Elective Lumbar Spinal Fusion Research Articles

Esophageal Foreign Body: The Case of the Missing Tooth

Introduction: Esophageal foreign bodies (FB) in adults are usually accidental rather than intentional ingestion of FB which may include fish bones (9-45%), bones (8-40%), and dentures (4-18%). Dental injury is one of the adverse effects of anesthesia, occurring in 1 in 5000 cases, more commonly in those with poor dentition or difficult laryngoscopy/intubation. Endoscopic removal of FB is recommended if the object size or shape or sharp edge poses risk of complication, is causing esophageal obstruction or a small FB remains in esophagus or stomach for over 24 hours or FB is considered valuable. We present a case of accidental dislodgement of partial denture during intubation for surgery which necessitated endoscopic retrieval in perioperative period. Case Report: 43year old female underwent elective lumbar spine fusion with allograft and plates with screws due to L3-4 foraminal and extraforaminal herniated disc. Upon recovery from uneventful surgery under general anesthesia, she noted missing one post of molar tooth which she recalled. Patient expressed her displeasure to the anesthesiologist at the loss of expensive dental work. Chest X-ray confirmed the presence of esophageal FB consistent with the reported missing dental (the radiopaque post was seen at the level of the mid esophagus), figure 1. Although the patient was asymptomatic of chest pain, dysphagia, odynophagia and handling secretions well, as the repeat imaging performed 4 hours and 6 hours later revealed no propagation of the FB. Emergent endoscopic retrieval of impacted mid esophageal FB was successfully performed using a Roth net, figure 2. The impacted post was returned to the patient.Figure 1Figure 2Discussion: Comprehensive preoperative examination includes oral exam for airway and should include dental examination for presence of loose teeth and dental implants in addition to attention to removable dentures. Dislodgment of dental implants during endotracheal intubation or endoscopic procedures (EGD, ERCP) can occur and may require emergent endoscopic FB retrieval.

Predictors of Unplanned Readmission for Adults Undergoing Elective Lumbar Spine Fusion

Predictors of Unplanned Readmission for Adults Undergoing Elective Lumbar Spine Fusion

The Value of Routine Postoperative Radiographs after Elective Lumbar Spinal Fusion Surgery

Introduction Both intra- and postoperative radiographs are traditionally obtained after instrumented lumbar spinal surgery; however, the clinical advantage of routine postoperative images has not been demonstrated. The aim of this study is to explore the usefulness of routine predischarge postoperative radiographs in patients undergoing instrumented spinal surgery. Patients and Methods Patients ( n = 124) who underwent a lumbar spinal fusion were identified from a retrospective database, 58 patients were excluded. Unaltered intraoperative and predischarge postoperative PACS images for 66 patients were reviewed and were scored for the following: (1) Quality (0 = nondiagnostic, 1 = suboptimal, 2 = diagnostic, and 3 = good quality), (2) Focus (number of vertebra and disc seen), (3) Centering using a numbered [1–9] grid system, and (4) Rotation. Results A total of 66 radiographs were analyzed for the following: (1) Quality: 60 AP and 56 lateral intraoperative images whereas 57 AP and 39 lateral postoperative images were diagnostic; (2) Focus: average number of unnecessary vertebra seen in intraoperative AP and lateral images were 0.89 and 1.09, whereas on postoperative AP and lateral images were 8.05 and 6.45, respectively; (3) Centering: 48 AP and 51 lateral intraoperative images, whereas 27 AP and 20 lateral postoperative images were adequately centered; and (4) Rotation was adequate in both intraoperative and postoperative images. Conclusion Intraoperative images scored higher in all parameters suggesting that routine postoperative prehospital discharge radiographs are unnecessary unless specifically indicated and this practice should be discontinued with benefits including reduction of radiation dose (and subsequent sequelae), fiscal burden, and length of stay.

Case series of elective instrumented posterior lumbar spinal fusions demonstrating a low incidence of venous thromboembolism

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in orthopaedic surgery. While specific guidelines exist for hip and knee arthroplasty, there is wide variation in VTE prophylaxis in complex spinal surgery. This study sought to determine the incidence of VTE, and risk factors associated with VTE, in patients undergoing elective instrumented posterior lumbar spinal fusion. In a single-centre case series study, 107 consecutive patients undergoing elective lumbar spinal fusion were evaluated for VTE by lower limb duplex ultrasonography and/or clinical observation, and where indicated, computed tomography pulmonary angiogram. The Caprini model for thrombosis risk factor assessment was retrospectively applied to grade levels of VTE risk, which were compared with overall VTE incidence. All patients were operated on a spinal frame and received mechanical prophylaxis (thromboembolic deterrent stockings and sequential calf-compression devices). Thirty-seven per cent also received chemoprophylaxis with low-molecular-weight heparin (LMWH). There was no significant relationship between LMWH use and protection from VTE. Risk scores ≥3 (high/highest risk categories) were observed in 96.2% of patients. Four (3.7%) patients encountered a VTE complication (all with no chemoprophylaxis), either deep vein thrombosis (1.9%) or pulmonary embolism (1.9%). No patients sustained an epidural haematoma. Although patients undergoing elective instrumental posterior lumbar spinal fusion are at high risk of developing VTE, the actual incidence of VTE in these patients is low. Our data support the use of mechanical prophylaxis with thromboembolic deterrent stockings and sequential calf-compression devices to prevent VTE in these patients.

Opioid sparing effect of low dose ketamine in patients with intravenous patient-controlled analgesia using fentanyl after lumbar spinal fusion surgery

BackgroundThe opioid sparing effect of low dose ketamine is influenced by bolus dose, infusion rate, duration of infusion, and differences in the intensity of postoperative pain. In this study, we investigated the opioid sparing effect of low dose ketamine in patients with intravenous patient-controlled analgesia (PCA) using fentanyl after lumbar spinal fusion surgery, which can cause severe postoperative pain.MethodsSixty patients scheduled for elective lumbar spinal fusion surgery were randomly assigned to receive one of three study medications (K1 group: ketamine infusion of 1 µg/kg/min following bolus 0.5 mg/kg, K2 group: ketamine infusion of 2 µg/kg/min following bolus 0.5 mg/kg, Control group: saline infusion following bolus of saline). Continuous infusion of ketamine began before skin incision intraoperatively, and continued until 48 h postoperatively. For postoperative pain control, patients were administered fentanyl using IV-PCA (bolus dose 15 µg of fentanyl, lockout interval of 5 min, no basal infusion). For 48 h postoperatively, the total amount of fentanyl consumption, postoperative pain score, adverse effects and patients' satisfaction were evaluated.ResultsThe total amount of fentanyl consumption was significantly lower in the K2 group (474 µg) compared to the control group (826 µg) and the K1 group (756 µg) during the 48 h after surgery. Pain scores at rest or with movement, the incidence of adverse events and patient satisfaction were not significantly different among the groups.ConclusionsLow-dose ketamine at 2 µg/kg/min following bolus 0.5 mg/kg significantly reduced the total amount of fentanyl consumption during the 48 h after lumbar spinal fusion surgery without increasing adverse effects.

Perioperative nutrition and postoperative complications in patients undergoing spinal surgery.

The authors undertook a three-part study to better understand the impact of perioperative nutritional status on postoperative complications in patients undergoing spinal surgery. In preliminary Parts I and II, the authors targeted two groups of patients who are particularly nutritionally challenged. In Part III, they studied a large group of consecutive patients undergoing routine lumbar spinal fusion. To determine whether preoperative nutritional status was a significant predictor of postoperative complications in patients undergoing elective lumbar spinal fusion. In Part I, 27 patients treated surgically for vertebral osteomyelitis were divided into two groups based on their preoperative nutritional status. Twenty-four of the 26 postoperative complications were in the malnourished group (P < 0.001). In Part II, 15 (75%) of 20 patients treated surgically for spinal cord injury were found to become malnourished in the postoperative period. Seventeen complications were noted, all in the malnourished group (P = 0.001). One hundred fourteen consecutive patients undergoing selective lumbar decompression and fusion were identified and their records reviewed. In addition to preoperative nutritional status, data gathered included age, sex, height, weight, past medical history, steroid use, alcohol use, tobacco use, type of bone graft (allograft vs. autograft), history of previous lumbar surgery, number of levels fused, and use of spinal instrumentation. Eleven of 13 postoperative infectious complications (10 deep wound infections) were noted in the malnourished group (P < 0.001). By stepwise logistic regression analysis, preoperative nutritional status was an extremely significant independent predictor of postoperative complications in patients undergoing elective lumbar spinal fusion (P = 0.0018). The prevalence data in our study population suggest that a large number (25%) of patients undergoing elective lumbar spine surgery are nourished inadequately at surgery. This number is higher (42%) in older patients. The authors recommend that close attention be paid to the perioperative nutritional status of patients undergoing lumbar spinal surgery. Patients with suboptimal nutritional parameters should be supplemented and replenished before elective surgery.