Thoracolumbar Spine Surgery Research Articles

118. Reduction of facial pressure injuries after prone positioning in spine surgery: a multidisciplinary approach

<h3>BACKGROUND CONTEXT</h3> Spine surgery requiring prone positioning subjects the skin to friction, shear, moisture, and pressure. These factors increase the risk of facial pressure injuries. Prone positioning for thoracolumbar spine surgery allows the surgeon access to the dorsal spine and is the most common positioning method. Facial pressure injury must be carefully considered during prone positioning with pressure sore rates reported between 5%-66%. These injuries may result in longer hospital stays, patient morbidity and increased health care costs. Literature addressing facial pressure injury prevention strategies during prone spinal surgery is limited. <h3>PURPOSE</h3> The purpose of this study was to assess the efficacy of a multidisciplinary-derived pressure ulcer prevention bundle intended to prevent facial pressure injuries during prone spinal surgery. <h3>STUDY DESIGN/SETTING</h3> Review of pre- and postintervention consecutive cases. <h3>PATIENT SAMPLE</h3> Patients undergoing prone spinal surgery between November 2018 and August 2020. <h3>OUTCOME MEASURES</h3> Total case volume, pre- and postintervention monthly case volumes, total and monthly facial pressure ulcer rates. <h3>Methods</h3> A multidisciplinary group at a quaternary academic medical center developed a plan to address facial pressure injuries. The group reviewed institutional baseline facial pressure injury data and a literature review was conducted for previously studied prevention techniques. A pressure injury prevention bundle was developed including the following elements: (1) prophylactic placement of silicone foam dressings on the chin and forehead, (2) use of a contoured foam head positioner, and (3) application of a skin barrier wipe prior to securing the endotracheal tube with tape. A preoperative baseline skin assessment was performed. Postoperative pressure injury staging was assessed on our inpatient unit postoperatively. Monthly ulcer rates were calculated by dividing the number of pressure injuries by the monthly case volume. Differences in monthly ulcer rates were evaluated between intervention groups. A cross-tabulation of intervention group versus presence/absence of an ulcer was performed and an odds ratio of ulcer occurrence was calculated. <h3>Results</h3> Intervention compliance was greater than 90% within 1 week of bundle implementation. There were 22 total months of data reviewed with 2,331 total prone spinal procedures. Mean cases per month for the entire period was 106.0±23 (range 20-127). There were no significant differences in mean cases per month between intervention groups (P>0.05). There were 17 total facial ulcers encountered across all 2,331 cases (0.73%). There were 15/992 (1.50%) total ulcers in the preintervention group and only 2/1339 (0.15%) ulcers in the postintervention group. Monthly ulcer rates were calculated and displayed a non-normal distribution. The median monthly ulcer rate was significantly lower in the postintervention vs the preintervention group (0.000% vs 0.820%, P=0.021). Cross-tabulation of the intervention group vs presence/absence of an ulcer revealed a 10.1x higher odds of sustaining an ulcer in the preintervention group (odds ratio 10.1; 95% confidence interval 2.3-44.2). <h3>Conclusions</h3> Utilizing a standardized pressure injury prevention bundle during prone spinal surgery reduces the occurrence of facial pressure injuries. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Accuracy assessment of pedicle screw insertion with patient specific 3D\u2011printed guides through superimpose CT-analysis in thoracolumbar spinal deformity surgery

PurposeIn order to avoid pedicle screw misplacement in posterior spinal deformity surgery, patient specific 3D‑printed guides can be used. An accuracy assessment of pedicle screw insertion can be obtained by superimposing CT-scan images from a preoperative plan over those of the postoperative result. The aim of this study is to report on the accuracy of drill guide assisted pedicle screw placement in thoracolumbar spinal deformity surgery by means of a superimpose CT-analysis.MethodsConcomitant with the clinical introduction of a new technique for drill guide assisted pedicle screw placement, the accuracy of pedicle screw insertion was analyzed in the first patients treated with this technique by using superimpose CT-analysis. Deviation from the planned ideal intrapedicular screw trajectory was classified according to the Gertzbein scale.ResultsSuperimpose CT-analysis of 99 pedicle screws in 5 patients was performed. The mean linear deviation was 0.92 mm, the mean angular deviation was 2.92° with respect to the preoperatively planned pedicle screw trajectories. According to the Gertzbein scale, 100% of screws were found to be positioned within the “safe zone”.ConclusionThe evaluated patient specific 3D-printed guide technology was demonstrated to constitute a safe and accurate tool for precise pedicle screw insertion in spinal deformity surgeries. Superimpose CT-analysis showed a 100% accuracy of pedicle screw placement without any violation of the pedicle wall or other relevant structures. We recommend a superimpose CT-analysis for the first consecutive patients when introducing new technologies into daily clinical practice, such as intraoperative imaging, navigation or robotics.

A Simple Versatile Technique to Retrieve Polyaxial Tulip-head Spinal Pedicle Screws Following Failed Pedicle Screw Removal: A Technical Note With Analysis of Efficacy and Outcomes

Introduction: With increase in the number of thoracolumbar spine surgeries using pedicle screw instrumentation, there is a proportionate increase in the number of revision surgeries requiring implant removal. Lack of standardization in manufacturing spinal pedicle screws has led to diverse variations in their design and dimensions. Removal of polyaxial pedicle screws becomes extremely difficult when there is a mismatch between their tulip-head and the screwdriver. With the rapidly changing concepts and designs of spinal pedicle screws this problem may arise when the appropriate pedicle screw instrumentation is out of production. There may be a need for special instruments or an array of screwdrivers of various dimensions/designs to overcome this problem. We describe a simple yet versatile technique to remove polyaxial tulip-head pedicle screws using commonly available instruments in the spinal instrumentation set. Materials and Methods: Polyaxial screws were removed after converting them into monoblock screws using the appropriate set-screw screwdriver, a 25-mm long 5.5 mm rod, and a counter torque wrench. Results: Using this technique we have successfully removed 167 screws in 53 revision surgeries [instrumented fusions for lumbar degenerative diseases (n=21), thoracolumbar fractures (n=15), and scoliosis (n=17)]. No failed retrievals or complications like pedicle breach or neurological deficit were observed. Discussion: The described technique is simple to execute, effective, quick, and safe. It is versatile and can be used to remove polyaxial pedicle screws of any design in the thoracic and lumbar spine using the commonly available instruments in the routine spinal instrumentation set (appropriate set-screw screwdriver, a 25-mm long 5.5 mm rod, a counter torque wrench).

2021 Canadian Spine Society Abstracts.

# Abstract 45. Determining clinically important improvement following surgery for degenerative conditions of the spine: analysis of the Canadian Spine Outcomes and Research Network (CSORN) Registry {#article-title-2} There is significant variability in clinically important improvement (CII)

Comparison of Propofol and Ketofol on Transcranial Motor Evoked Potentials in Patients Undergoing Thoracolumbar Spine Surgery.

Study DesignThis was a double-blind randomized study.PurposeThe primary purpose was to compare the effects of propofol and ketofol on amplitudes and latencies of transcranial motor evoked potentials (TcMEPs) during thoracolumbar spine surgery. In addition, intraoperative hemodynamics and muscle power were compared.Overview of LiteraturePropofol is commonly used during intraoperative TcMEP monitoring. However, propofol inhibits TcMEP amplitudes and causes hypotension in a dose-dependent fashion.MethodsAmplitude and latency of TcMEPs were recorded bilaterally from the abductor pollicis brevis (APB) and abductor hallucis (AH) muscles in 38 adult American Society of Anesthesiologists I and II patients undergoing thoracolumbar spine surgery. Baseline recordings of TcMEPs in both groups were recorded under propofol infusion. Group X patients then received propofol and fentanyl (1 mcg/kg/hr), and group Y patients received ketofol and fentanyl (1 mcg/kg/hr). Bispectral index was maintained at 40–60 in both groups. Amplitude and latency were recorded at 30 minutes intervals for 2 hours.ResultsPropofol caused no significant changes in amplitude and latency in any muscle. In contrast, amplitude increased significantly at all time points in the bilateral APB muscles and 60, 90, and 120 minutes in the left AH muscle without changes in latency in response to ketofol. When the two groups were compared, ketofol induced significantly higher amplitudes at 60, 90, and 120 minutes in the (left) APB, at all time points in the (right) APB, and at 120 minutes in both AH muscles, compared with propofol. Blood pressures were lower and fluid and vasopressor requirements were higher in group X. Muscle power was similar between the two groups.ConclusionsKetofol facilitates TcMEP amplitudes without affecting latency. Use of ketofol resulted in a better and more stable hemodynamic profile than did use of propofol.

Web-Based Calculator Predicts Surgical-Site Infection After Thoracolumbar Spine Surgery

Surgical-site infection (SSI) after spine surgery leads to increased length of stay, reoperation, and worse patient quality of life. We sought to develop a web-based calculator that computes an individual's risk of a wound infection following thoracolumbar spine surgery. We performed a retrospective review of consecutive patients undergoing elective degenerative thoracolumbar spine surgery at a tertiary-care institution between January 2016 and December 2018. Patients who developed SSI requiring reoperation were identified. Regression analysis was performed and model performance was assessed using receiver operating curve analysis to derive an area under the curve. Bootstrapping was performed to check for overfitting, and a Hosmer-Lemeshow test was employed to evaluate goodness-of-fit and model calibration. In total, 1259 patients were identified; 73% were index operations. The overall infection rate was 2.7%, and significant predictors of SSI included female sex (odds ratio [OR] 3.0), greater body mass index (OR 1.1), active smoking (OR 2.8), worse American Society of Anesthesiologists physical status (OR 2.1), and greater surgical invasiveness (OR 1.1). The prediction model had an optimism-corrected area under the curve of 0.81. A web-based calculator was created: https://jhuspine2.shinyapps.io/Wound_Infection_Calculator/. In this pilot study, we developed a model and simple web-based calculator to predict a patient's individualized risk of SSI after thoracolumbar spine surgery. This tool has a predictive accuracy of 83%. Through further multi-institutional validation studies, this tool has the potential to alert both patients and providers of an individual's SSI risk to improve informed consent, mitigate risk factors, and ultimately drive down rates of SSIs.

A randomised trial of bilateral erector spinae plane block vs. no block for thoracolumbar decompressive spinal surgery.

Major spinal surgery causes significant postoperative pain. We tested the efficacy and safety of bilateral erector spinae block on quality of recovery and pain after thoracolumbar decompression. We randomly allocated 60 adults to standard care or erector spinae block. Erector spinae block improved the mean (SD) quality of recovery-15 score at 24 postoperative hours, from 119 (20) to 132 (14), an increase (95%CI) of 13 (4-22), p=0.0044. Median (IQR [range]) comprehensive complication index was 1 (0-3 [0-5]) in the control group vs. 1 (0-1 [0-4]) after block, p=0.4. Erector spinae block reduced mean (SD) area under the curve pain during the first 24 postoperative hours: at rest, from 78 (49) to 50 (39), p=0.018; and on sitting, from 125 (51) to 91 (50), p=0.009. The cumulative mean (SD) oxycodone consumption to 24h was 27 (18) mg in the control group and 19 (26) mg after block, p=0.20. In conclusion, erector spinae block improved recovery and reduced pain for 24h after thoracolumbar decompression surgery.

Surgical treatment of senile spinal diseases

Advanced age is a well-known risk factor for spinal surgery-related complications. Decisions on spine surgery in the elderly are difficult due to higher morbidity and mortality than in younger age groups. In addition, spine surgery is a kind of ‘functional surgery’ which does not directly affect the survival of patients. In recent years, individualized risk stratification has gained ground over simple chronological age-based assessment. In the elderly, frailty is one of the strongest factors which affect surgical outcomes for both cervical and thoracolumbar spine surgery, regardless of the surgical technique used. Spine surgery in the elderly have worse surgical outcomes in terms of duration of hospital stay, degree of functional recovery, and complication, readmission, and mortality rates. However, the benefit of spine surgery even in the very-elderly is substantial. In conclusion, surgical decisions should be made based on both personalized risk assessment and benefits of surgery. Recent advanced surgical techniques such as minimally invasive surgical techniques and robotics assistance are likely to be helpful in minimizing surgical complications. Therefore, advanced age in itself should not be considered as a contraindication for spine surgery.

Efficacy of the erector spinae plane (ESP) block for quality of recovery in posterior thoraco-lumbar spinal decompression surgery: study protocol for a randomised controlled trial

BackgroundSpinal surgery can be associated with significant postoperative pain. Erector spinae plane (ESP) block is a new regional anaesthesia technique, which promises effective postoperative analgesia compared with systemically administered opioids, but has never been evaluated in terms of patient-centred outcomes such as quality of recovery and overall morbidity after major thoraco-lumbar spinal surgery.MethodsWe are conducting a prospective, randomised, double-blind trial in two hospitals in the Republic of Ireland. The sample size will be 50 patients (25 in the intervention group and 25 in the control group). Randomisation will be done using computer-generated concealed envelopes. Both patients and investigators collecting outcome data will be masked to group allocation. Participants will be male or female, aged 18 years and over, capable of providing informed consent and ASA grade I–IV. Patients scheduled to undergo posterior approach thoraco-lumbar decompression surgery involving 2 or more levels will be recruited to the study. Participants randomised to the intervention arm of the study will receive bilateral ultrasound-guided ESP block totalling 40 ml 0.25% levo-bupivcaine (20 ml each side), post induction of general anaesthesia and before surgical incision. The control group will not receive an ESP block. Both groups will receive the same standardised analgesic protocol both intra- and postoperatively. The primary outcome will be the quality of recovery at 24 h postoperatively as determined by the QoR-15 score. This score is determined by a questionnaire which measures patient responses to 15 subjective parameters, each response graded on a scale from 0 to 10. The maximum score achievable is 150 with a potential minimum score of 0. Higher scores indicate a higher quality of recovery experience.Secondary outcomes will include area under the curve (AUC) of VRS pain versus time at rest and on movement up to 24 h postoperatively, 24 h opioid consumption, time to first analgesia in recovery, length of stay (LOS), incidence and severity of postoperative complications as measured by the Comprehensive Complication Index (CCI) score.DiscussionTo the best of our knowledge, this will be the first randomised control trial to examine the efficacy and safety of the ESP block in terms of patient-centred outcomes in the setting of major spinal surgery. The QoR-15 is a validated means of assessing the quality of recovery after surgery and gives a more holistic assessment of the recovery experience from the patient’s point of view.Trial registrationThis trial is pre-registered on ClinicalTrials.gov reference number NCT04370951. Registered on 30 April 2020. All items from the World Health Organisation Trial Registration Data Set have been included.

Comparison of Plastic Surgeon and Spine Surgeon Closure in Revision Short Segment Thoracolumbar Spinal Fusions.

Retrospective cohort analysis. To compare outcomes of plastic versus spine surgeon wound closure in revision 1 to 4 level thoracolumbar fusions. Plastic surgeons perform layered musculocutaneous flap closures in high-risk spine patients such as revision posterior spinal fusion and complex deformity correction surgeries. Few studies have assessed outcomes of revision fusion performed with plastic surgical closures, particularly in nondeformity thoracolumbar spinal surgery. A retrospective review of 1 to 4 level revision thoracolumbar fusion performed by Orthopedic or Neurosurgical spine surgeons. Patient charts were reviewed for demographics and perioperative outcomes. Patients were divided into two cohorts: wound closures performed by spine surgeons and those closed by plastic surgeons. Outcomes were analyzed before and after propensity score match for prior levels fused, iliac fixation, and levels fused at index surgery. Significance was set at P < 0.05. Three hundred fifty-seven (87.3%) spine surgeon (SS) and 52 (12.7%) plastic surgeon (PS) closures were identified. PS group had significantly higher number of levels fused at index (PS 2.7 ± 1.0 vs. SS 1.8 ± 0.9, P < 0.001) and at prior surgeries (PS 1.8 ± 1.2 vs. SS 1.0 ± 0.9, P < 0.001), and rate of iliac instrumentation (PS 17.3% vs. SS 2.8%, P < 0.001). Plastics closure was an independent risk factor for length of stay > 5 days (odds ratio 2.3) and postoperative seroma formation (odds ratio 7.8). After propensity score match, PS had higher rates of seromas (PS 36.5% vs. SS 3.8%, P < 0.001). There were no differences between PS and SS groups in surgical outcomes, perioperative complication, surgical site infection, seroma requiring aspiration, or return to operating room at all time points until follow-up (P > 0.05 for all). Plastic spinal closure for 1 to 4 level revision posterior thoracolumbar fusions had no advantage in reducing wound complications over spine surgeon closure but increased postoperative seroma formation.Level of Evidence: 4.

Sarcopenia predicts perioperative adverse events following complex revision surgery for the thoracolumbar spine

Background ContextSarcopenia measured by psoas muscle index (PMI) has been shown to predict perioperative mortality and adverse events (AEs) after various surgical procedures. However, this relationship has not been studied in complex revision thoracolumbar spine surgery. PurposeThis study aimed to determine the relationship between sarcopenia and perioperative AEs among patients undergoing complex revision thoracolumbar spine surgery. Study DesignRetrospective cohort study Patient SampleA retrospective analysis was performed at a single institution between May 2016 and February 2020 of patients undergoing complex revision thoracolumbar spine surgery by three board certified fellowship-trained orthopaedic spine surgeons. Outcome MeasuresPerioperative adverse events including postoperative anemia requiring transfusion, cardiac complication, sepsis, wound complication, delirium, intra-operative dural tear, acute kidney injury, pneumonia, urinary tract infection, urinary retention, epidural hematoma, and deep vein thrombosis. Secondary outcome measures were 30-day readmission rates, 30-day re-operation rates, in-hospital mortality rates, discharge disposition, and postoperative length of stay (LOS). MethodsSarcopenia was analyzed using PMI, calculated at the L3 vertebral body measured on preoperative magnetic resonance imaging (MRI) or computed tomography (CT) normalized to height2 (mm2/m2). Receiver operating characteristic (ROC) curve analysis and Youden index were used to determine gender-specific PMI cut-off values for predicting perioperative AEs. Sarcopenia was defined as PMI below the cut-off values. Complex revision surgery was defined as Spine Surgical Invasiveness Index >10. ResultsA total of 114 consecutive patients were included in the study. ROC curve analysis demonstrated PMI <500 mm2/m2 for males and <412 mm2/m2 for females as predictors for perioperative AEs. 49 patients were in the sarcopenia cohort and 65 patients in the nonsarcopenia cohort. The sarcopenia group had higher overall perioperative AEs (75.5% vs 27.7%, p<.001) and individual AEs including: postoperative anemia requiring transfusion, wound complication, delirium, acute kidney injury, pneumonia, urinary tract infection, and deep vein thrombosis. The sarcopenia group had higher 30-day reoperation rate (14.3% vs 3.1%, p=.037), 30-day readmission rate (16.3% vs 3.1%, p=.018), rate of discharge to a facility (83.7% vs 50.8%, p<.001), and longer length of stay (LOS) (7.3±4.2 days vs 5.6±3.5 days, p=.023). ConclusionsSarcopenia measured by PMI is associated with higher perioperative AEs, 30-day readmission rates, 30-day reoperation rates, rate of discharge to a facility, and longer LOS among patients undergoing complex revision thoracolumbar spine surgery.

Deep Surgical-Site Infection Following Thoracolumbar Instrumented Spinal Surgery: The Experience of 25 Years.

Deep surgical-site infection following thoracolumbar instrumented spinal surgery (DSITIS) is a major complication in spine surgery and its impact on long-term morbidity and mortality is yet to be determined. This article describes the characteristics and evolution of DSITIS in our center over a period of 25 years. This single-center, retrospective cohort study included patients diagnosed with DSITIS between January 1992 and December 2016 and with a minimum follow-up after infection diagnosis of 1 year. The Infectious Diseases Society of America criteria and/or Centers for Disease Control and Prevention criteria were used to define DSITIS. Patient data (epidemiological and health status), surgical data, infection characteristics and presentation, isolated microorganisms, required surgical debridements, implant removal, and major complications linked to infection were evaluated. A total of 174 patients (106 females) were included in the analysis. Mean follow-up after infection diagnosis was 40 months (56 patients with over 5 years follow-up). Adolescent idiopathic scoliosis, adult deformity, and degenerative lumbar stenosis were the most frequent etiologies for primary surgery. Presentation of infection was considered early (0-3 months since first surgery) in 59.2% of the cases, delayed (3-24 months) in 11.5%, and late (more than 24 months) in 29.3%. All patients were treated by surgical debridement. More than 1 surgical debridement was necessary in 20.7% of cases. Implants were removed in 46.6% of the patients (72.83% in the first surgical debridement). Most frequently isolated microorganisms were Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes. Major complications appeared in 14.3% of the patients, and over 80% of them required major surgeries to resolve those complications. Late DSITIS is more frequent than previously reported. In DSITIS culprits, Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes predominate. DSITIS produce a high rate of major complications that usually require major surgery for treatment. 3.

Biomechanical comparison of semirigid junctional fixation techniques to prevent proximal junctional failure after thoracolumbar adult spinal deformity correction

BACKGROUND CONTEXTAdult spinal deformity patients treated operatively by long-segment instrumented spinal fusion are prone to develop proximal junctional kyphosis (PJK) and failure (PJF). A gradual transition in range of motion (ROM) at the proximal end of spinal instrumentation may reduce the incidence of PJK and PJF, however, previously evaluated techniques have not directly been compared. PURPOSETo determine the biomechanical characteristics of five different posterior spinal instrumentation techniques to achieve semirigid junctional fixation, or “topping-off,” between the rigid pedicle screw fixation (PSF) and the proximal uninstrumented spine. STUDY DESIGNBiomechanical cadaveric study. METHODSSeven fresh-frozen human cadaveric spine segments (T8–L3) were subjected to ex vivo pure moment loading in flexion-extension, lateral bending and axial rotation up to 5 Nm. The native condition, three-level PSF (T11–L2), PSF with supplemental transverse process hooks at T10 (TPH), and two sublaminar taping techniques (knotted and clamped) as one- (T10) or two-level (T9, T10) semirigid junctional fixation techniques were compared. The ROM and neutral zone (NZ) of the segments were normalized to the native condition. The linearity of the transition zones over three or four segments was determined through linear regression analysis. RESULTSAll techniques achieved a significantly reduced ROM at T10-T11 in flexion-extension and axial rotation relative to the PSF condition. Additionally, both two-level sublaminar taping techniques (CT2, KT2) had a significantly reduced ROM at T9-T10. One-level clamped sublaminar tape (CT1) had a significantly lower ROM and NZ compared with one-level knotted sublaminar tape (KT1) at T10-T11. Linear regression analysis showed the highest linear correlation between ROM and vertebral level for TPH and the lowest linear correlation for CT2. CONCLUSIONSAll studied semirigid junctional fixation techniques significantly reduced the ROM at the junctional levels and thus provide a more gradual transition than pedicle screws. TPH achieves the most linear transition over three vertebrae, whereas KT2 achieves that over four vertebrae. In contrast, CT2 effectively is a one-level semirigid junctional fixation technique with a shift in the upper rigid fixation level. Clamped sublaminar tape reduces the NZ greatly, whereas knotted sublaminar tape and TPH maintain a more physiologic NZ. Clinical validation is ultimately required to translate the biomechanics of various semirigid junctional fixation techniques into the clinical goal of reducing the incidence of proximal junctional kyphosis and failure. CLINICAL SIGNIFICANCEThe direct biomechanical comparison of multiple instrumentation techniques that aim to reduce the incidence of PJK after thoracolumbar spinal fusion surgery provides a basis upon which clinical studies could be designed. Furthermore, the data provided in this study can be used to further analyze the biomechanical effects of the studied techniques using finite element models to better predict their post-operative effectiveness.

Risk factors for developing delirium after thoracolumbar spinal surgery

Risk factors for developing delirium after thoracolumbar spinal surgery

Intraoperative image guidance for cervical spine surgery.

Intraoperative image-guidance in spinal surgery has been influenced by various technological developments in imaging science since the early 1990s. The technology has evolved from simple fluoroscopic-based guidance to state-of-art intraoperative computed tomography (iCT)-based navigation systems. Although the intraoperative navigation is more commonly used in thoracolumbar spine surgery, this newer imaging platform has rapidly gained popularity in cervical approaches. The purpose of this manuscript is to address the applications of advanced image-guidance in cervical spine surgery and to describe the use of intraoperative neuro-navigation in surgical planning and execution. In this review, we aim to cover the following surgical techniques: anterior cervical approaches, atlanto-axial fixation, subaxial instrumentation, percutaneous interfacet cage implantation as well as minimally invasive posterior cervical foraminotomy (PCF) and unilateral laminotomy for bilateral decompression. The currently available data suggested that the use of 3D navigation significantly reduces the screw malposition, operative time, mean blood loss, radiation exposure, and complication rates in comparison to the conventional fluoroscopic-guidance. With the advancements in technology and surgical techniques, 3D navigation has potential to replace conventional fluoroscopy completely.

Predictors of transfusion in adults undergoing elective posterior thoracolumbar spinal fusion: a retrospective case series

Background: Posterior thoracolumbar spinal fusion surgery can be associated with significant blood loss. The purpose of this study was to investigate suspected risk factors of blood transfusion in posterior thoracolumbar fusion patients and determine if blood transfusion had a negative impact on the outcomes for those patients after surgery. Methods: All adults undergoing posterior thoracolumbar spine fusion in our institution from May 2015 to May 2018 were included. Data collected included demographic data as well as body mass index (BMI), preoperative hemoglobin, American Society of Anesthesiologists (ASA) classification, change in hemoglobin, estimated blood loss, incidence of blood transfusion, number of units transfused, number of levels fused, length of stay, and readmission within 30 days. The data were analyzed to correlate these variables with the frequency of blood transfusion and to assess the association of adverse outcomes after blood transfusion. Results: This study included 125 patients. Six patients (4.8%) required readmission within the first 30 days after discharge. Length of stay averaged 8.4 days (range 3 to 74). Eighteen patients (14.4%) required blood transfusion perioperatively. When multiple variables were analyzed for any correlations, the number of levels fused, age, and BMI had statistically significant correlations with the need for blood transfusion (P&lt;0.005). None of the other factors showed any statistically significant correlation. Patients who required blood transfusion were more likely to stay in the hospital more than 7 days (P&lt;0.005). Conclusions: Patients undergoing posterior thoracolumbar fusion are more likely to require blood transfusion if they are older, have a higher BMI, or have a multilevel fusion. Receiving a blood transfusion is associated with increased complication rates. Level of Evidence: Level IV.

Web-based Calculator Predicts Surgical Site Infection After Thoracolumbar Spine Surgery

Web-based Calculator Predicts Surgical Site Infection After Thoracolumbar Spine Surgery

Adverse effects of surgeon performance after a night shift on the incidence of perioperative complications in elective thoracolumbar spine surgery

BackgroundDecline in cognitive function after night shift has been well described. However, in the field of spine surgery, the effect of surgeons’ sleeplessness on patient outcome is unclear. The purpose of this study was to investigate whether the risk of perioperative complications in elective thoracolumbar spine surgery could be higher if the surgeon had been on a night shift prior to the day of surgery. MethodsWe performed a retrospective review of patients who underwent elective posterior thoracolumbar spine surgery, as indicated in medical records, between March 2015 and September 2018. In total, 1189 patients were included and divided into two groups: the post-nighttime (n = 110) and control groups (n = 1079). A post-nighttime case was defined when the operating surgeon was on nighttime duty on the previous night, and other cases were defined as controls. We evaluated the incidence of perioperative complications (surgical site infection, postoperative hematoma, postoperative paralysis, nerve root injury, and dural tear) in both groups. ResultsOverall, we found no significant difference in the major or minor perioperative complication rates between the two groups, but according to the type of complication, the incidence rate of dural tear tended to be higher in the post-nighttime group (13.6% vs 8.2%, P = 0.074). Multivariate analysis showed that post-nighttime status was an independent risk factor of dural tear (adjusted odds ratio, 2.02; 95% confidence interval [CI], 1.10–3.70; P = 0.023). After stratification by surgical complexity, post-nighttime status was an independent risk factor of dural tear only in the surgeries of 3 levels or more (adjusted odds ratio, 2.81; 95% CI, 1.18–6.67; P = 0.019). ConclusionsPost-nighttime status was generally not a risk factor of perioperative complications in elective posterior thoracolumbar spine surgeries, but was an independent risk factor of dural tear, especially in complex cases.

Bilateral paraspinal muscle flap closure technique for reduction of wound complications from posterior thoracolumbar spinal fusion: results of a series of 716 patients.

Wound complications such as surgical site infection (SSI) and dehiscence are among the most common complications of thoracolumbar spinal fusion surgery and are particularly prevalent in patients with risk factors such as obesity, diabetes, smoking, malignancy, and multilevel and/or revision procedures. A specialized wound closure technique with muscle flap mobilization, which reduces tension at the wound edges and increases the bulk of vascularized tissue in the midline, can be employed as a salvage procedure to manage wound complications. The authors evaluated the effectiveness of prophylactic muscle flap closure for reducing SSI in patients with risk factors for wound complications who undergo thoracolumbar fusion surgery. A retrospective review of thoracolumbar fusion surgeries over a 15-year period was conducted in a group of patients at risk for wound complications to compare outcomes of patients who underwent prophylactic muscle flap closure with outcomes of patients who had conventional wound closure. Patients were selected for specialized closure based upon a protocol adopted during the study period. Patients were excluded if they had active infections or underwent tubular retractor-mediated decompression and did not have open surgery with a midline incision. Of 716 patients, wound closure was performed in 455 patients using conventional closure and in 261 using muscle flap closure. There were no significant differences in the ratios of male to female patients, with 251 men and 204 women with conventional closure and 133 men and 128 women with muscle flap closure, but the muscle flap patients were older than the conventional closure patients, with mean ages of 65.2 versus 62.9 years (p < 0.005). Indications for surgery in the muscle flap group and the conventional group, respectively, were metastatic disease in 44 (17%) and 32 (7%) patients; trauma in 10 (4%) and 14 (3%) patients; and degenerative disease, including spondylolisthesis, spondylolysis, and stenosis, in 207 (79%) and 409 (90%) patients, with more muscle flap patients having metastasis (p < 0.00001). Patients having muscle flaps had significantly higher rates of diabetes, smoking, and revision surgery, and a higher mean BMI and number of operative levels. The serum albumin level was slightly lower in the muscle flap group (p < 0.047). The wound infection rate was significantly lower in the muscle flap group (0.4%) compared with the conventional closure group (2.4%) (p < 0.033). Prophylactic muscle flap closure significantly lowers the rate of SSI in patients undergoing thoracolumbar spinal fusion who harbor risk factors for wound complications, with even fewer infections seen than in a group of patients without similar risk factors. Given the success of the technique, consideration of wider use for thoracolumbar fusion cases, even those without a high level of complexity, may be warranted.

Delayed Ejaculation After Lumbar Spine Surgery: A Claims Database Analysis.

Study Design:Retrospective cohort.Objectives:Delayed ejaculation (DE) is a distressing condition characterized by a notable delay in ejaculation or complete inability to achieve ejaculation, and there are no existing reports of DE following lumbar spine surgery. Inspired by our institutional experience, we sought to assess national rates of DE following surgery of the lumbar spine.Methods:We queried the Optum De-identified Clinformatics Database for adult men undergoing surgery of the lumbar spine between 2003 and 2017. The primary outcome was the development of DE within 2 years of surgery. Multivariable logistic regression was performed to identify factors associated with the development of DE.Results:We identified 117 918 men who underwent 162 646 lumbar spine surgeries, including anterior lumbar interbody fusion (ALIF), posterior lumbar fusion (PLF), and more. The overall incidence of DE was 0.09%, with the highest rate among ALIF surgeries at 0.13%. In multivariable analysis, the odds of developing DE did not vary between anterior/lateral lumbar interbody fusion, PLF, and other spine surgeries. A history of tobacco smoking (OR = 1.47, 95% CI 1.00-2.16, P = .05) and obesity (OR = 1.56, 95% CI 1.00-2.44, P = .05) were associated with development of DE.Conclusions:DE is a rare but distressing complication of thoracolumbar spine surgery, and patients should be queried for relevant symptoms at postoperative visits when indicated.