Sagittal balance and idiopathic scoliosis: does final sagittal alignment influence outcomes,degeneration rate or failure rate?

Introduction

In the last decade, spine surgeons have been impacted by the “sagittal plane analysis revolution”. Significant correlations have been found in adult spinal deformity (ASD) between sagittal lumbo-pelvic parameters and functional outcomes, but most of them do not apply in adolescent idiopathic scoliosis (AIS). Meanwhile, instrumentation and reduction strategies have considerably evolved. This paper aims to describe the preoperative sagittal alignment in AIS, and to report literature evidence regarding the influence of postoperative sagittal balance on complication rates, low back pain incidence and disc degeneration.

Methods

A bibliographic search in Medline and Google database from 1984 to May 2017 was performed. The keywords included ‘adolescent idiopathic scoliosis’, ‘adult scoliosis’, ‘sagittal alignment’, ‘proximal junctional kyphosis’, ‘distal junctional kyphosis’, ‘outcomes’, ‘low back pain’ and ‘complication’, used individually or in combination.

Results

Algorithms of sagittal balance analysis and treatment decision have been reported in ASD, but the clinical situation is very different in children. Sagittal alignment greatly varies in AIS among the various Lenke types. Most patients are clinically balanced before surgery, but the spinal harmony is altered, with overgrowth of the anterior column and global sagittal flattening (undersestimated in 2D). The exact role of pelvic incidence and whether or not patients also use pelvic compensation to maintain balance still require further clarification. The incidence of radiological junctional failures remains highly variable, depending on definitions, cohort size and follow-up. Preoperative hyperkyphosis seems to be a consistent and relevant risk factor. Current literature does not support the recent trend to save motion segments (selective fusion), and no significant association was found between the distal level of fusion and the incidence of low back pain. Postoperative sagittal alignment seems to be more important than LIV selection to avoid disc degeneration at mid-term follow-up.

Conclusion

It is clear now that sagittal alignment plays a major role in clinical outcomes and should not be neglected in AIS. Seven key guidelines that should be considered for each patient before surgery are reported (Table 2). Personalized planning using 3D technology is gaining popularity and might help in the future reducing complications.

     

How do SAGES members rate its guidelines?

Background

The development of practice guidelines should take into consideration the opinions of end users. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has implemented several changes in its guideline development and dissemination process based on previous end-user input.

Methods

An anonymous electronic survey was conducted via e-mail solicitation in September 2011. Respondents were asked to submit their feedback on the 26 guidelines produced by our society using a 32-item questionnaire and to suggest topics for new guideline development and areas of improvement.

Results

Responses from the survey were received by 494 people, of whom 474 (96 %) were clinicians; 373 (75 %) were general, laparoscopic, or bariatric surgeons; and 324 (65 %) held leadership roles within their institution. Most respondents were 35–44 years old (36 %), male (83 %), and had been in practice for over 10 years (54 %). A total of 383 (81 %) had used our guidelines, and, of those, 96 % agreed with their content. Guideline quality was rated 4.34; value 4.27; and ease of access 3.97 on a five-point Likert scale. The most commonly referenced guideline in the survey regarded surgical treatment of reflux (67 %), followed by laparoscopy during pregnancy (51 %). The three most common reasons guidelines were accessed were to update knowledge (68 %), to maximize patient care through evidence-based treatment (51 %), and to obtain a critical literature review.

Conclusions

The majority of respondents indicated they greatly value and agree with our guidelines. These results indicate that recent efforts to improve our guidelines have succeeded.     

Does fresh gas flow rate affect monitoring requirements?

Opinions vary on the monitoring requirements associated with low flow to closed circuit anesthesia. Fresh gas flow rate affects variables of anesthesia ventilation such as the time constant of the breathing system, the inspired concentrations of O2, N2O and anesthetic vapor and the potential for rebreathing. Furthermore, very low flow rates challenge the performance of rotameters and vaporizers. Consequently, the safe conduct of minimal flow or closed circuit anesthesia mandates oximetry, which should be redundant; the use of anesthetic agent monitors ("anesthetico-meters") is extremely helpful, and so is capnometry. However, none of these safety monitors is beyond the scope of the "essential requirements" proposed for anesthesia workstations by international standard-writing groups, such as CEN or ISO. It may hence be concluded that fresh gas flow rate does affect variables to be monitored, but it does not affect essential monitoring requirements.     

Can estimated glomerular filtration rate improve the EuroSCORE?

Several studies have shown that the glomerular filtration rate is a strong predictor of mortality following cardiac surgery. This study was designed to identify the estimated glomerular filtration rate using the MDRD-4 equation as an independent predictive variable of mortality and to determine whether the inclusion of this variable could improve the discriminating power of the EuroSCORE. Data from 2014 consecutive patients who underwent cardiac surgery over a 3-year period were analysed. Mean glomerular filtration rate was 68.4+/-22.7 ml/min per 1.73 m(2); 704 patients (35%) showed a rate 相似文献   

How useful is intrapartum electronic fetal heart rate monitoring?

It is essential for an obstetric anesthesiologist to be aware of the fetal status before undertaking care of the laboring mother. In the last 20 years electronic fetal monitoring has been the most widely used technique of evaluating the fetus in labor. Recently however, the ability to predict or improve fetal outcome using traditional interpretation has been questioned. This review presents a summary of the current technology and interpretation of intrapartum electronic fetal monitoring, as well as a discussion of its limitations and some of the developments in this field which may help improve the accuracy of fetal assessment. The new developments in fetal monitoring discussed in this article are computerized assessment of fetal heart tracings, heart rate variability analysis, fetal electrocardiogram waveform analysis, abdominal detection of fetal ECG, fetal scalp oxygen saturation, fetal pH sampling and transcutaneous oxygen and carbon dioxide measurement.     

Estimate or calculate? How surgeons rate volumes and surfaces

Purpose

Surgeons frequently describe the shape of intraoperative findings using visual judgement and their own sense of proportion or describing these findings in comparison to commonly used or metaphoric subjects. The aim of the study was to analyse the reliability of surgeon’s estimations of dimensions.

Methods

The study was performed in two phases. First, physicians had to estimate the metric proportions of four well-known objects. Second, surgeons were asked intraoperatively to estimate the liver resection surface after partial hepatectomy. The exact surface of the resection plane was measured using computed tomography-guided planimetry of the resection specimen. Physician’s estimations and the exact measurements of the well-known objects and the liver resection surface were compared. Systematic error was defined by the natural logarithm of estimated/real size.

Results

We found a large individual discrepancy in estimating the metric proportions of commonly used objects and a tendency to underestimate both commonly used objects and liver resection surface. Experienced liver surgeons were more accurate in estimating liver resection surface compared with younger staff members.

Conclusions

We found a large bias in estimating the dimension of both commonly used objects and the surface area of liver parenchyma transection. Obviously, estimating errors are more influenced by the individual subject who estimates than by the object itself. In clinical routine, surgeons should rely more on simple measuring devices than on their own sense of proportion. Education in how to estimate more correctly human liver resection surfaces can be achieved by ex vivo studies using porcine livers.     

Heart rate: is it truly a vital sign?

BACKGROUND: Tachycardia, often defined as heart rate >100 bpm, has been utilized as a physical sign of hypovolemic shock among the injured for decades without evidence to support its use as a predictor of injury or significant hypovolemia. We sought to determine whether admission heart rate is a valid predictor of hemodynamically significant injuries. METHODS: Trauma registry data from 1998 to 2004 were analyzed with logistic regression to determine whether heart rate was associated with need for emergent intervention for bleeding (laparotomy, thoracotomy, or angiography), need for packed red blood cell (pRBC) transfusion in the first 24 hours, or severe injury (ISS >25) after blunt or penetrating trauma. RESULTS: Records of 10,825 patients were analyzed. Overall, heart rate was neither sensitive nor specific in determining the need for emergent intervention, pRBCs in the first 24 hours or severe injury. This was not altered by the presence of hypotension (systolic blood pressure <90 mm Hg) or age in the blunt cohort. CONCLUSIONS: Heart rate alone is not sufficient to determine the need for emergent interventions for hemorrhage. Although tachycardia may still indicate need for emergent intervention in the trauma patient, its absence should not allay such concern.     

What is the rate of small bowel obstruction after colectomy?

The rate of small bowel obstruction (SBO) after colectomy is unknown. Given the large number of colectomies performed in the United States, elucidating SBO rates, outcomes, and identifying predictors of readmission is important. Using the California Inpatient File, we identified all patients readmitted with a principle diagnosis of SBO at least once in the 3 years after colectomy (n = 4555). Patients admitted with a diagnosis of SBO in the 3 years before surgery were excluded. Overall, 10 per cent of patients were readmitted for SBO at least once after colectomy. Approximately 58 per cent were readmitted in the first year and 22 per cent of these patients required surgery. The most common operation performed was lysis of adhesions. Median length of stay was twice as long in the surgery group versus the no surgery group (12 vs 6 days). Overall mortality was higher in the nonsurgery group compared with the surgery group (33% vs 21%, P < 0.001) and highest in the elderly (44% vs 30%, P < 0.001). One in 10 patients without a history of SBO who undergoes a colectomy will be readmitted at least once in the subsequent 3 years for SBO, and there is a high mortality rate in this group, especially in the elderly.     

What is the true catheterization rate after intravesical onabotulinumtoxinA injection?

Introduction and hypothesis

A known side effect of intravesical onabotulinumtoxinA (Botox®) injection for overactive bladder (OAB) is urinary retention requiring clean intermittent catheterization (CIC), the fear of which deters patients from choosing this therapy. In clinical practice, patients with an elevated postvoid residual (PVR) are often managed by observation only, providing they do not have subjective complaints or contraindications. We sought to determine the true rate of urinary retention requiring CIC in clinical practice.

Methods

A retrospective review was performed over a 3-year period of patients who received 100 units of intravesical onabotulinumtoxinA for the treatment of OAB. Patients were seen 2 weeks after the procedure to measure PVR. CIC was initiated in patients with a PVR ≥350 ml and in those with subjective voiding difficulty or acute retention.

Results

A total of 187 injections were performed on 99 female patients. CIC was required following three injections (1.6%): for acute retention in two patients and subjective voiding difficulty in one patient with a PVR of 353 ml. Following 12 injections, the patient had a PVR of ≥350 ml, and following 29 injections, the patient had a PVR of >200 but <350 ml without symptoms. CIC was not initiated in these 41 patients. None of these patients experienced subsequent retention, and all showed resolution of their elevated PVR within 8 weeks.

Conclusions

In our series of 187 intravesical injections for OAB, the rate of postprocedure urinary retention requiring catheterization was only 1.6%. This low rate can be attributed to less rigorous criteria for CIC initiation than those applied in previous studies. While important to counsel patients on the risk of retention, patients can be reassured that the actual rate of CIC is low.

     

Does the complication rate increase in laparoscopic cholecystectomy for acute cholecystitis?

BACKGROUND: Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy for the treatment of gallbladder disease. Despite the well-accepted success of LC in chronic cholecystitis, the efficacy of this technique has been subject to some debate in acute cholecystitis (AC). This study was designed to evaluate our institution's experience with LC for AC and chronic symptomatic calculous cholecystitis (CC), based on complication and conversion rates to open surgery. PATIENTS AND METHODS: The records of 1158 patients with LC from September 1991 to December 2001 were analyzed. The parameters of age, gender, early and late complication rates, and conversion rates from LC to open cholecystectomy were compared in patients with AC and CC. RESULTS: During the study period, LC was performed in 1158 patients. Of these, 162 patients had AC (group 1) and 996 patients had CC (group 2). The conversion rates were 4.3% (7/162) in group 1 and 2.4% (24/996) in group 2. The complication rates were not significantly different (5.6% in group 1, 5.1% in group 2, P > 0.05). Difficulty in dissection around Calot's triangle and obscure anatomy were the main reasons for conversion to conventional open surgery. The mortality rate was 1.2% in group 1 and 0.01% in group 2. CONCLUSION: LC appears to be a reliable, safe, and effective treatment modality for AC and CC. The surgical approach should be performed carefully because of the spectrum of potential hazards of the laparoscopic procedure. Conversion and complication rates are similar in both AC and CC groups, and improve as surgeons gain experience.     

Estimation of indocyanine green elimination rate constant k and retention rate at 15?min using patient age, weight, bilirubin, and albumin

Backgrounds  We sought to estimate the indocyanine green (ICG) clearance (Cl), the elimination rate constant (k), and the retention rate at 15 min (R ₁₅) using patient-specific covariates only. Methods  We analyzed plasma ICG concentration data at 5, 10, and 15 min after intravenous injection of 0.5 mg/kg of ICG and 17 kinds of patient-specific covariates in 1,276 patients using NONMEM^? (GloboMax LLC, Ellicott City, MD) for population pharmacokinetic modeling. The population models designed were externally validated on another dataset of 1,629 patients. Results  The population typical value (TV) of Cl (Cl _TV) and TV of volume of distribution (Vd _TV) were modeled as: Cl _TV (mL/min) = 117 × age (year)^−0.119 × body weight (kg)^0.348 × total bilirubin (mg/dL)^−0.226 × albumin (g/dL)^0.327. Vd _TV (L) = 0.415 × body weight (kg)^0.596 × albumin (g/dL)^−0.292. ICG concentration at zero time (C ₀) and 15 min (C ₁₅) for R ₁₅ (C ₁₅/C ₀ × 100) were derived from following equations. C ₀ = dose/Vd _TV and C ₁₅ = C ₀e^{−k t} where t = 15 min and k = Vd _TV/Cl _TV. Median percent prediction error and absolute prediction error in the estimated values were 18.0% and 25.6% for Cl; 6.1% and 16.5% for k; and −7.0% and 33.1% for R ₁₅. Conclusion  The predictive performance of ICG k was better than those of ICG Cl and R ₁₅. An erratum to this article can be found at     

Does gentamycin affect long term recurrence rate in pilonidal sinus surgery?

BACKGROUND: The influence of topical intraoperative gentamycin on long term recurrence rate in primary pilonidal sinus surgery has not yet been investigated. METHODS: One hundred and eight-seven patients following excision of primary pilonidal sinus disease (PSD) and primary symmetrical midline closure were analysed regarding the use (group 1) or non-use (group 2) of topical application of an intraoperative gentamycin sponge after a median follow-up of 16 years by a specific questionnaire. RESULTS: The actuarial 15-year-recurrence rate in group 1 was 31% (34/111) compared to 26% (20/76) in group 2, which was statistically not different (p = 0.99). Recurrences occurred with a median 2.7 (range 0.1–20.1) years after primary surgery, so time to recurrence did not differ between both groups (4.3 ± 0.8 years group 1 vs. 6.8 ± 1.5 years group 2; p = 0.99). CONCLUSIONS: The suggested positive effects of topical gentamycin application on long term recurrence rate could not be confirmed. Astonishingly though, surgical infection does not seem to alter long term recurrence rate.     

Can the use of marginal liver donors change recipient survival rate?

Liver transplantation as a therapeutic method for the treatment of end-stage liver disease is beclouded by a scarcity of organs. The aim of this study was to retrospectively analyze the relation between the classification of donors as marginal versus ideal and recipients survival after 148 of 197 orthotopic liver transplantations (OLT) performed from 1991 to 2001. Donors were classified as marginal if they showed the major criteria of: age over 55 years, aspartate aminotransferase greater than 150 UI/L; serum bilirubin greater than 2 mg/dL, serum sodium greater 150 mEq/L, high-dose dopamine or any other vasoactive amine, cardiac arrest, intensive care unit (ICU) stay over 5 days, and moderate severe macrosteatosis. The minor criteria for a marginal donor were: use of dopamine below 10 microg/kg/min, history of alcoholism, drug abuse, ICU stays less than 4 days, microsteatosis of any degree, and mild macrosteatosis. Statistical analysis was performed using Cox regression analyzing and the Kaplan-Meier survival method. The rate of marginal donors was 61.5%. The 180 postoperative day survival was 77.0%. Survival rates were 81.1% for recipients of marginal donor organs, and 70.7% for ideal donor recipients (P >.05). In conclusion, the use of marginal liver donors is viable and safely expands the numbers of liver transplants, thereby diminishing the number of waiting list deaths.     

Do we have to monitor foetal heart rate during general anesthesia?

We present a case of an emergency Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia for treatment of dental abscess. Following failure of the dental abscess treatment under local anaesthesia, a 29-year-old female in the 36th week of a twin pregnancy was to undergo general anaesthesia. Foetal well-being was monitored with ultrasonographic evaluations of foetal heart rate. During surgery, senior obstetrician recorded a lack of beat-to-beat variability of the cardiotocography trace. The CTG pattern was interpreted as foetal distress and an emergency Caesarean section was performed under general anaesthesia. That was probably due to general anaesthesia. Then, two infants were extracted without neonatal distress necessitating intubation. This case report underlines the risk to misread an intraoperative CTG monitoring and if the CTG monitoring is normal before anaesthesia, reduced foetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.