The risk of risk-adjustment measures for perioperative spine infection after spinal surgery.

STUDY DESIGN: Cross-sectional data analysis of the Nationwide Inpatient Sample (NIS). OBJECTIVE: To develop a risk-adjustment index specific for perioperative spine infection and compare this specific index to the Deyo Comorbidity Index. Assess specific mortality and morbidity adjustments between teaching and nonteaching facilities. SUMMARY OF BACKGROUND DATA: Risk-adjustment measures have been developed specifically for mortality and may not be sensitive enough to adjust for morbidity across all diagnosis. METHODS: This condition-specific index was developed by using the NIS in a two-step process to determine confounders and weighting. Crude and adjusted point estimates for the Deyo and condition-specific index were compared for routine discharge, death, length of stay, and total hospital charges and then stratified by teaching hospital status. RESULTS: A total of 23,846 perioperative spinal infection events occurred in the NIS database between 1988 and 2007 of 1,212,241 procedures. Twenty-three diagnoses made up this condition-specific index. Significant differences between the Deyo and the condition-specific index were seen among total charges and length of stay at nonteaching hospitals (P < 0.001) and death, length of stay, and total charges (P < 0.001) for teaching hospitals. CONCLUSION: This study demonstrates several key points. One, condition-specific measures may be useful when morbidity is of question. Two, a condition-specific perioperative spine infection adjustment index appears to be more sensitive at adjusting for comorbidities. Finally, there are inherent differences in hospital disposition characteristics for perioperative spine infection across teaching and nonteaching hospitals even after adjustment.

The use of antifibrinolytic agents in spine surgery. A meta-analysis.

BACKGROUND: Antifibrinolytic agents have been shown to decrease the blood loss associated with major orthopaedic surgical procedures. Spine surgery, particularly procedures performed for deformity correction and procedures involving long arthrodesis constructs, can be associated with a large amount of blood loss requiring blood transfusions. The purpose of the present study was to determine if antifibrinolytic agents reduced blood transfusions in patients managed with spine surgery and to see if one agent had a greater effect than another. METHODS: A systematic review and meta-analysis of the available literature were performed to investigate the efficacy of aprotinin, tranexamic acid, and epsilon-aminocaproic acid in terms of reducing blood loss and blood transfusions in patients undergoing spine surgery. This meta-analysis was focused on the role of these agents in major spine operations as reported in eighteen clinical trials that included information on the drug dosage, the age of the patient, blood loss, blood transfusions, surgery complexity, and complications. RESULTS: Compared with control groups, the treatment groups for all three antifibrinolytic agents maintained lower levels of total blood loss and transfusions associated with spine surgery. The effect size (d) of the differences in total blood loss between the treatment and control groups ranged from -0.668 (95% confidence interval, -0.971 to -0.365) to -0.936 (95% confidence interval, -1.240 to -0.632) across all three agents. The effect size (d) of the differences in total blood transfusions between the treatment and control groups ranged from -0.466 (95% confidence interval, -0.764 to -0.167) to -0.749 (95% confidence interval, -1.046 to -0.453) across all three agents. CONCLUSIONS: Aprotinin, tranexamic acid, and epsilon-aminocaproic acid are effective for reducing blood loss and transfusions in patients managed with spine surgery. With the exception of aprotinin, the side-effect profiles of these agents have not been shown to cause any substantial morbidity or to increase the rate of thromboembolic events. Epsilon-aminocaproic acid had a greater effect on reducing blood transfusions as the complexity of surgery increased. The surgeon and/or the anesthesiologist should consider the use of antifibrinolytic agents for patients undergoing spinal procedures in which a large amount of blood loss can be expected; however, at the present time, this is not a United States Food and Drug Administration-approved indication for these agents.

Corrective osteotomies in spine surgery.

Spinal deformities can result in increasing thoracic kyphosis or loss of lumbar lordosis, leading to imbalance in the sagittal plane. Such deformities can be functionally and psychologically debilitating. The Smith-Petersen osteotomy can achieve approximately 10 degrees of correction in the sagittal plane at each spinal level at which it is performed. This osteotomy is beneficial for patients who have a degenerative imbalance in the sagittal plane. The pedicle subtraction osteotomy can achieve approximately 30 degrees to 40 degrees of correction in the sagittal plane at each spinal level at which it is performed. It is the preferred osteotomy for patients with ankylosing spondylitis who have an imbalance of the spine in the sagittal plane. The cervical extension osteotomy is performed in the cervical spine, at the cervicothoracic junction, in patients who have a cervical flexion deformity that impedes their ability to look straight ahead while walking or who have difficulty swallowing. The vertebral column resection is used when the imbalance is severe enough that the other osteotomies cannot correct the deformity, especially in patients who have a combined sagittal and coronal spinal imbalance. Neurologic problems, whether transient or permanent, are the most commonly encountered complications following these procedures. Recent results have shown a high patient satisfaction rate and good functional outcomes after spinal osteotomies done to treat a variety of disorders.

Fat suppression imaging in epidural lipomatosis: case report.

A case of epidural lipomatosis associated with steroid use in rheumatoid arthritis is presented to describe the role of fat suppression imaging as a diagnostic tool. The plain radiographs revealed several vertebral compression fractures and the magnetic resonance imaging (MRI) showed a large extradural mass. A fat suppression MRI was obtained, which confirmed the diagnosis of epidural lipomatosis. A fat suppression MRI scan is a special imaging technique that is used in particular to either suppress the signal from adipose tissue or detect adipose tissue. An MRI scan is the imaging tool of choice to examine soft tissue lesions of the spine, and fat suppression imaging will provide additional information about any fatty soft tissue lesion, as in the case of epidural lipomatosis. This imaging modality is particularly useful in those patients who are morbidly obese or taking exogenous corticosteroids, because these conditions can proliferate adipose tissue leading to epidural lipomatosis.

Comparing pain reduction following kyphoplasty and vertebroplasty for osteoporotic vertebral compression fractures.

BACKGROUND: Osteoporosis with subsequent osteoporotic vertebral compression fractures is an increasingly important disease due not only to its significant economic impact but also to the increasing age of our population. Pain reduction and stabilization are of primary importance with osteoporotic vertebral compression fractures. Although many patients heal with conservative treatment consisting of rest or activity modification, analgesics, and bracing, the management of severe pain compels some patients to seek surgical intervention via 2 procedures: vertebroplasty and kyphoplasty. Although there is abundant support in the literature for both procedures, there remains debate over which procedure can most successfully reduce patients' perception of pain. OBJECTIVE: To determine the amount of pain reduction using the visual analog scale (VAS) with kyphoplasty and vertebroplasty in the treatment of osteoporotic vertebral compression fractures. DESIGN: Meta-analysis METHODS: A systematic review and meta-analysis of the available literature was performed to quantify the amount of pain reduction using the visual analog scale (VAS) between vertebroplasty and kyphoplasty for osteoporotic vertebral compression fractures. RESULTS: Twenty-one studies, 14 vertebroplasty and 7 kyphoplasty, qualified for inclusion representing totals of 1,046 vertebroplasty and 263 kyphoplasty patients treated, respectively. Kyphoplasty and vertebroplasty resulted in a more than 5 point drop in the VAS in the immediate postoperative period (p<0.00001). Between the two, the difference in early pain relief was not significant. At final follow-up, the long-term VAS was improved for both procedures, but the final follow-up VAS for vertebroplasty and kyphoplasty was not significant when compared to the initial postoperative VAS (p=0.25, p=0.38, respectively). CONCLUSIONS: The analysis demonstrates that both procedures reduce the amount of pain in the immediate postoperative period by approximately 50%. Both procedures reduce pain in symptomatic osteoporotic vertebral compression fractures that have failed conservative treatment. Randomized controlled trials are needed to provide definitive data on which procedure is the most effective for vertebral compression fractures.

Intertrochanteric hip fractures treated with the trochanteric fixation nail and sliding hip screw.

The primary treatment options for intertrochanteric hip fractures are a sliding hip screw (SHS) and an intramedullary device, with each having its own advantages and disadvantages. The authors retrospectively compared all intertrochanteric hip fractures between 2003 and 2005 using a cephalomedullary nail--the trochanteric fixation nail (TFN)--to those using a SHS. Outcome measures included the following parameters: age, gender, fracture classification, operation time, blood loss, transfusions, complications, follow-up, length of stay, and hospital cost. A total of 95 patients were included in the study (51 SHS and 44 TFN). The two groups were similar in age (p = .52), blood loss (p = .20), follow-up (p = .13), length of stay (p = .63), and hospital costs (p = .70). The TFN procedure required shorter operative times (56.5 min, p < .004) and was used in more complex fracture patterns (p < .03). The SHS group had fewer blood transfusions (1.2 units, p < .0008). The SHS group had a higher complication rate of 19.6%, versus the TFN group's 11.4% rate (p = .13). The TFN is an appropriate and acceptable treatment method for intertrochanteric hip fractures.

Comparison of manual and gravity stress radiographs for the evaluation of supination-external rotation fibular fractures.

BACKGROUND: Isolated distal fibular fractures most commonly result from a supination-external rotation injury of the ankle. Deltoid ligament ruptures can also be associated with these injuries, resulting in an unstable ankle fracture due to incompetent lateral and medial restraints. We hypothesized that a gravity stress radiograph is equivalent to a manual stress radiograph for the detection of deltoid ligament injury in association with an isolated fibular fracture. METHODS: All patients presenting to a level-1 trauma hospital emergency department with an isolated fibular fracture were screened. Ankle stability was determined on the basis of radiographic measurements of the medial clear space and talar shift. A manual stress radiograph and a gravity stress radiograph of the injured ankle were made for each patient. The manual stress radiograph was used to determine whether the ankle was stable or unstable. RESULTS: A total of twenty-five patients (thirteen with a supination-external rotation type-II fracture and twelve with a supination-external rotation type-IV-equivalent injury) were enrolled in the study. In the type-II group, the average medial clear space was 4.15 and 4.26 mm on the manual and gravity stress radiographs, respectively (p = 0.50). In the type-IV group, the average medial clear space was 5.21 and 5.00 mm on the manual and gravity stress radiographs, respectively (p = 0.69). CONCLUSIONS: The gravity stress radiograph is equivalent to the manual stress radiograph for determining deltoid ligament injury in association with an isolated distal fibular fracture, and thus it can be used to determine ankle stability in patients who present with an isolated distal fibular fracture.

The use of antifibrinolytic agents in total hip arthroplasty: a meta-analysis.

Total hip arthroplasty is associated with significant blood loss that often requires allogenic blood transfusions. Tranexamic acid and aprotinin have been shown to reduce blood loss and transfusions in clinical trials with variable results. This meta-analysis evaluates whether tranexamic acid and aprotinin significantly reduces blood loss and transfusion requirements in total hip arthroplasty. Thirteen clinical trials were identified. Combined, these agents were significant across all outcome measures in reducing blood loss and transfusions. Separately, only aprotinin was found to be significant. The data also showed that aprotinin (tranexamic acid is inconclusive) is only beneficial in revision total hip arthroplasty. Therefore, only aprotinin is effective in reducing both blood loss and transfusion requirements without an increase in thromboembolic complications in patients undergoing revision total hip arthroplasty.

Visual impairment following epidural fluid injections and epiduroscopy: a review.

INTRODUCTION: Visual impairment apparently is a rare but significant complication following epidural fluid injection and epiduroscopy. We report a review of cases reported in the literature with the aim of gaining an understanding of how the complication occurs as well as how to avoid it. MATERIALS AND METHODS: A literature review was performed using PubMed to find 1) case reports and 2) factors that contribute to the development of visual loss in the cases. RESULTS: Twelve cases of visual impairment following epiduroscopy or epidural fluid injection have been reported in the literature. The average age of the patients was approximately 50 years, 83.3% of the patients were female, 16.7% were male. Bolus injection of fluid with or without epiduroscopy was considered to be the precipitating event. The volume of solution injected epidurally varied from 20 mL to 120 mL (average = 59.4 mL). The common finding was retinal hemorrhage, with 58.3% occurring bilaterally. Recovery occurred in 79.2% of the cases. CONCLUSION: Retinal hemorrhage following epidural fluid injections/epiduroscopy apparently is due to an increase in cerebrospinal fluid pressure proportional to the rate and the amount of fluid injected. A sudden increase in epidural pressure is transmitted into the subarachnoid space to the optic nerve sheath, compressing the optic nerve and its vasculature. The vasculature compression ruptures retinal blood vessels.