Cervicothoracic junction fracture/subluxation after multilevel anterior cervical spine fusion surgery

Background context

Several authors have reported cervical dislocations and fracture-dislocations above, below or through the fused cervical segment after cervical fusion. No previous reports have described fracture/dislocations at the cervicothoracic junction (CTJ) after multilevel anterior cervical spine fusion.

Purpose

To report CTJ fracture/subluxation after multilevel anterior cervical spine fusion surgery, a technique for surgical management and strategies to prevent this avoidable complication.

Study design

A case report and review of the literature.

Methods

A 61-year-old women underwent anterior cervical decompression and fusion (ACDF) from C3 to C7. The patient did well postoperatively until she suffered a CTJ fracture/subluxation 4?months later sustained during a fall.

Results

The patient underwent posterior and anterior fusion surgery C7–T2. Radiographs 2?years after her reconstruction surgery showed solid fusion from C3 to T2.

Conclusions

The CTJ area is susceptible to injury because it represents the transition between mobile and relatively immobile portions of the spine, especially when a long lever arm is created by a low cervical fusion. It is difficult to image with plain radiographs, and therefore, injury may be easily overlooked. If overlooked, severe neurological injury can result. Anterior and posterior fusion is often necessary to appropriately stabilize the CTJ after fracture/dislocation.     

Early dysphagia complicating anterior cervical spine surgery: incidence and risk factors

Background

Dysphagia is a common complication of anterior cervical spine surgery, and most of them occurred in the early postoperative period. This study aimed to determine the incidence of early dysphagia after anterior cervical spine surgery and to identify its risk factors.

Methods

A review of 186 consecutive patients undergoing anterior cervical spine surgeries in a 3-year period was performed. Dysphagia at postoperative 1 month was surveyed, and the severity of dysphagia was evaluated. Demographic information and procedural characters were collected to determine their relationships to dysphagia.

Results

A total of 50 patients developed early postoperative dysphagia, including 23 males and 27 females. The incidence of early dysphagia after anterior cervical spine surgery was 26.9 % in this study. Mild, moderate, and severe dysphagia were found in 30, 14, and 6 patients, respectively. Female, advanced age, multi-levels surgery, use of plate, and a big protrusion of plate were found to be significantly increased early dysphagia after anterior cervical spine surgery.

Conclusion

There is a relatively high incidence of early dysphagia after anterior cervical spine surgery, which may be attributable to multiple factors.     

Perioperative mortality after lumbar spinal fusion surgery: an analysis of epidemiology and risk factors

Study design

Analysis of the Nationwide Inpatient Sample (NIS) from 1998 to 2008.

Objective

To analyze the most recent available and nationally representative data for risk factors contributing to in-hospital mortality after primary lumbar spine fusion.

Summary of background data

The total number of lumbar spine fusion surgeries has increased dramatically over the past decades. While the field of spine fusion surgery remains highly dynamic with changes in perioperative care constantly affecting patient care, recent data affecting rates and risk for perioperative mortality remain very limited.

Methods

We obtained the NIS from the Hospital cost and utilization project. The impact of patient and health care system related demographics, including various comorbidities as well as postoperative complications on the outcome of in-hospital mortality after spine fusion were studied. Furthermore, we analyzed the timing of in-hospital mortality.

Results

An estimated total of 1,288,496 primary posterior lumbar spine fusion procedures were performed in the US between 1998 and 2008. The average mortality rate for lumbar spine fusion surgery was 0.2 %. Independent risk factors for in-hospital mortality included advanced age, male gender, large hospital size, and emergency admission. Comorbidities associated with the highest in-hospital mortality after lumbar spine fusion surgery were coagulopathy, metastatic cancer, congestive heart failure and renal disease. Most lethal complications were cerebrovascular events, sepsis and pulmonary embolism. Furthermore, we demonstrated that the timing of death occurred relatively early in the in-hospital period with over half of fatalities occurring by postoperative day 9.

Conclusion

This study provides nationally representative information on risk factors for and timing of perioperative mortality after primary lumbar spine fusion surgery. These data can be used to assess risk for this event and to develop targeted intervention to decrease such risk.     

Glycemic instability of non-diabetic patients after spine surgery: a prospective cohort study

Purpose

Blood glucose (BG) dysregulation is a well-known condition for patients sustaining medical adverse events, such as sepsis or myocardial infarction. However, it has never been described following spine surgery. Our purpose was to assess postoperative glycemic dysregulation of non-diabetic patients undergoing spine surgery and determine if this is related to any complications within a 3-month postoperative period.

Methods

All the non-diabetic patients undergoing spine surgery in our center were prospectively included over a 6-month period. BG capillary measures were collected from the preoperative fasting period to the end of postoperative Day 3, six times a day. Patients were followed for 3 months after surgery.

Results

Data collected from 75 patients were eventually analyzed. A significant increase of BG level was observed from the preoperative to the second postoperative hour (P < 0.0001), remaining significantly elevated until Day 3 (P < 0.0001). Significant correlations were found between perioperative factors (age, smoking, revision status, instrumentation, operation time, blood loss and transfusion) and glycemic parameters. Day 2 mean BG level was found significantly higher for patients surgically revised than those not revised (P = 0.04).

Conclusions

Non-diabetic patients experience a statistically significant increase in BG levels in the first 3 days following a spine surgery. This increase in BG might be correlated with postsurgical complications.     

Posterior instrumentation, anterior column reconstruction with single posterior approach for treatment of pyogenic osteomyelitis of thoracic and lumbar spine

Purpose

Surgical treatment of thoracolumbar osteomyelitis consists of radical debridement, reconstruction of anterior column either with or without posterior stabilization. The objective of present study is to evaluate a case series of patients with osteomyelitis of thoracic and lumbar spine treated by single, posterior approach with posterior instrumentation and anterior column reconstruction.

Methods

Seventeen patients underwent clinical and radiological evaluation pre and postoperatively with latest follow-up at 19 months (8–56 months) after surgery. Parameters assessed were site of infection, causative organism, angle of deformity, blood loss, duration of surgery, ICU stay, deformity correction, time to solid bony fusion, ambulatory status, neurologic status (ASIA impairment scale), and functional outcome (Kirkaldy-Willis criteria).

Results

Mean operating time was 207 min and average blood loss 1,150 ml. Patients spent 2 (1–4) days in ICU and were able to walk unaided 1.6 (1–2) days after surgery. Infection receded in all 17 patients postoperatively. Solid bony fusion occurred in 15 out of 17 patients (88 %) on average 6.3 months after surgery. Functional outcome was assessed as excellent or good in 82 % of cases. Average deformity correction was 8 (1–18) degrees, with loss of correction of 4 (0–19) degrees at final follow-up.

Conclusions

Single, posterior approach addressing both columns poses safe alternative in treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine. It proved to be less invasive resulting in faster postoperative recovery.     

When Do Readmissions for Infection Occur After Spine and Total Joint Procedures?

Background

The episode-of-care concept promulgated by the federal government requires hospitals to assume the cost burden for all care rendered up to 30 days after discharge, including all readmissions occurring in that time. Although surgical site infections (SSIs) are a leading cause of readmission after total joint arthroplasties (TJA) and spine surgery, it is unclear whether these readmissions occur relative to the 30-day period.

Questions/Purposes

We determined whether (1) most readmissions for SSIs occurred in 30 days, (2) the type of procedure performed affected the timing of readmission, and (3) the type of infecting organism influenced the timing of readmission.

Methods

From our hospital database we identified 91 patients treated with elective TJAs and spine surgery from 2007 through 2010 who were readmitted with SSIs. Of the 91 patients, 46 had undergone spine surgery and 45 had TJAs. For each of these readmissions, we determined the type of surgery, the length of time from initial discharge to readmission, and the type of infecting organism.

Results

Readmissions after spine surgery were more likely to occur within 30 days of discharge (80.4% for spine, 58.3% for TJAs). In the TJA cohort, there was a trend toward readmissions occurring within 30 days of discharge more often in the THA subset. We identified no correlation between type of infecting organism and timing of readmission.

Conclusions

With the episode-of-care model, SSIs pose a substantial cost burden for hospitals since the majority would be included in the 30-day period included in the bundled reimbursement.     

Usefulness of endoscopic breast-conserving surgery for breast cancer

Purpose

We compared the safety, invasiveness and cosmetic outcomes between endoscopic breast-conserving surgery (endoscopic group) and surgery under direct vision (direct vision group) for treating breast cancer.

Methods

We compared 100 cases of endoscopic surgery with 150 cases of direct vision surgery. The safety was evaluated in terms of the blood loss, length of the operation and presence or absence of complications, whereas the degree of invasiveness was assessed using preoperative and postoperative leukocyte counts, neutrophil counts, interleukin (IL-6) levels and fever. The cosmetic outcome was assessed on the basis of a breast evaluation by the medical staff and the patient’s subjective satisfaction.

Results

In both groups, serious postoperative complications were absent. No significant differences were observed in the leukocyte counts, neutrophil counts, IL-6 level or fever between the groups. An evaluation of the cosmetic outcomes by the staff showed a more favorable breast size, breast shape and scar condition in the endoscopic group. A significantly higher level of patient satisfaction was also observed in the endoscopic group. Postoperative local recurrence was absent.

Conclusions

The endoscopic approach showed comparable safety and invasiveness, and provided better postoperative cosmetic outcomes than direct vision surgery. Our results suggest that endoscopic breast-conserving surgery is a potentially useful surgical method for the treatment of breast cancer.     

Massive bleeding during spine surgery in a patient with ankylosing spondylitis

Purpose

Ankylosing spondylitis is associated with pathophysiology that has important anaesthetic implications. We report a case where the sequelae of ankylosing spondylitis may have been responsible for massive bleeding during emergency spine surgery.

Clinical Features

A 69 yr old man with long standing ankylosing spondylitis sustained a complex fracture of the lumbar spine in a fall, and was scheduled for stabilization of the spine. Under general anaesthesia, prone positioning was difficult because of the extreme spinal deformity. During exploration, dilatation of epidural veins was encountered and sustained haemorrhage was encountered throughout,the surgical procedure. Estimated blood loss was 17,000 ml which was replaced with 31 units of packed red blood cells, 3200 ml of salvaged blood, 18 units of fresh frozen plasma, 26 units of platelets, 1,000 ml of albumin and 9,000 ml of crystalloid.

Conclusions

Extreme deformity of the spine led to positioning difficulties that may have contributed to massive blood loss during complex spine surgery. Difficulties with placement in the prone position in-patients with advanced ankylosing spondylitis should be anticipated.     

Wirbelsäulenverletzung im Sport

Background

The management of patients with sport-related injuries of the spine is a challenging issue with regard to the ability to resume former sport activities. The current study analyses the rate of resumption of sports participation after conservative and operative treatment.

Methods

In a 2-year period, 96 patients with sport-related injuries of the thoracic and lumbar spine were included in this prospective study. Conservative (19%) or operative treatment (81%) was performed depending on the extent, severity and instability of the trauma. The reduction, the loss of reduction over time and the VAS and Odom scores were assessed. A questionnaire was included to estimate the rate of resumption of sports participation.

Results

Of the patients 91% resumed sports participation and 9% had to abandon all sport activities mostly due to neurological deficits. Minor loss of correction was found in patients with 360° short segment fusions and major loss was found after conservative treatment.

Conclusion

The current management of injuries of the spine effectuates a high rate of resumption of sports activity following conservative or operative treatment.     

Blood loss and operative duration using monopolar electrosurgery versus ultrasound scissors for surgical preparation during thoracoscopic ventral spondylodesis: results of a randomized,blinded, controlled trial

Purpose

Monopolar electrosurgery is the gold standard for surgical preparation in thoracoscopic spine procedures. However, use of ultrasound scissors could decrease blood loss, accelerate the preparation time and improve patient safety, while minimizing operative costs. This trial compares both preparation techniques for ventral thoracoscopic spondylodesis.

Methods

The study design is an open, prospective, randomized, and double-blinded two-armed clinical trial performed in two centres. Forty-one patients with vertebral body fractures from T10 to L2 were included. Primary endpoint: preparation time. Secondary endpoints: blood loss, organ injuries, duration of hospitalization.

Results

Primary and secondary endpoints did not differ significantly between groups (p level 0.05). Increased blood loss (150 ml or more) was eliminated with ultrasound scissors (p = 0.0014).

Conclusions

Primary and secondary endpoints did not differ significantly between the two preparation techniques. The use of either ultrasound scissors or electric scalpel offers safe and effective preparation for thoracoscopic spine surgery.     

Polysegmental Dynesys system

Introduction

The advantages of using the Dynesys System are claimed to be sufficient and polysegmental dorsal stabilization of the spine while preserving a certain amount of motion.

Materials and methods

In this study 20?patients with a polysegmental spinal pathology were treated with polysegmental decompression and using the Dynesys Dynamic Stabilization system. None of the patients had had spinal surgery previously. Bone density was measured in all patients preoperatively.

Results

All 20?patients were followed up for an average of 11.8?months postoperatively. The ability to walk was improved from 581.5?m to 1640.0?m after surgery. Complications observed were one leakage of the dura and one hypertensive crisis. Implant loosening was observed in one female patient, which was revised and dorso-ventral fusion was carried out.

Conclusions

The use of the Dynesys Dynamic Stabilization system is a reasonable treatment in patients with polysegmental pathology of the spine. However, the system does not allow restoration of extensive malalignments or deformities of the spine.     

Risk factors for delayed extubation in thoracic and lumbar spine surgery: a retrospective analysis of 135 patients

Purpose

Extubation may be delayed after spine surgery mainly for the concerns of airway safety. Risk factors for delayed extubation in cervical spine surgery have been described to include prolonged surgery time and amount of crystalloids or blood transfused. To date, risk factors for delayed extubation in thoracic or lumbar spine surgery have not been investigated. We retrospectively reviewed 135 consecutive patients from 2006 to 2009 who underwent thoracic or lumbar spine surgery by one particular surgeon to identify risk factors for delayed extubation.

Methods

Data including patient factors, surgical time, anesthetic technique, blood loss, crystalloid and colloid administration, transfusion requirements, time to transfusion, and time to extubation were collected and analyzed. Delayed extubation was defined as the patient was not extubated in the operating room at completion of the surgery.

Results

One hundred and eight patients were extubated in the OR. Delayed extubation occurred in 27 patients. Delayed extubation was significantly related to total operative time (6.6 ± 0.4 vs. 5.2 ± 0.1 h), volume of crystalloid replacement (6,018 ± 408 vs. 4,186 ± 130 cm³), volume of total colloids infused (787 ± 93 vs. 442 ± 36 cm³), intraoperative blood transfused (3.7 ± 0.5 vs. 0.7 ± 0.1 units); blood loss (2,137 ± 286 vs. 832 ± 50 cm³), and time to starting blood transfusion (106 ± 12 vs. 199 ± 9 min).

Conclusions

Our study suggests that intraoperative factors including prolonged surgical time, significant blood loss, larger volume of crystalloid and colloid infusion, and blood transfusion may be risk factors for delayed extubation following thoracic or lumbar spine surgery. Early blood transfusion may also increase the risk of delayed extubation. Patient factors did not affect extubation time.     

Assessment and treatment of preoperative anemia: Continuing Professional Development

Purpose

The purpose of this continuing professional development (CPD) module is to review the risk of anemia and transfusion in perioperative patients and to propose an approach for the diagnosis and treatment of preoperative anemia.

Principal findings

Preoperative anemia has been associated with increased transfusion of red blood cells, organ injury, and mortality. Postoperative anemia has also been associated with impaired recovery from surgery. Transfusion also increases the risk of infection, organ injury, and mortality. Preoperatively, iron deficiency anemia can be corrected with oral or intravenous iron; certain types of patients might respond to administration of erythrocyte stimulating agents (ESAs). With ESAs, the increased risk of thrombosis should be balanced against the expected benefit.

Conclusions

Preoperative diagnosis and treatment of anemia may reduce the risk of morbidity and mortality associated with both anemia and transfusion.     

The posterior surgical treatment for focal kyphosis in upper-middle thoracic spine

Purpose

To analyze the clinical characteristics of focal kyphosis in upper thoracic spine, and observe the outcome of the posterior corrective surgical procedures.

Methods

Thirteen patients of focal kyphosis were treated with posterior surgical procedures in our medical center. The kyphosis apex was above T6 in all cases. The surgical procedures performed in this study included pedicle subtraction osteotomy (PSO) in six cases and vertebral column resection (VCR) in seven cases. For each case, the kyphosis angle, curvature of lower thoracic spine, lumbar lordosis angle, cervical lordosis angle, pelvic parameters, and the sagittal plane balance of the spine were compared before and after surgery. Neurological function change was assessed based on Frankel grading system and oswestry disability index (ODI).

Results

The average follow-up time of this study was 28.3 months. The average kyphosis angle was reduced from 73.5º before surgery to 32.7º immediately after surgery, and remained at 33.5º at follow-up. The average ODI improved from 22.5 before surgery to 15.5 at follow-up. The neurological function improved after surgery in eight cases. There were two cases of transient neurological deficiency in the lower extremities after VCR procedure, who eventually recovered under postoperative care. One case had recurrent kyphosis due to implant failure after VCR procedure, and recovered after the revision surgery.

Conclusions

Although high risk needs to be warned, the corrective surgery for focal kyphosis in upper thoracic spine still can achieve satisfactory results. Given the comparative surgical results yet less complications, PSO seems to be a preferable procedure over VCR for kyphosis at this region.     

Effectiveness of Bariatric Surgery in Reducing Weight and Body Mass Index Among Hispanic Adolescents

Background

Ethnic minority adolescents, Hispanics in particular, are disproportionately affected by extreme obesity and its associated co-morbidities. Bariatric surgery is one of the few effective treatments for morbid obesity, yet little information about weight outcomes after surgery in this demographic are available. We determined the effectiveness of bariatric surgery in reducing weight and body mass index (BMI) in adolescents, a majority of whom were non-Mexican American Hispanic and originated from Central and/or South America and the Caribbean Basin region.

Methods

Adolescents (16-to-19 years old) who had undergone gastric bypass or adjustable gastric band surgery between 2001 and 2010 and who had complete follow-up data available (91 %) were included in the analysis. Mean weight and BMI before and 1-year after surgery were compared.

Results

Among 71 adolescents (80 % Hispanic, 77 % female), mean BMI and weight, and z-scores and percentile transformations were all significantly lower after surgery for the entire sample (P?<?0.001). Gastric bypass surgery showed significantly better weight loss outcomes for all anthropometric measures versus adjustable gastric band surgery (P?<?0.05). Weight loss was similar among Hispanics and non-Hispanics. No peri-operative complications were reported. Three patients who stopped taking supplements as prescribed experienced iron deficiency anemia within the year following surgery.

Conclusions

Our results show that bariatric surgery, gastric bypass procedure in particular, can markedly reduce weight among a predominantly Hispanic adolescent patient sample. These findings indicate that bariatric surgery has the potential to be safe and effective in substantially reducing weight in a group of adolescents who are at a particularly high risk for obesity-related health consequences.     

Shortening spinal column reconstruction through posterior only approach for the treatment of unstable osteoporotic burst lumber fracture: a case report

Study design

Case report.

Clinical question

This study reports if shortening reconstruction procedure through posterior approach only can be used in osteoporotic unstable fracture as well as post-traumatic burst fracture.

Methods

An 80-year-old female patient with unstable burst osteoporotic fracture of L1 underwent posterior approach corpectomy and shortening reconstruction of the spinal column by non-expandable cages.

Result

The surgery was uneventful, with average blood loss. Using of small profile cages has helped us to avoid root injury. Augmentation of the screw with cement and the compressive force applied to the spine column aids in obtaining a rigid construct with good alignment without any neurological complication.

Conclusion

Shortening reconstruction procedure through only posterior approach is a viable option in treating unstable osteoporotic fracture as well as post-traumatic fractures. Using non-expandable cage is advocated to avoid cage subsidence.     

Intracranial hemorrhage following lumbar spine surgery

Background

Intracranial hemorrhage is a serious but rare complication of spinal surgery, which can occur in the intracerebral, cerebellar, epidural, or subdural compartment.

Purpose

To describe patients with intracranial hemorrhage after lumbar spinal surgery and present clinical and diagnostic imaging findings.

Methods

In this retrospective study, medical records of 1,077 patients who underwent lumbar spinal surgery in our tertiary referral neurosurgery center between January 2003 and September 2010 were studied. The original presentations of the patients before the surgical intervention were herniated lumbar disc, spinal canal stenosis, spondylolisthesis, lumbar spinal trauma, and lumbar spine and epidural tumor. The operations performed consisted of discectomy, multiple level laminectomy, stabilization and fusion, lumbar instrumentation, and lumbar spinal and epidural tumor resection.

Results

Four cases developed intracranial hemorrhage including acute subdural hematoma (one case), epidural hematoma (one case), and remote cerebellar hemorrhage (two cases). The clinical and diagnostic imaging characteristics along with treatments performed and outcomes of these four patients are described and the pertinent literature regarding post-lumbar spinal surgery intracranial hemorrhages is reviewed.

Conclusion

Though rare, intracranial hemorrhage can occur following lumbar spinal surgery. This complication may be asymptomatic or manifest with intense headache at early stages any time during the first week after surgery. Dural tear, bloody CSF leakage, focal neurologic symptoms, and headache are indicators of potential intracranial hemorrhage, which should be considered during or following surgery and necessitate diagnostic imaging.     

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.     

Quality of Life and Body Image After Circumferential Body Lifting of the Lower Trunk: a Prospective Clinical Trial

Background

Plastic surgery after massive weight loss remains a fast growing subspecialty. However, very few studies exist that investigate the quality of life and psychological outcome after body lift surgery.

Methods

Twenty-seven patients (25 females and 2 males) who had undergone bariatric surgery were scheduled for circumferential body lifting of the lower trunk. The patients, aged 21–58 years (mean?=?39.9, SD?=?10.9), underwent surgery in our department of plastic and reconstructive surgery between 2008 and 2010. All participants took part in two psychological examinations on a voluntary basis and completed the prospective pre–post study.

Results

Post-weight loss surgery improves the quality of life and body image.

Conclusions

It is therefore an important part in the interdisciplinary treatment of the massive weight loss patient.