Hemostats in Spine Surgery: Literature Review and Expert Panel Recommendations.

Bleeding in spine surgery is a common occurrence but when bleeding is uncontrolled the consequences can be severe due to the potential for spinal cord compression and damage to the central nervous system. There are many factors that influence bleeding during spine surgery including patient factors and those related to the type of surgery and the surgical approach to bleeding. There are a range of methods that can be employed to both reduce the risk of bleeding and achieve hemostasis, one of which is the adjunct use of hemostatic agents. Hemostatic agents are available in a variety of forms and materials and with considerable variation in cost, but specific evidence to support their use in spine surgery is sparse. A literature review was conducted to identify the pre-, peri-, and postsurgical considerations around bleeding in spine surgery. The review generated a set of recommendations that were discussed and ratified by a wider expert group of spine surgeons. The results are intended to provide a practical guide to the selection of hemostats for specific bleeding situations that may be encountered in spine surgery.

Infección de artrodesis lumbar por Klebsiella pneumoniae multirresistente, exitosamente tratada con retención del implante y ceftazidima/avibactam / Lumbar arthrodesis infection by multi-resistant Klebsiella pneumoniae, successfully treated with implant retention and ceftazidime/avibactam

Cada vez son más los pacientes portadores de implantes protésicos (prótesis ortopédicas, instrumentaciones lumbares, material de osteosíntesis). En la última década se han incrementado las infecciones producidas por enterobacterias resistentes a carbapenémicos (bacteriemias, abscesos, infecciones urinarias, etc.) con gran dificultad para el tratamiento y una importante comorbilidad asociada. Presentamos el primer caso de infección de una instrumentación lumbar por Klebsiella pneumoniae productora de carbapenemasa D, tipo OXA 48, exitosamente tratada

There are increasingly more patients with prosthetic implants (orthopaedic prostheses, lumbar instruments, osteosynthesis material). In the last decade, infections caused by carbapenem resistant Enterobacteriaceae have increased (bacteriaemia, abscesses, urinary tract infections...) with great difficulty in treatment and important associated comorbidity. We present the first case of infection of a lumbar instrumentation by Klebsiella pneumoniae producing carbapenemase D, OXA-48 type, and successfully treated

Lumbar arthrodesis infection by multi-resistant Klebsiella pneumoniae, successfully treated with implant retention and ceftazidime/avibactam. / Infección de artrodesis lumbar por Klebsiella pneumoniae multirresistente, exitosamente tratada con retención del implante y ceftazidima/avibactam.

There are increasingly more patients with prosthetic implants (orthopaedic prostheses, lumbar instruments, osteosynthesis material). In the last decade, infections caused by carbapenem resistant Enterobacteriaceae have increased (bacteriaemia, abscesses, urinary tract infections...) with great difficulty in treatment and important associated comorbidity. We present the first case of infection of a lumbar instrumentation by Klebsiella pneumoniae producing carbapenemase D, OXA-48 type, and successfully treated.

Escoliosis idiopáticas graves. ¿El abordaje y la instrumentación modifican los resultados? / Severe idiopathic scoliosis. Does the approach and the instruments used modify the results?

Objetivo: El objetivo de este trabajo es evaluar y comparar los resultados radiográficos y las complicaciones del tratamiento quirúrgico de escoliosis idiopáticas del adolescente mayores de 75◦ mediante doble abordaje (DA) o vía posterior aislada con instrumentación híbrida (PH) o «todo-tornillos» (PT). Material y método: Se realiza una revisión retrospectiva de 69 pacientes con escoliosis idiopática del adolescente mayor de 75◦ y seguimiento superior a los 2 años para analizar la flexibilidad de las curvas, la corrección obtenida y las complicaciones en función del tipo de cirugía. El análisis estadístico se realizó mediante el test de Kruskal-Wallis para variables no paramétricas. Resultados: No existen diferencias estadísticamente significativas entre los 3 grupos en los valores del ángulo de Cobb preoperatorio (DA = 89◦, PH = 83◦, PT = 83◦), en el postoperatorio inmediato (DA = 34◦, PH = 33◦, PT = 30◦) ni al final del seguimiento (DA = 36◦, PH = 36◦, PT = 33◦) (p > 0,05). El porcentaje de corrección (DA = 60%, PH = 57%, PT = 60%) fue similar entre grupos (p > 0,05). El porcentaje de complicaciones relacionadas con el procedimiento fue del 20,8% en DA, del 10% en PH y del 20% en PT. Dos pacientes en el grupo PT experimentaron cambios en la monitorización medular sin lesión neurológica y un paciente del mismo grupo experimentó una lesión incompleta diferida y temporal. Discusión y conclusiones: No se aprecian diferencias significativas en la corrección de las escoliosis idiopáticas graves entre los pacientes intervenidos mediante doble abordaje o por vía posterior aislada, independientemente del tipo de instrumentación utilizada (AU)

Objective: The aim of this work is to evaluate and compare the radiographic results and complications of the surgical treatment of adolescents with idiopathic scoliosis greater than 75 degrees, using a double approach (DA) or an isolated posterior approach with hybrid instruments (posterior hybrid [PH]), or with «all-pedicle screws» (posterior screws [PS]). Material and method: A retrospective review was performed on 69 patients with idiopathic scoliosis greater than 75◦, with a follow-up of more than 2 years, to analyze the flexibility of the curves, the correction obtained, and the complications depending on the type of surgery. The Kruskal-Wallis test for non-parametric variables was used for the statistical analysis. Results: There were no statistically significant differences between the 3 patient groups in the pre-surgical Cobb angle values (DA = 89◦, PH = 83◦, PS = 83◦), in the immediate post-surgical (DA = 34◦, PH = 33◦, PS = 30◦), nor at the end of follow-up (DA = 36◦, PH = 36◦, PS = 33◦) (P > .05). The percentage correction (DA = 60%, PH = 57%, PS = 60%) was similar between groups (P > .05). The percentage of complications associated with the procedure was 20.8% in DA, 10% in PH and 20% in PS. Two patients in the PS group showed changes, with no neurological lesions, in the spinal cord monitoring, and one patient in the same group suffered a delayed and transient incomplete lesion. Discussion and conclusions: No significant differences were observed in the correction of severe idiopathic scoliosis between patients operated using the double or isolated posterior approach, regardless of the type of instrumentation used (AU)

[Severe idiopathic scoliosis. Does the approach and the instruments used modify the results?]. / Escoliosis idiopáticas graves. ¿El abordaje y la instrumentación modifican los resultados?

OBJECTIVE: The aim of this work is to evaluate and compare the radiographic results and complications of the surgical treatment of adolescents with idiopathic scoliosis greater than 75 degrees, using a double approach (DA) or an isolated posterior approach with hybrid instruments (posterior hybrid [PH]), or with «all-pedicle screws¼ (posterior screws [PS]). MATERIAL AND METHOD: A retrospective review was performed on 69 patients with idiopathic scoliosis greater than 75°, with a follow-up of more than 2 years, to analyze the flexibility of the curves, the correction obtained, and the complications depending on the type of surgery. The Kruskal-Wallis test for non-parametric variables was used for the statistical analysis. RESULTS: There were no statistically significant differences between the 3 patient groups in the pre-surgical Cobb angle values (DA=89°, PH=83°, PS=83°), in the immediate post-surgical (DA=34°, PH=33°, PS=30°), nor at the end of follow-up (DA=36°, PH=36°, PS=33°) (P>.05). The percentage correction (DA=60%, PH=57%, PS=60%) was similar between groups (P>.05). The percentage of complications associated with the procedure was 20.8% in DA, 10% in PH and 20% in PS. Two patients in the PS group showed changes, with no neurological lesions, in the spinal cord monitoring, and one patient in the same group suffered a delayed and transient incomplete lesion. DISCUSSION AND CONCLUSIONS: No significant differences were observed in the correction of severe idiopathic scoliosis between patients operated using the double or isolated posterior approach, regardless of the type of instrumentation used.

Modulación del crecimiento de columnas escolióticas en animales de experimentación mediante el uso de barras de metal inteligente / Modulation of scoliotic spine growth in experimental animals using intelligent metal bars

Objetivo. Creación de un modelo experimental de escoliosis estructurada en ratas para evaluar la eficacia de los metales con memoria de forma para corregir gradualmente la deformidad a lo largo del tiempo. Material y método. Se generó una escoliosis experimental en ratas de 3 semanas mediante una sutura entre escápula y pelvis izquierdas durante 8 semanas, tras lo cual fueron aleatorizadas en 2 grupos: control, en los que se cortó la sutura, y nitinol, en los que además se implantó un alambre recto con memoria de forma anclado a la columna. Se realizaron radiografías seriadas para determinar la eficacia del nitinol en la corrección de la escoliosis. En un segundo tiempo, evaluamos los cambios histológicos a nivel del cuerpo vertebral apical y discos adyacentes pre y poscorrección. Resultados. Se indujo una cifoescoliosis progresiva media de 81,5°. En el grupo control, tras cortar la sutura, se produjo una reducción inicial de la deformidad pero luego permaneció estable a lo largo del tiempo (54° a las 2 semanas). En el grupo nitinol se observó una reducción progresiva del valor angular de la escoliosis, hasta 8,7° de media a las 2 semanas. El acuñamiento del cuerpo vertebral apical y de los discos adyacentes se corregía parcialmente tras 2 semanas de corrección de la deformidad. Conclusión. En este modelo de escoliosis, un alambre recto de nitinol anclado a la columna ha demostrado eficacia para la corrección gradual de la cifoescoliosis, y de los cambios estructurales asociados a la misma (AU)

Objective: To create an experimental structural scoliosis model in mice to evaluate the efficacy of shape-memory metals to gradually correct the deformity over time. Material and method: Experimental scoliosis was generated in 3 week-old mice by means of a suture between the left scapula and pelvis for 8 weeks. They were then randomised into two groups: a control group, in which the suture was cut, and another, in those that also had a Nitinol straight memory-wire implant fixed to the column. Serial X-rays were performed to determine the efficacy of the Nitinol in the correction of the scoliosis. In a second time, the histological changes at apical vertical body level and the adjacent discs were evaluated preand post-correction. Results: A mean 81.5◦ kyphoscoliosis was gradually induced. In the control group, after cutting the suture, an initial reduction in the deformity was observed, but later it remained stable throughout the time (54◦ at two weeks). In the Nitinol group, a gradual reduction was observed in the scoliosis angle value, to a mean of 8.7◦ at two weeks. The curvature of the apical vertebral body and adjacent discs were partially corrected after two weeks of correcting the deformity. Conclusion: This scoliosis model has demonstrated the efficacy of a straight Nitinol wire fixed to the spinal column in the gradual correction of kyphoscoliosis and in the changes in its adjacent structures (AU)

[Modulation of scoliotic spine growth in experimental animals using intelligent metal bars]. / Modulación del crecimiento de columnas escolióticas en animales de experimentación mediante el uso de barras de metal inteligente.

OBJECTIVE: To create an experimental structural scoliosis model in mice to evaluate the efficacy of shape-memory metals to gradually correct the deformity over time. MATERIAL AND METHOD: Experimental scoliosis was generated in 3 week-old mice by means of a suture between the left scapula and pelvis for 8 weeks. They were then randomised into two groups: a control group, in which the suture was cut, and another, in those that also had a Nitinol straight memory-wire implant fixed to the column. Serial X-rays were performed to determine the efficacy of the Nitinol in the correction of the scoliosis. In a second time, the histological changes at apical vertical body level and the adjacent discs were evaluated pre- and post-correction. RESULTS: A mean 81.5° kyphoscoliosis was gradually induced. In the control group, after cutting the suture, an initial reduction in the deformity was observed, but later it remained stable throughout the time (54° at two weeks). In the Nitinol group, a gradual reduction was observed in the scoliosis angle value, to a mean of 8.7° at two weeks. The curvature of the apical vertebral body and adjacent discs were partially corrected after two weeks of correcting the deformity. CONCLUSION: This scoliosis model has demonstrated the efficacy of a straight Nitinol wire fixed to the spinal column in the gradual correction of kyphoscoliosis and in the changes in its adjacent structures.

[Growing rods in early-onset scoliosis. Do they really help to control the deformity and spinal and thoracic growth?]. / Barras de crecimiento en escoliosis de inicio precoz ¿Permiten realmente el control de la deformidad y el crecimiento vertebral y torácico?

OBJECTIVE: To determine the efficacy of growing rods in the treatment of early onset scoliosis. MATERIAL AND METHODS: A total of 32 patients were treated using fusion techniques that included double growing rods and Vertical Expandable Prosthetic Titanium Ribs (VEPTR), in our Early Onset Scoliosis Centre between 2004 and 2011. After analysing the clinical histories and x-rays, 20 patients were included due to meeting the inclusion criteria. All patients had previously received conservative treatment with cranial traction and a series of plasters/corsets. The deformity was analysed before and after the initial surgery, and in successive tightenings, using the x-rays of the coronal and sagittal planes by means of the Cobb angle, as well as the longitudinal and coronal growth of the thorax, and the growth of the spinal column. A series of 188 x-rays of 53 patients with cystic fibrosis were studied in order to perform a comparative analysis with the patients with early-onset scoliosis. RESULTS: There was significant improvement in the angle (Cobb and kyphosis) and linear parameters (T1-S1 distance, T1-T12 distance, and coronal width of the thorax) after the initial surgery, but the successive tightenings had a minimal beneficial effect, losing effectiveness over a period of time. The patients with early-onset scoliosis showed a lower growth of the thorax compared to the patients with cystic fibrosis. DISCUSSION: Treatment of early-onset scoliosis with expandable devices is mainly beneficial with the initial procedure and the first tightenings, but shows a loss of efficacy over a period time.

Barras de crecimiento en escoliosis de inicio precoz ¿Permiten realmente el control de la deformidad y el crecimiento vertebral y torácico? / Growing rods in early-onset scoliosis. Do they really help to control the deformity and spinal and thoracic growth?

Objetivo. Determinar la eficacia de las barras de crecimiento en el tratamiento de la escoliosis de inicio precoz. Material y métodos. Entre 2004 y 2011, un total de 32 pacientes fueron intervenidos en nuestro centro de escoliosis de inicio precoz mediante técnicas sin fusión (barras de crecimiento dobles y VEPTR). De ellos, analizamos prospectivamente la historia clínica y las radiografías de 20 pacientes que cumplen los criterios de inclusión. Todos los pacientes habían recibido previamente tratamiento conservador con tracción craneal y yesos/corsés seriados. En cada radiografía (preoperatoria y postoperatoria de la cirugía inicial y de los sucesivos retensados) analizamos la deformidad en los planos coronal y sagital mediante el ángulo de Cobb, el crecimiento longitudinal y coronal del tórax, y el crecimiento de la columna vertebral. Se estudian 188 radiografías de tórax seriadas de 53 pacientes con fibrosis quística para hacer un análisis comparativo con los pacientes con escoliosis de inicio precoz. Resultados. La mejora de los parámetros angulares (Cobb y cifosis) y lineales (distancia T1-S1, distancia T1-T12 y anchura coronal del tórax) fue significativa con la cirugía inicial, pero los sucesivos retensados tuvieron un mínimo efecto beneficioso, perdiendo eficacia a lo largo del tiempo. Comparativamente con los pacientes con fibrosis quística, el crecimiento del tórax es menor en los pacientes con escoliosis de inicio precoz. Discusión. El tratamiento de la escoliosis de inicio precoz con sistemas expansibles resulta beneficioso fundamentalmente en el procedimiento inicial y primeros retensados, demostrando una pérdida de eficacia a lo largo del tiempo (AU)

Objective. To determine the efficacy of growing rods in the treatment of early onset scoliosis. Material and methods. A total of 32 patients were treated using fusion techniques that included double growing rods and Vertical Expandable Prosthetic Titanium Ribs (VEPTR), in our Early Onset Scoliosis Centre between 2004 and 2011. After analysing the clinical histories and x-rays, 20 patients were included due to meeting the inclusion criteria. All patients had previously received conservative treatment with cranial traction and a series of plasters/corsets. The deformity was analysed before and after the initial surgery, and in successive tightenings, using the x-rays of the coronal and sagittal planes by means of the Cobb angle, as well as the longitudinal and coronal growth of the thorax, and the growth of the spinal column. A series of 188 x-rays of 53 patients with cystic fibrosis were studied in order to perform a comparative analysis with the patients with early-onset scoliosis. Results. There was significant improvement in the angle (Cobb and kyphosis) and linear parameters (T1-S1 distance, T1-T12 distance, and coronal width of the thorax) after the initial surgery, but the successive tightenings had a minimal beneficial effect, losing effectiveness over a period of time. The patients with early-onset scoliosis showed a lower growth of the thorax compared to the patients with cystic fibrosis. Discussion. Treatment of early-onset scoliosis with expandable devices is mainly beneficial with the initial procedure and the first tightenings, but shows a loss of efficacy over a period time (AU)

Efecto de la costoplastia en la función pulmonar y la estética en pacientes con escoliosis idiopática del adolescente / Effect of thoracoplasty on pulmonary function and esthetics in patients with adolescent idiopathic scoliosis

Objetivo: Evaluar en pacientes con escoliosis idiopática del adolescente, intervenidos mediante artrodesis vertebral posterior y costoplastia, la función pulmonar y los resultados clínicos y funcionales. Material y método: Evaluamos prospectivamente a 18 pacientes consecutivas con escoliosis idiopática del adolescente con componente torácico, a las que se les realizó artrodesis vertebral posterior instrumentada con costoplastia asociada, con un seguimiento de 2 años. La función pulmonar se valoró por medio de la capacidad vital forzada (CVF) y el volumen espiratorio máximo en el primer segundo (VEM1) en la espirometría basal preoperatoria, al año y a los 2 años postoperatorios. Para la evaluación clínica y funcional se utilizó el cuestionario SRS-22, preoperatorio y a los 2 años de la cirugía. Resultados: La CVF preoperatoria media fue de 2,63 l (77,15% del valor teórico), mientras que el VEM1 medio fue de 2,29 l (79,46% del valor teórico). Los valores medios al año postoperatorio fueron de 2,77 l para la CVF y de 2,48 l para el VEM1 (un 79,8 y un 85,2% de los valores teóricos, respectivamente). A los 2 años postoperatorios, el valor medio de la CVF fue de 2,86 l y del VEM1 de 2,64 l, es decir, un 81,8 y un 89,15% de los valores teóricos, respectivamente. Resultó muy significativa la mejoría en la percepción de la autoimagen del paciente tras la cirugía. Conclusiones: Las pruebas funcionales respiratorias demuestran que los pacientes escolióticos intervenidos experimentaron una mejoría significativa y progresiva de la función respiratoria con respecto al control basal prequirúrgico (AU)

Purpose: To evaluate pulmonary function and clinical and functional outcomes in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion and thoracoplasty. Materials and methods: We evaluated prospectively 18 consecutive patients with thoracic AIS treated with instrumented posterior spinal fusion with concomitant thoracoplasty with a 2 years follow-up. Pulmonary function was assessed by forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) before surgery, and one and two years after surgery. We used the SRS-22 questionnaire to assess the clinical outcomes before surgery and two years after surgery. Results: Average absolute preoperative FVC was 2.63 L (theoretical predictive value FVC:77.15%) while FEV1 was 2.29 (theoretical predictive value FEV1:79.46%). At one year postsurgery, mean values of FVC and FEV1 were, respectively, 2.77 and 2.48 (theoretical predictive value FVC: 79.8% and FEV1:85.2%). At two years postsurgery, mean value of FVC was 2.86 L and 2.64L for FVC and FEV1 respectively, that is, FVC: 81.8%, and FEV1:89.15%. The improvement in the self-image item of the patients after surgery on the SRS-22 questionnaire is very significant. Conclusions: The pulmonary function tests show that these scoliotic patients have a significant progressive improvement of FVC and FEV1 at one and two years postsurgery, compared with the preoperative values (AU)

Lesión osteolítica vertebral en un varón joven / Vertebral osteolytic lesion in a young male

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The low lumbar spine below Cotrel-Dubousset instrumentation: long-term findings.

STUDY DESIGN: Retrospective review of long instrumented fusions down to the low lumbar spine for the treatment of adolescent idiopathic scoliosis. OBJECTIVES: To evaluate whether the use of instrumentation systems that preserve the sagittal profile could reduce the incidence of early degenerative changes. SUMMARY OF BACKGROUND DATA: Long fusions and distractive Harrington instrumentation in the surgical treatment of adolescent idiopathic scoliosis (AIS) are known to produce pain and degenerative changes in the free lumbar segments. Reports on the use of Cotrel-Dubousett instrumentation (CDI) confirm that the instrumentation maintains physiologic lumbar lordosis, but the evolution of the spine below the fusion is not addressed. METHOD: Thirty-five patients with AIS and CDI were studied. Their spines were fused to L3 or lower, and they had a minimum follow-up of 10 years. Radiologic measurements were recorded from frontal and lateral radiographs. At the time of last examination, lateral flexion-extension dynamic radiographs and magnetic resonance imaging evaluated the health of the disks below the fusion. Clinical outcome was assessed with the Scoliosis Research Society instrument. A control group consisting of 35 peers without scoliosis served as a reference for the outcome questionnaire. RESULTS: Surgery kept the sagittal profile in a physiologic range. All but two patients were satisfied with the results of surgery. There were no differences between patients and control group insofar as pain, self-image, general function, and daily activity were concerned. Eleven patients showed instability signs in dynamic radiographs and more than half of patients showed incipient degeneration on magnetic resonance images. These findings are similar to those found in the general population, according to the literature, and could evidence normal aging processes. CONCLUSIONS: Cotrel-Dubousset instrumentation maintains the physiologic sagittal contour. Although there are some degenerative changes in magnetic resonance images and dynamic radiographs, the quality of life and daily activities of the patients after surgery are similar to those of a normal population of the same age.

Rupture of the quadriceps tendon after total knee arthroplasty. A case report.

Reported herein is the case of a 45-year-old woman with knee involvement due to rheumatoid arthritis. She had a total knee arthroplasty with a rupture of the quadriceps tendon 1 month later. Surgical repair of the rupture was performed following the Scuderi technique plus reinforcement with Dacron (Lig Aid, Levallois, Cedex, France) tape cerclage. An above-knee walking-plaster cast was applied with the knee in full extension for 6 weeks. The functional result was good 1 year after surgery.

Osteomyelitis of the pubic symphysis due to Streptococcus anginosus. A case report.

An unusual case of osteomyelitis of the pubic symphysis in an insulin-dependent diabetic is reported. The infection occurred after the insertion of a penile prosthesis and the organism was streptococcus anginosus. Healing took place after wide excision and drainage, with penicillin given systemically.

Scintimetric study of the bone response around noncemented knee prosthesis. Preliminary results.

The bone response to a noncemented knee prosthesis was observed by quantified isotopic gammagraphy. One hundred six sequential scintimetric explorations were performed in 36 patients with total knee arthroplasty. Fifteen areas of interest were taken into consideration and their gammagraphic analyses were compared with radiologic findings during a postsurgery period of 24 months. Starting with a very high radionuclide uptake level obtained in the first postsurgery level, a gradual decrease was correlated with osteoblastic activity. In this first evaluation, the gammagraphic response around the implant is different in biologic prostheses than in cemented ones. These data may be useful for evaluating implants in orthopedic surgery.

Ilizarov technique. Results and difficulties.

Of 100 cases treated by the Ilizarov method, 91 patients were reviewed from February 1985 to March 1990. There were 32 tibial fractures (29 open) and 21 nonunions (nine infected). There were 47 cases of limb lengthening (28 tibia and 19 femur). The results were as follows: good, 83%; fair, 13%; and poor, 4%. Slight and intermittent pain in some wire of the device was frequent (69%). Average bone healing time in tibial fractures was 4.95 months and 5.83 months in tibial nonunions. In bone-lengthening operations, the average lengthening index in the tibia was 1.02 months/cm (lengthenings ranged from 3 cm to 10 cm, with a mean of 5.71 cm), whereas in the femur, the average lengthening index was 1.14 months/cm (lengthenings ranged from 3 cm to 7 cm, with a mean of 5.34 cm). Manually-tensed wires produced frequent problems (24.5%), whereas wire tensed by the dynamometric tensioner produced problems in only 7.8% of the cases. Despite good results, the Ilizarov technique requires adequate training to reduce an overall complication rate (approximately 30%).