Differences in Perioperative Management of Patients Undergoing Complex Spine Surgery: A Global Perspective.

BACKGROUND: The aim of this survey was to understand institutional spine surgery practices and their concordance with published best practices/recommendations. METHODS: Using a global internet-based survey examining perioperative spine surgery practice, reported institutional spine pathway elements (n=139) were compared with the level of evidence published in guideline recommendations. The concordance of clinical practice with guidelines was categorized as poor (≤20%), fair (21%-40%), moderate (41%-60%), good (61%-80%), or very good (81%-100%). RESULTS: Seventy-two of 409 (17.6%) institutional contacts started the survey, of which 31 (7.6%) completed the survey. Six (19.4%) of the completed surveys were from respondents in low/middle-income countries, and 25 (80.6%) were from respondents in high-income countries. Forty-one incomplete surveys were not included in the final analysis, as most were less than 40% complete. Five of 139 (3.6%) reported elements had very good concordance for the entire cohort; hospitals with spine surgery pathways reported 18 elements with very good concordance, whereas institutions without spine surgery pathways reported only 1 element with very good concordance. Reported spine pathways included between 7 and 47 separate pathway elements. There were 87 unique elements in the reviewed pathways. Only 3 of 87 (3.4%) elements with high-quality evidence demonstrated very good practice concordance. CONCLUSIONS: This global survey-based study identified practice variation and low adoption rates of high-quality evidence in the care of patients undergoing complex spine surgery.

Impact of preoperative opioid use disorder on outcomes following lumbar-spine surgery.

OBJECTIVES: Opioid use disorder (OUD) has previously been shown to negatively impact postoperative outcomes. As the number of spine surgeries continues to rise annually, more patients with preexisting OUD will be seen in operating rooms. Our retrospective cohort study aims to expand on the independent association between preoperative OUD and outcomes following lumbar-spine surgery. PATIENTS AND METHODS: Using 2007-2014 data from the State Inpatient Databases (SID) for the states of California (2007-2011), Florida, New York, Maryland, and Kentucky, we identified patients ≥18 years of age undergoing lumbar-spine surgery. Our primary variable of interest was present-on-admission OUD. Outcomes of interest included a range of postoperative complications divided into those specific to spinal surgery and general surgical complications, length of stay (LOS), 30- and 90-day readmission rates, and total hospital charges. RESULTS: Of the 267,976 patients undergoing lumbar-spine surgery, 1902 patients were identified as having OUD. After adjusting for patient- and hospital-level confounders, we found that patients with OUD were more likely to experience complications related specifically to spine surgery (aOR = 1.51, 95%CI = 1.33-1.71) as well as general postoperative complications (aOR = 1.63, 95%CI = 1.36-1.96) compared to those without OUD. OUD was additionally associated with longer LOS (aIRR = 1.29, CI = 1.24-1.34) and higher total charges (aIRR = 1.14, CI = 1.11-1.18). Whereas no statistically significant difference was detected for 30-day-readmission rates, patients with OUD experienced higher rates of readmission within 90 days of discharge (aOR = 1.20, CI = 1.08-1.35). CONCLUSIONS: Our study strengthens the evidence that patients with OUD fare poorly after lumbar-spine surgery. More research is needed to determine whether reducing opioid use before surgery can mitigate the postoperative risks associated with OUD.

Scoliosis Correction with One Ventricle: A Multispecialty Approach.

BACKGROUND: Patients with single-ventricle congenital heart disease may present for scoliosis correction. These patients undergo a series of cardiac operations that create a novel circulation that has a significant impact on the management of their spinal surgery. CASE DESCRIPTION: A 21-year-old man with severe scoliosis presented for posterior T4-L3 spinal fusion. He was born with complex congenital heart disease that resulted in his having a single functioning ventricle. He underwent a series of operations culminating in a Fontan procedure to palliate his heart disease. Both the surgical procedure and the anesthetic plan were modified based on his abnormal physiology, which led to a successful correction with no complications. CONCLUSIONS: Patients who have undergone a Fontan procedure can successfully undergo a lengthy scoliosis correction, but it requires multidisciplinary planning.

Optimizing Patient Access During an Emergency While Using Intraoperative Computed Tomography.

BACKGROUND: As minimally invasive spine surgery evolves, spine surgeons increasingly rely on advanced intraoperative computed tomography (iCT). iCT provides rapid acquisition of high-resolution images, reduces radiation exposure, improves surgical accuracy, and decreases operative time. However, all iCT systems currently available pose a patient safety risk as their physical space requirements limit patient access in the event of an emergency, particularly when patients are in the prone position. After a near-cardiac arrest at our institution during posterior cervical spine surgery, it was apparent that the presence of the iCT complicated the ability to rapidly reposition the patient in order to provide appropriate resuscitation. METHODS: To ensure our ability to provide timely care during an emergency, we determined that a process which included all members of the operating room (OR) team was required. We held an initial planning meeting where a detailed plan-of-action was created, reviewed, and revised in response to feedback from all stakeholders. We then simulated a cardiac arrest to test our resuscitation plan with all members of the neurosurgery team. A mannequin was positioned prone on an OR table within the iCT, and a resuscitation plan was created. RESULTS: The team orchestrated the mock resuscitation, and the time of cardiac arrest in the prone position to supine repositioning required 110 seconds. The simulation was recorded for post-"code" performance review. Application of the protocol during an actual cardiac arrest was associated with successful restoration of spontaneous circulation and full recovery. CONCLUSIONS: The development and rehearsal of an emergency plan of action greatly facilitated the timely responsiveness of the neurosurgical OR team during a simulated cardiac arrest and was an effective way to identify and address key logistical issues regarding the use of an iCT system.

Dexmedetomidine may impair cognitive testing during endovascular embolization of cerebral arteriovenous malformations: a retrospective case report series.

After the reported successful use of dexmedetomidine to sedate patients in the intensive care unit without respiratory depression, we began to use dexmedetomidine for interventional neuroradiologic procedures. We report on five patients who had dexmedetomidine administered for sedation during embolization of cerebral arteriovenous malformations. All patients were comfortably sedated and breathing spontaneously. However, although patients were awake and following simple commands 10 minutes after the discontinuation of the infusion of dexmedetomidine, they were nevertheless unable to undergo cognitive testing. They were still unable to undergo cognitive testing 45 minutes after the infusion was stopped. In contrast, 10 minutes after the discontinuation of the infusion of propofol, all patients were awake, alert, cooperative, and able to undergo cognitive testing without difficulty. In conclusion, on examination of five non-randomly selected case records, we found that dexmedetomidine significantly prevented neurologic and cognitive testing.

Reemergence of stroke deficits with midazolam challenge.

BACKGROUND AND PURPOSE: Patients who have sustained a neurological injury and then improved may experience transient reemergence of their syndromes when given benzodiazepines. As a step toward assessing whether neurotransmitter systems underlie poststroke clinical improvement, we selected midazolam, a gamma-aminobutyric acid(A) (GABA(A)) agonist, for systemic administration to measure general or stroke-specific effects in patients. METHODS: Eight patients with image-verified stroke (5 with left-sided and 3 with right-sided cerebral lesions) participated. The strokes had occurred from 7 days to 6 years earlier, with patients showing clinical improvement from their initial syndromes. Each patient underwent baseline testing for motor function, aphasia, and left hemispatial neglect, after which intravenous midazolam was delivered until mild drowsiness was detected. Patients were tested during this period and again after 2 hours when sedation had dissipated. RESULTS: After the administration of midazolam, the 5 patients with left hemisphere stroke demonstrated reemergence or worsening of their initial right hemiparesis and aphasia but showed no left neglect. The 3 patients with right cerebral stroke showed reemergence of left hemiparesis and left visual field neglect but no aphasia. All patients returned to baseline after 2 hours. CONCLUSIONS: Under conditions of light sedation, patients whose initial stroke syndrome had substantially improved clinically showed transient reemergence of their initial focal syndrome. These data suggest a possible role for GABA(A)-mediated neurochemical mechanisms in poststroke improvement and sensitivity to medication effects.