Routine Spinal Surgery Research Articles

Mesenchymal Stem Cells Isolated from Paediatric Paravertebral Adipose Tissue Show Strong Osteogenic Potential.

Mesenchymal stem cells (MSCs) represent the basis of novel clinical concepts in cellular therapy and tissue regeneration. Therefore, the isolation of MSCs from various tissues has become an important endeavour for stem cell biobanking and the development of regenerative therapies. Paravertebral adipose tissue is readily exposed during spinal procedures in children and could be a viable source of stem cells for therapeutic applications. Here, we describe the first case of MSCs isolated from paravertebral adipose tissue (PV-ADMSCs), obtained during a routine spinal surgery on a child. Using quantitative real-time PCR and flow cytometry, we show that PV-ADMSCs have different levels of stem marker expression compared to the MSCs from other sources while having the highest proliferation rate. Furthermore, we evaluate the multipotency of PV-ADMSCs by the three-lineage (adipogenic, osteogenic and chondrogenic) differentiation and compare it to the multipotency of MSCs from other sources. It was found that the PV-ADMSCs have a strong osteogenic potential in particular. Taken together, our data indicate that PV-ADMSCs meet the criteria for successful cell therapy, defined by the International Society for Cellular Therapy (ISCT), and thus, could provide a source of MSCs that is relatively easy to isolate and expand in culture. Due to their strong osteogenic potential, these cells provide a promising basis, especially for orthopaedic applications.

Does Prophylactic Administration of TXA Reduce Mean Operative Time and Postoperative Blood Loss in Posterior Approach Lumbar Spinal Fusion Surgery Performed for Degenerative Spinal Disease?

This is a level III retrospective cohort study. To investigate association between prophylactic tranexamic acid (TXA) administration before 1 and 2-level posterior lumbar interbody fusion operations and perioperative blood loss (including intraoperative blood loss and postoperative drain output), mean operative time, postoperative transfusion, and postoperative venous thromboembolic events. TXA is a systemic antifibrinolytic that competitively inhibits lysine binding sites on plasminogen, reversibly blocking its binding to fibrin and impeding fibrinolysis and clot degradation. TXA's role in routine spinal surgery remains poorly described. Most spinal literature on perioperative TXA administration has considered operations performed for major adult and pediatric spinal deformity. Two groups, a study group composed of 75 patients who underwent 1 and 2-level posterior lumbar interbody fusion operations for degenerative indications who received TXA before the start of the procedure, and a control group composed of 75 patients who underwent similar surgeries for the same indications and did not receive TXA preoperatively, were retrospectively enrolled. Demographic, laboratory, and surgical data were collected and analyzed. No statistically significant differences were found between groups with respect to surgery type, home anticoagulation, postoperative anticoagulation, preoperative hemoglobin and hematocrit, estimated intraoperative blood loss, postoperative day 2 drain output, postoperative day 3 drain output, rate of postoperative transfusion, and rate of postoperative thromboembolic events. Statistically significant reductions were noted in the TXA group with regards to postoperative day 1 drain output (P<0.0041), total postoperative drain output (P=0.027), and mean surgical time (P<0.0001). In the present study, perioperative TXA administration was associated with reduced postoperative drain output and surgical time. Further higher-level studies are required to investigate the safety and utility of TXA's routine use in 1 and 2-level posterior lumbar fusion operations performed for degenerative indications.

Knotted urethral catheter: an unusual complication in adults

Knotting of feeding tubes or urinary catheters has been reported as a rare complication in paediatrics when draining the bladder. This is caused by inserting thin flexible tubes too far...

Postoperative infections of the spine

Postoperative infections are an unfortunate and potentially devastating complication of routine spinal surgery. While primary prevention is the key, global management consists of perioperative strategies for risk reduction, accurate diagnosis, and careful decision-making for medical versus surgical treatment. When revision surgery is necessary, debridement with or without retention of implants (if present) in concert with administration of antimicrobial agents is indicated. The following section discusses these issues as well as specific operative techniques including adjunctive local antibiotic usage, vacuum-assisted closure, closed suction drainage, and soft tissue reconstruction for more complex wounds.

Evolving Compartment Syndrome Detected by Loss of Somatosensory- and Motor-evoked Potential Signals During Cervical Spine Surgery

Neurologic injury is a rare but devastating complication of spinal surgery that can result in mild sensory to severe motor deficits. Surgeons increasingly use electrophysiological spinal cord function monitoring, including somatosensory- and motor-evoked potentials, intraoperatively to provide information about spinal cord function, aid in surgical decision making, improve outcomes, and reduce complication rates. By providing real-time information about the dorsal and anterior motor column function, somatosensory- and motor-evoked potentials signals allow surgeons to reverse noticeable changes and avoid devastating neurologic injuries. Recognizing changes in baseline signals in the setting of known risk factors enables surgeons to correct these risks. This article describes a case in which somatosensory- and motor-evoked potentials monitoring were lost in the setting of an impending right forearm compartment syndrome during 2-level anterior cervical diskectomy and fusion. To the authors' knowledge, this is the first reported case of spinal cord monitoring detecting an evolving compartment syndrome during cervical spine surgery. The early changes in signal intensity enabled the surgeon to search for a cause and remedy the situation by removing the infiltrated intravenous line. Without the observed changes in somatosensory- and motor-evoked potentials, it is likely that the compartment syndrome may have progressed to the point of requiring fasciotomy to prevent lasting neuromuscular injury. This article describes a new cause of changes in electrophysiological monitoring and further displays the usefulness of somatosensory- and motor-evoked potentials monitoring during even routine spinal surgery.

Generic waiting lists for routine spinal surgery

National Health Service Hospitals are under pressure to reduce waiting lists within the constraints of a limited infrastructure. We implemented two systems to reduce waiting times for elective non-complex spinal surgery. The first of these was the introduction of managed generic waiting lists for both initial outpatient appointments and subsequent surgery. Thereafter, the MRI booking system was integrated with outpatient review appointments. Times from referral to first outpatient appointment and from scan to outpatient review and time on waiting list for surgery were analysed before and after implementation of these changes. Despite constant unit capacity there was a global decrease in waiting times. Before introduction of the generic waiting list, 37% of listed patients waited for more than 9 months; this figure fell to zero. Time from scan to outpatient review was 185 days before integration, 30 days after. Changes of this sort demand a quorum of consultants who will accept each others' recommendations. The generic waiting list will have impact only when there are large disparities in waiting times for different consultants. Targets are met at the expense of continuity of care.

Generic waiting lists for routine spinal surgery.

National Health Service Hospitals are under pressure to reduce waiting lists within the constraints of a limited infrastructure. We implemented two systems to reduce waiting times for elective non-complex spinal surgery. The first of these was the introduction of managed generic waiting lists for both initial outpatient appointments and subsequent surgery. Thereafter, the MRI booking system was integrated with outpatient review appointments. Times from referral to first outpatient appointment and from scan to outpatient review and time on waiting list for surgery were analysed before and after implementation of these changes. Despite constant unit capacity there was a global decrease in waiting times. Before introduction of the generic waiting list, 37% of listed patients waited for more than 9 months; this figure fell to zero. Time from scan to outpatient review was 185 days before integration, 30 days after. Changes of this sort demand a quorum of consultants who will accept each others' recommendations. The generic waiting list will have impact only when there are large disparities in waiting times for different consultants. Targets are met at the expense of continuity of care.

Direct cerebral vasodilatory effects of sevoflurane and isoflurane.

The effect of volatile anesthetics on cerebral blood flow depends on the balance between the indirect vasoconstrictive action secondary to flow-metabolism coupling and the agent's intrinsic vasodilatory action. This study compared the direct cerebral vasodilatory actions of 0.5 and 1.5 minimum alveolar concentration (MAC) sevoflurane and isoflurane during an propofol-induced isoelectric electroencephalogram. Twenty patients aged 20-62 yr with American Society of Anesthesiologists physical status I or II requiring general anesthesia for routine spinal surgery were recruited. In addition to routine monitoring, a transcranial Doppler ultrasound was used to measure blood flow velocity in the middle cerebral artery, and an electroencephalograph to measure brain electrical activity. Anesthesia was induced with propofol 2.5 mg/kg, fentanyl 2 micro/g/kg, and atracurium 0.5 mg/kg, and a propofol infusion was used to achieve electroencephalographic isoelectricity. End-tidal carbon dioxide, blood pressure, and temperature were maintained constant throughout the study period. Cerebral blood flow velocity, mean blood pressure, and heart rate were recorded after 20 min of isoelectric encephalogram. Patients were then assigned to receive either age-adjusted 0.5 MAC (0.8-1%) or 1.5 MAC (2.4-3%) end-tidal sevoflurane; or age-adjusted 0.5 MAC (0.5-0.7%) or 1.5 MAC (1.5-2%) end-tidal isoflurane. After 15 min of unchanged end-tidal concentration, the variables were measured again. The concentration of the inhalational agent was increased or decreased as appropriate, and all measurements were repeated again. All measurements were performed before the start of surgery. An infusion of 0.01% phenylephrine was used as necessary to maintain mean arterial pressure at baseline levels. Although both agents increased blood flow velocity in the middle cerebral artery at 0.5 and 1.5 MAC, this increase was significantly less during sevoflurane anesthesia (4+/-3 and 17+/-3% at 0.5 and 1.5 MAC sevoflurane; 19+/-3 and 72+/-9% at 0.5 and 1.5 MAC isoflurane [mean +/- SD]; P<0.05). All patients required phenylephrine (100-300 microg) to maintain mean arterial pressure within 20% of baseline during 1.5 MAC anesthesia. In common with other volatile anesthetic agents, sevoflurane has an intrinsic dose-dependent cerebral vasodilatory effect. However, this effect is less than that of isoflurane.