Effect of Steroid-Soaked Gelatin Sponge on Soft Tissue Swelling Following Anterior Cervical Discectomy and Fusion: A Radiographic Analysis

Topical hemostatic agents in spinal surgery

Spinal surgery can be associated with significant intraoperative blood loss which may lead to various complications. As the number of patients undergoing spinal surgery increases over time, accurate and effective hemostasis becomes critically important. Despite various surgical hemostatic techniques, conventional interventions such as compression, suture, ligation, and heat-generating cautery, are not suitable for osseous and epidural venous plexus bleeding during spinal procedures. Therefore, a variety of hemostatic agents have been developed to promote hemostasis. As they differ in terms of mechanism, form, application and potential adverse reactions, it is important to understand the natural features of existing agents. Here we comprehensively review currently available topical hemostatic agents from different sources and summarize their mechanisms of action, applications, and current or potential utilization in spinal surgery. We found hemostatic agents from different sources exert hemostatic actions through different mechanisms. In addition, topical hemostatic agents play various roles in spinal surgery including as hemostatic agent, dura mater repair, drug-carrier, skin closure, and fibrosis prevention. Compressive neurological complications are the most common complications of these hemostatic agents. Therefore, optimal use in spinal environments should match their features, indications, and efficacy with clinical conditions.

Effect of Furosemide on Prevertebral Soft Tissue Swelling after Anterior Cervical Fusion: A Comparative Study with Dexamethasone

STUDY DESIGN

Retrospective cohort study.

PURPOSE

This study aimed to investigate the effect of furosemide on prevertebral soft tissue swelling (PSTS) after anterior cervical fusion (ACF) and compare it with the effect of dexamethasone.

OVERVIEW OF LITERATURE

Postoperative PSTS is a common complication of ACF. Dexamethasone has been used for its treatment; however, its efficacy remains controversial. Furosemide may reduce PSTS if it is soft tissue edema; however, no studies have demonstrated the effect of furosemide on PSTS after ACF.

METHODS

The symptomatic PSTS group received intravenous (IV) administration of dexamethasone or furosemide. The asymptomatic PSTS group did not receive any medication. Patients were divided into the control (no medication, n=31), Dexa (IV dexamethasone, n=25), and Furo (IV furosemide, n=28) groups. PSTS was checked daily with simple radiographs and medication-induced reductions in PSTS from its peak or after medication.

RESULTS

The peak time (postoperative days) of PSTS in the control (2.27±0.47, p<0.05) and Dexa (1.91±0.54, p<0.01) groups were significantly later than that in the Furo group (1.38±0.74). PSTS was significantly lower in the Furo group than in the Dexa group from postoperative days 4 to 7 (p<0.05). PSTS reduction after the peak was significantly greater in the Furo group than in the control (p<0.01) and Dexa (p<0.01) groups. After starting the medication therapy, the Furo group showed a significantly greater reduction in PSTS than the Dexa group (p<0.01). No difference was found in symptom improvement among the three groups.

CONCLUSIONS

If furosemide is used to reduce PSTS after ACF, it can effectively reduce symptoms.

Safety and Efficacy of Local Steroid Application on Dysphagia Following Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

To evaluate the safety and efficacy of local steroid application (LSA) on dysphagia after anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Dysphagia is one of the most common adverse events in the early postoperative period of ACDF. LSA is reported as an effective method to reduce the swelling of soft tissues, thereby decreasing the incidence of dysphagia. However, the safety and efficacy of LSA on dysphagia after ACDF need to be systematically reviewed and analyzed.

METHODS

A comprehensive literature search was carried out in the database PubMed, Web of Science, EMBASE, Clinical key, Cochrane library, and Wiley Online Library to screen papers that report LSA in ACDF surgery. The Cochrane Collaboration tool and a methodological index for nonrandomized studies were used for the assessment of study quality. Data were analyzed with the Review Manager 5.3 software.

RESULTS

A total of 10 studies were included. The results revealed no significant differences between the steroid group and the control group in ACDF regarding postoperative drainage, estimated blood loss, and neck disability index score (P > 0.05). LSA significantly alleviates visual analog scale score for neck pain (or odynophagia) (P < 0.05), reduces the length of hospital stay (weighted mean difference, -1.00 (-1.05 to -0.95); P < 0.001), and mitigates dysphagia rate and prevertebral soft-tissue swelling in the early postoperative period (P < 0.05). There seemed to be no significant increase in the complication rate and steroid-related adverse events in the steroid group compared with the control group (P < 0.05).

CONCLUSIONS

LSA shows advantages in reducing the length of hospital stay, decreasing dysphagia rate, and mitigating prevertebral soft-tissue swelling in the early postoperative period of ACDF. Further large-scale studies are urgently required for the development of a standard protocol for LSA and further analysis of potential delay complications.

Comparing Clinical and Radiographic Outcomes Between the Self-locking Stand-alone Cage and Conventional Cage-plate Construct: A Five-year Retrospective Cohort Study

STUDY DESIGN/SETTING

A retrospective cohort study.

OBJECTIVE

To evaluate the clinical efficacy of the self-locking stand-alone (SA) cage and conventional cage-plate construct (CPC) in treating degenerative cervical spondylosis with a five-year follow-up.

SUMMARY OF BACKGROUND DATA

The SA approach was designed to reduce complications associated with traditional anterior cervical discectomy and fusion. These techniques have been shown to have satisfactory short-term clinical outcomes. Literature describing the mid-term clinical outcomes of SA cage is limited.

MATERIALS AND METHODS

We retrospectively analyzed patients with cervical spondylosis who had received an SA device or CPC between 2014 and 2016 at the Xijing Hospital. Participants were matched for sex, age, and operative level. Differences in clinical and radiographic outcomes and the occurrence of postoperative complications between the two groups were analyzed.

RESULTS

In total, 207 patients were included (101 with SA and 106 with CPC), the median follow-up for both groups were 60.2 and 60.9 months. Both groups exhibited significant improvements in all measured values compared with the preoperative values. The SA group had a shorter operation time, less intraoperative blood loss, and a significantly lower incidence of dysphagia after surgery than the CPC group ( P <0.05). At the last visit, cage subsidence was 6.9% and 3.8% in the SA and CPC groups, respectively ( P =0.365). The radiographic adjacent segment degeneration (ASD) was significantly lower in the SA group than in the CPC group (6.9% vs. 27.4%, P <0.01). No symptomatic ASD was observed in the SA group, and six (5.7%) cases occurred in the CPC group ( P =0.029).

CONCLUSIONS

In this study, the SA cage showed similar efficacy to that of the conventional CPC in treating cervical spondylosis using anterior cervical discectomy and fusion, with a significant reduction in the incidence of immediate postoperative dysphagia and mid-term ASD.

Variation in Prevertebral Soft Tissue Swelling after Staged Combined Multilevel Anterior-Posterior Complex Cervical Spine Surgery: Anterior Then Posterior (AP) versus Posterior Then Anterior-Posterior (PAP) Surgery

The influence of the sequence of surgery in the development of prevertebral soft tissue swelling (PSTS) in staged combined multilevel anterior-posterior complex spine surgery was examined. This study was conducted as a retrospective study of patients who underwent staged combined multilevel anterior-posterior complex cervical spine surgery from March 2014 to February 2021. Eighty-two patients were identified, of which fifty-seven were included in the final analysis after screening. PSTS was measured from routine serial monitoring lateral cervical radiographs prior to and after surgery for five consecutive days at each cervical level from C2 to C7 in patients who underwent anterior then posterior (AP) and posterior then anterior-posterior (PAP) surgery. The mean PSTS measurements significantly differed from the preoperative to postoperative monitoring days at all cervical levels (p = 0.0000) using repeated measures analysis of variance in both groups. PSTS was significantly greater in PAP than in AP at level C2 on postoperative day (POD) 1 (p = 0.0001). PSTS was more prominent at levels C2-4 during PODs 2-4 for both groups. In staged combined multilevel anterior-posterior complex spine surgery, PSTS is an inevitable complication. Therefore, surgeons should monitor PSTS after surgery when performing anterior-posterior complex cervical spine surgery, especially in the immediate postoperative period after PAP surgery.

Effect of perioperative steroids application on dysphagia, fusion rate, and visual analogue scale (VAS) following anterior cervical spine surgery: A meta-analysis of 14 randomized controlled trials (RCTs)

Objective

To conduct a high-level meta-analysis of the RCTs to evaluate perioperative steroids use in the management of fusion rate, dysphagia, and VAS following anterior cervical spine surgery for up to 1 year.

Methods

We searched the database PubMed, EMBASE, Web of Science, Cochrane Library, Google Scholar, Ovid, and ClinicalTrials.gov without time restriction to identify RCTs that evaluate the effectiveness of perioperative steroids after anterior cervical spine surgery. A subgroup analysis was undertaken to investigate the effects of intravenous and local steroids. This study was registered in the PROSPERO database prior to initiation (CRD42022313444).

Results

A total of 14 RCTs were eligible for final inclusion. This meta-analysis showed that steroids could achieve lower dysphagia rate (p < 0.001), severe dysphagia rate within 1 year (p < 0.001), lower VAS scores at both 1 day (p = 0.005), 2 weeks (p < 0.001) and shorter hospital stay (p = 0.014). However, there was no significant difference between the two groups regarding operation time (p = 0.670), fusion rates (p = 0.678), VAS scores at 6 months (p = 0.104) and 1 year (p = 0.062). There was no significant difference between intravenous and local steroid administration regarding dysphagia rates (p = 0.82), fusion rate (p = 1.00), and operative time (p = 0.10).

Conclusion

Steroids intravenously or locally following anterior cervical spine surgery can reduce incidence and severity of dysphagia within 1 year, VAS score within 2 weeks, and shorten the length of hospital stay without affecting fusion rates, increasing the operating time, VAS score at 6 months and 1 year.

Impact of local steroid application on dysphagia after anterior cervical spine surgery: a meta-analysis

INTRODUCTION

Dysphagia is one of the most common complications of anterior cervical spine surgery. Local steroid was widely used to reduce the postoperative swallowing pain. However, the effect of local steroid application on dysphagia after anterior cervical spine surgery was still uncertain.

MATERIALS AND METHODS

We searched Medline (PubMed), Embase and the Cochrane Library on July 27, 2021 for studies investigating the effect of local steroid application on dysphagia after anterior cervical spine surgery from their date of inception to 2021. The relative risk or weighted mean difference with 95% confidence interval was recorded as a summary statistic consist of postoperative dysphagia, swallowing VAS scores, SWAL-QOL scores, PSTSI, and steroid related complications.

RESULTS

This meta-analysis included 7 RCT studies involving 254 patients in the steroid group and 232 patients in the placebo group. Results showed local steroid group had less patients with dysphagia, lower swallowing VAS scores and less severe of prevertebral soft-tissue edema on the fourth day after surgery. No significant difference in non-fusion rate between the two groups was observed. And all included studies had no serious steroid related complications reported.

CONCLUSIONS

The use of local steroid in anterior cervical spine surgery could reduce the early postoperative dysphagia without serious steroid related complication. However, the safety of local steroid application still need further studies with larger samples.

Effect of Absorbable Collagen sponge and Steroid Injectionfor One or Two Segment Anterior Cervical Discectomy and fusion: A Retrospective comparison study

BACKGROUND

Dysphagia, mostly resulting from prevertebral soft tissue swelling (PSTS), is a common and refractory complication of anterior cervical discectomy and fusion (ACDF). Although the symptoms are mild and moderate in most cases, severe dysphagia can incur significant mental burdens and morbidity in some patients. This retrospective study aims to analyze the effect of absorbable collagen sponge and steroid injection (ACS-SI) for patients with ACDF.

METHOD

150 patients in the ACS-SI group and 175 in the ANCS-SI group were enrolled in this study from the Affiliated Lihuili Hospital of Ningbo University from January 2018 to November 2020. Baseline characteristics and operation parameters were collected from medical records. The swallowing function was evaluated by the Swallowing-Quality of Life (SWAL-QOL) survey, odynophagia was assessed by visual analog scale (VAS), and prevertebral soft tissue swelling index (PSTSI) was measured.

RESULTS

There was no significant difference in baseline characteristics and operation parameters between the two groups. The improvement of PSTSI and recovery of swallowing function in the ACS-SI group was better than that in the ANCS-SI group at 1 day and 1 month follow-up visit (P<0.05). The VAS score was significantly higher at 2 and 7 days after operation in the ANCS-SI group than that in the ACS-SI group (6.61±0.68 VS 5.52±0.74 and 4.23±0.90 VS 2.08±0.56, P<0.05). There was no significant difference in clinical outcomes between the two groups after 1 month (P>0.05).

CONCLUSION

The use of ACS-SI is beneficial to relieve postoperative odynophagia, reduce PSTS and recover swallow function.

The effect of local intraoperative corticosteroid application on postoperative dysphagia following anterior cervical spine surgery

Dysphagia is a common complication following anterior cervical spine surgery (ACSS). Although several literatures have reported the potential benefit of local corticosteroid application on dysphagia, its safety and efficacy are still unclear. A systematic review was performed aiming to evaluate the evidence of local corticosteroid application in prevention or treatment of postoperative dysphagia following ACSS. A systematic search was performed in September 2018 in PubMed and Embase database. The following information was extracted: study investigator, year of publication, number of patients, study design, inclusion/exclusion criteria, administration protocol of steroid, type of surgical procedure, number of levels performed, assessment methodology of dysphagia, radiologic assessment of prevertebral soft tissue swelling (PSTS), follow-up time points, outcome of dysphagia, and corticosteroid-related complications. Qualitative synthesis was performed. Finally, 5 studies met the inclusion/exclusion criteria. Four studies found that local corticosteroid application could decrease the incidence and magnitude of postoperative dysphagia while 1 study showed no effect on dysphagia significantly at 6 weeks and 3 months follow-up time. A total of 2325 patients received local corticosteroid intraoperatively; no early corticosteroid-related complication was reported. Totally, 4 adverse events occurred in long-term follow-up time, including 2 bone nonunion at 1.5 and 2.5 years postoperatively, 2 esophageal perforation at 2 months and 11 months of follow-up, respectively. Local corticosteroid application can reduce the incidence and severity of dysphagia following ACSS without increasing early corticosteroid-related complications. But further high-quality study is necessary to analyze potential delayed complications.

Upper Cervical Surgery, Increased Signal Intensity of the Spinal Cord, and Hypertension as Risk Factors for Dyspnea After Multilevel Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective study.

OBJECTIVE

To investigate the associated risk factors for acute respiratory distress after multilevel anterior cervical discectomy and fusion (ACDF) with a focus on the subjective symptom, dyspnea.

SUMMARY OF BACKGROUND DATA

Acute respiratory distress after ACDF is a relatively common adverse event, the cause of which is usually soft tissue swelling or hematoma. It can result in serious morbidity and requires careful, focused treatment.

METHODS

We reviewed the records of 532 patients (from January 2014 to August 2018) who had undergone multilevel ACDF surgery. Acute respiratory distress was defined as a complaint of dyspnea within 5 postoperative days. We investigated the patients' demographic parameters, comorbidities, and surgical procedure details. We also investigated radiologic parameters, including magnetic resonance imaging (MRI), with special attention to the prevertebral soft tissue thickness at C3 and C6. Statistical analysis was performed using the Student's t test and multiple logistic regression analysis.

RESULTS

Out of a total of 484 patients studied after exclusion criteria were applied, 31 patients (6.6%) experienced dyspnea after surgery. We selected 92 patients from the non-dyspnea group and compared them with 31 patients from the dyspnea group. On univariate analysis, upper cervical surgery involving C3, increased cord signal intensity on T2-weighted imaging (T2WI) magnetic resonance imaging (MRI), hypertension, smoking, and prevertebral soft tissue swelling at C3 level on postoperative day 1 were statistically significant factors associated with dyspnea. On logistic regression analysis, upper cervical surgery involving C3, increased cord signal intensity on T2WI MRI, and hypertension were found to be statistically significant variables (P < 0.05).

CONCLUSION

Patients undergoing upper cervical surgery involving C3, and having increased cord signal intensity on T2WI MRI and hypertension need to be monitored more carefully for acute respiratory distress after multilevel ACDF.

LEVEL OF EVIDENCE

4.