Blood Loss Reduction During Surgical Correction of Adolescent Idiopathic Scoliosis Utilizing an Ultrasonic Bone Scalpel

Ultrasonic bone scalpel in spine surgery

Background

Spine surgery has always been considered technically demanding even in the hands of the most experienced surgeon on account of close proximity of vital soft tissue structures. Technical advancements over the last few decades have been crucial for the progress of this complex speciality which not only increased the surgical accuracy, but patient safety as well. Ultrasonic devices are one such innovation based on piezoelectric vibrations, patented by Fernando Bianchetti, Domenico Vercellotti, and Tomaso Vercellotti in 1988.

Methods

We did an extensive literature search on ultrasonic devices and their applications in the field of spine surgery.

Results

We present the various ultrasonic bone devices available including their physical, technologic and clinical aspects in spine surgery. We also attempt to cover the limitations and future advances of Ultrasonic bone scalpel (UBS) in particular, which would be interesting and informative for any spine surgeon who is novice in this field.

Conclusion

UBS has been found to be safe and effective in all forms of spine surgeries offering distinct advantages over conventional instruments, although limited by an inherent learning curve.

Craniectomies for dogs with skull multilobular osteochondrosarcoma using the Misonix bone scalpel: cadaveric evaluation and retrospective case series

OBJECTIVES

To evaluate the Misonix bone scalpel (MBS) for craniotomies in dogs and describe clinical findings and surgical experience in three dogs with large multilobular osteochondrosarcoma (MLO) of the skull.

STUDY DESIGN

Cadaver evaluation and retrospective case series.

ANIMALS

One canine cadaver; three client-owned dogs.

METHODS

Craniotomies of different sizes and at different locations were performed with MBS. Dural tear and bone discoloration were recorded. Clinical, imaging, and surgical findings of dogs diagnosed with MLO and where MBS was used for craniectomies were retrospectively included.

RESULTS

Cadaveric evaluation identified MBS as an efficient tool for rapid craniectomies (> 5minutes) albeit dural tears and some small foci of bone discoloration were observed. Craniectomies could be performed without complications in three dogs with MLO without dural tear or bone discoloration. .Excision was in complete in all cases. The short-term outcome was good, and the long-term outcome was fair to good.

CONCLUSION

Piezoelectric bone surgery with the Misonix bone scalpel is an alternative technology to perform craniectomies in dogs. It was not associated with complications in 3 dogs diagnosed and surgically treated for MLO. Dural tears and suspected bone necrosis can occur. Great care should be taken when using CT to establish disease free surgical osteotomy.

Ergonomics in Spine Surgery

As physician burnout and wellness become increasingly recognized as vital themes for the medical community to address, the topic of chronic work-related conditions in surgeons must be further evaluated. While improving ergonomics and occupational health have been long emphasized in the executive and business worlds, particularly in relation to company morale and productivity, information within the surgical community remains relatively scarce. Chronic peripheral nerve compression syndromes, hand osteoarthritis, cervicalgia and back pain, as well as other repetitive musculoskeletal ailments affect many spinal surgeons. The use of ergonomic training programs, an operating microscope or exoscope, powered instruments for pedicle screw placement, pneumatic Kerrison punches and ultrasonic osteotomes, as well as utilizing multiple surgeons or microbreaks for larger cases comprise several methods by which spinal surgeons can potentially improve workspace health. As such, it is worthwhile exploring these areas to potentially improve operating room ergonomics and overall surgeon longevity.

Effect of Ultrasonic Osteotome on Therapeutic Efficacy and Safety of Spinal Surgery: A System Review and Meta-Analysis

Background. A meta-analysis was performed to evaluate the effectiveness and safety of ultrasonic osteotomes in spine surgery to standard spinal surgery procedures. Methods. Using the search keywords “bone curette”, “cutter”, “scalpel”, “bone shaver”, “aspirator”, “osteotome”, “ultrasonic”, “piezosurgery”, and “ ${\text{dent}\hspace{0.17em}\hspace{0.17em}}^{\ast }$ ” in the databases of PubMed (1966-2021.12), Cochrane Library, Embase (1986-2018.12), Web of Science (1978-2021.12), and China Academic Journals Full-Text Database (CNKI, 1979-2021.12). Two researchers reviewed the literature, extracted and extensively assessed the data, and included information on the study quality. RevMan v5.3.5.0 was used for the meta-analysis. Results. A total of 10 trials with a total of 911 patients were included. The meta-analysis findings revealed that, when compared to traditional methods, ultrasonic osteotomes could save operation time ( $\text{OR}=-18.83$ , 95 percent CI (-22.76, -14.99), $P=0.03$ ) and reduce intraoperative bleeding ( $\text{OR}=-66.73$ , 95 percent CI (-75.70, -57.76), $P=0.04$ ) and postoperative complications ( $\text{OR}=0.38$ , 95 percent CI (0.21, 0.69), $P=0.001$ ). There was, however, no significant difference in the hospital stay ( $\text{OR}=-1.34$ , 95 percent CI (-1.90, -0.77), $P=0.23$ ) and symptom improvement rate ( $\text{OR}=1.03$ , 95 percent CI (0.73, 1.45), $P=0.86$ ). Conclusion. There is evidence that using an ultrasonic osteotome in spine surgery is safe and effective and may minimize intraoperative bleeding and save time. However, there is no significant difference in symptom improvement rate, hospital stay length, or postoperative complications compared to standard surgical equipment. Therefore, more high-quality investigations are needed to corroborate the initial results.

High- versus low-dose tranexamic acid as part of a Patient Blood Management strategy for reducing blood loss in patients undergoing surgery for adolescent idiopathic scoliosis

PURPOSE

The administration of tranexamic acid (TXA) has been shown to be beneficial in reducing blood loss during surgery for adolescent idiopathic scoliosis (AIS), but optimal dosing has yet to be defined. This retrospective study compared high- versus low-dose TXA as part of a Patient Blood Management strategy for reducing blood loss in patients undergoing posterior spine fusion surgery.

METHODS

Clinical records were reviewed for 223 patients with AIS who underwent posterior spinal fusion of five or more levels during a 6-year time period. We compared normalized blood loss, total estimated blood loss (EBL), and the need for transfusion between patients receiving high-dose TXA (loading dose of ≥ 30 mg/kg) versus low-dose TXA (loading dose < 30 mg/kg). Both groups received maintenance TXA infusions of 10 mg/kg/h until skin closure.

RESULTS

Patient demographics, curves, and surgical characteristics were similar in both groups. The high-dose TXA group had a 36% reduction in normalized blood loss (1.8 cc/kg/level fused versus 2.8 cc/kg/level fused, p < 0.001) and a 37.5% reduction in total EBL (1000 cc versus 1600 cc, p < 0.001). Patients in the high-dose group had a 48% reduction in PRBC transfusion, with only 19% receiving a transfusion of PRBC compared to 67% in the low-dose group (p < 0.001).

CONCLUSION

When combined with other proven Patient Blood Management strategies, the use of high-dose TXA compared to low-dose TXA may be beneficial in reducing blood loss for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Posterior spine fusion in a Jehovah's Witness patient with severe rigid idiopathic scoliosis – A case report

Introduction

Early onset scoliosis (EOS) represent a challenge for spine surgeons. The selection of the best treatment is complex. Some patients, such as Jehovah's Witnesses who refuse blood transfusions, are at high risk of complication when surgical treatment is required because blood loss is a major cause of morbidity and postoperative transfusion rates.

Research question

Describe blood-saving techniques that allowed an extensive and invasive surgical procedure in a Jehovah's Witness patient.

Material and method

17-year-old Jehovah's Witness girl with severe 120° Cobb Lenke 1A idiopathic scoliosis started as EOS was prepared with 4 cycles of recombinant human erythropoietin, iron and folic acid supplementation that brought her hemoglobin level from 13.6 g/dl to 16.2 g/dl. In the first surgical time, a temporary rod was implanted. Spine dissection using bipolar sealer and a special electrocautery that operates at lower temperatures than traditional ones was performed. Facetectomies and multilevel Ponte osteotomies was performed using an ultrasonic bone scalpel. The second surgical time, the definitive rods were placed, and the correction of the deformity was achieved using the rod link reducer technique.

Results

A good correction of the main curve in the coronal plane is achieve. The Hb nadir was 7.2 g/dl four days after the second operation. The postoperative course was uneventful.

Discussion and conclusion

The integration of modern and traditional preoperative, intraoperative, and postoperative blood sparing techniques allowed us to perform an extensive and invasive surgical procedure in a Jehovah's Witness girl with a severe idiopathic scoliosis.

•

The management of spine deformities in JW patients represent a challenges for spine surgeons.

•

In pediatric scoliosis fusion surgery, blood loss is a major cause of morbidity.

•

Preoperative, intraoperative, postoperative blood sparing techniques are essential for a good result.

Ultrasonic Bone Scalpel (USBS) Does Not Reduce Blood Loss During Posterior Spinal Fusion (PSF) in Patients with Adolescent Idiopathic Scoliosis (AIS): Randomized Clinical Trial

STUDY DESIGN

Randomized Clinical Trial.

OBJECTIVE

The aim of this study was to compare the efficacy of USBS with standard-of-care surgical instruments during posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS) by evaluating the difference in estimated blood loss per level fused (EBL/level).

SUMMARY OF BACKGROUND DATA

PSF surgery for AIS is often associated with high blood loss. Use of an ultrasonic bone scalpel (USBS) has been proposed to reduce blood loss during scoliosis surgery.

METHODS

This was a single-blinded (patient-blinded), randomized, controlled superiority trial. We randomized 66 patients with AIS undergoing PSF to the control group (osteotome) or the experimental group (USBS). The primary outcome was intraoperative EBL/level obtained from red blood cell salvage reports. One-year follow-up was available for 57 of 62 (92%) of patients.

RESULTS

EBL/level averaged 35 and 39 mL/level in the experimental and control groups, respectively [adjusted mean difference USBS - osteotome -8 mL/level, 95% CI: -16.4 to 0.3 mL/level, P = 0.0575]. There was no difference in curve correction [adjusted mean difference: -1.7%, 95% CI: -7.0 to 3.6%, P = 0.5321] or operative time [adjusted mean difference: -3.55 minutes, 95% CI: -22.45 to 15.46 min, P = 0.7089] between groups. Complications requiring change in routine postoperative care were noted in eight patients: two occurred in patients assigned to the experimental group and six occurred in patients assigned to the control group.

CONCLUSION

There was no clinically significant difference in total blood loss, EBL/level, or complications between the two groups. In contrast to reports from other centers, at our high-volume spine center, USBS did not lead to reduced blood loss during PSF for AIS. These results may not be generalizable to centers with longer baseline operative times or higher baseline average blood loss during PSF for AIS.Level of Evidence: 1.

Topical tranexemic acid reduces intra-operative blood loss and transfusion requirements in spinal deformity correction in patients with adolescent idiopathic scoliosis

PURPOSE

To evaluate the effectiveness of the use of topical tranexamic acid (tTXA) in spinal deformity correction in AIS patients METHODS: Sixty consecutive operative AIS patients were reviewed from a single institution and divided into two groups with similar demographics. Standardized peri-operative blood salvage techniques were utilized in all 60 patients. In the latter 30 patients, tTXA soaked sponges (1 g mixed in 500 ml Normal Saline) was utilised for wound packing during the entire surgical procedure compared to dry sponges as used in the former 30 patients. Both the groups were compared for the magnitude of deformity corrected, EBL per level fused, total EBL, blood transfused, drain output and peri-operative events.

RESULTS

Sixty AIS patients (mean age 14.4 yrs, 43 females, mean BMI 21.5, mean levels 10.7) were included. Both groups achieved similar change in Coronal Cobb correction. The EBVL (Estimated blood volume loss) % lost in the topical TXA group was 38% less than the control group (11.2 vs. 18.3%, p = 0.006). Similarly, the EBL/level was significantly lower in the topical TXA group (41 ± 30 ml vs. 57 ± 26 ml, p = 0.03). Three of 30 patients in the control group required at least 1 unit of blood transfusion, whereas only 1 patient in the topical TXA group required transfusion (10 vs. 3.3%, p = 0.001). No differences were noted in post-operative drain output, change in hemoglobin levels, and peri-operative complication rates.

CONCLUSION

When used as an adjunct to the conventional blood salvage techniques in spinal deformity correction procedures, the use of tTXA resulted in reduced operative blood loss, and blood transfusion requirements.

Safe and effective performance of pediatric spinal deformity surgery in patients unwilling to accept blood transfusion: a clinical study and review of literature

BACKGROUND

Pediatric deformity surgery traditionally involves major blood loss. Patients refusing blood transfusion add extra clinical and medicolegal challenges; specifically the Jehovah's witnesses population. The objective of this study is to review the safety and effectiveness of blood conservation techniques in patients undergoing pediatric spine deformity surgery who refuse blood transfusion.

METHODS

After obtaining institutional review board approval, we retrospectively reviewed 20 consecutive patients who underwent spinal deformity surgery and refused blood transfusion at a single institution between 2014 and 2018. We collected pertinent preoperative, intraoperative and most recent clinical and radiological data with latest follow-up (minimum two-year follow-up).

RESULTS

Twenty patients (13 females) with a mean age of 14.1 years were identified. The type of scoliotic deformities were adolescent idiopathic (14), juvenile idiopathic (1), neuromuscular (3) and congenital (2). The major coronal Cobb angle was corrected from 55.4° to 11.2° (80% correction, p <  0.001) at the latest follow-up. A mean of 11.4 levels were fused and 5.6 levels of Pontes osteotomies were performed. One patient underwent L1 hemivertebra resection and three patients had fusion to pelvis. Estimated blood loss, percent estimated blood volume loss, and cell saver returned averaged 307.9 mL, 8.5%, and 80 mL, respectively. Average operative time was 214 min. The average drop in hemoglobin after surgery was 2.9 g/dL. The length of hospital stay averaged 5.1 days. There were no intraoperative complications. Three postoperative complications were identified, none related to their refusal of transfusion. One patient had in-hospital respiratory complication, one patient developed a late infection, and one patient developed asymptomatic radiographic distal junctional kyphosis.

CONCLUSIONS

Blood conservation techniques allow for safe and effective spine deformity surgery in pediatric patients refusing blood transfusion without major anesthetic or medical complications, when performed by an experienced multidisciplinary team.

LEVEL OF EVIDENCE

Level IV.

Primary lumbar decompression using ultrasonic bone curette compared to conventional technique

PURPOSE

The ultrasonic bone curette (Bone Scalpel) is a novel technique in neurosurgery for bony dissection. This study aimed to evaluate its use against conventional techniques for primary lumbar decompression.

MATERIALS AND METHODS

This study was a retrospective cohort comparison, using Spine Tango Registry data. All patients undergoing a primary procedure for lumbar decompression secondary to degenerative disease during a 2-year period (2014-2016) were identified, split into age and gender matched cohorts utilising either bone scalpel or conventional techniques intra-operatively.

RESULTS

Ninety-three patients were identified within each cohort, which did not differ significantly in terms of age, gender, BMI, number of operative vertebral levels or seniority of the principal surgeon. The incidence of intra-operative blood loss >100 ml was significantly reduced within the bone scalpel cohort (16.1% bone scalpel, 34.4% conventional, p = 0.04). There was no difference in the incidence of iatrogenic dural breach (9.7% bone scalpel, 16.1% conventional, p = 0.27). There was no significant difference in pre-operative Core Outcomes Measures Index (COMI) between the cohorts (7.91 bone scalpel, 8.02 conventional, p = 0.67) and both cohorts demonstrated a significant reduction in mean COMI at 24 months (bone scalpel p = 0.004, conventional p = <0.001). No difference in mean COMI existed between either cohort at any point across the 24-month post-operative period (p = 0.18).

CONCLUSIONS

The use of ultrasonic bone curette for primary lumbar decompression is associated with reduced intra-operative blood loss compared to conventional techniques, alongside a comparable safety profile and equivalent patient reported outcomes.

Do postoperative drain volumes correlate with intraoperative blood loss and postoperative transfusion requirements in posterior spinal fusion for adolescent idiopathic scoliosis?

Most studies have excluded postoperative drain volumes in analyzing blood loss associated with scoliosis surgery. We sought to analyze patient and surgical factors that influenced postoperative drain outputs. A retrospective review was conducted on 50 consecutive patients who had undergone posterior spinal fusion with pedicle screw instrumentation and subfascial drain placement over a 6-year period at a single institution for adolescent idiopathic scoliosis. Postoperative drain volumes were correlated to patient factors, surgical variables, and change in postoperative hemoglobin values. The association between drain output volumes and the need for allogeneic blood transfusion was also analyzed using univariate and multivariate analysis. Total postoperative drain volume positively correlated with Cell Saver volume (r=0.28, P=0.049), units of packed red blood cells transfused intraoperatively (r=0.31, P=0.03), and a number of Ponte osteotomies (r=0.43, P=0.002). On the basis of multiple linear regression analysis, only the number of osteotomies performed was associated with increasing total drain volume (R=0.25, P=0.003). Total drain output did not correlate with postoperative change in hemoglobin (P=0.85), the need for postoperative blood transfusion (P=0.22), or the total volume of blood transfused perioperatively (P=0.06). Patients with large intraoperative blood loss or multiple osteotomies are more likely to have higher postoperative drain volumes. Drain volume alone, however, should not be used as a trigger for recommending a postoperative blood transfusion.

Effect of the Ultrasonic Bone Scalpel on Blood Loss During Pediatric Spinal Deformity Correction Surgery

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Determine the effect of the ultrasonic bone scalpel (UBS) on intraoperative blood loss and surgical time.

SUMMARY OF BACKGROUND DATA

The UBS has shown beneficial effects in limiting blood loss in spinal surgery, but no study has examined its effect in patients with neuromuscular scoliosis.

METHODS

Clinical records were reviewed for patients aged 9-18 who underwent posterior spinal fusion surgery of five or more levels for scoliosis correction by the senior author from April 2013 until October 2016. Exclusion criteria included: vertebral column resections, previous spinal surgery, cell saver usage, cases complicated by signal loss on monitoring, and incomplete medical records. A total of 84 patients met the criteria and were included in data analysis. The UBS was routinely used for performing osteotomies and facetectomies for all cases operated after March 2015. These cases were compared to a control group who underwent surgery prior to this date in which the UBS was not used. The experimental and control groups were further divided into adolescent idiopathic (AIS) and neuromuscular (NMS) subgroups.

RESULTS

EBL in AIS patients decreased from 1,211 mL in the control group to 771 mL in the UBS group for an average total reduction of 440 mL (95% CI 106, 774, p = .01). In NMS patients, EBL fell from 2,171 mL in controls to 1228 mL in the study group for an average total reduction of 943 mL (95% CI 288, 1598, p < .01). On controlling for weight and number of levels fused, blood loss decreased 26.2% in AIS patients and 46.2% in NMS patients.

CONCLUSIONS

The ultrasonic bone scalpel is effective in reducing blood loss in AIS and NMS deformity correction surgery. Surgical time is not adversely affected by its use.

LEVEL OF EVIDENCE

Level II, cohort study.

Effects of Combined Use of Ultrasonic Bone Scalpel and Hemostatic Matrix on Perioperative Blood Loss and Surgical Duration in Degenerative Thoracolumbar Spine Surgery

How to decrease intraoperative bleeding, shorten surgical time, and increase safety in spinal surgery is an important issue. Ultrasonic bone removers and FloSeal have been proven to increase safety, reduce the surgical duration, and decrease intraoperative bleeding in skull base surgery. Therefore, we aimed to compare the surgical duration, blood loss, and complications during spinal surgery with or without the use of FloSeal and an ultrasonic bone scalpel. Therefore, we retrospectively reviewed 293 patients who underwent thoracolumbar spinal surgery with decompression and instrumented fusion performed by a single surgeon. We divided these patients into three groups, including nonuse of FloSeal nor a bone scalpel (group A), use of FloSeal only (group B), and use of FloSeal and a bone scalpel (group C) intraoperatively after pairing in terms of age, sex, and surgical level. The surgical duration, blood loss, and occurrence of complications were all recorded. The mean surgical duration in group A was 160 mins, in group B it was 167 mins, and in group C it was 134 mins. The mean blood loss was 700 ml in group A, 682 ml in group B, and 383 ml in group C. Six patients sustained intraoperative dura injuries in total, 3 in group A, 2 in group B, and 1 in group C. No postoperative neurologic defects or occurrences of hematoma were recorded. According to our results, we concluded that combined use of FloSeal and bone scalpels is recommended during primary thoracolumbar spinal surgery to reduce the intraoperative blood loss and shorten the surgical duration.

Ultrasonic bone scalpel: utility in cervical corpectomy. A technical note

PURPOSE

Anterior cervical corpectomy and fusion (ACCF) is a technically challenging surgery. Use of conventional instruments like high-speed burr and kerrison rongeurs is associated with high complication rates such as increased blood loss and incidental durotomy. Use of ultrasonic bone scalpel (UBS) in cervical corpectomy helps to minimize such adverse events.

METHODS

We performed a retrospective study based on the data of 101 consecutive patients who underwent cervical corpectomies with UBS for different cervical spine pathologies from December 2014 to December 2016. Total duration of surgery, time taken for corpectomy, estimated blood loss, and incidental durotomies were noted.

RESULTS

Total surgical time was 30-80 min (59.36 ± 13.21 min) for single-level ACCF and 60-120 min (92.74 ± 21.04 min) for double-level ACCF. Time taken for single-level corpectomy was 2 min 11  ± 10 s and 3 min 41  ± 20 s for double-level corpectomy. Estimated blood loss ranged from 20-150 ml (52.07 ± 29.86 ml) in single level and 40-200 ml (73.22 ± 41.64 ml) in double level. Four (3.96%) inadvertent dural tears were noted, two during single-level corpectomy and other two during double-level corpectomy.

CONCLUSIONS

Use of UBS is likely to provide a safe, rapid, and effective surgery when compared to conventional rongeurs and high-speed burr. The advantages such as lower blood loss and lower intra-operative incidental dural tears were noted with the use of UBS.

Development of Consensus Based Best Practice Guidelines for Perioperative Management of Blood Loss in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Delphi process with multiple iterative rounds using a nominal group technique.

OBJECTIVE

The aim of this study was to use expert opinion to achieve consensus on various methods for minimizing blood loss in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

BACKGROUND DATA

Perioperative blood loss management represents a critical component of safely performing PSF in children with AIS. Little consensus exists on ways to mitigate excessive blood loss after PSF.

METHODS

An expert panel composed of 21 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.

RESULTS

Consensus was reached to support 21 best practice guideline measures for perioperative management of blood loss in patients undergoing PSF for AIS. Areas included preoperative assessment and preparation, intraoperative strategies to decrease blood loss, and postoperative transfusion indications.

CONCLUSION

We present a consensus-based best practice guideline consisting of 21 recommendations for strategies to minimize and manage blood loss during PSF. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.

Use of image-guided bone scalpel for resection of spine tumors: technical note

In the literature, the use of navigation for spine tumor surgery has largely centered on implant placement. We describe the cases of two patients with spinal tumors on whom we utilized our resection technique of registering an ultrasonic bone scalpel (UBS) to a navigation system. In both cases, we achieved a satisfactory tumor resection with negative margins and excellent neurologic outcomes. We feel that using the navigation-registered UBS is a valuable tool to increase the operator's ability to achieve desired resections while minimizing the neurologic deficits and operative morbidity associated with these challenging surgical cases.

Beneficial effects of percutaneous minimally invasive surgery for patients with fractures in the thoracic spine

Percutaneous minimally invasive surgery (PMIS) is the most common surgical procedure used in patients with fractures in the thoracic spine. In the present study, the benefits of PMIS compared with the conventional open surgery (COS) were investigated in patients with thoracic spine fractures. A total of 84 patients were recruited in the current analysis. Inflammatory responses were measured in all patients subsequent to PMIS and COS. It was demonstrated that PMIS produced reduced inflammatory responses as compared with COS in clinical patients. In addition, the results revealed that kyphosis, anterolisthesis and the neurological state were significantly improved in patients subjected to PMIS compared with those receiving COS (P<0.01). The mean values of bone reduction and fracture correction loss were similar in the PMIS and COS groups (4.5 degrees). Furthermore, the outcomes indicated that the sensitivity for fracture localization to the correct vertebra was 0.90 in PMIS and 0.92 in COS (P>0.05). It was observed that patients who had undergone PMIS required reduced hospitalization time compared with the COS-treated patients (P=0.026). Additionally, the mean bleeding volume during surgery was 538 ml in the PMIS patients and 845 ml in the COS patients. Regarding physical activity, patients who underwent PMIS were relative more active compared with the COS patients (P=0.038) in a 14-day observation. In conclusion, the current clinical analysis indicated that PMIS was more beneficial for the treatment of patients with fractures in the thoracic spine, and the study provided further evidence for the management thoracic spine injuries.

THORACIC AND LUMBAR HEMIVERTEBRA EXCISION IN PEDIATRIC PATIENTS: HOW DOES THE OPERATION TECHNIQUE INFLUENCE ON OUTCOMES? (СOHORT ANALYSIS AND LITERATURE REVIEW)

Purpose of the study — to study impact of hemi-vertebrae extirpation technique in mono-segmental reconstruction on the surgical trauma.Material and Methods. 34 patients underwent 36 mono-segmental extirpations of hemi-vertebrae followed by a posterior fixation during a single center four years cohort study. Mean age of children at the moment of procedure was 4 years and 3 months (min — 1 year, max — 14 years). The authors studied impact of pathology level, surgical approach, type of bony structures removal technique and age of the patients on the time of procedure and volume of blood loss. Results. Extirpation of thoracic hemi-vertebrae was characterized by a lengthier procedure and greater blood loss in contrast to lumbar hemi-vertebrae. Patients were divided into three groups depending on extirpation technique: 1)  extirpation from two approaches using a high-speed burr; 2) from a single dorsal approach using the same extirpation technique; 3) from dorsal approach using ultrasonic bone scalpel. Surgery time was 208±72 min in the first group, 187±54 min in the second group, and 170±30 min in the third group; blood loss volume was 181±39, 181±53, 132±73 ml respectively in the groups, or 11.5±4.3%, 9.4±2.8% and 9.6±5.2% of total blood volume, respectively.Conclusion. Surgical approach and hemi-vertebrae extirpation technique in children have a varying impact on surgery time and intraoperative blood loss, and the least values were reported for posterior approach using ultrasonic bone scalpel.

Perioperative Management of Blood Loss in Spine Surgery

Spine procedures are associated with high rates of blood loss which can result in a greater need for transfusions. Repeated exposure to blood products is associated with risks and adverse reactions such as transfusion-related acute lung injury, fluid shifting, and infections. With the higher number of spine procedures and the increasing open surgery times associated with difficult procedures, excessive blood loss has become more prevalent. Perioperative methods have been established to combat the excessive blood loss and decrease the need for blood products. Preoperatively, anemia and coagulopathy screening is standard at least 4 weeks before elective procedures. Erythropoietin, iron loading or transfusions are used to decrease preoperative anemia, a predisposing factor for blood loss. Autologous predonation of blood has been shown to be ineffective and decreases preoperative hemoglobin levels. Intraoperatively, antifibrinolytics such as tranexamic acid and aminocaproic acid are used to decrease blood loss. In addition, fibrinogen concentrates, thromboelastometry, acute normovolemic hemodilution, controlled hypotension, and temperature regulation are some of the techniques used to decrease blood loss and the need for transfusions. Postoperatively, fibrin sealants, shed blood salvage, and erythropoietin or intravenous iron are used in management of blood loss, especially in instances when the patient refuses blood products.

Management of scoliosis in patients with Duchenne muscular dystrophy and spinal muscular atrophy: A literature review

Scoliosis occurs in nearly all non-ambulatory children with spinal muscular atrophy (SMA) and Duchenne muscular dystrophy (DMD). Non-operative treatments have not been shown to be effective at preventing progression of scoliosis. Progressive scoliosis can impact the ability of patients to sit comfortably, be cosmetically unappealing, and in severe cases exacerbate pulmonary disease. The main goal of operative treatment is to improve sitting balance and prevent progression of scoliosis. Complication rates are high and there is little data on effect of operative treatment on quality of life in children with SMA and DMD. Comprehensive multi-disciplinary pre-operative evaluations are vital to reduce the risks of operative treatment.

The Reliability of the Ultrasonic Bone Scalpel in Cervical Spondylotic Myelopathy: A Comparative Study of 46 Patients

BACKGROUND

In patients with cervical spondylotic myelopathy (CSM), laminectomy is usually performed with a Kerrison rongeur or a high speed drill (HSD).The HSD, which is most often selected for laminectomy, may cause complications such as duratomy, thermal and mechanical neural injuries. With an ultrasonic bone scalpel (UBS), a less traumatic laminectomy can be performed in a shorter time. The aim of this study was to compare the results of laminectomies using HSD and UBS.

METHODS

Evaluation was made in 46 patients who were operated on for CSM. Cervical laminectomy was performed on 23 patients using the UBS (group I) and to 23 using the HSD (group II). A comparison was made of the 2 groups in respect of demographic characteristics, laminectomy levels, mean laminectomy duration, bleeding rates, and surgical complications.

RESULTS

In group I, the mean laminectomy time was 2.2 ± 0.4 min/level, mean blood loss was 180 mL, hospitalization was 3.0 ± 0.0 days, and C5 radiculopathy was seen in 1 patient. In group II, the mean laminectomy time was 7.4 ± 2.6 min/level, mean blood loss was 380 mL, hospitalization was 3.7 ± 1.3 days, C5 radiculopathy was seen in 1 patient and dura injuries in 3 patients. The recovery rate was determined as 47.6% in group I and 48.8% in group II.

CONCLUSIONS

For patients with CSM, laminectomy using the UBS provides a safe, rapid, and effective decompression with a lesser blood loss. The low rate of complications lessens the postoperative morbidity rates and shortens hospital stay.