ULTRASOUND GUIDED DORSAL RAMUS NERVE BLOCK FOR REDUCTION OF POSTOPERATIVE PAIN IN PATIENTS UNDERGOING LUMBAR SPINE SURGERY: A CASE SERIES IMAGING STUDY.

In patients undergoing spine surgery postoperative pain management can often be complicated with side effects associated with high dose narcotic such as respiratory depression and those associated with non-steroidal anti-inflammatory drugs such as interference with bone healing process. Local anesthetics can help in both decreasing postoperative pain and minimizing side effects associated with systematically administered analgesics. This report describes the use of preoperative ultrasound guided dorsal ramus nerve block to reduce postoperative pain in six patients undergoing lumbar spine surgery under general anesthesia.

Intrawound low-dose vancomycin is superior to high-dose in controlling the risk of wound dehiscence in spine surgeries.

Wound complications in spine surgeries are common and serious. This study aimed to determine the risk of wound dehiscence with a low-dose of intrawound vancomycin compared to that with a high-dose and no-vancomycin and its effectiveness in the prevention of surgical site infection. Patients were categorized into 3 groups. The first group did not receive any intrawound vancomycin. In the second, patients received a high-dose of vancomycin (1 g). The third group included patients who received a low-dose of intrawound vancomycin (250 mg). Patient demographics, clinical data, and surgical data were also collected. Multivariate linear regression analysis was used to examine factors associated with dehiscence or infection. Of the 391 patients included in our study, 56 (14.3%) received a high-dose of intrawound vancomycin, 126 (32.2%) received a low-dose, and 209 (53.5%) did not receive any treatment. The overall incidence of wound dehiscence was 6.14% (24 out of 391 patients). Wound dehiscence was significantly higher (P = .039) in the high-dose vancomycin group than in the low-dose vancomycin group. The overall incidence of postoperative infection was 2.05% (8 patients) and no statistically significant differences were observed between the low-dose and high-dose vancomycin groups. Patients with higher body mass index were more likely to experience wound dehiscence and postoperative infection, irrespective of the dose of vancomycin used. The use of low-dose intrawound vancomycin (250 mg) resulted in less wound dehiscence compared with high-dose vancomycin. Further trials are required to evaluate the effectiveness of the low-dose in preventing postoperative infections.

Safety measures for COVID-19: a review of surgical preparedness at four major medical centres in Saudi Arabia.

In view of the worldwide coronavirus disease 2019 (COVID-19) pandemic, hospitals need contingency planning. This planning should include preparation for an unexpected patient surge. This measure is evolving concomitantly with the implementation of the needed infection control rules. Here, we present our experience in contingency planning at four large tertiary hospitals in Saudi Arabia during this global pandemic, with a focus on dealing with COVID-19 patients who need to undergo surgery. The planning covers response measures required in the operating room and supporting units, including the administrative department, intensive care unit, and different sections of the surgical department. Furthermore, it covers the role of education and simulation in preparing health care providers and ensuring smooth workflow between all sections. We additionally discuss the guidelines and policies implemented in different surgical specialties. These measures are necessary to prevent the transmission of COVID-19 within healthcare facilities. Throughout the COVID-19 pandemic, the healthcare system should develop a comprehensive pandemic plan and set guidelines addressing the management of urgent and malignant cases. The guidelines should be in concordance with internal guidelines.

Herniated intervertebral disc associated with a lumbar spine dislocation as a cause of cauda equina syndrome: a case report.

To report a case of Cauda Equina syndrome with the completion of the paralysis after the reduction of a L4L5 dislocation due to a herniated disc. Although several articles have described a post-traumatic disc herniation in the cervical spinal canal, this is not well known in the lumbar region. A 30-year-old man was admitted to the emergency room with blunt trauma to the chest and abdomen with multiple contusions plus a dislocation of L4-L5 with an incomplete neurological injury. After an emergency open reduction and instrumentation of the dislocation, the patient developed a complete cauda equina syndrome that has resulted from an additional compression of the dural sac by a herniated disc. In a dislocation of the lumbar spine, MRI study is mandatory to check the state of the spinal canal prior to surgical reduction. A posterior approach is sufficient for reduction of the vertebral displacement, however an intra-canal exploration for bony or disc material should be systematically done.

Serum levels of nickel and chromium after instrumented posterior spinal arthrodesis.

STUDY DESIGN: Cross-sectional study of 37 patients to measure serum levels of nickel and chromium after posterior spinal arthrodesis using stainless steel implants. OBJECTIVES: To investigate the relationship between factors such as age, gender, pain, time from surgery, length of arthrodesis, and level of arthrodesis to serum metal ion levels after instrumented spinal arthrodesis. SUMMARY OF BACKGROUND DATA: Measurable levels of metal ions in the serum can be detected after the use of stainless steel implants. There is some evidence to suggest that long-term exposure can potentially be toxic. Posterior spinal arthrodesis with stainless steel implants is a common procedure to treat spinal deformity in the adolescent population; however, the extent of metal ion exposure after posterior spinal arthrodesis is unknown. METHODS: Patients that underwent posterior instrumented spinal arthrodesis with more than 6 months follow-up were recruited for this study. Patients with altered neurologic function were excluded. Serum levels of nickel and chromium were measured using inductively coupled plasma mass spectrometry. Pain was assessed using the Oswestry questionnaire. Spine radiographs were used to look for evidence of pseudarthrosis. Forty-five patients were approached, and 37 agreed to the questionnaire and blood test. Ten patients were men and 27 were women. Mean age at surgery was 14 years with mean follow-up of 6 years. Statistical correlations between serum metal ion levels and age at surgery, time from surgery, gender, number of segments fused, spinal instrument interfaces, pain, and instrumentation type were assessed. RESULTS: Abnormally high levels of nickel and chromium above normal levels (0.3 ng/mL for nickel, 0.15 ng/mL for chromium) could be detected in serum after posterior spinal arthrodesis using stainless steel implants. There was a significant inverse correlation between serum nickel (r = -0.61, P < 0.001) and chromium (r = -0.64, P < 0.001) levels and time from surgery. When patients were grouped based on lengths of time from surgery, 0 to 2 years (n = 7), 2 to 4 years (n = 11), and >4 years (n = 8), the mean +/- SD for nickel (ng/mL) was 3.8 +/- 2.6, 1.3 +/- 1.1, and 0.9 +/- 0.8, respectively. Analysis ofvariance revealed significant group differences (P =0.004). Similarly, the chromium levels were 2.7 +/- 2.7, 0.6 +/- 0.4, and 0.3 +/- 0.3, respectively (P = 0.018). Only time from surgery was a significant multivariate predictor of nickel and chromium serum levels. Pseudarthrosis was not seen in this cohort. CONCLUSIONS: Elevated levels of nickel and chromium can be measured after posterior instrumented spinal arthrodesis. The levels diminish rapidly with time from surgery but still remained above normal levels 4 years after surgery. Long-term implication of this metal ion exposure is unknown and should be studied further.

Analysis of screw placement relative to the aorta and spinal canal following anterior instrumentation for thoracic idiopathic scoliosis.

STUDY DESIGN: Axial computed tomographic (CT) evaluation of the position of anterior vertebral body screws placed thoracoscopically in patients with adolescent idiopathic scoliosis (AIS). OBJECTIVE: To evaluate the position of the anterior vertebral body screws relative to the spinal canal and the thoracic aorta following anterior spinal fusion and instrumentation for AIS. SUMMARY OF BACKGROUND DATA: Thoracoscopic anterior instrumentation and fusion is gaining more widespread use in the treatment of idiopathic scoliosis. However, the accuracy in the positioning of instrumentation has not been previously studied for this technically difficult surgery. METHODS: CT examinations were performed following thoracoscopic anterior spinal fusion and instrumentation in 14 patients with right thoracic AIS. The vertebral body width (transverse dimension) and depth (anterior-posterior dimension) was measured for each thoracic vertebra. At each instrumented level, the position of the screw was analyzed to determine its proximity to the spinal canal and the aorta. The distance from the anterior cortex of the spinal canal to the posterior edge of the screw was measured. The position of each screw relative to the aorta was determined: D, the screw tip was distant to the aorta; A, the screw tip was adjacent to the aorta; C, the screw tip was felt to be against the aorta and creating some contour deformity on the outer wall of the aorta. RESULTS: All 14 patients were female and had a single right thoracic curve. The average age of the patients was 13.3 years (range 12.4-15.1 years). The average preoperative coronal Cobb measurement was 55.9 degrees (bending 26.4 degrees) with correction to 8.9 degrees at 2 years after surgery. The average number of levels fused was 6.6 (range 5-8) and a total of 106 screws were used (average 7.6/patient). The width of the vertebral bodies increased from T4 (24.0 mm) to T12 (33.6 mm), increasing an average of 1.2 mm per level, while the depth increased from 17.7 mm at T4 to 25.5 mm at T12. The average distance from the posterior aspect of the screw to the spinal canal was 5.3 mm (range-1.2 to 11.4 mm). There were no neurologic deficits in any patient. When analyzing the position of the screw tip relative to the aorta, 78 (73.6%) screws were distant from the aorta, 15 (14.2%) were adjacent to the aorta, and there were 13 (12.3%) screws that were thought to create a contour deformity of the aorta. There were no vascular complications at 2 years after surgery. CONCLUSIONS: Thoracoscopic instrumentation and fusion is technically demanding and relies on adequate visualization for accurate screw placement. The vertebral body width and depth are consistent between patients, with the vertebral body width increasing approximately 1.2 mm when progressing down the thoracic spine. Safe screw placement was achieved with adequate distance from the spinal canal; however, close screw proximity to the aorta was seen. The aorta was positioned on the left lateral aspect of the vertebral body in these patients, making anterior screw placement challenging in right thoracic AIS.