Postoperative Blood Salvage and Autotransfusion for Adult Spinal Deformity: A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: The aim of this study was to determine whether postoperative blood salvage and autotransfusion versus traditional closed suction drainage reduces the rate of homologous blood transfusions in patients undergoing surgery for adult spinal deformity. SUMMARY OF BACKGROUND DATA: The use of intraoperative blood salvage has become commonplace in spine surgery; however, the collection and reinfusion of blood drained from the wound postoperatively have not been employed routinely because of increased cost and questionable benefit. METHODS: Adult patients undergoing long posterior fusions were randomized to either a blood salvage and reinfusion system (OrthoPat - Group 1) or a standard subfascial closed suction drain (Group 2). Blood collected in Group 1 was reinfused according to the manufacturer's protocol. Reinfusion drains were converted to standard closed suction drains when output was <50 mL during 4 hours, and drains were removed when output was minimal. Patients received autologous or homologous blood transfusions when hemoglobin (Hg) <8 g/dL or they had symptomatic anemia. RESULTS: Thirty-four patients were randomized into Group 1 and 36 patients into Group 2. There were no differences in preoperative or intraoperative parameters. Patients in Group 1 had higher hemoglobin levels on postoperative day (POD) 2 and POD 3 compared to those in Group 2. However, there was no significant difference in the percentage of patients requiring homologous blood transfusion between the two groups (41% Group 1 vs. 60% Group 2, P = 0.17). Similarly a subgroup analysis in patients with estimated blood loss >2000 mL also showed no difference in homologous blood transfusion rates (67% Group 1 vs. 76% Group 2, P = 0.58). There were no differences in the rate or type of postoperative complications. CONCLUSION: Postoperative blood salvage and reinfusion result in a higher hemoglobin level in the early postoperative period, but does not significantly reduce the need for homologous blood transfusion. LEVEL OF EVIDENCE: 1.

A patient with extensive cerebral calcification due to pseudohypoparathyroidism: a case report.

BACKGROUND: Pseudohypoparathyroidism(PHP) is a heterogeneous group of disorders due to impaired activation of c AMP dependant pathways following binding of parathyroid hormone (PTH) to its receptor. In PHP end organ resistance to PTH results in hypocalcaemia, hyperphosphataemia and high PTH levels. CASE PRESENTATION: A 59 year old male presented with a history of progressive impairment of speech and unsteadiness of gait for 1 week and acute onset altered behavior for 1 day and one episode of generalized seizure. His muscle power was grade four according to MRC (medical research council) scale in all limbs and Chovstek's and Trousseau's signs were positive. Urgent non contrast computed tomography scan of the brain revealed extensive bilateral cerebral and cerebellar calcifications. A markedly low ionized calcium level of 0.5 mmol/l, an elevated phosphate level of 9.5 mg/dl (reference range: 2.7-4.5 mg/dl) and an elevated intact PTH of 76.3 pg/l were noted. His renal functions were normal. His hypocalcemia was accentuated by the presence of hypomagnesaemia. His 25 hydroxy vitamin D level was only marginally low which could not account for severe hypocalcaemia. A diagnosis of pseudohypoparathyroidism without phenotypic defects, was made due to hypocalcaemia and increased parathyroid hormone levels with cerebral calcifications. The patient was treated initially with parenteral calcium which was later converted to oral calcium supplements. His coexisting Vitamin D deficiency was corrected with 1αcholecalciferol escalating doses. His hypomagnesaemia was corrected with magnesium sulphate parenteral infusions initially and later with oral preparations. With treatment there was a significant clinical and biochemical response. CONCLUSION: Pseudohypoparathyroidism can present for the first time in elderly resulting in extensive cerebral calcifications. Identification and early correction of the deficit will result in both symptomatic and biochemical response.

Preoperative Assessment of Bone Quality in Spine Deformity Surgery: Correlation With Clinical Practice and Published Recommendations.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The goals of this study were to (A) evaluate preoperative bone quality assessment and intervention practice over time and (B) review the current evidence for bone evaluation in spine fusion surgery. SUMMARY OF BACKGROUND DATA: Deformity spine surgery has demonstrated improved quality of life in patients; however, its cost has made it controversial. If preoperative bone quality can be optimized then potentially these treatments could be more durable; however, at present, no clinical practice guidelines have been published by professional spine surgical organizations. METHODS: A retrospective cohort review was performed on patients who underwent a minimum five-level primary or revision fusion. Preoperative bone quality metrics were evaluated over time from 2012 to 2017 to find potential trends. Subgroup analysis was conducted based on age, sex, preoperative diagnosis, and spine fusion region. RESULTS: Patient characteristics including preoperative rates of pseudarthrosis and junctional failure did not change. An increasing trend of physician bone health documentation was noted (P = 0.045) but changes in other metrics were not significant. A sex bias favored females who had higher rates of preoperative DXA studies (P = 0.001), Vitamin D 25-OH serum labs (P = 0.005), Vitamin D supplementation (P = 0.022), calcium supplementation (P < 0.001), antiresorptive therapy (P = 0.016), and surgeon clinical documentation of bone health (P = 0.008) compared with men. CONCLUSION: Our spine surgeons have increased documentation of bone health discussions but this has not affected bone quality interventions. A discrepancy exists favoring females over males in nearly all preoperative bone quality assessment metrics. Preoperative vitamin D level and BMD assessment should be considered in patients undergoing long fusion constructs; however, the data for bone anabolic and resorptive agents have less support. Clinical practice guidelines on preoperative bone quality assessment spine patients should be defined. LEVEL OF EVIDENCE: 4.

Preoperative vitamin D status of adults undergoing surgical spinal fusion.

STUDY DESIGN: Retrospective investigation of cross-sectional data. OBJECTIVE: To define the prevalence and determinants of preoperative vitamin D deficiency among adults undergoing spinal fusion. SUMMARY OF BACKGROUND DATA: Vitamin D plays a critical role in establishing optimal bone health, which, in turn, is vital to the success of spinal arthrodesis. Recently, hypovitaminosis D was documented in 43% of adults undergoing any orthopedic surgery. METHODS: Serum 25-hydroxyvitamin D levels were routinely measured in adults undergoing spinal fusion at a single institution. Between January 2010 and March 2011, 313 patients were retrospectively identified for inclusion. Risk factors for vitamin D deficiency (<20 ng/mL) were analyzed using univariate analysis and multivariate logistic regression. RESULTS: The rates of inadequacy (<30 ng/mL) and deficiency were 57% and 27%, respectively. Although 260 patients were diagnosed with degenerative disease (spondylosis), 99 had deformity, and there were 73 revision cases. There was a higher rate of smoking (P = 0.03) and lower age (P < 0.01) in the vitamin D-deficient subset. There was no sex difference. Increasing body mass index (P < 0.01), increasing Neck and Oswestry Disability Index scores (P = 0.03), and lack of vitamin D and/or multivitamin supplementation (P < 0.01) remained predictors of deficiency after multivariate analysis. Those with previous supplementation were older (P < 0.01) and more likely to be at least 50 years old than those without repletion (P < 0.01). CONCLUSION: Our investigation revealed a substantially high prevalence of vitamin D abnormality in the analyzed population. Although advanced age is a well-established risk factor for hypovitaminosis, young adults undergoing fusion should not be overlooked with regard to vitamin D screening; this age bracket is less likely to have been previously supplemented. In the absence of better-recognized determinants, spinal disability indices may also be useful in identifying those with deficiency.

Effect of high doses of oral risedronate (20 mg/day) on serum parathyroid hormone levels and urinary collagen cross-link excretion in postmenopausal women with spinal osteoporosis.

The present study describes the biological effects of risedronate, a pyridinyl bisphosphonate, on bone and assesses the safety and tolerability of risedronate when given at high doses, with or without calcium, to postmenopausal women with spinal osteoporosis. This single-center descriptive, double-blind, placebo-controlled, randomized, parallel group study included 32 postmenopausal white women with at least one radiographically confirmed vertebral compression fracture. Patients were randomized to one of four different dose regimen groups: (i) R-P, risedronate 20 mg/day for 14 days, followed by placebo for 42 days; (ii) R-CP-P, risedronate 20 mg/day for 14 days, followed by elemental calcium 1000 mg/day and placebo for 14 days, then by placebo for 28 days; (iii) R-CP-R-CP, risedronate 20 mg/day for 7 days, followed by elemental calcium 1000 mg/day and placebo for 21 days, then risedronate 20 mg/day for 7 days, and finally elemental calcium 1000 mg/day and placebo for 21 days; and (iv) P, placebo for 56 days. The biological response was investigated by measuring serum calcium, parathyroid hormone (PTH), and 2 h urinary pyridinoline/creatinine (Pyr/Cr) and deoxypyridinoline/creatinine (DPyr/Cr) ratios at baseline and at days 3, 7, 14, 21, 28, 35, 42, 49, 56, and 84. Overall, there were no consistent trends observed between the active group and placebo for serum calcium. In groups R-P, R-CP-P, and R-CP-R-CP, mean serum PTH levels were elevated above baseline values for the entire 56 day treatment period and remained elevated, although to a lesser extent, at the day 84 follow-up visit. The effect of calcium supplementation on PTH was variable. Urinary Pyr/Cr and DPyr/Cr ratios were decreased from baseline over the entire study period in all groups receiving risedronate. The maximum observed percent decreases from baseline for Pyr/Cr and DPyr/Cr were -46.9% and -58.8%, respectively, at day 49 in the R-CP-R-CP group. In conclusion, risedronate given orally at a dose of 20 mg/day, continuously for 7 or 14 days, resulted in the expected biological response in osteoporotic women. The time course of changes in PTH levels following cessation of dosing was unaffected by calcium supplementation. There was no evidence of a PTH-mediated rebound in bone resorption following cessation of therapy. Furthermore, based on collagen cross-link data, patients did not show an excessive reduction in bone turnover.

Bone mass and biochemical parameters of bone metabolism in men with spinal osteoporosis.

With advancing age both sexes have an increased incidence of osteoporotic fractures, although fractures are more common in women than in men. Whereas in women several potential risk factors have been identified, less is known about osteoporosis in men. A total of 27 Austrian men (mean age: 65 +/- 2 years) with atraumatic spine fractures were studied. In all patients, medical history gave no evidence of disease or medications causing osteoporosis. Peripheral bone mass was determined by single-photonabsorptiometry on the distal non-dominant forearm; lumbal bone density was measured by quantitative computed tomography. Serum levels of calcium, phosphate, alkaline phosphatase, osteocalcin, testosterone, estrogen, parathyroid hormone and 25-hydroxy-vitamin D as well as 2-h-urinary-OH proline and calcium excretion were measured. All data were compared with those of an age and sex matched control group consisting of 19 healthy males. A significant difference in mean peripheral and axial bone mass (SPA: P less than 0.004; QCT: P less than 0.0001) was observed between osteoporotic men and controls. When compared to controls, serum levels of alkaline phosphatase (P less than 0.012), urinary OH proline (P less than 0.05) and urinary calcium excretion (P less than 0.003) were significantly higher in the osteoporotic males. Additionally, there was a significant positive correlation between serum alkaline phosphatase and urinary OH proline excretion (r = 0.32; P less than 0.04) in the osteoporotics. All other biochemical parameters showed no significant differences. Our results may lead to the assumption that osteopenia in men is related to increased bone turnover.

[Functional changes in the pituitary-adrenal system during the action of electroacupuncture on patients with spinal osteochondrosis]. / Izmenenie sostoianiia gipofizarno-nadpochechnikovoi sistemy pri vozdeistvii élektroakupunkury u bol'nykh osteokhondrozom pozvonochnika.

A session of low-frequency electroacupuncture (EAP) of the nerve points of the cervicobrachial or lumbosacral regions was performed in 61 patients with vertebral osteochondrosis. An EAP therapeutic effect, analgetic one in particular, was found to depend on cortisol and aldosterone blood levels: reduced levels of the hormones related to EAP procedure appeared associated with a positive therapeutic response.