In Response to a Letter to the Editor Coury, Josephine R; Sardar, Zeeshan M
Spine (Philadelphia, Pa. 1976),
2022-May-15, 2022-05-15, 20220515, Letnik:
47, Številka:
10
Journal Article
Retrospective, propensity-matched observational study.
To assess the impact of cell saver homologous transfusion on perioperative medical complications in adult patients undergoing spinal deformity ...surgery.
Despite many endorsing its use, many analyses still refute the efficacy of CS on decreasing total perioperative allogenic RBC transfusions, cost efficiency, and its effect on perioperative complications.
Adult patients that underwent spinal deformity surgery at a single center between 2015-2021 were retrospectively reviewed. Patient-specific, operative, radiographic, and 30-day complications/readmission data were collected for further analysis. Two methods were utilized to test our hypothesis: 1) absolute threshold model: two cohorts created among patients who received ≥550 mL of CS intraoperatively and those who received less; 2) adjusted ratio model: two cohorts created dependent on the ratio of CS to EBL. Propensity-score matching (PSM) and various statistical tests were utilized to test the association between CS and perioperative medical complications.
278 patients were included in this analysis with a mean age of 61.3±15.7yrs and 67.6% being female. Using the first method, 73 patients received ≥550 mL of CS and 205 received less. PSM resulted in 28 pairs of patients. 39.3% of patients with ≥550 mL CS required readmission within 30 days compared to 3.57% patients in the <550 mL cohort (P=0.016) despite a nearly identical proportion of patients requiring intraoperative blood transfusions (P>0.9999). Using the second method, 155 patients had CS/EBL< 0.33 and 123 with CS/EBL ≥0.33. 5.16% and 21.9% among patients with CS/EBL<0.33 and CS/EBL≥0.33 respectively, were readmitted by the 30 day marker (P<0.0001).
Our findings indicate that greater CS volumes transfused are associated with higher rates of 30-day readmissions. Thus, surgeons should consider limiting CS volume intraoperatively to 550 mL and when greater volumes are required or preferred, ensuring that the ratio of CS:EBL remains under 0.33.
Expert consensus study.
This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to elective spinal reconstruction.
Currently, no ...guidelines exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. Untreated osteoporosis in spine reconstruction surgery is associated with higher complications and worse outcomes.
A multidisciplinary panel with 18 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Surveys and discussions regarding the current literature were held according to Delphi method until a final set of guidelines was created with over 70% consensus.
Panelists agreed that bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic glucocorticoid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units of the vertebrae can be useful in identifying poor bone health. In the absence of contraindications, anabolic agents are considered first line therapy due to their bone building properties as compared with antiresorptive medications. Medications should be administered preoperatively for at least 2 months and postoperatively for minimum 8 months.
Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also established guidelines on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population.Level of Evidence: 5.
The COVID-19 pandemic has led to a surge in the use of telehealth visits across the country to minimize in-person visits and to limit the spread of COVID-19. To date, no standards or outlines for ...telehealth spine examinations have been detailed and many surgeons simply defer the physical examination when performing telehealth visits. Nevertheless, just as physical examination of the spine is an integral part of live clinical encounters, appropriately modified physical examinations should also be part of virtual visits.
In this study we provide our methodology for guiding providers and patients in efficiently performing telehealth spine examinations.
The study details steps for efficiently performing a physical examination in the telehealth setting. Our written suggestions are supplemented with photographs and video recordings to help streamline the virtual examination.
An effective and efficient spine physical examination can be performed during telehealth visits. Future directions include verifying the findings from our virtual physical examination with in-person examinations.
STUDY DESIGN.Biomechanical spine model. Comparison of stress in the implant and the adjacent cranial segment was done with conventional rigid versus dynamic stabilization system (DS) fixation.
...OBJECTIVE.The aim of this study was to study stress at the proximal end of spinal fixation with a novel DS.
SUMMARY OF BACKGROUND DATA.High stress at the implant bone junction may cause proximal junctional failure (PJF) in adult deformity surgery.
METHODS.Five life-size spine models were instrumented with pedicle screws and a 5.5-mm Titanium rod from T8-S1. The same models were subsequently instrumented with a similar rod and DS between T8-9 pedicle screws. The spine model was loaded with 25 Nm static load cranial to the proximal fixation in six directions. Strains were measured from the proximal screws. Disc pressure was measured from the proximal instrumented segment (T8-9) and cranial adjacent segment (T7-8).
RESULTS.Rigid fixation produced highest strain at T8, followed by T10 then T9. In contrast, DS fixation produced highest strain at T10, followed by T9 then T8. Strain at T8 was significantly less with DS fixation than rigid fixation (P = 0.019). The T10 screw strain was not significantly higher with DS stabilization compared to rigid fixation (P = 0.091). Rigid fixation allowed no load-sharing or pressure rise at T8-9 but an abrupt rise at T7-8. DS system permitted load-sharing and pressure rise in T8-9; the difference compared to rigid fixation was significant in flexion loading (P = 0.04) and similar trend but not significant in extension (P = 0.09). DS system produced a rise in the adjacent segment disc pressure (T7-8), which was smaller than rigid fixation but not significant.
CONCLUSION.Long spinal fixation using rigid rods produces maximum stress at the proximal end screw and increases adjacent disc pressure, possibly leading to PJF. Dynamic stabilization at the cranial end segment may prevent PJF by reducing these factors.Level of EvidenceN/A
The main objective of this review article is to examine the role that nutrition has on adult spinal deformity. The information presented in this review aims to provide spine surgeons with a broad ...overview of screening, assessment, and interventional strategies that may be used for presurgical nutritional optimization.
A comprehensive literature review utilizing three biomedical databases was performed to generate articles of interest. Published articles related to nutrition, adult spinal deformity, spine surgery and orthopaedics were reviewed for the composition of this article. Nutrition may play a role in optimizing postoperative outcomes following adult spinal deformity surgeries, such as limiting delirium, length of stay, blood transfusion, and other medical complications. The use of screening tools, such as the PNI and CONUT score can assess preoperative nutritional status and may provide some utility in evaluating nutrition status in patients undergoing deformity surgery. Balancing both macronutrients and micronutrients, notably, carbohydrates, protein, albumin, and vitamin D can play a role in preoperative optimization.
Adult spinal deformity patients are at an increased risk for malnutrition. These patients should be assessed for nutrition status to prime them for surgery, minimize complications, and maximize their outcomes. However, further studies are needed to determine how nutrition ultimately affects adult spinal deformity patients in the postoperative period and to establish specific nutritional recommendations for this unique population.
Craniopharyngiomas (CPs) are rare, benign tumors derived from Rathke’s pouch, known for their high recurrence rates and associated morbidity and mortality. Despite significant investigation on risk ...factors for recurrence, a lack of consensus persists. Recent research suggests that specific histopathological and molecular characteristics are prognostic for disease progression. In this systematic review, we analyzed and consolidated key features of CPs that contribute to increased recurrence rates. This systematic review was performed in accordance with PRISMA guidelines. A search string was created with the keywords “craniopharyngioma,” “histology,” “histopathology,” “molecular,” and “recurrence.” Literature was collected from 2006 to 2016 on the PubMed/Medline and Web of Science databases. The initial search resulted in 242 papers, examined with inclusion and exclusion criteria. The final review included a total of 37 studies, 36 primary studies covering a total of 1461 patients and 1 previous meta-analysis. Cystic lesions and whorl-like arrays were found to be associated with increased recurrence, while previously considered reactive gliosis and finger-shaped protrusions were not. The genetic elements found to be associated with increased risk of recurrence were Ki-67, Ep-CAM, PTTG-1, survivin, and certain RAR isotypes, as well as the glycoproteins osteonectin and chemokines CXCL12/CXCR4. The effects of VEGF, HIF-1α, and p53, despite extensive study, yielded conflicting results. Certain histopathological and molecular characteristics of CPs provide insight into their pathogenesis, likelihood of recurrence, and potential novel targets for therapy.
In Lenke type 5 and 6 curves, a major thoracolumbar or lumbar curve, the rates of PJK are reported as high as 50%. The purpose of this study was to confirm the rate of PJK, investigate possible risk ...factors, and evaluate surgical complications and the long-term effects of PJK on patient outcomes.
A retrospective review of multicenter data identified 192 with patients with 2 year and 94 with 5-year follow-up. Included patients had a Lenke type 5 or 6 curve and underwent a selective thoracolumbar or lumbar curve fusion. All radiographs preoperatively and postoperatively (1 year, 2 years, and 5 years) were evaluated. Demographic and radiographic data was analyzed as risk factors for PJK using a multi-variate regression. Outcomes scores and complications were compared between groups.
17 patients (8.9%) developed radiographic PJK; 1 at 1 year, 7 at 2 years, and another 9 at 5 years. All 17 patients had an upper instrumented vertebra (UIV) within 3 levels or less caudal of the thoracic kyphosis apex (the most horizontal vertebra on the sagittal); no patient with a UIV 4 or more levels from the thoracic apex (n = 96) developed PJK (X
= 13.03, p < 0.001). In addition, PJA > 8° was found to significantly increase the risk of PJK (p = 0.039). SRS scores were significantly worse for PJK patients at 5 years in the self-image and function (p < 0.01).
In Lenke 5/6 curves, no patient with a UIV 4 or more levels caudal to the thoracic kyphosis apex had PJK up to 5 years postoperatively. PJA greater than 8° was identified as a risk factor for PJK. Patients with radiographic PJK had worse SRS scores 5 years postoperatively.
Purpose
The purpose of this study was to utilize the National Readmission Database (NRD) to determine estimates for complication rates, 90-day readmission rates, and hospital costs associated with ...spinal fusion in pediatric patients with Marfan syndrome.
Methods
The 2012–2015 NRD databases were queried for all pediatric (< 19 years old) patients diagnosed with Marfan syndrome undergoing spinal fusion surgery. The primary outcome variables in this study were index admission complications and 90-day readmissions.
Results
A total of 249 patients with Marfan syndrome underwent spinal fusion surgery between 2012 and 2015 (mean age ± standard deviation at the time of surgery: 14 ± 2.0, 132 (53%) female). 25 (10.1%) were readmitted within 90 days of the index hospital discharge date. Overall, 59.7% of patients experienced at least one complication during the index admission. Unplanned 90-day readmission could be predicted by older age (odds ratio 2.3, 95% confidence interval 1.3–4.2,
p
= 0.006), Medicaid insurance status (56.0, 3.8–820.0,
p
= 0.003), and experiencing an inpatient medical complication (42.9, 4.6–398.7,
p
= 0.001). Patients were readmitted for wound dehiscence (8 patients, 3.2%), nervous system related complications (3 patients, 1.2%), and postoperative infectious related complications (4 patients, 1.6%).
Conclusion
This study is the first to demonstrate on a national level the complications and potential risk factors for 90-day hospital readmission for patients with Marfan syndrome undergoing spinal fusion. Patients with Marfan syndrome undergoing spinal fusion often present with multiple medical comorbidities that must be managed carefully perioperatively to reduce inpatient complications and early hospital readmissions.
Participation in sport is associated with numerous physical and psychological health benefits, but also can have negative consequences, such as career ending injuries, which may have long-term ...effects on mental health. Recent research suggests that involuntary retirement, due to injury, illness, or being cut from a sport, can be particularly detrimental. As such, this review focuses on the impact athletic retirement has on the psychological well-being of collegiate athletes. We provide an algorithm to inform clinical decision making regarding involuntary retirement, as well as recommendations for the development of support programs and educational resources for athletes struggling with career transition. Our aim is that in developing retirement algorithms, support programs, and educational resources for athletes who are retired from sport, we can intervene early thus reducing the potential long-term psychological burden they may experience.