on BIS values group (25.2% [28 of 111] vs. the general anesthesia with masked BIS values group (18.9% [20 of 106]; P = 0.259; relative risk, 1.22 [95% CI, 0.85 to 1.76]). In prespecified subgroup analyses, the effect of anesthetic strategy differed according to the Mini-Mental State Examination, but not the Charlson Comorbidity Index or age. Two strokes occurred among patients receiving spinal anesthesia and one death among patients receiving general anesthesia. CONCLUSIONS: Spinal anesthesia with targeted sedation based on BIS values compared with general anesthesia with masked BIS values did not reduce delirium after lumbar fusion.

Nonoperative treatment of traumatic spinal injuries in Tanzania: who is not undergoing surgery and why?

STUDY DESIGN: Retrospective, cohort study of a prospectively collected database. OBJECTIVES: In a cohort of patients with traumatic spine injury (TSI) in Tanzania who did not undergo surgery, we sought to: (1) describe this nonoperative population, (2) compare outcomes to operative patients, and (3) determine predictors of nonoperative treatment. SETTING: Tertiary referral hospital. METHODS: All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, fracture morphology, neurologic exam, indication for surgery, length of hospitalization, and mortality. Regression analyses were used to report outcomes and predictors of nonoperative treatment. RESULTS: 270 patients met inclusion criteria, of which 145 were managed nonoperatively. Demographics between groups were similar. The nonoperative group was young (mean = 35.5 years) and primarily male (n = 125, 86%). Nonoperative patients had 7.39 times the odds of death (p = 0.003). Patients with AO type A0/1/2/3 fractures (p < 0.001), ASIA E exams (p = 0.016), cervical spine injuries (p = 0.005), and central cord syndrome (p = 0.016) were more commonly managed nonoperatively. One hundred and twenty-four patients (86%) had indications for but did not undergo surgery. After multivariate analysis, the only predictor of nonoperative management was sustaining a cervical injury (p < 0.001). CONCLUSIONS: Eighty-six percent of nonoperative TSI patients had an indication for surgery. Nonoperative management was associated with an increased risk of mortality. Cervical injury was the single independent risk factor for not undergoing surgery. The principle reason for nonoperative management was cost of implants. While a causal relationship between nonoperative management and inferior outcomes cannot be made, efforts should be made to provide surgery when indicated, regardless of a patient's ability to pay.

Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania.

OBJECTIVE: The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings. METHODS: This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated. RESULTS: Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26-43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1-6) days; surgery was performed after a further median delay of 22 (IQR 13-39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively. CONCLUSIONS: Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors' results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.

Cost-Effectiveness of Operating on Traumatic Spinal Injuries in Low-Middle Income Countries: A Preliminary Report From a Major East African Referral Center.

STUDY DESIGN: Retrospective cost-effectiveness analysis. OBJECTIVES: While the incidence of traumatic spine injury (TSI) is high in low-middle income countries (LMICs), surgery is rarely possible due to cost-prohibitive implants. The objective of this study was to conduct a preliminary cost-effectiveness analysis of operative treatment of TSI patients in a LMIC setting. METHODS: At a tertiary hospital in Tanzania from September 2016 to May 2019, a retrospective analysis was conducted to estimate the cost-effectiveness of operative versus nonoperative treatment of TSI. Operative treatment included decompression/stabilization. Nonoperative treatment meant 3 months of bed rest. Direct costs included imaging, operating fees, surgical implants, and length of stay. Four patient scenarios were chosen to represent the heterogeneity of spine trauma: Quadriplegic, paraplegic, neurologic improvement, and neurologically intact. Disability-adjusted-life-years (DALYs) and incremental-cost-effectiveness ratios were calculated to determine the cost per unit benefit of operative versus nonoperative treatment. Cost/DALY averted was the primary outcome (i.e., the amount of money required to avoid losing 1 year of healthy life). RESULTS: A total of 270 TSI patients were included (125 operative; 145 nonoperative). Operative treatment averaged $731/patient. Nonoperative care averaged $212/patient. Comparing operative versus nonoperative treatment, the incremental cost/DALY averted for each patient outcome was: quadriplegic ($112-$158/DALY averted), paraplegic ($47-$67/DALY averted), neurologic improvement ($50-$71/DALY averted), neurologically intact ($41-$58/DALY averted). Sensitivity analysis confirmed these findings without major differences. CONCLUSIONS: This preliminary cost-effectiveness analysis suggests that the upfront costs of spine trauma surgery may be offset by a reduction in disability. LMIC governments should consider conducting more spine trauma cost-effectiveness analyses and including spine trauma surgery in universal health care.

Radiculopathy with concomitant sacroiliac dysfunction and lumbosacral degenerative disease: illustrative case.

BACKGROUND: The sacroiliac joint (SIJ) is an important cause of low back pain and referred leg pain (RLP). Pain from SIJ dysfunction may occur in isolation or may result from a combination with lumbosacral area-mediated pain. SIJ fusion is one treatment modality for medically refractory symptoms and may also have a role in the treatment of RLP. OBSERVATIONS: The authors present a challenging case of concomitant lumbosacral degenerative disease and SIJ dysfunction in a patient with radiculopathy. They provide clinical characteristics and imaging findings and discuss difficulties in dealing with the intersection of these two distinct diagnoses. In addition, the authors offer a review of the relevant literature, elucidating the role of SIJ dysfunction in causing radicular lower extremity pain, the relationship to concomitant lumbosacral degenerative disease, and outcome data for SIJ fusion as it relates to RLP. LESSONS: With increasing numbers of patients undergoing spinal instrumentation in the setting of degenerative lumbosacral arthritis, as well as randomized controlled trial data demonstrating the efficacy of SIJ fusion for medically refractory SIJ dysfunction, it is important to recognize the challenges in understanding how both of these patient groups may present with radiculopathy. Failure to do so may result in incorrect patient selection, poor outcomes, and increased morbidity for at-risk patients.

Cervical Spine Trauma in East Africa: Presentation, Treatment, and Mortality.

BACKGROUND: Cervical spine trauma (CST) leads to devastating neurologic injuries. In a cohort of CST patients from a major East Africa referral center, we sought to (a) describe presentation and operative treatment patterns, (b) report predictors of neurologic improvement, and (c) assess predictors of mortality. METHODS: A retrospective, cohort study of CST patients presenting to a tertiary hospital in Dar Es Salaam, Tanzania, was performed. Demographic, injury, and operative data were collected. Neurologic exam on admission/discharge and in-hospital mortality were recorded. Univariate/multivariate logistic regression assessed predictors of operative treatment, neurologic improvement, and mortality. RESULTS: Of 101 patients with CST, 25 (24.8%) were treated operatively on a median postadmission day 16.0 (7.0-25.0). Twenty-six patients (25.7%) died, with 3 (12.0%) in the operative cohort and 23 (30.3%) in the nonoperative cohort. The most common fracture pattern was bilateral facet dislocation (26.7%). Posterior cervical laminectomy and fusion and anterior cervical corpectomy were the 2 most common procedures. Undergoing surgery was associated with an injury at the C4-C7 region versus occiput-C3 region (odds ratio [OR] 6.36, 95% confidence interval [CI] 1.71-32.28, P = .011) and an incomplete injury (OR 3.64; 95% CI 1.19-12.25; P = .029). Twelve patients (15.8%) improved neurologically, out of the 76 total patients with a recorded discharge exam. Having a complete injury was associated with increased odds of mortality (OR 11.75, 95% CI 3.29-54.72, P < .001), and longer time from injury to admission was associated with decreased odds of mortality (OR 0.66, 95% CI 0.48-0.85, P = .006). CONCLUSIONS: Those most likely to undergo surgery had C4-C7 injuries and incomplete spinal cord injuries. The odds of mortality increased with complete spinal cord injuries and shorter time from injury to admission, probably due to more severely injured patients dying early within 24-48 hours of injury. Thus, patients living long enough to present to the hospital may represent a self-selecting population of more stable patients. These results underscore the severity and uniqueness of CST in a less-resourced setting. LEVEL OF EVIDENCE: 4.

Spinal Anesthesia for Geriatric Lumbar Spine Surgery: A Comparative Case Series.

BACKGROUND: The use of spinal anesthesia (SA) as opposed to general anesthesia (GA) during elective lumbar spine surgery is an emerging technique and represents a potentially modifiable factor to limit perioperative complications. Few studies, however, have compared these anesthetic techniques in an elderly population. The aim of this study is to determine if SA is a safe alternative to GA for lumbar spine surgery in elderly patients. METHODS: A retrospective, consecutive case series study was performed. All patients aged 70 years and older who underwent lumbar spine decompression or combined decompression and fusion using either SA or GA during a 2-year period at a single institution were identified. Demographics and perioperative outcomes were compared. RESULTS: Of all patients meeting the inclusion criteria, 56 patients (19%) received SA and 239 (81%) received GA. Patients receiving SA were slightly older (median age, 77 years versus 75 years, P = .002), consisted of more men (57% versus 36%, P = .01), and had a lower mean body mass index (28.3 versus 30.1, P = .03). Indications for surgery and type of surgery were similar between groups. On average, operative times with SA were 101 minutes versus 103 minutes with GA (P = .71). After controlling for age, sex, and body mass index, patients receiving SA had decreased estimated blood loss (ß = -75 mL; 95% confidence interval [CI], -140.6, -9.4; P = .025) and intraoperative intravenous fluid requirements (ß = -205 mL; 95% CI, -389.4, -21.0; P = .029), shorter postanesthesia care unit stays (ß = -41 minutes; 95% CI, -64.6, -16.9; P = .001), lower maximum visual analog scale pain scores (ß = -0.89 points; 95% CI, -1.6, -0.1; P = .020), and decreased odds of receiving blood transfusion (odds ratio, 0.12; 95% CI, 0.01, 0.62; P = .45); there were no significant differences in operative time, length of stay, nausea, or oral morphine equivalents consumed per day. Complication rates were similar between groups. CONCLUSION: Spinal anesthesia is a reasonable, safe alternative to general anesthesia for lumbar spine surgery in elderly patients with degenerative conditions.

Prehospital care of trauma patients in Tanzania: medical knowledge assessment and proposal for safe transportation of neurotrauma patients.

STUDY DESIGN: A descriptive, cross-sectional survey of individuals involved in prehospital transportation of neurotrauma patients was performed. OBJECTIVES: Little is known about prehospital care of neurotrauma patients in low- and middle-income countries. This study sought to assess the knowledge of prehospital transporters in Tanzania and propose an educational intervention to help identify patients with severe neurotrauma. SETTING: Dar es Salaam, Tanzania. METHODS: Surveys assessed demographic information and medical knowledge with three outcomes of identifying signs of a deceased, sick, or clinically deteriorating patient. Predictors of increased medical knowledge were investigated with univariate and multivariate logistic regression (MLR). RESULTS: The survey included 501 participants, who were predominantly young (mean: 36.7 years) and male (84.0%). More than 70% of participants self-reported being able to recognize a deceased or sick patient, yet fewer than 20% correctly listed more than two signs of a deceased, sick, or clinically deteriorating patient. MLR showed that first aid training (Odds ratio (OR): 2.3; 95% confidence interval (CI): 1.3, 3.9; p = 0.002) was predictive of identifying a deceased patient, being employed (OR: 0.5; 95% CI: 0.3, 0.9; p = 0.021) was a negative predictor of identifying a sick patient, and higher education level (OR: 2.3; 95% CI: 1.1, 4.8; p = 0.032) was predictive of identifying a clinically deteriorating patient. CONCLUSION: In a survey of prehospital transporters of neurotrauma patients in Tanzania, higher education level and first aid training were associated with higher medical knowledge scores. An educational flier was created to identify severe neurotrauma patients. Additional education of prehospital transporters in Tanzania may improve morbidity and mortality of neurotrauma patients.

Pressure ulcers after traumatic spinal injury in East Africa: risk factors, illustrative case, and low-cost protocol for prevention and treatment.

STUDY DESIGN: Retrospective, case-control study. OBJECTIVES: In a traumatic spinal injury (TSI) cohort from Tanzania, we sought to: (1) describe potential risk factors for pressure ulcer development, (2) present an illustrative case, and (3) propose a low-cost outpatient protocol for prevention and treatment. SETTING: Tertiary referral hospital. METHODS: All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, time to hospital, injury characteristics, operative management, length of hospitalization, and mortality. Pressure ulcer development was the primary outcome. Regressions were used to report potential predictors, and international guidelines were referenced to construct a low-cost outpatient protocol. RESULTS: Of 267 patients that met the inclusion criteria, 51 developed a pressure ulcer. Length of stay was greater for patients with pressure ulcers compared with those without (45 vs. 30 days, p < 0.001). Potential predictors for developing pressure ulcers were: increased days from injury to hospital admission (p = 0.036), American Spinal Injury Association Impairment Scale grade A upon admission (p < 0.001), and thoracic spine injury (p = 0.037). The illustrative case described a young male presenting ~2 months after complete thoracic spinal cord injury with a grade IV sacral pressure ulcer that lead to septic shock and death. Considering the dramatic consequences of pressure ulcers in lower- and middle-income countries (LMICs), we proposed a low-cost protocol for prevention and treatment targeting support surfaces, repositioning, skin care, nutrition, follow-up, and dressing. CONCLUSIONS: Pressure ulcers after TSI in LMICs can lead to increased hospital stays and major adverse events. High-risk patients were those with delayed presentation, complete neurologic injuries, and thoracic injuries. We recommended aggressive prevention and treatment strategies suitable for resource-constrained settings.

Deep Vein Thrombosis After Complex Posterior Spine Surgery: Does Staged Surgery Make a Difference?

STUDY DESIGN: Retrospective review of a prospectively collected database. OBJECTIVE: To assess the incidence of deep vein thrombosis (DVT) associated with single- versus multistage posterior-only complex spinal surgeries. SUMMARY OF BACKGROUND DATA: Dividing the physiologic burden of spinal deformity surgery into multiple stages has been suggested as a potential means of reducing perioperative complications. DVT is a worrisome complication owing to its potential to lead to pulmonary embolism. Whether or not staging affects DVT incidence in this population is unknown. METHODS: Consecutive patients undergoing either single- or multistage posterior complex spinal surgeries over a 12-year period at a single institution were eligible. All patients received lower extremity venous duplex ultrasonographic (US) examinations 2 to 4 days postoperatively in the single-stage group and 2 to 4 days postoperatively after each stage in the multistage group. Multivariate logistic regression was used to assess the independent contribution of staging to developing a DVT. RESULTS: A total of 107 consecutive patients were enrolled-26 underwent multistage surgery and 81 underwent single-stage surgery. The single-stage group was older (63 years vs. 45 years; p < .01) and had a higher Charlson comorbidity index (2.25 ± 1.27 vs. 1.23 ± 1.58; p < .01). More multistage patients had positive US tests than single-stage patients (5 of 26 vs. 6 of 81; 19% vs. 7%; p = .13). Adjusting for all the above-mentioned covariates, a multistage surgery was 8.17 (95% CI 0.35-250.6) times more likely to yield a DVT than a single-stage surgery. CONCLUSIONS: Patients who undergo multistage posterior complex spine surgery are at a high risk for developing a DVT compared to those who undergo single-stage procedures. The difference in DVT incidence may be understated as the multistage group had a lower pre- and intraoperative risk profile with a younger age, lower medical comorbidities, and less per-stage blood loss.

Complex Lumbar Spine Fusion for an Elderly Patient Under Spinal Anesthesia.

Spinal anesthesia for spine surgery is an emerging technique. Because of their lack of physiologic reserve, elderly patients are an appealing population for this technique. Unfortunately, the safe limits of spine surgery using spinal anesthesia for the geriatric population are not well defined. The authors describe an elderly patient with severe spine degeneration who elected for a 5-level lumbar spine fusion with spinal anesthesia. Adequate anesthesia was maintained throughout the procedure, which lasted 3 hours and 24 minutes. The patient experienced no perioperative complications. To the authors' knowledge, this is one of the longest spine surgeries using spinal anesthesia. Also, the fusion procedure spans more vertebral levels than previously reported. Further investigation is needed to determine the safety of this technique. [Orthopedics. 2017; 40(5):e915-e917.].

Spinal Anesthesia in Elderly Patients Undergoing Lumbar Spine Surgery.

Spinal anesthesia is increasingly viewed as a reasonable alternative to general anesthesia for lumbar spine surgery. However, the results of spinal anesthesia in elderly patients undergoing lumbar spine decompression and combined decompression and fusion procedures are limited in the literature. The aim of this study was to report a single institution's experience using spinal anesthesia in elderly patients undergoing lumbar spine surgery. A retrospective review was conducted using a prospectively collected database of consecutive lumbar spine surgeries performed under spinal anesthesia in patients 70 years or older at a single center between December 2013 and October 2015. A total of 56 patients were included in the study; 27 patients (48%) underwent lumbar decompression and 29 patients (52%) underwent combined decompression and fusion procedures. Mean operative time was 101 minutes (range, 30-210 minutes), and mean operative blood loss was 187 mL (range, 20-700 mL). Mean maximum inpatient postoperative visual analog scale score was 6.2 (range, 1-10). Nausea occurred in 21% (12 of 56) of the patients. Mean length of stay was 2.4 days (range, 1-6 days). No mortality, stroke, permanent loss of function, or pulmonary embolism occurred. None of the cases required conversion to general anesthesia. All of the patients were ambulatory on either the day of the surgery or the next morning. These results demonstrate that spinal anesthesia is a viable method of anesthesia for patients 70 years and older undergoing lumbar spine surgery. They also demonstrate the safety of this method for patients older than 84 years and for surgeries lasting up to 3½ hours. [Orthopedics. 2017; 40(2):e317-e322.].