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Chang PL, Chen MJW, Hsiao PH, Lin CY, Lo YS, Tseng C, Li LY, Lai CY, Chen HT. Navigation-Assisted One-Staged Posterior Spinal Fusion Using Pedicle Screw Instrumentation in Adolescent Idiopathic Scoliosis-A Case Series. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:300. [PMID: 38399587 PMCID: PMC10889939 DOI: 10.3390/medicina60020300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Adolescent idiopathic scoliosis (AIS) is a prevalent three-dimensional spinal disorder, with a multifactorial pathogenesis, including genetics and environmental aspects. Treatment options include non-surgical and surgical treatment. Surgical interventions demonstrate positive outcomes in terms of deformity correction, pain relief, and improvements of the cardiac and pulmonary function. Surgical complications, including excessive blood loss and neurologic deficits, are reported in 2.27-12% of cases. Navigation-assisted techniques, such as the O-arm system, have been a recent focus with enhanced precision. This study aims to evaluate the results and complications of one-stage posterior instrumentation fusion in AIS patients assisted by O-arm navigation. Materials and Methods: This retrospective study assesses 55 patients with AIS (12-28 years) who underwent one-stage posterior instrumentation correction supported by O-arm navigation from June 2016 to August 2023. We examined radiological surgical outcomes (initial correction rate, loss of correction rate, last follow-up correction rate) and complications as major outcomes. The characteristics of the patients, intraoperative blood loss, operation time, number of fusion levels, and screw density were documented. Results: Of 73 patients, 55 met the inclusion criteria. The average age was 16.67 years, with a predominance of females (78.2%). The surgical outcomes demonstrated substantial initial correction (58.88%) and sustained positive radiological impact at the last follow-up (56.56%). Perioperative complications, including major and minor, occurred in 18.18% of the cases. Two patients experienced a major complication. Blood loss (509.46 mL) and operation time (402.13 min) were comparable to the literature ranges. Trend analysis indicated improvements in operation time and blood loss over the study period. Conclusions: O-arm navigation-assisted one-stage posterior instrumentation proves reliable for AIS corrective surgery, achieving significant and sustained positive radiological outcomes, lower correction loss, reduced intraoperative blood loss, and absence of implant-related complications. Despite the challenges, our study demonstrates the efficacy and maturation of this surgical approach.
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Affiliation(s)
- Pao-Lung Chang
- Department of Education, China Medical University Hospital, China Medical University, Taichung 404, Taiwan;
| | - Michael Jian-Wen Chen
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; (M.J.-W.C.); (P.-H.H.); (C.-Y.L.); (Y.-S.L.); (C.T.); (L.-Y.L.); (C.-Y.L.)
- Spine Center, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
| | - Pang-Hsuan Hsiao
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; (M.J.-W.C.); (P.-H.H.); (C.-Y.L.); (Y.-S.L.); (C.T.); (L.-Y.L.); (C.-Y.L.)
- Spine Center, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
| | - Chia-Yu Lin
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; (M.J.-W.C.); (P.-H.H.); (C.-Y.L.); (Y.-S.L.); (C.T.); (L.-Y.L.); (C.-Y.L.)
- Spine Center, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
| | - Yuan-Shun Lo
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; (M.J.-W.C.); (P.-H.H.); (C.-Y.L.); (Y.-S.L.); (C.T.); (L.-Y.L.); (C.-Y.L.)
- Spine Center, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
- Department of Orthopedic Surgery, China Medical University Beigang Hospital, China Medical University, Yunlin County 651, Taiwan
- Graduate Institute of Precision Engineering, National Chung Hsing University, Taichung 402, Taiwan
| | - Chun Tseng
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; (M.J.-W.C.); (P.-H.H.); (C.-Y.L.); (Y.-S.L.); (C.T.); (L.-Y.L.); (C.-Y.L.)
- Spine Center, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
- Department of Orthopedic Surgery, China Medical University Beigang Hospital, China Medical University, Yunlin County 651, Taiwan
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404, Taiwan
| | - Ling-Yi Li
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; (M.J.-W.C.); (P.-H.H.); (C.-Y.L.); (Y.-S.L.); (C.T.); (L.-Y.L.); (C.-Y.L.)
- Spine Center, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
| | - Chien-Ying Lai
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; (M.J.-W.C.); (P.-H.H.); (C.-Y.L.); (Y.-S.L.); (C.T.); (L.-Y.L.); (C.-Y.L.)
- Spine Center, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
| | - Hsien-Te Chen
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; (M.J.-W.C.); (P.-H.H.); (C.-Y.L.); (Y.-S.L.); (C.T.); (L.-Y.L.); (C.-Y.L.)
- Spine Center, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
- Department of Sport Medicine, College of Health Care, China Medical University, Taichung 404, Taiwan
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Garg B, Bansal T, Mehta N, Sharan AD. Patient Positioning in Spine Surgery: What Spine Surgeons Should Know? Asian Spine J 2023; 17:770-781. [PMID: 37226380 PMCID: PMC10460667 DOI: 10.31616/asj.2022.0320] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/15/2022] [Indexed: 05/26/2023] Open
Abstract
Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi,
India
| | - Tungish Bansal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi,
India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi,
India
| | - Alok D. Sharan
- Spine and Orthopedics, NJ Spine and Wellness, Matawan, NJ,
USA
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3
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Li NY, Murthy NK, Franz CK, Spinner RJ, Bishop AT, Murray PM, Shin AY. Upper Extremity Neuropathies Following Severe COVID-19 Infection: A Multicenter Case Series. World Neurosurg 2023; 171:e391-e397. [PMID: 36513302 PMCID: PMC9737497 DOI: 10.1016/j.wneu.2022.12.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purpose of the study is to examine presentation, injury patterns, and clinical course, for COVID-19-related peripheral nerve injury following mechanical ventilation. METHODS A multicenter retrospective study of patients with COVID-19 complicated by acute respiratory distress syndrome (ARDS) that required mechanical ventilation was undertaken. Patient records were reviewed for intensive care unit and intubation characteristics, prone or lateral decubitus positioning, and the onset of neuropathy diagnosis. RESULTS Between September 2020 and January 2022, 11 patients were diagnosed with peripheral neuropathy, including 9 with brachial plexopathy following COVID-19 infection. Each patient developed ARDS requiring mechanical ventilation for a median of 39 days. Six patients (54.5%) underwent prone positioning and 1 lateral decubitus. Neuropathies involved 5 brachial pan-plexopathies, 2 incomplete brachial plexopathies, 2 lower trunk plexopathies, 1 radial neuropathy, and 1 bilateral ulnar neuropathy. At a mean follow-up of 10.2 months, patients with brachial pan-plexopathies demonstrated signs of reinnervation proximally, and 1 resolved to a radial mononeuropathy; however, the majority have demonstrated minimal clinical improvements. CONCLUSIONS Our series demonstrates that peripheral neuropathies and especially brachial plexopathies have occurred following mechanical ventilation for ARDS-related COVID-19 infections. Contrary to prior COVID-19 studies, only 54.5% of these patients underwent prone positioning. Aside from a traumatic disturbance of prone positioning, the increased incidence of neuropathy may involve an atraumatic effect of COVID-19 via direct invasion of nerves, autoantibody targeting of nervous tissue, or hypercoagulation-induced microthrombotic angiopathy.
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Affiliation(s)
- Neill Y Li
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikhil K Murthy
- McGaw Medical Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Collin K Franz
- Shirley Ryan Ability Lab, Chicago, Illinois, USA; Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen T Bishop
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter M Murray
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Alexander Y Shin
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Cavinato M, Vittoria F, Piccione F, Masiero S, Carbone M. The value of intraoperative neurophysiological monitoring during positioning in pediatric scoliosis correction: A case report. Clin Neurophysiol Pract 2022; 7:366-371. [PMID: 36504686 PMCID: PMC9731825 DOI: 10.1016/j.cnp.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/13/2022] [Accepted: 11/05/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Prone position during posterior spine surgery can represent a potentially risky procedure for the nervous system. Infrequent injuries due to prone positioning consist of subtle spinal cord infarction or myelopathy that can be promptly detected by intraoperative neurophysiological monitoring (IONM), if applied in this phase of surgery. Here, we report a case that stresses the value of IONM even in detecting spinal positioning-related neurological complications during kyphoscoliosis correction. Case presentation A 3-year-old child with a severe thoracic kyphoscoliosis with the angle in the tract T5-T6 underwent an early treatment of scoliosis with growing rods. Before instrumentation or the reduction maneuver, lower limb somatosensory and motor responses disappeared. The patient was repositioned with neck and chest in a more protective position and neuromonitoring signals returned to baseline. The surgery could be completed and the patient had no postoperative neurologic or vascular deficits. Conclusion Our findings suggest the importance of extending neuromonitoring in the early phases of anesthesia induction and patient positioning during corrective spinal deformity surgery.
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Affiliation(s)
- M. Cavinato
- Department of Neurosciences, Physical Medicine and Rehabilitation School, University of Padova, Padova, Italy
- Corresponding author at: Physical Medicine and Rehabilitation School, University of Padua, Padua, Italy.
| | - F. Vittoria
- Division of Trauma and Orthopedic Surgery, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - F. Piccione
- Department of Neurosciences, Physical Medicine and Rehabilitation School, University of Padova, Padova, Italy
| | - S. Masiero
- Department of Neurosciences, Physical Medicine and Rehabilitation School, University of Padova, Padova, Italy
| | - M. Carbone
- Division of Trauma and Orthopedic Surgery, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
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Rahmathulla G, Lara-Velazquez M, Pafford R, Hoefnagel A, Rao D. Upper Extremity Monoplegia following Prone Surrender Position for Spinal Surgery. J Neurosci Rural Pract 2022; 13:537-540. [PMID: 35945993 PMCID: PMC9357480 DOI: 10.1055/s-0042-1749405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Abstract
Background Secondary peripheral nerve injuries remain a significant perioperative problem due to patient positioning and contribute to reduced patient quality of life and exacerbated professional liability. Comorbidities and concomitant lesions can further elicit these injuries in patients undergoing spinal surgeries.
Case Presentation We report a case of a 70-year-old male polytrauma patient presenting with a left first-rib fracture and an adjacent hematoma around the brachial plexus without preoperative deficits. Subsequent to a lumbar spinal fusion in the prone position, he developed a postoperative left upper extremity monoplegia. The postoperative magnetic resonance imaging revealed an enhanced asymmetric signal in the trunks and cords of the left brachial plexus. He progressively improved with rehabilitation, a year after the initial presentation, with a residual wrist drop.
Conclusions Pan brachial plexus monoplegia, following spine surgery, is rare and under-reported pathology. To minimize the occurrence of this rare morbidity, appropriate considerations in preoperative evaluation and counseling, patient positioning, intraoperative anesthetic, and electrophysiological monitoring should be performed. We emphasize an unreported risk factor in polytrauma patients, predisposing this rare injury that is associated with prone spinal surgery positioning, SEPs being an extremely sensitive test intraoperatively and highlight the importance of counseling patients and families to the possibility of this rare occurrence.
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Affiliation(s)
- Gazanfar Rahmathulla
- Department of Neurological Surgery, University of Florida Jacksonville, Jacksonville, Florida, United States
| | - Montserrat Lara-Velazquez
- Department of Neurological Surgery, University of Florida Jacksonville, Jacksonville, Florida, United States
| | - Ryan Pafford
- Department of Neurological Surgery, University of Florida Jacksonville, Jacksonville, Florida, United States
| | - Amie Hoefnagel
- Department of Anesthesiology, University of Florida Jacksonville, Jacksonville, Florida, United States
| | - Dinesh Rao
- Department of Radiology, University of Florida Jacksonville, Jacksonville, Florida
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6
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King-Robson J, Bates E, Sokolov E, Hadden RDM. Prone position plexopathy: an avoidable complication of prone positioning for COVID-19 pneumonitis? BMJ Case Rep 2022; 15:15/1/e243798. [PMID: 34983806 PMCID: PMC8728371 DOI: 10.1136/bcr-2021-243798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Prone positioning is a mainstay of management for those presenting to the intensive care unit with moderate-to-severe acute respiratory distress syndrome due to COVID-19. While this is a necessary and life-saving intervention in selected patients, careful positioning and meticulous care are required to prevent compression and traction of the brachial plexus, and resultant brachial plexopathy. We describe two patients who developed a brachial plexus injury while undergoing prone positioning for management of COVID-19 pneumonitis. Both patients were diabetic and underwent prolonged periods in the prone position during which the plexopathy affected arm was abducted for 19 and 55 hours, respectively. We discuss strategies to reduce the risk of this rare but potentially disabling complication of prone positioning.
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Affiliation(s)
| | - Eleanor Bates
- Critical Care Department, King's College Hospital, London, UK
| | - Elisaveta Sokolov
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, London, UK
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7
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Arestov SO, Gerasimova EV, Gushcha AO. [Potential complications of patient positioning in spine surgery]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:112-120. [PMID: 35170284 DOI: 10.17116/neiro202286011112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Patient position on the operating table during spine surgery is important for optimal intraoperative manipulations. However, this position is far from physiological one. An unnatural position, surgery time and sometimes necessary intraoperative change in body position can lead to certain neurological and somatic complications. Most of these events can significantly reduce the patient's working capacity and quality of life and even result disability. Medical staff placing the patient on operating table, neurosurgeons and anesthesiologists should be aware of risk factors of similar complications and their prevention. The authors describe the most serious and difficult for correction conditions, such as peripheral neuropathy, damage to visual analyzer, as well as optimal method of patient positioning.
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8
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Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 34:257-276. [PMID: 34483301 DOI: 10.1097/ana.0000000000000799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 11/25/2022]
Abstract
Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.
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9
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Sánchez-Soblechero A, García CA, Sáez Ansotegui A, Fernández-Lorente J, Catalina-Álvarez I, Grandas F, Muñoz-Blanco JL. Upper trunk brachial plexopathy as a consequence of prone positioning due to SARS-CoV-2 acute respiratory distress syndrome. Muscle Nerve 2020; 62:E76-E78. [PMID: 32875575 DOI: 10.1002/mus.27055] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 11/06/2022]
Affiliation(s)
| | - Cristina Ausín García
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Aiala Sáez Ansotegui
- Clinical Neurophysiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Fernández-Lorente
- Clinical Neurophysiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Irene Catalina-Álvarez
- Neurology Department, ALS-Neuromuscular Diseases Unit, Hospital General Universitario Gregorio, Marañón, Madrid, Spain
| | - Francisco Grandas
- Neurology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (liSGM), Madrid, Spain
| | - José Luis Muñoz-Blanco
- Neurology Department, ALS-Neuromuscular Diseases Unit, Hospital General Universitario Gregorio, Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (liSGM), Madrid, Spain
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10
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Aldana E, Álvarez López-Herrero N, Benito H, Colomina MJ, Fernández-Candil J, García-Orellana M, Guzmán B, Ingelmo I, Iturri F, Martín Huerta B, León A, Pérez-Lorensu PJ, Valencia L, Valverde JL. Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals. ACTA ACUST UNITED AC 2020; 68:82-98. [PMID: 32624233 DOI: 10.1016/j.redar.2020.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/04/2020] [Accepted: 02/18/2020] [Indexed: 01/27/2023]
Abstract
The present work aims to establish a guide to action, agreed by anaesthesiologists and neurophysiologists alike, to perform effective intraoperative neurophysiological monitoring for procedures presenting a risk of functional neurological injury, and neurosurgical procedures. The first section discusses the main techniques currently used for intraoperative neurophysiological monitoring. The second exposes the anaesthetic and non-anaesthetic factors that are likely to affect the electrical records of the nervous system structures. This section is followed by an analysis detailing the adverse effects associated with the most common techniques and their use. Finally, the last section describes a series of guidelines to be followed upon the various intraoperative clinical events.
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Affiliation(s)
- E Aldana
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, España
| | - N Álvarez López-Herrero
- Neurofisiología, Servicio de Neurocirugía, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - H Benito
- Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - M J Colomina
- Anestesiología y Reanimación, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Universitat de Barcelona, Barcelona, España
| | | | - M García-Orellana
- Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
| | - B Guzmán
- Neurofisiología clínica, Hospital Clínico Universitario Lozano de Blesa, Zaragoza, España
| | - I Ingelmo
- Anestesiología y Reanimación, Hospital Universitario Ramón y Cajal, Madrid, España
| | - F Iturri
- Anestesiología y Reanimación, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España
| | - B Martín Huerta
- Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - A León
- Neurofisiología, Servicio de Neurología, Parc de Salut Mar, Barcelona, España
| | - P J Pérez-Lorensu
- Neurofisiología Clínica, Unidad de Monitorización Neurofisiológica Intraoperatoria, Hospital Universitario de Canarias, Tenerife, España
| | - L Valencia
- Anestesiología y Reanimación, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España
| | - J L Valverde
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, España
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11
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Peko L, Barakat-Johnson M, Gefen A. Protecting prone positioned patients from facial pressure ulcers using prophylactic dressings: A timely biomechanical analysis in the context of the COVID-19 pandemic. Int Wound J 2020; 17:1595-1606. [PMID: 32618418 PMCID: PMC7361768 DOI: 10.1111/iwj.13435] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/08/2020] [Indexed: 01/08/2023] Open
Abstract
Prone positioning is used for surgical access and recently in exponentially growing numbers of coronavirus disease 2019 patients who are ventilated prone. To reduce their facial pressure ulcer risk, prophylactic dressings can be used; however, the biomechanical efficacy of this intervention has not been studied yet. We, therefore, evaluated facial soft tissue exposures to sustained mechanical loads in a prone position, with versus without multi‐layered silicone foam dressings applied as tissue protectors at the forehead and chin. We used an anatomically realistic validated finite element model of an adult male head to determine the contribution of the dressings to the alleviation of the sustained tissue loads. The application of the dressings considerably relieved the tissue exposures to loading. Specifically, with respect to the forehead, the application of a dressing resulted in 52% and 71% reductions in soft tissue exposures to effective stresses and strain energy densities, respectively. Likewise, a chin dressing lowered the soft tissue exposures to stresses and strain energy densities by 78% and 92%, respectively. While the surgical context is clear and there is a solid, relevant need for biomechanical information regarding prophylaxis for the prone positions, the projected consequences of the coronavirus pandemic make the present work more relevant than ever before.
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Affiliation(s)
- Lea Peko
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Michelle Barakat-Johnson
- Pressure Injury Prevention and Management, Sydney Local Health District, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Amit Gefen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
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12
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Gefen A, Creehan S, Black J. Critical biomechanical and clinical insights concerning tissue protection when positioning patients in the operating room: A scoping review. Int Wound J 2020; 17:1405-1423. [PMID: 32496025 DOI: 10.1111/iwj.13408] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 12/30/2022] Open
Abstract
An optimal position of the patient during operation may require a compromise between the best position for surgical access and the position a patient and his or her tissues can tolerate without sustaining injury. This scoping review analysed the existing, contemporary evidence regarding surgical positioning-related tissue damage risks, from both biomechanical and clinical perspectives, focusing on the challenges in preventing tissue damage in the constraining operating room environment, which does not allow repositioning and limits the use of dynamic or thick and soft support surfaces. Deep and multidisciplinary aetiological understanding is required for effective prevention of intraoperatively acquired tissue damage, primarily including pressure ulcers (injuries) and neural injuries. Lack of such understanding typically leads to misconceptions and increased risk to patients. This article therefore provides a comprehensive aetiological description concerning the types of potential tissue damage, vulnerable anatomical locations, the risk factors specific to the operative setting (eg, the effects of anaesthetics and instruments), the complex interactions between the tissue damage risk and the pathophysiology of the surgery itself (eg, the inflammatory response to the surgical incisions), risk assessments for surgical patients and their limitations, and available (including emerging) technologies for positioning. The present multidisciplinary and integrated approach, which holistically joins the bioengineering and clinical perspectives, is unique to this work and has not been taken before. Close collaboration between bioengineers and clinicians, such as demonstrated here, is required to revisit the design of operating tables, support surfaces for surgery, surgical instruments for patient stabilisation, and for surgical access. Each type of equipment and its combined use should be evaluated and improved where needed with regard to the two major threats to tissue health in the operative setting: pressure ulcers and neural damage.
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Affiliation(s)
- Amit Gefen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Sue Creehan
- Wound/Ostomy Program Team, VCU Health System, Richmond, Virginia, USA
| | - Joyce Black
- College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska, USA
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13
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Charalampidis A, Jiang F, Wilson JRF, Badhiwala JH, Brodke DS, Fehlings MG. The Use of Intraoperative Neurophysiological Monitoring in Spine Surgery. Global Spine J 2020; 10:104S-114S. [PMID: 31934514 PMCID: PMC6947672 DOI: 10.1177/2192568219859314] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE To summarize relevant studies regarding the utilization of intraoperative neurophysiological monitoring (IONM) techniques in spine surgery implemented in recent years. METHODS A literature search of the Medline database was performed. Relevant studies from all evidence levels have been included. Titles, abstracts, and reference lists of key articles were included. RESULTS Multimodal intraoperative neurophysiological monitoring (MIONM) has the advantage of compensating for the limitations of each individual technique and seems to be effective and accurate for detecting perioperative neurological injury during spine surgery. CONCLUSION Although there are no prospective studies validating the efficacy of IONM, there is a growing body of evidence supporting its use during spinal surgery. However, the lack of validated protocols to manage intraoperative alerts highlights a critical knowledge gap. Future investigation should focus on developing treatment methodology, validating practice protocols, and synthesizing clinical guidelines.
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Affiliation(s)
- Anastasios Charalampidis
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Fan Jiang
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jamie R. F. Wilson
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jetan H. Badhiwala
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | | | - Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst St, Toronto, Ontario M5T2S8, Canada.
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Biscevic M, Sehic A, Biscevic S, Gavrankapetanovic I, Smrke B, Vukomanovic D, Krupic F. Kyphosis - A risk factor for positioning brachial plexopathy during spinal surgeries. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2019; 53:199-202. [PMID: 30898433 PMCID: PMC6599389 DOI: 10.1016/j.aott.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 12/22/2018] [Accepted: 02/05/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the differences in transcranial electric motor-evoked potentials - TceMEP on upper limbs and the incidences of postoperative brachial plexopathy between patients with kyphotic and scoliotic trunk shapes. METHODS In the period of January 2011-January 2017, 61 consecutive patients (mean age: 18.4 years ± 4.4 years (range: 10-32)) with pediatric spinal deformity underwent surgery in our Department. Eight of them had a kyphotic trunk deformity (Scheuermann kyphosis, neurofibromatosis, posterior thoracic hemivertebra), and the rest of the 53 patients had a scoliotic trunk deformity (mostly adolescent idiopathic scoliosis - AIS, lateral hemivertebra). The TceMEP recordings in all four limbs were analyzed every 30 min, or upon the surgeon's command. Upper limb TceMEP recordings were used as a control of systemic and anesthetic related changes, and as the indicator of positioning brachial plexopathy. RESULTS Four out of 8 patients (50.0%) from the kyphotic group experienced noteworthy decreases in TceMEP amplitude (≥65%) in one or both arms, and only 2 out of 53 patients (3.8%) from the scoliotic group, confirming significant statistical difference (Chi-square 16.75, p < 0.05). Two out of 8 patients with decreases in TceMEP amplitude suffered from transitory postoperative brachial plexopathy, and both of them were from the kyphotic group. CONCLUSION It seems that kyphotic trunks have a higher risk for positioning-related brachial plexopathy, probably due to distribution of trunk's weight onto only four points (two iliac bones and two shoulders), compared to the scoliotic trunks that have wider weight-bearing areas. We emphasize the importance of proper patient positioning and close intraoperative neuro-monitoring of all four limbs in more than one channel per limb. LEVEL OF EVIDENCE Level IV Therapeutic Study.
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Saiwai H, Okada S, Kawaguchi KI, Saito T, Hayashida M, Matsushita A, Matsumoto Y, Nakashima Y. Prone position surgery for a professional sumo wrestler with thoracic ossification of the posterior longitudinal ligament resulting in intraoperative brachial plexus injury by hypertrophic pectoral muscles. J Clin Neurosci 2019; 63:227-230. [PMID: 30777366 DOI: 10.1016/j.jocn.2019.01.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 01/30/2019] [Indexed: 11/28/2022]
Abstract
Surgery in the prone position is associated with a variety of complications due to the positioning, including the widely recognized peripheral nerve compression injuries and brachial plexus neuropathy. Previous studies have reported that thin body habitus is a predisposing risk factor for the compressive peripheral nerve injuries due to the prone position surgery. However, prone-position-related brachial plexus injury in patients who are overweight due to hypertrophic muscles have never been reported. Here we report a case of a professional sumo wrestler with severe thoracic ossification of the posterior longitudinal ligament (OPLL). Thoracic OPLL was successfully treated by posterior spinal fusion and decompression surgery. Despite a preoperative simulation and intraoperative inspection of the patient's surgical positioning, he suffered from bilateral upper extremity paralysis immediately after the surgery. Postoperative axillary MRI image revealed a high-intensity area on both sides of his pectoral muscles and axillary fossa, which implied that the pectoral muscles between the ribs and chest pad were pushed out toward the axillary fossa, resulting in compressive brachial plexus injury. His upper extremity motor paralysis was fully recovered in 6 months, but he still has mild tingling sensation even after 12 months of his surgery. In conclusion, overweight patients with hypertrophic muscles pose a risk for brachial plexus entrapment injury by pectoral muscles during prone-position surgery, and therefore it would be more effective to use a wide chest pad to reduce the pressure on the pectoral muscles to prevent it from being pushed out toward the axillary fossa.
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Affiliation(s)
- Hirokazu Saiwai
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan.
| | - Seiji Okada
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan; Department of Immunobiology and Neuroscience, Medical Institute of Bioregulation, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Ken-Ichi Kawaguchi
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Takeyuki Saito
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Mitsumasa Hayashida
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Akinobu Matsushita
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yasuharu Nakashima
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
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Breen DT, Mahar PD, Batty LM, Rosenfeld JV. Implications for Australian Anaesthetists and Proceduralists of a Recent Court Decision regarding Informed Consent and Patient Positioning. Anaesth Intensive Care 2019; 42:11-4. [DOI: 10.1177/0310057x1404200104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- D. T. Breen
- Department of General Surgery, The Alfred Hospital, Alfred Health, Prahran, Victoria
| | - P. D. Mahar
- Department of General Surgery, The Alfred Hospital, Alfred Health, Prahran, Victoria
- Department of Surgery, Deakin University, Melbourne, Victoria and Clinical Fellow, Department of Medicine, St Vincent's Hospital, Melbourne, Victoria
| | - L. M. Batty
- Department of General Surgery, The Alfred Hospital, Alfred Health, Prahran, Victoria
- Department of Orthopaedic Surgery, Monash Health, Melbourne, Victoria
| | - J. V. Rosenfeld
- Department of General Surgery, The Alfred Hospital, Alfred Health, Prahran, Victoria
- Department of Neurosurgery, The Alfred Hospital, Alfred Health, Prahran, Victoria and Head, Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria
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Qian BP, Huang JC, Qiu Y, Wang B, Yu Y, Zhu ZZ, Mao SH, Jiang J. Complications of spinal osteotomy for thoracolumbar kyphosis secondary to ankylosing spondylitis in 342 patients: incidence and risk factors. J Neurosurg Spine 2019; 30:91-98. [PMID: 30485225 DOI: 10.3171/2018.6.spine171277] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 06/06/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVETo describe the incidence of complications in spinal osteotomy for thoracolumbar kyphosis caused by ankylosing spondylitis (AS) and to investigate the risk factors for these complications.METHODSFrom April 2000 to July 2017, 342 consecutive AS patients with a mean age (± SD) of 35.4 ± 9.8 years (range 17-71 years) undergoing spinal osteotomy were enrolled. Patients with complications within the 1st postoperative year were identified. Demographic, radiological, and surgical data were compared between patients with and without complications. The complications were classified into intraoperative and postoperative complications.RESULTSA total of 310 consecutive pedicle subtraction osteotomy (PSO) and 37 multiple Smith-Petersen osteotomy (SPO) procedures were performed in 342 patients. Overall, 47 complications were identified in 47 patients (13.7%), including 31 intraoperative complications and 16 postoperative complications. Patients with complications were older than those without (p = 0.006). A significant difference was observed in preoperative global kyphosis (GK), lumbar lordosis (LL), sagittal vertical axis (SVA), and the correction of these radiographic parameters between patients with and without complications (p < 0.05). Two-level PSO (p = 0.022) and an increased number of instrumented vertebrae (p = 0.019) were significantly associated with an increased risk of complications.CONCLUSIONSThe overall incidence of complications was 13.7%. Age; preoperative GK, LL, and SVA; the correction of GK, LL, and SVA; 2-level PSO; and number of instrumented vertebrae were risk factors. Therefore, the potential risk of extensive surgeries with large correction and long fusion in older AS patients with severe GK should be seriously considered in surgical decision-making.
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Rui L, Xu G, Lv X, Ma Z. A Comprehensive Protocol to Prevent Brachial Plexus Injury During Ankylosing Spondylitis Surgery. J Perianesth Nurs 2018; 33:908-914. [PMID: 30449439 DOI: 10.1016/j.jopan.2017.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/16/2017] [Accepted: 09/17/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE This article describes a comprehensive protocol to protect the brachial plexus when performing pedicle subtraction osteotomy for ankylosing spondylitis patients with thoracolumbar kyphosis. DESIGN A descriptive study was conducted. METHODS Records of 101 cases from October 2013 to December 2016 were retrospectively audited. The protocol included five items: (1) preoperative assessment of motion range and nerve function of limbs and trunks; (2) preoperative positioning according to the assessment results; (3) intra-operative somatosensory evoked potential and blood pressure monitoring; (4) intra-operative repositioning according to the monitoring alarm signals; and (5) postoperative neurological function check. FINDINGS Five patients showed impending brachial plexus injury indicators, including two who had a decrease in blood pressure and three who had a decrease in the amplitude of somatosensory evoked potential. After adjustment of position and soft pads, one patient had brachial plexus injury (0.99%) and the recovery time was 2 weeks. CONCLUSIONS With this comprehensive strategy, the brachial plexus could be effectively protected during the surgery.
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19
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Graham RB, Cotton M, Koht A, Koski TR. Loss of intraoperative neurological monitoring signals during flexed prone positioning on a hinged open frame during surgery for kyphoscoliosis correction: case report. J Neurosurg Spine 2018; 29:339-343. [DOI: 10.3171/2018.1.spine17811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Various complications of prone positioning in spine surgery have been described in the literature. Patients in the prone position for extended periods are subject to neurological deficits and/or loss of intraoperative signals due to compression neuropathies, but positioning-related spinal deficits are rare in the thoracolumbar deformity population. The authors present a case of severe kyphoscoliotic deformity with critical thoracolumbar stenosis in which, during the use of a hinged open frame in the prone position, complete loss of intraoperative neural monitoring signals occurred while the frame was flexed into kyphosis to facilitate exposure and instrumentation placement. When the frame was reset to a neutral position, evoked potentials returned to baseline and the operation proceeded without complications. This case represents, to the authors’ knowledge, the first report of loss of evoked potentials due to an alteration of prone positioning on a hinged open frame. When positioning patients in such a manner, careful attention should be directed to intraoperative signals in patients with critical stenosis and kyphotic deformity.
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Affiliation(s)
| | - Mathew Cotton
- 2Division of Intraoperative Neurophysiologic Monitoring, Department of Neurology,
| | | | - Tyler R. Koski
- 4Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Wang ZQ, Xiu DH, Liu GF, Jiang JL. Overexpression of Neuregulin-1 (NRG-1) Gene Contributes to Surgical Repair of Brachial Plexus Injury After Contralateral C7 Nerve Root Transfer in Rats. Med Sci Monit 2018; 24:5779-5787. [PMID: 30121695 PMCID: PMC6111774 DOI: 10.12659/msm.908144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Surgeons usually transfer the contralateral C7 to the median nerve on the injured side via a nerve graft to recover sensation and movement in a paralyzed hand. The purpose of our study was to determine whether NRG-1 affects the recovery of nerve function in brachial plexus injury after contralateral C7 nerve root transfer in a rat model. Material/Methods An injury model of left brachial plexus and contralateral C7 nerve root transfer was established. Four weeks after the operation, NRG-1 expression was examined by reverse transcription quantitative polymerase chain reaction and Western blot analysis. The diameter rate differences of the healthy limb and affected limb were estimated. The postoperative mass of the left latissimus dorsi, triceps, extensor carpi radialis brevis, and musculus extensor digitorum were examined. The number of nerve fibers and typical area of the affected side were assessed. Postoperative left motor nerve conduction velocity (MNCV) and motor nerve action potential (MNAP) were tested by use of a biological information recording and collecting system. Results Eukaryotic expression plasmid of pcDNA4/myc/A-NRG-1 was successfully constructed, and NRG-1 was overexpressed. Compared with the model group, the NRG-1 group had a lower rate of differences of the limbs; higher mass of left latissimus dorsi, triceps, extensor carpi radialis brevis, and musculus extensor digitorum; more nerve fibers and larger typical area in the affected side, left MNCV, and MNAP; and wider CSA of the left triceps. Conclusions These results demonstrated that NRG-1 can promote recovery of nerve function in brachial plexus injury after contralateral C7 nerve root transfer in rats.
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Affiliation(s)
- Zong-Qiang Wang
- Medical Department, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China (mainland)
| | - Dian-Hui Xiu
- Department of Radiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China (mainland)
| | - Gui-Feng Liu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China (mainland)
| | - Jin-Lan Jiang
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China (mainland).,Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China (mainland)
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Abstract
Multimodal intraoperative neurophysiologic monitoring is a reliable tool for detecting intraoperative spine injury and is recommended during surgery for degenerative cervical myopathy (DCM). Somatosensory evoked potential (SEP) can be used to monitor spine and peripheral nerve injury during positioning in surgery for DCM. Compensation technique for transcranial evoked muscle action potentials (tcMEPs) should be adopted in intraoperative monitoring during surgery for DCM. Free-running electromyography is a useful real-time monitoring add-on modality in addition to SEP and tcMEP.
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Kamat AS, Ebrahim MZ, Vlok AJ. Thoracic disc herniation: An unusual complication after prone positioning in spinal surgery. Int J Spine Surg 2017; 10:39. [PMID: 28377853 DOI: 10.14444/3039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neurological complications of the prone position have been well documented. Post-operative paraplegia and neurological deterioration unrelated to the site of surgery after proning in spinal surgery is a rare but potentially devastating complication. We describe the case of a 47 year old female who underwent an L4/5 discectomy and posterior instrumented fusion. A few hours after surgery she developed bilateral lower limb weakness with a T11 sensory level. Post-operative MRI revealed an acute disc herniation at the T11/12 level with associated spinal cord compression. This was not present on the pre-operative imaging. A subsequent T11/12 discectomy and instrumented fusion was performed and the patient's motor and sensory function returned to normal.
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Affiliation(s)
- Ameya S Kamat
- Division of Neurosurgery, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
| | - Mohammed Zahier Ebrahim
- Division of Neurosurgery, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
| | - Adriaan J Vlok
- Division of Neurosurgery, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
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23
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Nerve Injuries in Gynecologic Laparoscopy. J Minim Invasive Gynecol 2017; 24:16-27. [DOI: 10.1016/j.jmig.2016.09.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/02/2016] [Accepted: 09/07/2016] [Indexed: 11/30/2022]
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Narita W, Takatori R, Arai Y, Nagae M, Tonomura H, Hayashida T, Ogura T, Fujiwara H, Kubo T. Prevention of neurological complications using a neural monitoring system with a finger electrode in the extreme lateral interbody fusion approach. J Neurosurg Spine 2016; 25:456-463. [DOI: 10.3171/2016.1.spine151069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Extreme lateral interbody fusion (XLIF) is a minimally disruptive surgical procedure that uses a lateral approach. There is, however, concern about the development of neurological complications when this approach is used, particularly at the L4–5 level. The authors performed a prospective study of the effects of a new neural monitoring system using a finger electrode to prevent neurological complications in patients treated with XLIF and compared the results to results obtained in historical controls.
METHODS
The study group comprised 36 patients (12 male and 24 female) who underwent XLIF for lumbar spine degenerative spondylolisthesis or lumbar spine degenerative scoliosis at L4–5 or a lower level. Using preoperative axial MR images obtained at the mid-height of the disc at the treated level, we calculated the psoas position value (PP%) by dividing the distance from the posterior border of the vertebral disc to the posterior border of the psoas major muscle by the anteroposterior diameter of the vertebral disc. During the operation, the psoas major muscle was dissected using an index finger fitted with a finger electrode, and threshold values of the dilator were recorded before and after dissection. Eighteen cases in which patients had undergone the same procedure for the same indications but without use of the finger electrode served as historical controls. Baseline clinical and demographic characteristics, PP values, clinical results, and neurological complications were compared between the 2 groups.
RESULTS
The mean PP% values in the control and finger electrode groups were 17.5% and 20.1%, respectively (no significant difference). However, 6 patients in the finger electrode group had a rising psoas sign with PP% values of 50% or higher. The mean threshold value before dissection in the finger electrode group was 13.1 ± 5.9 mA, and this was significantly increased to 19.0 ± 1.5 mA after dissection (p < 0.001). A strong negative correlation was found between PP% and threshold values before dissection, but there was no correlation with threshold values after dissection. The thresholds after dissection improved to 11 mA or higher in all patients. There were no serious neurological complications in any patient, but there was a significantly lower incidence of transient neurological symptoms in the finger electrode group (7 [38%] of 18 cases vs 5 [14%] of 36 cases, p = 0.047).
CONCLUSIONS
The new neural monitoring system using a finger electrode may be useful to prevent XLIF-induced neurological complications.
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Affiliation(s)
- Wataru Narita
- 1Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine; and
- 2Spine Surgery and Related Research Center, Nantan General Hospital, Nantan City, Kyoto, Japan
| | - Ryota Takatori
- 1Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine; and
| | - Yuji Arai
- 1Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine; and
| | - Masateru Nagae
- 1Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine; and
| | - Hitoshi Tonomura
- 1Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine; and
| | - Tatsuro Hayashida
- 2Spine Surgery and Related Research Center, Nantan General Hospital, Nantan City, Kyoto, Japan
| | - Taku Ogura
- 2Spine Surgery and Related Research Center, Nantan General Hospital, Nantan City, Kyoto, Japan
| | - Hiroyoshi Fujiwara
- 1Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine; and
| | - Toshikazu Kubo
- 1Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine; and
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Borden TC, Bellaire LL, Fletcher ND. Improving perioperative care for adolescent idiopathic scoliosis patients: the impact of a multidisciplinary care approach. J Multidiscip Healthc 2016; 9:435-445. [PMID: 27695340 PMCID: PMC5028162 DOI: 10.2147/jmdh.s95319] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The complex nature of the surgical treatment of adolescent idiopathic scoliosis (AIS) requires a wide variety of health care providers. A well-coordinated, multidisciplinary team approach to the care of these patients is essential for providing high-quality care. This review offers an up-to-date overview of the numerous interventions and safety measures for improving outcomes after AIS surgery throughout the perioperative phases of care. Reducing the risk of potentially devastating and costly complications after AIS surgery is the responsibility of every single member of the health care team. Specifically, this review will focus on the perioperative measures for preventing surgical site infections, reducing the risk of neurologic injury, minimizing surgical blood loss, and preventing postoperative complications. Also, the review will highlight the postoperative protocols that emphasize early mobilization and accelerated discharge.
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Affiliation(s)
- Timothy C Borden
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Laura L Bellaire
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
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Causal factors for position-related SSEP changes in spinal surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3208-3213. [DOI: 10.1007/s00586-016-4618-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 04/28/2016] [Accepted: 05/15/2016] [Indexed: 01/13/2023]
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Clinical Decision Support and Perioperative Peripheral Nerve Injury: A Quality Improvement Project. Comput Inform Nurs 2016; 33:238-48; quiz E1. [PMID: 25851559 DOI: 10.1097/cin.0000000000000148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Decision support at the point of care has been demonstrated to be an effective tool in providing a safe environment and improving patient outcomes. The operating room is typically an area where advanced technology is introduced to nurses on a regular basis. This quality improvement project focused on preventing a peripheral nerve injury, which is an example of a postoperative adverse event that is considered preventable. Injury of a peripheral nerve is the result of compression, hyperextension, flexion, or ischemia surrounding the nerve. The goals for this project were to improve the knowledge of peripheral nerve injury of the operating room nurses, design and implement a peripheral nerve injury assessment screen that could provide decision support within the operating room record, improve the nursing documentation of peripheral nerve injury interventions, and (long term) decrease the incidence of peripheral nerve injury. A decision support screen within the operating room record was designed to supplement the operating room nurse's risk assessment for peripheral nerve injury. The components of this project involved a preliminary and postproject surveys on peripheral nerve injury knowledge, an educational presentation, and a retrospective random review of nursing documentation in the operating room electronic health records. Project results demonstrated a significant increase in nursing documentation of peripheral nerve injury interventions (63%-92%) and a positive attitude toward their exposure to basic decision support (P = .046). Recommendations for future studies and establishing a standardized coding system for peripheral nerve injury identification were identified.
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Rice K, Scott A, Guyot A. Detection of Position-Related Sciatic Nerve Dysfunction by Somatosensory Evoked Potentials During Spinal Surgery. Neurodiagn J 2015; 55:82-90. [PMID: 26173346 DOI: 10.1080/21646821.2015.1043219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
It is well established that intraoperative somatosensory evoked potentials (SSEPs) are sensitive to plexus and peripheral nerve dysfunction related to malpositioning of patients during spinal surgery. While most reports focus on upper extremity nerve or brachial plexus effects, there is very little on detection of sciatic nerve compromise. Recording of the SSEP at the popliteal fossa is a common strategy to aid in troubleshooting stimulus-related problems or distal peripheral tibial nerve failure; yet position-related sciatic nerve effects may not be realized by changes in the popliteal fossa response. Three posterior lumbar surgeries are reviewed in which there was evidence of proximal lower extremity peripheral nerve dysfunction related to positioning. Loss of posterior tibial nerve SSEPs with preservation of the peripheral popliteal fossa response recording occurred in the absence of critical surgical manipulations. Efforts at repositioning and release of tension on the lower limbs promptly resulted in recovey of lost responses. Two of the three cases involved patients in a kneeling position with a tight strap across the posterior thigh. Standard SSEP recordings used in intraoperative neuromonitoring do not specifically localize intraoperative changes to the sciatic nerve; thus, such changes affecting SSEPs above the popliteal fossa mimic iatrogenic changes occurring at the surgical site. These case reports show that when the stage of surgery does not support iatrogenic changes, malpositioning affecting sciatic nerve should be considered, especially for patients placed in a kneeling position on an Andrews frame.
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Gomes C, Kuchenbuch M, Lucas G, Sauleau P, Violas P. Monopolar-probe monitoring during spinal surgery with expandable prosthetic ribs. Orthop Traumatol Surg Res 2015; 101:S193-7. [PMID: 25890812 DOI: 10.1016/j.otsr.2015.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Intraoperative monitoring (IOM) has been proven to decrease the risk of neurological injury during scoliosis surgery. The vertical expandable prosthetic titanium rib (VEPTR) is a device that allows spinal growth. However, injuries to the spinal cord and brachial plexus have been reported after VEPTR implantation in 2 and 5% of patients, respectively. Simultaneous monitoring of these two structures requires the use of multiple time-consuming and complex methods that are ill-suited to the requirements of paediatric surgery, particularly when repeated VEPTR lengthening procedures are needed. We developed a monopolar stimulation method derived from Owen's monitoring technique. This method is easy to implement, requires only widely available equipment, and allows concomitant monitoring of the spinal cord and brachial plexus. The primary objective of this study was to assess the reliability of our technique for brachial plexus monitoring by comparing the stability of neurogenic mixed evoked potentials (NMEPs) at the upper and lower limbs. HYPOTHESIS We hypothesised that the coefficients of variation (CVs) of NMEPs were the same at the upper and lower limbs. MATERIAL AND METHODS Twelve VEPTR procedures performed in 6 patients between 1st January 2012 and 1st September 2014 were monitored using a monopolar stimulating probe. NMEPs were recorded simultaneously at the upper and lower limbs, at intervals of 150 s. The recording sites were the elbow over the ulnar nerve and the popliteal fossa near the sciatic nerve. Wilcoxon's test for paired data was used to compare CVs of the upper and lower limb NMEPs on the same side. RESULTS Mean CV of NMEP amplitude at the lower limbs was 16.34% on the right and 16.67% on the left; corresponding values for the upper limbs were 18.30 and 19.75%, respectively. Mean CVs of NMEP latencies at the lower limbs were 1.31% on the right and 1.19% on the left; corresponding values for the upper limbs were 1.96 and 1.73%. The risk of type I error for a significant difference between the upper and lower limbs was 0.5843 on the right and 0.7312 on the left for NMEP amplitudes and 0.7618 on the right and 0.4987 on the left for NMEP latencies. CONCLUSION Using an epidural active electrode and a sternal return electrode allows simultaneous stimulation of the cervical spinal cord and brachial plexus roots. The NMEPs thus obtained are as stable (reliable) at the upper limbs as at the lower limbs. This easy-to-implement method allows simultaneous monitoring of the upper and lower limbs. It seems well suited to VEPTR procedures. LEVEL OF EVIDENCE IV, retrospective single-centre non-randomised study.
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Affiliation(s)
- C Gomes
- Service de neurophysiologie, CHU de Rennes, 35033 Rennes, France.
| | - M Kuchenbuch
- Service de neurophysiologie, CHU de Rennes, 35033 Rennes, France; Université Rennes 1, 35043 Rennes, France
| | - G Lucas
- Service de chirurgie orthopédique pédiatrique, CHU de Rennes, 35033 Rennes, France; Université Rennes 1, 35043 Rennes, France
| | - P Sauleau
- Service de neurophysiologie, CHU de Rennes, 35033 Rennes, France; Inserm, EA 4712, 35043 Rennes, France
| | - P Violas
- Service de chirurgie orthopédique pédiatrique, CHU de Rennes, 35033 Rennes, France; Université Rennes 1, 35043 Rennes, France
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Colsa Gutiérrez P, Viadero Cervera R, Morales-García D, Ingelmo Setién A. Intraoperative peripheral nerve injury in colorectal surgery. An update. Cir Esp 2015; 94:125-36. [PMID: 26008880 DOI: 10.1016/j.ciresp.2015.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 02/04/2015] [Accepted: 03/08/2015] [Indexed: 12/15/2022]
Abstract
Intraoperative peripheral nerve injury during colorectal surgery procedures is a potentially serious complication that is often underestimated. The Trendelenburg position, use of inappropriately padded armboards and excessive shoulder abduction may encourage the development of brachial plexopathy during laparoscopic procedures. In open colorectal surgery, nerve injuries are less common. It usually involves the femoral plexus associated with lithotomy position and self-retaining retractor systems. Although in most cases the recovery is mostly complete, treatment consists of physical therapy to prevent muscular atrophy, protection of hypoesthesic skin areas and analgesics for neuropathic pain. The aim of the present study is to review the incidence, prevention and management of intraoperative peripheral nerve injury.
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Affiliation(s)
- Pablo Colsa Gutiérrez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Sierrallana , Torrelavega, Cantabria, España.
| | | | - Dieter Morales-García
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Alfredo Ingelmo Setién
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Sierrallana , Torrelavega, Cantabria, España
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DePasse JM, Palumbo MA, Haque M, Eberson CP, Daniels AH. Complications associated with prone positioning in elective spinal surgery. World J Orthop 2015; 6:351-359. [PMID: 25893178 PMCID: PMC4390897 DOI: 10.5312/wjo.v6.i3.351] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 02/12/2015] [Accepted: 03/09/2015] [Indexed: 02/06/2023] Open
Abstract
Complications associated with prone surgical positioning during elective spine surgery have the potential to cause serious patient morbidity. Although many of these complications remain uncommon, the range of possible morbidities is wide and includes multiple organ systems. Perioperative visual loss (POVL) is a well described, but uncommon complication that may occur due to ischemia to the optic nerve, retina, or cerebral cortex. Closed-angle glaucoma and amaurosis have been reported as additional etiologies for vision loss following spinal surgery. Peripheral nerve injuries, such as those caused by prolonged traction to the brachial plexus, are more commonly encountered postoperative events. Myocutaneous complications including pressure ulcers and compartment syndrome may also occur after prone positioning, albeit rarely. Other uncommon positioning complications such as tongue swelling resulting in airway compromise, femoral artery ischemia, and avascular necrosis of the femoral head have also been reported. Many of these are well-understood and largely avoidable through thoughtful attention to detail. Other complications, such as POVL, remain incompletely understood and thus more difficult to predict or prevent. Here, the current literature on the complications of prone positioning for spine surgery is reviewed to increase awareness of the spectrum of potential complications and to inform spine surgeons of strategies to minimize the risk of prone patient morbidity.
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La Neve JE, Zitney GP. Use of somatosensory evoked potentials to detect and prevent impending brachial plexus injury during surgical positioning for the treatment of supratentorial pathologies. Neurodiagn J 2014; 54:260-273. [PMID: 25351034 DOI: 10.1080/21646821.2014.11106808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Somatosensory evoked potentials (SSEPs) are widely utilized for the intraoperative detection and prevention of nerve conduction injuries. Their use in identifying position-related injuries to the brachial plexus in patients undergoing supine craniotomies for the treatment of supratentorial pathology is not well documented. This case series describes three instances of unilateral upper extremity SSEP changes in patients positioned for supine craniotomies. In all three cases SSEP responses improved after repositioning. None of the patients exhibited new neurological deficits post-operatively. This case series highlights the importance of vigilant monitoring in the period after final positioning and demonstrates the usefulness of SSEPs as a tool to aid in the early detection and prevention of impending position-related nerve injury.
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Abstract
Strategies to improve the success of robotic hysterectomy in the morbidly obese patient are reviewed in this study. Background and Objectives: The purpose of this study was to present strategies for performing computer-enhanced telesurgery in the morbidly obese patient. Methods: This was a prospective, institutional review board-approved, descriptive feasibility study (Canadian Task Force classification II-2) conducted at a university-affiliated hospital. Twelve class III morbidly obese women with a body mass index of 40 kg/m2 or greater were selected to undergo robotic-assisted total laparoscopic hysterectomy. Robotic-assisted total laparoscopic hysterectomy, classified as type IVE, with complete detachment of the cardinal-uterosacral ligament complex, unilateral or bilateral, with entry into the vagina was performed. Results: The median estimated blood loss was 146.3 mL (range, 15–550 mL), the mean length of stay in the hospital was 25.3 hours (range, 23–48 hours), and the complication rate was 0%. The rate of conversion to laparotomy was 8%. The median surgical time was 109.6 minutes (range, 99–145 minutes). Conclusion: Robotic-assisted total laparoscopic hysterectomy can be a safe and effective method of performing hysterectomies in select morbidly obese patients, allowing them the opportunity to undergo minimally invasive surgery without increased perioperative complications.
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Affiliation(s)
- Oscar D Almeida
- Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, 176 Mobile Infirmary Blvd, Mobile, AL 36607, USA.
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Garreau de Loubresse C. Neurological risks in scheduled spinal surgery. Orthop Traumatol Surg Res 2014; 100:S85-90. [PMID: 24412042 DOI: 10.1016/j.otsr.2013.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 06/21/2013] [Accepted: 11/08/2013] [Indexed: 02/02/2023]
Abstract
Spinal surgery is a high-risk specialty with an ever-increasing patient volume. Results are very largely favorable, but neurologic damage, the most severe complication, may leave major sequelae, some of which can be life-threatening. Neurologic complications may be classified according to onset (per- vs. postoperative) and surgical site (cervical vs. thoracolumbar). The present paper provides quantitative data for the risks involved. Knowledge of these complications and their risk of onset is the best means of guiding prevention strategies. The spine surgeon is part of a multidisciplinary team, with the radiologist and electrophysiologist, which is able to identify risk factors preoperatively and diagnose neurologic complications per- or postoperatively.
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Affiliation(s)
- C Garreau de Loubresse
- Service de chirurgie orthopédique, hôpital Raymond-Poincaré, 104, boulevard R.-Poincaré, 92380 Garches, France.
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Cooney AD, Gill I, Stuart PR. The outcome of scapulothoracic arthrodesis using cerclage wires, plates, and allograft for facioscapulohumeral dystrophy. J Shoulder Elbow Surg 2014; 23:e8-13. [PMID: 23790678 DOI: 10.1016/j.jse.2013.04.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 04/13/2013] [Accepted: 04/17/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Scapulothoracic arthrodesis is a recognized treatment for impaired shoulder function in patients with facioscapulohumeral dystrophy (FSHD) and is traditionally performed with autograft. The purpose of the study was to report our experience with scapulothoracic arthrodesis in patients with FSHD using allograft, rather than autograft, with particular respect to the effect of fusion on preoperative and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores; forced vital capacity (FVC); and complications. MATERIALS AND METHODS The early results of 14 consecutive scapulothoracic arthrodeses in FSHD patients with cerclage wires, plates, and allograft (fresh-frozen femoral heads) are reported. DASH scores were recorded preoperatively and 6 months postoperatively. Preoperative and 6-month FVCs were compared. The surgical technique is described. RESULTS Eleven patients underwent 14 fusions. The mean follow-up period was 29 months (range, 6-50 months). Forward flexion improved from 70° to 115° (P = .001) and abduction from 68° to 109° (P = .007). The DASH score improved from 48 points to 34 points (P = .005). FVC decreased from 98% to 92% of predicted (P = .021), although this was not clinically significant. One patient required revision for nonunion, and metalwork was removed in 5 scapulae. A postoperative chest infection developed in 1 patient and a pleural effusion in another. One brachial plexus palsy occurred, which had almost completely resolved by 27 months postoperatively. CONCLUSION Scapulothoracic arthrodesis can be performed successfully with allograft. The nonunion and complication rates are similar to those in the existing literature. A small decrease in FVC does occur but not to a clinically significant level.
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Affiliation(s)
- Alan D Cooney
- Department of Orthopaedics and Trauma, Freeman Hospital, Newcastle upon Tyne, UK.
| | - Inder Gill
- Department of Orthopaedics and Trauma, Freeman Hospital, Newcastle upon Tyne, UK
| | - Paul R Stuart
- Department of Orthopaedics and Trauma, Freeman Hospital, Newcastle upon Tyne, UK
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Abstract
The use of intraoperative neuromonitoring (IONM) during pediatric scoliosis repair has become commonplace to reduce the risk of potentially devastating postoperative neurologic deficits. IONM techniques include somatosensory evoked potentials, motor evoked potentials, electromyography, and intraoperative wake-up tests. Special considerations for scoliosis repair in pediatric patients include preexisting neurologic deficits and young patients with immature neural pathways in whom neurophysiologic monitoring may prove difficult or unreliable.
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Affiliation(s)
- Chris D Glover
- Department of Pediatrics and Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, Suite A3300, Houston, TX 77030, USA.
| | - Nicholas P Carling
- Department of Pediatrics and Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, Suite A3300, Houston, TX 77030, USA
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Behrens L, Bäumer P, Veltkamp R, Meinck HM, Bendszus M, Pham M. MR neurography of acute and regenerated brachial plexus pressure palsy. J Neurol 2013; 260:3176-7. [DOI: 10.1007/s00415-013-7173-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 10/26/2022]
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Bouyer-Ferullo S. Preventing perioperative peripheral nerve injuries. AORN J 2013; 97:110-124.e9. [PMID: 23265653 DOI: 10.1016/j.aorn.2012.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/16/2012] [Accepted: 10/23/2012] [Indexed: 10/27/2022]
Abstract
Peripheral nerve injuries are largely preventable injuries that can result from incorrect patient positioning during surgery. Patients who are diabetic, are extremely thin or obese, use tobacco, or undergo surgery lasting more than four hours are at increased risk for developing these injuries. When peripheral nerve injuries occur, patients may experience numbness, burning, or tingling and may have difficulty getting out of bed, walking, gripping objects, or raising their arms. These symptoms can interrupt activities of daily living and impede recovery. Signs and symptoms of peripheral nerve injury may appear within 24 to 48 hours of surgery or may take as long as a week to appear. Careful attention to body alignment and proper padding of bony prominences when positioning patients for surgery is necessary to prevent peripheral nerve injury. The use of a preoperative assessment tool to identify at-risk patients, collaboration between physical therapy and OR staff members regarding patient positioning, and neurophysiological monitoring can help prevent peripheral nerve injuries.
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Jellish WS, Sherazee G, Patel J, Cunanan R, Steele J, Garibashvilli K, Baldwin M, Anderson D, Leonetti JP. Somatosensory evoked potentials help prevent positioning-related brachial plexus injury during skull base surgery. Otolaryngol Head Neck Surg 2013; 149:168-73. [PMID: 23520073 DOI: 10.1177/0194599813482878] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Evaluate the use of somatosensory evoked potentials (SSEP) monitoring to detect positioning-related brachial plexus injury during skull base surgery. STUDY DESIGN Prospective cohort observational study. SETTING University Hospital. SUBJECTS AND METHODS Patients undergoing skull base surgery had a focused neurologic exam of the brachial plexus performed before and after surgery. Under stable anesthesia, brachial plexus SSEP values were obtained before and after surgical positioning. Significant SSEP changes required a readjustment of arm or neck positions. SSEPs were assessed every 30 minutes. If changes were noted, position was readjusted and SSEPs were reassessed until surgical completion. Demographic data, neurologic exams, SSEP latency, and amplitude values were recorded. Persistent changes were correlated with postoperative neurologic findings. RESULTS Sixty-five patients, 15 to 77 years old, were studied. Six patients (9.2%) developed SSEP amplitude changes after positioning (average amplitude decrease 72.8%). One patient had a significant latency increase. The sensitivity of SSEP for detection of injury was 57%, while specificity was 94.7%. The average body mass index (BMI) of patients with normal and abnormal SSEPs was 28.7 ± 5.6 versus 29.2 ± 8.0, respectively. Average BMI of patients with postoperative symptoms regardless of SSEP findings was 33.8 ± 4.3. Two patients who had persistent SSEP changes after positioning had BMIs of 40.1 and 31.2 kg/m(2), respectively. Improvement in neurologic findings occurred in all patients after surgery. CONCLUSIONS This study demonstrates that upper extremity nerve stress can be detected in real time using SSEP and may be of value in protecting patients from nerve injury undergoing lateral skull base surgery.
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Affiliation(s)
- W Scott Jellish
- Department of Anesthesiology, Loyola University Medical Center, Maywood, Illinois 60153, USA.
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Barman A, Chatterjee A, Prakash H, Viswanathan A, Tharion G, Thomas R. Traumatic brachial plexus injury: electrodiagnostic findings from 111 patients in a tertiary care hospital in India. Injury 2012; 43:1943-8. [PMID: 22884248 DOI: 10.1016/j.injury.2012.07.182] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 06/26/2012] [Accepted: 07/19/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The study aims to characterise the electrodiagnostic findings of patients with traumatic brachial plexus injuries (BPIs) in India and to analyse the association between aetiologies and levels of injuries. METHODS A total of 111 consecutive electrodiagnostic studies done between January 2009 and June 2011 on persons with traumatic BPI were retrospectively analysed. SETTING Electrodiagnostic Laboratory, Department of Physical Medicine and Rehabilitation in a tertiary care university teaching hospital in South India. MAIN OUTCOME MEASURES Nerve conduction velocities and electromyography (EMG) to locate the level of BPI, Dumitru and Wilbourne scale to assess the severity of BPI. RESULTS We studied 106 males and five females, ranging from 11 to 59 years of age. All but one had unilateral BPI. Motorcycle crashes were the most frequent cause (n=64, 58%). Isolated supraclavicular injury was found in 98 arms (88%) and infraclavicular injury in seven arms (6%). Root-level injuries were more common in motorcycle crashes and occupation-related trauma, while trunk-level injuries were more often found in automobile crashes, falls, bicycle-related trauma and penetrating wounds. Pan root (C5-T1) involvement was more common in the motorcycle trauma group (74%). There was no significant association between aetiologies and levels of BPIs. A total of 73 (65%) plexus injuries were of 'severe' category as per Dumitru and Wilbourn scale. CONCLUSIONS Motorcycle crash is the most common cause of traumatic BPIs. Supraclavicular injury is the rule in most cases. Proper attention needs to be given to differentiate the mild to moderate injuries from the severe injuries with EMG techniques since most of the cases are severe. There was no significant association found between aetiologies and levels of injury.
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Affiliation(s)
- Apurba Barman
- Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, Tamil Nadu, India.
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Stecker MM. A review of intraoperative monitoring for spinal surgery. Surg Neurol Int 2012; 3:S174-87. [PMID: 22905324 PMCID: PMC3422092 DOI: 10.4103/2152-7806.98579] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 04/25/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Intraoperative neurophysiologic monitoring (IONM) is a technique that is helpful for assessing the nervous system during spine surgery. METHODS This is a review of the field describing the basic mechanisms behind the techniques of IONM. These include the most often utilized trancranial motor evoked potentials (Tc-MEPs), somatosensory evoked potentials (SSEPs), and stimulated and spontaneous EMG activity. It also describes some of the issues regarding practices and qualifications of practitioners. RESULTS Although the anatomic pathways responsible for the Tc-MEP and SSEP are well known and these clinical techniques have a high sensitivity and specificity, there is little published data showing that monitoring actually leads to improved patient outcomes. It is evident that IONM has high utility when the risk of injury is high, but may be only marginally helpful when the risk of injury is very low. The monitoring team must be well trained, be able to provide the surgeon feedback in real time, and coordinate activities with those of the surgical and anesthesia teams. CONCLUSIONS Although IONM is a valuable technique that provides sensitive and specific indications of neurologic injury, it does have limitations that must be understood. Maintaining a high quality of practice with appropriately trained personnel is critical.
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Affiliation(s)
- Mark M. Stecker
- Department of Neuroscience, Winthrop University Hospital, Mineola, NY, USA
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Nouh MR. Spinal fusion-hardware construct: Basic concepts and imaging review. World J Radiol 2012; 4:193-207. [PMID: 22761979 PMCID: PMC3386531 DOI: 10.4329/wjr.v4.i5.193] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 08/07/2011] [Accepted: 08/14/2011] [Indexed: 02/06/2023] Open
Abstract
The interpretation of spinal images fixed with metallic hardware forms an increasing bulk of daily practice in a busy imaging department. Radiologists are required to be familiar with the instrumentation and operative options used in spinal fixation and fusion procedures, especially in his or her institute. This is critical in evaluating the position of implants and potential complications associated with the operative approaches and spinal fixation devices used. Thus, the radiologist can play an important role in patient care and outcome. This review outlines the advantages and disadvantages of commonly used imaging methods and reports on the best yield for each modality and how to overcome the problematic issues associated with the presence of metallic hardware during imaging. Baseline radiographs are essential as they are the baseline point for evaluation of future studies should patients develop symptoms suggesting possible complications. They may justify further imaging workup with computed tomography, magnetic resonance and/or nuclear medicine studies as the evaluation of a patient with a spinal implant involves a multi-modality approach. This review describes imaging features of potential complications associated with spinal fusion surgery as well as the instrumentation used. This basic knowledge aims to help radiologists approach everyday practice in clinical imaging.
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Chen Z, Chen L, Kwon P, Montez M, Voegeli T, Bueff H. Detection of positional brachial plexus injury by radial arterial line during spinal exposure before neuromonitoring confirmation: a retrospective case study. J Clin Monit Comput 2012; 26:483-6. [PMID: 22552876 DOI: 10.1007/s10877-012-9366-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 04/23/2012] [Indexed: 11/24/2022]
Abstract
To demonstrate the potential usefulness of radial arterial line monitoring in detection of brachial plexus injury in spinal surgery. Multiple neuromonitoring modalities including SEPs, MEPs and EMG were performed for a posterior thoracicolumbar surgery. Radial arterial line (A-line) was placed on the right wrist for arterial blood pressure monitoring. Reliable ulnar nerve SEPs, hand muscle MEPs and arterial blood pressure readings were obtained after patient was placed in a prone position. A-line malfunction was noted about 15 min after incision. Loss of ulnar nerve SEPs and hand muscle MEPs with a cold hand on the right was noticed when neuromonitoring resumed after spine exposure. SEPs, MEPs, A-line readings and hand temperature returned after modification of the right arm position. Radial arterial line monitoring may help detect positional brachial plexus injury in spinal surgery when continuous neuromonitoring is interrupted during spine exposure in prone position.
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Affiliation(s)
- Zhengyong Chen
- Department of Neurosurgery, Kaiser Permanente Medical Center, 2025 Morse Ave, Sacramento, CA 95825, USA.
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Chen Z, Lerman J. Protection of the remaining spinal cord function with intraoperative neurophysiological monitoring during paraparetic scoliosis surgery: a case report. J Clin Monit Comput 2011; 26:13-6. [DOI: 10.1007/s10877-011-9325-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 12/01/2011] [Indexed: 10/14/2022]
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Mikell CB, Winfree CJ. Intraoperative brachial plexus injuries: association with thoracic surgery and current management. World Neurosurg 2011; 80:e229-30. [PMID: 22099556 DOI: 10.1016/j.wneu.2010.12.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 12/15/2010] [Indexed: 11/28/2022]
Affiliation(s)
- Charles B Mikell
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
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