Dural injury following elective spine surgery – A prospective analysis of risk factors,management and complications

Incidental dural tears being a familiar complication in spine surgery could result in dreaded postoperative outcomes. Though the literature pertaining to their incidence and management is vast, it is limited by the retrospective study designs and smaller case series. Hence, we performed a prospective study in our institute to determine the incidence, surgical risk factors, complications and surgical outcomes in patients with unintended durotomy during spine surgery over a period of one year. The overall incidence in our study was 2.3% (44/1912). Revision spine surgeries in particular had a higher incidence of 16.6%. The average age of the study population was 51.6 years. The most common intraoperative surgical step associated with dural tear was removal of the lamina, and 50% of the injuries were during usage of kerrison rongeur. The most common location of the tear was paramedian location (20 patients) and the most common size of the tear was about 1 mm-5mm (31 patients). We observed that the dural repair techniques, placement of drain and prolonged post-operative bed rest didnot significantly affect the post-operative outcomes. One patient in our study developed persistent CSF leak, which was treated by subarachnoid lumbar drain placement. No patients developed pseudomeningocele or post-operative neurological worsening or re-exploration for dural repair. Wound complications were noted in 4 patients and treated by debridement and antibiotics. Based on our study, we have proposed a treatment algorithm for the management of dural tears in spine surgery.     

Short- and long term hyposmia,hypogeusia, dysphagia and dysphonia after facial burn injury – A prospective matched cohort study

BackgroundFacial burns frequently occur in occupational or household accidents. While dysphagia and dysphonia are known sequelae, little is known about impaired smell and taste after facial burns.MethodsIn a prospective observational controlled study, we evaluated hyposmia via the Sniffin’ Stick Test (SnS), hypogeusia via a taste strip test, and dysphonia and dysphagia via validated questionnaires acutely and one-year after burn, respectively. A matched control group consisting of a convenience sample of healthy volunteers underwent the same assessments.ResultsFifty-five facial burn patients (FB) and 55 healthy controls (CTR) were enrolled. Mean burn size was 11 (IQR: 29) % total body surface area (TBSA); CTR and FB were comparable regarding age, sex and smoking status. Acutely, hyposmia was present in 29% of the FB group (CTR: 9%, p = 0.014) and burn patients scored worse on the SnS than CTR (FB: 10; CTR: 11; IQR: 2; p = 0.013). Hyposmia per SnS correlated with subjective self-assessment. Hyposmia and SnS scores improved over time (FB acute: 10.5 IQR: 2; FB one year: 11; IQR: 2; p = 0.042) and returned to normal at one-year post burn in most patients who completed the study (lost to follow-up: 21 patients). Taste strip scores were comparable between FB and CTR, as was the acute prevalence of dysphagia and dysphonia.ConclusionHyposmia acutely after facial thermal trauma appeared frequently in this study, especially when complicated by inhalation trauma or large TBSA involvement. Of all complete assessments, a fraction of burn patients retained hyposmia after one year while most improved over time to normal. Prevalence of dysphonia, dysphagia and hypogeusia was comparable to healthy controls in this study, perhaps due to overall minor burn severity.     

Integration of fluoroscopy-based guidance in orthopaedic trauma surgery – A prospective cohort study

Introduction

Computer-assisted guidance systems are not used frequently for musculoskeletal injuries unless there are potential advantages. We investigated a novel fluoroscopy-based image guidance system in orthopaedic trauma surgery.

Materials and methods

The study was a prospective, not randomised, single-centre case series at a level I trauma centre. A total of 45 patients with 46 injuries (foot 12, shoulder 10, long bones seven, hand and wrist seven, ankle seven and spine and pelvis four) were included. Different surgical procedures were examined following the basic principles of the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF). Main outcome measurements were the number of trials for implant placement, total surgery time, usability via user questionnaire and system failure rate.

Results

In all cases, the trajectory function was used, inserting a total of 56 guided implants. The system failed when used in pelvic and spinal injuries, resulting in a total failure rate of 6.5% (n = 3) of all included cases. The overall usability was rated as good, scoring 84.3%.

Conclusion

The novel image-guidance system could be integrated into the surgical workflow and was used successfully in orthopaedic trauma surgery. Expected advantages should be explored in randomised studies.     

Urinary sulfate excretion and risk of late graft failure in renal transplant recipients – a prospective cohort study

Hydrogen sulfide (H₂S), produced from metabolism of dietary sulfur-containing amino acids, is allegedly a renoprotective compound. Twenty-four-hour urinary sulfate excretion (USE) may reflect H₂S bioavailability. We aimed to investigate the association of USE with graft failure in a large prospective cohort of renal transplant recipients (RTR). We included 704 stable RTR, recruited at least 1 year after transplantation. We applied log-rank testing and Cox regression analyses to study association of USE, measured from baseline 24 h urine samples, with graft failure. Median age was 55 [45–63] years (57% male, eGFR was 45 ± 19 ml/min/1.73 m²). Median USE was 17.1 [13.1–21.1] mmol/24 h. Over median follow-up of 5.3 [4.5–6.0] years, 84 RTR experienced graft failure. RTR in the lowest sex-specific tertile of USE experienced a higher rate of graft failure during follow-up than RTR in the middle and highest sex-specific tertiles (18%, 13%, and 5%, respectively, log-rank P < 0.001). In Cox regression analyses, USE was inversely associated with graft failure [HR per 10 mmol/24 h: 0.37 (0.24–0.55), P < 0.001]. The association remained independent of adjustment for potential confounders, including age, sex, eGFR, proteinuria, time between transplantation and baseline, BMI, smoking, and high sensitivity C-reactive protein [HR per 10 mmol/24 h: 0.51 (0.31–0.82), P = 0.01]. In conclusion, this study demonstrates a significant inverse association of USE with graft failure in RTR, suggesting high H₂S bioavailability as a novel, potentially modifiable factor for prevention of graft failure in RTR.     

Does preoperative hydration affect postoperative nausea and vomiting? A randomized, controlled trial

BACKGROUND: It has been suggested that relative hypovolemia due to overnight fasting may result in postoperative nausea and vomiting (PONV). The aim of this study was to investigate the effect of preoperative and intraoperative hydration (the necessary amount of fluid preoperatively to cover the fluid deficit) on PONV. MATERIALS AND METHODS: Two hundred and ten consecutive patients who underwent elective laparoscopic cholecystectomy with The American Society of Anesthesiologists (ASA)-I physical statuses were studied prospectively. The patients were randomly assigned to one of two groups, each having 104 patients. Group 1 received intraoperative volume replacement, but Group-II received preoperative volume replacement. Postoperative antiemetic efficacy was assessed by the ratio of the patients that require an antiemetic over the whole group. RESULTS: The PONV was significantly less detected in the preoperative replacement group (48% in Group 2) than the intraoperative one (64% in Group 1) (P = 0.019). CONCLUSIONS: PONV was reduced when the fluid deficit was replaced preoperatively.     

What can be expected from risk scores for predicting postoperative nausea and vomiting?

Several risk scores have been developed to calculate the probabilityof postoperative nausea and vomiting (PONV). However, the powerto discriminate which individual will suffer from PONV is stilllimited. Thus, we wondered how the number of predictors in ascore affects the discriminating power and how the characteristicsof a population—which is needed to measure the power ofa score—may affect the results. For ethical reasons andto be independent from centre specific populations, we developeda computer model to simulate virtual populations. Four populationswere created according to number, frequency, and odds ratioof predictors. Population I: parameters were derived from apreviously published paper to verify whether calculated andreported values are in accordance. Population II: a gynaecologicalpopulation was created to investigate the impact of the studysetting. Populations III and IV: to meet ideal assumptions amodel with up to seven predictors with an odds ratio of 2 and3 was tested, respectively. The discriminating power of a riskscore was measured by the area under a receiver operating characteristiccurve (AUC) and an increase of more than 0.025 per predictorwas considered to be clinically relevant. The AUC of populationI was similar to those reported in clinical investigations (0.72).The study setting had a considerable impact on the discriminatingpower since the AUC decreased to 0.65 in a gynaecological setting.The AUC with the ‘idealized’ populations III andIV was at best in the range of 0.7–0.8. The inclusionof more than five predictors did not lead to a clinically relevantimprovement. The currently available simplified risk scores(with four or five predictors) are useful both as a method toestimate individual risk of PONV and as a method for comparinggroups of patients for antiemetic trials. They are also superiorto single predictor models which are just using the patients’history of PONV or female gender alone. However, our analysissuggests that the power to discriminate which individual willsuffer from PONV will remain imperfect, even when more predictorsare considered. Br J Anaesth 2001; 86: 822–7     

Postoperative nausea and vomiting after total intravenous anesthesia with propofol and remifentanil or alfentanil: how important is the opioid?

STUDY OBJECTIVE: To compare the frequency and duration of postoperative nausea and vomiting (PONV) following total intravenous anesthesia (TIVA) with propofol and either remifentanil or alfentanil in outpatients undergoing arthroscopic surgery of the extremities.DESIGN: Randomized, third-party blinded study. SETTING: University medical center. PATIENTS: 100 ASA physical status I and II patients scheduled for arthroscopic surgery of the knee or shoulder. INTERVENTIONS: The anesthesia regimen consisted of a bolus followed by continuous infusion of propofol (2 mg/kg followed by 120 microg/kg/min) and the opioid (remifentanil 0.5 microg/kg followed by 0.1 microg/kg/min or alfentanil 10 microg/kg followed by 0.25 microg/kg/min). Patients breathed 100% oxygen spontaneously through a Laryngeal Mask Airway (or an endotracheal tube when medically indicated). Opioids were titrated to maintain blood pressure and heart rate within 20% of baseline and a respiratory rate of 10 to 16 breaths/min. Propofol was titrated downward as low as possible without permitting patient movement. MEASUREMENTS: Nausea was determined by an 11-point categorical scale and was recorded before surgery and multiple time points thereafter. The times of emetic episodes were recorded. Treatment of PONV was at the discretion of the postanesthesia care unit (PACU) nurses who were blinded to the identity of the opioid used. MAIN RESULTS: Nausea scores were 0 at all time points in over 70% of the patients in each group. None of the 100 patients vomited while in the hospital, and only one patient required antiemetic therapy. CONCLUSION: When propofol-based TIVA is used for arthroscopic surgery, short-acting opioids do not significantly affect the risk of PONV.     

Incidence and risk factors for osteoporotic vertebral fracture in low-income community-dwelling elderly: a population-based prospective cohort study in Brazil. The São Paulo Ageing & Health (SPAH) Study

Summary

We ascertained the incidence and predictors of radiographic vertebral fracture in a Brazilian elderly cohort, since no data in this field have been reported in low-income countries. This is the first population-based study to demonstrate the high frequency of vertebral fracture in elderly Latin Americans. Age, prior fracture, BMD, and bone turnover were predictors of fracture.

Introduction

Vertebral fractures are associated with increased future fracture risk and mortality. No data on incidence of osteoporotic vertebral fracture have been reported in low-income countries where the population’s aging has been faster. Thus, we sought to describe the incidence and risk factors for radiographic vertebral fracture in a longitudinal prospective Brazilian population-based elderly cohort.

Methods

707 older adults (449 women and 258 men) were evaluated with spinal radiographs obtained at baseline and after a mean follow-up of 4.3?±?0.8 years. New vertebral fracture was defined as distinct alteration in the morphology of vertebrae resulting in higher grade of deformity on the second radiograph when compared to the baseline radiograph. Clinical questionnaire, bone mineral density (BMD), and laboratory tests were performed at baseline. Multivariate Poisson regression models were used to identify independent predictors of fracture.

Results

The age-standardized incidence of vertebral fracture was 40.3/1,000 person-years in women and 30.6/1,000 in men. In women, three models of risk factors for fracture were fitted: (1) age (relative risks (RR) 2.46, 95 % confidence interval (CI) 1.66–3.65), previous osteoporotic fracture (RR 1.65, 95 % CI 1.00–2.71), and lumbar spine BMD (RR 1.21, 95 % CI 1.03–1.41); (2) age (RR 2.25, 95 % CI 1.52–3.34) and femoral neck BMD (RR 1.42, 95 % CI 1.11–1.81); (3) age (RR 2.11, 95 % CI 1.41–3.15) and total hip BMD (RR 1.56, 95 % CI 1.21–2.0). In men, the highest quartile of cross-linked C-telopeptide (CTx) (RR 1.96, 95 % CI 0.98–3.91) and prior fracture (RR 2.10, 95 % CI 1.00–4.39) were predictors of new vertebral fracture.

Conclusions

This is the first population-based study to ascertain the incidence of vertebral fracture in elderly Latin Americans, confirming the high frequency of the disorder. Age, prior fracture, BMD, and bone turnover were predictors of the short-term incidence of vertebral fracture.     

The one-leg portion of the Stand–Up Test predicts fall risk in aged individuals: A prospective cohort study

BackgroundFalls are a primary cause of physical disability in older adults, making them a major public health problem. Locomotive syndrome risk assessments have proven to be simple to administer, practical, and useful as screening tools in detecting decreased mobility in middle-aged and elderly adults. The current prospective study investigated whether these tests were associated with future falls among elderly Japanese.MethodsThis study was a two-year prospective observational study. A total of 1800 individuals (aged 65–79 years) who were without certification of long-term care or physical disability were initially invited through letters to participate in the study. Of these, 499 individuals (225 men, 274 women) agreed to participate and underwent baseline assessments. Demographic information, body function physical performance measurements, and locomotive syndrome risk tests [Stand–Up Test (SUT), Two-Step Test (TST), and the 25-question Geriatric Locomotive Function Scale (GLFS-25)] were assessed. Following baseline evaluation, we sent a follow-up questionnaire to assess fall history in the past two years. Participants were classified as either “non-fallers” or “fallers” (denoted by one or more falls). Multiple logistic regression was used to evaluate the association between falls and each factor by providing adjusted odds ratio estimates.ResultsThe follow-up questionnaire was returned by 399 participants, 54 of whom (13.5%) fell at least once during the two-year observation period. The multiple logistic regression analysis revealed that difficulty with standing on one leg from a 40-cm-high seat (a portion of the SUT) was a significant predictor of future falls (odds ratio = 2.20, 95%CI = 1.04–4.69, p = 0.04). A history of falling was also a risk factor of falls.ConclusionOur results suggest that standing on one leg from a 40-cm-high seat is predictive of falling in older adults, even after adjustment for previous falls and other confounding variables.