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2.
Global Spine J ; : 2192568220984128, 2021 Jan 25.
Artigo em Inglês | MEDLINE | ID: mdl-33487047

RESUMO

STUDY DESIGN: Retrospective observational. OBJECTIVES: This study aimed to document the safety and efficacy of lumbar corpectomy with reconstruction of anterior column through posterior-only approach in complete burst fractures. METHODS: In this retrospective study, we analyzed complete lumbar burst fractures treated with corpectomy through posterior only approach between 2014 and 2018. Clinical and intraoperative data including pre and post-operative neurology as per the ISNCSCI grade, VAS score, operative time, blood loss and radiological parameters, including pre and post-surgery kyphosis, height loss and canal compromise was assessed. RESULTS: A total of 45 patients, with a mean age of 38.89 and a TLICS score 5 or more were analyzed. Preoperative VAS was 7-10. Mean operating time was 219.56 ± 30.15 minutes. Mean blood loss was 1280 ± 224.21 ml. 23 patients underwent short segment fixation and 22 underwent long segment fixation. There was no deterioration in post-operative neurological status in any patient. At follow-up, the VAS score was in the range of 1-3. The difference in preoperative kyphosis and immediate post-operative deformity correction, preoperative loss of height in vertebra and immediate post-operative correction in height were significant (p < 0.05). CONCLUSION: The posterior-only approach is safe, efficient, and provides rigid posterior stabilization, 360° neural decompression, and anterior reconstruction without the need for the anterior approach and its possible approach-related morbidity. We achieved good results with an all posterior approach in 45 patients of lumbar burst fracture (LBF) which is the largest series of this nature.

3.
Asian J Neurosurg ; 15(3): 674-677, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33145226

RESUMO

About 35%-72% of lumbar disc herniations are associated with fragment migration. However, the posterior epidural migration is rare. We present a strange situation encountered during surgical decompression of the posterior migrated fragment. A 72-year-old male presented with a history of pain radiating to the left lower limb and Grade 3 power of the extensor hallucis longus. Magnetic resonance imaging revealed a prolapsed intervertebral disc and a possible posterior epidural migration of disc fragment. Routine surgical steps for microdiscectomy were followed after confirmation of level using fluoroscopy. However, the extruded disc fragment was not seen, and both exiting and traversing roots were free with adequate mobility. After extensively searching for a disc in the spinal canal, suction fluid was filtered through a surgical mop used as a sieve. Material collected was sent for histopathological study. Biopsy report confirmed material filtered was indeed the intervertebral disc. Thus, accidental suction of disc material in case of the posterior epidural migrated disc is a possibility, and we should be vigilant about this scenario to avoid disaster.

4.
Surg Neurol Int ; 11: 265, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33024603

RESUMO

Background: Mini-open thoracoscopic-assisted thoracotomy (MOTA) has been introduced to mitigate disadvantages of conventional open anterior or conventional posterior only thoracoscopic procedures. Here, we evaluated the results of utilizing the MOTA technique to perform anterior decompression/fusion for 22 traumatic thoracic fractures. Methods: There were 22 patients with unstable thoracic burst fractures (TBF) who underwent surgery utilizing the MOTA thoracotomy technique. Multiple variables were studied including; the neurological status of the patient preoperatively/postoperatively, the level and type of fracture, associated injuries, operative time, estimated blood loss, chest tube drainage (intercostal drainage), length of hospital stay (LOS), and complication rate. Results: In 22 patients (averaging 35.5 years of age), T9 and T12 vertebral fractures were most frequently encountered. There were 20 patients who had single level and 2 patients who had two-level fractures warranting corpectomies. Average operating time and blood loss for single-level corpectomy were 91.5 ± 14.5 min and 311 ml and 150 ± 18.6 min and 550 ml for two levels, respectively. Mean hospital stay was 5 days. About 95.45% of cases showed fusion at latest follow-up. Average preoperative kyphotic angle corrected from 34.2 ± 3.5° to 20.5 ± 1.0° postoperatively with an average correction of 41.1% and correction loss of 2.4%. Conclusion: We concluded that utilization of the MOTA technique was safe and effective for providing decompression/fusion of traumatic TBF.

5.
J Clin Orthop Trauma ; 11(5): 778-785, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32904223

RESUMO

With the global rise in the population of elderly along with other risk factors, spine surgeons have to encounter osteoporotic spine more often. Osteoporotic spine, however, causes problems in management, particularly where instrumentation is involved, resulting in screw loosening, pull out, pseudoarthroses or adjacent segment kyphosis. Osteoporosis alters the bio mechanics at the bone implant interface resulting in various degrees of fixation failure. Various advancements have been made in this field to deal with such issues in addition to modification of basic surgical techniques such as increasing the diameter and length of the screw, smaller pilot hole, under tapping, longer constructs, supplemental anterior fixation, sublaminar wires or laminar hooks, use of transverse connectors and triangulation techniques, among others. They include novel surgical techniques such as cortical bone trajectory, superior cortical trajectory, double screw technique, cross trajectory technique, bicortical screw technique or prophylactic vertebroplasty. Advances in the screw design include expandable screws, fenestrated screws, conical screws and coated screws. In addition to PMMA cement augmentation, other biodegradable cements have been introduced to mitigate the side effects of PMMA such as calcium phosphate, calcium apatite and hydroxyapatite. Pharmacotherapy with teriparatide can aid fusion and lower the rate of pedicle screw loosening. Many of these strategies have only bio mechanical evidence and require well designed clinical trials to establish their clinical efficacy. Though no single technique is fool proof, little modifications in the existing techniques or utilizing a combination of techniques without adding to the cost of the surgery may help to achieve a near-ideal result. Surgeons have to equip their armamentarium with all the recent advances, and should be open to novel thoughts and techniques.

6.
Br J Anaesth ; 2020 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-32768179

RESUMO

BACKGROUND: We aimed to establish diagnostic criteria for bleeding independently associated with mortality after noncardiac surgery (BIMS) defined as bleeding during or within 30 days after noncardiac surgery that is independently associated with mortality within 30 days of surgery, and to estimate the proportion of 30-day postoperative mortality potentially attributable to BIMS. METHODS: This was a prospective cohort study of participants ≥45 yr old having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011. Cox proportional hazards models evaluated the adjusted relationship between candidate diagnostic criteria for BIMS and all-cause mortality within 30 days of surgery. RESULTS: Of 16 079 participants, 2.0% (315) died and 36.1% (5810) met predefined screening criteria for bleeding. Based on independent association with 30-day mortality, BIMS was identified as bleeding leading to a postoperative haemoglobin <70 g L-1, transfusion of ≥1 unit of red blood cells, or that was judged to be the cause of death. Bleeding independently associated with mortality after noncardiac surgery occurred in 17.3% of patients (2782). Death occurred in 5.8% of patients with BIMS (161/2782), 1.3% (39/3028) who met bleeding screening criteria but not BIMS criteria, and 1.1% (115/10 269) without bleeding. BIMS was associated with mortality (adjusted hazard ratio: 1.87; 95% confidence interval: 1.42-2.47). We estimated the proportion of 30-day postoperative deaths potentially attributable to BIMS to be 20.1-31.9%. CONCLUSIONS: Bleeding independently associated with mortality after noncardiac surgery (BIMS), defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, blood transfusion, or that is judged to be the cause of death, is common and may account for a quarter of deaths after noncardiac surgery. CLINICAL TRIAL REGISTRATION: NCT00512109.

7.
Br J Anaesth ; 2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-32718723

RESUMO

BACKGROUND: Diagnostic criteria for Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS) have been defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, leads to blood transfusion, or is judged to be the direct cause of death. Preoperative prediction guides for BIMS can facilitate informed consent and planning of perioperative care. METHODS: In a prospective cohort study of 16 079 participants aged ≥45 yr having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011, 17.3% (2782) experienced BIMS. An electronic risk calculator for BIMS was developed and internally validated by logistic regression with bootstrapping, and further simplified to a risk index. Decision curve analysis assessed the potential utility of each prediction guide compared with a strategy of identifying risk of BIMS based on preoperative haemoglobin <120 g L-1. RESULTS: With information about the type of surgery, preoperative haemoglobin, age, sex, functional status, kidney function, history of high-risk coronary artery disease, and active cancer, the risk calculator accurately predicted BIMS (bias-corrected C-statistic, 0.84; 95% confidence interval, 0.837-0.852). A simplified index based on preoperative haemoglobin <120 g L-1, open surgery, and high-risk surgery also predicted BIMS, but less accurately (C-statistic, 0.787; 95% confidence interval, 0.779-0.796). Both prediction guides could improve decision making compared with knowledge of haemoglobin <120 g L-1 alone. CONCLUSIONS: BIMS, defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, leads to blood transfusion, or that is judged to be the direct cause of death, can be predicted by a simple risk index before surgery. CLINICAL TRIAL REGISTRATION: NCT00512109.

9.
World Neurosurg ; 140: 89-95, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32407923

RESUMO

INTRODUCTION: Sympathetic system injury is a known but rare complication in scoliosis deformity correction. It is not common following posterior correction. We report a case of diastematomyelia with neuromuscular scoliosis with unusual complication of sympathetic outflow disturbance, after posterior instrumented correction. CASE DESCRIPTION: A 13-year-old girl presented with complaints of deformity in the back first noticed 4 years ago. Roentgenogram revealed a right thoracolumbar kyphoscoliotic deformity of 105° with apex at T8 with non-structural lumbar and cervicothoracic curves with positive sagittal alignment. Magnetic resonance imaging showed split-cord malformation with bony crest near the apex of the curve. Detethering followed by removal of the bony crest and restoration of the dual dural sleeves of the split cord into single neural tube was done in the first stage. In the second stage, pedicle screw fixation with was done from D3 to L3. Deformity correction was achieved using multilevel Smith Peterson osteotomy and concave rib osteotomy. On the second postoperative day, intensive care unit staff noticed persistent sinus tachycardia and profuse sweating in both upper limbs, chest, and upper-back. Twenty-four-hour Holter monitoring did not reveal any abnormality. Patient improved gradually and was discharged on postoperative day 9 when both sinus tachycardia and hyperhidrosis resolved. CONCLUSIONS: Sympathetic chain disturbances after surgery recover with time. The exact time duration needed for recovery is not yet defined, however. Spine surgeons should be aware of this postsurgical complication and identify it so that management can be initiated. The symptoms may be long and drawn out, thus the roles of communication with and counseling of the patient as cannot be underemphasized.


Assuntos
Doenças do Sistema Nervoso Autônomo/etiologia , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/etiologia , Escoliose/cirurgia , Adolescente , Feminino , Humanos , Defeitos do Tubo Neural/complicações , Escoliose/etiologia , Fusão Vertebral/efeitos adversos
10.
Asian J Neurosurg ; 15(1): 218-221, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32181207

RESUMO

Cervical osteophytes may be seen in diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, posttraumatic, postoperative, degenerative causes, cervical spondylosis, and infectious spondylitis. A cervical osteophyte is very rarely considered among the differentials for symptoms of dysphagia. C5-C6 as well as C6-C7 being a site of greater load-bearing and mobility, the propensity to form osteophytes is high, with a small osteophyte leading to local mass effect. A 42-year-old male patient presented with mild dyspnea and significant dysphagia since 8 months, accompanied by dysphonia, weight loss, and intermittent aspiration. Clinical examination including neurological examination was normal. A barium swallow showed that osteophytes were severely protruding and displacing the lower pharynx and the proximal esophagus anterosuperiorly. The patient underwent surgical removal of the osteophyte through Smith-Robinson approach. Complaints of dysphagia were significantly decreased in postoperative period. A thorough evaluation is necessary to rule out other causes of dysphagia. Surgical management of this uncommon condition might be considered after confirmation of the osteophyte to be the offending lesion as it has favorable clinical outcomes.

11.
Asian Spine J ; 14(3): 357-363, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31906610

RESUMO

STUDY DESIGN: Prospective case study. PURPOSE: Osteoporotic spine fixation by pedicle screw instrumentation is complicated by screw loosening, migration, or pullout with rates of up to 62% documented in the literature. Contemporary solutions have not adequately addressed these complications. We propose a modified surgical technique of cement augmentation with bicortical pedicle screw fixation to address the issue related to implant failure in osteoporotic spine. OVERVIEW OF LITERATURE: Zindrick and his colleagues described a "windshield wiper" effect owing to the shift of center of rotation to the distal tip of the screw in the bicortical purchase of screws. An increase in pullout strength from 119% to 250% with polymethyl methacrylate augmentation has been documented in the literature. This technique has not been described in the literature. METHODS: A prospective study was conducted with 40 patients who underwent surgery by the modified technique. Intraoperative and postoperative complications directly related to the procedure were assessed. Improvement in pain and functional status were assessed. Follow-up radiographs were assessed to check for appreciable screw migration, loosening, or pullout. RESULTS: This technique was used in inserting 364 screws in 40 patients. We did not encounter any difficulty in inserting the screws. A total of 19 screws failed to breach the anterior cortex owing to an error in measurement. There were no complications during the procedure in any of the patients, and the postoperative period was uneventful. The mean follow-up period was 18 months. There were two patients in whom proximal junctional failure with kyphosis was noted during follow-up, who were surgically managed by extension of the fixation levels. CONCLUSIONS: Bicortical fixation with cement augmentation is a technically feasible, safe, and effective technique to augment the strength of pedicle screws in osteoporotic spine fixation. It has the potential to be established as a standard of care in osteoporotic spine fixation.

13.
World Neurosurg ; 134: e808-e814, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31715405

RESUMO

BACKGROUND: Vertebral osteomyelitis manifesting as a compression fracture misdiagnosed in the setting of steroid-induced or senile osteoporosis is very rare, although such patients are prone to infection or reactivation, as their immune system is exhausted. Spondylodiscitis occurring at adjacent levels following instrumented spinal fusion leading to pathologic fracture and proximal junctional failure, especially caused by tuberculosis, to our knowledge, has not been discussed in the literature. METHODS: In case 1, a 61-year-old woman with osteoporotic T12 collapse was treated with corpectomy, anterior reconstruction, and posterior fixation from T9-L2. Initial biopsy and culture were normal. She presented 4 months later with compression fracture of T8; T8 corpectomy with anterior reconstruction and proximal extension of the construct was performed. In case 2, a 65-year-old woman with multiple comorbidities and osteoporotic L1 compression fracture was treated with L1 corpectomy, anterior reconstruction, and posterior instrumentation from T11-L3. She presented 4 months later with T10 vertebral body acute collapse; 2-stage anterior corpectomy and reconstruction was performed. In both cases, probing the affected vertebral body yielded pus. Pus and bone tissue samples sent for culture and histopathologic examination were positive for tuberculosis suggesting tuberculous spondylitis in both cases. RESULTS: In both patients, tuberculous spondylodiscitis at the proximal adjacent level was diagnosed <1 year after the initial spinal surgery. Neither patient had a previous history of pulmonary or extrapulmonary tuberculosis. They were successfully treated with antituberculous therapy and proximal extension of the construct with anterior reconstruction. CONCLUSIONS: Adjacent segment spondylodiscitis should be suspected and intraoperative biopsy must be considered for histopathologic and microbiologic examination to rule out subclinical infection in immunosuppressed patients with multiple comorbidities. Management should be individualized, considering the context of infection, causative organism, extent of bone destruction, and neurologic involvement.


Assuntos
Discite/diagnóstico , Fraturas Espontâneas/diagnóstico , Fraturas por Osteoporose/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Espondilite/diagnóstico , Infecção da Ferida Cirúrgica/diagnóstico , Tuberculose da Coluna Vertebral/diagnóstico , Idoso , Antituberculosos/uso terapêutico , Discite/complicações , Discite/terapia , Feminino , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/cirurgia , Humanos , Cifose/etiologia , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Reconstrutivos , Fraturas da Coluna Vertebral/diagnóstico , Fraturas da Coluna Vertebral/etiologia , Espondilite/complicações , Espondilite/cirurgia , Infecção da Ferida Cirúrgica/complicações , Infecção da Ferida Cirúrgica/terapia , Vértebras Torácicas/diagnóstico por imagem , Vértebras Torácicas/cirurgia , Tuberculose da Coluna Vertebral/complicações , Tuberculose da Coluna Vertebral/terapia , Vertebroplastia
14.
BMJ Open ; 9(9): e033150, 2019 09 24.
Artigo em Inglês | MEDLINE | ID: mdl-31551393

RESUMO

INTRODUCTION: Inflammation, dehydration, hypotension and bleeding may all contribute to the development of acute kidney injury (AKI). Accelerated surgery after a hip fracture can decrease the exposure time to such contributors and may reduce the risk of AKI. METHODS AND ANALYSIS: Hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) is a multicentre, international, parallel-group randomised controlled trial (RCT). Patients who suffer a hip fracture are randomly allocated to either accelerated medical assessment and surgical repair with a goal of surgery within 6 hours of diagnosis or standard care where a repair typically occurs 24 to 48 hours after diagnosis. The primary outcome of this substudy is the development of AKI within 7 days of randomisation. We anticipate at least 1998 patients will participate in this substudy. ETHICS AND DISSEMINATION: We obtained ethics approval for additional serum creatinine recordings in consecutive patients enrolled at 70 participating centres. All patients provide consent before randomisation. We anticipate reporting substudy results by 2021. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.


Assuntos
Lesão Renal Aguda , Fixação de Fratura , Fraturas do Quadril , Complicações Pós-Operatórias/prevenção & controle , Risco Ajustado/métodos , Tempo para o Tratamento/normas , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/prevenção & controle , Adulto , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/métodos , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/fisiopatologia , Fraturas do Quadril/cirurgia , Humanos , Masculino , Planejamento de Assistência ao Paciente/normas , Medição de Risco/métodos , Fatores de Risco
15.
World Neurosurg ; 128: 385-389, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31121367

RESUMO

BACKGROUND: Intradural lumbar disc herniation is rare, with an incidence of 0.3%-1%, but has been well reported in the literature. Transdural migration of the disc penetrating both ventral and dorsal dura is extremely rare, and there is a dearth of literature in the pathophysiology and surgical management of transdural herniation. Lack of knowledge on this type of presentation can cause intraoperative surprises and inadvertent cauda equina root injuries and lead to prolonged operative time. We report 1 such case, describe our surgical experience, and discuss the pathological mechanisms and signs. CASE DESCRIPTION: A 30-year-old woman presented to outpatient clinic with chronic cauda equina syndrome due to massive L4-L5 disc herniation. L4-L5 decompression and transforaminal lumbar interbody fusion were planned. Unexpectedly, however, surgery revealed a transdural herniation, which was effectively managed with laminectomy, extension of durotomy, discectomy, repair of both dorsal and ventral dura, and interbody fusion, but at the expense of prolonged surgical time. CONCLUSIONS: Transdural herniation of a lumbar disc is very rare presentation. It can be effectively managed with laminectomy, extension of durotomy, discectomy and repair of both dorsal and ventral dura. It can be diagnosed by magnetic resonance imaging preoperatively only if read with suspicion of such presentation.


Assuntos
Síndrome da Cauda Equina/cirurgia , Dura-Máter/cirurgia , Deslocamento do Disco Intervertebral/cirurgia , Adulto , Síndrome da Cauda Equina/etiologia , Descompressão Cirúrgica , Discotomia , Dura-Máter/diagnóstico por imagem , Feminino , Humanos , Deslocamento do Disco Intervertebral/complicações , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Laminectomia , Vértebras Lombares , Duração da Cirurgia , Fusão Vertebral
16.
BMJ Open ; 9(4): e028537, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-31048449

RESUMO

INTRODUCTION: Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. METHODS AND ANALYSIS: HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. ETHICS AND DISSEMINATION: All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.


Assuntos
Fraturas do Quadril/cirurgia , Idoso , Feminino , Fraturas do Quadril/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Projetos de Pesquisa , Fatores de Tempo
17.
Anesthesiology ; 130(5): 756-766, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30870165

RESUMO

BACKGROUND: Perioperative hypotension is associated with cardiovascular events in patients having noncardiac surgery. It is unknown if the severity of preexisting coronary artery disease determines susceptibility to the cardiovascular risks of perioperative hypotension. METHODS: In this retrospective exploratory analysis of a substudy of an international prospective blinded cohort study, 955 patients 45 yr of age or older with history or risk factors for coronary artery disease underwent coronary computed tomographic angiography before elective inpatient noncardiac surgery. The authors evaluated the potential interaction between angiographic findings and perioperative hypotension (defined as systolic blood pressure less than 90 mmHg for a total of 10 min or more during surgery or for any duration after surgery and for which intervention was initiated) on the composite outcome of time to myocardial infarction or cardiovascular death up to 30 days after surgery. Angiography assessors were blinded to study outcomes; patients, treating clinicians, and outcome assessors were blinded to angiography findings. RESULTS: Cardiovascular events (myocardial infarction or cardiovascular death within 30 days after surgery) occurred in 7.7% of patients (74/955), including in 2.7% (8/293) without obstructive coronary disease or hypotension compared to 6.7% (21/314) with obstructive coronary disease but no hypotension (hazard ratio, 2.51; 95% CI, 1.11 to 5.66; P = 0.027), 8.8% (14/159) in patients with hypotension but without obstructive coronary disease (hazard ratio, 3.85; 95% CI, 1.62 to 9.19; P = 0.002), and 16.4% (31/189) with obstructive coronary disease and hypotension (hazard ratio, 7.34; 95% CI, 3.37 to 15.96; P < 0.001). Hypotension was independently associated with cardiovascular events (hazard ratio, 3.17; 95% CI, 1.99 to 5.06; P < 0.001). This association remained in patients without obstructive disease and did not differ significantly across degrees of coronary disease (P value for interaction, 0.599). CONCLUSIONS: In patients having noncardiac surgery, perioperative hypotension was associated with cardiovascular events regardless of the degree of coronary artery disease on preoperative coronary computed tomographic angiography.


Assuntos
Doença da Artéria Coronariana/complicações , Hipotensão/complicações , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
18.
Spinal Cord ; 57(1): 26-32, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30089891

RESUMO

STUDY DESIGN: A psychometrics study. OBJECTIVES: To determine intra and inter-observer reliability of Allen Ferguson system (AF) and sub-axial injury classification and severity scale (SLIC), two sub axial cervical spine injury (SACI) classification systems. SETTING: Online multi-national study METHODS: Clinico-radiological data of 34 random patients with traumatic SACI were distributed as power point presentations to 13 spine surgeons of the Spine Trauma Study Group of ISCoS from seven different institutions. They were advised to classify patients using AF and SLIC systems. A reference guide of the two systems had been mailed to them earlier. After 6 weeks, the same cases were re-presented to them in a different order for classification using both systems. Intra and inter-observer reliability scores were calculated and analysed with Fleiss Kappa coefficient (k value) for both the systems and Intraclass correlation coefficient(ICC) for the SLIC. RESULTS: Allen Ferguson system displayed a uniformly moderate inter and intra-observer reliability. SLIC showed slight to fair inter-observer reliability and fair to substantial intra-observer reliability. AF mechanistic types showed better inter-observer reliability than the SLIC morphological types. Within SLIC, the total SLIC had the least inter-observer agreement and the SLIC neurology had the highest intra-observer agreement. CONCLUSION: This first external reliability study shows a better reliability for AF as compared to SLIC system. Among the SLIC variables, the DLC status and the total SLIC had least agreement. Low-reliability highlights the need for improving the existing classification systems or coming out with newer ones that consider limitations of the existing ones.


Assuntos
Vértebras Cervicais/lesões , Traumatismos da Coluna Vertebral/classificação , Índices de Gravidade do Trauma , Vértebras Cervicais/diagnóstico por imagem , Humanos , Internacionalidade , Variações Dependentes do Observador , Psicometria , Reprodutibilidade dos Testes , Traumatismos da Coluna Vertebral/diagnóstico por imagem
19.
Artigo em Inglês | MEDLINE | ID: mdl-30374412

RESUMO

Background: The management of acute traumatic cervical spine injury in a third-trimester pregnancy is challenging with risks involved for both the mother and the fetus. We report one such case that was managed successfully with good maternal and fetal outcomes. Case presentation: A 30 years female, gravida 2, para 1, living 1 at 31 weeks 5 days of pregnancy, met with a RTA and was diagnosed with AIS B C4-C5 extension compression spinal cord injury (SCI) with a viable fetus. Closed reduction of C4-C5 dislocation was achieved through controlled cervical traction. Having involved the patient in informed decision-making, anterior cervical discectomy and fusion (ACDF) was performed under general anesthesia (GA), with obstetrician, as well as neonatologist available in the operation theater. The pregnancy was uneventful in the post-operative stage. A healthy baby was delivered at 36 weeks of gestation through cesarean section. At final follow-up review of 12 months the patient was ambulatory without support and was able to perform most of the regular activities independently. Discussion: The significant risk of a spontaneous delivery with GA posed the dilemma of either managing the injury conservatively through bed rest, continuing the pregnancy till its term and then opting for surgical stabilization after delivery or opting for surgical stabilization of the spine immediately, with a view for early mobilization and rehabilitation. A successful outcome of traumatic cervical SCI in third-trimester pregnancy can be achieved by multi-disciplinary (anesthetist, obstetrician, neonatologist, spine surgeon, and physiatrist) team, and timely surgical spinal stabilization, followed by early comprehensive rehabilitation.

20.
Lancet ; 391(10137): 2325-2334, 2018 06 09.
Artigo em Inglês | MEDLINE | ID: mdl-29900874

RESUMO

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients. METHODS: In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101. FINDINGS: Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0·72, 95% CI 0·55-0·93; p=0·0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0·92, 95% CI 0·55-1·53; p=0·76). INTERPRETATION: Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 110 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication [corrected]. FUNDING: Boehringer Ingelheim and Canadian Institutes of Health Research.


Assuntos
Dabigatrana/farmacologia , Hemorragia/complicações , Infarto do Miocárdio/tratamento farmacológico , Doença Arterial Periférica/complicações , Acidente Vascular Cerebral/complicações , Tromboembolia Venosa/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Antitrombinas/farmacologia , Dabigatrana/administração & dosagem , Dabigatrana/efeitos adversos , Feminino , Hemorragia/tratamento farmacológico , Hemorragia/prevenção & controle , Humanos , Masculino , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Omeprazol/administração & dosagem , Omeprazol/uso terapêutico , Período Perioperatório/mortalidade , Doença Arterial Periférica/tratamento farmacológico , Doença Arterial Periférica/prevenção & controle , Efeito Placebo , Inibidores da Bomba de Prótons/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Trombose/patologia , Resultado do Tratamento , Troponina/efeitos dos fármacos , Troponina/metabolismo , Tromboembolia Venosa/prevenção & controle
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