A prospective randomised controlled trial evaluating prophylactic Floseal, a gelatin and thrombin-based haemostatic matrix, in postoperative drain output and blood transfusion in transforaminal lumbar interbody fusion surgery.

PURPOSE: To evaluate the prophylactic use of Floseal in reducing postoperative blood loss in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). TLIF is a lumbar spine decompression and fusion procedure with potential for postoperative blood loss. Prophylactic application of Floseal, a gelatin and thrombin-based haemostatic matrix to the surgical wound before closure was shown to be effective in reducing postoperative drain output in anterior cervical discectomy and fusion. This study postulated that prophylactic use of Floseal before wound closure would reduce postoperative blood loss in patients who underwent TLIF. METHODS: Randomised controlled trial comparing prophylactic use of Floseal and control in patients undergoing single level or two-level TLIF. Primary outcomes included postoperative drain output within 24 h and postoperative transfusion rate. Secondary outcomes included days of drain placement, length of stay and haemoglobin level. RESULTS: A total of 50 patients was recruited. Twenty six patients were allocated to the Floseal group and 24 were allocated to the control group. There were no baseline characteristic differences between the groups. There were no statistically significant differences in primary outcomes which included postoperative drain output within 24 h and postoperative transfusion rate between patients who received prophylactic Floseal and control. There were no statistically significant differences in secondary outcomes which included haemoglobin level, days of drain placement and length of stay between the two groups. CONCLUSION: Prophylactic use of Floseal was not shown to reduce postoperative bleeding in single level or two-level TLIF.

Pulsed electromagnetic field therapy promotes healing and microcirculation of chronic diabetic foot ulcers: a pilot study.

OBJECTIVE: To examine the effects of pulsed electromagnetic field (PEMF) therapy on promoting the healing and microcirculation of chronic diabetic foot ulcers. DESIGN: A randomized, double-blind, placebo-controlled clinical trial on a homogenous subset of chronic diabetic foot ulcers. SETTING: Hospital and university. PATIENTS: Thirteen subjects (7 in the PEMF group and 6 in the control group) diagnosed with type 2 diabetes and had unsatisfactory healing of ulcer(s) in the preceding 4 weeks were recruited. INTERVENTIONS: Subjects were randomly allocated to receive either active PEMF therapy (duration: 60 minutes; frequency: 12 Hz; intensity: 12 Gauss) or nonactive PEMF for 14 sessions within 3 weeks. MAIN OUTCOME MEASURES: Assessment on wound closure, wound depth, and microcirculation were performed at the baseline, end of the treatment period, and 1-month follow-up. MAIN RESULTS: By the end of the treatment period, there was an 18% decrease in wound size in the active PEMF group as compared with a 10% decrease in the control group. The PEMF group demonstrated significant cumulative increase in cutaneous capillary blood velocity (by 28%) and 14% increase in capillary diameter. In contrast, the control group showed a decrease in both capillary blood velocity and diameter. CONCLUSION: In this study, PEMF therapy seemed to accelerate wound healing and improve microcirculation.

Nightmare of lumbar diskectomy: aorta laceration.

STUDY DESIGN: Case report. OBJECTIVE: To present a rare case of a patient who during posterior lumbar spinal decompression and diskectomy underwent a laceration of the aorta. The patient survived with prompt treatment. SUMMARY OF BACKGROUND DATA: Intraoperative injuries of the prevertebral and pelvic vessels are infrequent but serious complications of posterior lumbar disc surgery. Injury may cause laceration of the vessel with acute life-threatening retroperitoneal hemorrhage, which is usually massive. The aortic bifurcation is closely approximated to the anterior surface of the L4-L5 disc. METHODS: A 70-year-old gentleman with prolapsed intervertebral disc between fourth and fifth lumbar vertebrae and left-sided radiculopathy of L5 root was operated with L4-L5 laminectomy and L4-L5 diskectomy. During diskectomy, it was noticed by the surgeon that there was one episode of giving way of the pituitary rongeur anteriorly. However, no major bleeding was encountered from the disc space immediately after the event; vital signs were stable hemodynamically and we completed the diskectomy. Five minutes later, we noted the dural sac to have a collapsing pulsation. Prevertebral vessel injury was suspected. Patient became pulseless. RESULTS: We turned the patient supine for cardiopulmonary resuscitation without extubation. Vascular surgeons proceeded with laparotomy. Huge retroperitoneal hematoma and a 1.5 × 1.5 cm laceration at the bifurcation of aorta were noted anterior to the L4-L5 intervertebral disc. The vascular surgeon repaired the aorta by primary repair. The patient was extubated on day 5 and was allowed to ambulate. He was discharged subsequently with a normal neurological and vascular examination. No pseudoaneurysm or arteriovenous fistula formation was detected on magnetic resonance imaging and magnetic resonance angiography at 2 years follow-up. CONCLUSION: Iatrogenic vascular injury during posterior lumbar disc surgery, although rare, should be suspected if signs of circulatory instability or abnormal pulsation of the dural sac are noted, especially if any lapse in the ordinary technique has been observed. In preoperative imaging, note the position of the aorta and prevertebral veins and the depth and integrity of the anterior wall of the disc.

Calcinosis cutis of the hand in a renal failure patient: a case report.

A 25-year-old woman with end-stage renal failure presented with subcutaneous calcinosis cutis that grew rapidly in both hands. Radiographs showed subcutaneous lobulated calcific deposits. Magnetic resonance imaging revealed a heterogeneous mass encasing segments of the abductor pollicis longus and extensor pollicis brevis tendons. Excision of the masses was performed. Histopathology revealed amorphous calcified deposits in fibrous tissue and a foreign body reaction. There was no evidence of a tubercular lesion. Further investigation revealed the presence of hyperphosphataemia and secondary hyperparathyroidism, despite a normal serum calcium level. Oral phosphate-lowering agents failed to control the condition, and recurrence was noted 6 months later. The patient finally underwent parathyroidectomy and has had no further recurrence.

Pick-up test: an indication for opponensplasty in patients with severe carpal tunnel syndrome.

PURPOSE: To use a pick-up test to assess thenar motor deficit and results of opponensplasty. METHODS: Eight consecutive patients with idiopathic severe carpal tunnel syndrome and severe thenar motor deficit were identified. All were females aged 39 to 60 (mean, 53) years and right-hand dominant. The severity of thenar motor deficit was assessed using the pick-up test. Failure to pick up a coin with the thumb and index finger only in a normal pulp-to-pulp pincer grip was an indication for an opponensplasty (in addition to open carpal tunnel release) to hasten recovery of thumb abduction. Treatment outcome was assessed using the pick-up test at 6, 8, and 12 weeks. RESULTS: Preoperatively, all patients were unable to perform the pick-up test. At postoperative 6 weeks, all patients could pick up the coin with no difficulty and were satisfied with the result of opponensplasty. There was no relapse at subsequent follow-ups and no donor-site morbidity in terms of cosmesis, scar pain or infection. Grip strength and the range of wrist motion were 63% and 92% of the normal side, respectively. CONCLUSION: The pick-up test is a simple and reliable means of identifying those in need of an opponensplasty.