Intraoperative blood loss during different stages of scoliosis surgery: A prospective study

Modified Thoracoplasty for Rib Hump Deformity in Scoliosis Patients: A Case-Control Study

BACKGROUND

Razorback deformity with stiff thoracic scoliosis creates a complex three-dimensional deformity. Posterior spinal fusion (PSF) and thoracoplasty can correct rib hump deformity and improve patient satisfaction. However, conventional thoracoplasty may impair pulmonary function and increase complications. We present a modified thoracoplasty (MTP) technique for addressing rib hump deformity in stiff thoracic scoliosis patients, emphasizing its clinical efficacy and safety.

METHODS

This study included 44 patients with stiff thoracic scoliosis and razorback deformity who underwent surgery between January 2010 and May 2021. Patients were divided into PSF + MTP (n = 27) and PSF (n = 17) groups. Surgical parameters, complications, radiographic improvements, pulmonary function, and Scoliosis Research Society-22 scores were evaluated preoperatively and at 3 months and 2 years postoperatively.

RESULTS

There were no significant differences in baseline characteristics between the 2 groups, except for the rib hump height, which was higher in the PSF + MTP group. The PSF + MTP group showed superior correction of the thoracic curve and rib hump height compared to the PSF group, with significant improvements in self-image scores. No significant differences were observed in pulmonary function between the groups. The operative time was longer in the PSF + MTP group, but there were no significant differences in intraoperative blood loss, hospitalization costs, or major complications. Regression analysis indicated that the type of surgery, thoracic Cobb angle, and preoperative self-image scores were significant predictors of postoperative self-image scores.

CONCLUSIONS

MTP provides enhanced correction of thoracic curve and rib hump deformity without significantly increasing pulmonary function impairment or complication rates. It also improves patients' self-image, making it a valuable addition to PSF in treating stiff thoracic scoliosis with rib hump deformity.

Elevated preoperative blood pressure and its relationship to intraoperative mean arterial pressure and blood loss in posterior spinal fusion for adolescent idiopathic scoliosis

PURPOSE

The relationship between preoperative blood pressure (BP) and intraoperative mean arterial pressure (MAP) and estimated blood loss (EBL) in pediatric spine surgery is currently unknown. The objectives of this study were to determine if elevated preoperative BP is associated with elevated intraoperative MAP, EBL, and percentage estimated blood volume (EBV) lost, and to determine if intraoperative MAP is associated with percentage of EBV lost during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

This is a retrospective cohort analysis of 209 patients undergoing PSF for AIS between 2016 and 2019 by a single surgeon. Data extracted included demographic characteristics, preoperative systolic and diastolic BP, continuous intraoperative MAP measured by arterial line, EBL, radiographic, and surgical characteristics. Time points of interest for MAP included incision and exposure. Elevated BP was defined as > 1 standard deviation above the mean BP of patients included in the study, and elevated MAP was defined as > 65 mmHg.

RESULTS

Elevated preoperative systolic BP was associated with elevated MAP at incision (p = 0.002). Patients with elevated preoperative diastolic BP had significantly higher MAP at exposure and throughout the procedure (p = 0.04). MAP > 65 at incision was associated with a 5% increase in EBV lost (p < 0.001).

CONCLUSIONS

Patients with elevated preoperative BP parameters have increased MAPs at incision, exposure, and throughout surgery. Elevated MAP at incision is associated with an increased percentage of EBV lost in a small number of patients undergoing PSF for AIS.

Integrated spine trauma team protocol: Combined neurosurgical and orthopedic experience for the management of traumatic spinal injuries

Objectives

During the last decades, spine surgery has grown exponentially. In spite of that, it remains a surgical specialty without a well-defined own certification. It is usually carried out, separately, by neurosurgeons and orthopedic surgeons, even if there is an overlapping of competence and skills.

Materials and Methods

In our hospital, from January 2019, a systematic protocol called integrated spine trauma team protocol (ISTTP) was implemented to improve the management of traumatic spinal injuries in a multidisciplinary way. It is characterized by a specific algorithm from diagnosis to postoperative care. According to the new protocol, orthopedic spinal surgeons and neurosurgeons work together as an integrated spine trauma team. The authors analyzed, retrospectively, the results obtained by comparing patients treated before and after the application of the ISTTP.

Results

The new protocol allowed a statistically significant reduction in waiting time before surgery and complication rate. Moreover, early discharge of patients was recorded. To the best of our knowledge, this is the first study that described a specific algorithm for a standardized multidisciplinary management of the spinal trauma with combined orthopedic and neurosurgeon expertise.

Conclusion

Our preliminary results suggest that the application of our ISTTP leads to better results for treating traumatic spinal injury (TSI).

Intraoperative Blood Loss at Different Surgical-Procedure Stages during Posterior Spinal Fusion for Idiopathic Scoliosis

Background and Objectives: Several predictive factors have been reportedly associated with intraoperative total blood loss (TBL) during posterior spinal fusion (PSF) for idiopathic scoliosis (IS). To reduce TBL, preoperative factors and interoperative factors are considered important. However, there are few reports that have evaluated bleeding patterns according to surgical stages. This study aimed to elucidate bleeding patterns at different surgical stages and determine the predictive factors for TBL during PSF surgery in patients with IS. Materials and Methods: Preoperative data, radiographic parameters, and intraoperative data of patients undergoing PSF for IS were retrospectively collected. We divided the patients into six stages: stage 1, exposure; stage 2, implant placement; stage 3, release; stage 4, correction; stage 5, bone grafting; and stage 6, closure; then we reviewed the blood loss and bleeding speed. Multiple-regression analysis was performed to generate a predictive formula for blood loss using preoperative and intraoperative factors, including blood loss at stage 1, as explanatory variables. Results: Forty-five patients (mean age: 17.6 years) were included. The mean operative time and TBL were 287.9 min and 756.5 mL, respectively. Blood loss was the highest at stage 3, followed by stage 4. Bleeding speed was the highest at stage 4, followed by stage 3. Bleeding speeds at stages 3 and 4 were significantly higher than those at stages 1 and 2. Preoperative Cobb angle, activated partial thromboplastin time (aPTT), number of fused vertebrae, and blood loss at stage 1 were significant contributing factors. Conclusions: Blood loss and bleeding speed during the release and correction stages were high. Specifically, bleeding speed significantly increased during and after the release procedure. The preoperative Cobb angle, aPTT, number of fixed vertebrae, and blood-loss volume during PSF were significantly associated with TBL. Our findings would be helpful for reducing TBL in patients undergoing PSF for IS.

Application of vertebral body compression osteotomy in pedicle subtraction osteotomy on ankylosing spondylitis kyphosis: Finite element analysis and retrospective study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease, with pathological characteristics of bone erosion, inflammation of attachment point, and bone ankylosis. Due to the ossified intervertebral disc and ligament, pedicle subtraction osteotomy (PSO) is one of the mainstream surgeries of AS-related thoracolumbar kyphosis, but the large amount of blood loss and high risk of instrumental instability limit its clinical application. The purpose of our study is to propose a new transpedicular vertebral body compression osteotomy (VBCO) in PSO to reduce blood loss and improve stability.

METHODS

A retrospective analysis was performed on patients with AS-related thoracolumbar kyphosis who underwent one-level PSO in our hospital from February 2009 to May 2019. A total of 31 patients were included in this study; 6 received VBCO and 25 received eggshell vertebral body osteotomy. We collected demographic data containing gender and age at diagnosis. Surgical data contained operation time, estimated blood loss (EBL), and complications. Radiographic data contained pre-operative and follow-up sagittal parameters including chin brow-vertical angle (CBVA), global kyphosis (GK), thoracic kyphosis (TK), and lumbar lordosis (LL). A typical case with L2-PSO was used to establish a finite element model. The mechanical characteristics of the internal fixation device, vertebral body, and osteotomy plane of the two osteotomy models were analyzed under different working conditions.

RESULTS

The VBCO could provide comparable restoring of CBVA, GK, TK, and LL in the eggshell osteotomy procedure (all p > 0.05). The VBCO significantly reduced EBL compared to those with eggshell osteotomy [800.0 ml (500.0-1,439.5 ml) vs. 1,455.5 ml (1,410.5-1,497.8 ml), p = 0.033]. Compared with the eggshell osteotomy, VBCO showed better mechanical property. For the intra-pedicular screw fixation, the VBCO group had a more average distributed and lower stress condition on both nails and connecting rod. VBCO had a flattened osteotomy plane than the pitted osteotomy plane of the eggshell group, showing a lower and more average distributed maximum stress and displacement of osteotomy plane.

CONCLUSION

In our study, we introduced VBCO as an improved method in PSO, with advantages in reducing blood loss and providing greater stability. Further investigation should focus on clinical research and biomechanical analysis for the application of VBCO.

Minimally Invasive Scoliosis Surgery Is a Feasible Option for Management of Idiopathic Scoliosis and Has Equivalent Outcomes to Open Surgery: A Meta-Analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVE

To compare outcomes between minimally invasive scoliosis surgery (MISS) and traditional posterior instrumentation and fusion in the correction of adolescent idiopathic scoliosis (AIS).

METHODS

A literature search was performed using MEDLINE, PubMed, EMBASE, Google scholar and Cochrane databases, including studies reporting outcomes for both MISS and open correction of AIS. Study details, demographics, and outcomes, including curve correction, estimated blood loss (EBL), operative time, postoperative pain, length of stay (LOS), and complications, were collected and analyzed.

RESULTS

A total of 4 studies met the selection criteria and were included in the analysis, totaling 107 patients (42 MIS and 65 open) with a mean age of 16 years. Overall there was no difference in curve correction between MISS (73.2%) and open (76.7%) cohorts. EBL was significantly lower in the MISS (271 ml) compared to the open (527 ml) group, but operative time was significantly longer (380 min for MISS versus 302 min for open). There were no significant differences between the approaches in pain, LOS, complications, or reoperations.

CONCLUSION

MISS was associated with less blood loss but longer operative times compared to traditional open fusion for AIS. There was no difference in curve correction, postoperative pain, LOS, or complications/reoperations. While MISS has emerged as a feasible option for the surgical management of AIS, further research is warranted to compare these 2 approaches.

Association between the reactivity of local cerebral oxygen saturation after hypo-to-hypercapnic tests and delirium after abdominal surgery in older adults: A prospective study

OBJECTIVE

This study aimed to investigate the correlation between changes in regional cerebral oxygen saturation (rSO2) and postoperative delirium in older adults undergoing major abdominal surgery.

MATERIALS AND METHODS

This prospective study enrolled older adults scheduled for elective major abdominal surgery at the Second Affiliated Hospital of Anhui Medical University from August 2021 to January 2022. The change in rSO2 from baseline was determined using the hypo-to-hypercapnic test. The main study outcome was the occurrence of postoperative delirium.

RESULTS

A total of 101 participants were included for analysis, of whom 16 (15.8%) developed postoperative delirium. Compared with non-delirium participants, the mean arterial pressure and heart rate were not significantly different in the postoperative delirium group at T0, T1, T2, T3, T4, and T6 (all P_interaction > 0.05), but the delirium group had lower pH, lower PaO2, and higher lactate levels at T4, T5, and T6 (all P_interaction < 0.05). rSO2 at T0, T1, T2, T3, T4, and T6 was 69.0 (63.2-75.2), 70.7 ± 7.3, 68.2 ± 7.5, 72.1 ± 8.0, 69.9 ± 7.8, 67.4 ± 7.2, and 71.7 ± 8.1, respectively. The postoperative change in rSO2 during the hypercapnia test (TΔrSO2%) was 6.62 (5.31-9.36). Multivariable analysis showed that the Cumulative Illness Rating Scale (odd ratio, OR = 1.89, 95% confidence interval, CI: 1.10-3.25, P = 0.021), preoperative albumin levels (OR = 0.67, 95% CI: 0.48-0.94, P = 0.022), rSO2 at T4 (OR = 0.61, 95% CI: 0.41-0.89, P = 0.010), and postoperative TΔrSO2% (OR = 0.80, 95% CI: 0.66-0.98, P = 0.028) were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery.

CONCLUSION

The rSO2 measured at T4 and postoperative TΔrSO2% were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery.

Minimally invasive scoliosis surgery for adolescent idiopathic scoliosis using posterior mini-open technique

The purpose of this study aimed to analyze and evaluate the radiologic and clinical outcomes of minimally invasive scoliosis surgery (MISS) for correcting adolescent idiopathic scoliosis (AIS) using the mini-open technique. Thirty-four AIS patients who underwent MISS using the mini-open technique for deformity correction. Using two to four 3-centimeter-long skin incisions (mini-open) and tubular retractors, we performed screw fixations, rod assembly, rod derotation maneuver (RD), and bone graft. For thoracoplasty, four to six ribs were resected using the same incisions. Correction was attempted using rod translation and RD maneuvers. Radiological outcomes and clinical outcomes (SRS-22) were evaluated. Mean preoperative Cobb's angle was 61.3° and curve flexibility (major curve) was 26.1%. This angle was corrected to 21.6° with a correction rate of 65.2% (P < 0.001). The coronal balance was not changed significantly. Sagittal vertical axes were corrected from -3.5 mm to 8.6 mm (-22 to 36.3 mm) (P = 0.009). Thoracic kyphosis angles and lumbar lordosis angles were not changed significantly but the values were within normal range. Each score of self-image in the SRS-22 questionnaire as well as the total score were improved significantly (P < 0.001). In conclusion, the MISS for correcting AIS using the mini-open technique showed comparable radiologic and clinical outcomes with fewer complications in patients with non-rigid scoliosis with Cobb's angle between 50° and 80°. Long-term results of this novel MISS using the mini-open technique could further strengthen the rationale for adopting this technique for curve correction in selected cases of AIS.

Improving Safety and Efficacy in the Surgical Management of Low-tone Neuromuscular Scoliosis: Integrated Approach With a 2-attending Surgeon Operative Team and Modified Anesthesia Protocol

BACKGROUND

Substantially increased operative time and amount of bleeding may complicate the course of surgical treatment in neuromuscular scoliosis. A well-organized team approach is required to reduce morbidity. The aim of this study is to review our early, short-term surgical outcomes with our new integrated approach that includes a 2-attending surgeon team and modifications in the anesthesia protocol in low-tone neuromuscular scoliosis and compare with a matched cohort of our historic patients.

METHODS

We retrospectively reviewed our patients with (1) neuromuscular scoliosis with collapsing spine deformity, (2) low-tone neuromuscular etiology, (3) multilevel posterior column osteotomies with posterior all pedicle screw spinal fusion, and (4) more than 1-year follow-up. Patients were grouped into 2: group 1 consisted of patients managed with the integrated surgical team approach, group 2 included the matched historic patients.

RESULTS

There were 16 patients in group 1 and 17 patients in group 2. There was no significant difference between the groups regarding age, sex, body mass index, number of levels fused, major coronal deformity magnitude, pelvic obliquity, number of posterior column osteotomies, or amount of deformity correction. However, significantly shorter operative time (241 vs. 297 min, P=0.006), less intraoperative bleeding (1082 vs. 1852 mL, P=0.001), less intraoperative blood transfusion (2.1 vs. 3.1 U, P=0.028), less postoperative intensive care unit admission (23% vs. 100%, P=0.001), and shorter hospital stay (4.7 vs. 5.9 d, P=0.013) were observed in group 1.

CONCLUSIONS

Our results indicate that spinal deformity surgery in patients with underlying low-tone neuromuscular disease may not be as intimidating as previously thought. Our surgical team approach integrating a 2-attending surgeon operative team, a new anesthetic protocol that includes a modification of perioperative blood management is effective in reducing operative times, blood loss, transfusion rates, intensive care unit admission, and length of hospital stay.

LEVELS OF EVIDENCE

Level III-retrospective comparative study.

Does Menses Affect the Risk of Blood Loss in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion Surgeries?: A Propensity-Score Matching Study

STUDY DESIGN

Retrospective propensity score matching study.

OBJECTIVE

To investigate whether menses affect intraoperative blood loss in female adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) surgeries.

SUMMARY OF BACKGROUND DATA

There were concerns whether patients having menses will have higher intraoperative blood loss if surgery were to be done during this period.

METHODS

This study included 372 females who were operated between May 2016 to May 2019. Fifty-five patients had menses during surgery (Group 1, G1) and 317 patients did not have menses during surgery (Group 2, G2). Propensity score matching (PSM) analysis with one-to-one, nearest neighbor matching technique and with a match tolerance of 0.001 was used. The main outcome measures were intraoperative blood loss (IBL), volume of blood salvaged, transfusion rate, preoperative hemoglobin, preoperative platelet, preoperative prothrombin time, preoperative activated partial thromboplastin time (APTT), international normalized ratio (INR), and postoperative hemoglobin. Postoperative Cobb angle and correction rate were also documented.

RESULTS

At the end of PSM analysis, 46 patients from each group were matched and balanced. The average operation duration for G1 was 140.8 ± 43.0 minutes compared with 143.1 ± 48.3 minutes in G2 (P = 0.806). The intraoperative blood loss for G1 was 904.3 ± 496.3 mL and for G2 was 907.9 ± 482.8 mL (P = 0.972). There was no significant difference in terms of normalized blood loss (NBL), volume of blood salvaged during surgery, preoperative hemoglobin, postoperative hemoglobin, hemoglobin drift, estimated blood volume (EBV), IBL per EBV and IBL per level fused (P > 0.05). No postoperative complications were encountered in both groups. On average, the postoperative hospital stay was 3.5 ± 0.8 days for both groups (P = 0.143).

CONCLUSION

Performing corrective surgery during the menstrual phase in female AIS patients is safe without risk of increased blood loss.

LEVEL OF EVIDENCE

4.

What Factors can Influence Massive Blood Loss in the Surgical Treatment of Neuromuscular Scoliosis?

Objective  The aim of the present study is to identify the incidence, predisposing factors and prognostic impact of blood loss in patients with neuromuscular scoliosis submitted to corrective surgery. Methods  Retrospective cohort study, including pediatric patients diagnosed with neuromuscular scoliosis undergoing instrumentation and posterior vertebral fusion in a university hospital. Patient characteristics were collected from the hospital information system. Results  A total of 39 patients were included in the study. The intraoperative blood losses were 962 ml, representing a loss of 35.63% of the blood volume. In 20 cases, there was a massive blood loss (> 30%) and only 7 patients did not need a transfusion. The group of patients with massive blood loss had a slightly higher age (13.75 versus 13.53 years old), a lower body mass index (BMI) percentile (25 versus 50), and for each decrease of 0.38 in the BMI, intraoperative blood losses increased 1% ( p  < 0.05). The value of preoperative albumin had influence on the percentage of blood loss, and for each decrease of 0.4 of albumin, blood loss increased 1% ( p  < 0.05). Conclusions  The factors that most contributed to the differences in blood loss were age, BMI, and preoperative albumin value. There was no significant association between Cobb angle, number of fusion levels and duration of surgery. We can conclude that these patients would benefit from preoperative nutritional control.

Acute Normovolemic Hemodilution in Spinal Deformity Surgery

Objective  To prospectively compare the clinical and laboratorial aspects of patients undergoing spine deformity surgery, using the acute normovolemic hemodilution technique with tranexamic acid, versus a control group with tranexamic acid alone, and to evaluate the influence of hemodilution in intraoperative bleeding and the need for homologous transfusion.

Materials and Methods  Comparative prospective study with patients aged between 12 and 65 years undergoing spine deformity surgery with the acute normovolemic hemodilution technique associated with tranexamic acid versus a control group to which only tranexamic acid (15 mg/kg) was administered. Laboratorial exams were performed and analyzed in three different moments.

Results  A total of 30 patients were included in the present study: 17 in the hemodilution group, and 13 in the control group. The mean duration of the surgery in the hemodilution group was longer. The number of levels submitted to surgery ranged from 7 to 16 in the hemodilution group, and from 4 to 13 in the control group. Osteotomy, predominantly of the posterior kind, was performed in 20 patients. There was more intraoperative bleeding in the control group. All patients were stable during the procedures. Only 6 participants needed homologous blood transfusion, mostly from the control group ( p  > 0.05).

Conclusion  There was no significant difference between the two groups regarding the need for blood transfusion and intraoperative bleeding. The severity of the deformity was the main determinant for homologous blood transfusion.

State-of-the-Art Reviews: Safety in Complex Spine Surgery

The surgical correction of spinal deformities carries a high risk of perioperative morbidity. As the incidence of debilitating spinal deformities continues to increase, so too does our obligation to search for ways to enhance safety in our delivery of surgical care. Standardized work processes and other lean manufacturing methodologies have the potential to improve efficiency, safety, and hence value in our delivery of surgical care to patients with complex spine pathologies by reducing variability in our work processes. These principles can be applied to patient care from the initial preoperative assessment to long-term postoperative follow-up in the creation of comprehensive protocols that guide the management of these complex patients. Early evidence suggests that short-term outcomes can be improved by implementing packages of systems reform aimed at reducing variability in our work processes; however, contradicting evidence exists on the utility of several specific components of these systems-reform packages.

Two Surgeon Approach for Complex Spine Surgery: Rationale, Outcome, Expectations, and the Case for Payment Reform

There is an increased trend in complex spine deformity cases toward a two attending surgeon approach, but the practice has not become widely accepted by payers. Multiple studies have shown that spine surgery complications increase with the duration of case, estimated blood loss, and use of transfusions, as well as in certain high-risk populations or those requiring three-column osteotomies. Dual-surgeon cases have been shown to decrease estimated blood loss, transfusion rate, surgical times, and therefore complication rates. Although this practice comes at an uncertain price to medical training and short-term costs, the patient's quality of care should be prioritized by institutions and payers to include dual-surgeon coverage for these high-risk cases. Because we enter an era where the value of spine care and demonstrating cost-effectiveness is essential, dual surgeon attending approaches can enhance these tenets.

Thoracic Lordosis, Especially in Males, Increases Blood Loss in Adolescent Idiopathic Scoliosis

BACKGROUND

Intraoperative blood loss during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been reportedly associated with multiple factors. This study aims to investigate the effect of thoracic kyphosis on blood loss in AIS spinal fusion.

METHODS

Patients with AIS who underwent posterior-only procedures for Lenke I and II type curves were identified. All included patients had intraoperative tranexamic acid. Difference in estimated blood loss per blood volume (EBL/BV) was identified between hypokyphotic curves (-), normal curves (N), and hyperkyphotic curves (+) classified based on Lenke sagittal modifier. Regression analysis was then performed with EBL/BV as dependent variable. Independent variables included radiographically measured T5-T12 kyphosis and calculated 3D T5-T12 kyphosis in addition to sex, body mass index (BMI), operative time, number of fused vertebrae, number of Ponte osteotomy levels, and main thoracic coronal curve.

RESULTS

In total, 837 patients were included. For female patients: EBL/BV was significantly higher for (-) (18%) compared with (N) (16%) and (+) (14%). A total of 29 female patients had T5-T12≤0 (-15 to 0 degree). EBL/BV was not significantly higher than patients with T5-T12>0 degree (18%±9% vs. 16%±11%; P=0.212). For male patients: EBL/BV was significantly higher in (-) (23%) compared with (+) (16%). In total, 14 male patients had T5-T12≤0 (-13 to 0) degree. EBL/BV was significantly higher than patients with T5-T12>0 degree (32%±18% vs. 18%±13%; P=0.015). Significant factors in predicting EBL/BV were sex, BMI, number of fused levels, and both 2D and 3D T5-T12 kyphosis. Male sex as well as every fused-level predicted an increase in EBL/BV~2%. Every 10-unit decrease in BMI predicted an increase in EBL/BV of 7%. Every 10-degree decrease in 2D or 3D T5-T12 kyphosis predicted an increase in EBL/BV~1%. The impact of the number of Ponte osteotomy levels was not significant.

CONCLUSIONS

This study supports the role of sagittal thoracic alignment in affecting EBL/BV in AIS surgery. Male patients with severe thoracic lordosis (T5-T12≤0 degree) are the highest risk group for intraoperative bleeding. These findings are helpful in predicting the intraoperative blood loss for patients with AIS undergoing posterior spinal fusion. In addition to sex and number of fused levels, decreased thoracic kyphosis is associated with increased blood loss.

LEVEL OF EVIDENCE

Level III-prognostic study.

The SPOT GRADE: A New Method for Reproducibly Quantifying Surgical Wound Bleeding

STUDY DESIGN

Benchtop model with prospective surgeon video testing.

OBJECTIVE

To create a surface bleeding severity scale, the SPOT GRADE (SG), for quantitative assessment of target bleeding site (TBS) blood loss. This is of particular interest for spinal surgery due to epidural bleeding and an inability to use diathermy and radiofrequency cautery close to nerve roots.

SUMMARY OF BACKGROUND DATA

A novel apparatus perfusable at known flow rates and simulating different sized wounds was used to create movies to educate surgeons on specific degrees of bleeding.

METHODS

Training (36) and testing (108) videos were created using a benchtop apparatus employing different bleeding severities based on the six-level SG (none, minimal, mild, moderate, severe, and extreme) and TBS sizes (1, 10, and 50 cm). Fourteen surgeons in four specialties (cardiothoracic, abdominal, spine, and orthopedic lower extremity) were trained and tested to evaluate SG characteristics including inter-rater and intrarater reliability.

RESULTS

The interclass correlation coefficient was estimated to be 0.89840 (95% confidence interval [CI]: 0.85771, 1), whereas the intraclass correlation coefficient was estimated to be 0.93673 (95% CI: 0.89603, 1). In 98% of cases (95% CI: 0.9736, 0.9927), surgeons correctly identified eligible bleeds for a future clinical trial (scores = 1, 2, or 3) and in 91% of cases (95% CI: 0.8895, 0.9344), surgeons correctly identified noneligible bleeds (scores = 4 or 5). In 98.6% of cases (95% CI: 0.9777, 0.9945), physicians correctly identified true hemostasis (score = 0). Based upon these data the probability of a physician rating a bleed incorrectly as hemostasis (score = 0) is estimated to be 1.51% (95% CI: 0.0061, 0.0363).

CONCLUSION

This SG is reproducible and reliable providing a basis for educating surgeons on TBS blood loss. It appears to be a new standard for evaluating wound blood loss.

LEVEL OF EVIDENCE

2.

Analysis of the impact of race on blood transfusion in pediatric scoliosis surgery

INTRODUCTION

Surgical correction of pediatric scoliosis is associated with significant blood loss. Minimizing estimated blood loss and blood transfusion is beneficial as transfusions have been associated with increased morbidity, including risk of surgical site infections, longer hospitalizations, and increased cost. Although there is evidence that African-American or Black adults are more likely to require intraoperative blood transfusion compared with Caucasian or White adults, the reasons for this difference are unclear.

METHODS

The electronic records for all patients <18 y/o undergoing primary corrective scoliosis surgery by a single pediatric orthopedic surgeon at a single academic medical center between 2013 and 2015 were collected and reviewed. Multivariate models were performed to assess the association between Black race and blood loss/transfusion in primary pediatric scoliosis surgery.

RESULTS

In a multivariate model, Black race was independently associated with 1.61 times higher estimated blood loss than White race (P < .01; 95% CI = 1.16-2.23). Additionally, compared to a White patient, the odds a Black patient received blood transfusion was 6.25 times higher (P = .03; 95% CI = 1.56-25.06) and among the patients who received blood transfusion, Black race was independently associated with 2.61 times greater volume of blood transfusion than White race (P < .01; 95% CI = 1.54-4.41).

CONCLUSION

Black race was independently associated with increased estimated blood loss, increased rate of blood transfusion, and increased amount of blood transfused during surgical correction of pediatric scoliosis. Further investigation is needed to better understand the etiology of the disparity and assess opportunities for improving outcomes.

[Characteristics of neuromuscular scoliosis]

Usually, neuromuscular scolioses become clinically symptomatic relatively early and are rapidly progressive even after the end of growth. Without sufficient treatment they lead to a severe reduction of quality of life, to a loss of the ability of walking, standing or sitting as well as to an impairment of the cardiopulmonary system resulting in an increased mortality. Therefore, an intensive interdisciplinary treatment by physio- and ergotherapists, internists, pediatricians, orthotists, and orthopedists is indispensable. In contrast to idiopathic scoliosis the treatment of patients with neuromuscular scoliosis with orthosis is controversially discussed, whereas physiotherapy is established and essential to prevent contractures and to maintain the residual sensorimotor function.Frequently, the surgical treatment of the scoliosis is indicated. It should be noted that only long-segment posterior correction and fusion of the whole deformity leads to a significant improvement of the quality of life as well as to a prevention of a progression of the scoliosis and the development of junctional problems. The surgical intervention is usually performed before the end of growth. A prolonged delay of surgical intervention does not result in an increased height but only in a deformity progression and is therefore not justifiable. In early onset neuromuscular scolioses guided-growth implants are used to guarantee the adequat development. Because of the high complication rates, further optimization of these implant systems with regard to efficiency and safety have to be addressed in future research.

Effects of preconditioning of electro-acupuncture on postoperative cognitive dysfunction in elderly: A prospective, randomized, controlled trial

Electro-acupuncture is a burgeoning treatment using the needle inserting into the body acupoints and the low-frequency pulse current being electrified by an electric acupuncture machine. This study was designed to evaluate the effects of preconditioning of electro-acupuncture on postoperative cognitive dysfunction in elderly.Ninety patients scheduled spine surgery were randomly assigned into 2 groups using a random number table: control group (group C) and electro-acupuncture group (group EA). In group EA, electro-acupuncture was applied on Baihui, Dazhui, and Zusanli acupoints 30 minutes before anesthesia. At 0 minute before treatment of electro-acupuncture, 1 hour after skin incision and surgery completed (T1-3), blood samples were taken for detection of interleukin (IL)-6, IL-10, and S100β by enzyme-linked immunosorbent assay. The total dose of remifentanil and propofol during surgery were recorded. Mini-Mental State Examination was applied to evaluate the cognitive function of patients at 1 day before surgery and 7th and 30th day after surgery.The results showed that compared with group C, score of MMSE increased after surgery, the serum concentration of IL-6, IL-10, and S100β decreased at 1 hour after skin incision, and surgery completed in group EA. Moreover, the total dose of remifentanil and propofol reduced during surgery in group EA.The present study suggests that preconditioning of electro-acupuncture could improve the postoperative cognitive function, and the reduction of inflammatory reaction and brain injury may be involved in the mechanism.

Effects of nimodipine on postoperative delirium in elderly under general anesthesia: A prospective, randomized, controlled clinical trial

Nimodipine is a clinical commonly used calcium antagonistscan lowering the apoptosis rate of hippocampal neuron to reduce the incidence of postoperative cognitive dysfunction (POCD). This study was designed to evaluate the effects of nimodipine on postoperative delirium in elderly under general anesthesia.Sixty patients shceduced spine surgery under general anesthesia were randomly assigned into 2 groups using a random number table: control group (Group C) and nimodipine group (Group N). In Group N, nimodipine 7.5 μg/(kg × h) was injected continually 30 minutes before anesthesia induction, while the equal volume of normal saline was given in Group C. At 0 minute before injection, 0 minute after tracheal intubation, 1 hour after skin incision and surgery completed (T1-4), blood samples were taken from the radial artery and jugular bulb for blood gas analysis. Cerebral oxygen metabolism-related indicators were calculated at the same time. Concentration of S100β and glial fibrillary acidic protein (GFAP) were tested by ELISA. The incidence of postoperative delirium within 7 days after surgery was recorded.Cerebral oxygen metabolism-related indicators fluctuationed in the normal range in 2 groups at different time points and the difference were not statistically significant. Compared with Group C, S100β and GFAP decreased and incidence of postoperative delirium reduced at T3-4 in Group N, the difference was statistically significant (P<.05).The present study suggests that nimodipine can reduce the development of postoperative delirium in elderly patients under general anesthesia, the reduction of brain injury and improvement of cerebral oxygen metabolism may be involved in the mechanism.

Halo Gravity Traction Is Associated with Reduced Bone Mineral Density of Patients with Severe Kyphoscoliosis

Background. Halo gravity traction (HGT) is one of the most commonly used perioperative techniques for the treatment of severe kyphoscoliosis. This study was to explore the influence of HGT on the BMD of these patients. Methods. Patients with severe kyphoscoliosis treated by preoperative HGT for at least 2 months were included. Patients' BMD were assessed by dual-energy X-ray absorptiometry at lumbar spine (LS, L2–L4) and femur neck (FN) of the nondominant side. The weight and duration of traction, as well as baseline characteristics, were recorded. Results. Twenty patients were recruited. The average traction duration was 77.9 ± 13.0 days while the mean traction weight was 39.9% ± 11.1% of total body weight. Remarkable decrease of BMD was observed at LS of 17 (85%) patients and at FN of 18 (90%) patients. After HGT, 75% of patients were found to have osteoporosis, the incidence of which was significantly higher than that before HGT (35%). The correlation analysis revealed BMD reduction was only significantly correlated with the traction duration. Conclusions. The current study showed that preoperative HGT can have obvious impact on the BMD. The BMD reduction is associated with traction duration, suggesting that long traction duration may bring more bone mineral loss.

A comparative study of Sterofundin and Ringer lactate based infusion protocol in scoliosis correction surgery

Background:

A major change in anesthesia practice as regards to intraoperative infusion therapy is the present requirement. Switching over to balanced fluids can substantially decrease the incidence of lactic acidosis and hyperchloremic acidosis. The deleterious effects of unbalanced fluids are more recognizable during major surgeries. We prospectively studied the influence of Sterofundin (SF) and Ringer lactate (RL) on acid–base changes, hemodynamics, and readiness for extubation during scoliosis surgery.

Subjects and Methods:

Thirty consecutive children posted for scoliosis surgery were randomized to receive either RL (n = 15) or SF (n = 15) as intraoperative fluid at 10 mg/kg/h. Fluid boluses were added according to the study fluid algorithm. Arterial blood was sampled and analyzed at hourly intervals during surgery. Red blood cell transfusion was guided by hematocrit below 27. Patients were followed for 24 h postoperatively in the Intensive Care Unit.

Results:

There was no statistically significant difference in the volume of infused fluid (2400 ± 512 ml in Group RL and 2200 ± 640 ml in Group SF. There were no significant changes in pH of patients infused with SF. Statistically, significant higher lactate levels were seen in RL-infused group. The strong ion difference was decreased in both groups, but it normalized earlier with SF.

Conclusions:

SF-infused patients had nonremarkable changes in acid–base physiology in scoliosis surgery.

Complication avoidance with pre-operative screening: insights from the Seattle spine team

Complication rates for complex adult lumbar scoliosis surgery are unacceptably high. Standardized preoperative evaluation protocols have been shown to significantly reduce the likelihood of a spectrum of negative outcomes associated with complex adult lumbar scoliosis surgery. To increase patient safety and reduce complication risk, an entire medical and surgical team should work together to care for adult lumbar scoliosis patients. This article describes preoperative patient evaluation strategies with a particular focus on adult lumbar scoliosis surgery involving six or more levels of spinal fusion. Domains considered include recent preoperative evaluation literature, predictive risk modeling, the appropriate management of medical conditions, and the composition and activities of a multidisciplinary conference review team. An evidence-based comprehensive systematic preoperative surgical evaluation process is described.

Assessment of Intraoperative Blood Loss at Different Surgical Stages During Posterior Spinal Fusion Surgery in the Treatment of Adolescent Idiopathic Scoliosis

STUDY DESIGN

Prospective clinical study.

OBJECTIVE

To analyze the amount of blood loss at different stages of Posterior Instrumented Spinal Fusion (PSF) surgery in adolescent idiopathic scoliosis (AIS) patients.

SUMMARY OF BACKGROUND DATA

Knowing the pattern of blood loss at different surgical stages may enable the surgical team to formulate a management strategy to reduce intraoperative blood loss.

METHODS

One hundred AIS patients who underwent PSF from January 2013 to December 2014 were recruited. The operation was divided into six stages; stage 1-exposure, stage 2-screw insertion, stage 3-release, stage 4-correction, stage 5-corticotomies and bone grafting, and stage 6-closure. The duration and blood loss at each stage was documented. The following values were calculated: total blood loss, blood loss per estimated blood volume, blood loss per minute, blood loss per vertebral level fused, and blood loss per minute per vertebral level fused.

RESULTS

There were 89 females and 11 males. The mean age was 17.0 ± 5.8 years old. Majority (50.0%) were Lenke 1 curve type. The mean preoperative major Cobb angle was 64.9 ± 15.0°. The mean number of levels fused was 9.5 ± 2.3 levels. The mean operating time was 188.5 ± 53.4 minutes with a mean total blood loss 951.0 ± 454.0 mLs. The highest mean blood loss occurred at stage 2 (301.0 ± 196.7 mL), followed by stage 4 (226.8 ± 171.2 mL) and stage 5 (161.5 ± 146.6 mL). The highest mean blood loss per minute was at stage 5 (17.1 ± 18.3 mL/min), followed by stage 3 (12.0 ± 10.8 mL/min). The highest mean blood loss per vertebral levels fused was at stage 2 (31.0 ± 17.7 mL/level), followed by stage 4 (23.9 ± 18.1 mL/level) and stage 5 (16.6 ± 13.3 mL/level).

CONCLUSION

All stages were significant contributors to the total blood loss except exposure (stage 1) and closure (stage 6). Blood loss per minute and blood loss per minute per level was highest during corticotomies (stage 5), followed by release (stage 3). However, the largest amount of total blood loss occurred during screw insertion (stage 2).

LEVEL OF EVIDENCE

2.

Predicting excessive hemorrhage in adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion

BACKGROUND CONTEXT

Blood loss in patients with adolescent idiopathic scoliosis (AIS) who are undergoing posterior spinal instrumentation and fusion (PSIF) varies greatly. The reason for this wide range is not clear. There are reports of unexpected massive hemorrhage during these surgeries. Many studies reflect authors' preferences for describing blood loss in terms of levels fused, weight, or percent blood volume.

PURPOSE

We sought to define excessive blood loss clinically, determine its incidence in our study population, and identify associated variables. Results are intended to inform perioperative preparation for these cases. Results may be used to inform prospective study designs.

STUDY DESIGN

This was a retrospective uncontrolled case series.

PATIENT SAMPLE

A total of 311 consecutive AIS PSIF cases during the years 2005-2010 performed at Children's Hospital Colorado were studied.

OUTCOME MEASURES

We measured estimated blood loss (EBL) and its association with multiple patient, surgical, and anesthetic variables.

METHODS

Thirty-one variables potentially related to blood loss were collected retrospectively from electronic medical records for analysis. When no cases of clearly excessive blood loss were identified on the basis of visual examination of EBL distribution, we chose to use the top 10% of blood loss cases as an arbitrary determinant of excessive blood loss. Three cut-off strategies captured the top 10% of EBL cases with little variation in who was selected: 1) >1,700 mL of EBL, 2) >50% EBL/estimated blood volume, and 3) >150 mL/level fused EBL. Variables were compared with the χ(2) test, Fisher exact, or t-tests, when appropriate. A generalized linear mixed logistic model was used to determine the probability of excessive blood loss based on the number of levels fused.

RESULTS

The average EBL was 89.17 mL/level fused (range, 45-133 mL). EBL fit a progressively wider distribution as surgical complexity (number of levels fused) increased. Number of levels fused (p<.0001), operative time (p=.0139), number of screws (p<.0001), and maximal preoperative Cobb angle (p=.0491) were significantly associated with excessive blood loss. The variable that was most strongly associated with excessive blood loss was the number of levels fused, with ≥12 levels having a probability of >10% of excessive hemorrhage.

CONCLUSION

Excessive blood loss may be an arbitrary number until future research suggests otherwise. We show that the probability of exceeding one of our arbitrary definitions is approximately 10% when 12 or more levels are fused. If a 10% incidence of excessive blood loss is determined to be clinically relevant, teams might wish to pursue hematologic consultation and maximal blood conservation strategy when 12 or more levels are planned for fusion.

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

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVES

To evaluate blood loss associated with posterior spinal fusion in adolescent idiopathic scoliosis patients performed with and without the use of an ultrasonic bone scalpel (UBS).

SUMMARY OF BACKGROUND INFORMATION

After using an ultrasonic-powered bone-cutting device with recent Food and Drug Administration approval for use in the spine, the authors perceived a reduction in bone bleeding associated with the cut boney surfaces.

METHODS

The first 20 patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion using the UBS by a single surgeon were compared with 2 control groups: 1) the 20 most recent prior cases of the same surgeon before beginning use of the bone scalpel; and 2) 20 cases of the same surgeon before using the bone scalpel matched based on Cobb angle magnitudes. Both cases and controls had Ponte-type posterior apical releases; none had an anterior procedure. Patient demographic and surgical data were analyzed using analysis of variance (p < .05).

RESULTS

Preoperatively, the UBS group was similar to both control groups in terms of primary and secondary curve magnitudes, number of levels fused, number of levels with Ponte release, antifibrinolytic use, and patient age (p > .05). The UBS group had significantly less estimated blood loss (EBL) (550 ± 359 mL), Cell Saver blood transfused (94 ± 146 mL), and EBL per level fused (48 ± 30 mL) than the most recent controls (EBL: 799 ± 376 mL; Cell Saver: 184 ± 122 mL; EBL/level fused: 72 ± 28 mL) and Cobb-matched controls (EBL: 886 ± 383 mL; Cell Saver: 198 ± 115 mL; EBL/level fused: 78 ± 30 mL) (p < .05). Surgical times were equivalent and there were no dural tears in any group.

CONCLUSIONS

The use of an ultrasonic bone scalpel to perform the bone cuts associated with facetectomies and apical Ponte-type posterior releases resulted in significantly less bleeding compared with cuts made with standard osteotomes and rongeurs, limiting overall blood loss by 30% to 40%.

The Seattle Spine Team Approach to Adult Deformity Surgery: A Systems-Based Approach to Perioperative Care and Subsequent Reduction in Perioperative Complication Rates

STUDY DESIGN

Retrospective consecutive case review pre- and postintervention.

OBJECTIVES

Characterize the effects of the intervention.

SUMMARY OF BACKGROUND DATA

Complication rates in adult spinal deformity surgery are unacceptable. System approaches are necessary to increase patient safety. This group reported on the dual-attending surgeon approach, a live multidisciplinary preoperative screening conference, and the intraoperative protocol for the management of coagulopathy. The outcomes were demonstrated by complication rates before and after the institution of this protocol.

METHODS

Forty consecutive patients in Group A were managed without the 3-pronged approach. A total of 124 consecutive patients in Group B had a dual-attending surgeon approach, were presented and cleared by a live multidisciplinary preoperative conference, and were managed according to the intraoperative protocol.

RESULTS

Group A had an average age of 62 years (range, 39-84 years). Group B had an average age of 64 years (range, 18-84 years). Most patients in both groups had fusions from 9 to 15 levels. Complication rates in Group B were significantly lower (16% vs. 52%) (p < .001). Group B showed significantly lower return rates to the operating room during the perioperative 90-day period (0.8% vs. 12.5%) (p < .001). Group B also had lower rates of wound infection requiring debridement (1.6% vs. 7.5%), lower rates of deep vein thrombosis/pulmonary embolism (3.2% vs. 10%), and lower rates of postoperative neurological complications (0.5% vs. 2.5%) (not significant). Group B had significantly lower rates of urinary tract infection requiring antibiotics (9.7% vs. 32.5%) (p < .001).

CONCLUSIONS

These data suggests that a team approach consisting of a dual-attending surgeon approach in the operating room, a live preoperative screening conference, and an intraoperative protocol for managing coagulopathy will significantly reduce perioperative complication rates and enhance patient safety in patients undergoing complex spinal reconstructions for adult spinal deformity.

Treating venous thromboembolic events in the pediatric population

In the pediatric population, the risk of venous thromboembolism (VTE) is lower and less defined than in adults, making the diagnosis easy to overlook. Signs and symptoms in children are usually vague, so nurse practitioners need to be aware of what to look for and how to manage VTE in children.