The "In-Parallel" Technique for Awake, Bilateral Simultaneous Minimally Invasive Transforaminal Lumbar Interbody Fusion and Multilevel Lumbar Decompression.

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) and MIS lumbar decompression have been successfully undertaken in the absence of general anesthesia in well-selected patients. By leveraging spinal anesthesia, surgeons may safely conduct surgeries on one- or two-level lumbar pathology. However, surgeries on more extensive pathology have not yet been described, because of concerns about the duration of efficacy of spinal anesthetic in the awake patient. OBJECTIVE: To report the use of a novel awake technique for "in parallel," simultaneous lumbar spinal surgery on three-segment pathology. METHODS: We describe concurrent performance of a dual microscopic, navigated MIS TLIF and MIS two-level decompression, using a combination of liposomal bupivacaine erector spinae block in conjunction with a spinal anesthetic. RESULTS: We show that a left-sided, two-level MIS tubular microscopic decompression combined with a concurrent right-sided, transfacet MIS TLIF via a tubular microscopic approach was well tolerated in an 87-year-old patient with multilevel lumbar stenosis with a mobile spondylolisthesis. CONCLUSION: We provide the first description of a dual-surgeon approach for minimally invasive spine surgery. This "in-parallel" technique-reliant on 2, independent spine surgeons-may aid in the performance of surgeries previously considered too extensive, given the time constraints of regional anesthesia and can be successfully applied to patients who otherwise may not be candidates for general anesthesia.

Perioperative outcomes of general versus spinal anesthesia in the lumbar spine surgery population: A systematic review and meta-analysis of data from 2005 through 2021.

Study design: Meta-analysis. Objectives: Perform a systematic review and meta-analysis to determine the perioperative utility of general versus spinal anesthesia in the lumbar spine surgery population. Methods: PubMed and Embase were queried for manuscripts reporting perioperative outcomes for patients undergoing one to three-level lumbar spine surgery (including decompression, fusion, and decompression with fusion) using either general or spinal anesthesia. Inclusion criteria included studies published from 2005 to 2021, in English, involving primary data from human subjects. Studies were further screened for data on total operative time, blood loss, intraoperative hypotension, pain scores, postoperative nausea and vomiting, time required in post-anesthesia care unit (PACU), PACU pain anesthetic requirement, and length of stay. Risk of bias for each study was assessed using standardized tools (i.e., RoB 2, ROBINS-I, NOS, as appropriate). Potential predictors of outcome were compared using univariate analysis, and variables potentially associated with outcome were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to produce standard mean differences (SMD) or odds ratios (OR) and 95% confidence intervals (CI). Results: In total, 12 studies totaling 2796 patients met inclusion criteria. 1414 (50.6%) and 1382 (49.4%) patients underwent lumbar spine surgery with general anesthesia and spinal anesthesia, respectively. Patients undergoing spinal anesthesia were statistically more likely to have coronary artery disease and respiratory dysfunction. Total operative time (SMD: 12.62 min, 95% CI -18.65 to -6.59), estimated blood loss (SMD: 0.57 mL, 95% CI -0.68 to -0.46), postoperative nausea and vomiting (OR = 0.20, 95% CI 0.15 to 0.26), time required in PACU (SMD = -0.20 min, 95% CI -0.32 to -0.08), and length of stay (SMD = -0.14 day, 95% CI -0.18 to -0.10), all statistically significantly favored spinal anesthesia over general anesthesia (p < 0.05). Conclusion: In one to three-level lumbar spine surgery, current literature supports spinal anesthesia as a viable alternative to general anesthesia. As this was a heterogeneous patient population, prospective randomized trials are needed to corroborate findings.

Robotic-Assisted Trajectory Into Kambin's Triangle During Percutaneous Transforaminal Lumbar Interbody Fusion-Initial Case Series Investigating Safety and Efficacy.

BACKGROUND: Minimally invasive spine surgery (MISS) has the potential to further advance with the use of robot-assisted (RA) techniques. While RA pedicle screw placement has been extensively investigated, there is a lack of literature on the use of the robot for other tasks, such as accessing Kambin's triangle in percutaneous lumbar interbody fusion (percLIF). OBJECTIVE: To characterize the surgical feasibility and preliminary outcomes of an initial case series of 10 patients receiving percLIF with RA cage placement via Kambin's triangle. METHODS: We performed a single-center, retrospective review of patients undergoing RA percLIF using robot-guided trajectory to access Kambin's triangle for cage placement. Patients undergoing RA percLIF were eligible for enrollment. Baseline health and demographic information in addition to peri- and postoperative data was collected. The dimensions of each patient's Kambin's triangle were measured. RESULTS: Ten patients and 11 levels with spondylolisthesis were retrospectively reviewed. All patients successfully underwent the planned procedure without perioperative complications. Four patients underwent their procedure with awake anesthesia. The average dimension of Kambin's triangle was 66.3 m2. With the exception of 1 patient who stayed in the hospital for 7 d, the average length of stay was 1.2 d, with 2 patients discharged the day of surgery. No patients suffered postoperative motor or sensory deficits. Spinopelvic parameters and anterior and posterior disc heights were improved with surgery. CONCLUSION: As MISS continues to evolve, further exploration of robot-guided surgical practice, such as our technique, will lead to creative solutions to challenging anatomical variation and overall improved patient care.

Hematocrit as a predictor of preoperative transfusion-associated complications in spine surgery: A NSQIP study.

BACKGROUND CONTEXT: Preoperative optimization of medical comorbidities prior to spinal surgery is becoming an increasingly important intervention in decreasing postoperative complications and ensuring a satisfactory postoperative course. The treatment of preoperative anemia is based on guidelines made by the American College of Cardiology (ACC), which recommends packed red blood cell transfusion when hematocrit is less than 21% in patients without cardiovascular disease and 24% in patients with cardiovascular disease. The literature has yet to quantify the risk profile associated with preoperative pRBC transfusion. PURPOSE: To determine the incidence of complications following preoperative pRBC transfusion in a cohort of patients undergoing spine surgery. STUDY DESIGN: Retrospective review of a national surgical database. PATIENT SAMPLE: The national surgical quality improvement program database OUTCOME NEASURES: Postoperative physiologic complications after a preoperative transfusion. Complications were defined as the occurrence of any DVT, PE, stroke, cardiac arrest, myocardial infarction, longer length of stay, need for mechanical ventilation greater than 48 h, surgical site infections, sepsis, urinary tract infections, pneumonia, or higher 30-day mortality. METHODS: The national surgical quality improvement program database was queried, and patients were included if they had any type of spine surgery and had a preoperative transfusion. RESULTS: Preoperative pRBC transfusion was found to be protective against complications when the hematocrit was less than 20% and associated with more complications when the hematocrit was higher than 20%. In patients with a hematocrit higher than 20%, pRBC transfusion was associated with longer lengths of stay, and higher rates of ventilator dependency greater than 48 h, pneumonia, and 30-day mortality. CONCLUSION: This is the first study to identify an inflection point in determining when a preoperative pRBC transfusion may be protective or may contribute to complications. Further studies are needed to be conducted to stratify by the prevalence of cardiovascular disease.

Identifying Components Necessary for an Enhanced Recovery After Surgery Pathway for Elective Intracranial Surgery: An Improvement Project Using the Quality of Recovery-15 Score.

OBJECTIVE: To identify the domains of recovery, as determined by the Quality of Recovery-15 (QoR-15) score, that needed improvement to develop initial interventions for an enhanced recovery after surgery protocol for patients undergoing elective intracranial surgery under general anesthesia. METHODS: A paired-availability design was used to assess 2 groups of 41 patients undergoing elective intracranial surgery. The baseline QoR-15 score and scores 0, 6, 12, and 24 hours after arrival in the intensive care unit characterized the postoperative recovery trajectory. The lowest scoring domains of the QoR-15 score were identified in the preimplementation group, and pharmacologic interventions were initiated in the postimplementation group. RESULTS: Postoperative analgesia and postoperative nausea and vomiting were identified as the lowest scoring domains. The pharmacologic interventions implemented were chosen because they produced minimal sedation and were easy to administer-1 40-mg oral preoperative dose of aprepitant to target postoperative nausea and vomiting and 2 perioperative 1-g doses of intravenous acetaminophen to improve analgesia. We observed a clinically significant as well as statistically significant improvement in analgesia on arrival in the intensive care unit and at the 6-hour postoperative time point. The total QoR-15 score was improved through the 12-hour time point. CONCLUSIONS: In this quality improvement project, the QoR-15 score allowed us to identify domains that slowed the recovery course in this patient population. Two 1-g doses of intravenous acetaminophen improved patients' well-being and analgesia after elective intracranial surgery.

Paradox of age: older patients receive higher age-adjusted minimum alveolar concentration fractions of volatile anaesthetics yet display higher bispectral index values.

BACKGROUND: Minimum alveolar concentration (MAC) and MAC-awake decrease with age. We hypothesised that, in clinical practice, (i) end-tidal MAC fraction in older patients would decline by less than the predicted age-dependent MAC decrease (i.e. older patients would receive relatively excessive anaesthetic concentrations), and (ii) bispectral index (BIS) values would therefore be lower in older patients. METHODS: We examined the relationship between end-tidal MAC fraction, BIS values, and age in 4699 patients > 30 yr in age at a single centre using unadjusted local regression (locally estimated scatterplot smoothing), Spearman's correlation, stratification, and robust univariable and multivariable linear regression. RESULTS: The end-tidal MAC fraction in older patients declined by 3.01% per decade (95% confidence interval [CI]: 2.56-3.45; P<0.001), less than the 6.47% MAC decrease per decade that we found in a meta-regression analysis of published studies of age-dependent changes in MAC (P<0.001), and less than the age-dependent decrease in MAC-awake. The BIS values correlated positively with age (ρ=0.15; 95% CI: 0.12-0.17; P<0.001), and inversely with the age-adjusted end-tidal MAC (aaMAC) fraction (ρ= -0.13; 95% CI: -0.16, -0.11; P<0.001). CONCLUSIONS: The age-dependent decline in end-tidal MAC fraction delivered in clinical practice at our institution was less than the age-dependent percentage decrease in MAC and MAC-awake determined from published studies. Despite receiving higher aaMAC fractions, older patients paradoxically showed higher BIS values. This most likely suggests that the BIS algorithm is inaccurate in older adults.

Laboratory Monitoring and Transfusion Guidelines to Influence Care in Patients Undergoing Multilevel Spinal Fusion Surgery.

PURPOSE: The purpose of this project was to determine whether the use of the modified Northwestern high risk spine protocol in patients undergoing multilevel spinal fusion surgery would result in improved transfusion practices. DESIGN: Preimplementation and postimplementation design. METHODS: A laboratory monitoring and transfusion guideline protocol was implemented in patients undergoing multilevel spinal fusions. Data were collected via a manual retrospective chart review of the electronic medical record before and after implementation of the protocol. FINDINGS: Laboratory values were monitored at guided intervals. There was a statistically significant (P = .004) decrease in the mean hemoglobin value at which a packed red blood cell transfusion was initiated. CONCLUSIONS: Through the use of the protocol, laboratory value monitoring provided quantitative data to aid and improve clinical decision making for practitioners in the perioperative period.

Implementation of an Obstructive Sleep Apnea Protocol in the Postanesthesia Care Unit for Patients Undergoing Spinal Fusion Surgery.

PURPOSE: The purpose of this project was to implement and evaluate the effectiveness of a postanesthesia care unit (PACU) obstructive sleep apnea (OSA) protocol in patients undergoing spinal fusion surgery. DESIGN: The structure of this project was a preimplementation and postimplementation design. METHODS: A convenience sample of 63 patients admitted to the PACU after spinal fusion surgery, with diagnosed or high-risk OSA, was included in protocol implementation. FINDINGS: The prevalence of diagnosed and high-risk OSA at the project implementation site totaled 74% in the spinal fusion population. The incidence of oxygen desaturations was 41% in the preimplementation group and 35% in the postimplementation group. The PACU to intensive care unit transfers were 10% in the preimplementation group and 3% in the postimplementation group. CONCLUSIONS: Protocols for surgical patients with OSA require further examination but may function as a guide for postoperative nursing care.

Low-Dose Ketamine Infusion to Decrease Postoperative Delirium for Spinal Fusion Patients.

PURPOSE: The primary aim of this project was to decrease the incidence of postoperative delirium after spine surgery. DESIGN: A prospective preimplementation and postimplementation design was used. METHODS: A reduced dose ketamine protocol was implemented for adult patients undergoing elective spinal fusion surgery. Thirty patients were assessed at five time points for the presence of postoperative delirium in the postanesthesia care unit (PACU) using the 3-Minute Diagnostic Interview for Confusion Assessment Method Defined Delirium tool and opioid requirements were compared. FINDINGS: A statistical difference was noted between two groups in the incidence of delirium at three of five time points: on arrival to the PACU, and at 60 and 90 minutes after arrival to the PACU. CONCLUSIONS: This pilot study establishes groundwork for further studies to investigate if the ketamine dose can decrease the incidence of postoperative delirium in the initial 90 minutes after surgery without decreasing its analgesic effect.

Implementation of Physiological Scoring to Determine Discharge Readiness for Patients Undergoing Otolaryngology Head and Neck Procedures.

PURPOSE: This quality improvement project examined whether the use of a validated physiological scoring protocol to determine discharge readiness for surgical procedures proximal to the airway would decrease the time at which discharge criteria were met and postanesthesia care unit (PACU) length of stay. DESIGN: An observational pre-post design compared preimplementation recovery times to postimplementation recovery times. METHODS: PACU nurses were trained to use two physiological scoring protocols to determine when patients met discharge criteria and to document when discharge criteria were met. FINDINGS: During the postimplementation period, there was a significant decrease in the time it took patients to meet PACU discharge criteria when using the physiological scoring protocols compared with the preimplementation group (P < .001). CONCLUSIONS: These results suggest that physiological scoring protocols are safe and appropriate to determine discharge readiness for patients who have surgery proximal to the airway.

Preprocedural Checklist for Magnetic Resonance Imaging Patients Undergoing General Anesthesia: A Process Improvement Plan to Enhance Reimbursement.

Thorough documentation is essential for hospital reimbursement from payors such as the Centers for Medicare & Medicaid Services. Inconsistencies and incomplete documentation can occur if workflow is not standardized especially in cases with interdisciplinary involvement. Documentation for patients undergoing magnetic resonance imaging (MRI) with anesthesia services was examined and revealed an opportunity for improvement to avoid financial losses. A preprocedure checklist to improve documentation and standardize workflow was implemented. We compared documentation from preintervention MRI to postintervention MRI with anesthesia services. Documentation that met the reimbursement requirements increased from 5% in the preintervention group to 90% in the postintervention group after the preprocedural checklist implementation. A cost estimate showed a reduction in potential revenue loss from preimplementation to postimplementation groups. The standardization of workflow with the aid of checklists helped meet the documentation requirements for adequate reimbursements and reduced the risk of potential reimbursement losses from payors.

A Randomized Controlled Trial of Low-Dose Tranexamic Acid versus Placebo to Reduce Red Blood Cell Transfusion During Complex Multilevel Spine Fusion Surgery.

BACKGROUND: Multilevel spine fusion surgery for adult deformity correction is associated with significant blood loss and coagulopathy. Tranexamic acid reduces blood loss in high-risk surgery, but the efficacy of a low-dose regimen is unknown. METHODS: Sixty-one patients undergoing multilevel complex spinal fusion with and without osteotomies were randomly assigned to receive low-dose tranexamic acid (10 mg/kg loading dose, then 1 mg·kg-1·hr-1 throughout surgery) or placebo. The primary outcome was the total volume of red blood cells transfused intraoperatively. RESULTS: Thirty-one patients received tranexamic acid, and 30 patients received placebo. Patient demographics, risk of major transfusion, preoperative hemoglobin, and surgical risk of the 2 groups were similar. There was a significant decrease in total volume of red blood cells transfused (placebo group median 1460 mL vs. tranexamic acid group 1140 mL; median difference 463 mL, 95% confidence interval 15 to 914 mL, P = 0.034), with a decrease in cell saver transfusion (placebo group median 490 mL vs. tranexamic acid group 256 mL; median difference 166 mL, 95% confidence interval 0 to 368 mL, P = 0.042). The decrease in packed red blood cell transfusion did not reach statistical significance (placebo group median 1050 mL vs. tranexamic acid group 600 mL; median difference 300 mL, 95% confidence interval 0 to 600 mL, P = 0.097). CONCLUSIONS: Our results support the use of low-dose tranexamic acid during complex multilevel spine fusion surgery to decrease total red blood cell transfusion.

Frequency and pattern of radiological and laboratory investigations in patients with mental illnesses: A study from North Rajasthan.

BACKGROUND: There are widespread perceptions that excessive and unnecessary investigations are done in many patients with mental illnesses. There are no studies from India looking into this issue. AIMS: (i) To study the frequency and pattern of various investigations such as electroencephalography (EEG), computerized tomography (CT) scan of head, magnetic resolution imaging (MRI) scan of brain, and blood investigations carried out by the previous doctors on patients seeking treatment in three different settings. (ii) To study the socio-demographic and clinical correlates of investigations carried out on these patients. STUDY DESIGN AND SETTINGS: A cross-sectional study in a community outreach clinic, a district level psychiatric hospital, and psychiatry outpatient clinic of a medical college. MATERIALS AND METHODS: 160 newly registered patients seeking treatment at these settings were assessed using a semi-structured pro forma regarding various investigations that they had undergone before seeking the current consultation. Frequency of investigations was analyzed. RESULTS: About 47.5% of patients had at least one of the three brain investigations done. EEG, CT head, and MRI brain had been done in 37.5%, 20.0%, and 8.8% of the patients, respectively. Only 1.8% of the patients had blood tests done before current consultation. CONCLUSION: This study results raise question whether certain investigations such as EEG and CT head were carried out excessively and blood investigations were done infrequently. Further studies on larger samples with prospective study design to evaluate the appropriateness of current practices of carrying out investigations in patients presenting with psychiatric symptoms are required.

Intraoperative Methadone for the Prevention of Postoperative Pain: A Randomized, Double-blinded Clinical Trial in Cardiac Surgical Patients.

BACKGROUND: The intensity of pain after cardiac surgery is often underestimated, and inadequate pain control may be associated with poorer quality of recovery. The aim of this investigation was to examine the effect of intraoperative methadone on postoperative analgesic requirements, pain scores, patient satisfaction, and clinical recovery. METHODS: Patients undergoing cardiac surgery with cardiopulmonary bypass (n = 156) were randomized to receive methadone (0.3 mg/kg) or fentanyl (12 µg/kg) intraoperatively. Postoperative analgesic requirements were recorded. Patients were assessed for pain at rest and with coughing 15 min and 2, 4, 8, 12, 24, 48, and 72 h after tracheal extubation. Patients were also evaluated for level of sedation, nausea, vomiting, itching, hypoventilation, and hypoxia at these times. RESULTS: Postoperative morphine requirements during the first 24 h were reduced from a median of 10 mg in the fentanyl group to 6 mg in the methadone group (median difference [99% CI], -4 [-8 to -2] mg; P < 0.001). Reductions in pain scores with coughing were observed during the first 24 h after extubation; the level of pain with coughing at 12 h was reduced from a median of 6 in the fentanyl group to 4 in the methadone group (-2 [-3 to -1]; P < 0.001). Improvements in patient-perceived quality of pain management were described in the methadone group. The incidence of opioid-related adverse events was not increased in patients administered methadone. CONCLUSIONS: Intraoperative methadone administration resulted in reduced postoperative morphine requirements, improved pain scores, and enhanced patient-perceived quality of pain management.