Posterior Cervical Spine Surgery Research Articles

Extracranial Vertebral Artery Injuries.

Paired vertebral arteries (VAs) travel from the subclavian artery through the cervical spine and into the intracranial space where they contribute to posterior cerebral circulation. Blunt and penetrating injuries to the cervical spine risk injury to the VA. Among the most feared complications of vertebral artery injury (VAI) is posterior circulation stroke. Appropriate screening and treatment of these injuries in the trauma setting remain vitally important to aid in the prevention of devastating neurologic sequelae. A robust knowledge of the VA anatomy is required for spine surgeons to avoid VAI during cervical spine approaches and instrumentation. Both anterior and posterior cervical spine surgeries can place the VA at risk. Careful preoperative assessment with the appropriate advanced imaging studies is necessary to verify the course of the VA in the cervical spine and thus prevent iatrogenic injury because anatomic variations along the course of the artery can prove hazardous if not properly anticipated. Iatrogenic VAI can be treated successfully with tamponade. However, in some cases, ligation, repair, or endovascular procedures may be indicated.

Cervical Spine Surgery Following COVID-19 Infection: When is it Safe to Proceed?

Retrospective. We utilized the NIH National COVID Cohort Collaborative (N3C) database to characterize the risk profile of patients undergoing spine surgery during multiple time windows following the COVID-19 infection. While the impact of COVID-19 on various organ systems is well documented, there is limited knowledge regarding its effect on perioperative complications following spine surgery or the optimal timing of surgery after an infection. We asked the National COVID Cohort Collaborative for patients who underwent cervical spine surgery. Patients were stratified into those with an initial documented COVID-19 infection within 3 time periods: 0-2 weeks, 2-6 weeks, or 6-12 weeks before surgery. A total of 29,449 patients who underwent anterior approach cervical spine surgery and 46,379 patients who underwent posterior approach cervical spine surgery were included. Patients who underwent surgery within 2 weeks of their COVID-19 diagnosis had a significantly increased risk for venous thromboembolic events, sepsis, 30-day mortality, and 1-year mortality, irrespective of the anterior or posterior approach. Among patients undergoing surgery between 2 and 6 weeks after COVID-19 infection, the 30-day mortality risk remained elevated in patients undergoing a posterior approach only. Patients undergoing surgery between 6 and 12 weeks from the date of the COVID-19 infection did not show significantly elevated rates of any complications analyzed. Patients undergoing either anterior or posterior cervical spine surgery within 2 weeks from the initial COVID-19 diagnosis are at increased risk for perioperative venous thromboembolic events, sepsis, and mortality. Elevated perioperative complication risk does not persist beyond 2 weeks, except for 30-day mortality in posterior approach surgeries. On the basis of these results, it may be warranted to postpone nonurgent spine surgeries for at least 2 weeks following a COVID-19 infection and advise patients of the increased perioperative complication risk when urgent surgery is required.

A Retrospective Comparative Analysis on the Effect of Tranexamic Acid to Reduce Perioperative Blood Loss in Patients Undergoing Cervical Spine Surgery.

Retrospective Cohort Study. The purpose of this study is to assess the impact of intravenous TXA on blood loss outcomes in anterior, posterior, and combined approaches for elective cervical spine surgery. Tranexamic acid (TXA) has been shown to reduce blood loss in a variety of operations, such as lumbar spine surgery. However, limited studies have evaluated the efficacy of TXA in cervical spine surgery. We performed a retrospective review of a single surgeon's elective cervical spine operations between September 2011 and March 2017. Patients were divided into 3 groups: anterior approach, posterior approach, or combined approach. Patients were then further subdivided into TXA versus control groups based on whether they received TXA treatment. We performed multiple linear regressions to assess the relationship between the use of TXA and other dependent variables (number of vertebral levels treated, need for a vertebral corpectomy) on total perioperative blood loss, intraoperative estimated blood loss, postoperative drain output, total operative time, postoperative change in hemoglobin, and occurrence of transfusion and/or postoperative deep venous thrombus (DVT). We found that the use of TXA statistically significantly reduced total perioperative blood loss (P=0.04) and postoperative drain output (P=0.004) in posterior surgical approach cervical spine surgery but did not statistically significantly impact any blood loss variables in anterior or combined surgical approaches to elective cervical spine surgery. The use of TXA was a significant predictor for a decrease in intraoperative (P=0.02) and postoperative (P<0.01) blood loss. This study found that TXA statistically significantly decreased total blood loss and postoperative drain output when controlling for multiple confounding factors. Level III.

Inter-Semispinalis Plane Block Versus General Anesthesia for Postoperative Analgesia in Posterior Cervical Spine Surgery: A Randomized Controlled Trial.

Postoperative pain management is crucial for improving patient outcomes following posterior cervical spine surgery. Opioids are effective but carry a risk of respiratory depression. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used but may not provide adequate pain relief and have potential complications. The inter-semispinalis plane (ISPB) block is a novel technique for postoperative analgesia in cervical spine surgery. This study aims to evaluate and compare the efficacy of the ISPB with general anesthesia in terms of analgesia, postoperative Visual Analog Scale (VAS) pain scores, patient-surgeon satisfaction levels, and the occurrence of postoperative complications. This double-blind, randomized controlled trial was blinded to both the patient and the assessor. Fifty adult patients (18 - 60 years old) undergoing elective posterior cervical spine surgery were enrolled. The participants were divided into 2 groups: The ISPB group (receiving bilateral ultrasound-guided ISPB at the C5 level) and the control group (receiving general anesthesia only), with each group comprising 25 patients. The study assessed intraoperative fentanyl use, postoperative VAS pain levels, the need for rescue analgesia, and complications. The ISPB group showed significantly lower intraoperative fentanyl consumption (median 100 vs. 100 - 150 μg, P = 0.022) and lower postoperative pain scores at 1, 8, 12, and 48 hours (P = 0.016, 0.009, 0.005, 0.016). Additionally, the ISPB group required less postoperative pethidine (20% vs. 64%, P = 0.002) and had a longer delay before requesting pethidine (hazard ratio 0.215, P = 0.001). Surgeon satisfaction was significantly higher in the ISPB group (P = 0.003). These results suggest that the ISPB can effectively reduce pain and analgesic requirements. The ISPB is an effective analgesic technique for posterior cervical spine surgery, reducing opioid consumption, providing better pain control, and enhancing surgeon satisfaction without increasing complications. This approach has the potential to improve postoperative care and patient outcomes in this surgical population.

A rare case of phrenic nerve palsy after cervical spine surgery

Abstract Phrenic nerve palsy is a rare complication of cervical spine surgery. There are very few previously reported cases of unilateral diaphragmatic paralysis following posterior cervical spine surgery. We present a case of a 61-year-old man with cervical canal stenosis and myelopathy for which we performed C3–C6 laminectomy and lateral mass screw fixation. Postoperatively the patient developed right C5 palsy affecting his deltoid function which gradually improved. The patient developed respiratory distress postoperatively and was found to have an elevated hemidiaphragm secondary to phrenic nerve palsy. He was treated with respiratory support, with significant improvement in dyspnea. It is a very rare case of unilateral diaphragmatic paralysis causing dyspnea due to phrenic nerve palsy following cervical spine surgery. This rare complication should be kept in mind when assessing any patient with respiratory distress following cervical spine surgery.

Clinical efficacy of duloxetine in the treatment of axial symptoms after posterior cervical spine surgery: a retrospective study

PurposeTo evaluate the efficacy of duloxetine in the treatment of patients with axial symptoms after posterior cervical spine surgery.MethodsPatients with axial symptoms after posterior cervical spine surgery treated by duloxetine or non-drug therapy from 2018 to 2021 were reviewed. Duloxetine was administered gradually, with oral administration of 30 mg in the first week and oral administration of 60 mg from the second week. Visual analogue scale (VAS), 36-Item Short-Form Health Survey questionnaire (SF-36) and EuroQol-5 Dimensions (EQ-5D) questionnaire were used to evaluate the severity of AS at baseline and 1 week, 2 weeks, 1 month, 3 months and 6 months after medication. The occurrence of adverse reactions was recorded.ResultsA total of 63 eligible patients who received duloxetine therapy (n = 35) or non-drug therapy (n = 28) were included. All patients were followed up for 6 months. Significant improvements were found in VAS score compared with baseline in both groups (1.87 ± 0.81 vs 6.61 ± 1.16, 3.18 ± 0.67 vs 6.31 ± 1.40; P < 0.05 for all). Meanwhile, the VAS score of the duloxetine group was significantly better than that of the non-drug therapy group at 1 week, 2 weeks, 1 month, 3 months and 6 months (P < 0.05). Besides, according to 36-Item Short-Form Health Survey questionnaire (SF-36), the PCS score and MCS score are significantly higher than before the treatment in duloxetine group (PCS 62.82 ± 6.04 vs 44.36 ± 7.25, MCS 65.50 ± 4.53 vs 55.55 ± 6.06; P < 0.05 for all). And when we compared variables between the two groups, the PCS score of the duloxetine group was significantly better than that of the non-drug therapy group (P < 0.05), but there was no significant difference in MCS score between the two groups (P > 0.05). What’s more, EQ-5D score had significant improvements in the duloxetine group compared with the non-drug therapy group at 1 week, 2 weeks, 1 month, 3 months and 6 months (P < 0.05).ConclusionOral duloxetine has a better short-term outcome than conventional non-drug therapy in patients with axial symptoms following posterior decompression surgery in the cervical spine.

Assessment of Biomechanical Advantages in Combined Anterior-Posterior Cervical Spine Surgery by Radiological Outcomes: Pedicle Screws over Lateral Mass Screws.

The combined anterior-posterior approach has shown good clinical outcomes for multilevel cervical diseases. This work describes the biomechanical advantage of cervical-pedicle-screw fixation over lateral-mass-screw fixation in combined anterior-posterior cases. Seventy-six patients who received combined cervical surgery from June 2013 to December 2020 were included. The patients were divided into two groups: the lateral-mass-screw group (LMS) and the pedicle-screw group (PPS). Radiological outcomes were assessed with lateral cervical spine X-rays for evaluating sagittal alignment, subsidence, and bone remodeling. At 1 year postoperatively, the numbers of patients whose C2-C7 cervical lordosis was less than 20 degrees decreased by more in the PPS group (p-value = 0.001). The amount of vertical-length change from immediately to 1 year postsurgery was less in the PPS group than in the LMS group (p-value = 0.030). The mean vertebral-body-width change was larger in the PPS group than in the LMS group during 3 months to 1 year postsurgery (p-value = 0.000). In combined anterior-posterior cervical surgery cases, maintenance of cervical lordosis and protection of the vertebral body from subsidence were better with the pedicle-screw fixation. More bone remodeling occurred when using the pedicle-screw fixation method.

Frequency and Associated Factors of Postoperative Wound Dehiscence in Posterior Cervical Spine Surgery.

Wound dehiscence after cervical spine surgery is a well-known complication that can be a challenge for spine surgeons to manage, especially in cases of exposed implants. However, few studies have focused primarily on this phenomenon in cervical spine surgery to date. This investigation sought to determine the frequency of wound dehiscence following posterior cervical spine surgery and identify patient-based risk factors. The medical data of 405 consecutive patients (290 male and 115 female; mean age: 68.9years) who underwent posterior cervical spine surgery were retrospectively examined. Logistic regression models were employed to examine the prevalence, characteristics, and risk factors of postoperative wound dehiscence. We observed that 5.2% of cervical spine surgery patients experienced procedural postoperative wound dehiscence. In comparisons of dehiscence and non-dehiscence groups, significant differences were found for posterior instrumented fusion (81.0% vs. 45.3%; P < 0.01), extended T1 fusion (57.1% vs. 12.8%; P < 0.01), occipitocervical fusion (19.0% vs. 6.2%; P= 0.048), fused intervertebral levels (4.0 vs. 1.5; P < 0.01), surgical time (246minutes vs. 165minutes; P < 0.01), blood loss volume (228mL vs. 148mL; P= 0.023), and dialysis (14.3% vs. 1.8%; P= 0.011). Multivariate analysis identified extended T1 fusion and dialysis to be significantly associated with wound dehiscence with odds ratios of 5.82 and 10.70, respectively. The observed frequency of postoperative wound dehiscence in cervical spine surgery was 5.2%. As extended T1 fusion and dialysis may increase the risk of dehiscence after surgery, patients who display such risk factors may require additional observation and care.

171 Neurosurgical Utilization, Charges, and Reimbursement Following the Affordable Care Act: Trends from 2011 to 2019

INTRODUCTION: An estimated fifty million Americans receive Medicare healthcare coverage, a number expected to increase with an aging population. Despite rising costs, prior studies have established a downward trend in Medicare reimbursement rates adjusted for inflation for commonly billed surgical procedures. However, it is unclear if these trends hold true across all neurosurgical procedures. METHODS: We review the yearly Physician/Supplier Procedure Summary datasets from the Centers for Medicare and Medicaid Services for all procedures billed by neurosurgeons to Medicare Part B between 2011 and 2019. Procedural coding was categorized into cranial, spine, vascular, peripheral nerve, and radiosurgery cases. Weighted averages for charges and reimbursements adjusted for inflation were calculated each year. The ratio of the weighted mean reimbursement to weighted mean charge was calculated as the reimbursement-to-charge ratio (RCR), representing the proportion of charges reimbursed by Medicare. RESULTS: Overall enrollment-adjusted utilization of neurosurgical procedures decreased by 12%, with utilization in the inpatient setting decreasing by 24%. However, we identified a large increase in procedures at ambulatory surgery centers (639%) and in the outpatient setting (80%). Over the study period, inflation-adjusted, weighted mean charges decreased by 4.0% while reimbursement decreased by 4.6%, resulting in a decrease in the RCR of 0.6%. Procedure groups that saw increases in reimbursement included anterior and posterior cervical spine surgery, cranial functional and epilepsy procedures, cranial pain procedures, and endovascular procedures. Ambulatory surgery centers saw the greatest increase in charges and reimbursements. CONCLUSIONS: Overall reimbursement declined over the study period; however, significant variations emerged across procedural categories. We further find a significant shift in utilization and reimbursement for neurosurgical procedures outside of inpatient care settings.

Analgesic efficacy of inter-semispinal fascial plane block in Patients undergoing Cervical Spine Surgery through Posterior Approach: a randomized controlled trial

BackgroundPosterior cervical spine surgery is commonly performed in elderly patients with significant comorbidities and is considered one of the most painful surgical procedures. Accordingly, perioperative pain management during posterior cervical spine surgery represents a unique challenge for anesthesiologists. Inter-semispinal plane block (ISPB) represents a promising analgesic technique for spine surgery through the blockade of the dorsal rami of the cervical spinal nerves. The present study aimed to investigate the analgesic effect of bilateral ISPB as an opioid-sparing nerve block technique for posterior cervical spine surgeries. MethodsThis prospective randomized controlled trial enrolled 52 patients planned for cervical spine surgery via the posterior approach. Patients were randomly assigned to one of two groups in a one-to-one ratio, with 26 patients allocated to the block group (ISPB) who received general anesthesia preceded by bilateral ISP using 20 mL 0.25% bupivacaine on each side and the remaining 26 patients allocated to the control group who received general anesthesia only. The primary outcome was total perioperative opioid consumption through two co-primary outcomes, i.e. total amount of fentanyl administered intraoperatively and total morphine consumption during the first 24 hours postoperatively. The secondary outcomes included intraoperative hemodynamic parameters, assessment of numerical rating scores (NRS) during the first 24 hours postoperatively, time to first rescue analgesia and opioid-related side effects. ResultsA significantly lower amount of intraoperative fentanyl was administered in the ISPB group (median, 175 μg; range, 110–220 μg] compared to the control group [median, 290 μg; range 110–350 μg). Patients in the ISPB group consumed significantly lower doses of morphine (median, 7 mg; range, 5–12 mg]) within the first 24 h postoperatively compared to the control group (median, 12 mg; range, 8–21 mg). In addition, NRS values were significantly lower in the ISPB group during the first 12 h postoperatively than in the control group. No significant differences in mean arterial pressure (MAP) or heart rate (HR) were observed between intraoperative time points in the ISPB group. However, a significant increase in MAP was observed during surgery in the control group (p < 0.001). The incidence of opioid side effects such as nausea, vomiting, and sedation was significantly greater in the control group compared to the ISPB group. ConclusionsInter-semispinal plane block (ISPB) represents an effective analgesic technique and reduces opioid consumption in both intra- and postoperative settings. Moreover, the ISPB could significantly decrease opioid-associated side effects.

Double Hatchet Flap for the Reconstruction of a Posterior Neck Soft Tissue Defect due to Surgical Site Infection After Posterior Cervical Spine Surgery

Double Hatchet Flap for the Reconstruction of a Posterior Neck Soft Tissue Defect due to Surgical Site Infection After Posterior Cervical Spine Surgery

Low-cost 3D Modeling Software for Generating Patient-specific Drill Guide Templates for Cervical Pedicle Screw Insertion: An In Vitro Study

Background. Instrumented posterior cervical spine surgery (IPCSS) can be conducted using screws inserted through the pedicles of the vertebra. A safe IPCSS method uses 3D-printing to produce templates that will serve as drill guides for screw placement.Objectives. This study describes the generation of 3D-printed drill guides using low-cost general purpose 3D modeling software and the comparison of screw insertion accuracy scores against the traditional landmark method and guides created using commercial grade software.Methods. Twenty-five (25) subaxial pedicles of five cadaveric spines were selected and scanned using computedtomography (CT). A digital reconstruction of the five cadaveric spines were created based on the CT DICOM data. A low-cost 3D modeling software, Rhinoceros 3D, was utilized for trajectory planning and generation of a patientspecific drill template using the digital reconstruction. The templates were then fabricated in ABS plastic using a fused deposition modeling (FDM) 3D printer. Insertion of cervical pedicle screws on the cadaveric spines was done by an orthopedic resident using the 3D printed guides. Postoperative CT scans were obtained, and placement accuracy of the screws were scored by two assessors utilizing a four-point rating system. Screws in correct placement were scored Grade 0 while misplaced screws with neurovascular damage were given a score of Grade 3.Results. Accuracy scores for the 3D-printed drill guides were 52% for assessor 1 and 44% for assessor 2. Forassessor 1, screw placement in C3, C6, and C7 received the highest scores. For assessor 2, the highest scores were achieved in C3 and C7. The hybrid method of Bundoc et al. achieved scores of 94% while 3D printed guides utilizing commercial software like Materialise Mimics, Geomagic Freeform, or UG Imageware achieved scores of 80-100%. The traditional landmark method had scores ranging from 12% to 94% depending on the skill of the surgeon.Conclusion. Commercial medical 3D image-based engineering software has high acquisition costs that might be beyond the reach of most institutions. A sub-$1000 general purpose 3D modeling software can be used to create drill templates. Several factors were identified in the design and fabrication of the template that can be addressed to increase accuracy. Trajectory planning can also be improved by automating the process. The researchers recommend further studies in these areas specially in the context of developing 3D printing as a support service for surgical operations in the Philippines.

Ultrasound-Guided Cervical Cervicis Plane Block for Postoperative Pain Control in Cervical Spine Surgery: A Technical Note

New peripheral nerve blocks targeting the dorsal rami are possible for postoperative analgesia in patients undergoing posterior cervical spine surgeries. A cervical cervicis plane (CCeP) block can be performed under ultrasound guidance. We provide a description of this nerve block and ultrasound imaging with relevant sonographic structures. Sonographic imaging from 2 spine surgeries showed CCeP blocks at the upper and lower cervical levels. A CCeP block targets the fascial plane between the semispinalis cervicis muscle and the semispinalis capitis muscle because the CCeP is a continuous plane from occiput to C7, which contains the dorsal rami of the cervical spinal nerves. The deep cervical artery can always be identified under ultrasound in this plane. The CCeP block is an easy nerve block to perform under ultrasound guidance to block the dorsal rami of the cervical nerves. It can provide effective analgesic effects for patients undergoing upper and lower posterior cervical spine surgery without compromising neurophysiology monitoring.

Variation in Prevertebral Soft Tissue Swelling after Staged Combined Multilevel Anterior-Posterior Complex Cervical Spine Surgery: Anterior Then Posterior (AP) versus Posterior Then Anterior-Posterior (PAP) Surgery.

The influence of the sequence of surgery in the development of prevertebral soft tissue swelling (PSTS) in staged combined multilevel anterior-posterior complex spine surgery was examined. This study was conducted as a retrospective study of patients who underwent staged combined multilevel anterior-posterior complex cervical spine surgery from March 2014 to February 2021. Eighty-two patients were identified, of which fifty-seven were included in the final analysis after screening. PSTS was measured from routine serial monitoring lateral cervical radiographs prior to and after surgery for five consecutive days at each cervical level from C2 to C7 in patients who underwent anterior then posterior (AP) and posterior then anterior-posterior (PAP) surgery. The mean PSTS measurements significantly differed from the preoperative to postoperative monitoring days at all cervical levels (p = 0.0000) using repeated measures analysis of variance in both groups. PSTS was significantly greater in PAP than in AP at level C2 on postoperative day (POD) 1 (p = 0.0001). PSTS was more prominent at levels C2-4 during PODs 2-4 for both groups. In staged combined multilevel anterior-posterior complex spine surgery, PSTS is an inevitable complication. Therefore, surgeons should monitor PSTS after surgery when performing anterior-posterior complex cervical spine surgery, especially in the immediate postoperative period after PAP surgery.

Barbed Suture versus Interrupted Suture in Posterior Cervical Spine Surgery: Are They Equivalent?

Posterior cervical spine approaches have been associated with increased rates of wound complications compared to anterior approaches. While barbed suture wound closure for lumbar spine surgery has been shown to be safe and efficacious, there is no literature regarding its use in posterior cervical spine surgery. In a cohort of patients undergoing elective posterior cervical spine surgery, we sought to compare postoperative complication rates between barbed and traditional interrupted suture closure. A retrospective review of demographics, past medical history, and operative and postoperative variables collected from a prospective registry between July 1, 2016, and June 30, 2020 was undertaken. All patients 18 years old and above undergoing elective posterior cervical fusion were included. The primary outcome of interest was wound complications, including surgical site infection (SSI), dehiscence, or hematoma. In addition, numerical rating scale (NRS) neck pain (NP), NRS arm pain (AP), Neck Disability Index (NDI), and operative time were collected. A variety of statistical tests were used to compare the two suture groups. Of 117 patients undergoing posterior cervical fusion, 89 (76%) were closed with interrupted suture and 28 (24%) with barbed suture. The interrupted cohort were more likely to have >1 comorbidity (p<0.001), diabetes mellitus (p=0.013), and coronary artery disease (p=0.002). No difference in postoperative wound complications between interrupted/barbed sutures was observed after univariate (OR 1.07, 95% CI: 0.27-4.25, p=0.927) and multivariable logistic regression analysis (OR 0.77, 95% CI: 0.15-4.00, p=0.756). Univariate logistic regression revealed no differences in achieving minimal clinically important difference (MCID) NRS-NP (OR 0.73, 95% CI: 0.28-1.88, p=0.508) or NRS-AP (OR 0.68, 95% CI: 0.25-1.90, p=0.464) at 3 months between suture groups. The interrupted suture group was less likely to achieve MCID NDI at 3 months (OR 0.29, 95% CI: 0.11-0.80, p=0.016). Barbed suture closure in posterior cervical spine surgery does not lead to higher rates of postoperative wound complications/SSI compared to traditional interrupted fascial closure.

Variation in Cervical Pedicle Morphology: Important Considerations for Posterior Cervical Procedures.

Safe posterior cervical spine surgery requires in-depth understanding of the surgical anatomy and common variations. The cervical pedicle attachment site to the vertebral body (VB) affects the location of exiting nerve roots and warrants preoperative evaluation. The relative site of attachment of the cervical pedicle has not been previously described. To describe the site of the pedicle attachment to the VB in the subaxial cervical spine. Cervical spine computed tomography scans without any structural, degenerative, or traumatic pathology as read by a board-certified neuroradiologist during 2021 were reviewed. Multiplanar reconstructions were created and cross-registered. The pedicle's attachment to the VB was measured relative to the VB height using a novel calculation system. Fifty computed tomography scans met inclusion criteria yielding 600 total pedicles between C3-T1 (100 per level). The average patient age was 26 ± 5.3 years, and 21/50 (42%) were female. 468/600 (78%) pedicles attached in the cranial third of the VB, 132/600 (22%) attached in the middle third, and 0 attached to the caudal third. The highest prevalence of variant anatomy occurred at C3 (36/100 C3 pedicles; 36%). In the subaxial cervical spine, pedicles frequently attach to the top third of the VB, but significant variation is observed. The rate of variation is highest at C3 and decreases linearly with caudal progression down the subaxial cervical spine to T1. This is the first report investigating this morphological phenomenon.

Inter-semispinal plane (ISP) block for postoperative analgesia following cervical spine surgery: A prospective randomized controlled trial

Study objectiveWe evaluated the perioperative analgesic effects of the inter-semispinal plane (ISP) block in patients undergoing posterior cervical spine surgery. DesignProspective, randomized, controlled, double-blinded trial. SettingOperating room and surgical ward. Patients60 patients aged 18–60 years of either gender, ASA I-II, undergoing elective posterior cervical spine surgery. InterventionsPatients were randomly assigned into a control group (general anesthesia only), ISP group received bilateral ultrasound guided ISP block at the level of C5 using 20 ml bupivacaine 0.25% on each side. MeasurementsVisual analog scale (VAS), intraoperative fentanyl and 24 h postoperative pethidine consumptions and time to first rescue analgesic request were documented. Main resultsThe median (quartiles) of 24 h postoperative rescue pethidine consumption was significantly lower in the ISP group [0 (0–46.25) mg] compared to that of the control group [143 (116.75–169.00) mg]; P < 0.001). VAS was significantly lower in the ISP group at 30 min, 1 h, 2 h,4 h, 6 h, 8 h and 12 h postoperative compared to control group (P < 0.05). At 18 and 24 h, VAS was not significantly different between groups. The median (quartiles) of intraoperative fentanyl consumption in the ISP group [0 (0–40.75) μg] was significantly lower compared to that of the control group [63.5 (39.5–90.25) μg]; P < 0.001]. The time to first rescue analgesic administration was significantly longer in the ISP group compared to the control group (P < 0.001). ConclusionBilateral ultrasound-guided ISP block can provide decreased 24 h postoperative analgesic consumption as well as lower pain scores in the first 12 postoperative hours in patients undergoing posterior cervical spine surgery.

Effect of Posture Comfort Care on Patients Undergoing Posterior Cervical Spine Surgery

Effect of Posture Comfort Care on Patients Undergoing Posterior Cervical Spine Surgery

Perioperative analgesic efficacy and safety of erector spinae plane block in posterior cervical spine surgery: a double-blinded, randomized controlled study

<h3>BACKGROUND CONTEXT</h3> Posterior cervical spine surgeries (PCSS) are typically open surgeries and entail significant postoperative pain. Current perioperative pain management in PCSS is reliant on multimodal analgesia. While perioperative epidural anesthetic infusion can be used in lumbar surgeries, this is not an option in the cervical spine. Pre-emptive regional analgesia through erector spinae plane block (ESPB) has shown significant perioperative analgesic benefits in lumbar spine surgeries. There are no such clinical studies in PCSS. <h3>PURPOSE</h3> To assess the safety and efficacy of ultrasound-guided ESPB for perioperative analgesia in PCSS. <h3>STUDY DESIGN</h3> Prospective, randomized controlled, double-blinded study. <h3>PATIENT SAMPLE</h3> This study included 86 patients requiring sub-axial PCSS with or without instrumentation randomized into two groups, those who underwent ESPB with multimodal analgesia (case) and those with only multimodal analgesia (control). <h3>OUTCOME MEASURES</h3> Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization and complications were recorded. <h3>METHODS</h3> After anesthesia and prone position, case patients received ultrasound-guided ESPB at the T1 level using 15ml of 0.25% bupivacaine and 8mg dexamethasone bilaterally while the control patients received only standard postoperative multimodal analgesia. <h3>RESULTS</h3> Each group included 43 patients; the two groups were identical in demographic and surgical profile. The intraoperative opioid consumption (119.53±40.35 vs 308.6±189.78; p<0.001) in mcg), muscle relaxant usage (50.00±0.00 mg vs 59.53±3.75 mg, p<0.001), surgical duration (124.77±26.63/ 156.74±37.01 mins; p<0.01) and intraoperative blood loss (310.47±130.73 ml vs 429.77±148.50 ml; p<0.05) were significantly less in the ESPB group. In the postoperative period, the control group's pain score was significantly higher (p<0.001). The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores also showed significant differences between the case and control groups (p<0.001). The mean time required to ambulate (sitting/walking) was statistically less in cases (15.81±6.15/20.72±4.02 hours) when compared to controls (16.86±6.18/ 23.05±8.88 hours) (p<0.001). <h3>CONCLUSION</h3> In patients undergoing PCSS, ESPB is a safe and effective technique with better outcomes than standard multi-modal analgesia alone, in terms of reduced intraoperative opioid requirements and blood loss, better postoperative analgesia and early mobilization. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

234. Does nasal screening for methicillin resistant Staphylococcus aureus (MRSA) prevent deep surgical site infections for elective cervical spinal fusion?

<h3>BACKGROUND CONTEXT</h3> Preoperative MRSA screening and decolonization has demonstrated success for some orthopaedic subspecialties in prevention of surgical site infections (SSIs). Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. <h3>PURPOSE</h3> The purpose of this study was to determine the relationship between nasal MRSA testing and SSI rates specifically in the setting of primary posterior cervical instrumented spine surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 at two tertiary academic referral centers in an urban setting <h3>OUTCOME MEASURES</h3> Physiologic measures: subfascial presumed infected collection or abscess within 90 days of the index operation. <h3>METHODS</h3> Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 were reviewed for MRSA testing < 90-days before surgery, preoperative mupirocin, perioperative antibiotics and SSI defined as operative incision and drainage (I&D) < 90-days after surgery. Trauma, tumor and infection cases were excluded. Logistic regression modeling was used with SSI the primary outcome and MRSA screening the primary predictor with clinical and demographic factors as covariates. <h3>RESULTS</h3> This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, six patients (50%) grew MSSA from intraoperative cultures, with no cases of MRSA. <h3>CONCLUSIONS</h3> There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram-positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.