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Meyrat R, Vivian E, Sridhar A, Gulden RH, Bruce S, Martinez A, Montgomery L, Reed DN, Rappa PJ, Makanbhai H, Raney K, Belisle J, Castellanos S, Cwikla J, Elzey K, Wilck K, Nicolosi F, Sabat ME, Shoup C, Graham RB, Katzen S, Mitchell B, Oh MC, Patel N. Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review. Medicine (Baltimore) 2023; 102:e36142. [PMID: 38013300 PMCID: PMC10681460 DOI: 10.1097/md.0000000000036142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023] Open
Abstract
The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.
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Affiliation(s)
- Richard Meyrat
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Elaina Vivian
- Performance Improvement, Methodist Dallas Medical Center, Dallas, TX
| | - Archana Sridhar
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - R. Heath Gulden
- Anesthesia Consultants of Dallas Division, US Anesthesia Partners, Dallas, TX
| | - Sue Bruce
- Clinical Outcomes Management, Methodist Dallas Medical Center, Dallas, TX
| | - Amber Martinez
- Pre-Surgery Assessment, Methodist Dallas Medical Center, Dallas, TX
| | - Lisa Montgomery
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Donald N. Reed
- Neurosurgery Division, Methodist Health System, Dallas, TX
| | | | | | | | | | - Stacey Castellanos
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Judy Cwikla
- Neurocritical Care Unit, Methodist Dallas Medical Center, Dallas, TX
| | - Kristin Elzey
- Pharmacy, Methodist Dallas Medical Center, Dallas, TX
| | - Kristen Wilck
- Clinical Nutrition, Methodist Dallas Medical Center, Dallas, TX
| | - Fallon Nicolosi
- Methodist Community Pharmacy – Dallas, Methodist Dallas Medical Center, Dallas, TX
| | - Michael E. Sabat
- Surgery and Recovery, Methodist Dallas Medical Center, Dallas, TX
| | - Chris Shoup
- Executive Office, Methodist Health System, Dallas, TX
| | - Randall B. Graham
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Stephen Katzen
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Bartley Mitchell
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Michael C. Oh
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Nimesh Patel
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
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Clinical Trials of Probiotic Strains in Selected Disease Entities. Int J Microbiol 2020; 2020:8854119. [PMID: 32565816 PMCID: PMC7292209 DOI: 10.1155/2020/8854119] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022] Open
Abstract
Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host. Although their mechanism of action is not clearly explained, it is known that they positively modulate the immune system, which leads to immunity potentiation. A number of studies prove that probiotics strengthen cognitive functions, reduce anxiety, and regulate the lipid metabolism in the human body. Probiotics used in humans are most often of the Lactobacillus and Bifidobacterium species. However, as more research is conducted, new species with beneficial, probiotic properties are being discovered. This paper provides a review of available information about the influence of probiotics on human health. It summarizes the current knowledge on the mechanism of action of probiotics as well as clinical trial results proving their efficacy in allergic, neurodegenerative, and cardiac diseases. This review also discusses the data concerning the safety of probiotics in clinical treatment.
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Helenius LL, Oksanen H, Lastikka M, Pajulo O, Löyttyniemi E, Manner T, Helenius IJ. Preemptive Pregabalin in Children and Adolescents Undergoing Posterior Instrumented Spinal Fusion: A Double-Blinded, Placebo-Controlled, Randomized Clinical Trial. J Bone Joint Surg Am 2020; 102:205-212. [PMID: 31770296 DOI: 10.2106/jbjs.19.00650] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pregabalin as part of a multimodal pain-management regimen has been shown to reduce opioid consumption after spinal surgery in adults but it is unclear whether this is also true in adolescents. Pregabalin has been found to have neuroprotective effects and therefore could have a positive impact on pain after spinal deformity surgery. We conducted a randomized, double-blinded, placebo-controlled clinical trial of adolescent patients undergoing spinal fusion to evaluate the short-term effects of pregabalin on postoperative pain and opioid consumption. METHODS Adolescents with adolescent idiopathic scoliosis, Scheuermann kyphosis, or spondylolisthesis who were scheduled for posterior spinal fusion with all-pedicle-screw instrumentation were randomized to receive either pregabalin (2 mg/kg twice daily) or placebo preoperatively and for 5 days after surgery. The patients ranged from 10 to 21 years of age. The primary outcome was total opioid consumption as measured with use of patient-controlled analgesia. Postoperative pain scores and opioid-related adverse effects were evaluated. RESULTS Sixty-three of 77 eligible patients were included and analyzed. Cumulative oxycodone consumption per kilogram did not differ between the study groups during the first 48 hours postoperatively, with a median of 1.44 mg/kg (95% confidence interval [CI],1.32 to 1.67 mg/kg) in the pregabalin group and 1.50 mg/kg (95% CI, 1.39 to 1.79 mg/kg) in the placebo group (p = 0.433). A subgroup analysis of 51 patients with adolescent idiopathic scoliosis showed the same result, with a mean of 1.45 mg/kg (95% CI, 1.24 to 1.65 mg/kg) in the pregabalin group and 1.59 mg/kg (95% CI, 1.37 to 1.82 mg/kg) in the placebo group (p = 0.289). Total oxycodone consumption per hour (mg/kg/hr) was not different between the groups over the time points (p = 0.752). The postoperative pain scores did not differ significantly between the groups (p = 0.196). CONCLUSIONS The use of perioperative pregabalin does not reduce the postoperative opioid consumption or pain scores in adolescents after posterior spinal fusion surgery. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Linda L Helenius
- Departments of Anaesthesiology and Intensive Care (L.L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.L.H., H.O., M.L., O.P., and I.J.H.), University of Turku and Turku University Hospital, Turku, Finland
| | - Hanna Oksanen
- Departments of Anaesthesiology and Intensive Care (L.L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.L.H., H.O., M.L., O.P., and I.J.H.), University of Turku and Turku University Hospital, Turku, Finland
| | - Markus Lastikka
- Departments of Anaesthesiology and Intensive Care (L.L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.L.H., H.O., M.L., O.P., and I.J.H.), University of Turku and Turku University Hospital, Turku, Finland
| | - Olli Pajulo
- Departments of Anaesthesiology and Intensive Care (L.L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.L.H., H.O., M.L., O.P., and I.J.H.), University of Turku and Turku University Hospital, Turku, Finland
| | | | - Tuula Manner
- Departments of Anaesthesiology and Intensive Care (L.L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.L.H., H.O., M.L., O.P., and I.J.H.), University of Turku and Turku University Hospital, Turku, Finland
| | - Ilkka J Helenius
- Departments of Anaesthesiology and Intensive Care (L.L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.L.H., H.O., M.L., O.P., and I.J.H.), University of Turku and Turku University Hospital, Turku, Finland
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Anesthetic management of complex spine surgery in adult patients: a review based on outcome evidence. Curr Opin Anaesthesiol 2020; 32:600-608. [PMID: 31461735 DOI: 10.1097/aco.0000000000000765] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to review the evidence regarding the anesthetic management of blood loss, pain control, and position-related complications of adult patients undergoing complex spine procedures. RECENT FINDINGS The most recent evidence of the anesthetic management of complex spine surgery was identified with a systematic search and graded. In our review, prophylactic tranexamic acid and optimal prone positioning were shown to be effective blood conservation strategies with minimal risks to the patients. Cell saver was cost-effective in complex surgeries with expected blood loss of greater than 500 ml. As for pain control, most interventions only produced mild analgesic effects, suggesting a multimodal approach is necessary to achieve optimal pain control after spine surgery. Regional techniques and NSAIDs were effective but because of their risks, their usage should be discussed with the surgical team. Further studies are required to assess the effectiveness, cost-effectiveness, and risks associated with combined uses of different analgesic interventions. On the basis of the available evidence, we recommend a combined use of gabapentinoids, ketamine, and opioids to achieve optimal analgesia. Lastly, literature for position-related injuries is heavily relied on case reports and the Anesthesia Closed Claim Study because of their rarity. Therefore, we advocate for a structured team-based approach with checklists to minimize position-related complications. SUMMARY As the number and complexity of spine procedures are being performed worldwide is increasing, we suggested to bundle the aforementioned effective interventions as part of an ERAS spine protocol to improve the patient outcome of spine surgery.
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Khanna P, Sarkar S, Garg B. Anesthetic considerations in spine surgery: What orthopaedic surgeon should know! J Clin Orthop Trauma 2020; 11:742-748. [PMID: 32879562 PMCID: PMC7452283 DOI: 10.1016/j.jcot.2020.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/26/2022] Open
Abstract
With clinical innovation and technological advancement, the paradigm of surgical procedures on the spine and spinal cord along with the perioperative management are rapidly evolving. Irrespective of different modes the anesthetic management of spine surgery is challenging in view of significant blood loss, prolong procedure, position-related complications, and complex pain management. The enhanced recovery after surgery (ERAS) for this kind of surgery is yet to be finalized. The aim of this article is to highlight the current evidence-based major perioperative considerations for patients undergoing spine surgery.
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Affiliation(s)
- Puneet Khanna
- Department of Anaesthesia, Pain Medicine & Critical Care, AIIMS, New Delhi, India
- Corresponding author.
| | - Soumya Sarkar
- Department of Anaesthesia, Pain Medicine & Critical Care, AIIMS, New Delhi, India
| | - Bhavuk Garg
- Department of Orthopaedics, AIIMS, New Delhi, India
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