Comparison of the effect of epidural versus intravenous patient controlled analgesia on inpatient and outpatient functional outcomes after adult degenerative scoliosis surgery: a comparative study.

BACKGROUND: Perioperative pain can negatively impact patient recovery after spine surgery and be a contributing factor to increased hospital length of stay and cost. Most data currently available is extrapolated from adolescent idiopathic cases and may not apply to adult and geriatric populations with thoracolumbar spine degeneration. PURPOSE: Study the impact of epidural analgesia on pain control and outcomes after adult degenerative scoliosis surgery in a large single-institution series of adult patients undergoing thoraco-lumbar-pelvic fusion. STUDY DESIGN/SETTING: Retrospective single-center review of prospectively collected data. PATIENT SAMPLE: Patients undergoing thoracolumbar fusion with pelvic fixation. OUTCOME MEASURES: Self-reported measures: Visual analog scale for pain. Physiologic Measures: Oral pain control requirements converted into daily morphine equivalents. Functional Measures: Ambulation perimeter after surgery, urinary retention and constipation rates. METHODS: We retrospectively reviewed patient data for the years 2016 and 2017 before the use of patient controlled epidural analgesia (PCEA), and then 2018 and 2019 after its implementation, for all thoracolumbar degenerative procedures, and compared their postoperative outcomes measures. RESULTS: There were 46 patients in the PCEA group and 37 patients in the intravenous PCA (IVPCA) groups. All patients underwent long segment posterolateral thoracolumbar spinal fusion with pelvic fixation. Patients in the PCEA group had lower pain scores and ambulated greater distances compared with those in the IVPCA group. PCEA patients also had lower urinary retention and constipation rates, but no increased intraoperative or postoperative complications related to catheter placement. CONCLUSIONS: PCEA can provide optimal pain control after adult degenerative scoliosis spine surgery, and may promote greater early ambulation, while decreasing postoperative constipation and urinary retention rates.

Smoking has a dose-dependent effect on the incidence of preoperative opioid consumption in female geriatric patients with spine disease.

Tobacco use and narcotic medication have been associated with worse functional outcomes after surgery. Our goal was to investigate potential associations between smoking and preoperative opioid consumption in a geriatric population undergoing spine surgery, and their impact on postoperative outcomes. The records of 536 consecutive patients aged more than 65 years who underwent elective spinal surgery between November 2014 and August 2017 at a single institution were reviewed. Primary outcomes included rates of preoperative opioid consumption and postoperative hospital length of stay and complications. Males were more likely to be smokers than females (p < 0.001), whereas females were more likely to take opioid analgesics preoperatively (p = 0.022). Women with a history of smoking were more likely to have increased preoperative opioid consumption compared to those with no history of smoking (63.64% vs. 42.04%; p < 0.001). Such a relationship was not found in men. Subgroups analysis of female patients with a history of tobacco use comparing current and former smoker status showed that both groups exhibited increased preoperative opioid consumption compared to patients who never smoked (88.89% vs 42.04%; p < 0.001 for current users; 59.42% vs 42.04% for former users; p = 0.008). There was also a dose-depended relationship between smoking and increased preoperative opioid consumption. Geriatric female spine patients with a history of smoking have a higher incidence of preoperative opioid consumption. Opioid intake appears to increase with the number of pack-years, both in patients with a history of smoking and in those who currently smoke.

Recent advances in understanding and managing chordomas: an update.

Chordomas are rare and difficult-to-treat tumors arising from the embryonic notochord. While surgery is the mainstay of treatment, and despite new techniques aimed at maximizing total tumoral resection, recurrence remains high and the probability of disease-free survival low. New breakthroughs in genetics, targeted molecular therapy, and heavy-particle beam therapy offer some promise as adjuvant treatments in addition to surgical resection. A multidisciplinary approach encompassing genetics, immunotherapy, radiation therapy, and surgery, at a facility experienced in the management of this complex disease, offers the best chance of survival and quality of life to patients while limiting the intrinsic morbidity of these treatments.

The effectiveness of tranexamic acid on operative and perioperative blood loss in long-segment spinal fusions: a consecutive series of 119 primary procedures.

OBJECTIVE: The aim of this study was to determine if the use of tranexamic acid (TXA) in long-segment spinal fusion surgery can help reduce perioperative blood loss, transfusion requirements, and morbidity. METHODS: In this retrospective single-center study, the authors included 119 consecutive patients who underwent thoracolumbar fusion spanning at least 4 spinal levels from October 2016 to February 2019. Blood loss, transfusion requirements, perioperative morbidity, and adverse thrombotic events were compared between a cohort receiving intravenous TXA and a control group that did not. RESULTS: There was no significant difference in any measure of intraoperative blood loss (1514.3 vs 1209.1 mL, p = 0.29) or transfusion requirement volume between the TXA and control groups despite a higher number of pelvic fusion procedures in the TXA group (85.9% vs 62.5%, p = 0.003). Postoperative transfusion volume was significantly lower in TXA patients (954 vs 572 mL, p = 0.01). There was no difference in the incidence of thrombotic complications between the groups. CONCLUSIONS: TXA appears to provide a protective effect against blood loss in long-segment spine fusion surgery specifically when pelvic dissection and fixation is performed. TXA also seems to decrease postoperative transfusion requirements without increasing the risk of adverse thrombotic events.

Stem cell injections for axial back pain: a systematic review of associated risks and complications with a case illustration of diffuse hyperplastic gliosis resulting in cauda equina syndrome.

OBJECTIVE: Axial low-back pain is a disease of epidemic proportions that exerts a heavy global toll on the active workforce and results in more than half a trillion dollars in annual costs. Stem cell injections are being increasingly advertised as a restorative solution for various degenerative diseases and are becoming more affordable and attainable by the public. There have been multiple reports in the media of these injections being easily available abroad outside of clinical trials, but scientific evidence supporting them remains scarce. The authors present a case of a serious complication after a stem cell injection for back pain and provide a systematic review of the literature of the efficacy of this treatment as well as the associated risks and complications. METHODS: A systematic review of the literature was performed using the PubMed, Google Scholar, and Scopus online electronic databases to identify articles reporting stem cell injections for axial back pain in accordance with the PRISMA guidelines. The primary focus was on outcomes and complications. A case of glial hyperplasia of the roots of the cauda equina directly related to stem cell injections performed abroad is also reported. RESULTS: The authors identified 14 publications (including a total of 147 patients) that met the search criteria. Three of the articles presented data for the same patient population with different durations of follow-up and were thus analyzed as a single study, reducing the total number of studies to 12. In these 12 studies, follow-up periods ranged from 6 months to 6 years, with 50% having a follow-up period of 1 year or less. Most studies reported favorable outcomes, although 36% used subjective measures. There was a tendency for pain relief to wane after 6 months to 2 years, with patients seeking a surgical solution. Only 1 study was a randomized controlled trial (RCT). CONCLUSIONS: There are still insufficient data to support stem cell injections for back pain. Additional RCTs with long-term follow-up are necessary before statements can be made regarding the efficacy and safety.