The utility of local smoke evacuation in reducing surgical smoke exposure in spine surgery: a prospective self-controlled study

BACKGROUND CONTEXTExposure to surgical smoke remains a potential occupational health concern to spine operating room personnel. Using a smoke evacuator (local exhaust ventilation) is currently regarded as a primary means of protection, yet few studies have evaluated its utility in actual surgeries.OBJECTIVETo examine the utility of two common types of local smoke evacuators, a para incisional evacuator and a smoke evacuation pencil, in reducing surgical smoke exposure in spine surgery.STUDY DESIGNA prospective self-controlled study.PATIENT SAMPLEAfter the pre-estimation of sample size, 51 consecutive spine surgeries (25 and 26 patients using the para incisional smoke evacuator and the smoke evacuation pencil, respectively) were enrolled between February 2018 and March 2019.OUTCOME MEASURESTwo outcome measures were used to evaluate the level of surgical smoke exposure, which was defined as the concentration of ultrafine smoke particles in the air (number of particles per cm³, ppc) around the operating table: (a) the average smoke level was the arithmetic mean of all measurements recorded during the surgery; and (b) the peak smoke level was the highest measurement recorded.METHODSConsecutive surgeries that involved bilateral symmetrical surgical exposure of the spine via a posterior midline incision were evaluated. Cauterized smoke was evacuated by two smoke evacuators: a “para incisional evacuator,” which used a flat broad suction pad positioned immediately adjacent to the incision (25 patients), and a “surgical smoke evacuation pencil” which is an incorporated part of the electrocautery (26 patients). The level of smoke exposure was measured separately when surgically exposing the two sides of the spine: starting with one side (determined randomly) with the smoke evacuator being turned on and, then, the other side with the smoke evacuator off. The results were compared between the two sides.RESULTSThe para incisional smoke evacuator significantly reduced the average smoke level by an average of 59.7% (287 [interquartile range {IQR}: 126, 526] vs. 1,177 [IQR: 395, 2,702], p<.001). The surgical smoke evacuation pencil also reduced the average smoke level by an average of 44.1% (917 [IQR: 448, 1936] vs. 1,605 [IQR: 775, 4,280], p<.001). Both evacuators significantly reduced peak smoke levels as well.CONCLUSIONSThis study provides evidence supporting the utility of local smoke evacuation in reducing surgical smoke exposure in spine surgery. Such technology may help to improve the occupational health protection for spine operating room workers.     

Evaluation of a smoke evacuator used for laser surgery

A preliminary study was conducted to determine the effectiveness of a smoke evacuation system used in laser surgery. A 30 W medical CO2 continuous wave (CW) laser was used to make cuts in a pork chop to simulate smoke production during laser surgery. A commercially available smoke evacuation system was used to control the smoke from the simulated surgery. The smoke concentration was measured at 6 in and at 3 and 4 ft from site of laser interaction. The nozzle of the smoke evacuator was located at distances of 2, 6, and 12 in from the surgical site to measure the relative effectiveness of the control. Complete control of smoke was achieved when the nozzle was located at 2 in, but significant amounts of smoke escaped when the nozzle was located at 6 and 12 in. Suggestions for the use of the smoke evacuation system and areas for further study are given.     

Surgical smoke: modern mobile smoke evacuation systems improve occupational safety in the operating theatre

Open in a separate window OBJECTIVESEvaluation of smoke capture efficiency of different mobile smoke evacuation devices with respect to volatile organic compounds and their noise emission.METHODSElectrosurgical incisions were performed on fresh porcine liver in an operating room with vertical laminar flow. The generated surgical smoke was analysed with proton-transfer-reaction mass spectrometry with and without the use of a mobile smoke evacuation system consisting of a smoke evacuator machine, a suction hose and a handpiece. The inlet of the mass spectrometer was positioned 40 cm above the specimen. Various devices were compared: a hard plastic funnel, a flexible foam funnel, an on-tip integrated aspirator of an electrosurgical knife and a standard secretion suction (Yankauer). Also, sound levels were measured at a distance of 40 cm from the handpieces’ inlet.RESULTSThe smoke capture efficiency of the secretion suction was only 53%, while foam funnel, plastic funnel and integrated aspirator were all significantly more effective with a clearance of 95%, 91% and 91%, respectively. The mean sound levels were 68 and 59 A-weighted decibels with the plastic and foam funnel, respectively, 66 A-weighted decibels with the integrated aspirator and 63 A-weighted decibels with the secretion suction.CONCLUSIONSCarcinogenic, mutagenic and reprotoxic volatile organic compounds in surgical smoke can be efficiently reduced by mobile smoke evacuation system, providing improved protection for medical personnel. Devices specifically designed for smoke evacuation are more efficient than standard suction tools. Noise exposure for the surgeon was lowest with the flexible foam funnel and higher with the other handpieces tested.     

COVID-19 infection risk by open and laparoscopic surgical smoke: A systematic review of the literature

BackgroundThe current COVID-19 pandemic has greatly changed the way surgery is delivered. In particular, current guidelines and policies have highlighted the need to use high level Personal Protective Equipment to reduce the risk of viral infection during open and laparoscopic surgical procedures. In particular, it was felt that the laparoscopic approach was at higher risk of viral transmission due to the chimney effect of the smoke escape from the trocars during and after the procedure. However, with this being a new and largely unknown viral agent, guidelines have been based on speculation and extrapolation from previous studies conducted in completely different situations, and led to anxiety amongst surgeons and theatre staff. We decided to conduct a systematic review of the Literature to try to clarify whether inhalation of surgical smoke can increase the risk of COVID-19 infection.MethodsA thorough search of the relevant Literature was performed following the PRISMA guidelines and the most relevant papers on this topic were selected for qualitative analysis. Duplicates, review, personal opinions and guidelines have been excluded. Quantitative analysis has not been performed due to the lack of homogeneous high-quality studies.ResultsLiterature search identified 740 papers but only 34 of them were suitable for qualitative analysis. The quality of those studies is generally quite low. We were not able to find any evidence directly linking surgical smoke with viral transmission, other than in patients with active HPV infection.DiscussionInhalation of surgical smoke can be generally hazardous, and therefore the use of PPE during surgical operations must be recommended in any case. However, the present systematic review of the existent Literature did not identify any significant evidence of the risk of viral transmission with the surgical smoke, therefore the current guidelines restricting the use of laparoscopy and/or diathermy during the current Covid-19 pandemic may be considered excessive and non-evidence based.     

A single-blind controlled study of electrocautery and ultrasonic scalpel smoke plumes in laparoscopic surgery

Background  

Surgical smoke containing potentially carcinogenic and irritant chemicals is an inevitable consequence of intraoperative energized dissection. Different energized dissection methods have not been compared directly in human laparoscopic surgery or against commonly encountered pollutants. This study undertook an analysis of carcinogenic and irritant volatile hydrocarbon concentrations in electrocautery and ultrasonic scalpel plumes compared with cigarette smoke and urban city air control samples.     

Automatic smoke evacuation in laparoscopic surgery: a simplified method for objective evaluation

Background

Although its theoretical usefulness has been reported, the true value of automatic smoke evacuation system in laparoscopic surgery remains unknown. This is mainly due to the lack of objective evaluation. The purpose of this study was to determine the efficacy of the automatic smoke evacuator in laparoscopic surgery, by real-time objective evaluation system using an industrial smoke-detection device.

Methods

Six pigs were used in this study. Three surgical ports were placed and electrosurgical smoke was generated in a standard fashion, using either a high-frequency electrosurgical unit (HF-ESU) or laparosonic coagulating shears (LCS). The smoke was evacuated immediately in the evacuation group but not in the control nonevacuation group. The laparoscopic field-of-view was subjectively evaluated by ten independent surgeons. The composition of the surgical smoke was analyzed by mass spectrometry. The residual smoke in the abdominal cavity was aspirated manually into a smoke tester, and stains on a filter paper were image captured, digitized, and semiquantified.

Results

Subjective evaluation indicated superior field-of-view in the evacuation group, compared with the control, at 15 s after activation of the HF-ESU (P < 0.05). The smoke comprised various chemical compounds, including known carcinogens. The estimated volume of intra-abdominal residual smoke after activation of HF-ESU was significantly lower in the evacuation group (47.4 ± 16.6) than the control (76.7 ± 2.4, P = 0.0018). Only marginal amount of surgical smoke was detected in both groups after LCS when the tissue pad was free from burnt tissue deposits. However, the amount was significantly lower in the evacuation group (21.3 ± 10.7) than the control (75 ± 39.9, P = 0.044) when the tissue pad contained tissue sludge.

Conclusions

Automatic smoke evacuation provides better field-of-view and reduces the risk of exposure to harmful compounds.     

Laser smoke evacuator: Effective removal of mutagenic cautery smoke

Electrocautery knife smoke is mutagenic, unpleasant, and possibly a health hazard to operating room personnel. Traditional smoke removal methods have been largely ineffective during procedures that generate significant smoke with electrocautery use. A commercial laser smoke evacuation and filtration unit, available in most hospital operating rooms today, has proven highly effective in rapidly eliminating essentially all visible electrocautery knife smoke and odor during breast reductions and other high smoke procedures.     

Postoperative spinal epidural hematoma (SEH): incidence,risk factors,onset, and management

Background contextSpinal epidural hematoma (SEH) is a rare, yet potentially devastating complication of spinal surgery. There is limited evidence available regarding the risk factors and timing for development of symptomatic SEH after spinal surgery.PurposeTo assess the incidence, risk factors, time of the onset, and effect of early evacuation of symptomatic SEH after spinal surgery.Study designMulticenter case control study.Patient sampleAll patients who underwent open spinal surgery between October 1, 1999, and September 30, 2006, at the National Hospital For Neurology and Neurosurgery (NHNN) and the Wellington Hospital (WH) were reviewed.Outcome measuresFrankel grade.MethodsPatients who developed SEH and underwent evacuation of the hematoma were identified. Two controls per case were selected. Each control had undergone a procedure with similar complexity, at the same section of the spine, at the same hospital, and under the same surgeon within 6 months of the initial operation.ResultsA total of 4,568 open spinal operations were performed at NHNN and WH. After spinal surgery, 0.22% of patients developed symptomatic SEH. Alcohol greater than 10 units a week (p=.031), previous spinal surgery (p=.007), and multilevel procedures (p=.002) were shown to be risk factors. Initial symptoms of SEH presented after a median time of 2.7 hours (interquartile range [IQR], 1.1–126.1). Patients who had evacuation surgery within 6 hours of the onset of initial symptoms improved a median of 2 (IQR, 1.0–3.0) Frankel grades, and those who had surgery more than 6 hours after the onset of symptoms improved 1.0 (IQR, 0.0–1.5) Frankel grade, p=.379.ConclusionsSymptomatic postoperative SEH is rare, occurring in 0.22% of cases. Alcohol consumption greater than 10 units a week, multilevel procedure, and previous spinal surgery were identified as risk factors for developing SEH. Spinal epidural hematoma often presents early in the postoperative period, highlighting the importance of close patient monitoring within the first 4 hours after surgery. This study suggests that earlier surgical intervention may result in greater neurological recovery.     

Postoperative spinal epidural hematoma at a site distant from the main surgical procedure: a case report and review of the literature

Background ContextPostoperative spinal epidural hematomas are known complications of spinal surgery. However, to our knowledge, there are no known cases of postoperative spinal epidural hematoma that occurred distant from the portion of the procedure that breached the spinal canal.PurposeTo report a case and review the literature on the development of postoperative spinal epidural hematoma at a site distant from the portion of the surgical procedure that breached the spinal canal.Study DesignCase report and review of the literature.MethodsOne patient at our institution developed a hematoma at a site distant from the surgical procedure that breached the spinal canal. We retrospectively reviewed the patient's clinical charts, radiographs, and computed tomography scans.ResultsA 57-year-old woman with adult scoliosis and junctional kyphosis underwent a pedicle subtraction osteotomy and long spinal fusion from T3 to the sacrum. Three hours postoperatively, she developed paraplegia with a neurologic deficit at a level distant from the site at which the spinal canal was surgically breached. A computed tomography myelogram revealed a spinal epidural hematoma that was causing compression of the spinal cord in the upper thoracic spine. The patient was returned to the operating room emergently and underwent laminectomy and hematoma evacuation. She had near-complete recovery 5 months after surgery.ConclusionSpinal epidural hematomas are rare but dangerous complications that can result in severe neurologic deficits. A neurologic examination should always be conducted in the operating room immediately after surgery; if it is abnormal, spinal epidural hematoma should be suspected. If the examination indicates a deficit at a site distant from the original surgery, then diagnostic reimaging (magnetic resonance imaging or computed tomography myelogram) is indicated.     

Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment

Background: High-frequency (HF) electrocoagulation and cutting procedures produce smoke by high-temperature pyrolysis of tissues. As distinct from the experience of conventional surgery, electrosurgical smoke is produced in a closed gaseous environment during laparoscopic operations. As a result, toxic chemicals may be absorbed into the circulation. The effects of this absorption are not known. Furthermore, the chemical composition of electrosurgical smoke produced in an anoxic environment may be different from that produced in air. Methods: Smoke was produced in vitro by HF electrocutting of fresh porcine liver in helium, CO₂, and air-saturated closed environments. Smoke samples were collected and analyzed by gas chromatography–mass spectrometry (GC-MS). Results: The chemical constituents of electrosurgical smoke produced in air, CO₂, and helium were similar. To date, 21 chemicals, some highly toxic, have been identified in the electrosurgical smoke produced in a closed environment. These consist of hydrocarbons, nitriles, fatty acids, and phenols. Conclusions: Electrosurgical smoke produced in a closed environment contains several toxic chemicals. The effects of these on cell viability, macrophage, and endothelial cell activation are not known but are being investigated. Meantime, measures to reduce smoke and evacuate it during endoscopic surgery are advisable. Received: 23 September 1997/Accepted: 3 December 1997     

Spinal surgery in a patient with essential thrombocythemia resulting in leg paraplegia: a case report

Background contextEssential thrombocythemia (ET) is a chronic myeloproliferative disorder characterized by a relatively benign clinical course that may be complicated by conflicting thrombosis and bleeding. Postoperative spinal epidural hematoma is an uncommon, but well-known, complication after spinal surgery.PurposeTo describe a patient with ET who underwent surgery for lumbar spinal canal stenosis resulting in leg paraplegia and discuss the perioperative management for ET.Study designCase report.ResultsThe patient with ET underwent laminoplasty and posterolateral fusion for degenerative spondylolisthesis and spinal stenosis at L4–L5. A hematoma was observed in the epidural cavity after surgery, and emergency surgical evacuation was performed. After revision surgery, bleeding from the wound continued for 2 months, despite transfusions of platelets and coagulation factors, and right unilateral leg paralysis developed.ConclusionsThis case presentation increases the awareness of this disorder to the spinal community and the need to establish guidelines for the perioperative management of patients who require surgery in similar settings.     

Unilateral partial hemilaminectomy in the removal of a large spinal ependymoma

Background contextAlthough the hemilaminectomy technique is known to neurosurgeons performing spinal surgery, laminectomy traditionally has been used during spinal canal surgery for extirpation of spinal cord tumors.PurposeAlthough the technique of unilateral partial hemilaminectomy is familiar in its various permutations to surgeons, its application in the spinal tumor surgery has been rarely reported. The aim of this study was to review the literature about the management of spinal cord ependymomas and to discuss the major controversies in treatment.Study designCase report.Patient sampleA 52-year-old man.MethodsThe 52-year-old man complained of backache and leg pain bilaterally, dominant on the left side. Spinal magnetic resonance images revealed an intradural mass at the T12–L2 level. A left unilateral hemilaminectomy of the T12–L1 and L2 was performed with the help of high-speed air drills under microscopic magnification and a midline incision was made on the dura. The tumor was totally removed.ResultsBy using microsurgical techniques and with the help of high-speed drills, a unilateral approach to the intramedullary tumors proved itself to be a safe and easy method in this case. It protected the posterior supporting elements and also permitted the surgeon to manipulate the intradural contralateral side easily. The only difficulty during the operation was the suturing of the dural sac.ConclusionsThis case report emphasizes the need to consider the hemilaminectomy technique in spinal tumor surgery.     

Ultrasonically activated scalpel is an effective tool for cutting the pancreas in biliary-pancreatic surgery: experimental and clinical studies

The ultrasonically activated scalpel, a new tool for cutting and coagulating tissue, uses high-frequency ultrasonic vibrations, and has been widely employed in the field of laparoscopic surgery. We evaluated its usefulness for cutting the pancreas in biliary-pancreatic surgery. We planned experimental and clinical studies using an ultrasonically activated scalpel (harmonic scalpel) for cutting the pancreas. The harmonic scalpel was set up at a power level of 3 (75% of full power) in the knife mode. In the experimental study, using dogs, cutting of the pancreas with the harmonic scalpel resulted in significantly less bleeding and significantly less histologicall tissue damage to the cut stumps than cutting of the pancreas with an electric or a regular scalpel. In the clinical study: (1) the hemostatic effect of the harmonic scalpel was excellent or good in any condition of the pancreas; (2) of 50 stumps of the main pancreatic duct cut with the harmonic scalpel, the stump was easily found in 48 (96%), while ultrasonography was necessary to find the remaining 2 stumps in soft pancreas; (3) in 41 anastomoses (29 soft and 12 hard pancreas) there were no postoperative pancreatic fistulae. These results indicate that the ultrasonically activated scalpel is an effective tool for cutting the pancreas in biliary-pancreatic surgery. Received for publication on May 1, 1999; accepted on July 12, 1999     

超声刀在开放性甲状腺手术中应用的前瞻性研究

目的：探讨超声刀在开放性甲状腺手术中应用的有效性及安全性。 方法：采用前瞻性随机对照方法,将2010年2月—2012年5月210例患者分为超声刀组与电刀组,各105例,分别采用超声刀与传统电刀手术方法行开放性甲状腺切除术,手术均由普外科甲状腺手术经验丰富同一手术团队完成。比较两组在不同手术方式中手术时间、术中出血量、术后引流量、术后并发症等指标。 结果：两组患者年龄、性别、肿块大小及疾病构成比差异无统计学意义（均P>0.05）。在相同的手术方式中,超声刀组手术时间手术、术中出血量及术后引流量（减少10~40 mL）均较传统结扎结合电刀组明显减少,组间差异均有统计学意义（P<0.05）;两组间术后并发症的差异无统计学意义（P>0.05）。 结论：超声刀集切割、止血于一体,简化手术操作过程;在开放性甲状腺手术中应用超声刀,可缩短手术时间,减少出血。     

The Comarr Memorial Award for Distinguished Clinical Service: The Legacy of A. Estin Comarr,MD

Abstract

Background

Subfascial wound suction drains are commonly used after spinal surgery to decrease the incidence of post-operative hematoma. However, there is a paucity of literature regarding their effectiveness.

Objective

To report four cases of post-operative spinal epidural hematoma causing massive neurological deficit in patients who had subfascial suction wound drains.

Methods

During an 8-year period, a retrospective review of 1750 consecutive adult spinal surgery cases was performed to determine the incidence, commonalities, and outcomes of catastrophic neurological deficit caused by post-operative spinal epidural hematoma.

Findings

Epidural hematoma causing major neurological deficit (American Spinal Injury Association B) was identified in 4 out of 1750 patients (0.23%). All four patients in this series had subfascial wound suction drains placed prophylactically at the conclusion of their initial procedure.

Results

Three patients developed massive neurological deficits with the drain in place; one patient had the drain removed at 24 hours and subsequently developed neurological symptoms during the following post-operative day. Significant risk factors for the development of hematoma were identified in two of the four patients. Average time to return to the operating room for hematoma evacuation was 6 hours (range 3–12 hours). Neurological status significantly improved in all four patients after hematoma evacuation.

Conclusions

Post-operative epidural hematoma causing catastrophic neurological deficit is a rare complication after spinal surgery. The presence of suction wound drains does not appear to prevent the occurrence of this devastating complication.     

The spontaneous restoration of the course of psoas muscles after corrective surgery for adult spinal deformity

BackgroundA previous study demonstrated that spinopelvic alignment and morphology influence a deviation in the course of psoas muscle (PM). However, it is unknown whether such deviations might be caused by a decrease in lumbar lordosis (LL) or the lateral deviation of the lumbar spine following scoliosis. The purpose of this study was to elucidate the close relationship between the coronal and sagittal lumbar alignment and a deviation in the course of PM.MethodsWe investigated the preoperative and postoperative spinopelvic parameters and the morphology of PM at L4/5 level in 30 patients treated with corrective surgery for adult spinal deformity who were diagnosed with “rising psoas sign” before surgery. Spinopelvic parameters were measured on X-ray films. Investigation of the morphology of PM and the morphological measurements were performed using computed tomography (CT) images. The “rising psoas sign” was classified as bilateral- or unilateral-type as defined in the previous study.ResultsAmong 18 patients who had bilateral-type rising psoas sign before surgery, 11 patients remained bilateral-type after surgery despite an increase in LL. The pelvic incidence of these 11 patients was significantly larger than that of the other 7 patients (53.5 ± 10.2° vs 43.2 ± 5.8°) (p = 0.037). The magnitude of postoperative increase in LL positively correlated with that of the posterior shift of PM (r = 0.41, p = 0.025). The degree of restoration of the lumbar spine following scoliosis was positively correlated with that of the medial shift of PM (r = 0.66, p = 0.025).ConclusionThe decrease in LL and the lateral deviation of lumbar spine following scoliosis caused a deviated course of the PM, which was spontaneously corrected by the restoration of lumbar alignment. However, the bilateral-type deviation in patients with higher pelvic incidence was considered to be within the range of normal variation.     

Fire in the Surgical Center

Background and objectivesThere are several factors in operating rooms that increase the risk of fire. Besides being an oxygen-enriched environment, it contains combustible materials and equipment with available ignition sources. Although fires in operating rooms are a relatively rare event, the consequences are potentially serious and mostly avoidable. We present a case report of a fire occurring in the surgical drape during a blepharoplasty in which oxygen was supplemented by nasal catheter.Case ReportFemale patient, 52-years old, without comorbidities, admitted to hospital for a bilateral blepharoplasty. After monitoring and venoclysis, the patient underwent intravenous sedation and additional oxygen given via spectacle-type catheter at a flow rate of 4 L.min^?1, followed by local anesthesia in the eyelids. During surgery, the use of electric scalpel provoked combustion in the surgical drapes and burns on the patient's face.ConclusionsAnesthesiologists play an important role preventing fire in operating rooms, as they can recognize possible ignition sources and rationally administer the oxygen, especially in open systems. The first step toward prevention is to be constantly aware of potential fire.     

Patient experiences of decision-making in the treatment of spinal metastases: a qualitative study

BACKGROUNDIn the treatment of spinal metastases the risks of surgery must be balanced against potential benefits, particularly in light of limited life-expectancy. Patient experiences and preferences regarding decision-making in this context are not well explored.PURPOSEWe performed a qualitative study involving patients receiving treatment for spinal metastatic disease. We sought to understand factors that influenced decision-making around care for spinal metastases.STUDY SETTINGThree tertiary academic medical centers.PATIENT SAMPLEWe recruited patients presenting for treatment of spinal metastatic disease at one of three tertiary centers in Boston, MA.OUTCOME MEASURESWe conducted semistructured interviews using a guide that probed participants’ experiences with making treatment decisions.METHODSWe performed a thematic analysis that produced a list of themes, subthemes, and statement explaining how the themes related to the study's guiding questions. Patients were recruited until thematic saturation was reached.RESULTSWe interviewed 23 participants before reaching thematic saturation. The enormity of treatment decisions, and of the diagnosis of spinal metastases itself, shaped participant preferences for who should take responsibility for the decision and whether to accept treatments bearing greater risk of complications. Pre-existing participant beliefs about decision-making and about surgery interacted with the clinical context in a way that tended to promote accepting physician recommendations and delaying or avoiding surgery.CONCLUSIONSThe diagnosis of spinal metastatic disease played an outsized role in shaping participant preferences for agency in treatment decision-making. Further research should address strategies to support patient understanding of treatment options in clinical contexts—such as spinal metastases—characterized by ominous underlying disease and high-risk, often urgent interventions.     

Surgical smoke - a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units

Surgeons and operating theatre personnel are routinely exposed to the surgical smoke plume generated through thermal tissue destruction. This represents a significant chemical and biological hazard and has been shown to be as mutagenic as cigarette smoke. It has previously been reported that ablation of 1 g of tissue produces a smoke plume with an equivalent mutagenicity to six unfiltered cigarettes. We studied six human and 78 porcine tissue samples to find the mass of tissue ablated during 5 min of monopolar diathermy. The total daily duration of diathermy use in a plastic surgery theatre was electronically recorded over a two-month period. On average the smoke produced daily was equivalent to 27-30 cigarettes. Our survey of smoke extractor use in UK plastic surgery units revealed that only 66% of units had these devices available. The Health and Safety Executive recommend specialist smoke extractor use, however they are not universally utilised. Surgical smoke inhalation is an occupational hazard in the operating department. Our study provides data to quantify this exposure. We hope this evidence can be used together with current legislation to make the use of surgical smoke extractors mandatory to protect all personnel in the operating theatre.     

Spinal arachnoid web—a distinct entity of focal arachnopathy with favorable long-term outcome after surgical resection: analysis of a multicenter patient population

BACKGROUND CONTEXTSpinal arachnoid web (SAW) is a rare condition characterized by focal thickening of the arachnoid membrane causing displacement and compression of the spinal cord with progressive symptoms and neurological deficits. Recent reports and clinical experience suggest that SAW is a distinct entity with specific radiological findings and treatment strategies distinguishable from other arachnopathies and potential differential diagnoses.PURPOSETo better define the diagnostic and clinical features, treatment options and outcomes of surgically treated SAW.STUDY DESIGNMulticentric retrospective cohort study.PATIENT SAMPLETwelve cases of SAW surgically treated at three different centers.OUTCOME MEASURESSelf-reported and neurological outcome measurements (pain, sensory-motor deficits, vegetative dysfunctions) were assessed at follow-up timepoints.METHODSRetrospective review of prospectively collected data on all patients surgically treated for SAW from three participating neurosurgical centers between 2014 and 2020. Clinicopathological data, including neurological presentation, radiological and histological findings and outcome data were analyzed.RESULTSTwelve radiologically and surgically confirmed cases of SAW were analyzed. Mean patient age was 54.7 [±12.7], 67% were male. All SAWs were located in the posterior thoracic dural sac. On magnetic resonance imaging (MRI), the “scalpel sign” - a characteristic focal dorsal indentation of the spinal cord resembling a scalpel blade - was identified in all patients. A focal intramedullary syrinx was present in 83%. Preoperative clinical symptoms included signs of myelopathy, pain, weakness and sensory loss, most commonly affecting the trunk/upper back or lower extremities. Laminectomy or laminoplasty with intradural excision of the SAW was the surgical treatment of choice in all cases. Intraoperative ultrasound was valuable to visualize the cerebrospinal fluid (CSF) flow obstruction, confirm the SAW location before dura incision and to control adequacy of resection. After surgery, sensory loss and weakness in particular showed significant improvement.CONCLUSIONSThe present study comprises the largest series of surgically treated SAW, underscoring the unique clinical, radiographic, histopathological, and surgical findings. We want to emphasize SAW being a distinct entity of spinal arachnopathy with a favorable long-term outcome if diagnosed correctly and treated surgically. Intraoperative ultrasound aids visualizing the SAW before dural incision, as well as verifying restored CSF flow after resection.