Spine procedures are associated with high rates of blood loss which can result in a greater need for transfusions. Repeated exposure to blood products is associated with risks and adverse reactions ...such as transfusion-related acute lung injury, fluid shifting, and infections. With the higher number of spine procedures and the increasing open surgery times associated with difficult procedures, excessive blood loss has become more prevalent. Perioperative methods have been established to combat the excessive blood loss and decrease the need for blood products. Preoperatively, anemia and coagulopathy screening is standard at least 4 weeks before elective procedures. Erythropoietin, iron loading or transfusions are used to decrease preoperative anemia, a predisposing factor for blood loss. Autologous predonation of blood has been shown to be ineffective and decreases preoperative hemoglobin levels. Intraoperatively, antifibrinolytics such as tranexamic acid and aminocaproic acid are used to decrease blood loss. In addition, fibrinogen concentrates, thromboelastometry, acute normovolemic hemodilution, controlled hypotension, and temperature regulation are some of the techniques used to decrease blood loss and the need for transfusions. Postoperatively, fibrin sealants, shed blood salvage, and erythropoietin or intravenous iron are used in management of blood loss, especially in instances when the patient refuses blood products.
In Pakistan, power outages have become frequent over the past two decades, due to a continuing energy crisis. Reliance on machines for thermal comfort of buildings has led to high energy demands of ...the increasing population. The negative impacts of artificial environments have, also, diminished the sense of place, biophilia and cultural values. Moreover, globalization has standardized the built environments, causing a lack of regional identity and an absence of climate sensitivity in design. Keeping all these issues in focus, this article re-examines the fundamental aspects of traditional architecture and aims to stimulate architects and designers to create sustainable and life-enriching designs, which are appropriate for contemporary times. In this research, the first two levels of Deep Beauty (functional and typological) are used, as a conceptual framework for sustainable design, to analyse a representative of a traditional courtyard house. In conjunction with the theoretical underpinnings of the Deep Beauty framework, the analysis utilizes photographs, drawings, and diagrams to support the arguments. The research shows that the traditional courtyard house possesses numerous attributes of sustainable design, which can be incorporated into contemporary house design.
Adult spinal deformity (ASD) is an important problem to consider in the elderly. Although studies have examined the complications of ASD surgery and have compared functional and radiographic results ...of primary surgery versus revision, no studies have compared the costs of primary procedures with revisions. We assessed the in-hospital costs of these 2 surgery types in patients with ASD.
The PearlDiver Database, a database of Medicare records, was used in this study. Mutually exclusive groups of patients undergoing primary or revision surgery were identified. Patients in each group were queried for age, sex, and comorbidities. Thirty-day readmission rates, 30-day and 90-day complication rates, and postoperative costs of care were assessed with multivariate analysis. For analyses, significance was set at P < 0.001.
The average reimbursement of the primary surgery cohort was $57,078 ± $30,767. Reimbursement of revision surgery cohort was $52,999 ± $27,658. The adjusted difference in average costs between the 2 groups is $4773 ± $1069 (P < 0.001). The 30-day and 90-day adjusted difference in cost of care when sustaining any of the major medical complications in primary surgery versus revision surgery was insignificant.
Patients undergoing primary and revision corrective procedures for ASD have similar readmission rates, lengths of stays, and complication rates. Our data showed a higher cost of primary surgery compared with revision surgery, although costs of sustaining postoperative complications were similar. This finding supports the decision to perform revision procedures in patients with ASD when indicated because neither outcomes nor costs are a hindrance to correction.
Abstract Objective Little data is available concerning clinical outcomes in patients with Parkinson disease who undergo elective thoracolumbar spine fusion surgery. The goal of this study is to ...elucidate complication and revision rates following posterior thoracolumbar fusion surgery in Parkinson disease patients with a focus on how Parkinson disease modifies these rates. Methods The PearlDiver database (2005-2012) was queried for patients who underwent posterior approach thoracolumbar fusion from 2006 to 2011. Cohorts of patients with a previous diagnosis of Parkinson disease (n=4,816) and without (n=280,702) were compared. Multivariate analysis that included various comorbidities and demographics was utilized to calculate effects of Parkinson disease on development of postoperative infection and major medical complications within 90 days and revision surgery within 1 year. For analyses, significance was set at p < 0.001. Results Major medical complications were observed in 545 patients (11.3%) for ninety days following the index procedure. Post-operative infection was noted in 91 patients (1.9%) within ninety days, while revision surgeries were performed in 250 patients (5.2%) within one year. Multivariate analysis revealed that Parkinson disease was significantly associated with an increased risk for medical complications (adjusted OR: 1.22, 95% CI: 1.11 – 1.34, p < 0.001) and revision surgery (adjusted OR: 1.70, 95% CI: 1.49 – 1.93, p < 0.001), but not postoperative infection (p = 0.02). Conclusions Parkinson disease patients are more likely to require revision surgery and have higher rates of adverse medical events post-operatively. Parkinson disease patients should be appropriately selected to ensure favorable clinical outcomes.
Abstract Bone morphogenic proteins (BMPs) are signaling proteins which promote osteogenesis and facilitate fusion of bone in lumbar spinal procedures. Research is targeted towards the benefits of use ...in lumbar fusions and the use of BMPs in anterior lumbar interbody fusions (ALIFs) is FDA approved. However, fewer studies have detailed adverse effects and use in cervical fusion procedures, which is currently considered “off-label”. BMP use in cervical fusion procedures may improve radiographic outcomes and functionality of patients in the long term, though overall rates of serious medical complications from use are increased in the early postoperative period. Complications of BMP use include: ectopic bone formation, inflammation, swelling and seroma. These adverse outcomes can be much more fatal in the cervical spine as compared to their occurrence in the lumbar spine. Because of the adverse effects, low doses of BMPs have been recommended, reducing risks of complications while still aiding in the fusion process. Additionally, BMPs have not been approved for use in pediatric populations, though off-label use in fusion patients with paucity of autologous bone may prove advantageous. Patients who are considered high risk for pseudoarthrosis may also be candidates for the use of BMPs in cervical procedures. Physicians and patients should be aware of the potential adverse outcomes of using BMPs in cervical fusion procedures and weigh the risks and benefits before deciding on use.
Retrospective database review.
To understand medical complication rates, readmission rates, costs, and discharge dispositions in anterior lumbar interbody fusion (ALIFs) versus transforaminal lumbar ...interbody fusions (TLIFs)/posterior lumbar interbody fusions (PLIFs) for lumbar degenerative disease.
Indications for ALIFs versus PLIFs can vary, though benefits of anterior approach surgery include full access to the anterior column and ability to place fusion devices.
The PearlDiver Database of Medicare records was utilized for this retrospective database review. A study group consisting solely of ALIF procedure patients was selected for. Similarly, a TLIF/PLIF group was selected for. Both groups were queried for comorbidities, 30 and 90-day complication and readmission rates. Additionally, discharge dispositions, and in-hospital/30-day/90-day Medicare reimbursements were determined.
At both 30 and 90 days postoperatively odds of ileus, wound infection, and lower extremity deep venous thrombosis were significantly increased in the ALIF. However, unadjusted rates and adjusted odds of transfusion or dural tear were significantly decreased in the ALIF patients. Odds of 30-day readmission were 4 times higher in ALIF patients. Additionally, 30 and 90-day total costs of care in ALIF patients were significantly increased by approximately $4800 and $5800 respectively, as compared with patients undergoing TLIF/PLIF.
Despite higher initial routine discharge rates, readmissions and costs of postoperative care were significantly increased in ALIF procedures. It is necessary to evaluate etiology of degenerative pathology as ALIFs are successful solutions to anterior translational instability and anterior disc slippage, but may not have the best long-term outcomes and may not be cost-effective compared with a TLIF/PLIF. In light of our data, it is important to assess the risks and benefits of the varying approaches, and the necessity to access the anterior column, when deciding on surgical technique to treat lumbar degenerative pathology.
4.
To identify independent risk factors, additional length of stay, and additional cost associated with postoperative ileus following anterior lumbar interbody fusion in elderly patients.
The PearlDiver ...Patient Records Database was queried for all Medicare patients ≥65 years of age undergoing 1- or 2-level primary elective anterior lumbar interbody fusion from 2005 to 2014. Independent risk factors, additional length of stay, and additional cost associated with postoperative ileus were evaluated with multivariate analysis.
There were 13,139 patients identified, and 642 patients experienced postoperative ileus within 3 days after surgery. Multivariate analysis identified perioperative fluid or electrolyte imbalance (odds ratio = 4.03; 95% confidence interval, 3.37–4.80; P < 0.001) and male sex (odds ratio = 1.72; 95% confidence interval, 1.48–2.00; P < 0.001) as independent risk factors for ileus. Multivariate analysis associated postoperative ileus with additional length of stay of 2.83 ± 0.11 days (P < 0.001) and additional cost of $2,349 ± $419 (P < 0.001).
Patients with perioperative fluid and electrolyte imbalances were 4 times as likely to experience postoperative ileus. Fluid balance and electrolyte levels should be carefully monitored during the perioperative period in patients undergoing anterior lumbar interbody fusion as a potential means to reduce the incidence of postoperative ileus and the additional length of stay and cost burden associated with this complication.
•Postoperative ileus after ALIF was associated with additional LOS of 2.83 days and additional cost of $2349.•Male sex and perioperative fluid and electrolyte imbalances were independent risk factors for postoperative ileus.•Patients with perioperative fluid and electrolyte imbalances were 4 times as likely to experience postoperative ileus.•Fluid balance and electrolytes should be carefully monitored during the perioperative period in patients undergoing ALIF.
Surgical management of complex spinal reconstructions remains a clinical challenge, as pseudoarthrosis with subsequent rod breakage can occur. Increased rod density in the form of “satellite” or ...“outrigger” rods have been described; however, rod-fracture above or below satellite rods persist and can result in dissociation of the construct, loss of correction, and recurrence of deformity. The use of four distinct and mechanically independent rods (dual construct) reduces this concern. Since the original case description in 2006, there have been no other studies that use the dual construct for the surgical management of complex spinal reconstructions.
The purpose of this study is to review the long-term experience and surgical technique using the dual construct, and to present our complications, rod fracture rates, and outcomes for the surgical management of complex spinal reconstructions.
This study used a surgical technique with case series outcomes.
Patients were from a single-institute who underwent dual construct between 2010 and 2014 and who were available for 2-year follow-up.
Radiographic and functional outcomes, complications, rod fracture rates, and revision surgery rates were the outcome measures.
A retrospective review was conducted from a single institution between 2010 and 2014, with a subsequent 2-year follow-up period. Extensive review of patients' medical record, radiographs, and advanced imaging where available was performed. Medical record was evaluated for patient demographics, surgical procedure, and complications. Radiographic measurements included presence or absence of implant failure and proximal junctional kyphosis or distal junctional kyphosis.
A total of 36 patients underwent surgical reconstruction. The average estimated blood loss was 1,856 cc (range, 400–4,000 cc). The average length of stay was 7.3 days (range, 4–22 days). Clinical follow-up reported 21 patients (58.3%) with no or minimal pain. There were six deaths during the follow-up unrelated to the index procedure. Radiographic follow-up revealed three patients (8.3%) with rod fracture; one patient with one rod fracture, and two patients with two rod fractures. No patient had three or all four rod fractures. There were no screw fractures. None of the patients with rod fractures required revision surgery.
The biggest advantage of the dual construct is that rod breakage, although uncommon, is typically minimal, or asymptomatic, and more importantly does not result in loss of alignment, and therefore has not required revision surgery. The dual construct approach is a safe alternative to traditional two-rod constructs, with encouraging outcomes at follow-up.
STUDY DESIGN.A retrospective database analysis among Medicare beneficiaries
OBJECTIVE.The aim of this study was to determine the effect of chronic steroid use and chronic methicillin-resistant ...Staphylococcus aureus (MRSA) infection on rates of surgical site infection (SSI) and mortality in patients 65 years of age and older who were treated with lumbar spine fusion.
SUMMARY OF BACKGROUND DATA.Systemic immunosuppression and infection focus elsewhere in the body are considered risk factors for SSI. Chronic steroid use and previous MRSA infection have been associated with an increased risk of SSI in some surgical procedures, but their impact on the risk of infection and mortality after lumbar fusion surgery has not been studied in detail.
METHODS.The PearlDiver insurance-based database (2005–2012) was queried to identify 360,005 patients over 65 years of age who had undergone lumbar spine fusion. Of these patients, those who had been taking oral glucocorticoids chronically and those with a history of chronic MRSA infection were identified. The rates of SSI and mortality in these two cohorts were compared with an age- and risk-factor matched control cohort and odds ratio (OR) was calculated.
RESULTS.Chronic oral steroid use was associated with a significantly increased risk of 1-year mortality OR = 2.06, 95% confidence interval (95% CI) 1.13–3.78, P = 0.018 and significantly increased risk of SSI at 90 days (OR = 1.74, 95% CI 1.33–1.92, P < 0.001) and 1 year (OR = 1.88, 95% CI 1.41–2.01, P < 0.001). Chronic MRSA infection was associated with a significantly increased risk of SSI at 90 days (OR = 6.99, 95% CI 5.61–9.91, P < 0.001) and 1 year (OR = 24.0, 95%CI 22.20–28.46, P < 0.001) but did not significantly impact mortality.
CONCLUSION.Patients over 65 years of age who are on chronic oral steroids or have a history of chronic MRSA infection are at a significantly increased risk of SSI following lumbar spine fusion.Level of Evidence3
Long-term narcotic use has risks and potentially life-threatening opioid-related side effects. Extended narcotic use in patients undergoing discectomy raises concerns of other underlying causes of ...pain or overprescription and/or abuse. The goal of this study was to determine which factors have an effect on active narcotic prescription >3 months after discectomy.
The PearlDiver Database was used in this study. Patients 30–55 years old undergoing discectomy without fusions were queried for active narcotic drug prescription occurring >30 days and >3 months after original surgery. Medical co-diagnoses were independently analyzed for effects on long-term active narcotic prescriptions. Prior narcotic use was defined by use within 4 months before surgery.
Of 1321 patients undergoing discectomy, 621 had actively prescribed narcotics >3 months after surgery. Preoperative narcotic use had the largest effect on odds of postoperative prescription (odds ratio OR = 3.4). Medical comorbidities increasing odds of long-term narcotic prescriptions included migraines (OR = 1.4), diabetes mellitus (OR = 1.4), depression (OR = 1.6), and smoking (OR = 1.9).
Narcotic abuse is a serious problem rooted in overprescription of these drugs, which has ultimately led to much more caution in prescribing among physicians. Because pain management and drug prescription must be balanced, identifying patients who may be susceptible to narcotic overprescription is important. Patients with co-diagnoses increasing odds of long-term narcotic prescriptions would benefit from early and continual postsurgical follow-up to ensure accurate pain management and to determine if narcotic prescriptions are justly warranted in the later postoperative period.
•Long-term narcotic use after discectomy raises concern for alternative causes of pain or drug abuse.•Patients with certain co-diagnoses experienced increased odds of long-term narcotic use following discectomy.•Obesity did not affect odds of narcotic use beyond 3 months after discectomy.•This information can be used to counsel patients before surgery and to identify patients who may require close follow-up.
