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OBJECTIVE: De novo spinal infections are an increasing medical problem. The decision-making for surgical or nonsurgical treatment for de novo spinal infections is often a non-evidence-based process and commonly a case-by-case decision by single physicians. A scoring system based on the latest evidence might help improve the decision-making process compared with other purely radiology-based scoring systems or the judgment of a single senior physician. METHODS: Patients older than 18 years with an infection of the spine who underwent nonsurgical or surgical treatment between 2019 and 2021 were identified. Clinical data for neurological status, pain, and existing comorbidities were gathered and transferred to an anonymous spreadsheet. Patients without an MR image and a CT scan of the affected spine region were excluded from the investigation. A multidisciplinary expert panel used the Spine Instability Neoplastic Score (SINS), Spinal Instability Spondylodiscitis Score (SISS), and Spinal Infection Treatment Evaluation Score (SITE Score), previously developed by the authors' group, on every clinical case. Each physician of the expert panel gave an individual treatment recommendation for surgical or nonsurgical treatment for each patient. Treatment recommendations formed the expert panel opinion, which was used to calculate predictive validities for each score. RESULTS: A total of 263 patients with spinal infections were identified. After the exclusion of doubled patients, patients without de novo infections, or those without CT and MRI scans, 123 patients remained for the investigation. Overall, 70.70% of patients were treated surgically and 29.30% were treated nonoperatively. Intraclass correlation coefficients (ICCs) for the SITE Score, SINS, and SISS were 0.94 (95% CI 0.91-0.95, p < 0.01), 0.65 (95% CI 0.91-0.83, p < 0.01), and 0.80 (95% CI 0.91-0.89, p < 0.01). In comparison with the expert panel decision, the SITE Score reached a sensitivity of 96.97% and a specificity of 81.90% for all included patients. For potentially unstable and unstable lesions, the SISS and the SINS yielded sensitivities of 84.42% and 64.07%, respectively, and specificities of 31.16% and 56.52%, respectively. The SITE Score showed higher overall sensitivity with 97.53% and a higher specificity for patients with epidural abscesses (75.00%) compared with potentially unstable and unstable lesions for the SINS and the SISS. The SITE Score showed a significantly higher agreement for the definitive treatment decision regarding the expert panel decision, compared with the decision by a single physician for patients with spondylodiscitis, discitis, or spinal osteomyelitis. CONCLUSIONS: The SITE Score shows high sensitivity and specificity regarding the treatment recommendation by a multidisciplinary expert panel. The SITE Score shows higher predictive validity compared with radiology-based scoring systems or a single physician and demonstrates a high validity for patients with epidural abscesses.
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Discite , Humanos , Discite/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Tomada de Decisão Clínica , Adulto , Neoplasias da Coluna Vertebral/terapia , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/complicações , Instabilidade Articular/cirurgia , Instabilidade Articular/terapia , Tomada de Decisões , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Acute upper airway compromise is a rare but catastrophic complication after anterior cervical discectomy and fusion. This study aims to develop a score to identify patients at risk of acute postoperative airway compromise (PAC). METHODS: Potential risk factors for acute PAC were selected by a modified Delphi process. Ten patients with acute PAC were identified of 1466 patients who underwent elective anterior cervical discectomy and fusion between July 2014 and May 2019. A comparison group was created by a randomized selection process (non-PAC group). Factors associated with PAC and a P value of < 0.10 were entered into a logistic regression model and coefficients contributed to each risk factor's overall score. Calibration of the model was evaluated using the Hosmer-Lemeshow goodness-of-fit test. Quantitative discrimination was calculated, and the final model was internally validated with bootstrap sampling. RESULTS: We identified 18 potential risk factors from our Delphi process, of which 6 factors demonstrated a significant association with airway compromise: age >65 years, current smoking status, American Society of Anesthesiologists class >2, history of a bleeding disorder, surgery of upper subaxial cervical spine (above C4), and duration of surgery >179 minutes. The final prediction model included 5 predictors with very strong performance characteristics. These 5 factors formed the PAC score, with a range from 0 to 100. A score of 20 yielded the greatest balance of sensitivity (80%) and specificity (88%). CONCLUSIONS: The acute PAC score demonstrates strong performance characteristics. The PAC score might help identify patients at risk of upper airway compromise caused by surgical site abnormalities.
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Vértebras Cervicais , Discotomia , Complicações Pós-Operatórias , Fusão Vertebral , Humanos , Vértebras Cervicais/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Fusão Vertebral/efeitos adversos , Idoso , Discotomia/efeitos adversos , Fatores de Risco , Adulto , Técnica Delphi , Obstrução das Vias Respiratórias/etiologiaRESUMO
STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Venous thromboembolic events (VTE) and post-operative epidural hematoma (EDH) are significant complications after spine surgery. Guidelines for chemoprophylaxis are controversial and variability amongst surgeons remains. The objective of this study was to establish the incidence of clinical VTE and EDH at our institution and evaluate the association of chemoprophylaxis with clinical VTE and EDH. METHODS: We conducted a retrospective cohort study of patients undergoing spine surgery at a high-volume tertiary care center in Seattle, WA between January 2016 and December 2019. The Premier Health Care Database and Agency for Healthcare Research and Quality (AHRQ) patient indicators PSI-9 (Perioperative hemorrhage and hematoma) and PSI-12(Perioperative PE or DVT) were used to identify patients experiencing VTE and/or post-operative EDH. The primary outcome was the incidence of clinical VTE and EDH in post-operative spine patients. Secondary outcomes included the association of chemoprophylaxis with clinical VTE and EDH. RESULTS: From 2016 to 2019, 4587 patients underwent spine surgery, totaling 4764 hospital stays. The incidence of clinical VTE was .21% (10/4764) and the incidence of EDH was .10% (5/4764). Most hemorrhages occurred prior to the initiation of chemoprophylaxis. One patient with EDH received chemoprophylaxis prior to hemorrhage. CONCLUSIONS: The rate of post-operative clinical VTE and EDH in spine surgery is low. Despite early initiation of chemoprophylaxis after major spine surgery we did not appreciate a high rate of EDH. We attribute our low rate of clinical VTE to multimodal prophylaxis with SCDs, early mobilization and chemoprophylaxis on post-operative day 1.
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STUDY DESIGN: Retrospective cohort study OBJECTIVE: Wider cages are associated with improved decompression and reduced subsidence, but variation in cage physical properties limits consistent outcome analysis after thoracolumbar interbody fusion. This study investigated cage subsidence and its relationship to lateral and posterior approaches with a focus on the hypothesis that the larger surface area of lateral cages results in lower subsidence rates. METHODS: This study retrospectively reviewed 194 patients who underwent interbody fusion between 2016 and 2019 with a primary outcome of cage subsidence. Secondary outcomes were cage distribution (patients, approaches, expandability), cage dimensions, tscores, length of hospital stay, blood loss, surgical time, and pelvic incidence-lumbar lordosis (PI-LL) mismatch. RESULTS: Medical records were reviewed for 194 patients receiving 387 cages at 379 disc levels. Subsidence was identified in 35.1% of lateral cages, 40.9% of posterior cages, and 36.3% of all cages. Lower surface area (pâ¯= 0.008) and cage expandability were associated with subsidence risk. Lower anteroposterior cage length proved to be a significant factor in the subsidence of posteriorly placed cages (pâ¯= 0.007). Osteopenic and osteoporotic patients experienced cage subsidence 36.8% of the time compared to 3.5% of patients with normal tscores (pâ¯= 0.001). Cage subsidence correlated with postoperative deterioration of the PI-LL mismatch (pâ¯= 0.03). Patients receiving fusion augmentation with bone morphogenic protein experienced higher fusion rates (pâ¯< 0.01). CONCLUSION: Cage subsidence is a common complication that can significantly impact operative outcomes following thoracolumbar interbody fusion. Low tscores, smaller surface area, cage expandability, and lower cage length in posterior approaches contribute significantly to cage subsidence.
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Lordose , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Lordose/diagnóstico por imagemRESUMO
OBJECTIVE: De novo infections of the spine are an increasing healthcare problem. The decision for nonsurgical or surgical treatment is often made case by case on the basis of physician experience, specialty, or practice affiliation rather than evidence-based medicine. To create a more systematic foundation for surgical assessments of de novo spinal infections, the authors applied a formal validation process toward developing a spinal infection scoring system using principles gained from other spine severity scoring systems like the Spine Instability Neoplastic Score, Thoracolumbar Injury Classification and Severity Score, and AO Spine classification of thoracolumbar injuries. They utilized an expert panel and literature reviews to develop a severity scale called the "Spinal Infection Treatment Evaluation Score" (SITE Score). METHODS: The authors conducted an evidence-based process of combining literature reviews, extracting key elements from previous scoring systems, and obtaining iterative expert panel input while following a formal Delphi process. The resulting basic SITE scoring system was tested on selected de novo spinal infection cases and serially refined by an international multidisciplinary expert panel. Intra- and interobserver reliabilities were calculated using the intraclass correlation coefficient (ICC) and Fleiss' and Cohen's kappa, respectively. A receiver operating characteristic analysis was performed for cutoff value analysis. The predictive validity was assessed through cross-tabulation analysis. RESULTS: The conceptual SITE scoring system combines the key variables of neurological symptoms, infection location, radiological variables for instability and impingement of neural elements, pain, and patient comorbidities. Ten patients formed the first cohort of de novo spinal infections, which was used to validate the conceptual scoring system. A second cohort of 30 patients with de novo spinal infections, including the 10 patients from the first cohort, was utilized to validate the SITE Score. Mean scores of 6.73 ± 1.5 and 6.90 ± 3.61 were found in the first and second cohorts, respectively. The ICCs for the total score were 0.989 (95% CI 0.975-0.997, p < 0.01) in the first round of scoring system validation, 0.992 (95% CI 0.981-0.998, p < 0.01) in the second round, and 0.961 (95% CI 0.929-0.980, p < 0.01) in the third round. The mean intraobserver reliability was 0.851 ± 0.089 in the third validation round. The SITE Score yielded a sensitivity of 97.77% ± 3.87% and a specificity of 95.53% ± 3.87% in the last validation round for the panel treatment decision. CONCLUSIONS: The SITE scoring concept showed statistically meaningful reliability parameters. Hopefully, this effort will provide a foundation for a future evidence-based decision aid for treating de novo spinal infections. The SITE Score showed promising inter- and intraobserver reliability. It could serve as a helpful tool to guide physicians' therapeutic decisions in managing de novo spinal infections and help in comparison studies to better understand disease severity and outcomes.
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Doenças da Coluna Vertebral , Coluna Vertebral , Humanos , Reprodutibilidade dos Testes , Coluna Vertebral/cirurgia , Radiografia , Índice de Gravidade de Doença , Variações Dependentes do ObservadorRESUMO
OBJECTIVES: Primary objectives were outcomes comparison of instrumented surgery used for de-novo spinal infections in terms of infection recurrence, reoperations, primary failure, mortality, and length of stay relative to non-instrumented surgery. Secondary objectives were outcomes for surgical and non-surgical treatment of de-novo spinal infections regarding recurrence of infection, mortality, quality of life, and length-of-stay. METHODS: A systematic literature review was performed using the PubMed database. Studies comparing outcome variables of patients with de-novo spinal infections (DNSI) treated with and without instrumentation and surgical versus non-surgical treatment were included. Studies primarily focusing on epidural abscesses or non-de-novo infections were excluded. A meta-analysis was performed for infection recurrence, reoperation, primary treatment failure, mortality, and quality-of-life parameters. RESULTS: A total of 17 retrospective studies with 2.069 patients met the inclusion criteria. 1.378 patients received surgical treatment with or without instrumentation; 676 patients were treated non-surgically. For the comparison of instrumented to non-instrumented surgery Odds-Ratios were .98 (P = .95) for infection recurrence, .83 (P = .92) for primary failure, .53 (P = .02) for mortality and .32 (P = .05) for reoperation. For the comparison of non-surgical to surgical treatment, Odds-Ratios were .98 (P = .95) for infection recurrence, and 1.05 (P = .89) for mortality. CONCLUSION: Available data support that instrumented surgery can be performed safely without higher rates of infection recurrence or primary failure and lower reoperation and mortality rates compared to nonsurgical treatment for DNSI. Furthermore, spine surgical treatment may generally be performed without higher risk of infection recurrence and mortality and better quality-of-life outcomes compared to generic non-surgical treatment.
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STUDY DESIGN: Retrospective study. OBJECTIVES: Although type II odontoid fractures mainly occur due to high-energy trauma (HET), the number of odontoid type II fractures after low-energy trauma (LET) in the elderly is on the rise. However, there is a paucity of conclusive evidence on the relationship between trauma mechanism and cervical spine alignment in the elderly population. Consequently, we examined cervical alignment and osteoporotic and osteoarthritic patterns in elderly individuals (aged ≥65 years) with type II odontoid fractures. METHODS: We retrospectively assessed cervical spine alignment in 76 elderly individuals who experienced type II odontoid fractures after HET (n = 36) and LET (n = 40) between 2005 and 2020. Osteoporotic and osteoarthritic changes on computed tomography and cervical alignment parameters on sagittal plane radiographs were examined. RESULTS: Moderate and severe osteoporosis of the dens-body junction and osteoarthritis of the atlanto-odontoid joint were more prevalent in the LET than the HET group (P<.005). The anterior atlantodental interval (ADI) was significantly smaller in the LET group than in the HET group (.7 [.7] millimeter vs 1.2 [.8] mm; P=.003). An ADI equal 0 mm indicative for anterior fusion of C1/C2 was present in 37.5% of patients of the LET group. The C0-C2 angle, C1-C2 lordosis, and C2-C7 sagittal vertical axis were significantly different (HET vs LET: 33.2 [7.2]° vs 41.6 [11.4]°, P=.005; 28.1 [7.0]° vs 34.0 [8.0]°, P=.002; and 16.1 [11.1] millimeter vs 27.1 [12.4] mm, P=.008; respectively). CONCLUSION: Significantly higher rates of osteoporotic and degenerative changes were observed after LET. Furthermore, previous cervical malalignment represents a risk factor for type II odontoid fractures after LET.
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PURPOSE: This retrospective single institution study's goal was to analyze and report the complications from stand-alone lateral lumbar interbody fusions (LLIF). METHODS: This research was approved by the institutional review board (STUDY2021000113). We retrospectively reviewed the database of patients with adult degenerative spine deformity treated via LLIF at our institution between January 2016 and December 2020. RESULTS: Stand-alone LLIF was performed in 158 patients (145 XLIF, 13 OLIF; mean age 65 y.; 88 f., 70 m.). Mean surgical time was 85 min (± 24 min). Mean follow-up was 14 months (± 5 m). Surgical blood loss averaged 120 mL (± 187 mL) and the mean number of fused levels was 1.2 (± 0.4 levels). Overall complication rate was 19.6% (31 total; 23 approach-related, 8 secondary complications). CONCLUSION: Lateral interbody fusion appears to be a safe surgical intervention with relatively low complication- and revision rates.
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Vértebras Lombares , Complicações Pós-Operatórias , Adulto , Humanos , Idoso , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Vértebras Lombares/cirurgia , Perda Sanguínea Cirúrgica , Reoperação/efeitos adversosRESUMO
STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: Determine if tobacco use is associated with increased risk of postoperative adverse events within 90 days in patients undergoing spinal fusion surgery. METHODS: Databases were queried to identify cohort studies that directly compared smokers with non-smokers and provided the absolute number of adverse events and the population at risk. Data quality was evaluated using the Quality in Prognosis Studies tool. Risk ratios (RR) and 95% confidence intervals were calculated and compared between studies. The grading of recommendation, assessment, development and evaluation (GRADE) criteria were used to assess the strength of the evidence. RESULTS: Seventeen studies assessing 37 897 participants met the inclusion criteria. Of these, 10 031 (26.5%) were smokers and 27 866 (73.5%) were nonsmokers. The mean age for the study population was 58 years, and 45% were males. Smoking was not associated with increased risk of one or more major adverse events within 90 days following spine surgery (seven studies, pooled RR 1.13, 95% CI [.75-1.71], I2 = 41%). However, smoking was significantly associated with one or more major adverse events in ≤2 level fusion (three studies, pooled RR 2.46, 95% CI [1.18-5.12], I2 = 0%), but not in fusions of ≥3 levels (four studies, pooled RR .87, 95% CI [.70-1.08], I2 = 0%). Additionally, there was no statistically significant association between smoking and any adverse event, nor increased reoperation risk due to adverse events. CONCLUSIONS: In this meta-analysis, tobacco use was not associated with a statistically significant increased risk of adverse events within 90 days in patients undergoing spinal fusion surgery. Our results are limited by the variable reporting methodology for both complication rates as well as smoking incidence between the included individual studies.
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STUDY DESIGN: Retrospective case series analysis. OBJECTIVE: To identify relevant clinical and radiographic markers for patients presenting with infectious spondylo-discitis associated with spinal instability directly related to the infectious process. METHODS: We evaluated patients presenting with de-novo intervertebral discitis or vertebral osteomyelitis /discitis (VOD) who initiated non-surgical treatment. Patients who failed conservative treatment and required stabilization surgery within 90 days were defined as "failed treatment group" (FTG). Patients who experienced an uneventful course served as controls and were labeled as "nonsurgical group" (NSG). A wide array of baseline clinical and radiographic parameters was retrieved and compared between 2 groups. RESULTS: Overall 35 patients had initiated non-surgical treatment for VOD. 25 patients had an uneventful course (NSG), while 10 patients failed conservative treatment ("FTG") within 90 days. Factors found to be associated with poorer outcome were intra-venous drug abuse (IVDA) as well as the presence of fever upon initial presentation. Radiographically, involvement of the same-level facets and the extent of caudal and rostral VB involvement in both MRI and CT were found to be significantly associated with poorer clinical and radiographic outcome. CONCLUSIONS: We show that clinical factors such as IVDA status and fever as well as the extent of osseous and posterior element involvement may prove to be helpful in favoring surgical treatment early on in the management of spinal infections.
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STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of the study was to compare early complication, morbidity and mortality risks associated with fusion surgery crossing the cervico-thoracic junction in patients aged over 80 years undergoing combined anterior and posterior approach versus a posterior-only approach. METHODS: We retrospectively identified octogenarian patients with myelopathy who underwent fusion crossing the cervico-thoracic junction. Patient demographics, Nurick score, surgical characteristics, complications, hospital course, early outcome and 90-day mortality were collected. Comorbidities were classified using the age-adjusted Charlson Comorbidity Index (AACCI). Radiographic measurements for deformity correction included the C2-C7 sagittal Cobb angle, C2-7 sagittal vertical axis and T1 slope pre- and postoperatively. RESULTS: Out of 8,521 surgically treated patients, 12 octogenarian patients had a combined anterior and posterior approach (AP group) and 14 were treated from posterior-only (P group). Mean age was 81.4 ± 1.2 and 82.5 ± 2.7 years, respectively. There was no significant difference in Nurick scores between the groups (P > 0.05). The major complication risk in the AP group was significantly higher, requiring PEG tube placement due to severe dysphagia in 4 patients (33%) compared to none in the P group. A greater improvement in cervical lordosis could be achieved through a combined approach. The 90-day mortality risk was 8% for the AP group and 0% for the P group. CONCLUSIONS: A combined anterior and posterior approach is associated with a significantly higher major complication rate and can result in severe dysphagia requiring PEG tube placement in one-third of patients over 80 years of age.
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OBJECTIVE: This study assessed the quality of educational content for lateral spine fusion procedures on YouTube™. METHODS: YouTube™ was searched using the following keywords and phrases: "Lateral lumbar interbody fusion," "lateral lumbar spine surgery," "Oblique lateral interbody fusion (OLIF)," "Extreme lateral interbody fusion (XLIF)," and "Lateral lumbar interbody fusion (LLIF)." An expert panel of three senior-level spine surgeons [rater one to three (R1-R3)] rated videos on 13 qualitative evaluation parameters via a modified Delphi approach. RESULTS: Thirty-eight videos were included for evaluation. Interrater reliability analysis indicated a moderate agreement between R1 and R2 (κ=0.50; standard error, SE = 0.05), R1 and R3 (κ = 0.60, SE = 0.04), and a substantial agreement between R2 and R3 (κ = 0.65, SE = 0.04). Unanimously positive assessments of the quality of the intraoperative presentation varied between 42% and 63% of the rated videos. However, perioperative quality features were unanimously rated positively less than 21% of the videos. CONCLUSION: With regard to the surgical approach and execution of lateral lumbar fusions, YouTube™ videos can be seen as a valuable addition to academic education. The main problem, however, is the lack of control mechanisms that check the quality of the content offered before it is consumed by patients, students, and doctors in training.
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STUDY DESIGN: Retrospective review. OBJECTIVES: This study aimed to assess and compare the clinical course and complications between surgical decompression and decompression with fusion in lumbar spine patients aged ≥80 years. METHODS: A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2021. Logistic regression was used to identify potential risk factors for the occurrence of complications. RESULTS: Over a 16-year period, 327 patients were allocated to the decompression only group and 89 patients were allocated to the decompression and instrumented fusion group. The study had a mean follow-up duration of 36.7 ± 12.4 months. When assessing the CCI, patients of the instrumentation group had fewer comorbidities (8.9 ± .5 points vs 6.2 ± 1.5 points; P < .001), significantly longer surgical duration (290 ± 106 minutes vs 145 ±50.2 minutes; P < .001), significantly higher volume of intraoperative blood loss (791 ± 319.3 ml vs 336.1 ± 150.8 ml; P < .001), more frequent intraoperative blood transfusion (7 ± 2.1% vs 16± 18.0%; P < .001), and extended stays in the intensive care unit and hospitalization rates. Logistic regression analysis revealed that surgical duration and extent of surgery were unique risk factors for the occurrence of complications. CONCLUSIONS: Lumbar decompression and additional fusion in octogenarians are considerable treatment techniques; albeit associated with increased complication risks. Prolonged operative time and extent of surgery are critical confounding factors associated with higher rates of postoperative complications. Surgery should only be performed after careful outweighing of potential benefits and risks.
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STUDY DESIGN: Cross-sectional study. OBJECTIVE: The aim was to create and validate a novel patient-reported outcome measure (PROM) focusing on stiffness-related patient functional limitations after cervical spine fusion. SUMMARY OF BACKGROUND DATA: Cervical arthrodesis is a common treatment for myelopathy/radiculopathy, however, results in increased neck stiffness as a collateral outcome. No current PROM exists quantifying the impact of postoperative stiffness on patient function. METHODS: The Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI) was created through a modified Delphi process. The resultant 10-item questionnaire yields a score out of 100 with higher scores indicating increased functional difficulty related to neck stiffness. Cross-sectional study of control and postoperative patients was completed for CSRS-CSDI validation. Retest reliability (intraclass correlation coefficient), internal consistency (Cronbach alpha), responsiveness (levels fused vs. CSRS-CSDI scores), and discriminatory validation (CSRS-CSDI vs. neck disability index) scores) were completed. RESULTS: Fifty-seven surgical and 24 control patients completed the questionnaire. Surgical patients underwent a variety of procedures: 11 (19%) motion preserving operations, nine (16%) subaxial 1-2 level fusions, seven (12%) subaxial 3-5 level fusions, five (9%) C1-subaxial cervical spine fusions, 20 (35%) C2-upper thoracic spine fusions, five (9%) occiput-subaxial or thoracic spine fusions. The questionnaire demonstrated high internal consistency (Cronbach alpha=0.92) and retest reliability (intraclass correlation coefficient=0.95, P <0.001). Good responsiveness validity with a significant difference between fusion cohorts was found ( P <0.001, rs =0.63). Patient CSRS-CSDI scores also correlated with neck disability index scores recorded ( P <0.001, r =0.70). CONCLUSION: This is the first study to create a PROM addressing the functional impact of cervical stiffness following surgical arthrodesis. The CSRS-CSDI was a reliable and valid measure of postoperative stiffness impact on patient function. This may prove useful in counseling patients regarding their expected outcomes with further investigation demonstrating its value in a prospective fashion.
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Qualidade de Vida , Fusão Vertebral , Dor nas Costas/etiologia , Vértebras Cervicais/cirurgia , Estudos Transversais , Humanos , Reprodutibilidade dos Testes , Fusão Vertebral/métodosRESUMO
STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Vasoplegia is a life-threatening form of distributive or vasodilatory shock that is characterized by reduced systemic vascular resistance with resultant hypotension and normal to elevated cardiac output affecting morbidity and mortality. Vasoplegia in the context of Spine Surgery has not been described previously. The purpose of this case series is to determine incidence, risk factors, complications and postoperative outcome in patients with vasoplegia after complex multi-level thoraco-lumbar spine surgery. METHODS: A retrospective review of the electronic medical records at our institution was conducted between January 2014 and June 2018. All patients undergoing multi-level spine surgery (>6 levels) were screened for intraoperative hypotension. Patient demographics, surgical characteristics, neurological status, blood loss, risk factors, medical treatment, complications, hospital course and mortality were collected. All patients included in this study had a minimum follow-up period of 3 months. RESULTS: Out of 8521 surgically treated patients, 994 patients with multi-level thoraco-lumbar spine surgery were identified. A total of 41 patients had intraoperative hypotensive events. Of those, 5 patients with vasoplegia could be identified after elimination of all other potential contributing factors. Vasoplegia did not influence the neurological outcome. One major and three minor complications occurred. All patients showed full recovery. The risk factors identified for vasoplegia include prolonged surgery with osteotomies. CONCLUSIONS: Vasoplegia is a rare condition with an incidence of .6%. Patients experiencing vasoplegia did not appear to experience worse surgical outcomes. The use of special intraoperative hemodynamic monitoring should be considered in selected cases.
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Despite increased life expectancy due to health care quality improvements globally, pyogenic vertebral osteomyelitis (PVO) treatment with a spinal epidural abscess (SEA) remains challenging in patients older than 80 years. We aimed to assess octogenarians for PVO prevalence with SEA and compare after-surgery clinical outcomes of decompression and decompression and instrumentation. A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Over 16 years, 35 patients aged ≥80 years with PVO and SEA were identified. Eighteen patients underwent surgical decompression ("decompression group"), and 17 underwent surgical decompression with instrumentation ("instrumentation group"). Both groups had a CCI >6 (mean±SD, 8.9±2.1 vs. 9.6±2.7, respectively; p=0.065). Instrumentation group patients had a significantly longer hospital stay but no ICU stay. In-hospital and 90-days mortality rates were similar in both groups. The mean follow-up was 26.6±12.4 months. No further surgeries were performed. Infection levels and neurological status were improved in both groups at discharge. At the second-stage analysis, significant improvements in the blood infection parameters and the neurological status were detected in the decompression group. Octogenarians with PVO and SEA have a high adverse events risk after surgical procedures. Surgical decompression might contribute to earlier clinical recovery in older patients. Thus, the surgical approach should be discussed with patients and their relatives and be carefully weighed.
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Abscesso Epidural , Osteomielite , Fusão Vertebral , Idoso , Idoso de 80 Anos ou mais , Descompressão Cirúrgica/métodos , Abscesso Epidural/cirurgia , Seguimentos , Humanos , Octogenários , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To critically analyze the evidence and efficacy of cannabis to treat surgical and nonsurgical back pain via a Systematic Review. METHODS: We conducted a systematic review to investigate the efficacy of cannabis to treat non-surgical and surgical back pain. A literature search was performed with MEDLINE and Embase databases. Only RCTs and prospective cohort studies with concurrent control were included in this study. Risk of bias and quality grading was assessed for each included study. RESULTS: Database searches returned 1738 non-duplicated results. An initial screening excluded 1716 results. Twenty-two full text articles were assessed for eligibility. Four articles ultimately met pre-determined eligibility and were included in the study. Two studies addressed post-SCI pain while other two studies addressed low back pain. No studies specifically examined the use of cannabis for surgical back pain. The type of cannabis varied between study and included THC, dronabinol, and Nabilone. A total of 110 patients were included in the four studies reviewed. In each study, there was a quantifiable advantage of cannabis therapy for alleviating back pain. There were no serious adverse effects reported. CONCLUSIONS: In all articles, cannabis was shown to be effective to treat back pain with an acceptable side effect profile. However, long-term follow up is lacking. As medicinal cannabis is being used more commonly for analgesic effect and patients are "self-prescribing" cannabis for back pain, additional studies are needed for healthcare providers to confidently recommend cannabis therapy for back pain. STUDY DESIGN: Systematic review.
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BACKGROUND: Patients undergoing spine surgery may experience substantial postoperative pain. The aim of this systematic review is to examine the clinical efficacy of a newly introduced regional anesthetic block, the erector spinae plane block (ESPB), for adults undergoing posterior spine surgeries. METHODS: A formal systematic database search was conducted in PubMed, Ovid Medline, Embase, Cochrane library, and Google Scholar for randomized controlled trials comparing ESPB with control or placebo. RESULTS: Our systematic review demonstrates a reduction of postoperative pain and opioid consumption in patients who had ESPB compared with control groups for lumbar spine surgery. However, the effect obtained revealed only a short-term benefit. CONCLUSIONS: Current evidence is insufficient to support the widespread use of ESPB for spine surgery. More studies are warranted to confirm or refute its role in clinical practice.
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Bloqueio Nervoso , Adulto , Anestésicos Locais/uso terapêutico , Humanos , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/cirurgia , Músculos Paraespinais/cirurgia , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
L5 nerve palsy is a well-known complication following reduction of high-grade spondylolisthesis. While several mechanisms for its occurrence have been proposed, the hypothesis of L5 nerve root strain or displacement secondary to mechanical reduction remains poorly studied. The aim of this cadaveric study is to determine changes in morphologic parameters of the L5 nerve root during simulated intraoperative reduction of high-grade spondylolisthesis. A standard posterior approach to the lumbosacral junction was performed in eight fresh-frozen cadavers with lumbosacral or lumbopelvic screw fixation. Wide decompressions of the spinal canal and L5 nerve roots with complete facetectomies were accomplished with full exposure of the L5 nerve roots. A 100% translational slip was provoked by release of the iliolumbar ligaments and cutting the disc with the attached anterior longitudinal ligament. To evaluate the path of the L5 nerves during reduction maneuvers, metal bars were inserted bilaterally at the inferomedial aspects of the L5 pedicle at a distance of 10 mm from the midpoint of the L5 pedicle screws. There was no measurable change in length of the L5 nerve roots after 50% and 100% reduction of spondylolisthesis. Mechanical strain or displacement during reduction is an unlikely cause of L5 nerve root injury. Further anatomical or physiological studies are necessary to explore alternative mechanisms of L5 nerve palsy in the setting of high-grade spondylolisthesis correction, and surgeons should favor extensive surgical decompression of the L5 nerve roots when feasible.