Complications of Venous Thromboembolism Chemoprophylaxis in Lumbar Laminectomy With and Without Fusion.

BACKGROUND: The benefit of chemoprophylaxis (CPX) agents in preventing venous thromboembolism must be weighed against potential risks. Current literature regarding the efficacy of CPX after laminectomies with or without fusion is limited, with no clear consensus to inform guidelines. OBJECTIVE: This study evaluated the association between CPX and surgical complications after lumbar laminectomy with and without fusion. STUDY DESIGN: Retrospective study of patients at a single large academic institution. METHODS: The medical records of patients who underwent lumbar laminectomies with or without lumbar fusion from 2018 to 2020 were reviewed for demographics, surgical characteristics, CPX agents, postoperative complications, epidural hematomas, and wound drainage. Patients receiving CPX (n = 316) were compared with patients not receiving CPX (n = 316) via t test following propensity score matching, and patients on CPX were further stratified by fusion status. RESULTS: The CPX group had higher body mass index and American Society of Anesthesiologists grades. Rates of venous thromboembolism, epidural hematomas, infections, postoperative incision and drainage, transfusions, wound dehiscence, and reoperation were not associated with CPX. Moist dressings were more frequent, and average days of drain duration were longer with CPX. Overall postoperative complication rate and length of stay (LOS) were greater with CPX. The fusion subgroup had a lower Charlson Comorbidity Index, had a lower American Society of Anesthesiologists grade, was younger, had more women, and underwent more minimally invasive laminectomies. While estimated blood loss, operative times, and LOS were significantly greater in the fusion group, there was no difference in rate of intraoperative and postoperative complications. CONCLUSION: CPX after lumbar laminectomies with or without fusion was not associated with increased rates of epidural hematomas, wound complications, or reoperation. Patients receiving CPX had more postoperative cardiac complications, but it is possible that surgeons were more likely to prescribe CPX for higher-risk patients. They also had higher rates of ileus and moist dressings, greater LOS, and longer length of drain duration. Patients who underwent lumbar laminectomy with fusion on CPX tended to be lower risk yet incurred greater blood loss, operative times, LOS, cardiac complications, and hematomas/seromas than patients not undergoing fusion. CLINICAL RELEVANCE: This retrospective study compared surgical complications of lumbar laminectomies in patients who received chemoprophylaxis vs patients who did not. Chemoprophylaxis was not associated with increased rates of epidural hematomas, wound complications, or reoperation, but it was associated with higher rates of postoperative cardiac complications and ileus.

The Impact of Social Determinants of Health on Discharge Disposition Following One- and Two-Level Posterior Interbody Fusion.

Background Current research is limited in exploring the impact of social determinants of health (SDOH) on the discharge location within elective spine surgery. Further understanding of the influence of SDOH on disposition is necessary to improve outcomes. This study explores how SDOH influence discharge disposition for patients undergoing one- or two-level posterior interbody fusion (TLIF/PLIF). Methods This was a retrospective propensity-matched cohort study. Patients who underwent TLIF/PLIF between 2017 and 2020 at a single academic medical center were identified. The chart review gathered demographics, perioperative characteristics, intra/post-operative complications, discharge disposition, and 90-day outcomes. Discharge dispositions included subacute nursing facility (SNF), home with self-care (HSC), home with health services (HHS), and acute rehab facility (ARF). Demographic, perioperative, and disposition outcomes were analyzed by chi-square analysis and one-way ANOVA based on gender, race, and income quartiles. Results Propensity score matching for significant demographic factors isolated 326 patients. The rate of discharge to SNF was higher in females compared to males (25.00% vs 10.56%; p=0.001). Men were discharged to home at a higher rate than women (75.4% vs 61.95%; p=0.010). LatinX patients had the highest rate of home discharge, followed by Asians, Caucasians, and African Americans (83.33% vs 70.31% vs 66.45% vs 65.90%; p<0.001). The post hoc Tukey test demonstrated statistically significant differences between Asians and all other races in the context of age and BMI. Additionally, patients discharged to SNF showed the highest Charlson comorbidity index (CCI) score, followed by those at ARF, HHS, and HSC (4.36 vs 4.05 vs 2.87 vs 2.37; p<0.001). The estimated median income for the cohort ranged from $52,000 to $250,001, with no significant differences in income seen across comparisons. Conclusion Discharge disposition following one- or two-level TLIF/PLIF shows significant association with gender and race. No association was seen when comparing discharge rates among zip code-level median income quartiles.

Clinical outcomes and complications after biportal endoscopic spine surgery: a comprehensive systematic review and meta-analysis of 3673 cases.

PURPOSE: Current literature suggests that biportal spinal endoscopy is safe and effective in treating lumbar spine pathology such as lumbar disc herniation, lumbar stenosis, and degenerative spondylolisthesis. No prior study has investigated the postoperative outcomes or complication profile of the technique as a whole. This study serves as the first comprehensive systematic review and meta-analysis of biportal spinal endoscopy in the lumbar spine. METHODS: A PubMed literature search provided over 100 studies. 42 papers were reviewed and 3673 cases were identified with average follow-up time of 12.5 months. Preoperative diagnoses consisted of acute disc herniation (1098), lumbar stenosis (2432), and degenerative spondylolisthesis (229). Demographics, operative details, complications, and perioperative outcome and satisfaction scores were analyzed. RESULTS: Average age was 61.32 years, 48% male. 2402 decompressions, 1056 discectomies, and 261 transforaminal lumbar Interbody fusions (TLIFs) were performed. Surgery was performed on 4376 lumbar levels, with L4-5 being most common(61.3%). 290 total complications occurred, 2.23% durotomies, 1.29% inadequate decompressions, 3.79% epidural hematomas, and < 1% transient nerve root injuries, infections, and iatrogenic instability. Significant improvement in VAS-Back, VAS-Leg, ODI, and Macnab Scores were seen across the cohort. CONCLUSION: Biportal spinal endoscopy is a novel method to address pathology in the lumbar spine with direct visualization through an endoscopic approach. Complications are comparable to previously published rates. Clinical outcomes demonstrate effectiveness. Prospective studies are required to assess the efficacy of the technique as compared to traditional techniques. This study demonstrates that the technique can be successful in the lumbar spine.

Analysis of microsatellite instability in Korean patients with pancreatic cancer.

BACKGROUND: Pancreatic cancer (PC) is a dangerous malignancy with a high mortality rate. Diagnosing PC at an early stage is difficult, and approximately 5% of the patients survive for 5 years. Microsatellite instability (MSI) plays an important role in colorectal cancer (CRC) for prognosis and immunotherapy. Evaluation of MSI status is important as it is recognized biomarker for the positive response of immune checkpoint blockade therapy in cancer. To our knowledge, there is no report yet on the prevalence of MSI in Korean PC patients. Studies have reported conflicting prevalence of MSI in PC. METHODS: Therefore, to improve the likelihood of MSI identification in PC, we included 133 patients with PC; paired tumor and normal tissue DNA were isolated and MSI was analyzed using Promega panel and immunohistochemistry (IHC) was also performed. RESULTS: Our results from the Promega panel indicated that one (0.7%) tumor was MSI-high (MSI-H), 13 (9.8%) were MSI-low (MSI-L), and 119 (89.5%) were microsatellite stable (MSS). IHC result also confirmed dMMR in only one sample. CONCLUSIONS: The finding of low incidence of MSI-H observed by the Promega panel also matched IHC results, so this study suggested that in Korean PC patients, MSI prevalence is infrequent.

Bone Graft Options in Spinal Fusion: A Review of Current Options and the Use of Mesenchymal Cellular Bone Matrices.

BACKGROUND: Spinal fusion is the mainstay treatment for various spinal conditions ranging from lumbar and cervical stenosis to degenerative spondylolisthesis as well as extensive deformity corrections. A new emerging category of allograft is cellular bone matrices (CBMs), which take allogeneic mesenchymal stem cells and incorporate them into an osteoconductive and osteoinductive matrix. This study reviewed the current spinal fusion options and new emerging treatment options. METHODS: Articles were searched using PubMed. The search included English publications since January 1, 2014, using the search terms "cellular bone matrix," "mesenchymal stem cells spinal fusion," "spinal arthrodesis AND mesenchymal stem cells," and "spine fusion AND cellular bone matrix." RESULTS: Spinal fusion is accomplished through the use of allografts, autografts, and bone graft substitutes in combination or alone. An emerging category of allograft is CBMs, in which an osteoconductive and osteoinductive matrix is filled with mesenchymal stem cells. Studies demonstrate that CBMs have achieved equivalent or better fusion rates compared with traditional options for anterior cervical discectomy and fusions and posterolateral lumbar fusions; however, the studies have been retrospective and lacking control groups and therefore not ideal. CONCLUSIONS: Many treatment options have been successfully used in spinal fusion. Newer allografts such as CBMs have shown promising results in both animal and clinical studies. Further research is needed to determine the therapeutic dose of mesenchymal stem cells delivered within CBMs.

MRI Radiological Predictors of Requiring Microscopic Lumbar Discectomy After Lumbar Disc Herniation.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate radiological differences in lumbar disc herniations (herniated nucleus pulposus [HNP]) between patients receiving microscopic lumbar discectomy (MLD) and nonoperative patients. METHODS: Patients with primary treatment for an HNP at a single academic institution between November 2012 to March 2017 were divided into MLD and nonoperative treatment groups. Using magnetic resonance imaging (MRI), axial HNP area; axial canal area; HNP canal compromise; HNP cephalad/caudal migration and HNP MRI signal (black, gray, or mixed) were measured. T test and chi-square analyses compared differences in the groups, binary logistic regression analysis determined odds ratios (ORs), and decision tree analysis compared the cutoff values for risk factors. RESULTS: A total of 285 patients (78 MLD, 207 nonoperative) were included. Risk factors for MLD treatment included larger axial HNP area (P < .01, OR = 1.01), caudal migration, and migration magnitude (P < .05, OR = 1.90; P < .01, OR = 1.14), and gray HNP MRI signal (P < .01, OR = 5.42). Cutoff values for risks included axial HNP area (70.52 mm2, OR = 2.66, P < .01), HNP canal compromise (20.0%, OR = 3.29, P < .01), and cephalad/caudal migration (6.8 mm, OR = 2.43, P < .01). MLD risk for those with gray HNP MRI signal (67.6% alone) increased when combined with axial HNP area >70.52 mm2 (75.5%, P = .01) and HNP canal compromise >20.0% (71.1%, P = .05) cutoffs. MLD risk in patients with cephalad/caudal migration >6.8 mm (40.5% alone) increased when combined with axial HNP area and HNP canal compromise (52.4%, 50%; P < .01). CONCLUSION: Patients who underwent MLD treatment had significantly different axial HNP area, frequency of caudal migration, magnitude of cephalad/caudal migration, and disc herniation MRI signal compared to patients with nonoperative treatment.

Comment on: Does sugammadex decrease the severity of agitation and complications in pediatric patients undergoing adenotonsillectomy?

[No Abstract Available].

Retrolisthesis and lumbar disc herniation: a postoperative assessment of outcomes at 8-year follow-up.

BACKGROUND CONTEXT: Lumbar disc herniation and retrolisthesis have been shown to be significant degenerative changes that can be associated with back pain. Current literature has shown evidence that retrolisthesis is associated with similar baseline function in patients with L5-S1 disc herniation, but worse postoperative outcomes 2 years after lumbar discectomy. However, literature comparing long-term postoperative outcomes at 8-year follow-up in patients with L5-S1 disc herniation with retrolisthesis is lacking. PURPOSE: The purpose of the present study is to compare long-term postoperative outcomes at 8-year follow-up in patients with retrolisthesis and L5-S1 disc herniations to patients with L5-S1 disc herniations without retrolisthesis. STUDY DESIGN: Retrospective review of prospectively collected data from the Spine Patients Outcomes Research Trial (SPORT) database. PATIENT SAMPLE: Sixty-five patients who underwent lumbar discectomy for L5-S1 disc herniations with 8-year follow-up from the SPORT. OUTCOME MEASURES: Short Form (SF)-36 bodily pain scale, SF-36 physical function scale, Oswestry Disability Index, Sciatica Bothersomeness Index, and reoperation rate. METHODS: Baseline surgical parameters, length of stay, complication rates, reoperation rates, and outcome measures were recorded in the SPORT database. Follow-up data were collected at 6 weeks, 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, 5 years, 6 years, 7 years, and 8 years. Retrolisthesis was defined as posterior subluxation ≥8%. Patients with and without retrolisthesis were compared using a mixed-effects model of longitudinal regression. Outcomes were calculated as time-weighted averages over 8 years. Reoperation rates were compared using the log-rank test based on time to first reoperation. RESULTS: One hundred-twenty five patients met inclusion criteria for the present study, including 29 patients with retrolisthesis (23.3%) and 96 patients who did not have retrolisthesis (76.7%). The greatest difference in clinical outcome measures was found at 2 years postoperatively. This was the only point at which both the Short Form-36 Bodily Pain scale (SF-36 BP) and PF showed significant differences between the retrolisthesis and nonretrolisthesis group. At 3 years, SF-36 BP was significantly lower in patients with retrolisthesis (39.9 vs. 52, p=.046). At 8-year follow-up, the presence of retrolisthesis in patients undergoing L5-S1 discectomy was not associated with worse outcome measure scores based on the area under the curve analysis for any metric investigated (SF-36 BP 41.4 vs. 47.1, p=.18; SF-36 Physical Function scale 38.9 vs. 45.4, p=.12; Oswestry Disability Index -39.4 vs. -34.8, p=.23; -11.6 vs. -10.4, p=.25) or a difference in reoperation rate (retrolisthesis group 10%, nonretrolisthesis group 17%, p=.41). CONCLUSIONS: While retrolisthesis can contribute to low back pain and dysfunction in patients undergoing lumbar discectomy for L5-S1 herniated nucleus pulposus in early follow-up, no significant difference was found in postoperative outcomes after 3 years. Additionally, retrolisthesis was not found to be associated with different reoperation rates at 8 years postoperatively.

Prognostic significance of Glasgow prognostic score in patients with acute exacerbation of idiopathic pulmonary fibrosis.

BACKGROUND AND OBJECTIVE: The Glasgow prognostic score (GPS) reflects the host systemic inflammatory response and is a validated independent prognostic factor in lung cancer. We investigated GPS as a potential predictive factor of clinical outcomes in idiopathic pulmonary fibrosis (IPF) patients with acute exacerbation (AE). METHODS: This was a retrospective study performed between January 2006 and March 2016 in Bucheon St. Mary's Hospital, The Catholic University of Korea. Overall, 327 admitted IPF patients were registered in the study. Patients with definite pneumonia at the time of admission, those with left-sided heart failure, pulmonary embolism and an identifiable cause of acute lung injury, and those whose albumin or C-reactive protein levels were not measured were excluded. RESULTS: A total of 66 patients hospitalized with IPF-AE were finally included. Median survival was 20.7 days and 29 (43.9%) patients died during hospitalization. The median length of overall survival (OS) was 26.0, 20.0 and 15.0 days for GPS-0, GPS-1 and GPS-2, respectively. There were significant differences in OS between GPS-0 and GPS-2 (P = 0.002). In a multivariate analysis performed using a Cox regression model, eosinopenia (P = 0.007), lower partial pressure of oxygen/fraction of inspired oxygen ratio (P = 0.014), and higher GPS (P = 0.006) were independent predictors of mortality. CONCLUSION: GPS can be helpful in predicting mortality in IPF patients with AE.

Thoracic juxtafacet cyst (JFC): a cause of spinal myelopathy.

Spinal cord compression due to synovial facet cyst in thoracolumbar spine is rare. Several etiologies of juxtafacet cysts (JFCs) in this location have been discussed, particularly overload of the arthritic facet joints. Due to the narrow caliber of the thoracic spine, JFC in this location can present with radicular pain or progressive myelopathy. We report an interesting case of a 67 year-old woman who presented with the signs and symptoms of thoracic myelopathy. A left-sided T11/12 JFC was identified on MRI and CT scans correlating with her myelopathy. She experienced a substantial improvement in her myelopathic symptoms after surgical excision of the JFC. The presentation, etiology, and therapeutic aspects of JFC are discussed in detail.

Updates in the use of bone grafts in the lumbar spine.

There has been a rapid increase in the number of lumbar fusion procedures performed in the last 10 years. Many of these procedures involve the use of bone grafts and specifically bone graft extenders and substitutes. Fusion depends on host and surgical factors including the selection of an appropriate graft. Bone grafts have osteoconductive, osteoinductive, and osteogenic properties. Iliac crest autograft has long been considered the gold standard for bone graft procedures as it inherently imparts all three. However, its use is associated with significant disadvantages including donor site pain, increased operative time, and insufficient availability. Allograft has been used to avoid the complications of donor site morbidity but has increased risks of rejection, disease transmission, and slower incorporation into the host bone. The use of alternative bone grafting options, such as demineralized bone matrix, synthetics (ceramics), bone morphogenetic proteins, collagen-based matrices, autogenous growth factors, and bone marrow aspirate, have become routine in some institutions. This review paper highlights the different bone grafting options currently available, discusses their pros and cons, and briefly reviews the relevant literature.

Multi-level spondylolysis.

The incidence of isthmic spondylolysis is approximately 3% to 6% in the general population. Spondylolytic defects involving multiple vertebral levels, on the other hand, are extremely rare. Only a handful of reports have examined the outcomes of surgical treatment of multi-level spondylolysis. Here, we present one case of bilateral pars defects at L3, L4, and L5. The patient, a 46-year-old female, presented with lower back pain radiating into the left lower extremity. Radiographs and CT scans of the lumbar spine revealed bilateral pars defects at L3-L5. The patient underwent lumbar discectomy and interbody fusion of L4-S1 as well as direct repair of the pars defect at L3. There were no postoperative complications, and by seven months the patient had improved clinically. While previous reports describe the use of either direct repair or fusion in the treatment of spondylolysis, we are unaware of reports describing the use of both techniques at adjacent levels.

Sacral osteomyelitis after robotically assisted laparoscopic sacral colpopexy.

BACKGROUND: Osteomyelitis associated with using synthetic mesh for laparoscopic sacral colpopexy is rare. CASE: We present a patient who developed Staphylococcus sacral osteomyelitis after sacral colpopexy with synthetic mesh and titanium tack fixation to the sacral promontory in the absence of mesh erosion or fistula formation. The patient presented with low back pain 6 weeks postoperatively. Magnetic resonance imaging, bone aspirate, and culture confirmed sacral osteomyelitis and discitis 10 weeks after surgery. The patient underwent 8 weeks of outpatient antibiotic treatment. Six months after surgery, serial laboratory values have demonstrated excellent response to antibiotic treatment, and the patient has clinically improved without the need for mesh removal. CONCLUSION: We recommend a high index of suspicion for osteomyelitis in patients who present with back pain after sacral colpopexy. Osteomyelitis can occur as a complication of laparoscopic, robotic sacral colpopexy using mesh in the absence of abscess or fistula formation.

Disruption of mouse corneal epithelial differentiation by conditional inactivation of pnn.

Purpose. To investigate the specific role of Pinin (Pnn) in the development of anterior eye segment in mice. Methods. Conditional inactivation of Pnn in the developing surface eye ectoderm and lens was achieved by creating mice carrying a Pnn null and a floxed Pnn allele as well as a Pax6-Cre-GFP (Le-Cre) transgene. The resultant Pnn conditional knockout mice were examined by histologic and immunohistologic approaches. Results. Pax6-Cre-mediated deletion of Pnn resulted in severe malformation of lens placode-derived tissues including cornea and lens. Pnn mutant corneal epithelium displayed the loss of corneal epithelial identity and appeared epidermis-like, downregulating corneal keratins (K12) and ectopically expressing epidermal keratins (K10 and K14). This squamous metaplasia of Pnn mutant corneal epithelium closely correlated with significantly elevated beta-catenin activity and Tcf4 level. In addition, Pnn inactivation also led to misregulated level of p68 RNA helicase in mutant corneal epithelium. Conclusions. These data indicate that Pnn plays an essential role in modulating and/or orchestrating the activities of major developmental factors of anterior eye segments.

Facilitation of fas mediated apoptosis of human chondrocytes by the proteasome inhibitor and actinomycin D.

OBJECTIVE: We investigated the susceptibility of chondrocytes to apoptosis induced by anti-Fas and various potentiators, and the relevant signaling pathway. METHODS: Chondrocytes were cultured from cartilages obtained at the time of joint replacement surgery for knee osteoarthritis (OA) or femur neck fracture. Fas receptor ligation was performed with agonistic anti-Fas antibody (clone CH-11) at concentrations ranging from 0.5 to 1.0 micro g/ml. Mitogen activated protein kinase inhibitors SB203580 and PD98059, cycloheximide, bisindolylmaleimide, actinomycin D, or MG132 were added with anti-Fas to facilitate cell death. Chondrocyte surface expression of Fas was analyzed by FACS, and the expression of apoptosis related proteins analyzed by Western blot. RESULTS: Cell death increased upon coculture with 0.5 micro g/ml of anti-Fas and 0.2 micro g/ml of actinomycin D or 20 micro M MG132. Apoptosis potentiated by actinomycin D or MG132 was effectively inhibited by caspase inhibitors, implicating the involvement of the caspase cascade in chondrocyte apoptosis. Compared with untreated cells or actinomycin D treated cells, cells treated with MG132 showed distinct shifts in the distribution of surface Fas fluorescence. Although concentrations of Bcl-2, Bax, FLICE inhibitory protein (FLIP), and Fas ligand were unaffected by MG132 or actinomycin D, both treatments led to a significant increase of p53. The expression of the p53 response proteins, MDM2 and p21, was elevated in MG132 treated chondrocytes. CONCLUSION: Our results suggest that chondrocytes can be rendered sensitive to anti-Fas mediated apoptosis by the proteasome inhibitor MG132 and the transcription inhibitor actinomycin D. MG132 and actinomycin D show different characteristics in terms of apoptosis signaling.