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Sharifi G, Paraandavaji E, Mousavi Nasab MM, Hajikarimloo B, Mohammadi E, Pourghazi M. Delayed-onset recurrent spinal epidural hematoma: A case of unusual postoperative complications in a high-risk patient. INTERDISCIPLINARY NEUROSURGERY 2025; 40:102038. [DOI: 10.1016/j.inat.2025.102038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2025] Open
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Chang CY, Chen HT, Yang FS, Hsu CC, Yin TC, Wu RW, Chen SH, Lu ML. Optimal timing for decompression in post-operative epidural hematoma: a retrospective analysis and treatment flowchart. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2025; 34:1505-1512. [PMID: 40047892 DOI: 10.1007/s00586-025-08775-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Revised: 10/28/2024] [Accepted: 02/27/2025] [Indexed: 04/16/2025]
Abstract
PURPOSE Post-operative epidural hematoma is a rare but devastating complication of spine surgery. The importance of timely decompression for preserving neurologic function has been repeatedly stressed, but the acceptable timescale for decompression remains controversial. The purpose of this study was to propose a diagnosis and treatment flowchart for post-operative epidural hematoma. METHODS A retrospective chart review from the registry database of 93 patients who underwent epidural hematoma evacuation from January 2007 to December 2021 was conducted. Statistical analysis was performed to assess the correlation between recovery of neurologic function and time to decompression. RESULTS Sixty patients were included in the statistical analysis. Time to decompression was significantly associated with recovery of neurologic function in the overall analysis and in subgroup analysis of cases of acute post-operative epidural hematoma. As the time to decompression decreases, there is an improvement in the odds of neurological function recovery. Moreover, a critical threshold for the time to decompression was determined to be < 6 h. CONCLUSION Timely decompression is strongly suggested for post-operative epidural hematoma. We proposed a flowchart as a tool to guide treatment of post-operative epidural hematoma. For acute post-operative epidural hematoma, decompression within 6 h promises better neurologic recovery, and decompression should not be delayed by imaging examination. For delayed post-operative epidural hematoma, decompression should be performed as soon as possible after a definite diagnosis is reached.
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Affiliation(s)
- Cheh-Yung Chang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan
- Department of Orthopaedic Surgery, Kaohsiung Municipal Fong Shan Hospital - Under the management of Chang Gung Medical Foundation, Kaohsiung City, Taiwan
| | - Hou-Tsung Chen
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan
| | - Fu-Shine Yang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan
| | - Chieh-Cheng Hsu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan
- Department of Orthopaedic Surgery, Kaohsiung Municipal Fong Shan Hospital - Under the management of Chang Gung Medical Foundation, Kaohsiung City, Taiwan
| | - Tsung-Cheng Yin
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan
| | - Re-Wen Wu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan
| | - Sung-Hsiung Chen
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan
| | - Meng-Ling Lu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan.
- Department of Orthopaedic Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung City, Taiwan.
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Anaspure OS, Baumann AN, Fiorentino A, Sidloski K, Hinton JB, Conry KT, Preston G, Hoffmann JC. The Effectiveness and Safety of Chemoprophylaxis in the Surgical Management of Spinal Trauma: A Systematic Review and Meta-Analysis. World Neurosurg 2025; 194:123554. [PMID: 39674320 DOI: 10.1016/j.wneu.2024.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Revised: 12/02/2024] [Accepted: 12/03/2024] [Indexed: 12/16/2024]
Abstract
OBJECTIVE Chemoprophylaxis for preventing venous thromboembolism (VTE) in spine surgery is debated due to effectiveness and safety concerns. Guidelines lack consensus on regimens and timing for spinal trauma. We examined chemoprophylaxis in spine trauma surgery to further guide surgeon decision-making. METHODS This systematic review and meta-analysis searched PubMed, CINAHL, MEDLINE, and Web of Science until March 14, 2024, for articles on chemoprophylaxis and spine trauma surgery. A random-effects meta-analysis compared VTE events by chemoprophylaxis use and timing. RESULTS Fourteen observational studies (n = 13,754 patients; mean age: 41.74 ± 9.09 years; mean follow-up: 76.98 ± 213.45 days) were included. The total VTE prevalence was 6.28% (425/6771). VTE prevalence was 4.08% (143/3502) with chemoprophylaxis and 8.62% (282/3269) without. Meta-analysis showed no significant VTE difference between patients with (n = 516; 3.88%) and without chemoprophylaxis (n = 528; 5.68%) (P = 0.119, relative risk [RR]: 1.03; 95% confidence interval [CI]: [0.99, 1.08]). No significant difference in postoperative bleeding was found between patients with (3.01% of 722 patients) and without chemoprophylaxis (5.74% of 766 patients) (P = 0.549, RR: 1.00; 95% CI: [0.99, 1.02]). Comparing early (n = 305; 5.90%) and late chemoprophylaxis (n = 271; 8.86%) showed no significant VTE difference (P = 0.289, RR: 1.06; 95% CI: [0.96, 1.14]). Postoperative bleeding was also not significantly different between early (n = 305; no complications) and late chemoprophylaxis (2.58%) (P = 0.328, RR: 1.14; 95% CI: [0.88, 1.48]). CONCLUSIONS No significant association was found between chemoprophylaxis use or timing and VTE risk after spine trauma surgery, though this finding may be underpowered. Chemoprophylaxis did not appear to significantly increase postoperative bleeding.
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Affiliation(s)
- Omkar S Anaspure
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Anthony N Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA; Department of Rehabilitation Services, University Hospitals, Cleveland, Ohio, USA
| | - Andrew Fiorentino
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Katelyn Sidloski
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Jared B Hinton
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Keegan T Conry
- Department of Orthopedics, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Gordon Preston
- Department of Orthopedics, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Jacob C Hoffmann
- Department of Orthopedics, Cleveland Clinic Akron General, Akron, Ohio, USA
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Pivazyan G, Kim AJ, Aguilera CJ, Khan Z, Bryant JP, Stewart JJ, Voyadzis JM, Nair MN, Felbaum DR, Sandhu FA. Incidence, Risk Factors, and Functional Outcomes of Symptomatic Postoperative Spinal Epidural Hematoma: A Case-Control Study. World Neurosurg 2025; 193:851-860. [PMID: 39455001 DOI: 10.1016/j.wneu.2024.10.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 10/15/2024] [Accepted: 10/16/2024] [Indexed: 10/28/2024]
Abstract
BACKGROUND Symptomatic postoperative spinal epidural hematomas (PEDHs) are rare complications, with significant implications on patients' functional outcomes. Strategies for PEDH prevention are poorly understood. This study sought to evaluate preoperative and intraoperative variables predicting the risk of PEDH and patients' functional outcomes after PEDH evacuation. METHODS This is a single institution study of all patients with PEDH requiring reoperation and matched controls over a 6-year period. The incidence of PEDH was calculated by region and operative technique. The preoperative and intraoperative parameters of 40 patients and 40 matched controls were compared. RESULTS A total of 5941 spine surgeries and 40 patients with symptomatic PEDH requiring reoperation were identified (0.67% overall incidence). The highest incidence of PEDH was observed after minimally invasive lumbar laminectomies. Higher preoperative diastolic blood pressure was a risk factor for PEDH. Of the 17 PEDH patients in whom a drain was placed at the time of index surgery, 8 patients (47%) still had the drain in place at the time of diagnosis of PEDH. Among the posterior index approaches, 18 patients (51.43%) (1 cervicothoracic and 17 lumbar) did not develop paresis at the time of PEDH diagnosis. Seventeen patients (48.57%) (9 cervicothoracic and 8 lumbar) developed paresis. Ten of the patients with paresis had complete resolution of motor weakness, whereas 7 never achieved complete resolution. CONCLUSIONS Although the incidence of PEDH was less than 1%, nearly half of the patients developed motor weakness as a presenting symptom and a third of the patients never had resolution of the weakness.
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Affiliation(s)
- Gnel Pivazyan
- Department of Neurosurgery, MedStar Georgetown University Hospital, Seattle, Washington, USA.
| | - Alexander J Kim
- School of Medicine, Georgetown University, Washington, District of Columbia, USA
| | - Carlos J Aguilera
- School of Medicine, Georgetown University, Washington, District of Columbia, USA
| | - Ziam Khan
- School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Jean-Paul Bryant
- Department of Neurosurgery, MedStar Georgetown University Hospital, Seattle, Washington, USA
| | - Jeffrey J Stewart
- Department of Neurosurgery, MedStar Georgetown University Hospital, Seattle, Washington, USA
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, MedStar Georgetown University Hospital, Seattle, Washington, USA
| | - Mani N Nair
- Department of Neurosurgery, MedStar Georgetown University Hospital, Seattle, Washington, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Seattle, Washington, USA
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Seattle, Washington, USA
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Smeijers S, Collignon F, Costa E, Desmedt K, Pouleau HB, Vantomme N, Cailliau B, Depreitere B, Peuskens D. Consensus statement by the Belgian Society of Neurosurgery and literature review on the diagnosis and management of postoperative spinal epidural hematoma. BRAIN & SPINE 2024; 4:103904. [PMID: 39377047 PMCID: PMC11456791 DOI: 10.1016/j.bas.2024.103904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 07/14/2024] [Accepted: 09/11/2024] [Indexed: 10/09/2024]
Abstract
Introduction Postoperative spinal epidural hematoma (SEH) is a potentially devastating complication for patients and caregivers, and a leading cause for litigation in spine surgery. This article provides a literature review and the consensus statement of the Belgian Society of Neurosurgery (BSN) on the management of postoperative SEH. Research question Can we implement current evidence to establish a framework on the management of postoperative SEH? Material and methods Based on a Pubmed search, abstracts were screened for topics covering incidence, pathophysiology, risk factors, surveillance, diagnosis, treatment, and outcome. Relevant topics are presented in a narrative review format, followed by a consensus statement of the BSN with emphasis on rapid diagnosis and treatment. Results Symptomatic SEH is rare (0.3-1%) and can have an insidious onset with rapid progression to neurological deficits. Recurring risk factors are coagulation deficiencies and multilevel surgery. The protective effect of a postoperative drainage system is uncertain, and early thrombo-embolic prophylaxis does not increase the risk of SEH. Prognosis is dependent on residual neurological function and critically, on the time to reintervention. There is a need for structured neurological observation formats after spine surgery. Discussion and conclusion Symptomatic SEH after surgery is an unpredictable and severe complication requiring rapid action to maximize outcomes. The BSN proposes three nuclear terms central to SEH management, converging on a triple 'S': 1) high level of suspicion 2) speed of diagnosis and 3) immediate surgery. All spine centers can benefit from an institutional protocol in which SEH should be treated as an emergency.
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Affiliation(s)
| | - Frederic Collignon
- Department of Neurosurgery, Centre Hospitalier Interrégional Edith Cavell, Brussels, Belgium
| | - Emmanuel Costa
- Department of Neurosurgery, Clinique Notre Dame de Grace, Charleroi, Belgium
| | - Kris Desmedt
- Department of Neurosurgery, Ziekenhuizen Gasthuiszusters Antwerpen, Antwerpen, Belgium
| | | | | | | | | | - Dieter Peuskens
- Department of Neurosurgery, Ziekenuis Oost-Limburg, Genk, Belgium
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Strony JT, Sabbagh RS, Ahn J, Du JY, Ahn UM, Ahn NU. The effect of high-normal preoperative international normalized ratios on postoperative outcomes and complications following posterior cervical spine surgery. J Orthop Surg Res 2024; 19:552. [PMID: 39252112 PMCID: PMC11382497 DOI: 10.1186/s13018-024-05009-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Accepted: 08/19/2024] [Indexed: 09/11/2024] Open
Abstract
INTRODUCTION Current guidelines recommend that the International Normalized Ratio (INR) be less than 1.5 prior to spine intervention. Recent studies have shown that an INR > 1.25 is associated worse outcomes following anterior cervical surgery. We sought to determine the risk of complications associated with an INR > 1.25 following elective posterior cervical surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried. Patients undergoing elective posterior cervical surgery from 2012 to 2016 with an INR level within 24 h of surgery were included. Primary outcomes were hematoma requiring surgery, 30-day mortality, and transfusions within 72-hours. There were 815 patients in the INR ≤ 1 cohort (Cohort A), 410 patients in the 1 < INR ≤ 1.25 cohort (Cohort B), and 33 patients in the 1.25 < INR ≤ 1.5 cohort (Cohort C). RESULTS Cohort C had a higher rate of transfusion (4% Cohort A; 6% Cohort B; 12% Cohort C; p = 0.028) and the rate of mortality within 30 days postoperatively trended toward significance (0.4% Cohort A; 0.5% Cohort B; 3% Cohort C; p = 0.094). There was no significant difference in the rate of postoperative hematoma formation requiring surgery (0.2% Cohort A; 0% Cohort B; 0% Cohort C; p = 0.58). On multivariate analysis, increasing INR was not associated with an increased risk of developing a major complication. CONCLUSION An INR > 1.25 but ≤ 1.5 may be safe for posterior cervical surgery. An INR > 1.25 but ≤ 1.5 was associated with a significantly higher rate of transfusions. However, increasing INR was not significantly associated with increased risk of any of the major complications.
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Affiliation(s)
- John T Strony
- Department of Orthopaedics, University Hospitals/Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Ramsey S Sabbagh
- Department of Orthopaedics, University Hospitals/Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St., Chicago, IL, 60612, USA
| | - Jerry Y Du
- Department of Orthopaedics, University Hospitals/Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Uri M Ahn
- New Hampshire NeuroSpine Institute, 4 Hawthorne Dr., Bedford, NH, 03110, USA
| | - Nicholas U Ahn
- Department of Orthopaedic Surgery, University of Louisville, 215 Central Avenue, Suite 201, Louisville, KY, 40208, USA
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Nerelius F, Sigmundsson FG, Karlén N, Wretenberg P, Joelson A. Patient-reported Outcome After Surgical Evacuation of Postoperative Spinal Epidural Hematomas at One-year Follow-up. Spine (Phila Pa 1976) 2024; 49:701-707. [PMID: 37235784 DOI: 10.1097/brs.0000000000004720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data from the National Swedish Spine Register (Swespine). OBJECTIVE The objective of this study was to evaluate the effects of symptomatic spinal epidural hematoma (SSEH) requiring reoperation on one-year patient-reported outcome measures (PROMs) in a large cohort of patients treated surgically for lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA Studies exploring the outcomes of reoperations after SSEH are scarce and often lack validated outcome measures. As SSEH is considered a serious complication, understanding of the outcome after hematoma evacuation is important. MATERIALS AND METHODS After retrieving data from 2007 to 2017 from Swespine, we included all patients with lumbar spinal stenosis without concomitant spondylolisthesis who were treated surgically with decompression without fusion. Patients with evacuated SSEH were identified in the registry. Back/leg pain numerical rating scales (NRSs), the Oswestry Disability Index (ODI), and EuroQol Visual Analogue Scale were used for the outcome assessment. PROMs before and one year after decompression surgery were compared between evacuated patients and all other patients. Multivariate linear regression was performed to determine whether hematoma evacuation predicted inferior one-year PROM scores. RESULTS A total of 113 patients with an evacuated SSEH were compared with 19527 patients with no evacuation. One-year after decompression surgery, both groups showed significant improvement in all PROMs. When comparing the two groups' one-year improvement, there were no significant differences in any PROM. The proportion of patients achieving the minimum important change was not significantly different for any PROM. Multivariate linear regression found that hematoma evacuation significantly predicted inferior one-year ODI (β=4.35, P =0.043), but it was not a significant predictor of inferior NRS Back (β=0.50, P =0.105), NRS Leg (β=0.41, P =0.221), or EuroQol Visual Analogue Scale (β=-1.97, P =0.470). CONCLUSIONS A surgically evacuated SSEH does not affect the outcome in terms of back/leg pain or health-related quality of life. Commonly used PROM surveys may not capture neurological deficits associated with SSEH.
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Affiliation(s)
- Fredrik Nerelius
- Department of Orthopaedics, Orebro University School of Medical Sciences and Orebro University Hospital, Orebro, Sweden
| | - Freyr G Sigmundsson
- Department of Orthopaedics, Orebro University School of Medical Sciences and Orebro University Hospital, Orebro, Sweden
| | - Niklas Karlén
- Department of War Studies and Military History, Swedish Defence University, Stockholm, Sweden
| | - Per Wretenberg
- Department of Orthopaedics, Orebro University School of Medical Sciences and Orebro University Hospital, Orebro, Sweden
| | - Anders Joelson
- Department of Orthopaedics, Orebro University School of Medical Sciences and Orebro University Hospital, Orebro, Sweden
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Sweda R, Mannion AF, O'Riordan D, Haschtmann D, Loibl M, Kleinstück F, Jeszenszky D, Galbusera F, Fekete TF. A decade of experience in over 300 surgically treated spine patients with long-term oral anticoagulation: a propensity score matched cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1360-1368. [PMID: 38381387 DOI: 10.1007/s00586-024-08134-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 03/12/2023] [Accepted: 01/04/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE The aim of this study was to investigate the risks and outcomes of patients with long-term oral anticoagulation (OAC) undergoing spine surgery. METHODS All patients on long-term OAC who underwent spine surgery between 01/2005 and 06/2015 were included. Data were prospectively collected within our in-house Spine Surgery registry and retrospectively supplemented with patient chart and administrative database information. A 1:1 propensity score-matched group of patients without OAC from the same time interval served as control. Primary outcomes were post-operative bleeding, wound complications and thromboembolic events up to 90 days post-surgery. Secondary outcomes included intraoperative blood loss, length of hospital stay, death and 3-month post-operative patient-rated outcomes. RESULTS In comparison with the control group, patients with OAC (n = 332) had a 3.4-fold (95%CI 1.3-9.0) higher risk for post-operative bleeding, whereas the risks for wound complications and thromboembolic events were comparable between groups. The higher bleeding risk was driven by a higher rate of extraspinal haematomas (3.3% vs. 0.6%; p = 0.001), while there was no difference in epidural haematomas and haematoma evacuations. Risk factors for adverse events among patients with OAC were mechanical heart valves, posterior neck surgery, blood loss > 1000 mL, age, female sex, BMI > 30 kg/m2 and post-operative PTT levels. At 3-month follow-up, most patients reported favourable outcomes with no difference between groups. CONCLUSION Although OAC patients have a higher risk for complications after spine surgery, the risk for major events is low and patients benefit similarly from surgery.
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Affiliation(s)
- Romy Sweda
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne F Mannion
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Dave O'Riordan
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Daniel Haschtmann
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Markus Loibl
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Frank Kleinstück
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Dezső Jeszenszky
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Fabio Galbusera
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Tamás F Fekete
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland.
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Cloney MB, Dhillon E, Hopkins B, El Tecle N, Koski TR, Dahdaleh NS. Chemoprophylactic Anticoagulation After Spine Surgery Does Not Increase Epidural Hematoma Risk: A Propensity-matched Analysis. Clin Spine Surg 2024; 37:E97-E105. [PMID: 37941100 DOI: 10.1097/bsd.0000000000001552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/03/2023] [Indexed: 11/10/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE To calculate the magnitude of any increased risk of epidural hematoma (EDH) associated with chemoprophylactic anticoagulation (chemoprophylaxis), if any. SUMMARY OF BACKGROUND DATA Chemoprophylaxis for the prevention of venous thromboembolic events may be associated with an increased risk of EDH after spine surgery. MATERIALS AND METHODS A total of 6869 consecutive spine surgeries performed at our institution were identified, and clinical and demographic data were collected. We identified cases in which symptomatic EDHs were evacuated within 30 days postoperatively. Patients receiving chemoprophylaxis and controls were matched using K-nearest neighbor propensity score matching to calculate the effect of anticoagulation on the rate of postoperative EDH. RESULTS After propensity score matching, 1071 patients who received chemoprophylaxis were matched to 1585 controls. Propensity scores were well balanced between populations (Rubin B=20.6, Rubin R=1.05), and an 89.6% reduction in bias was achieved, with a remaining mean bias of 3.2%. The effect of chemoprophylaxis on EDH was insignificant ( P =0.294). Symptomatic EDH was independently associated with having a transfusion [odds ratio (OR)=7.30 (1.15, 46.20), P =0.035], having thoracic-level surgery [OR=41.19 (3.75, 452.4), P =0.002], and increasing body mass index [OR=1.44 (1.04, 1.98), P =0.028] but was not associated with chemoprophylaxis. Five out of 13 patients who developed EDH (38.5%) were receiving some form of anticoagulation, including 1 patient on therapeutic anticoagulation, 1 concurrently on aspirin and chemoprophylaxis, and 2 who were also found to have developed thrombocytopenia postoperatively. The median time on anticoagulation before EDH was 8.1 days. A higher proportion of patients who developed EDH also developed venous thromboembolic events than the general population [38.5% vs. 2.4%, OR=25.34 (9.226, 79.68), P <0.0001], and 1 EDH patient died from pulmonary embolism while off chemoprophylaxis. CONCLUSIONS Chemoprophylactic anticoagulation did not cause an increase in the rate of spinal EDH in our patient population.
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Affiliation(s)
- Michael B Cloney
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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Luo G, Xie Y. A commentary on 'Risk factors of epidural hematoma in patients undergoing spinal surgery: a meta-analysis of 29 cohort studies'. Int J Surg 2024; 110:1846-1847. [PMID: 38100639 PMCID: PMC10942230 DOI: 10.1097/js9.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023]
Affiliation(s)
| | - Yanqiu Xie
- Department of Orthopaedics, People’s Hospital of Jingshan, Jingshan Union Hospital of Huazhong University of Science and Technology, Jingmen City, Hubei Province, People’s Republic of China
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Lu J, Zhang W, Jiang G, Luo K, Cai K, Zhang K, Lu B. Risk factors for spinal subdural hematoma after minimally invasive transforaminal lumbar Interbody Fusion (MI-TLIF): a multivariate analysis. BMC Musculoskelet Disord 2023; 24:939. [PMID: 38053117 DOI: 10.1186/s12891-023-06902-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/21/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Spinal subdural hematoma (SSH) is a rare cause of compression of the neutral elements of the spinal cord. However, little is known about the presentation of acute SSH after lumbar spine surgery. The reason for this may be that symptomatic SSH occurs rarely and is not given enough attention by spine surgeons. Currently, the decision to perform MRI postoperatively is more dependent on surgeon preference; therefore, no high-quality studies have been published. Our team reports our experience in the diagnosis and management of SSH after lumbar decompression and fusion surgery. METHODS We retrospectively studied 215 patients who underwent routine MRI following minimal invasive transforaminal lumbar interbody fusion (MI-TLIF) between 2020-01-01 and 2022-06-30. The patients were divided into SSH group (17 cases) and non-SSH group (198 cases) according to the occurrence of SSH. Univariate analysis and multivariate logistic regression analysis were performed to identify relevant risk factors that increase the risk of SSH postoperatively. RESULTS None of the patients presented with serious neurologic symptoms, such as lower extremity paralysis or cauda equina syndrome that required emergency hematoma debridement. SSH was found in 17 (7.9%) patients and non-SSH in 198 (92.1%). Factors affecting SSH were presence of hypertension, presence of diabetes and postoperative anticoagulant therapy. The significantly independent risk factor of postoperative SSH were diabetes (P = 0.008, OR: 6.988) and postoperative anticoagulant therapy (P = 0.003, OR: 8.808). CONCLUSIONS SSH after MI-TLIF is not a rare condition, with generally no requirement of emergency evacuation. Comprehensive anti-symptomatic treatment could achieve satisfactory results. Diabetes mellitus and postoperative anticoagulant therapy are independent risk factors for SSH. Spine surgeons should hold applicability of the use of anticoagulants after lumbar surgery.
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Affiliation(s)
- Jiye Lu
- Department of Spinal Surgery, The First Affiliated Hospital of Ningbo University, Work, 315000, China
| | - Wei Zhang
- Department of Spinal Surgery, The First Affiliated Hospital of Ningbo University, Work, 315000, China
| | - Guoqiang Jiang
- Department of Spinal Surgery, The First Affiliated Hospital of Ningbo University, Work, 315000, China
| | - Kefeng Luo
- Department of Spinal Surgery, The First Affiliated Hospital of Ningbo University, Work, 315000, China
| | - Kaiwen Cai
- Department of Spinal Surgery, The First Affiliated Hospital of Ningbo University, Work, 315000, China
| | - Kai Zhang
- Department of Spinal Surgery, The First Affiliated Hospital of Ningbo University, Work, 315000, China
| | - Bin Lu
- Department of Spinal Surgery, The First Affiliated Hospital of Ningbo University, Work, 315000, China.
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12
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Saitta BH, Shultz P, Hanson K, Mikhael MM. Post-Operative Spinal Epidural Hematoma: Are We Discontinuing Aspirin Early Enough? Global Spine J 2023; 13:2255-2261. [PMID: 35253459 PMCID: PMC10538344 DOI: 10.1177/21925682221079259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES (1) To compare the risk of Spinal Epidural Hematoma (SEH) associated with specific pre-operative and post-operative anticoagulation (AC) and antiplatelet medications (APM). (2) To define the incidence of SEH and identify risk factors for SEH in our population. METHODS Thoracolumbar surgeries between October 2009 and March 2020 were collected. Patients who underwent incision and drainage of a symptomatic SEH were identified. AC and APM was recorded 14 days pre-operatively and post-operatively. Demographics and intra-operative factors were recorded. Relative risk with 95% confidence interval was used, with Bonferroni-corrected P-values <.05 used for significance. RESULTS 9307 surgeries were identified. 177 (1.9%) patients returned to the OR within 30 days, 37 of whom (.39%) returned due to SEH. Seven patients were on either AC or APM pre-op, and sixteen post-op. Five were on aspirin pre-operatively (RR 3.2, 95% CI 1.25-8.22, P = .015). Risk was not increased in patients on multiple agents. No AC or APM demonstrated increased risk of hematoma post-operatively, despite trends toward significance with multiple agents. The use of a drain and complicated hypertension were associated with increased risk of SEH. CONCLUSIONS Pre-operative aspirin is associated with increased risk of SEH, even when appropriately discontinued. Appropriately dosed post-operative anticoagulation does not increase the risk of SEH, though being on multiple agents trends toward statistical significance and should be better studied. Surgeons should be vigilant and carefully monitor patients on pre-operative antiplatelet medications for spinal epidural hematoma.
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Affiliation(s)
| | | | - Kathryn Hanson
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark M Mikhael
- Illinois Bone and Joint Institute Glenview, Glenview, IL, USA
- NorthShore University Health System, Evanston, IL, USA
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13
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McCabe RW, Tong D, Kelkar P, Richards B, Soo TM. Preventing Surgical Site Hematoma Using Topical with or Without Intravenous Tranexamic Acid in Lumbosacral Surgery: A Quality Improvement Project. World Neurosurg 2023; 177:e44-e51. [PMID: 37169074 DOI: 10.1016/j.wneu.2023.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Postoperative surgical site hematoma (SSH) following lumbosacral surgery carries significant morbidity and increased length of stay (LOS). Intravenous tranexamic acid (ivTXA) has been shown to reduce SSH rate. Topical TXA (tTXA) could benefit patients with contraindications to ivTXA. However, this has not been widely studied. We sought to demonstrate that a quality improvement (QI) protocol using tTXA with/without ivTXA in patients undergoing elective open and minimally invasive lumbosacral surgery could decrease the SSH rate and LOS with no increase in associated complications. METHODS A retrospective chart review for July 2018-June 2019 demonstrated our preimplementation baseline SSH rate. We conducted interdisciplinary meetings to develop standardized institutional measures and perioperative tTXA administration protocol. The primary outcome was SSH necessitating evacuation. The secondary outcome was LOS and TXA-related complications. The postimplementation data were collected prospectively from July 2020-October 2020. Univariate analysis was used to compare preimplementation and postimplementation cohorts. We considered a P-value <0.05 significant. RESULTS Comparing consecutive lumbosacral surgical patients in pre- (219 patients) and postimplementation (258 patients), the postimplementation group demonstrated a significantly reduced rate of SSH requiring evacuation (0.38% vs. 3.3%, P < 0.001), significantly increased tTXA utilization (86.0% vs. 9.6%, P < 0.001), significantly lower incidence of SSH in tTXA patients (0.45% vs. 4.8%, P = 0.037), and significantly decreased LOS (3.4 ± 2.5 vs. 3.1 ± 2.7, P = 0.003). There were no complications attributable to TXA use. CONCLUSIONS Our Quality Improvement (QI) project successfully increased compliance with the use of tTXA. Post-implementation rate of SSH requiring evacuation and LOS was significantly lowered with no associated complications.
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Affiliation(s)
- Robert W McCabe
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, Michigan, USA.
| | - Doris Tong
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, Michigan, USA
| | - Prashant Kelkar
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, Michigan, USA
| | - Boyd Richards
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, Michigan, USA
| | - Teck-Mun Soo
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, Michigan, USA
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Stone BK, Paradkar R, Anderson GM, Daniels A, Iyer S, Derman PB, Telfeian AE, Basques B. Development of an Endoscopic Spine Surgery Program: Overview and Basic Considerations for Implementation. JB JS Open Access 2023; 8:e22.00152. [PMID: 37731772 PMCID: PMC10508372 DOI: 10.2106/jbjs.oa.22.00152] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
Endoscopic spine surgery (ESS) is an innovative technique allowing for minimally invasive, direct visualization of spinal abnormalities. The growth of ESS in the United States has been stunted by high start-up costs, low reimbursement rates, and the steep learning curve associated with mastering endoscopic techniques. Hergrae, we describe the current state and future direction of ESS and provide key action items for ESS program implementation.
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Affiliation(s)
- Benjamin K. Stone
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - George M. Anderson
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Alan Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | | | - Albert E. Telfeian
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Bryce Basques
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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15
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Ahn DK, Kim YH, Ko YR, Jang SJ, Jung JS. The Influence of Systolic Blood Pressure at the Time of Extubation on the Development of Postoperative Spinal Epidural Hematoma. Clin Orthop Surg 2023; 15:265-271. [PMID: 37008976 PMCID: PMC10060781 DOI: 10.4055/cios22297] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/22/2022] [Accepted: 10/25/2022] [Indexed: 04/04/2023] Open
Abstract
Background The most common cause of neurological complications after a biportal endoscopic spine surgery (BESS) is postoperative spinal epidural hematomas (POSEH). The objective of this study was to determine the influence of systolic blood pressure at extubation (e-SBP) on POSEH. Methods A total of 352 patients who underwent single-level decompression surgery including laminectomy and/or discectomy with BESS under the diagnosis of spinal stenosis and herniated nucleus pulposus between August 1, 2018, and June 30, 2021, were reviewed retrospectively. The patients were divided into two, a POSEH group and a normal group without POSEH (no neurological complication). The e-SBP, demographic factors, and the preoperative and intraoperative factors suspected to influence the POSEH were analyzed. The e-SBP was converted to a categorical variable by the threshold level that was decided by maximum area under the curve (AUC) in receiver operating characteristic (ROC) curve analysis. Antiplatelet drugs (APDs) were taken in 21 patients (6.0%), discontinued in 24 patients (6.8%), and not taken in 307 patients (87.2%). Tranexamic acid (TXA) was used in 292 patients (83.0%) in the perioperative period. Results Of the 352 patients, 18 patients (5.1%) underwent revision surgery for the removal of POSEH. The POSEH and normal groups were homogenous in age, sex, diagnosis, operation segments, operation time, and lab findings that were related to blood clotting, whereas there were differences in e-SBP (163.7 ± 15.7 mmHg in POSEH group and 154.1 ± 18.3 mmHg in normal group), APD (4 takers, 2 stoppers, 12 non-takers in POSEH group and 16 takers, 22 stoppers, 296 non-takers in normal group), and TXA (12 use, 6 not use in POSEH group and 280 use, 54 not use in normal group) in single variable analysis. The highest AUC in the ROC curve analysis was 0.652 for 170 mmHg e-SBP (p < 0.05). There were 94 patients in the high e-SBP group (≥ 170 mmHg) and 258 patients in the low e-SBP group. In multivariable logistic regression analysis, only high e-SBP was a significant risk factor for POSEH (p = 0.013; odds ratio, 3.434). Conclusions High e-SBP (≥ 170 mmHg) can influence the development of POSEH in biportal endoscopic spine surgery.
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Affiliation(s)
- Dong Ki Ahn
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Yong Ho Kim
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Young Rok Ko
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Sung Jun Jang
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Jong Seo Jung
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
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Jang HD, Park SS, Kim K, Kim EH, Lee JC, Choi SW, Shin BJ. Is Routine Use of Drain Really Necessary for Posterior Lumbar Interbody Fusion Surgery? A Retrospective Case Series with a Historical Control Group. Global Spine J 2023; 13:621-629. [PMID: 33733887 DOI: 10.1177/21925682211001801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN A retrospective case-control study. OBJECTIVES The usefulness of a drain in spinal surgery has always been controversial. The purposes of this study were to determine the incidence of hematoma-related complications after posterior lumbar interbody fusion (PLIF) without a drain and to evaluate its usefulness. METHODS We included 347 consecutive patients with degenerative lumbar disease who underwent single- or double-level PLIF. The participants were divided into 2 groups by the use of a drain or not; drain group and no-drain group. RESULTS In 165 cases of PLIF without drain, there was neither a newly developed neurological deficit due to hematoma nor reoperation for hematoma evacuation. In the no-drain group, there were 5 (3.0%) patients who suffered from surgical site infection (SSI), all superficial, and 17 (10.3%) patients who complained of postoperative transient recurred leg pain, all treated conservatively. Days from surgery to ambulation and length of hospital stay (LOS) of the no-drain group were faster than those of the drain group (P < 0.001). In a multiple regression analysis, a drain insertion was found to have a significant effect on the delayed ambulation and increased LOS. No significant differences existed between the 2 groups in additional surgery for hematoma evacuation, or SSI. CONCLUSIONS No hematoma-related neurological deficits or reoperations caused by epidural hematoma and SSI were observed in the no-drain group. The no-drain group did not show significantly more frequent postoperative complications than the drain use group, hence the routine insertion of a drain following PLIF should be reconsidered carefully.
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Affiliation(s)
- Hae-Dong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Seong San Park
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Kyungbum Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Eung-Ha Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Jae Chul Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Sung-Woo Choi
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Byung-Joon Shin
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
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17
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Tsujimoto T, Kanayama M, Oha F, Shimamura Y, Tanaka M, Hasegawa Y, Fukada S, Hashimoto T, Takahata M, Iwasaki N. Characteristics of the Patients with Poor Clinical Outcomes After Symptomatic Postoperative Lumbar Epidural Hematoma. World Neurosurg 2023; 172:e364-e371. [PMID: 36640830 DOI: 10.1016/j.wneu.2023.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Symptomatic postoperative lumbar epidural hematoma (PLEH) may lead to poor outcomes even after evacuation. This study aimed to verify the short-term clinical outcomes after the evacuation of PLEH and to clarify the characteristics of the patients with poor postoperative outcomes. METHODS Twenty-five patients (average age; 70.4 years) underwent PLEH evacuation after lumbar spine surgery. The mean follow-up period was 12.0 (range 3-37) months. Pre and postoperative Japanese Orthopedic Association scores and visual analog scale (VAS) of low back pain (LBP), leg pain, and leg numbness were retrospectively collected. The dural sac cross-sectional area at the most compressed level was measured on magnetic resonance imaging. The patients were classified into 2 groups: poor outcome group (P group) had less than 50% of Japanese Orthopedic Associationrecovery rate and good group (G group) with 50% or more recovery rate. RESULTS The rate of delayed evacuation (over 24 hours of onset) was significantly higher in P group than in G group (P = 0.027). There was no significant difference in dural sac cross-sectional areabetween the 2 groups (P = 0.438). VAS of LBP, leg pain, and leg numbness in G group significantly improved postoperatively. Although VAS of LBP and leg pain in P group significantly improved postoperatively, there was no significant difference between the pre and postoperative VAS of leg numbness. CONCLUSIONS Delayed evacuation of PLEH can lead to poor postoperative outcomes after lumbar spine surgery. Moreover, patients with poor outcomes remained with postoperative leg numbness. Early evacuation of symptomatic PLEH is key to avoid poor outcomes and persistent leg numbness.
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Affiliation(s)
- Takeru Tsujimoto
- Spine Center, Hakodate Central General Hospital, Hakodate, Hokkaido, Japan.
| | - Masahiro Kanayama
- Spine Center, Hakodate Central General Hospital, Hakodate, Hokkaido, Japan
| | - Fumihiro Oha
- Spine Center, Hakodate Central General Hospital, Hakodate, Hokkaido, Japan
| | | | - Masaru Tanaka
- Spine Center, Hakodate Central General Hospital, Hakodate, Hokkaido, Japan
| | - Yuichi Hasegawa
- Spine Center, Hakodate Central General Hospital, Hakodate, Hokkaido, Japan
| | - Syotaro Fukada
- Spine Center, Hakodate Central General Hospital, Hakodate, Hokkaido, Japan
| | - Tomoyuki Hashimoto
- Spine Center, Hakodate Central General Hospital, Hakodate, Hokkaido, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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18
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Cao Z, Li Q, Guo J, Li Y, Wu J. Optimal administration strategies of tranexamic acid to minimize blood loss during spinal surgery: results of a Bayesian network meta-analysis. Ann Med 2022; 54:2053-2063. [PMID: 35862264 PMCID: PMC9307111 DOI: 10.1080/07853890.2022.2101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has been widely used for bleeding reduction in spinal surgery. Available evidence is insufficient to inform clinical decisions making and there remains a lack of comprehensive comparisons of dose regimens and delivery routes. This study is aimed to assess and compare different strategies regarding the involvement of TXA in spinal surgery for the optimal pathway of efficacy and safety. MATERIALS AND METHODS Cochrane Library, PubMed, Embase, Scopus and CNKI were searched for the period from January 1990 to October 2021. A random-effect model was built in the Bayesian network meta-analysis. The surface under the cumulative ranking analysis (SUCRA) and clustering rank analysis was performed for ranking the effects. RESULTS The current network meta-analysis incorporated data from 33 studies with 3302 patients. Combination administration showed superior effects on reducing intraoperative bleeding (SUCRA 78.78%, MD -129.67, 95% CI [(-222.33, -40.58)]) than placebo, and was ranked as top in reducing postoperative bleeding (SUCRA 86.91%, MD -169.92, 95% CI [(-262.71, -83.52)]), changes in haemoglobin (SUCRA 97.21%, MD -1.28, 95% CI [(-1.84, -0.73)]), and perioperative blood transfusion (SUCRA 93.23%, RR 0.10, 95% CI [(0.03, 0.25)]) simultaneously, and was shown as the best effectiveness and safety (cluster-rank value for IBL and VTE: 4057.99 and for TRF and VTE: 4802.26). CONCLUSIONS Intravenous (IV) plus topical administration of TXA appears optimal in the reduction of perioperative bleeding and blood transfusion, while the local infiltration administration is not effective for blood conservation. Further studies are required to verify the current findings.
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Affiliation(s)
- Ziqin Cao
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Qiangxiang Li
- Ningxia Geriatric Disease Clinical Research Center, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, P. R. China.,National Clinical Research Center for Geriatric Disorders of Xiangya Hospital, Central South University (Sub-Center of Ningxia), Yinchuan, P. R. China.,Department of Hunan Institute of Geriatrics, Hunan People's Hospital, Changsha, P. R. China
| | - Jia Guo
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Yajia Li
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Jianhuang Wu
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, P. R. China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, P. R. China
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Chen Q, Zhong X, Liu W, Wong C, He Q, Chen Y. Incidence of postoperative symptomatic spinal epidural hematoma requiring surgical evacuation: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3274-3285. [PMID: 36260132 DOI: 10.1007/s00586-022-07421-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 09/07/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE This systematic review and meta-analysis aimed to determine the incidence of symptomatic spinal epidural hematoma (SSEH) following spine surgery. METHODS We systematically searched for all relevant articles that mentioned the incidence of SSEH following the spine surgery published in the PubMed, Embase, and Cochrane Library databases through March 2022 and manually searched the reference lists of included studies. The Newcastle-Ottawa quality assessment scale (NOS) was used to assess the quality of the included studies. A fixed-effects or random-effects model was performed to calculate the pooled incidence of the totality and subgroups based on the heterogeneity. The potential publication bias was assessed by Egger's linear regression and a funnel plot. Sensitivity analysis was also conducted. RESULTS A total of 40 studies were included in our meta-analysis based on our inclusion and exclusion criteria. The overall pooled incidence of SSEH was 0.52% (95% CI 0.004-0.007). In the subgroup analysis, the pooled incidence of SSEH in males and females was 0.86% (95% CI 0.004-0.023) and 0.68% (95% CI 0.003-0.017). Among the different indications, a higher incidence (2.9%, 95% CI 0.006-0.084) was found in patients with deformity than degeneration (1.12%, 95% CI 0.006-0.020) and tumor (0.30%, 95% CI 0.006-0.084). For different surgical sites, the incidences of SSEH in cervical, thoracic and lumbar spine were 0.32% (95% CI 0.002-0.005), 0.84% (95% CI 0.004-0.017) and 0.63% (95% CI 0.004-0.010), respectively. The incidences of SSEH in anterior and posterior approach were 0.24% (95% CI 0.001-0.006) and 0.70% (95% CI 0.004-0.011), respectively. The pooled incidence of SSEH was five times higher with minimally invasive surgery (1.94%, 95% CI 0.009-0.043) than with open surgery (0.42%, 95% CI 0.003-0.006). Delayed onset of SSEH had a lower incidence of 0.16% (95% CI 0.001-0.002) than early onset. There were no significant variations in the incidence of SSEH between patients who received perioperative anticoagulation therapy and those who did not or did not report getting chemopreventive therapy (0.44%, 95% CI 0.006-0.084 versus 0.42%, 95% CI 0.003-0.006). CONCLUSION We evaluated the overall incidence proportion of SSEH after spine surgery and performed stratified analysis, including sex, surgical indication, site, approach, minimally invasive surgery, and delayed onset of SSEH. Our research would be helpful for patients to be accurately informed of their risk and for spinal surgeons to estimate the probability of SSEH after spine surgery.
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Affiliation(s)
- Qian Chen
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.107, Yanjiang West Road, Yuexiu District, Guangzhou, 510120, China
| | - Xiaoxin Zhong
- Department of Surgical Intensive Care Unit, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.107, Yanjiang West Road, Yuexiu District, Guangzhou, 510120, China
| | - Wenzhou Liu
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.107, Yanjiang West Road, Yuexiu District, Guangzhou, 510120, China
| | - Chipiu Wong
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.107, Yanjiang West Road, Yuexiu District, Guangzhou, 510120, China
| | - Qing He
- Department of Surgical Intensive Care Unit, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.107, Yanjiang West Road, Yuexiu District, Guangzhou, 510120, China.
| | - Yantao Chen
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.107, Yanjiang West Road, Yuexiu District, Guangzhou, 510120, China.
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Use of a Multifunctional Cocktail for Postoperative Bleeding and Pain Control in Spinal Fusion: A Randomized, Double-blind, Controlled Trial. Spine (Phila Pa 1976) 2022; 47:1328-1335. [PMID: 34610611 DOI: 10.1097/brs.0000000000004249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/31/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, randomized, double-blind controlled trial. OBJECTIVE To explore the effect of multifunctional cocktail for bleeding and pain control after spinal fusion. SUMMARY OF BACKGROUND DATA Managing postoperative bleeding and pain after spinal fusion remains a challenge. Topical application of tranexamic acid or anesthetic agents for bleeding or pain management just started recently, and the multifunctional cocktail for bleeding and pain control simultaneously after spinal fusion have never been published. METHODS Ninety patients who underwent posterior spinal fusion were enrolled in this study. The multifunctional cocktail was injected into the incision before wound closure in the cocktail group. In the control group, an equal volume of normal saline was injected and a patient-controlled analgesic pump was used. Visual analogue scale score; opioid consumption; intraoperative, postoperative, hidden and total blood loss; volume of drainage, hematocrit levels of drainage; hemoglobin levels; and complications were compared between the two groups. RESULTS There were no differences in the visual analogue scale within 48 hours after surgery between the two groups. However, the opioid dosages in the control group were higher than those in the cocktail group. The postoperative blood loss, total blood loss, and hidden blood loss were lower in the cocktail group than in the control group. The drainage volume showed no differences between the two groups; however, the hematocrit level of drainage at 24 hours after surgery was lower in the cocktail group than in the control group. The hemoglobin level was higher in the cocktail group than in the control group at postoperative day 3. Thirteen patients with unbearable nausea and vomiting in the control group, whereas no complications in the cocktail group. CONCLUSION Topical application of a multifunctional cocktail that we designed provides an effective and safe method for reducing pain and bleeding after spinal fusion.
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Hao SS, Gao ZF, Li HK, Liu S, Dong SL, Chen HL, Zhang ZF. Delayed arterial symptomatic epidural hematoma on the 14 th day after posterior lumbar interbody fusion: A case report. World J Clin Cases 2022; 10:7973-7981. [PMID: 36158505 PMCID: PMC9372828 DOI: 10.12998/wjcc.v10.i22.7973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 05/16/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Delayed arterial symptomatic epidural hematoma (SEH) on the 14th day after posterior lumbar interbody fusion (PLIF) is rare but it may lead to severe complications if not identified and treated in a timely manner. After diagnosis of the current case, early surgical removal of the hematoma and strict hemostasis treatment was accomplished. This case report highlights the importance of swift diagnosis and treatment in SEH patients.
CASE SUMMARY A 41-year-old male patient with a single-segment lumbar disc herniation underwent left-side PLIF. On the 14th post-operative day, the patient complained of lumbar incision pain with sudden onset accompanied by left limb radiation pain and aggravated cauda equina symptoms. Magnetic resonance imaging examination and a puncture blood draw at the incision site confirmed a delayed arterial SEH. Emergency surgical removal of the hematoma and hemostasis was performed. About 70 mL of hematoma was found in the left incision. Continuous bleeding was found in the anterior branch of the transverse process of the 4th lumbar artery in the muscle area about 2 cm below the transverse process of the 4th lumbar vertebra. A blood jet of about 10 cm in height was observed and bipolar electrocoagulation was used to stop the bleeding. Post-operative lumbar incision pain and left lower limb pain were relieved immediately and gradually disappeared. There was no recurrence during the 12-mo follow-up.
CONCLUSION For delayed arterial SEH on the 14th day after PLIF, preventive measures including pre-, intra- and post-operative prevention should be implemented.
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Affiliation(s)
- Shen-Shen Hao
- Department of Spine and Bone Oncology, General Hospital of Pingmei Shenma Medical Group, Pingdingshan 467000, Henan Province, China
| | - Zhen-Fu Gao
- Department of Spine and Bone Oncology, General Hospital of Pingmei Shenma Medical Group, Pingdingshan 467000, Henan Province, China
| | - Hong-Ke Li
- Department of Spine and Bone Oncology, General Hospital of Pingmei Shenma Medical Group, Pingdingshan 467000, Henan Province, China
| | - Shuai Liu
- Department of Spine and Bone Oncology, General Hospital of Pingmei Shenma Medical Group, Pingdingshan 467000, Henan Province, China
| | - Sheng-Li Dong
- Department of Spine and Bone Oncology, General Hospital of Pingmei Shenma Medical Group, Pingdingshan 467000, Henan Province, China
| | - Hong-Lei Chen
- Department of Spine and Bone Oncology, General Hospital of Pingmei Shenma Medical Group, Pingdingshan 467000, Henan Province, China
| | - Zhi-Fang Zhang
- Department of Spine and Bone Oncology, General Hospital of Pingmei Shenma Medical Group, Pingdingshan 467000, Henan Province, China
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22
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Yang JS, Kwon YS, Kim JH, Lee JJ, Seo EM. The Influence of High Blood Pressure on Developing Symptomatic Lumbar Epidural Hematoma after Posterior Lumbar Spinal Fusion Surgery: Clinical Data Warehouse Analysis. J Clin Med 2022; 11:jcm11154522. [PMID: 35956136 PMCID: PMC9369553 DOI: 10.3390/jcm11154522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Determining the risk factors for symptomatic lumbar epidural hematoma (SLEH) is important for preventing postoperative SLEH. However, the relationship between blood pressure and SLEH is still debatable. The purpose of our study was to determine the risk factors for postoperative SLEH, to assess the influence of high blood pressure on developing SLEH after posterior lumbar spinal fusion surgery, and to evaluate the usefulness of big data analysis utilizing a clinical data warehouse (CDW). Methods: The clinical data of patients who had undergone posterior lumbar spinal fusion surgery were acquired from the CDW of Hallym University Medical Center. The acquired clinical data were compared between patients without postoperative SLEH and with postoperative SLEH. Results: Postoperative SLEH that required hematoma evacuation surgery within 72 h after posterior lumbar spinal fusion surgery occurred in 17 (1.3%) of 1313 patients. According to the multivariate logistic regression analysis, the risk factors for postoperative SLEH are platelet count difference (OR 1.28, p = 0.03), postoperative international normalized ratio (INR) difference (OR 31.4, p = 0.028), and postoperative systolic blood pressure (SBP) difference (≥10 mmHg) (OR 1.68, p = 0.048). An increase in postoperative SBP (OR 1.68, p = 0.048) had a statistically significant influence on the occurrence of postoperative SLEH. Conclusions: Big data analysis utilizing a CDW could be useful for extending our knowledge of the risk factors for postoperative SLEH and preventing postoperative SLEH after posterior lumbar spinal fusion surgery.
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Affiliation(s)
- Jin-Seo Yang
- Department of Neurosurgery, Chunchon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24252, Korea;
| | - Young-Suk Kwon
- Division of Big Data and Artificial Intelligence, Institute of New Frontier Research, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Korea; (Y.-S.K.); (J.-H.K.); (J.-J.L.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Korea
| | - Jong-Ho Kim
- Division of Big Data and Artificial Intelligence, Institute of New Frontier Research, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Korea; (Y.-S.K.); (J.-H.K.); (J.-J.L.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Korea
| | - Jae-Jun Lee
- Division of Big Data and Artificial Intelligence, Institute of New Frontier Research, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Korea; (Y.-S.K.); (J.-H.K.); (J.-J.L.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Korea
| | - Eun-Min Seo
- Division of Big Data and Artificial Intelligence, Institute of New Frontier Research, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Korea; (Y.-S.K.); (J.-H.K.); (J.-J.L.)
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Korea
- Correspondence: ; Tel.: +82-33-240-5198
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Wang L, Wang H, Sun Z, Chen Z, Sun C, Li W. Incidence and Risk Factors for Symptomatic Spinal Epidural Hematoma Following Posterior Thoracic Spinal Surgery in a Single Institute. Global Spine J 2022; 12:1175-1183. [PMID: 33334185 PMCID: PMC9210222 DOI: 10.1177/2192568220979141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
STUDY DESIGN Case-control study. OBJECTIVES To investigate the incidence of symptomatic spinal epidural hematoma (SSEH) and recognize its risk factors in a cohort of patients undergoing posterior thoracic surgery in isolation. METHODS From January 2010 to December 2019, patients who developed SSEH after posterior thoracic surgery and underwent hematoma evacuation were enrolled. For each SSEH patient, 2 or 3 controls who did not develop SSEH and underwent the same procedures with similar complexity at the same section of the thoracic spine in the same period were collected. The preoperative and intraoperative factors, blood pressure-related factors and radiographic parameters were collected to identify possible risk factors by comparing between the 2 groups. RESULTS A total of 24 of 1612 patients (1.49%) were identified as having SSEH after thoracic spinal surgery. Compared to the control group (53 patients), SSEH patients had significant differences in the APTT (p = 0.028), INR (p = 0.009), ratio of previous spinal surgery (p = 0.012), ratio of cerebrospinal fluid leakage (p = 0.004), thoracic kyphosis (p<0.05), local kyphosis angle (p<0.05), epidural fat ratio at T7 (p = 0.003), occupying ratio of the cross-sectional area (p<0.05) and spinal epidural venous plexus grade (p<0.05). Multiple logistic regression analysis revealed 3 risk factors for SSEH: cerebrospinal fluid leakage, the local kyphosis angle (>8.77°) and the occupying ratio of the cross-sectional area (>49.58%). CONCLUSIONS The incidence of SSEH was 1.49% in posterior thoracic spinal surgeries. Large local kyphosis angle (>8.77°), high occupying ratio of cross-sectional area (>49.58%) and cerebrospinal fluid leakage were identified as risk factors for SSEH.
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Affiliation(s)
- Longjie Wang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Hui Wang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Zhuoran Sun
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Zhongqiang Chen
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Chuiguo Sun
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Weishi Li
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Beijing, China,Weishi Li, MD, Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, China.
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24
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Reier L, Fowler JB, Arshad M, Siddiqi J. Drains in Spine Surgery for Degenerative Disc Diseases: A Literature Review to Determine Its Usage. Cureus 2022; 14:e23129. [PMID: 35464540 PMCID: PMC9001810 DOI: 10.7759/cureus.23129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/13/2022] [Indexed: 11/21/2022] Open
Abstract
No guidelines currently exist for surgeons to follow regarding drain use after spine surgery for degenerative disc disease. Therefore, we conducted a literature review to determine what situations warrant drain placement versus those which do not. When placed, we further investigate optimal drain duration. The goal of this article is to provide spine surgeons insight into the current literature and guidance when deciding if a drain should be used or discontinued. We performed a PubMed search and analyzed 44peer-reviewed journal articles. Only studies that had the full article available were included. The highest-quality studies that were reviewed, demonstrated that in most situations using a drain is not associated with superior outcomes. It revealed that when drains are retained for a longer duration they run a greater risk of surgical site infection (SSI). Additionally, drains are associated with increased blood loss, a greater chance of requiring blood transfusions, and longer hospital stays. We conclude that drains are currently being overused in spine surgery for cases of degenerative disc disease, which exposes patients to unnecessary complications while providing minimal benefit.
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25
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Srour R. Comparison of Operative Time and Blood Loss With the FFX® Device Versus Pedicle Screw Fixation During Surgery for Lumbar Spinal Stenosis: A Retrospective Cohort Study. Cureus 2022; 14:e22931. [PMID: 35399487 PMCID: PMC8986517 DOI: 10.7759/cureus.22931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 11/05/2022] Open
Abstract
Background Pedicle screw (PS) placement can be associated with soft tissue damage and blood loss. The study objective was to evaluate differences in operative time and blood loss between PS fixation and an implantable facet fusion device in patients undergoing lumbar fusion surgery. Materials and methods A retrospective analysis was performed on patients undergoing lumbar fusion surgery with PS fixation or the lumbar Facet FiXation (FFX) device. Procedures were performed by the same surgeon at a single institution. The PS group included patients from 2016 and the FFX group included patients from 2018. Variables including age, sex, levels operated on, operative time, and operative blood loss were collected. Results A total of 70 patients were included in the study. Twenty-eight in the PS arm and 42 in the FFX arm. The PS group had a mean age of 67.5 ± 9.3 years compared to 70.4 ± 11.5 years for the FFX group. The PS group had a higher percentage of females (57.1%) versus the FFX group (31.0%); p = 0.025. Mean number of levels operated on were similar between the PS and FFX groups (2.3 ± 1 .1 vs. 2.2 ± 1.0, respectively; p = 0.89). Mean operative time was significantly longer for the PS group versus the FFX group (152.5 ± 39.4 vs. 99.4 ± 44.0 minutes; p < 0.001). Mean operative blood loss was significantly greater for the PS group versus the FFX group (446.5 ± 272.0 vs. 251.0 ± 315.9 mL; p < 0.01). Differences were independent of the number of levels operated on. Conclusion Placement of the FFX device is associated with a significant reduction in operative time and blood loss compared to PS fixation in patients undergoing spinal fusion surgery.
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Affiliation(s)
- Robin Srour
- Neurosurgery, Hôpitaux Civils de Colmar, Colmar, FRA
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26
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Kidwell RL, Tan LA. Commentary: Symptomatic Epidural Hematoma After Elective Cervical Spine Surgery: Incidence, Timing, Risk Factors, and Associated Complications. Oper Neurosurg (Hagerstown) 2022; 22:e115-e116. [PMID: 35007237 DOI: 10.1227/ons.0000000000000070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/03/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Lee A Tan
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California; USA
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27
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Jiang Y, Yin J, Nong L, Xu N. Uniportal Full-Endoscopic versus Minimally Invasive Decompression for Lumbar Spinal Stenosis: A Meta-analysis. J Neurol Surg A Cent Eur Neurosurg 2022; 83:523-534. [PMID: 34991170 DOI: 10.1055/s-0041-1739208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND In this study, we systematically analyze the effectiveness of the uniportal full-endoscopic (UPFE) and minimally invasive (MIS) decompression for treatment of lumbar spinal stenosis patients. METHODS We performed a systematic search in Medline, Embase, Europe PMC, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, China national knowledge infrastructure, and Wanfang Data databases for all relevant studies. All statistical analyses were performed using Review Manager version 5.3. RESULTS A total of 9 articles with 522 patients in the UPFE group and 367 patients in the MIS group were included. The results of the meta-analysis showed that the UPFE group had significantly better results in hospital stay time (mean difference [MD]: -2.05; 95% confidence interval [CI]: -2.87 to -1.23), intraoperative blood loss (MD: -36.56; 95% CI: -54.57 to -18.56), and wound-related complications (MD: -36.56; 95%CI: -54.57 to -18.56) compared with the MIS group, whereas the postoperative clinical scores (MD: -0.66; 95%CI: -1.79 to 0.47; MD: -0.75; 95%CI: -1.86 to 0.36; and MD: -4.58; 95%CI: -16.80 to 7.63), satisfaction rate (odds ratio [OR] = 1.24; 95%CI: 0.70-2.20), operation time (MD: 30.31; 95%CI: -12.55 to 73.18), complication rates for dural injury (OR = 0.60; 95%CI: 0.29-1.26), epidural hematoma (OR = 0.60; 95%CI: 0.29-1.26), and postoperative transient dysesthesia and weakness (OR = 0.73; 95%CI: 0.36-1.51) showed no significant differences between the two groups. CONCLUSIONS The UPFE decompression is associated with shorter hospital stay time and lower intraoperative blood loss and wound-related complications compared with MIS decompression for treatment of lumbar spinal stenosis patients. The postoperative clinical scores, satisfaction rate, operation time, complication rates for dural injury, epidural hematoma, and postoperative transient dysesthesia and weakness did not differ significantly between two groups.
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Affiliation(s)
- Yuqing Jiang
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Jianjian Yin
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Luming Nong
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Nanwei Xu
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
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28
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Abstract
Symptomatic postoperative epidural hematomas are rare, with an incidence of 0.10% to 0.69%. Risk factors have varied in the literature, but multiple studies have reported advanced age, preoperative or postoperative coagulopathy, and multilevel laminectomy as risk factors for hematoma. The role of pharmacologic anticoagulation after spine surgery remains unclear, but multiple studies suggest it can be done safely with a low risk of epidural hematoma. Prophylactic suction drains have not been found to lower hematoma incidence. Most symptomatic postoperative epidural hematomas present within the first 24 to 48 hours after surgery but can present later. Diagnosis of a symptomatic hematoma requires correlation of clinical signs and symptoms with a compressive hematoma on MRI. Patients will usually first complain of a marked increase in axial pain, followed by radicular symptoms in the extremities, followed by motor weakness and sphincter dysfunction. An MRI should be obtained emergently, and if it confirms a compressive hematoma, surgical evacuation should be carried out as quickly as possible. The prognosis for neurologic improvement after evacuation depends on the time delay and the degree of neurologic impairment before evacuation.
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Affiliation(s)
- Mladen Djurasovic
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA.
| | - Chad Campion
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA
| | - John R Dimar
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA
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29
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Xiong GX, Tobert D, Fogel H, Cha T, Schwab J, Shin J, Bono C, Hershman S. Open epidural blood patch to augment durotomy repair in lumbar spine surgery: surgical technique and cohort study. Spine J 2021; 21:2010-2018. [PMID: 34144204 DOI: 10.1016/j.spinee.2021.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/18/2021] [Accepted: 06/11/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence. PURPOSE The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique. STUDY DESIGN/SETTING Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE: Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded. OUTCOME MEASURES The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique ("hydrogel" group), or the use of an epidural blood patch ("EBP" group). METHODS The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data. RESULTS Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration. CONCLUSIONS An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Boston, MA
| | | | | | - Thomas Cha
- Massachusetts General Hospital, Boston, MA
| | | | - John Shin
- Massachusetts General Hospital, Boston, MA
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Erdogan U, Sari S, Akbas A. The Efficiency of Simultaneous Systemic and Topical Use of Tranexamic Acid in Spinal Fusion Surgery. J Neurol Surg A Cent Eur Neurosurg 2021; 83:46-51. [PMID: 34794191 DOI: 10.1055/s-0041-1731751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIM Multilevel posterior spinal fusion surgery in adults is associated with significant intra- and postoperative blood loss. Tranexamic acid (TXA) is an antifibrinolytic agent for reducing blood loss and allogenic blood transfusion. The purpose of this study was to evaluate the efficiency of TXA in reducing blood loss and improving hematologic parameters in adult patients undergoing posterior thoracic/lumbar instrumented spinal fusion surgery. PATIENTS AND METHODS This is a retrospective observational study comparing the intra- and postoperative hemodynamic findings of two groups treated with and without TXA. The study included 112 adult patients receiving elective posterior thoracic/lumbar instrumented spinal fusion surgery. The patients were evaluated in terms of age, gender, type of surgery, intraoperative blood loss, pre- and postoperative hemoglobin (Hb) and hematocrit values, postoperative systemic anticoagulant use, intra- and postoperative use of blood products, and the volume of the drainage fluid as an indicator of postoperative blood loss. The TXA group received preoperative 10 mg/kg intravenous TXA, another dose of 10 mg/kg/h in isotonic solution during the operation, and local administration of TXA before the closure of the surgical site (1g in patients undergoing surgery in ≤3 segments, and 2g in patients undergoing surgery in ≥4 segment group). RESULTS Intra- and postoperative blood loss and need for transfusion were significantly lower in the TXA group. Fifty-three of 112 patients required intra- and postoperative transfusion, and postoperative anticoagulants were given to 25/112 patients. The postoperative Hb level was lower, and the difference of pre- and postoperative Hb values was higher in the non-TXA group (not significant). CONCLUSION Simultaneous systemic and topical application of TXA is a safe and efficient blood conservation strategy for adult patients undergoing major multilevel spinal surgery.
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Affiliation(s)
- Uzay Erdogan
- Department of Neurosurgery, University of Health Sciences, Bakırköy Prof. Dr. Mazhar Osman Training and Research Hospital for Neurology, Neurosurgery and Psychiatry, Istanbul, Turkey
| | - Seckin Sari
- Department of Orthopedics, Sportoteam Sport and Spine Center, Istanbul, Turkey
| | - Ahmet Akbas
- Department of Neurosurgery, Istanbul Taksim Training and Research Hospital, Istanbul, Turkey
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31
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Abola MV, Du JY, Lin CC, Schreiber-Stainthorp W, Passias PG. Symptomatic Epidural Hematoma After Elective Cervical Spine Surgery: Incidence, Timing, Risk Factors, and Associated Complications. Oper Neurosurg (Hagerstown) 2021; 21:452-460. [PMID: 34624885 DOI: 10.1093/ons/opab344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/04/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND As the rate of elective cervical spine surgery increases, studies of complications may improve quality of care. Symptomatic postoperative cervical epidural hematomas (PCEH) are rare but result in significant morbidity. Because of their low incidence, the risk factors and complications associated with symptomatic PCEH remain unclear. OBJECTIVE To clarify the prevalence, timing, variables, and complications associated with PCEH following elective cervical spine surgery. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database, cervical spine surgeries performed between 2012 and 2016 were identified using Current Procedural Terminology codes. Symptomatic PCEH was defined as readmission or reoperation events specifically associated with International Classification of Diseases code diagnoses of postoperative hematoma within 30 d of index surgery. Multivariate models were created to assess the independent association of symptomatic PCEH with other postoperative complications. RESULTS There were 53233 patients included for analysis. The overall incidence of symptomatic PCEH was 0.4% (n = 198). Reoperation occurred in 158 cases (78.8%), of which 2 required a second reoperation (1.3%). The majority (91.8%) of hematomas occurred within 15 d of surgery. Multivariate analysis identified male gender, American Society of Anesthesiologists classes 3 to 5, bleeding disorder, increasing number of operative levels, revision surgery, dural repair, and perioperative transfusion as independent factors associated with PCEH. Upon controlling for those confounders, PCEH was independently associated with cardiac arrest, stroke, deep vein thrombosis, surgical site infection, and pneumonia. CONCLUSION Postoperative epidural hematomas requiring readmission or reoperation following elective cervical spine surgery occurred at an incidence of 0.4%. Symptomatic PCEHs are associated with increased rates of numerous major morbidities.
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Affiliation(s)
- Matthew V Abola
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
| | - Jerry Y Du
- Department of Orthopedics, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Charles C Lin
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
| | - William Schreiber-Stainthorp
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
| | - Peter G Passias
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
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32
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Leroy HA, Portella T, Amouyel T, Bougeard R, Assaker R, Mourier KL. Management of symptomatic postoperative epidural hematoma in spine surgery: Medicolegal implications. Orthop Traumatol Surg Res 2021; 107:103024. [PMID: 34329762 DOI: 10.1016/j.otsr.2021.103024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Spine surgery is one of the specialties with the highest medicolegal risk, with a legal action initiated every 17 months per practitioner. One of the most dreaded complications is an epidural hematoma with postoperative deficit. The treatment of this complication is still being debated. We therefore conducted a retrospective study of the database of a medical liability insurer to assess perioperative factors determining the liability of the surgeon or paramedical team during an expert review in the event of a postoperative symptomatic epidural hematoma. HYPOTHESIS To identify the factors determining the liability of the medical team in the event of a postoperative symptomatic epidural hematoma. MATERIALS AND METHODS We retrospectively analyzed the largest French register of medicolegal expert reviews between 2011 and 2018. We identified 68 cases by entering the following keywords in this database: "spine surgery," "complications," and "epidural hematoma." After a thorough review of each case, only 14 were deemed to be truly relevant to our study. We collected for each patient the perioperative data, complications (including neurologic deficits) and their clinical course. RESULTS Only one surgeon was accused and found liable for failing to perform a surgical revision within a reasonable timeframe (time to revision of 11 days). In 2 cases, the liability of a nurse working in the surgical department was called into question for failing to contact the surgeon upon the onset of symptoms. In the other cases (11 patients, 79%), the occurrence of a symptomatic epidural hematoma was considered a no-fault medical accident that was not caused by the surgeon. The presence of a drain did not have any medicolegal impact in the cases reviewed. CONCLUSION The key element in medicolegal decisions is the reaction time of the healthcare teams, in particular the time between the onset of symptoms and surgical revision. According to these expert reviews, the placement of a drain was not taken into consideration during the medicolegal assessment of a postoperative symptomatic epidural hematoma. LEVEL OF EVIDENCE II; retrospective prognostic study, investigation of patient characteristics and their impact on functional outcome.
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Affiliation(s)
- Henri-Arthur Leroy
- University Lille, CHU Lille, Département de Neurochirurgie, 1, rue Émile Laine, 59000 Lille, France.
| | - Thibault Portella
- CHU Dijon, Département de Neurochirurgie, 14, rue Paul Gaffarel, 21000 Dijon, France
| | - Thomas Amouyel
- University Lille, CHU Lille, Département de Chirurgie orthopédique, 1, rue Émile Laine, 59000 Lille, France
| | - Renaud Bougeard
- Clinique du Val D'Ouest, Département de Neurochirurgie, 39, chemin de la Vernique, 69130 Écully, France
| | - Richard Assaker
- University Lille, CHU Lille, Département de Neurochirurgie, 1, rue Émile Laine, 59000 Lille, France
| | - Klaus-Luc Mourier
- CHU Dijon, Département de Neurochirurgie, 14, rue Paul Gaffarel, 21000 Dijon, France
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Li S, Xing F, Cen Y, Zhang Z. The Efficacy and Safety of Epsilon-Aminocaproic Acid for Perioperative Blood Management in Spinal Fusion Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 156:12-21. [PMID: 34478888 DOI: 10.1016/j.wneu.2021.08.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Perioperative blood loss is a major concern in spinal fusion surgery and often requires blood transfusion. A large amount of perioperative blood loss might increase the risks of various perioperative complications. Recent clinical studies have focused on the perioperative administration of epsilon-aminocaproic acid (EACA) in spinal fusion surgery. The aim of this review was to evaluate the efficacy and safety of EACA in spinal fusion surgery. METHODS Electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials) were systematically searched up to April 2021. Data on perioperative blood loss, blood transfusion, and complications were extracted and analyzed by RevMan software. RESULTS Six randomized controlled studies comprising 398 patients undergoing spinal fusion surgery were included in this systematic review. Compared with the control group, the EACA group had significantly lower total perioperative blood loss, postoperative blood loss, postoperative hemoglobin, postoperative blood transfusion units, total blood transfusion units, and postoperative red blood cell transfusion units. Additionally, no significant differences were observed between the EACA and control groups in intraoperative blood loss, intraoperative blood transfusion units, intraoperative crystalloid administered, hospital stays, operative time, perioperative respiratory complications, and wound bleeding. CONCLUSIONS EACA in patients undergoing spinal fusion surgery is effective in perioperative hemostasis without increasing the incidence of postoperative complications. However, more large-scale trials are needed to examine the long-term adverse side effects of EACA in spinal fusion surgery.
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Affiliation(s)
- Shang Li
- Department of Plastic and Burn Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Xing
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Cen
- Department of Plastic and Burn Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenyu Zhang
- Department of Plastic and Burn Surgery, West China Hospital, Sichuan University, Chengdu, China.
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Wang F, Wang SG, Yang Q, Nan LP, Cai TC, Wu DS, Zhang L. Cytotoxicity and Effect of Topical Application of Tranexamic Acid on Human Fibroblast in Spine Surgery. World Neurosurg 2021; 153:e380-e391. [PMID: 34224885 DOI: 10.1016/j.wneu.2021.06.125] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE In spinal surgery, considerable blood loss is increasingly treated with the local application of tranexamic acid (TXA). However, little is known about its cytotoxicity and effect on human fibroblasts. This study was to identify the effect of TXA solution on human fibroblast at different concentrations and exposure times in vitro. METHODS To mimic the actual clinical situation, human fibroblasts were subjected to both limited and chronic exposure to various clinically relevant concentrations of TXA to mimic different ways of topical administration. At time points after treatment, the viability, proliferation, apoptosis, collagen synthesis, adhesion, and migration of fibroblasts were analyzed in vitro. RESULTS Limited exposure (10 minutes) to a high concentration of TXA (100 mg/mL) did not affect the viability, proliferation, and apoptosis of fibroblasts, and chronic exposure to low concentration of TXA (≤12.5 mg/mL) exerted little effect on viability, proliferation, apoptosis, collagen synthesis, adhesion, and migration of human fibroblasts (P > 0.05). However, the chronic exposure to a high concentration of TXA (≥25 mg/mL) can inhibit the viability, proliferation, collagen synthesis, adhesion and migration, and induce apoptosis of fibroblasts. CONCLUSIONS Although limited exposure to high concentration of TXA and chronic exposure to low concentration of TXA exerted little effect on fibroblasts, chronic exposure to high concentration of TXA can lead to fibroblast injury.
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Affiliation(s)
- Feng Wang
- Department of Orthopedic, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shu-Guang Wang
- Department of Orthopedic, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qian Yang
- Department of Ophthalmology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Li-Ping Nan
- Department of Orthopedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Tong-Chuan Cai
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - De-Sheng Wu
- Department of Orthopedic, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Liang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China.
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Yeo JB, Lee E, Lee JW, Kim BR, Kang Y, Ahn JM, Park SM, Kang HS. Immediate postoperative MRI findings after lumbar decompression surgery: Correlation of imaging features with clinical outcome. J Clin Neurosci 2021; 89:365-374. [PMID: 34088576 DOI: 10.1016/j.jocn.2021.05.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/25/2020] [Accepted: 05/23/2021] [Indexed: 11/18/2022]
Abstract
An understanding of the common MRI findings observed after decompression surgery is important. However, to date, no study addressing this has been published. The aim of this study was to analyze and describe the immediate postoperative MRI findings after lumbar decompression surgery. We retrospectively analyzed the immediate postoperative MRIs of 121 consecutive patients who underwent lumbar decompression surgery between July 2017 and June 2018. Changes in stenosis at the decompressed and adjacent levels, epidural fat edema, epidural and subdural fluid collections, nerve root swelling, facet joint effusions, intervertebral disc signal, and paravertebral muscle edema were correlated with clinical characteristics. Both groups had reduced central canal stenosis postoperatively (p < 0.001) but worsened stenosis at adjacent segments. Fluid collection, hemorrhagic or non-hemorrhagic, at the laminectomy site was the commonest finding (one-level: 73.8%, two-level: 88.5%), with a higher percentage of severe central canal compromise in the two-level decompression group (p = 0.003). Other postoperative MRI findings, such as epidural fat edema, nerve root swelling, subdural fluid collection, and facet joint effusion, were noted without statistical significance. In conclusion, even with successful decompression for lumbar canal stenosis, increased central canal stenosis at adjacent segments is common on immediate postoperative MRI scans, showing no statistically significant correlation with the immediate postoperative outcome. Postoperative fluid collection at the laminectomy site is the commonest imaging finding, and higher rates of hemorrhagic fluid and more severe central canal compromise occur in two-level decompression, but rarely cause clinical problems.
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Affiliation(s)
- Joon Bum Yeo
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Bo Ram Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Joong Mo Ahn
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Sang-Min Park
- Spine Center and Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
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Impact of acetylsalicylic acid (ASA) on postoperative hemorrhage in spinal lumbar surgery: Should preoperative ASA be discontinued for elective surgery? J Neurol Sci 2021; 427:117508. [PMID: 34087567 DOI: 10.1016/j.jns.2021.117508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The application of acetylsalicylic acid (ASA) represents high evidence in the aging society due to primary and secondary prevention in cardiovascular disease and stroke. However, this presents a challenge for neurosurgeons in terms of preoperative and postoperative management of care. This study aimed to analyze the risk of bleeding by applying ASA before lumbar spinal surgery. METHODS Retrospective analysis of medical records of 3051 patients was performed from 2008 to 2018 who underwent lumbar surgery at our institution. The risk of postoperative hemorrhage was compared in patients treated with ASA versus patients without ASA treatment. Additionally, the relationship between discontinuation of ASA preoperatively (≥7 days) or no previous history of ASA versus continuation with ASA (<7 days) on postoperative hemorrhage was analyzed. RESULTS Postoperative hemorrhagic were observed in 2.1% (n = 63) of all lumbar operations. In 421 patients, the effect of ASA (<7 days) was still persistent at the time of surgery (ASA impact group). Of these, 12 (2.85%) patients had a hemorrhage. No significant differences were found in comparison to the No ASA impact group (p = 0.272). Sex (p = 0.003), hypertension (p = 0.015), recurrent surgery (p = 0.001) and use of hemostatic agents (p = 0.023) had a significant impact on postoperative hemorrhage. CONCLUSION The continuation of ASA medication is not associated with increased risk of postoperative hemorrhage after spinal surgery. However, sex, hypertension, recurrent surgery and the use of hemostatic agents under continued ASA treatment were found to be associated with an increased risk of hemorrhage.
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Takami M, Yoshida M, Minamide A, Hashizume H, Yukawa Y, Nakagawa Y, Iwasaki H, Tsutsui S, Nagata K, Taiji R, Nishi H, Schoenfeld AJ, Simpson AK, Yamada H. Does prophylactic use of topical gelatin-thrombin matrix sealant affect postoperative drainage volume and hematoma formation following microendoscopic spine surgery? A randomized controlled trial. Spine J 2021; 21:446-454. [PMID: 33189909 DOI: 10.1016/j.spinee.2020.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Microendoscopic spinal surgery has demonstrated efficacy and is increasingly utilized as a minimally invasive approach to neural decompression, but there is a theoretical concern that bleeding and postoperative epidural hematoma (PEH) may occur with increased frequency in a contained small surgical field. Hemostatic agents, such as topical gelatin-thrombin matrix sealant (TGTMS), are routinely used in spine surgery procedures, yet there has been no data on whether PEH is suppressed by these agents when administered in microendoscopic spine surgery. PURPOSE The purpose of this study was to investigate the effect of TGTMS on bleeding and PEH formation in lumbar micoroendoscopic surgery. STUDY DESIGN This is a randomized controlled trial (RCT) with additional prospective observational cohort. PATIENT SAMPLE Patients were registered from July 2017 to September 2018 and a hundred and three patients undergoing microendoscopic laminectomy for lumbar spinal stenosis at a single institution were enrolled in this study. OUTCOME MEASURES The primary outcome was the drainage volume within 48 hours after surgery. Secondary outcomes were the numerical rating scale (NRS) of leg pain on the second (NRS2) and seventh day (NRS7) after surgery and the hematoma area ratio (HAR) in horizontal images on magnetic resonance image (MRI). METHODS In the RCT, 41 cases that received TGTMS (F group) were compared with 41 control group cases (C group) that did not receive TGTMS at the end of the procedure. Drainage volume, NRS2, NRS7, and HAR on MRI were evaluated. Nineteen cases were excluded from the RCT (I group) due to difficulty of hemostasis during surgery and the intentional use of TGTMS for hemostasis. I group was compared with C group in the drainage volume and NRS of leg pain as a prospective observational study. RESULTS The RCT demonstrated no statistically significant difference in drainage volume between those receiving TGTMS (117.0±71.7; mean±standard deviation) and controls (125.0±127.0; p=.345). The NRS2 and NRS7 was 3.5±2.6 and 2.8±2.5 in the F group, respectively, and 3.1±2.6 and 2.1±2.3 in the C group, respectively. The HAR on MRI was 0.19±0.19 in the F group and 0.17±0.13 in the C group. There was no significant difference in postoperative leg pain and HAR (p=.644 for NRS2, p=.129 for NRS7, and p=.705 for HAR). In the secondary observational cohort, the drainage volume in the I group was 118.3±151.4, and NRS2 and NRS7 was 3.5±2.0 and 2.6±2.6, respectively. There were no statistically significant differences in drainage volume (p=.386) or postoperative NRS of leg pain between these two groups (p=.981 and .477 for NRS2 and NRS7, respectively). CONCLUSIONS The prophylactic use of TGTMS in patients undergoing microendoscopic laminotomy for lumbar spinal stenosis did not demonstrate any difference in postoperative bleeding or PEH. Nonetheless, for patients that had active bleeding that required the use of TGTMS, there was no evidence of difference in postoperative clinical outcomes relative to controls.
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Affiliation(s)
- Masanari Takami
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan.
| | - Munehito Yoshida
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Akihito Minamide
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Hiroshi Hashizume
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Yasutsugu Yukawa
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Yukihiro Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Wakayama 649-7113, Japan
| | - Hiroshi Iwasaki
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Shunji Tsutsui
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Keiji Nagata
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Ryo Taiji
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Hideto Nishi
- Department of Orthopaedic Surgery, Hidaka Hospital, 116-2 Sono, Gobo-city, Wakayama 644-0002, Japan
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Hiroshi Yamada
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
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Abstract
PURPOSE OF REVIEW Neurologists should be able to identify clinical and neuroimaging features that distinguish vascular disorders from other causes of myelopathy. RECENT FINDINGS Although certain clinical features suggest a vascular etiology in acute and chronic myelopathy settings, accurate MRI interpretation within the clinical context is key. Recent studies have shown vascular myelopathies are frequently misdiagnosed as transverse myelitis, and recognition of this diagnostic pitfall is important. Many different vascular mechanisms can cause myelopathy; this article provides a comprehensive review that simplifies disease categories into arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage. SUMMARY It is important to recognize and manage vascular disorders of the spinal cord as significant causes of acute, subacute, and progressive myelopathy.
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Shrestha IK, Ruan TY, Lin L, Tan M, Na XQ, Qu QC, Chen JC, Si YY, Tao JP. The efficacy and safety of high-dose tranexamic acid in adolescent idiopathic scoliosis: a meta-analysis. J Orthop Surg Res 2021; 16:53. [PMID: 33446219 PMCID: PMC7807519 DOI: 10.1186/s13018-020-02158-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Background This study aimed to evaluate the efficacy and safety of using high-dose intravenous tranexamic acid (TXA) to reduce blood loss in idiopathic scoliosis surgery. Methods This study was a meta-analysis, which consisted of retrospective cohort studies (RCSs) and randomized control trials (RCTs) found by searching electronic databases, namely PubMed, Web of Science, The Cochrane Central Register of Controlled Trials (CENTRAL), and the Google Scholar Database, dating from 1960 to 2019. The points of interest included total blood loss, a need for transfusion and transfusion criteria, surgery time, and the evidence of intraoperative and postoperative complications, such as seizures or thromboembolic events. The weighted mean differences (WMD) and 95% confidence interval (CI) of blood loss in the TXA intervention group compared to the control or placebo group were extracted and combined using the random effects model. Results In this meta-analysis, there was a total of three RCSs and two RCTs, which involved 334 patients. The results showed that blood loss is significantly reduced, with a weighted mean difference in the TXA group (WMD = − 525.14, P = 0.0000, CI ranged from − 839.83, − 210.44, I2 = 82%). Heterogeneity was assessed using the random effects model. Conclusions A high dose of intravenous TXA reduced blood loss during adolescent idiopathic scoliosis surgery and did not lead to any significant thromboembolic event. Therefore, a high dose appears to be effective and safe for adolescent idiopathic scoliosis surgery. However, more high-quality research based on larger randomized controlled trials is still needed.
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Affiliation(s)
- Indra K Shrestha
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Tian-Yi Ruan
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Lan Lin
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Miao Tan
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Xue-Qing Na
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Qi-Cai Qu
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Jian-Chun Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Yong-Yu Si
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China.
| | - Jian-Ping Tao
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China.
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Symptomatic Epidural Hematoma after Elective Posterior Lumbar Decompression: Incidence, Timing, Risk Factors, and Associated Complications. HSS J 2020; 16:230-237. [PMID: 33380952 PMCID: PMC7749891 DOI: 10.1007/s11420-019-09690-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/23/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Symptomatic post-operative lumbar epidural hematoma (PLEH) is a complication of lumbar spine surgery that can cause permanent neurologic consequences through compression of the cauda equina and nerve roots. QUESTIONS/PURPOSES We sought to investigate the incidence, timing, and risk factors for symptomatic epidural hematomas following posterior lumbar decompression, as well as to identify additional post-operative complications associated with symptomatic lumbar epidural hematomas. METHODS Elective lumbar spine procedures were identified in the National Surgical Quality Improvement Program (NSQIP) database between 2012 and 2016. Analyzed predictors of reoperation or readmission within 30 days for symptomatic PLEH included demographics, comorbidities, pre-operative laboratory values, peri-operative characteristics, and post-operative complications. RESULTS There were 75,878 cases included in the analysis. The incidence rate of symptomatic PLEH was 0.27% (n = 206), 54.4% (n = 112) of which occurred within 5 days of the procedure. Increased age, obesity (body mass index of 35 or higher), peri-operative transfusion, multilevel surgery (two or more levels), dural tear repair, and microscope use were independently associated with PLEH. Post-operative complications associated with PLEH included surgical site infection and urinary tract infection. CONCLUSIONS Readmission or reoperation for symptomatic PLEH following elective lumbar spine surgery is rare and can occur many days or weeks after a procedure. There are modifiable risk factors for PLEH and associated additional post-operative complications that physicians should be suspicious of following posterior lumbar decompression.
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Merter A, Shibayama M. A new classification for spinal epidural hematoma following microendoscopic decompressive laminotomy: A prospective clinical and magnetic resonance imaging study of 245 patients. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:596-603. [PMID: 33423991 DOI: 10.5152/j.aott.2020.19181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to develop a new radiological classification system for postoperative spinal epidural hematoma (SEH) using magnetic resonance imaging (MRI) and to determine the correlation of this classification system with clinical and radiological outcomes. METHODS This prospective study included a total of 245 consecutive patients (126 females, 119 males; mean age=72 years; age range=39-91 years) with single level spinal stenosis who were treated by microendoscopic decompressive laminotomy (MEDL). MRI was performed for all patients 24 hours postoperatively and at 12 months. SHEs were categorized into four grades using our new MRI-based classification system based on the measurement of dural sac area: Grade A, small hematoma with a round shape; grade B, small hematoma that show no round shape; grade C, moderate hematoma; grade D: severe hematoma. Patients were then divided into four groups according to their hematoma grades, Group A, 107 patients with grade A hematomas; group B, 47 with grade B; group C, 67 with grade C; group D, 24 with grade D. Also, patients who had neurological deterioration or who pain resistant to medical treatment were treated surgically, and those were assigned to group H+(14 patients). The study, therefore, contained five groups. Clinical evaluation was done using Japanese Orthopaedic Association (JOA) score preoperatively and at 12 months postoperatively. RESULTS No significant difference existed among groups in the preoperative median measurement of the dural sac area, which were 0.90 cm2 in group A, 0.80 cm2 in group B, 0.70 cm2 in group C, 1.1 cm2 in group D, and 0.80 cm2 in group H+ (p=0.076). At the postoperative 12-month measurement, no significant difference was noted among groups A (2.05 cm2), B (1.80 cm2 ), and H+ (1.90cm2) (A vs B: p=0.891, A vs H+: p=0.089, B vs H +: p=0.933). The measurements were greater in groups A and B than in groups C and D (p<0.05). Also, larger dural sac areas were determined in group H+ (1.90cm2) compared to Groups C (1.80 cm2) and D (1.60 cm2) but the difference reached no statistical significance (p=0.078). In preoperative JOA scores, there were no significant differences among groups (p>0.05). At 12-month JOA scores, no significant difference was observed between groups A and B (p=0.061) and between groups C and D (p=0.511). The scores were higher in groups A and B than in groups C and D (p<0.05). CONCLUSION It seems that the narrower the preoperative dural sac area, the better the clinical symptoms of the patients with SEHs based on our new MRI-based classification system. This classification may be useful to predict the clinical status of these patients at one-year follow-up. LEVEL OF EVIDENCE Level IV, Diagnostic study.
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Affiliation(s)
- Abdullah Merter
- Department of Orthopedics, Ankara University, School of Medicine, İbn-i Sina Hospital, Spine Section, Ankara, Turkey
| | - Motohide Shibayama
- Department of Orthopedics, Spine Section, Aichi Spine Hospital, Aichi Prefecture, Japan
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Tranexamic Acid for Blood Loss after Transforaminal Posterior Lumbar Interbody Fusion Surgery: A Double-Blind, Placebo-Controlled, Randomized Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8516504. [PMID: 32855972 PMCID: PMC7443232 DOI: 10.1155/2020/8516504] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/12/2020] [Accepted: 07/22/2020] [Indexed: 12/17/2022]
Abstract
Background Transforaminal lumbar interbody fusion (TLIF) may result in significant blood loss and an increase in blood transfusion. Though tranexamic acid (TXA) is widely studied for the hemostasis of arthroplasty, there is little information on the use of TXA for TLIF surgery. Methods This prospective randomized, double-blind, placebo-controlled trial was conducted to study the influence of TXA (intravenous bolus of 10 mg/kg 15 minutes before skin incision followed by intravenous infusion of 6-8 mg/kg/h up to a total dose of 15 mg/kg during the surgery) on the blood loss and Enhanced Recovery After Surgery (ERAS) after TLIF surgery. 40 patients were randomized into two groups: TXA group (tranexamic acid) and control group (placebo). Baseline characteristics were comparable between the TXA group and the control group before the surgery. Outcomes assessed included blood loss, total postoperative drainage, time for drainage removal, time to ambulation, hospital stay after surgery, postoperative hemoglobin (Hb) one day after surgery, and adverse events. Results Compared to patients in the control group after TLIF surgery, patients in the TXA group have significantly reduced intraoperative hemorrhage and time to ambulation after surgery but show similar hospital stay, postoperative drainage, time for drainage removal, postoperative Hb one day after surgery, and adverse events. Conclusions TXA shows important ability in controlling blood loss and promoting the ERAS after TLIF surgery.
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Merter A, Shibayama M. Does the drain placement technique affect the amount of postoperative spinal epidural hematoma after microendoscopic decompressive laminotomy for lumbar spinal stenosis? J Orthop Surg (Hong Kong) 2020; 27:2309499019869023. [PMID: 31451095 DOI: 10.1177/2309499019869023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To prospectively evaluate with magnetic resonance imaging (MRI), the relationship between the distance from the incision of the drain output location and postoperative spinal epidural hematoma (SEH) in patients performed with microendoscopic decompressive laminotomy (MEDL) for lumbar spinal stenosis. METHODS Between January 2016 and June 2018, three different kinds of drain placement techniques, according to the drain output location, were performed to a total of 184 patients after MEDL for single-level spinal stenosis. The location of the drain output was within the incision in group 1, 1 cm lateral of the incision in group 2, and 5 cm lateral of the incision in group 3. At 24 h postoperatively, before removal of the drain, MRI examination was carried out in patients. A specific classification was developed by the authors to measure SEH, and the groups were evaluated by comparison. RESULTS The mean postoperative dural sac cross-sectional area was 1.73 cm2 (standard deviation (SD): 0.711) in group 1, 1.66 cm2 (SD: 0.732) in group 2, and 1.52 cm2 in group 3 (SD: 0.841).The mean cross-sectional area of the postoperative hematoma was 1.45 cm2 (SD: 1.007) in group 1, 1.57 cm2 (SD: 1.053) in group 2, and 2.11 cm2 (SD: 1.024) in group 3. Four grades were defined according to the specific classification. According to this classification, grades C and D postoperative hematomas were determined at a statistically significantly higher rate in group 3 patients (drain output 5 cm lateral from the incision) compared to the other groups (p = 0.000). No significant difference was determined between groups 1 and 2 in respect of hematoma classification. CONCLUSION In conclusion, it was determined that better drainage was provided in groups 1 and 2, where the drain output location was in the incision or close to it.
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Affiliation(s)
- Abdullah Merter
- 1 Department of Orthopedics, Spine Section, School of Medicine, Ibn-i Sina Hospital, Ankara University, Ankara, Turkey
| | - Motohide Shibayama
- 2 Department of Orthopaedics, Spine Section, Aichi Spine Hospital, Inuyama, Japan
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Chen T, Chang H, Liu K, Shi M, Song C, Meng X. Drainage after posterior single-level instrumented lumbar fusion: Natural pressure vs negative pressure. Medicine (Baltimore) 2020; 99:e19154. [PMID: 32049842 PMCID: PMC7035085 DOI: 10.1097/md.0000000000019154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Recent findings have shown a trend toward recommending against the routine use of drains in spinal surgery because it carries the risk for potential complications. However, most surgeons still use closed suction drainage to prevent hematoma formation. This study is to compare the clinical outcomes between natural pressure drainage and negative pressure drainage after posterior lumbar interbody fusion.Consecutive 132 patients who underwent spinal fusion in the Third Hospital of Hebei Medical University and met the inclusion criteria were reviewed from January 2018 to January 2019 and divided into negative pressure drainage group and natural pressure drainage group according to different pressure drainage. There were 64 patients who had a negative pressure drainage placed and 68 patients who had a natural pressure drainage placed. Demographics, intraoperative blood loss, operative room time, drainage volume at the 1st postoperative day, total volume of postoperative drainage, the total drainage days, postoperative temperature, and postoperative complications (wound infection, symptomatic hematoma) were compared between the 2 groups.The median drainage volume at the 1st postoperative day in negative pressure group was 204.89 ± 95.19 mL, while in natural pressure group, it was 141.00 ± 52.19 mL (P = .000). The median total volume of postoperative drainage in negative pressure group was 378.06 ± 117.98 mL, while in natural pressure group, it was 249.32 ± 70.74 mL (P = .000). The median total drainage days between natural pressure group and negative pressure group were obviously different (2.93 ± 0.55 vs 3.51 ± 0.71 days, P = .000). There was no difference in patient characteristics, operative data, postoperative temperature, and complications.Natural pressure drainage significantly reduced postoperative drainage volume and indwelling time, but did not increase postoperative complications. Therefore, it may offer an alternative to negative pressure drainage and is as safe and effective as negative pressure drainage.
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Liao Y, Tian Y, Ye R, Tang C, Tang Q, Ma F, Yang S, He H, Zhong D. Risk and treatment of symptomatic epidural hematoma after anterior cervical spine surgery: A retrospective clinical study. Medicine (Baltimore) 2020; 99:e18711. [PMID: 31914081 PMCID: PMC6959927 DOI: 10.1097/md.0000000000018711] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Symptomatic epidural hematoma (SEH) after anterior cervical spine surgery is very rare, but it has disastrous consequences for the patients. Timely diagnosis and evaluation can effectively reduce the sequelae of neurological deficit in SEH. The purpose of this study was to retrospectively analyze a subset of clinical data of SEH after anterior cervical spine surgery, and to investigate the risk factors and treatment experience of this serious complication.Neurological deterioration after anterior cervical spine surgery was detected in six patients. Epidural hematoma was confirmed by emergency cervical magnetic resonance imaging (MRI). The patients included five males and one female, with an average age of 56.7 ± 13.1 years (range 42-76 years). Three patients had a history of drinking and/or smoking. All of the patients were treated with nonsteroidal anti-inflammatory drugs (NSAIDs) preoperatively, but without anticoagulant drugs or pre-spinal surgery. The coagulation function was normal in all patients. Except for one patient, who had lower blood pressure (BP) during the operation and higher BP after the operation, the other patients had a normal level of BP during the pre-, intra-, and post-operation periods. The average time was 9.9 ± 6.7 hours (range, 2-19 hours) from the postoperative period to the initial neurological deficit and 6.3 ± 6.0 hours (range, 1.8-16.7 hours) from the initial deterioration to evacuation. Five patients underwent emergency evacuation, and one patient underwent conservative treatment. Four patients who underwent evacuation and one patient who received conservative treatment achieved neurological function recovery with an American Spinal Injury Association (ASIA) grade 2.4 ± 0.9 (range, 2-4 score) score at the last follow-up. One patient with confirmed arterial epidural hemorrhage during the evaluation showed no neurological function recovery at the last follow-up.Wide exposure of the epidural space and BP level during the perioperative period play an important role in the formation of SEH after anterior cervical spine surgery. Arterial epidural hematoma has serious consequences; therefore, early diagnosis and evaluation play an important role in the recovery from paralysis.
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Affiliation(s)
| | | | - Rupei Ye
- Department of Pathology, The affiliated Hospital of Southwest Medical University, Luzhou city, Sichuan province, China
| | | | | | - Fei Ma
- Department of Spinal Surgery
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Ji W, Zhang YJ, Zhou F, Mao HQ, Yang HL, Liu T. Comparing clinical outcomes of using 3 versus 5 titanium miniplates in laminoplasty for multilevel cervical myelopathy: A prospective cohort study. J Orthop Translat 2020; 20:67-72. [PMID: 31908935 PMCID: PMC6939103 DOI: 10.1016/j.jot.2019.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/15/2019] [Accepted: 10/18/2019] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE The aim of this study was to compare clinical outcomes, radiographic changes, and complications of cervical expansive open-door laminoplasty（EOLP）for cervical multilevel myelopathy, using either 3 or 5 titanium miniplates. SUMMARY OF BACKGROUND DATA Cervical EOLP is a common and effective operation for cervical myelopathy. Standard procedures utilise either 3 or 5 titanium miniplates; however, no definite conclusion has been given yet on the relationship between clinical outcomes and the quantity of titanium miniplates. METHOD We performed a prospective study of 92 patients who underwent EOLP with either 3 (n = 34) or 5 (n = 58) titanium miniplates at our institution from March 2012 to June 2016. Clinical and radiologic outcomes and complications were compared. RESULT Compared with the 5 titanium miniplates group, the 3 titanium miniplates group had shorter operation times and less blood loss (P < 0.05) and needed fewer costs (P < 0.01) during index hospitalisation. The preoperative cervical curvature angle decreased in both groups and revealed no significant differences. There was no significant difference between the two groups in the Japanese Orthopedic Association (JOA) score, JOA recovery rate, loss of range of motion (ROM), anteroposterior diameter (APD), or spinal canal complications (P > 0.05). CONCLUSION Cervical EOLP using 3 titanium miniplates is associated with shorter operation times, less blood loss, and lower operation costs compared with using 5 titanium miniplates. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE Expansive open-door laminoplasty (EOLP) is an effective procedure for treating multilevel cervical spondylotic myelopathy. The present study indicated that 3 titanium miniplates could achieve similar clinical outcomes but with shorter operation times, less blood loss and operation costs compared with 5 titanium miniplates. These findings may provide some references for clinical applications.
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Affiliation(s)
- Wei Ji
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yi-Jian Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Feng Zhou
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hai-qing Mao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hui-lin Yang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Tao Liu
- Department of Orthopaedic Surgery, The Friendship Hospital of Yili Kazakh Autonomous Prefecture, Xinjiang, China
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Abstract
STUDY DESIGN This study was a retrospective cohort design. OBJECTIVE The objective of this study was to examine the impact of tranexamic acid (TXA) on total perioperative wound output following thoracic and lumbar spinal fusions. SUMMARY OF BACKGROUND DATA TXA has been extensively studied with regard to intraoperative blood loss and transfusion rates. Few studies have looked specifically at the effect of TXA on postoperative drain output. MATERIALS AND METHODS We examined blood loss patterns in 617 consecutive adult patients undergoing lumbar and/or thoracic fusions at a single institution from January 2009 to 2016. These patients were divided into TXA and non-TXA, as well as high-dose and low-dose TXA, groups and analyzed using a propensity score to account for differences between cohorts. RESULTS The TXA and non-TXA groups were demographically similar. The mean number of levels fused was higher in the TXA group (4.8 vs. 3.1 levels, P<0.01). There was a significant reduction in both intraoperative blood loss (77.7 mL per level, P=0.020) and postoperative drain output (83.3 mL per level, P=0.002) in the TXA group when examined on a per level fused basis, but no significant difference without controlling for a number of levels. Postoperative blood loss tended to be higher in the TXA group for surgeries involving >5 levels fused. There was a significantly less blood loss in the high-dose TKA group both intraoperatively (296.4 mL per level fused, P<0.001) and postoperatively (133.4 mL per level fused, P<0.001). CONCLUSIONS TXA significantly reduced both intraoperative and postoperative blood loss in lumbar and thoracic fusions when examined on a per level basis. However, with surgeries involving fusions >5 levels, TXA may increase postoperative drain output, with those losses offset by reduced intraoperative blood loss. High-dose TXA further reduced both intraoperative and postoperative blood loss as compared with low-dose TXA.
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Neurological injury as a complication of spinal surgery: incidence, risk factors, and prognosis. Spinal Cord 2019; 58:318-323. [DOI: 10.1038/s41393-019-0367-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/16/2019] [Accepted: 09/24/2019] [Indexed: 02/05/2023]
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Navarro JN, Sampaio FDAU, Andrioli MSD, Ribeiro FR, Fiore ME, Quidute BSQ, Neves MWF. Spinal subdural hematoma after lumbar discectomy without dural injury - Is it possible? A case report and literature review. Surg Neurol Int 2019; 10:66. [PMID: 31528404 PMCID: PMC6744825 DOI: 10.25259/sni-32-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/15/2019] [Indexed: 12/04/2022] Open
Abstract
Background: Spinal subdural hematoma (SSDH) is a rare complication of lumbar discectomy. Here, the authors reviewed 10 articles concerning the etiology, clinical, diagnostic, and surgical management of SSDH. Case Description: A postoperative SSDH occurred following a lumbar microdiscectomy in an 80-year-old patient in the absence of a dural injury. Conclusion: SSDH is a rare complication of lumbar discectomy and may even occur without a dural fistula. Notably, magnetic resonance is the diagnostic study of choice to identify this pathology that may then be appropriately managed.
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Affiliation(s)
| | | | | | | | - Mariano Ebram Fiore
- Department of Neurosurgery, Instituto Paulista de Referência, São Paulo, Brazil
| | - Bartolomeu Souto Queiroz Quidute
- Department of Neurosurgery, Neurosurgery Resident of Hospital Beneficência Portuguesa de São Paulo - Equipe CENNA (Centro Especializado de Neurologia e Neurocirurgia Associados LTDA), São Paulo, Brazil
| | - Maick Wilen Fernandes Neves
- Department of Neurosurgery, Neurosurgery Resident of Hospital Celso Pierro, PUC Campinas, Campinas, São Paulo, Brazil
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Risk Factors of Postoperative Spinal Epidural Hematoma After Biportal Endoscopic Spinal Surgery. World Neurosurg 2019; 129:e324-e329. [DOI: 10.1016/j.wneu.2019.05.141] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 11/22/2022]
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