Opioid use trends in patients undergoing elective thoracic and lumbar spine surgery

BackgroundOpioid use in North America has increased rapidly in recent years. Preoperative opioid use is associated with several negative outcomes. Our objectives were to assess patterns of opioid use over time in Canadian patients who undergo spine surgery and to determine the effect of spine surgery on 1-year postoperative opioid use.MethodsA retrospective analysis was performed on prospectively collected data from the Canadian Spine Outcomes and Research Network for patients undergoing elective thoracic and lumbar surgery. Self-reported opioid use at baseline, before surgery and at 1 year after surgery was compared. Baseline opioid use was compared by age, sex, radiologic diagnosis and presenting complaint. All patients meeting eligibility criteria from 2008 to 2017 were included.ResultsA total of 3134 patients provided baseline opioid use data. No significant change in the proportion of patients taking daily (range 32.3%–38.2%) or intermittent (range 13.7%–22.5%) opioids was found from pre-2014 to 2017. Among patients who waited more than 6 weeks for surgery, the frequency of opioid use did not differ significantly between the baseline and preoperative time points. Significantly more patients using opioids had a chief complaint of back pain or radiculopathy than neurogenic claudication (p < 0.001), and significantly more were under 65 years of age than aged 65 years or older (p < 0.001). Approximately 41% of patients on daily opioids at baseline remained so at 1 year after surgery.ConclusionThese data suggest that additional opioid reduction strategies are needed in the population of patients undergoing elective thoracic and lumbar spine surgery. Spine surgeons can be involved in identifying patients taking opioids preoperatively, emphasizing the risks of continued opioid use and referring patients to appropriate evidence-based treatment programs.     

Effect of autologous blood donation in patients undergoing elective spine surgery.

Autologous blood predeposit before elective surgery is a rapidly expanding transfusion practice. A 3-year analysis of an autologous blood predeposit program was conducted to assess its impact on orthopaedic spine surgery. It was concluded that, first, autologous blood donation has resulted in a reduction of homologous blood transfusions in patients undergoing elective spine procedures from 26% to 13% (P = .02). Second, autologous blood preoperative donation in elective spine surgery has increased significantly, so that autologous blood as an alternative to homologous blood transfusion now represents a standard of practice for elective spine surgery at the institution included in the study. Third, limitations of preoperative autologous blood procurement suggest that application of additional blood conservation interventions as alternatives to homologous blood would be important contributors to achieving "bloodless" surgery in this setting.     

Management of the airway in patients undergoing cervical spine surgery

The perioperative management of the airway in patients with cervical spine disease requires careful consideration. In an observational prospective cohort study, we assessed the preoperative factors that may have influenced the anesthesiologists' choice for the technique of intubation and the incidence of postoperative airway complications. We recorded information from 327 patients: mean (+/-SD) age 51+/-15 year, 138 females and 189 males, for anterior surgical approach (n=195) and posterior (n=132). The technique of intubation used was awake fiberoptic bronchoscopy (FOB) in 39% (n=128), asleep FOB 32% (n=103), asleep laryngoscopy 22% (n=72), and other asleep 7% (n=24). Awake FOB was predominately chosen for intubating patients with myelopathy (45%), unstable/fractured spine (73%), and spinal stenosis (55%) but patients with radiculopathy had more asleep FOB (49%) (P<0.001). There was no association between method of intubation and postoperative airway complications. Acute postoperative airway obstruction occurred in 4 (1.2%) patients requiring reintubation. The technique of management of the airway for cervical spine surgery varied considerably among the anesthesiologists, although the choice was not associated with postoperative airway complications.     

Obesity and perioperative outcomes in older surgical patients undergoing elective spine and major arthroplasty surgery

Study objectiveTo determine whether obesity status is associated with perioperative complications, discharge outcomes and hospital length of stay in older surgical patients.DesignSecondary analysis of five independent study cohorts (N = 1262).SettingAn academic medical center between 2001 and 2017 in the United States.PatientsPatients aged 65 years or older who were scheduled to undergo elective spine, knee, or hip surgery with an expected hospital stay of at least 2 days.MeasurementsBody mass index (BMI) was stratified as nonobese (BMI ≤ 30 kg/m²), obesity class 1 (30 kg/m² ≤ BMI < 35 kg/m²) or obesity class 2–3 (BMI ≥ 35 kg/m²). Primary outcomes included predefined intraoperative and postoperative complications, hospital length of stay (LOS), and discharge location. Univariate and multivariate logistic regression was performed.Main resultsObesity status was not associated with intraoperative adverse events. However, obesity class 2–3 significantly increased the risk for postoperative complications (IRR 1.43, 95% CI 1.03–1.95, P = 0.03), hospital LOS (IRR 1.13, 95% CI 1.02–1.25, P = 0.02) and non-home discharge destination (OR 1.95, 95% CI 1.35–2.81, P < 0.001) after accounting for patient related factors and surgery type.ConclusionsObesity class 2–3 status has prognostic value in predicting an increased incidence of postoperative complications, increased hospital LOS, and non-home discharge location. These results have important clinical implications for preoperative informed consent and provide areas to target for care improvement for the older obese individual.     

Predictors of blood transfusion in patients undergoing elective surgery for degenerative conditions of the spine

Background

The requirement of blood in the surgery of degenerative conditions of lumbar spine is around 10?%. Preoperative autologous blood donation is an effective method that is used in surgeries with an important blood loss. This is an expensive method because of the great number of predonated blood units not used in the postoperative period (around 70?% in our practice).

Objective

To know the risk factors associated with transfusion in the postoperative period in patients who undergo surgeries of degenerative conditions of the lumbar spine.

Methods

We designed a retrospective study of 142 cases of patients operated for degenerative conditions of the lumbar spine (not including simple disk hernia or adult degenerative scoliosis).

Results

Female sex, age >60?years, preoperative ASA score 3 and preoperative hemoglobin ≤136?g/L are the risk factors related to the need of blood transfusion in the postoperative period. After application of a statistical study, female sex and preoperative ASA score 3 were the most important variables to explain transfusional risk. A woman with ASA score 3 has a 61?% foretold probability to be transfused in the postoperative period, while a man with ASA?Conclusions Females, ASA 3, preoperative hemoglobin ≤136?g/L and age older than 60?years increase the risk to be transfused in the postoperative period for degenerative conditions of the spine.     

Segmental cervical spine movement with the intubating laryngeal mask during manual in-line stabilization in patients with cervical pathology undergoing cervical spine surgery

We quantified the extent and distribution of segmental cervical movement produced by the intubating laryngeal mask (ILM) during manual in-line stabilization in 20 anesthetized patients with cervical pathology undergoing cervical spine surgery. All patients had neurological symptoms preoperatively. The ILM was inserted with the head and neck in the neutral position. Intubation was facilitated by transillumination of the neck with a lightwand. Cervical movement was recorded with single-frame lateral radiographic images taken 1) immediately before induction (baseline); 2) during ILM insertion (insertion); 3) when transillumination was first seen at the cricothyroid membrane (intubation A); 4) when the tube was being advanced into the trachea (intubation B); and 5) during ILM removal (removal). Radiographic images were digitized and the degree of flexion/extension and posterior movement measured for the occiput (C0) through to C5. During ILM insertion, C0-5 were flexed by an average of 1-1.6 degrees (all P < 0.05). During intubation A/B, C0-4 were flexed by an average of 1.4-3.0 degrees (all P < 0.01), but C5 was unchanged. During ILM removal, C0-3 were flexed by an average of 1 degree (all: P < 0.05), but C3-5 were unchanged. During insertion and intubation A/B, C2-5 were displaced posteriorly by an average of 0.5-1.0 mm (all: P < 0.05). During removal, there was no change at C1-5. Neurological symptoms improved in all patients. We conclude that the ILM produces segmental movement of the cervical spine despite manual in-line stabilization in patients with cervical spine pathology undergoing cervical spine surgery. This motion is in the opposite direction to direct laryngoscopy, suggesting that different approaches to airway management may be more appropriate depending on the nature of the cervical instability. IMPLICATIONS: The intubating laryngeal mask produces segmental movement of the cervical spine, despite manual in-line stabilization in patients with cervical spine pathology undergoing cervical spine surgery. This motion is in the opposite direction to direct laryngoscopy, suggesting that different approaches to airway management may be more appropriate depending on the nature of the cervical instability.     

Revision surgery in cervical spine

European Spine Journal - To report the indications, presurgical planning, operative techniques, complications for making decisions in cervical revision surgery (CRS). Hundred and two patients...     

Revision cervical spine surgery

Principles of revision cervical spine surgery are based on adequate decompression of neural elements and mechanical stability via appropriate selection of surgical approach and constructs producing long-term stability with arthrodesis. When planning revision surgery, the surgeon must consider the cause of the underlying problem (eg, biological, mechanical), the potential for complications, and clinical outcomes that can reasonably be expected. This information should be clearly explained to the patient during the informed consent process. This article provides the spine care provider with an understanding of how to appropriately evaluate and manage the most common cervical conditions that require revision cervical spine surgery.     

Microvascular response to transfusion in elective spine surgery

AIM To investigate the microvascular(skeletal muscle tissue oxygenation; SmO_2) response to transfusion in patients undergoing elective complex spine surgery.METHODS After IRB approval and written informed consent, 20 patients aged 18 to 85 years of age undergoing 3level anterior and posterior spine fusion surgery were enrolled in the study. Patients were followed throughout the operative procedure, and for 12 h postoperatively. In addition to standard American Society of Anesthesiologists monitors, invasive measurements including central venous pressure, continual analysis of stroke volume(SV), cardiac output(CO), cardiac index(CI), and stroke volume variability(SVV) was performed. To measure skeletal muscle oxygen saturation(SmO_2) during the study period, a non-invasive adhesive skin sensor based on Near Infrared Spectroscopy was placed over the deltoid muscle for continuous recording of optical spectra. All administration of fluids and blood products followed standard procedures at the Hospital for Special Surgery, without deviation from usual standards of care at the discretion of the Attending Anesthesiologist based on individual patient comorbidities, hemodynamic status, and laboratory data. Time stamps were collected for administration of colloids and blood products, to allow for analysis of SmO_2 immediately before, during, and after administration of these fluids, and to allow for analysis of hemodynamic data around the same time points. Hemodynamic and oxygenation variables were collected continuously throughout the surgery, including heart rate, blood pressure, mean arterial pressure, SV, CO, CI, SVV, and SmO_2. Bivariate analyses were conducted to examine the potential associations between the outcome of interest, SmO_2, and each hemodynamic parameter measured using Pearson's correlation coeffi-cient, both for the overall cohort and within-patients individually. The association between receipt of packed red blood cells and SmO_2 was performed by running an interrupted time series model, with SmO_2 as our outcome, controlling for the amount of time spent in surgery before and after receipt of PRBC and for the inherent correlation between observations. Our model was fit using PROC AUTOREG in SAS version 9.2. All other analyses were also conducted in SAS version 9.2(SAS Institute Inc., Cary, NC, United States).RESULTS Pearson correlation coefficients varied widely between SmO_2 and each hemodynamic parameter examined. The strongest positive correlations existed between ScvO_2(P = 0.41) and SV(P = 0.31) and SmO_2; the strongest negative correlations were seen between albumin(P =-0.43) and cell saver(P =-0.37) and SmO_2. Correlations for other laboratory parameters studied were weak and only based on a few observations. In the final model we found a small, but significant increase in SmO_2 at the time of PRBC administration by 1.29 units(P = 0.0002). SmO_2 values did not change over time prior to PRBC administration(P = 0.6658) but following PRBC administration, SmO_2 values declined significantly by 0.015 units(P 0.0001).CONCLUSION Intra-operative measurement of SmO_2 during large volume, yet controlled hemorrhage, does not show a statistically significant correlation with either invasivehemodynamic, or laboratory parameters in patients undergoing elective complex spine surgery.     

Massive pulmonary thromboembolism during elective spine surgery

Massive pulmonary thromboembolism (PTE) is a condition that can still be seen in the operating room despite the use of thromboprophylaxis. A high degree of suspicion of this condition is necessary to achieve an early diagnosis and a rapid treatment to improve patient outcome. We report on a 27-year-old patient who sustained a massive PTE while undergoing a second-stage anterior release and posterior fusion of his thoracolumbar spine for idiopathic scoliosis.     

Spinal anesthesia for elective lumbar spine surgery

Study Objective: To evaluate a large series of elective lumbar spine surgical procedures by a single surgeon whose patients were all offered spinal anesthesia.

Design: Retrospective chart review.

Setting: Tertiary-care teaching hospital.

Measurements and Main Results: The records of all elective lumbar spine procedures between 1984 and 1995 performed by one surgeon (GRB) were obtained, and 803 were identified. Of those 803 patients, 611 accepted spinal anesthesia. Data collected included patient demographics, details of the spinal and general anesthesia, perioperative complications, and impact of the spinal anesthetic options on the outcome of spinal anesthesia. General and spinal anesthesia patients were comparable for age, gender, height, and ASA physical status. Patients who received spinal anesthesia were significantly heavier than the general anesthesia patients. Among perioperative complications, nausea and deep venous thrombosis occurred significantly more often in the general than spinal anesthesia patients. Mild hypotension and decreased heart rate (HR) were the most common hemodynamic changes with spinal anesthesia, whereas hypertension and increased HR were the result of general anesthesia. Among spinal anesthetic drugs, plain bupivacaine was associated with the lowest incidence of supplemental local anesthetic use intraoperatively compared to hyperbaric bupivacaine or hyperbaric tetracaine.

Conclusion: Spinal anesthesia is an effective alternative to general anesthesia for lumbar spine surgery and has a reduced rate of minor complications.     

Complications in posterior cervical spine surgery

The posterior approach to the cervical spine has been described since the early 1900s and it is still commonly used to treat various cervical pathologies. It allows for an extensile exposure of the posterior cervical spine, and when employed for the correct indications it yields good results. However, there are various complications associated with this approach that can negatively impact patient outcomes. In general, avoiding complications is best achieved with careful diagnostic assessment, good patient selection and meticulous technical execution of the surgical procedure. This article reviews some of the most common complications following posterior cervical spine procedures.     

Emergent reintubation following elective cervical surgery:A case series

AIM To review cases of emergent reintubation after cervical surgery.METHODS Patients who were emergently intubated in the postoperative period following cervical surgery were identified. The patients' prospectively documented demographic parameters, medical history and clinical symptoms were ascertained. Pre-operative radiographs were examined for the extent of their pathology. The details of the operative procedure were discerned.RESULTS Eight hundred and eighty patients received anterioror combined anterior-posterior cervical surgery from 2008-2013. Nine patients(1.02%) required emergent reintubation. The interval between extubation to reintubation was 6.2 h [1-12]. Patients were kept intubated after reintubation for 2.3 d [2-3]. Seven patients displayed moderate postoperative edema. One patient was diagnosed with a compressive hematoma whichwas subsequently evacuated in the OR. Another patient was diagnosed with a pulmonary effusion and treated with diuretics. One patient received a late debridement for an infected hematoma. Six patients reported residual symptoms and three patients made a complete recovery. CONCLUSION Respiratory compromise is a rare but potentially life threatening complication following cervical surgery. Patients at increased risk should be monitored closely for extended periods of time post-operatively. If the airway is restored adequately in a timely manner through emergent re-intubation, the outcome of the patients is generally favorable.     

A randomised controlled trial of prehabilitation in patients undergoing elective cardiac surgery

The feasibility, safety and efficacy of prehabilitation in adult patients awaiting elective cardiac surgery are unknown. A total of 180 participants undergoing elective cardiac surgery were allocated randomly to receive either standard pre-operative care or prehabilitation, consisting of pre-operative exercise and inspiratory muscle training. The primary outcome was change in six-minute walk test distance from baseline to pre-operative assessment. Secondary outcomes included change in inspiratory muscle strength (maximal inspiratory pressure); sarcopenia (handgrip strength); quality of life and compliance. Safety outcomes were pre-specified surgical and pulmonary complications and adverse events. All outcomes were assessed at baseline; at pre-operative assessment; and 6 and 12 weeks following surgery. Mean (SD) age was 64.7 (10.2) years; 33/180 (18%) were women. In total, 65/91 (71.4%) participants who were allocated to prehabilitation attended at least four of eight supervised in-hospital exercise classes; participants aged > 50 years were more likely than younger participants to attend (odds ratio (95%CI) of 4.6 (1.0–25.1)). Six-minute walk test was not significantly different between groups (mean difference (95%CI) -7.8 m (-30.6–15.0), p = 0.503) in the intention-to-treat analysis. Subgroup analyses based on tests for interaction indicated improvements in six-minute walk test distance were larger amongst sarcopenic patients in the prehabilitation group (p = 0.004). Change in maximal inspiratory pressure from baseline to all time-points was significantly greater in the prehabilitation group, with the greatest mean difference (95%CI) observed 12 weeks after surgery (10.6 cmH₂O (4.6–16.6) cmH₂O, p < 0.001). There were no differences in handgrip strength or quality of life up to 12 weeks after surgery. There was no significant difference in postoperative mortality (one death in each group), surgical or pulmonary complications. Of 71 pre-operative adverse events, six (8.5%) were related to prehabilitation. The combination of exercise and inspiratory muscle training in a prehabilitation intervention before cardiac surgery was not superior to standard care in improving functional exercise capacity measured by six-minute walk test distance pre-operatively. Future trials should target patients living with sarcopenia and include inspiratory muscle strength training.     

A novel thermoregulatory system maintains perioperative normothermia in children undergoing elective surgery

BACKGROUND: Body heat loss during anaesthesia may result in increased morbidity, particularly in high-risk populations such as children. To avoid hypothermia, a novel thermoregulatory system (Allon) was devised. We tested the safety and efficacy of this system in maintaining normothermia in children undergoing routine surgical procedures. METHODS: The system consists of a computerized body, which receives continuous afferent data, i.e. core (rectal) temperature. These data are then compared with a preset temperature (37 degrees C) and a microprocessor heating/cooling unit warms/cools the temperature of circulating water in a garment that is specially designed to allow maximal coverage of body surface area, without impingement on the surgical field. Water temperature to the garment was limited to a maximum of 39.5 degrees C. Continuous perioperative monitoring of skin and rectal temperature, heart rate and blood pressure was performed. Postoperative shivering and adverse effects were also assessed. RESULTS: The Allon system was used in 38 patients aged 3 months to 14 years undergoing surgery under general anaesthesia lasting more than 30 min. Fifty to 80% body surface area was covered by the garment. Mean operative and postoperative core temperatures were 36.9 +/- 0.5 degrees C and 36.7 +/- 0.5 degrees C, respectively. Intraoperative skin temperatures were maintained at 34.4 +/- 2.7 degrees C. The average core- to-periphery intraoperative gradient was 2.9 +/- 4.9 degrees C. Postoperative shivering was absent in 36 cases and mild in two cases. No device-related adverse effects were observed. CONCLUSIONS: Perioperative thermoregulation using the Allon system is safe and effective in maintaining body temperature within a narrow range in children undergoing brief surgical procedures.     

大剂量甲基强的松龙在脊髓型颈椎病围手术期应用的探讨

目的：探讨大剂量甲基强的松龙（MP）在脊髓型颈椎病患者围手术期应用的价值。方法：脊髓型颈椎病患者125例，分为3组，A组：术后未用激素治疗组，42例；B组：氟美松治疗组，38例；C组：大剂量MP＋抗酸药组，45例。比较三组患者手术前后的神经功能评分（JOA 17分法），统计并发症，观察患者术后咽部不适的时间。结果：3组患者术前、术后1周及术后3个月的JOA评分比较无显著性差异；C组患者术后无症状反跳现象，术后咽部不适的时间明显短于A、B两组（P〈0．001）；A组发生l例伤口感染，B组出现1例消化道隐性失血，C组出现1例毛囊炎、2例消化道隐性失血。结论：大剂量甲基强的松龙可以改善脊髓型颈椎病患者术后咽部不适的症状，应用安全，但对神经功能恢复无明显作用。