Subsidence after total lumbar disc replacement is predictable and related to clinical outcome.

PURPOSE: As yet, there are no studies describing a relationship between radiographic subsidence after lumbar total disc replacement (TDR) and patient symptoms. To investigate if subsidence, in terms of penetrated bone volume or angular rotation over time (ΔPBV and ΔAR), is related to clinical outcome. To assess if subsidence can be predicted by position implant asymmetry (IA) or relative size of the TDR, areal undersizing index (AUI) on direct post-operative radiographs. METHODS: Retrospective cohort study consists of 209 consecutive patients with lumbar TDR for degenerative disc disease. A three-dimensional graphical representation of the implant in relation to the bony endplates was created on conventional radiographs. Consequently, the PBV, AR, IA and AUI were calculated, direct post-operative (DPO) and at last follow-up (LFU). For clinical evaluation, patients with substantial pain (VAS ≥ 50) and malfunction (ODI ≥ 40) were considered failures. RESULTS: At a mean follow-up of 16.7 years, 152 patients (73%) were available for analysis. In 32 patients, revision by spinal fusion had been performed. Both ΔAR (4.33° vs. 1.83°, p = 0.019) and ΔPBV (1448.4 mm3 vs. 747.3 mm3, p = 0.003) were significantly higher in the failure-compared to the success-group. Using ROC curves, thresholds for symptomatic subsidence were defined as ΔPBV ≥ 829 mm3 or PBV-LFU ≥ 1223 mm3 [area under the curve (AUC) 0.723, p = 0.003 and 0.724, p = 0.005, respectively]. Associations between symptomatic subsidence and AUI-DPO ≥ 0.50 (AUC 0.750, p = 0.002) and AR-DPO ≥ 3.95° (AUC 0.690, p = 0.022) were found. CONCLUSION: Subsidence of a TDR is associated with a worse clinical outcome. The occurrence of subsidence is higher in case of incorrect placement or shape mismatch.

[Hypobaric spinal anesthesia in a large ventral hernia]. / Anestesia espinal hipobara en hernia supraumbilical de gran tamaño.

High abdominal wall surgery may require general anesthesia but, in patients with high risk of difficult airway and respiratory complications, local or regional anesthesia is the choice whenever possible. Spinal anesthesia usually used (both isobaric and hyperbaric) could compromise the respiratory function due to blockade of the T6 metamere or higher. Hypobaric spinal anesthesia (HSA) at low doses (3.6 cc of 0.1% hypobaric bupivacaine plus 0.2 cc of 0.005% fentanyl) achieves sufficient analgesia with minimal motor blockade. We present the case of a patient with a large supraumbilical hernia with high risk of difficult airway and respiratory complications, who went through HSA. The patient did not report pain or dyspnea during the surgical procedure thus, HSA at low doses is an option to be taken into account in high abdominal wall surgery despite not having been described for this use.

Homocisteina plasmática como factor pronóstico de mortalidad en pacientes con fractura de cadera / Plasmatic homocysteine as prognostic factor for mortality for patients with hip fracture

Introducción y objetivos: Los objetivos del estudio fueron describir la población sometida a cirugía por fractura de cadera, valorar la incidencia de morbilidad y mortalidad e identificar los factores pronósticos asociados a la mortalidad. Pacientes y métodos: Estudio prospectivo, con seguimiento de seis meses después del alta hospitalaria, de pacientes mayores de 64 años sometidos a cirugía de fractura de cadera en el Hospital Santa Bárbara, Soria (España). Se estudiaron parámetros sociodemográficos, complicaciones clínicas y mortalidad. Resultados: Se incluyó a 97 pacientes, de edad media de 85,86 años (DE 7,61), de los cuales 76,90% eran mujeres. El 83,50% de los pacientes tenían un riesgo anestésico ASA III-IV. La estancia media hospitalaria fue de 14,04 días (DE 4,78). La quinta parte de los pacientes (21,65%) presentaron alguna complicación postoperatoria, principalmente de origen respiratorio. La mortalidad intrahospitalaria fue del 13,20% y de 16,50% a los 6 meses. Los factores pronósticos independientes de mortalidad fueron la infección respiratoria, el riesgo anestésico ASA IV y los niveles elevados de homocisteina. Conclusiones: La fractura de cadera está asociada con una elevada tasa de morbilidad y mortalidad a los seis meses de la intervención. La infección respiratoria, el riesgo anestésico ASA IV y los niveles elevados de homocisteina son factores pronósticos de mortalidad en estos pacientes

Background and objective: The objetive of the study was to describe the population of patients undergoing surgery for hip fracture, to assess the incidence of mortality and identify associated prognostic factors. Patients and methods. A prospective study, with follow-up during six months after hospital discharge, of patients over 64 years old undergoing surgery for hip fracture at Santa Barbara Hospital, Soria (Spain). Variables studied were sociodemographic parameters, clinical complications and mortality. Results. A total of 97patients were included, with a mean age of 85.86 years (7.61), of whom 76.9% were woman and 83.50% were ASA III-IV. The mean hospital stay was 14.04 days (SD 4.78). The figth part (21.65%) of the patients had postoperative complications, the most frequent being respiratory. In hospital mortality was 13.2 % and 16.50% at 6 months. Indepent prognostic factors of mortality after surgery were the respiratory infection, ASA IV anesthesia risk and high levels of homocysteine. Conclusions: Hip fracture is associate with a high post-operative morbidity and mortality rate at six months after surgery. The respiratory infection, ASA IV anesthesia risk and high levels of homocysteine are indepent prognostic factor of mortality in these patients

Histerectomía radical en paciente con enfermedad de Steinert: raquianestesia, ketamina y bloqueos TA P y de la vaina de los rectos / Radical hysterectomy in a patient with Steinert disease: spinal anaesthesia, ketamine and TAP and rectus sheath blocks

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[Radical hysterectomy in a patient with Steinert disease: spinal anaesthesia, ketamine and TAP and rectus sheath blocks]. / Histerectomía radical en paciente con enfermedad de Steinert: raquianestesia, ketamina y bloqueos TAP y de la vaina de los rectos.

The case of a patient with Steinert disease who underwent surgery for radical hysterectomy is presented. Because of her advanced disease, she suffered from chronic respiratory failure which required non-invasive ventilation (NIV) at night. Spinal anaesthesia was chosen as an anaesthetic treatment. At the time of aortic lymphadenectomy, the patient reported moderate pain at hypogastrium, which was well controlled with boluses of 10 mg of ketamine. Postoperatively, opioid administration was avoided by applying abdominal wall blocks: transverse abdominis plane (TAP) block and sheath of rectus abdominis muscle block. The evolution of the patient was satisfactory and she was discharged on the fifth day after surgery.