Tranexamic acid reduces perioperative blood loss in cervical laminoplasty: a prospective randomized study.

STUDY DESIGN: A prospective randomized comparative study. OBJECTIVE: To evaluate the effect of tranexamic acid (TXA) on decreasing perioperative blood loss in cervical laminoplasty, in which the surgical procedure is identical in all cases. SUMMARY OF BACKGROUND DATA: TXA, an inhibitor of fibrinolysis, has proven to be effective in reducing perioperative blood loss in patients undergoing total hip and knee arthroplasty. However, only a limited number of well-controlled spinal surgery trials have been conducted due to heterogeneity in the performed surgical procedures. METHODS: Forty consecutive patients with cervical compressive myelopathy were prospectively randomized into groups that received 15 mg/kg body weight of TXA or placebo intravenously before the skin incision was made. "French-door" cervical laminoplasty from C3 to C6 was performed for all patients by using a consistent procedure. Intraoperative and postoperative blood loss was compared between the groups. The surgery and follow-up were conducted at a single institution. RESULTS: There were no statistically significant differences between the TXA and control groups in terms of age, sex, body mass index, and operating time. Intraoperative blood loss in the TXA group (49.1 ± 30.6 mL) was not significantly different from that in the control group (63.4 ± 53.0 mL, P = 0.30). However, in the TXA group, postoperative blood loss during the first 16 hours was reduced by 37% as compared to the control group (132.0 ± 45.3 vs. 211.0 ± 41.5 mL; P < 0.01). The total blood loss (intraoperative plus postoperative blood loss during the first 40 hours) in the TXA group (264.1 ± 75.1 mL) was significantly lower than that in the control group (353.9 ± 60.8 mL, P < 0.01). No thromboembolic events or complications occurred in either group. CONCLUSION: TXA significantly reduced perioperative blood loss, primarily through a reduction in postoperative blood loss, in cervical laminoplasty.

Mini-open versus conventional open posterior lumbar interbody fusion for the treatment of lumbar degenerative spondylolisthesis: comparison of paraspinal muscle damage and slip reduction.

STUDY DESIGN: A comparative analysis of paraspinal muscle damage and radiographic parameters after mini-open and conventional open posterior lumbar interbody fusion (PLIF). OBJECTIVE: To determine whether mini-open PLIF decreases paraspinal muscle damage and yields the same radiographic results as those in conventional open PLIF. SUMMARY OF BACKGROUND DATA: Compared with conventional open PLIF, mini-open PLIF using a paramedian approach reduces intraoperative hemorrhage and decreases postoperative back pain. However, whether the latter produces less paraspinal muscle damage than the former remains unclear. No comparative study has investigated slip reduction and segmental lordosis at the fusion level in the 2 techniques. METHODS: We studied 20 patients (10 in each group) who had undergone single-level conventional (midline approach) or mini-open (bilateral Wiltse approach) PLIF with pedicle screws and interbody cages at the L4-L5 level for lumbar degenerative spondylolisthesis. The rate of improvement in the Japanese Orthopedic Association score; radiographic parameters, including %slip; segmental lordotic angle at the L4-L5 level; and fusion rate were examined. Postoperative multifidus (MF) atrophy and degeneration were evaluated using magnetic resonance imaging. RESULTS.: No significant differences were detected between the 2 groups with respect to the rate of improvement in the Japanese Orthopedic Association score, segmental lordotic angle, and fusion rate. Both groups showed significant reduction in %slip after surgery. The degree of MF atrophy and the increase in T2-signal intensity in the MF muscle after mini-open PLIF were significantly lesser than those following open PLIF. CONCLUSION: Mini-open PLIF is safe and effective. Mini-open PLIF was less invasive than open PLIF with regard to the MF muscle.

Union versus nonunion after posterolateral lumbar fusion: a comparison of long-term surgical outcomes in patients with degenerative lumbar spondylolisthesis.

It has been reported that in patients undergoing posterolateral lumbar fusion (PLF), the fusion status is not related to the short-term operative results. To determine whether the fusion status influences the long-term operative results of PLF, we retrospectively examined the surgical outcomes of uninstrumented PLF for a minimum of 8 years (average, 9.5 years), by comparing cases exhibiting union with those exhibiting nonunion. Uninstrumented PLF was performed for the treatment of lumbar canal stenosis (LCS) with degenerative spondylolisthesis. Since nine patients were lost to final follow-up, the study included 42 patients, and the follow-up rate was 82.4%. The mean age of the patients was 64.1 years (range 46-77 years). Eight patients exhibited fusion at the L3-4 level and 34 patients, at the L4-5 level. The fusion status was assessed using plain radiographs. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scores. Nonunion was noted in 26% (11/42) of the patients. There were no statistically significant differences between the groups exhibiting union and nonunion with respect to age, sex, preoperative JOA score, or preoperative lumbar instability. The union group achieved better operative results than the nonunion group at the 5-year and final follow-up (P = 0.006 and 0.008, respectively) although there was no significant difference in the percent recovery at 1 and 3-year follow-up (P = 0.515 and 0.506, respectively). A stepwise regression analysis revealed that the best combination of predictors for percent recovery at the time of final follow-up included the fusion status and the presence of comorbid disease. The results indicate that the fusion status following PLF is a critical factor influencing the long-term but not short-term operative results in the treatment of LCS with degenerative spondylolisthesis.

Pro-inflammatory and anti-inflammatory cytokine increases after spinal instrumentation surgery.

We investigated the effects of instrumentation on postoperative inflammatory reaction and identified standard changes in serum cytokine concentrations after spinal surgery. Pro-inflammatory cytokines [interleukin (IL)-6 and IL-8] and anti-inflammatory cytokines [IL-10, IL-1 receptor antagonist (ra), and soluble tumor necrosis factor receptors (sTNF-R) I and II] were assayed in serum from seven patients with lumbar spinal posterior decompression, six with spinal decompression and posterolateral fusion without instrumentation and seven with spinal decompression and posterolateral fusion with instrumentation. All cytokines after spinal instrumentation increased significantly more than in other groups on postoperative days 0 and 1. Seven days after SI, IL-6, -8, and -10 had normalized, but IL-1ra and sTNF-RI and sTNF-RII remained elevated. Both pro-inflammatory and anti-inflammatory cytokines were enhanced by implants in the acute phase, whereas only anti-inflammatory cytokines were enhanced by instruments in the subacute phase.