Cost Savings Associated with Vacuum-Assisted Closure in Trauma Patients Undergoing Posterior Spinal Fusion.

OBJECTIVE: To investigate the implications of vacuum-assisted closure (VAC) versus standard wound dressings on postoperative posterior spinal fusion (PSF) wounds with respect to potential cost savings associated with reduced incidence of surgical site infections. METHODS: This was a retrospective review of trauma patients who underwent open PSF under the care of a single surgeon at a Level I trauma center. Patients were postoperatively monitored for 90 days. Statistical analysis was performed with χ2 testing with the calculation of number needed to treat values. RESULTS: Inclusion criteria were met by 208 patients who underwent open PSF. The χ2 test revealed a significant increase in incidence of surgical site infections (20% vs. 8%; P = 0.021) in the non-VAC group (n = 112) compared with the VAC group (n = 96). Cost-benefit analysis revealed that use of VAC in patients undergoing open PSF could enable a mean cost savings of $163,492 per 100 patients. CONCLUSIONS: Use of VAC in patients undergoing open PSF was associated with a 2-fold decrease in incidence of surgical site infections and an infection-related cost savings of $163,492 per 100 patients. Further investigation is needed to ascertain additional benefits of VAC usage in patients undergoing open PSF.

Incisional Wound Vacuum-Evaluation of Wound Outcomes in Comparison With Standard Dressings for Posterior Spinal Fusions in Traumatic Patients.

BACKGROUND: Postoperative incisional negative pressure wound vacuum-assisted closure (VAC) dressings are being used as a primary dressing to optimize wound healing and help avoid complications of infection and dehiscence. Few studies have investigated whether application of VAC dressings on postoperative posterior spinal wounds can reduce the incidence of surgical site infections. OBJECTIVE: To describe our single-surgeon experience of using primary VAC after posterior spinal fusion (PSF) in a large sample of trauma patients. METHODS: This was an Institutional Review Board-approved retrospective comparative study and included all trauma patients presenting to our level 1 safety-net trauma center who required PSF and were operated on by the senior surgeon between 2016 and 2021. Primary outcomes were complications (surgical site infection, readmission for infection, and wound-related return to operating room [OR]) within 90 days after surgery. χ2 testing and Student t testing were used to assess differences between treatment groups while bivariate and multivariate regression was performed for outcome assessment. RESULTS: Two hundred sixty-four patients met criteria and were included. One hundred fifty-seven (59%) were treated with standard dressing and 107 (41%) with VAC. Patients treated with VAC were more likely to be older (P = .015), have diabetes (P = .041), have an elevated body mass index (P = .020), and had more levels of fusion (P = .002). Despite this, presence of VAC was independently associated with decreased 90-day infection (hazard ratio = 0.397, P = .023) and decreased 90-day return to OR for wound-related reasons (hazard ratio = 0.099, P = .031). CONCLUSION: Compared with the use of standard dressing, VAC was found to decrease surgical site infection and return to OR risk in trauma patients undergoing PSF.

Upper Extremity Monoplegia following Prone Surrender Position for Spinal Surgery.

Background Secondary peripheral nerve injuries remain a significant perioperative problem due to patient positioning and contribute to reduced patient quality of life and exacerbated professional liability. Comorbidities and concomitant lesions can further elicit these injuries in patients undergoing spinal surgeries. Case Presentation We report a case of a 70-year-old male polytrauma patient presenting with a left first-rib fracture and an adjacent hematoma around the brachial plexus without preoperative deficits. Subsequent to a lumbar spinal fusion in the prone position, he developed a postoperative left upper extremity monoplegia. The postoperative magnetic resonance imaging revealed an enhanced asymmetric signal in the trunks and cords of the left brachial plexus. He progressively improved with rehabilitation, a year after the initial presentation, with a residual wrist drop. Conclusions Pan brachial plexus monoplegia, following spine surgery, is rare and under-reported pathology. To minimize the occurrence of this rare morbidity, appropriate considerations in preoperative evaluation and counseling, patient positioning, intraoperative anesthetic, and electrophysiological monitoring should be performed. We emphasize an unreported risk factor in polytrauma patients, predisposing this rare injury that is associated with prone spinal surgery positioning, SEPs being an extremely sensitive test intraoperatively and highlight the importance of counseling patients and families to the possibility of this rare occurrence.

Spinal Tuberculosis Secondary to Intravesical Bacille Calmette-Guerin Treatment for Bladder Cancer.

Intravesical administration of bacille Calmette-Guérin (BCG) is an important component of the gold standard in treating non-muscle invasive bladder cancer (NMIBC). However, complications of this treatment include infections caused by the dissemination of Mycobacterium bovis. We present a case of a 62-year-old man who had been treated with intravesical BCG for bladder cancer and developed an M. bovis infection of his vertebral column. About four months after completing the BCG treatment, he developed an acute onset of severe upper thoracic radicular back pain, with radiation anteriorly to his sternum. Examination revealed the presence of early myelopathy. After other causes were ruled out, he was diagnosed with the infection four months later. He was investigated for the pain, with resulting imaging identifying an erosive ventral epidural mass at the T4-T5 levels causing cord compression. The patient underwent a transthoracic procedure to evacuate the paraspinal mass lesion and obtain a diagnostic biopsy, followed by a posterolateral decompression of the lesion and posterior instrumented stabilization. Pathology resulted in the identification of a granuloma with a single acid-fast bacillus (AFB) from the paraspinal abscess, thus being diagnostic of a mycobacterial granuloma with paraspinal involvement. We subsequently performed an extensive review of current literature, looking at articles on spinal osteomyelitis following intravesical BCG treatment of bladder cancer. We identified 26 documented cases in English literature. We present our case report with a good outcome at 24 months, resolving with appropriate chemotherapy. Additionally, we completed a systematic review of the literature and discuss this infrequent iatrogenic pathology. Our report reveals the good response to targeted therapy in the case of osteomyelitis at other skeletal sites and that practitioners caring for these patients maintain a high degree of suspicion in the workup of these patients. Early identification and treatment can appropriately treat osteomyelitis with good long-term outcomes.

Transradial access in acute ischemic stroke intervention.

OBJECTIVE: To describe the feasibility and safety of transradial access (TRA) in the interventional management of acute ischemic stroke (AIS). METHODS: A retrospective review of the local institutional AIS interventional databases of three tertiary academic centers was performed and the use of TRA identified. RESULTS: TRA was attempted in 15 (1.5%) of 1001 patients; it was used in 12 cases due to transfemoral access (TFA) failure and in 3 as the primary strategy. The mean age was 72.3±8.6 and 46% were male. Baseline National Institutes of Health Stroke Scale score was 19.5±8.7, two patients (14%) received intravenous tissue plasminogen activator, and mean time from last known normal to intra-arterial therapy was 17.0±20.1 h. Five patients had anterior circulation occlusive disease and 10 had vertebrobasilar occlusions. TRA was effective in allowing clot engagement in 13 of 15 cases: one patient had a hypoplastic radial artery that precluded sheath advancement and one had chronic innominate artery occlusion that could not be crossed. Mean time to switch from TFA to TRA was 1.9±1.3 h and the mean time from radial puncture to reperfusion was 2.2±1.0 h. Modified Thrombolysis In Cerebral Infarction 2b-3 reperfusion via TRA was achieved in 9 of 15 patients (60%). No radial puncture site complications were noted. At 90 days, two patients (13%) had a good clinical outcome and seven (50%) had died. CONCLUSIONS: Failure of TFA in the endovascular treatment of AIS is uncommon but leads to unacceptable delays in reperfusion and poor outcomes. Standardization of benchmarks for access switch could serve as a guide for neurointerventionalists. TRA is a valid approach for the endovascular treatment of AIS.

Dexamethasone otoprotection in a multidose cisplatin ototoxicity mouse model.

OBJECTIVE: To develop a murine model for multidose administration of cisplatin that produces significant hearing threshold elevations and to use this model to assess the protective properties of intratympanic (IT) dexamethasone against cisplatin ototoxicity. STUDY DESIGN: Controlled repeated measures design. SETTING: Translational research laboratory. SUBJECTS AND METHODS: Intraperitoneal (IP) cisplatin, 2 or 3 mg/kg/day, was administered for a total of 5 or 10 days in young CBA/J mice. Pure-tone evoked auditory brainstem response (ABR) thresholds were performed on days 7, 14, 21, and 28 to evaluate hearing threshold shifts. After development of the optimal dosing regimen, 15 mice received IT dexamethasone (24 mg/ml) in one ear and IT saline in the contralateral ear. RESULTS: Significant threshold elevations were obtained for the 2 and 3 mg/kg/day 10 day groups, but both had high mortality rates and were excluded as potential multidose murine models. The 3 mg/kg/day 5 day group had a lower mortality rate and significant ABR threshold elevations for all frequencies on days 7, 14, 21, and 28. Using this dosing model, no statistically significant difference between IT dexamethasone and saline treated ears was found. CONCLUSIONS: Unlike previous single dose models, IT dexamethasone did not have an otoprotective effect in a multidose murine model of cisplatin ototoxicity.