Intravenous and Oral Tranexamic Acid Are Equivalent at Reducing Blood Loss in Thoracolumbar Spinal Fusion: A Prospective Randomized Trial.

STUDY DESIGN: A prospective randomized trial of patients enrolled at a university affiliated tertiary medical center between February and December 2017. OBJECTIVE: To compare perioperative blood loss in patients undergoing elective posterior thoracolumbar fusion who were treated with intravenous (IV) versus oral (PO) tranexamic acid (TXA). SUMMARY OF BACKGROUND DATA: The use of antifibrinolytic agents such as TXA to decrease operative blood loss and allogenic blood transfusions is well documented in the literature. While evidence supports the use of IV and topical formulations of TXA in spine surgery, the use of PO TXA has not been studied. METHODS: Eighty-three patients undergoing thoracolumbar fusion were randomized to receive 1.95 g of PO TXA 2 hours preoperatively or 2 g IV TXA (1 g before incision and 1 g before wound closure) intraoperatively. The sample was further stratified into three categories based on number of levels fused (1-2 level fusions, 3-5, and >5). The primary outcome was the reduction of hemoglobin. Secondary outcomes included calculated blood loss, drain output, postoperative transfusion, complications, and length of hospital stay. Equivalence analysis was performed with a two one-sided test (TOST). A P-value of <0.05 suggested equivalence between treatments. RESULTS: Fourty three patients received IV TXA and 40 patients received PO TXA. Patient demographic factors were similar between groups except for body mass index (BMI). The mean reduction of hemoglobin was similar between IV and PO groups (3.36 g/dL vs. 3.43 g/dL, respectively; P = 0.01, equivalence). Similarly, the calculated blood loss was equivalent (1235 mL vs. 1312 mL, respectively; P = 0.02, equivalence). Eight patients (19%) in IV TXA group received a transfusion compared with five patients in PO TXA group (13%) (P = 0.44). One patient (2% and 3% in IV and PO, respectively) in each group experienced a deep venous thrombosis/pulmonary embolism (P = 0.96). CONCLUSION: Patients treated with IV and PO TXA experienced the same perioperative blood loss after spinal fusions. Given its lower cost, PO TXA represents an excellent alternative to IV TXA in patients undergoing elective posterior thoracolumbar fusion and may improve healthcare cost-efficiency in the studied population. LEVEL OF EVIDENCE: 1.

Effect of forced-air warming blanket position in elective lumbar spine surgery: Intraoperative body temperature and postoperative complications.

BACKGROUND: Perioperative hypothermia is linked to multiple postoperative complications including increased surgical bleeding, surgical site infection, myocardial events, and increased length of hospital stay. The purpose of this study is to determine the effects of forced-air warming blanket position, above the shoulders versus under the trunk/legs, on intraoperative core body temperature and perioperative complications in elective lumbar spine surgery. METHODS: After IRB approval, patients were enrolled in a consecutive fashion and randomized to either upper body (Group I) or lower body (Group II) groups. Primary outcomes were intraoperative body temperature, incidence of hypothermia, postoperative complications, and infection. Secondary outcomes included blood loss, operative time, and length of stay. RESULTS: Seventy-four patients were included (Group I, 38; Group II, 36, mean age 60.7 years, 54% of male). Average patient follow-up was 69 ± 33.6 days in Group I and 67 ± 34.6 days in Group II. Average intraoperative body temperature was 35.7 in Group I and 35.8 in Group II (P = 0.27). Incidence of critical hypothermia (T < 35°C) was 18.4% and 11.1% in Groups I and II, respectively (P = 0.52). Incidence of mild hypothermia (T: 35°C-36°C) was 34.2% and 30.56% in Groups I and II, respectively (P = 0.81). Separately, pooled analysis comparing average body temperature and incidence infection demonstrated a relationship between mild hypothermia and infection (P = 0.03). CONCLUSION: Compared to using a lower body Bair Hugger under the patient, using standard upper body Bair Hugger may be associated with increased surgical site infection. Given equivalent body warming, we recommend using the lower body Bair Hugger to avoid infection.

Facet Sparing Foraminal Decompression Using the Flexible Shaver Foraminotomy System: Nerve Safety, Pain Relief, and Patient Satisfaction.

BACKGROUND: A number of surgical options exist for decompressing lumbar foraminal stenosis. Flexible shaver foraminotomy is a recent addition to this armamentarium. While the foraminotomy device has been incorporated into clinical practice, the literature on its safety and efficacy remain limited. We aimed to evaluate nerve safety, pain relief, and patient satisfaction in a series of patients treated with the iO-Flex shaver system (Amendia, Inc., Marietta, Georgia). METHODS: Thirty-one consecutive patients with lumbar foraminal stenosis underwent foraminal decompression using the flexible microblade shaver system at 62 neuroforamina. The shavers were inserted into each foramen using an open hemilaminotomy and fluoroscopic guidance. Nerve mapping via mechanomyography (MMG) was used to ensure nerve safety. Perioperative charts were reviewed to find the incidence of neurologic complications and to quantify pain relief. Average office-based follow-up was 5.3 months. A 3-item questionnaire was administered to assess patient satisfaction during late follow-up, which occurred at an average of 21 months. RESULTS: No planned iO-Flex foraminotomies were aborted. Neurologic complications included transient dysesthetic pain in 1 patient (3.2%, n = 31), and transient numbness in 3 patients (9.7%, n = 31). There were no motor deficits. The composite nerve complication rate was 12.7%. Preoperative visual analog scale scores decreased from a mean of 7.1 (n = 31, standard deviation [SD] 2.0) to a mean of 3.5 (n = 30, SD 2.5). If asked to repeat their decision to do surgery, 81% of patients would redo the procedure. The rate of patient dissatisfaction was 19%. CONCLUSIONS: Decompression of lumbar foramina using the flexible shaver system and MMG nerve mapping is safe and effective, although the short-term sensory complication with this technique may be higher than previously reported. Patient satisfaction with iO-Flex foraminotomy is comparable to reported satisfaction outcomes for traditional lumbar decompression. LEVEL OF EVIDENCE: 4.

Origins of eponymous instruments in spine surgery.

Every day, spine surgeons call for instruments named after surgical pioneers. Few know the designers or the histories behind their instruments. In this paper the authors provide a historical perspective on the Penfield dissector, Leksell rongeur, Hibbs retractor, Woodson elevator, Kerrison rongeur, McCulloch retractor, Caspar pin retractor system, and Cloward handheld retractor, and a biographical review of their inventors. Historical data were obtained by searching the HathiTrust Digital Library, PubMed, Google Scholar, Google Books, and Google, and personal communications with relatives, colleagues, and foundations of the surgeon-designers. The authors found that the Penfield dissectors filled a need for delicate tools for manipulating the brain and that the Leksell rongeur increased surgical efficiency during war-related laminectomies. Hibbs' retractor facilitated his spine fusion technique. Woodson was both a dentist and a physician whose instrument was adopted by spine surgeons. Kerrison rongeurs were developed in otology to decompress bone near the facial nerve. The McCulloch, Caspar, and Cloward retractors helped improve exposure during the emergence of new techniques, i.e., microdiscectomy and anterior cervical discectomy and fusion. The histories behind these eponymous instruments remind us that innovation sometimes begins in other specialties and demonstrate the role of innovation in improving patient care.

Assessment of radiographic and clinical outcomes of an articulating expandable interbody cage in minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis.

OBJECTIVE The inability to significantly improve sagittal parameters has been a limitation of minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF). Traditional cages have a limited capacity to restore lordosis. This study evaluates the use of a crescent-shaped articulating expandable cage (Altera) for MIS TLIF. METHODS This is a retrospective review of 1- and 2-level MIS TLIF. Radiographic outcomes included differences in segmental and lumbar lordosis, disc height, evidence of fusion, and any endplate violations. Clinical outcomes included the numeric rating scale for leg and back pain and the Oswestry Disability Index (ODI) for low-back pain. RESULTS Thirty-nine patients underwent single-level MIS TLIF, and 5 underwent 2-level MIS TLIF. The mean age was 63.1 years, with 64% women. On average, spondylolisthesis was corrected by 4.3 mm (preoperative = 6.69 mm, postoperative = 2.39 mm, p < 0.001), the segmental angle was improved by 4.94° (preoperative = 5.63°, postoperative = 10.58°, p < 0.001), and segmental height increased by 3.1 mm (preoperative = 5.09 mm, postoperative = 8.19 mm, p < 0.001). At 90 days after surgery the authors observed the following: a smaller postoperative sagittal vertical axis was associated with larger changes in back pain at 90 days (r = -0.558, p = 0.013); a larger decrease in spondylolisthesis was associated with greater improvements in ODI and back pain scores (r = -0.425, p = 0.043, and r = -0.43, p = 0.031, respectively); and a larger decrease in pelvic tilt (PT) was associated with greater improvements in back pain (r = -0.548, p = 0.043). For the 1-year PROs, the relationship between the change in PT and changes in ODI and numeric rating scale back pain were significant (r = 0.612, p = 0.009, and r = -0.803, p = 0.001, respectively) with larger decreases in PT associated with larger improvements in ODI and back pain. Overall for this study there was a 96% fusion rate. Fourteen patients were noted to have endplate violation on intraoperative fluoroscopy during placement of the cage. Only 3 of these had progression of their subsidence, with an overall subsidence rate of 6% (3 of 49) visible on postoperative CT. CONCLUSIONS The use of this expandable, articulating, lordotic, or hyperlordotic interbody cage for MIS TLIF provides a significant restoration of segmental height and segmental lordosis, with associated improvements in sagittal balance parameters. Patients treated with this technique had acceptable levels of fusion and significant reductions in pain and disability.

A biomechanical comparison of subscapularis repair techniques in total shoulder arthroplasty: lesser tuberosity osteotomy versus subscapularis peel.

BACKGROUND: The subscapularis peel (SP) and the lesser tuberosity osteotomy (LTO) are 2 common exposure techniques for total shoulder arthroplasty. Although some biomechanical studies have suggested a higher resistance to failure with the LTO, clinical studies have demonstrated no difference in repair failure or tendon healing. We hypothesized that there would be no difference in biomechanically tested repair strength between our SP technique and the previously tested LTO technique. METHODS: Eleven cadaver shoulders were separated into 2 groups: 6 SPs and 5 LTOs. After initial loading for 3000 cycles, the specimens were incrementally loaded to 450 ± 50 N or catastrophic failure. Repair gapping was measured after cyclical loading, and fatigue life was analyzed after incremental loading. RESULTS: There was no significant difference in mean repair gapping between the SP (2.40 ± 0.36 mm; mean ± standard deviation) and the LTO groups (3.10 ± 2.93 mm; P = .57). There was also no difference in the mean number of cycles to failure (6894 ± 956 vs. 6018 ± 1179; P = .14) and mean load to failure (400 ± 79 N vs. 340 ± 91 N; P = .21) between the SP and LTO techniques. However, there was more variability in bead gapping in the LTO group (P < .01). CONCLUSION: No significant differences were found in repair gapping, fatigue failure, and load to failure in comparing the SP and LTO repairs. However, the SP repair demonstrated significantly less variability in repair gapping. These findings suggest that initial fixation biomechanical properties between the 2 constructs are similar in vitro.

Sacroiliac stabilization for sacral metastasis: A case series.

BACKGROUND: The sacrum is a rare location for spinal metastasis. These lesions are typically large and destructive by the time of diagnosis, making treatment difficult. When indicated, surgical stabilization offers pain relief and preserves independence in patients with impending and acute pathological sacral fractures. CASE DESCRIPTION: Three consecutive patients presented with sacral metastases. After either failing radiation therapy or presenting with acute fracture and instability, the patients underwent intralesional excision, bilateral L4 to ilium fusion with instrumentation, and sacroiliac (SI) screw fixation. Pain improved after surgery, and there were no wound healing complications. Two patients could continue walking without any assistive device, while one patient required a walker. CONCLUSION: Stabilization with combined modified Galveston fixation and SI screw fixation relieves pain and allows maintenance of independence in patients with sacral metastasis.

Lateral Atlantoaxial Osteoarthritis: A Narrative Literature Review.

Lateral atlantoaxial osteoarthritis (AAOA), or C1-C2 lateral mass arthritis (LMA), is an unfamiliar degenerative cervical disease with a clinical presentation that markedly differs from subaxial spondylosis. The prevalence of LMA in the nonsurgical outpatient setting is 4%. Risk factors include age and occupation. The typical patient is between 50 and 90 years old, presents with upper cervical or occipital pain, has limited rotation, and has pain provocation during passive rotation to the affected side. Pain stems from degeneration of the lateral C1-C2 articulation and may be referred or radicular, through the greater occipital nerve. Although there is no consensus on diagnostic work-up, the disease is classically seen on the open-mouth odontoid radiograph. Computerized tomography, magnetic resonance imaging, bone scan, and diagnostic injections are also useful. Initial treatment is conservative, and upwards of two-thirds of LMA patients obtain lasting relief with noninvasive measures and injections. In patients with severe, recalcitrant pain, limited C1-C2 fusion offers satisfactory and reliable relief. The goals of this review article are to provide a synthesis of the literature on LMA, to offer a treatment approach to LMA, and to identify problems with the current state of knowledge on LMA.

Chronic thoracolumbar subdural empyema: Case report and surgical management.

BACKGROUND: Spinal cord abscesses and spinal subdural empyemas are rare and difficult to treat. CASE DESCRIPTION: A 35-year-old male presented to an outside institution with 2 months of progressive low back pain, weakness, and bowel incontinence; he was diagnosed with an L4 epidural abscess that was poorly managed. When the patient presented to our institution, magnetic resonance imaging (MRI) revealed a well-organized chronic subdural abscess at the thoracolumbar junction. Following resection, his back pain resolved but he was left with a residual paraparesis. CONCLUSION: Subdural abscesses are rare and should be considered among the differential diagnoses for intraspinal mass lesions. Treatment should include prompt surgical exploration and decompression combined with appropriate prolonged antibiotic treatment.