Survey of anesthesia practice in spine surgery patients in the United States

Purpose. There is a wide range of anesthetic practice in spine surgery with respect to anesthetic choice, blood conservation, and monitoring. There is no ideal technique with respect to each of these choices. This study was designed to determine the usual practice for members of the Society of Neurosurgical Anesthesia and Critical Care (SNACC), with regard to the use of anesthetic technique, the type of monitoring used (and the person responsible for its application and interpretation), and the blood conservation strategies most often utilized for the management of patients undergoing spinal surgery. Methods. A total of 415 questionnaires were mailed to all current members of the SNACC. Of these, 85 (23%) were completed and returned. Results. The majority of the respondents administer general anesthesia for lumbar laminectomy. Somatosensory evoked potential (SSEP) monitoring is available at most of the institutions (94%) but only utilized in 75% of patients undergoing a Harrington rod placement. Motor evoked potential monitoring is available at 50% of the institutions, but utilized 25% of the time for these surgeries. The two most frequent blood conservation strategies utilized are intraoperative salvage and autologous donation. Conclusion. The most frequent monitoring utilized for major spinal surgeries is SSEP. Autologous donation and intraoperative salvage are the most frequent blood conservation methods utilized. Received: June 5, 2002 / Accepted: October 2, 2002 Address correspondence to: N.R. Connelly     

Surgery in spinal metastasis without spinal cord compression: indications and strategy related to the risk of recurrence

Surgery in patients presenting with vertebral metastasis without neural deficit is controversial. A series of 107 patients (54 female, 53 male) were operated on at a mean age of 58. The metastasis was the first manifestation of the cancer in seven cases. In 100 patients, the cancer had been diagnosed 30 months earlier (average). Vertebral pain was present in all cases, with associated radicular pain in 43 cases. Pyramidal irritation without neural deficit was present in seven cases. The mean preoperative Karnofsky index was 64.7%. The mean preoperative Tokuhashi score was 8.6. The surgical approach depended on the topography of the metastasis. Ninety-three patients were dead at review, with a mean survival of 8 months. Seventeen patients underwent further spinal surgery, for local recurrence in nine cases, and for another spinal localization in eight cases, after a mean interval of 8 months. Recurrence occurred at the same level in all seven patients presenting with neural deficit at recurrence. Among ten recurrences without neural deficit, two were observed at the same level and eight were observed on another level. Surgery in vertebral metastasis without neural deficit results in substantial functional improvement, but does not increase the duration of life. For kidney metastasis, total vertebrectomy must be performed because of the risk of recurrence. For thyroid metastasis, total vertebrectomy is a good alternative to increase the efficacy of iodotherapy. In other cases, for patients with good general status, surgery must be adapted to the location of the involvement. Received: 8 February 2000 Revised: 23 March 2000 Accepted: 30 March 2000     

脊柱骨髓瘤的诊断与治疗

目的:探讨脊柱骨髓瘤的诊断方法与治疗效果。方法:回顾性分析1993～2001年收治的14例脊柱骨髓瘤患者的资料,13例行脊椎活检,其中经皮穿刺活检12例,切开活检1例,另1例行术中病理检查。病理报告均为骨髓瘤。孤立性骨髓瘤9例,多发骨髓瘤5例。10例行手术治疗。结果:8例手术患者获15～102个月(平均37.6个月)随访,7例存活。未手术的4例中1例无瘤存活76个月,另3例分别于确诊后6、18和25个月死亡。结论:经皮脊椎穿刺活检是确诊脊柱骨髓瘤的重要手段,选择性手术结合放疗及化疗可稳定脊柱、解除脊髓压迫、提高患者生活质量。     

脊柱结核外科治疗的术式选择

目的根据脊柱稳定性状况,探讨脊柱结核外科治疗的术式选择。方法1998年1月至2003年12月采用手术治疗成人胸、腰、骶椎脊柱结核100例,男57例,女43例;年龄17～75岁,平均39.4岁;病史1～60个月,平均16个月。根据结核破坏程度及手术可能带来的脊柱稳定性改变,采用不同的手术治疗方式。12例脊柱稳定性无明显破坏的病例采用单纯病灶清除术,8例脊柱稳定性部分破坏的病例采用病灶清除并植骨融合术,而80例脊柱稳定性显著破坏的病例则采用一期病灶清除、植骨融合并内固定术。结果100例患者切口均一期愈合,无慢性窦道形成。除5例失访外,其余95例均获得1～7年随访(平均2.9年)。68例前路椎体间植骨病例,界面骨性融合时间平均3.5个月。65例有后凸畸形者,后凸畸形平均矫正20.2°,随访期内丢失2°～4°。除病灶清除、植骨融合并内固定术组1例因抗结核化疗周期不足复发外,其余患者均临床治愈。32例有明显神经损害的患者术后均获得明显改善。结论脊柱稳定性在脊柱结核外科治疗中具有重要意义,根据脊柱稳定性改变选择合适的外科治疗术式,均可获得满意的临床疗效。     

脊柱转移瘤的预后分析

目的：探讨预测脊柱转移瘤预后的方法及按其制定治疗方案的可能性。方法：对我院1994年10月～2001年10月收治并有随访资料的41例脊柱转移瘤患者进行Cox生存分析，按照Tomita脊柱转移瘤预后评分法进行评分。保守治疗26例，手术治疗15例，其中全脊椎切除术5例。结果：30例原发癌诊断明确，11例原发癌诊断不明确。36例死亡．5例仍存活，平均生存11-3个月。生存期与Tomita脊柱转移瘤预后评分呈指数关系。保守治疗26例，疼痛，脊髓及神经根损害无明显改善；手术治疗15例，其中全脊椎切除术5例，术后疼痛均有不同程度减轻，脊髓及神经根损害均有改善。结论：原发肿瘤性质及重要脏器转移情况影响患者预后。Tomita预后评分法可有效判断预后，指导制定治疗方案。对于单发的、原发肿瘤生长较慢的脊柱转移瘤采取积极手术治疗，并结合综合治疗，可取得较满意的疗效。     

脊柱椎弓根定位数字化导航模板的试验研究

目的 利用逆向工程原理和快速成型技术为脊柱椎弓根定位提供一种新的方法,并通过尸体标本试验验证其可行性.方法 选取老年男性正常人体脊柱标本一具,范围:L1-3 CT连续扫描数据集,三维重建软件Amira3.1建立L4-3,椎体模型,以.stl格式导出模型.在UG lmageware 12.0平台打开三维重建模型,定位三维参考平面.利用椎弓根内切圆原理设计椎弓根的最佳进钉钉道.提取椎板的表面解剖学形态,建立与椎体后部解剖学形态一致的模板.拟合模板和椎弓根孔道成定位模板,将椎体和定位模板通过激光快速成型技术生产出实物模板.将制作的实物模板与标本的椎板相吻合,利用导航模板的导航孔进行椎弓根的定位,置入椎弓根钉,术后利用X线片、CT扫描验证椎弓根钉位置的准确性.结果 建立了椎体个体化钉道模型,通过快速成型技术生产出的带椎弓根准确信息的导航模板具有较好的准确性.结论 利用逆向工程原理和快速成型技术为椎弓根的定位提供了一种新的方法,该方法为脊柱椎弓根螺钉的置入提供了一种新的方法,值得进一步在临床推广应用.     

脊柱病变为主的骨髓瘤的诊断和外科治疗

[目的]探讨以脊柱病变为主的骨髓瘤的的诊断方法和外科治疗的指征、方式及效果。[方法]对本科自1996。2004年收治的13例以脊柱病变为主的骨髓瘤患者的临床表现、辅助检查及外科治疗情况进行回顾分析。本组资料13例患者，男性5例，女性8例，平均47．67岁。行X线、CT、MRI、ECT、术前／术中病理活检等检查，均行外科手术治疗：经前路椎体肿瘤切除、钛网植骨或骨水泥椎体植入、钢／钛板内固定7例，经后路全脊椎切除、钛网植骨、椎弓根钉固定4例，联合入路肿瘤切除、前路钛网植入、钛板内固定、后路经椎弓根固定2例。[结果]术后患者疼痛症状明显缓解，脊髓或神经根压迫症状改善，生活质量提高，2例截瘫患者Frankel分级分别由B级、C级变为D级，患者均获随访，平均随访36．75个月，1例复发，3例死亡。[结论]X线检查可提供诊断线索，CT与MRI在诊断和鉴别诊断中有重要作用，ECT检查可发现全身多个病灶，病理活检是可靠的诊断方法，选择性手术治疗可使患者症状得到明显持久缓解，须结合化疗、放疗等其他治疗，才能得到最好的治疗效果。     

Minimally invasive spinal surgery

Recent advances in endoscopy, imaging and retractor technology have led to major developments in minimal access surgery of the spine. Their place in practice probably awaits the results of prospective trials.     

Primary spinal extradural hydatid cyst in a child: case report and review of the literature

Spinal hydatid cyst is a rare but serious condition. An 8-year-old boy presented with back pain, progressive weakness and numbness in both legs. Magnetic resonance imaging (MRI) of the lumbar region showed a cystic lesion with regular contour located in extradural space. There was cerebrospinal fluid- (CSF-) like signal intensity on T1- and T2-weighted images. The lesion had excessively compressed the dural sac and caudal roots, and expanded to the L3 and L4 neural foramina. The case was explored with L2, L3, L4 laminectomy and the hydatid cyst was removed totally. The clinical presentation, diagnosis and surgical treatment of this rare case of spinal hydatid disease is discussed, and all available cases of primary extradural hydatid cyst reported in the literature are presented.     

脊柱骨巨细胞瘤的手术治疗策略

目的:探讨脊柱骨巨细胞瘤合理的手术治疗策略.方法:回顾性分析1998年7月至2007年6月我科收治的41例良性脊柱骨巨细胞瘤患者的临床资料,男21例,女20例,平均年龄31岁,初次手术27例,外院治疗后复发14例.患者均有不同程度疼痛症状.病变累及颈椎3例,胸惟25例,腰椎13例 14例患者术前行动脉造影,同时栓塞肿瘤节段血管.18例肿瘤只累及椎体的患者采用经前路肿瘤切除椎管减压术,前路植自体骨或人工椎体重建切除的椎体,并应用钢板螺钉固定;16例病灶同时累及椎体及附件的患者采用前后联合入路,术中先行椎管后路减压,切除附件内肿物,并应用椎弓根钉行内固定术,后行前路椎体肿瘤切除手术;4例患者一般情况较好,肿瘤只破坏1～2个脊椎、没有明显的软组织肿块,行一期后路全脊椎切除术;3例椎体部分受累的患者行后路次全脊椎切除术,随访观察治疗效果结果:行节段动脉栓塞组14例.平均出血约3100ml;未栓塞组27例,平均出血量约4500ml.2例复发的患者最终未能彻底切除肿瘤,术后行放疗,分刖随访35及29个月,荷瘤生存.其余39例患者中,36例(92.3%)术后疼痛得到明显缓解;术后平均随访52.9个月,16例复发(41.0%).初治的27例患者9例复发(33.3%).其中单纯前路手术11例,复发6例;前后路联合手术12例,复发3例;全脊椎切除术4例,未见复发.12例外院复发病例7例再次复发(57.1%),其中2例因肿瘤发展,全身衰竭死亡.21例随访3年以上,其中13例末见复发,所有病例均未见内固定松动、移位或折断.结论:对于脊柱骨巨细胞瘤,首次冶疗选择较为彻底的手术方案是降低复发率的关键.     

Cervical spinal extradural meningioma: Case report

Extradural meningiomas account for approximately 7% of all spinal meningiomas and are most commonly located in the thoracic spine. Although rare, they should be included in the differential diagnosis of an extradural contrast-enhancing mass. Prognosis depends greatly on the extent of surgical resection. If considered safe, complete resection should be attempted to decrease the risk of recurrence. We report a case of spinal epidural meningioma diagnosed in an elderly woman complaining of right cervicobrachial pain of several years duration, associated with diffuse paresthesia and permanent numbness of her right index finger. The surgical removal of the tumor was incomplete because of the deep lateral extension of the lesion.     

Independent predictors of complication following surgery for spinal metastasis

Purpose

Surgery for spinal metastasis is often associated with significant morbidity. Despite a number of preoperative scoring systems/scales and identified variables that have been reported to predict complication risk, clinical studies that directly evaluate this issue using multivariate analysis are scarce. The goal of our study was to assess independent predictors of complication after surgery for spinal metastasis.

Methods

We queried electronic medical records to identify a consecutive population of adult patients who underwent surgery for spinal metastasis for the period June 2005 through June 2011. Utilizing multivariate logistic regression, we assessed independent predictors of perioperative and postoperative adverse events.

Results

A total of 106 patients were included in the final analysis. Overall complication rate was 21.7 %. Independent predictors for higher rates of complication were age greater than 40 years [40–65 years had odds ratio (OR) 1.91, 95 % confidence interval (CI) 1.02–16.78 and >65 years had OR 5.17, 95 % CI 1.54–29.81] and metastatic lesions involving three or more contiguous levels of the spine (OR 2.76, 95 % CI 1.09–9.61).

Conclusions

Patients older than 40 years or patients who have metastatic lesions involving three or more contiguous vertebral levels appear to be at higher risk for complication. Patients older than 65 years have the greatest likelihood of complication.

     

脊柱转移瘤的外科治疗效果

目的：探讨脊柱转移瘤患者手术治疗的适应证与疗效。方法：对1998年7月至2003年7月5年间收治的167例脊柱转移瘤患者的临床资料进行回顾性分析。胸椎转移99例，腰椎转移53例．颈椎转移15例。男性96例，女性71例。出现神经系统受损者112例，其中Frankel分级A级17例．B级11例．C级22例．D级62例。患者均有不同程度的疼痛，手术根据肿瘤破坏脊椎的部位行前路椎体切除、钢板内固定术或后路病变椎板切除、肿瘤切除、椎管减压、经椎弓根内固定术。结果：167例患者中，155例（92．8％）术后疼痛得到缓解。112例有神经功能损害的患中，67例（59．8％）术后Frankel分级有不同程度的改善。随访6～48个月．术后存活1年以上的患者117例，约占患者总数的70％。结论：由于转移瘤所致椎体塌陷或不稳定造成严重的神经损害或机械性不稳脊柱痛疼的患者，手术治疗可改善其神经功能，增加脊椎稳定性．提高生存质量。     

胸腔镜辅助下前路手术治疗胸椎肿瘤

目的：探讨在胸腔镜辅助下行胸椎转移性肿瘤前路手术切除的方法及效果。方法：在胸腔镜辅助下对11例胸椎转移瘤患者行病椎切除及椎体重建术，术前神经功能ASIA分级A级1例，C级6例，D级4例。7例行病椎切除及钢板骨水泥椎体重建术；4例行病椎切除、钢板骨水泥椎体重建及内固定术。结果：手术均获成功，术中肿瘤切除满意，术后影像学显示内固定固定确切。随访4～14个月，平均8个月，胸背痛均完全消失．术后神经功能除1例A级无恢复外，其余均明显恢复；1例冈肿瘤脑转移4个月死亡，其余患者存活8个月以上．其中1例乳腺癌术后多椎体转移患者手术后14个月随访时仍存活。结论：在胸腔镜辅助下行胸椎转移肿瘤切除椎体重建术安全、有效，可提高患者的生活质量。     

经皮椎体成形术与开放性手术治疗脊柱转移瘤

【摘要】 目的：探讨经皮椎体成形术（PVP）与开放手术治疗脊柱转移瘤的手术适应证、临床疗效、并发症及外科治疗方式的选择。方法：2004年4月～2011年4月行手术治疗并获得随访的脊柱转移瘤患者共177例,根据手术方法不同分为两组,对原发瘤切除后的孤立转移者,或肿瘤进入椎管压迫脊髓、神经根者,以及脊柱严重不稳者行开放性手术治疗,共87例;对无明显脊髓或神经根受压者,不适宜开放手术者行经皮椎体成形术治疗,共90例。采用VAS评分、ECOG评分、Frankel分级对两组患者的疼痛、功能状况和脊髓功能进行评价;使用Kaplan-Meier法评估两组患者生存率。结果：PVP组共治疗242个椎体,基本无出血,中位手术时间70min;术后2d时VAS评分即有显著降低,并持续至术后1、3、6个月;ECOG评分在术后1周和3个月时均有显著降低;除了无症状的骨水泥渗漏（91/242）外,未发生神经损伤或肺栓塞等严重并发症;中位生存时间为16个月。开放手术组中位手术时间240min,中位出血量1600ml;术后1个月时VAS评分显著降低,并持续至术后3、6个月;ECOG评分在术后1个月和3个月均有显著降低;术前47例有脊髓功能障碍患者中有39例术后Frankel分级得到提高（83%）;29%运动功能完全丧失患者（4/14）和60%运动功能不完全丧失患者（20/33）的神经功能完全恢复;术后17例出现并发症（19.5%）,并发症发生率高,围手术期死亡3例（3.4%）;中位生存时间为11个月。结论：经皮椎体成形术对于椎体转移瘤所导致的疼痛和轻中度不稳定是一种安全有效的微创治疗,应作为一线的姑息治疗方法;开放手术应限于原发瘤切除后的孤立转移有硬膜压迫或严重脊柱不稳定的患者。     

Low-dose aspirin before spinal surgery: results of a survey among neurosurgeons in Germany

The main problem faced by the increasing numbers of patients presenting for spinal surgery are receiving concurrent medication with low-dose aspirin, leading to dysfunctional circulating platelets. The contribution of low-dose aspirin to increased peri-operative risk of bleeding and blood loss is a contentious issue with conflicting published results from different surgical groups. Data from neurosurgical spine patients is sparse, but aspirin has been identified as an important risk factor in the development of post-operative hematoma following intracranial surgery. We surveyed the opinions and working practices of the neurosurgical facilities performing spinal operations in Germany regarding patients who present for elective spinal surgery. Identical questionnaires were sent to 210 neurosurgical facilities and proffered five main questions: (1) the adherence of any policy of stopping aspirin pre-operatively, (2) the personal risk assessment for patients with spinal surgery under low-dose aspirin medication, (3) the preferred method of treatment for excessive bleeding in this context, (4) personal knowledge of hemorrhagic complications in this group of patients, and (5) the characteristics of the neurosurgical units concerned. There were 145 (69.1%) responses of which 142 (67.6%) were valid. Of the respondents, 114 (80.3%) had a (written) departmental policy for the discontinuation of pre-operative aspirin treatment, 28 (19.7%) were unaware of such a policy. The mean time suggested for discontinuation of aspirin pre-operatively was 6.9 days (range: 0–21 days), with seven respondents who perform the operations despite the ongoing aspirin medication. Ninety-four respondents (66.2%) considered that patients taking low-dose aspirin were at increased risk for excessive peri-operative hemorrhage or were indetermined (8.6%), and 73 (51.4%) reported having personal experience of such problems. Ninety-two respondents (65.5%) would use special medical therapy, preferably Desmopressin alone or in combination with other blood products or prohemostatic agents (46.1%), if hemorrhagic complications developed intra- or post-operatively. The average number of spinal operations per year in each service was 607.9 (range: 40–1,500). Despite the existence of distinct departmental policies concerning the discontinuation of low-dose aspirin pre-operatively in the majority of neurosurgical facilities performing spinal operations, there is a wide range of the moment of this interruption with an average of 7 days. Two-thirds of the respondents felt that aspirin was a risk factor for hemorrhagic complications associated with spinal procedures, and more than half of the interviewees reported having personal experience of such problems. Finally, various medicamentous methods of counteracting aspirin-induced platelet dysfunction and excessive bleeding in this context are elicited, discussed and evaluated.     

颈胸段脊柱疾病的手术治疗策略

目的探讨颈胸段脊柱疾病的临床特点及手术治疗策略。方法回顾性分析自2007-01—2014-12采用前路、后路或前后路联合手术治疗的83例颈胸段脊柱疾病。19例骨折、11例椎间盘病变、6例肿瘤、5例结核采用下颈椎低位前方入路手术;11例骨折、6例椎间盘病变、5例肿瘤、3例结核经颈前胸骨柄联合入路手术;6例骨折、3例后凸畸形采用颈胸段后方入路手术;6例骨折、2例结核采用前后联合入路手术。结果本组手术时间80~260 min,平均145 min;术中出血量100~3 100 ml,平均780 ml。75例术后获得随访9~62个月,平均26个月。所有患者术后植骨部位均达到骨性融合,骨性融合时间6~12个月,平均8.5个月。所有患者颈胸段脊柱生理力线恢复,无内固定失败等并发症发生。结论颈胸段脊柱疾病发生率低,但手术风险大,手术入路的选择应根据病变的位置、患者的耐受能力以及手术医师的熟悉程度而定,以减少创伤和并发症的发生。     

Follow-up of burned patients in the United Kingdom

The nature of follow-up procedure practised by burn treatment units in the United Kingdom was investigated using a questionnaire sent to 30 units. Information from 23 units who replied indicated that all units consider that follow-up is essential and pressurized patients by a variety of means to attend. All units also recognized that medical, nursing and a variety of rehabilitation staff are required for follow-up care. There was a lesser involvement of social workers and a minimal involvement of psychiatric staff. All units obviously utilize a variety of clinics to follow patients after discharge from the burns unit. There appears to be no standard form of follow-up, units having made pragmatic arrangements to cover problems identified in clinical practice.