Surgical Protocol for Infections, Nonhealing Wound Prophylaxis, and Analgesia: Development and Implementation for Posterior Spinal Fusions.

OBJECTIVE: To analyze the effects of a surgical protocol for infections, nonhealing wound prophylaxis, and analgesia among patients who underwent posterior spinal fusion at a single tertiary-care neurosurgical center. METHODS: This prospective study was conducted in the neurosurgery department of a tertiary-care neurosurgical center and compared a control group of patients who had posterior spinal fusion within 3 months before implementation of a surgical protocol with a study group of patients enrolled within 1 year after protocol implementation. The protocol included a surgical safety checklist, control of modifiable risks associated with surgical site infection, administration of intrawound vancomycin and local analgesia, and standard closure. Postoperative pain, demand for analgesics, and postoperative surgical site infections were assessed among patients before and after the introduction of the protocol. RESULTS: The control group (n = 35; 30 women; median age, 40 years [interquartile range, 31-54 years]) experienced a higher-than-predicted rate of minor surgical infections and nonhealing wounds (12 patients; 34%). In the study group (n = 113; 74 women; median age, 45 years [interquartile range, 37-54 years]), 11 patients (10%) had minor surgical infections and nonhealing wounds. Introduction of the protocol was associated with a 24% absolute risk reduction for minor surgical site infection and a significant decrease in pain on postoperative days 1 and 2 (P < 0.01 for both). Interpersonal communication improved among specialists involved in patient management. CONCLUSIONS: The protocol was effective in reducing postoperative pain and the rate of surgical site infection among patients with posterior spinal surgeries.

Facet Joint Fixation and Anterior, Direct Lateral, and Transforaminal Lumbar Interbody Fusions for Treatment of Degenerative Lumbar Disc Diseases: Retrospective Cohort Study of a New Minimally Invasive Technique.

BACKGROUND: Anterior, direct lateral, and transforaminal lumbar interbody fusions (ALIF, DLIF, and TLIF) are usually combined with posterior fixation to treat degenerative spinal diseases. Outcomes of ALIF, TLIF, or DLIF combined with a new wedge-shaped interfacet cage plate have not been reported. We assessed early clinical outcomes of patients treated with interbody fusion and facet fixation using a titanium wedge-shaped cage plate. METHODS: This retrospective observational cohort study included patients (n = 80) who underwent 1-level interbody fusion and facet joint fixation via ALIF (n = 24) or DLIF (n = 26) with bilateral facet fixation or TLIF with ipsilateral pedicle screws and contralateral facet fixation (n = 30). Duration of surgery, estimated blood loss, pain (visual analog scale), Oswestry Disability Index (ODI) scores, and Macnab score were assessed up to 12 months after surgery. RESULTS: All patients had a significant decrease in pain scores (P < 0.01) and an increase in ODI scores (P < 0.01), without significant differences between treatment groups. Most surgical outcomes were excellent or good (n = 75, 93.8%) with 5 patients (6.2%) having satisfactory outcomes. Within 2 months, all patients returned to their previous work (66, 82.5%) or lighter work (14, 17.5%). Two patients had fusion failure requiring reoperation. CONCLUSIONS: Facet fixation with the wedge-shaped cage plate was associated with minimal soft tissue damage and a low level of postoperative pain. ALIF, DLIF, and TLIF combined with this technique showed good early postoperative clinical and radiologic outcomes. Further studies are needed to assess long-term results and compare them with other fusion methods.

Apparent diffusion coefficient maps in the assessment of surgical patients with lumbar spine degeneration.

PURPOSE: To assess the utility of apparent diffusion coefficient (ADC) maps for the assessment of patients with advanced degenerative lumbar spine disease and describe characteristic features of ADC maps in various degenerative lumbar spinal conditions. METHODS: T1-weighted, T2-weighted and diffusion weighted (DWI) MR images of 100 consecutive patients admitted to the spinal surgery service were assessed. ADC maps were generated from DWI images using Osyrix software. The ADC values and characteristic ADC maps were assessed in the regions of interest over the different pathological entities of the lumbar spine. RESULTS: The study included 452 lumbar vertebral segments available for analysis of ADCs. Characteristic ADC map features were identified for protrusion, extrusion and sequester types of lumbar disk herniations, spondylolisthesis, reactive Modic endplate changes, Pfirrmann grades of IVD degeneration, and compromised spinal nerves. Compromised nerve roots had significantly higher mean ADC values than adjacent (p < 0.001), contralateral (p < 0.001) or adjacent contralateral (p < 0.001) nerve roots. Compared to the normal bone marrow, Modic I changes showed higher ADC values (p = 0.01) and Modic 2 changes showed lower ADC values (p = 0.02) respectively. ADC values correlated with the Pfirrmann grading, however differed from herniated and non-herniated disks of the matched Pfirrmann 3 and 4 grades. CONCLUSION: Quantitative and qualitative evaluation of ADC mapping may provide additional useful information regarding the fluid dynamics of the degenerated spine and may complement standard MRI imaging protocol for the comprehensive assessment of surgical patients with lumbar spine pathology. ADC maps were advantageous in differentiating reactive bone marrow changes, and more precise assessment of the disk degeneration state. ADC mapping of compressed nerve roots showed promise but requires further investigation on a larger cohort of patients.