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McIntosh A, Lachmann E, Datcu A, McLeod C. Posterior spinal fusion for adolescent idiopathic scoliosis and the impact of postoperative intravenous dexamethasone supplementation. PAEDIATRIC & NEONATAL PAIN 2024; 6:19-26. [PMID: 38863457 PMCID: PMC11163225 DOI: 10.1002/pne2.12117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/05/2023] [Accepted: 10/24/2023] [Indexed: 06/13/2024]
Abstract
Postoperative care pathways for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion have demonstrated decreases in postoperative opioid consumption, improved pain control, and lead to decreased lengths of stay. Our objective was to implement postoperative steroids to reduce acute postoperative opioid consumption, pain scores, and length of stay. Dosing consisted of intravenous dexamethasone 0.1 mg/kg up to 4 mg per dose for a total of three doses at 8, 16, and 24 h postoperatively. As part of a quality initiative, we compared three cohorts of patients. The initial retrospective epidural cohort (EPI) (n = 59) had surgeon placed epidural catheters with infusion of ropivacaine 0.1% postoperatively for 18-24 h. Following an institutional change in postoperative care, epidural use was discontinued. A second cohort (n = 149), with prospectively collected data, received a surgeon placed erector spinae plane block and wound infiltration with a combination of liposomal and plain bupivacaine (LB). A third cohort (n = 168) was evaluated prospectively. This cohort received a surgeon placed erector spinae plane block and wound infiltration with liposomal and plain bupivacaine and additionally received postoperative dexamethasone for three doses (LB + D). Compared to the LB cohort, the LB + D cohort demonstrated statistically significant decreases in oral milligram morphine equivalents per kilogram at 0-24, 24-48, and 48-72 h. There was a statistically significant difference in median pain scores at 24-48 and 48-72 h in LB + D versus LB. The LB + D cohort's median length of stay in hours was significantly less compared to the LB cohort (52 h vs. 70 h, p < 0.0001). Postoperative intravenous dexamethasone was added to an established postoperative care pathway for patients undergoing posterior spinal fusion for idiopathic scoliosis resulting in decreased VAS pain scores, opioid consumption, and shorter length of stay.
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Affiliation(s)
- Amy McIntosh
- Department of Orthopedic Surgery, Scottish Rite for ChildrenUT Southwestern Medical CenterDallasTexasUSA
| | - Emily Lachmann
- Department of Orthopedic SurgeryScottish Rite for ChildrenDallasTexasUSA
| | - Anne‐Marie Datcu
- Department of Orthopedic SurgeryScottish Rite for ChildrenDallasTexasUSA
| | - Christopher McLeod
- Department of Anesthesiology, Scottish Rite for ChildrenUT Southwestern Medical CenterDallasTexasUSA
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Freshman RD, Kotlier JL, Mayfield CK, Fathi A, Ahmad A, Cruz C, Liu JN, Petrigliano FA. Perioperative intravenous dexamethasone use is not associated with periprosthetic joint infection or wound healing complications following shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00247-7. [PMID: 38604400 DOI: 10.1016/j.jse.2024.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Perioperative intravenous (IV) dexamethasone is commonly used in lower extremity total joint arthroplasty to manage postoperative pain and nausea/vomiting, and recent studies have demonstrated that its use may lower rates of acute postoperative medical complications. However, there is limited information regarding the safety and efficacy of IV dexamethasone in patients undergoing total shoulder arthroplasty (TSA). Additionally, there is concern surrounding corticosteroid use prior to surgery as preoperative corticosteroid injections have been associated with adverse outcomes after TSA, including periprosthetic joint infection (PJI) and revision surgery. Thus, the purpose of this study was to evaluate the effect of perioperative IV dexamethasone on 90-day rates of PJI, wound complications, and medical complications after TSA. METHODS The Premiere national hospital database was used to identify adult patients undergoing elective TSA between 2016 and 2020; patients were excluded if they were under 18 years old, were undergoing revision TSA, or had a prior proximal humerus open reduction internal fixation procedure. Patients who did and did not receive perioperative IV dexamethasone were then compared in both univariate and multivariate analyses. A Bonferroni correction was utilized to adjust for multiple comparisons. The primary end point was risk of acute infectious complications within 90 days of surgery, including PJI and wound infection/dehiscence. Secondary end points included acute pulmonary, renal, and thromboembolic complications. RESULTS A total of 135,333 patients underwent TSA during the study period; 61.2% underwent reverse total shoulder arthroplasty, 33.8% underwent anatomic total shoulder arthroplasty, and 5.0% underwent hemiarthroplasty. From 2016 to 2020, perioperative IV dexamethasone use increased by 135%. Multivariate analysis revealed that patients who received perioperative IV dexamethasone did not have increased odds of PJI, superficial wound infection, or wound dehiscence (P = .15-.47) but did have decreased odds of sepsis (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.55-0.81) and other medical complications such as urinary tract infection and acute kidney injury. Additionally, there was a trend towards decreased 90-day hospital readmission (OR 0.88, 95% CI 0.81-0.96, P = .003). CONCLUSIONS Perioperative IV dexamethasone was not associated with increased risk of acute infectious and wound healing complications. Moreover, patients who received perioperative IV dexamethasone had decreased odds of medical complications and trended toward lower rates of 90-day hospital readmission. The results of this study support the safety of perioperative IV dexamethasone use in patients undergoing elective TSA.
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Affiliation(s)
- Ryan D Freshman
- Department of Orthopedic Surgery, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Jacob L Kotlier
- Department of Orthopedic Surgery, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Cory K Mayfield
- Department of Orthopedic Surgery, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Amir Fathi
- Department of Orthopedic Surgery, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Aamir Ahmad
- Department of Orthopedic Surgery, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Christian Cruz
- Department of Orthopedic Surgery, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Joseph N Liu
- Department of Orthopedic Surgery, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Frank A Petrigliano
- Department of Orthopedic Surgery, USC Keck School of Medicine, Los Angeles, CA, USA.
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Lee JE, Stewart KO, Swain JL, Bond E, Calderwood MS, Kim JJ. Association between in situ steroids and spine surgical site infections among instrumented procedures. Infect Control Hosp Epidemiol 2023; 44:1596-1600. [PMID: 36883273 DOI: 10.1017/ice.2023.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVE To estimate the association between in situ steroids and spine surgical-site infections (SSIs), assessing spinal instrumentation as an effect modifier and adjusting for confounders. DESIGN Case-control study. SETTING Rural academic medical center. PARTICIPANTS We identified 1,058 adults undergoing posterior fusion and laminectomy procedures as defined by the National Healthcare Safety Network without a pre-existing SSI between January 2020 and December 2021. We identified 26 SSI as cases and randomly selected 104 controls from the remaining patients without SSI. METHODS The primary exposure was the intraoperative administration of methylprednisolone in situ (ie, either in the wound bed or as an epidural injection). The primary outcome was a clinical diagnosis of SSI within 6 months of a patient's first spine surgery at our facility. We quantified the association between the exposure and outcome using logistic regression, using a product term to assess for effect modification by spinal instrumentation and the change-in-estimate approach to select significant confounders. RESULTS Adjusting for Charlson comorbidity index and malignancy, in situ steroids were significantly associated with spine SSI relative to no in situ steroids for instrumented procedures (adjusted odds ratio [aOR], 9.93; 95% confidence interval [CI], 1.54-64.0), but they were not associated with spine SSIs among noninstrumented procedures (aOR, 0.86; 95% CI, 0.15-4.93). CONCLUSIONS In situ steroids were significantly associated with spine SSI among instrumented procedures. The benefits of in situ steroids for pain management following spine surgery should be weighed against the risk of SSI, especially for instrumented procedures.
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Affiliation(s)
- James E Lee
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kathleen O Stewart
- Collaborative Healthcare-associated Infection Prevention Program, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Quality Assurance and Safety, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jessica L Swain
- Quality Assurance and Safety, Dartmouth Health, Lebanon, New Hampshire
| | - Evalina Bond
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michael S Calderwood
- Quality Assurance and Safety, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Section of Infectious Disease and International Health, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Justin J Kim
- Collaborative Healthcare-associated Infection Prevention Program, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Section of Infectious Disease and International Health, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Seilhamer C, Miller K, Holstine J. Reducing Postoperative Length of Stay for Idiopathic Scoliosis Patients using Quality Improvement Methodology. Pediatr Qual Saf 2023; 8:e672. [PMID: 37551258 PMCID: PMC10403041 DOI: 10.1097/pq9.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/16/2023] [Indexed: 08/09/2023] Open
Abstract
Approximately 1%-3% of the US population is diagnosed with scoliosis. In addition, 80% of those diagnosed have idiopathic scoliosis, with about 10% requiring surgical intervention. This Quality Improvement initiative aimed to reduce the length of stay (LOS) after posterior spinal fusion for these patients. According to the Pediatric Health Information System, our institution had a poorer performance, with an actual LOS greater than or equal to the expected LOS compared with peer institutions. METHODS The aim was to increase the percentage of idiopathic scoliosis patients with a procedure to discharge LOS of less than or equal to 4 days after posterior spinal fusion from 39.13% to 90%. Interventions included implementing a new pain management protocol, a daily checklist, education on expectations of postoperative pain, and updated order sets. RESULTS Interventions improved patients discharged in less than 4 days from 39.13% to 93.48% (P ≤ 0.001), reducing the average postprocedure LOS from 4.93 to 2.59 (P ≤ 0.001) days. A key process measure tracked was the percentage of patients off the patient-control analgesia pump by postoperative day 2, which increased from 13% to 97.75% (P ≤ 0.001). These improvements did not affect the balancing measure of readmissions or Emergency Department visits for pain. CONCLUSIONS By implementing a more standardized pathway, including a patient-focused daily checklist for providers and families, we established expectations for LOS and pain. This checklist and updates to the pain management protocol successfully reduced the length of stay in idiopathic scoliosis patients after posterior spinal fusion.
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Affiliation(s)
- Crystal Seilhamer
- From the Center for Comprehensive Spine Care, Department of Orthopedics, Nationwide Children's Hospital, Columbus, Ohio
| | - Kelly Miller
- From the Center for Comprehensive Spine Care, Department of Orthopedics, Nationwide Children's Hospital, Columbus, Ohio
| | - Jessica Holstine
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
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Ruska T, Austin TM, Bruce RW, Fletcher ND. Post-operative steroids in patients with patients with severe cerebral palsy undergoing posterior spinal fusion. Spine Deform 2023; 11:415-422. [PMID: 36260207 DOI: 10.1007/s43390-022-00603-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/08/2022] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Posterior spinal fusion (PSF) represents a large physiologic challenge for children with neuromuscular scoliosis (NMS). Perioperative complications are numerous with many occurring in the post-operative period due to pain and relative immobilization. This study assessed the impact of steroids on patients undergoing PSF for NMS. METHODS A retrospective review of consecutive patients managed at a single center with PSF for NMS was reviewed. Clinical and radiographic analysis was used to evaluate baseline demographics, curve characteristics, and post-operative course. RESULTS Eighty-nine patients who underwent PSF for NMS were included. Fifty-seven of these patients did not receive post-operative steroids (NS) while 32 patients were treated with post-operative steroids (dexamethasone, WS) for a median of 3 doses (median 6.0 mg/dose every 8 h after surgery). The demographic variables of the cohorts were similar with no difference in curve magnitude, number of vertebrae fused, number of osteotomies, or EBL between groups. A 70% decrease in the median post-operative morphine equivalents was observed in the steroid cohort (0.50 mg/kg WS vs 1.65 mg/kg NS, p value < 0.001). There was an association between post-operative morphine equivalents and length of stay (Spearman's rho = 0.22, p value = 0.04). There was no difference in wound healing, infection, and pulmonary or gastrointestinal complications between groups. No difference was found in pain at discharge, 30-day ED returns, or 30-day OR returns between groups. CONCLUSIONS Post-operative dexamethasone resulted in a 70% decrease in morphine equivalent use after PSF for NMS without any increase in perioperative wound infections. LEVEL OF EVIDENCE Level 3: case-control series.
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Affiliation(s)
- Tracy Ruska
- Department of Orthopaedic Surgery, Clinical Practice Group, Children's Healthcare of Atlanta, 1400 Tullie Rd NE, Atlanta, GA, 30329, USA
| | - Thomas M Austin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Robert W Bruce
- Department of Orthopaedic Surgery, Clinical Practice Group, Children's Healthcare of Atlanta, 1400 Tullie Rd NE, Atlanta, GA, 30329, USA
| | - Nicholas D Fletcher
- Department of Orthopaedic Surgery, Clinical Practice Group, Children's Healthcare of Atlanta, 1400 Tullie Rd NE, Atlanta, GA, 30329, USA.
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Diagnostic and Treatment of Spinal Fracture and Luxation in Italian Wolves (Canis lupus italicus). Animals (Basel) 2022; 12:ani12213044. [DOI: 10.3390/ani12213044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/24/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
The medical records of 14 Italian wolves (Canis lupus italicus) with a vertebral fracture or luxation (SFL) between C1 and L7 treated at Ospedale Veterinario San Michele from 2017 and 2022 were reviewed. The most common cause of SFL was “road traffic accident”. Neurological signs were graded from 0 to 6 using a modified Frankel scale. Spinal fractures occurred in C1–C5 in 1 case, in T3–L3 in 11 cases and in L4–L7 in 2 cases. Six wolves were euthanized without treatment because they presented paraplegia without deep pain perception (DPP). Two animals with motor function were treated conservatively, and later on one of them was euthanized because of neurological impairment. Six wolves were surgically treated. Seven wolves had good neurological recovery, and six of them were released into the wild. Our results suggest that wolves with DPP before surgery may have a good functional recovery.
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Very rare incidence of ascending paralysis in a patient of traumatic spinal cord injury: a case report. Spinal Cord Ser Cases 2022; 8:69. [PMID: 35882848 PMCID: PMC9325770 DOI: 10.1038/s41394-022-00536-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 07/08/2022] [Accepted: 07/17/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION After spinal cord injury, further neurological deterioration up to one to two neurological levels is not uncommon. Late neurological deterioration can occur after two months, mainly due to the syrinx formation. In a rare case like in sub-acute post-traumatic ascending myelopathy, the neurological level may ascend more than four levels from the initial level of injury and it usually starts within a few weeks after injury. CASE PRESENTATION Our case was diagnosed as a case of traumatic spinal cord injury having a lower thoracic neurological level of injury initially, which rapidly progressed over a few weeks into a higher thoracic neurological level. He was operated with pedicle screw fixation of the spine before admission to rehabilitation unit. He was having progressive ascending neurological deterioration, starting a few days after surgery, which was evident by the progression of neurological level by more than four segments clinically. Cerebrospinal fluid(CSF) study showed no significant abnormality. Magnetic resonance imaging (MRI) study showed involvement of the spinal cord at the upper thoracic region. Patient was monitored to note any further worsening. Rehabilitation and supportive measures were provided according to standard protocol. DISCUSSION Very few cases of ascending paralysis of more than four levels have been reported globally. It results in increased morbidity and mortality in spinal cord injury patients. In our case few possible reasons are ruled out but the actual underlying reason was not clear. Various hypotheses have been proposed as the cause in previous published literatures. Management is mostly supportive.
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Continued Increase in Cost of Care Despite Decrease in Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202203000-00012. [PMID: 35285819 PMCID: PMC8920416 DOI: 10.5435/jaaosglobal-d-21-00192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 01/12/2022] [Indexed: 11/18/2022]
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Johnson MA, Andras LM, Andras LE, Ellington MD, Upasani VV, Shah AS. What's New in Pain Management for Pediatric Orthopaedic Surgery. J Pediatr Orthop 2021; 41:e923-e928. [PMID: 34469397 DOI: 10.1097/bpo.0000000000001956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery. METHODS An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers. RESULTS A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions. CONCLUSIONS There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery. LEVEL OF EVIDENCE Level IV-literature review.
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Affiliation(s)
- Mitchell A Johnson
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Matthew D Ellington
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas, Austin, TX
| | | | - Apurva S Shah
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Andras LM, Abousamra O. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2021; 103:287-294. [PMID: 33369978 DOI: 10.2106/jbjs.20.01953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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