Rhabdomyolysis and acute renal failure following minimally invasive spine surgery

Rhabdomyolysis after spinal fusion surgery: management schema and prevention of a catastrophic complication

PURPOSE

Rhabdomyolysis is a clinical syndrome with the potential to cause cardiac arrhythmias, renal failure, and even death. Currently, there are no studies regarding risk factors for developing post-operative rhabdomyolysis (POR) after spinal fusion surgeries. Our objective was to study risk factors associated with, and to develop a decision-making framework for post-operative rhabdomyolysis after spinal fusion surgery.

METHODS

We performed a retrospective cohort study of all spinal fusions of three or more levels over 2.25 years by a single surgeon at two centers. POR was defined as a creatine phosphokinase (CPK) greater than 2000 IU/L.

RESULTS

76 surgical procedures on 72 patients were identified. Rate of POR in our cohort was 22% (17/76). Male sex was associated with POR (p < 0.05). Previously validated risk factors: younger age, lower ASA score, elevated BMI, higher pre-operative creatinine, increased intraoperative blood loss, specific surgical positions, and length of surgery, were not associated with POR. In a logistic regression model, male gender increases the odds of POR in all patients 5.82-fold (p = 0.047). In patients without a second surgery within seven days, a logistic regression model suggests each additional level fused via transpsoas approach, and male gender, increases the risk of POR 1.81-times (p = 0.015), and 6.26-times (p = 0.047), respectively. In patients with posterior fusions, a logistic regression model suggests increasing the number of lateral levels fused via transpsoas approach in the same surgery, and male gender, increases the risk of POR 1.68-times and 6.34-times, respectively. In these same subgroups, increased thickness of the psoas major in lateral transpsoas fusions increased risk of POR (p = 0.023, p = 0.046, respectively).

CONCLUSIONS

In spinal fusions, increasing the number of lateral levels fused via transpsoas approach, and male gender, predispose patients to increased risk of POR in those without a second surgery within seven days, and in those with a simultaneous posterior fusion.

Postoperative rhabdomyolysis following otoplasty: an autopsy case report

Postoperative rhabdomyolysis is a significant complication that can arise from prolonged surgery, causing potential harm to the kidneys and leading to acute renal failure. Despite its importance, the incidence of rhabdomyolysis following ear reconstruction surgery remains undocumented in the literature. In this report, we present a case study of a male patient in his forties who underwent otoplasty for ear reconstruction after the amputation of his right ear due to a physical assault. The surgery lasted for 8 h under general anesthesia, and unfortunately, the patient developed postoperative rhabdomyolysis, which resulted in severe renal failure and ultimately an unrecoverable cardiac arrest, leading to his death. The autopsy findings indicated no identifiable lesions except for organ congestion, while histopathology revealed acute tubular necrosis of the kidney and muscle rhabdomyolysis. Previous literature has explored the association between surgical duration, location, and rhabdomyolysis, underscoring that this condition is an infrequent yet preventable consequence of prolonged surgery. The co-occurrence of rhabdomyolysis and acute renal injury in this case suggests the presence of comorbidity, emphasizing the need for prompt action to mitigate the negative consequences of rhabdomyolysis. Awareness and early intervention are crucial in preventing and managing this condition effectively.

Single-Position Lateral Approach for Revision Thoracolumbar Corpectomy With Delayed Ipsilateral Kidney Atrophy: Technical Note and Discussion of Complications

Improvements in navigation technology have enabled surgeons to safely offer single-position fusion surgeries, demonstrating shorter operating times and reduced length of stay (LOS) as compared to traditional lateral and prone dual-position surgeries. However, no studies to date describe revision thoracolumbar corpectomy with simultaneous posterior rod removal and replacement in the lateral position. Furthermore, this is the first reported complication of delayed ipsilateral kidney atrophy following lateral lumbar surgery. A 56-year-old male patient with history of metastatic hepatocellular carcinoma and complex surgical history for a prior T12 pathologic fracture presented to the clinic for follow-up. Computed tomography (CT) demonstrated bilateral broken rods and subsidence of the T12 interbody cage, for which he underwent revision T12 corpectomy and posterior instrumentation revision via a single-position, left-sided lateral approach. Simultaneous exposure and removal of the broken rods enabled the placement of two short temporary rods between the T11-L1 screws posteriorly, allowing for rod distraction and the placement of the expandable corpectomy cage into the appropriate position. On follow-up cancer surveillance imaging, the left kidney became progressively atrophic within six months after surgery. According to a review of PubMed, Scopus, and Embase databases, we describe the first reported case of a single-position thoracolumbar revision corpectomy with simultaneous rod replacement. Of particular importance in this technique is the use of temporary rod placement for distraction across the index level to facilitate interbody cage placement. Furthermore, we discussed the first reported complication of delayed ipsilateral kidney atrophy following lateral lumbar fusion.

Rhabdomyolysis following Nuss Procedure: A Prospective Study in Children

INTRODUCTION

 Postoperative rhabdomyolysis (RML) has been documented after several surgical procedures in adults. Musculoskeletal remodeling after Nuss procedure for pectus excavatum (PE) could cause RML. We evaluated the incidence of RML after Nuss procedure in children.

METHODS

 This study was a prospective study from 2018 to 2021. We enrolled all otherwise healthy patients who underwent PE correction with only one bar. Studied variables included demographic and clinical data, duration of surgery, complications, and length of hospitalization. The patients included underwent serial measurements of serum creatine kinase (CK), troponin I, N terminal pro B-type natriuretic peptide (NT-proBNP), serum creatinine, urea, and glomerular filtration rate at 6 and 48 hours postoperatively, and hospital discharge.

RESULTS

 Forty-six patients met criteria (40 males/6 females), with a mean age of 15.1 ± 1.4 years. Mean duration of surgery was 74 ± 28 minutes, and length of hospitalization was 4.6 ± 1.6 days. RML was diagnosed in 30.4% of patients at 6 hours, 91.3% at 48 hours, and 21.7% at hospital discharge. Mean preoperative CK value was 181.1 ± 141.6 IU/L, and postoperative values were 863.3 ± 302.6 IU/L at 6 hours, 1,675.2 ± 561 IU/L at 48 hours, and 850 ± 683.7 IU/L at hospital discharge, with statistically significant differences (p = 0.001). High-sensitivity troponin I and NT-proBNP levels increased significantly during the postoperative time (p = 0.001). Renal function remained stable (p = 0.55).

CONCLUSION

 Nuss technique produces RML without kidney injury in healthy patients. This knowledge should be considered for patients at increased risk of developing acute kidney injury and other complications.

The role of serum creatine kinase levels in anterior cervical spinal surgery: Change trends and risk factors

This study aimed to describe change trends in serum creatine kinase (CK) values for patients undergoing anterior cervical spinal surgery and identify risk factors that affect the CK values perioperatively, intending to decrease the degree of the iatrogenic invasiveness of the procedure.We retrospectively analyzed 122 patients undergoing anterior cervical spinal surgery from January 2019 to May 2020. For all patients, CK level was measured 1 day before the operation. Daily CK levels were evaluated on postoperative days 1 to 7. These data were analyzed in terms of age, gender, the use of microendoscopy during surgery, the number of cervical operative segments, and operative methods to determine whether these risk factors influenced postoperative CK increases.A total of 122 patients were enrolled. The preoperative average CK level was 72.7 U/L, and the average CK levels were 130.6, 122.4, 99.1, 82.8, 73.7, 63.9, and 55.4 U/L from the postoperative day (POD) 1 to POD7, respectively. CK level changes on POD1 increased with the number of operated cervical segments. However, changes were not related to age, gender, microendoscopy, or the operative method.Increased serum CK level was associated with the number of cervical operative segments, rather than age, gender, the use of microendoscopy, or the operative methods. These findings suggest that the number of cervical operative segments determined the degree of iatrogenic injury for anterior cervical spinal surgery.

Effects of Surgical Positioning on L4-L5 Accessibility and Lumbar Lordosis in Lateral Transpsoas Lumbar Interbody Fusion: A Comparison of Prone and Lateral Decubitus in Asymptomatic Adults

BACKGROUND

Lateral interbody fusion (LIF) is traditionally performed in lateral decubitus on a breaking surgical table to improve L4-L5 access. Prone transpsoas (PTP) LIF may improve sagittal alignment and facilitate single-position circumferential procedures; but may require manipulation of the iliac crest for L4-L5 accessibility.

METHODS

Healthy adult volunteers (n = 41) were positioned as if for surgery in right-lateral decubitus on a radiolucent breaking table, and also prone on a Jackson-style surgical frame atop a custom PTP bolster. Iliac crest distance from the L5 superior endplate, and coronal and sagittal plane alignments were measured from fluororadiographs obtained in each of 5 positions: standard lateral decubitus (LD), prone-hips and spine neutral (PR-NN), prone-hips neutral and spine coronally bent (PR-NCB), prone-hips extended and spine neutral (PR-EN), and prone-hips extended and spine coronally bent (PR-ECB).

RESULTS

L4-L5 accessibility was lowest in prone-neutral and improved in all augmented positional configurations: PR-NN<>PR-EN<LD<PR-ECB<PR-NCB. Coronal bending with the PTP positioner created greater accessibility than that achieved by lateral decubitus breaking (PR-NCB>LD, P = 0.0480). Coronal angulations were greatest in LD, and statistically different from both prone neutral (LD>PR-NN, P < 0.0001) and prone coronally bent (LD>PR-NCB, P < 0.0001). Lordosis was greatest in extended prone positions and lowest in lateral decubitus: PR-EN>PR-ECB>PR-NCB<>PR-NN>LD. All prone positions showed significantly greater lordosis than lateral decubitus (P < 0.001).

CONCLUSIONS

Compared with lateral decubitus, prone positioning provides equivalent or better L4-L5 LIF access around the iliac crest when a positioner is used that enables coronal bending, and improved positional lordosis, which may facilitate segmental correction and achievement of surgical alignment goals.

Incidence of and factors associated with acute kidney injury after scoliosis surgery in pediatric patients

PURPOSE

We sought to identify the national incidence of acute kidney injury (AKI) associated with pediatric posterior spinal fusion (PSF) surgery for scoliosis, and to determine factors that increase risk.

METHODS

The 1998-2014 National Inpatient Sample (NIS), a large United States hospital discharge database, was queried for discharges aged 0-17 years with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for scoliosis undergoing PSF for the outcome of AKI. Discharges were divided into those with AKI and unaffected. We fit adjusted logistic regression models to yield point estimates, odds ratios, 95% confidence intervals, and p values for the weighted, national population sample with postulated risk factors. The fit of the multivariable regression model was tested using the Hosmer-Lemeshow test, and collinearity using the variance inflation factor.

RESULTS

The NIS contained 103,270 weighted discharges meeting inclusion criteria. AKI incidence was 0.1%. Multivariable logistic regression model showed significantly increased odds ratios with thrombocytopenia, rhabdomyolysis, chronic kidney disease, abnormal coagulation, and male sex. AKI increased both hospital stay and cost by threefold compared to unaffected children.

CONCLUSION

This study suggests that AKI after pediatric PSF is rare. It is associated with abnormal coagulation, chronic kidney disease, and rhabdomyolysis, but not with the number of vertebral levels fused. Female sex appears to be protective. The retrospective nature of study and reliance on ICD-9-CM codes may under-represent the incidence of AKI in pediatric PSF patients.

Predictive Factors for Muscle Injury After Posterior Lumbar Spinal Surgery

OBJECTIVE

The aims of this study were to evaluate the risk factors for muscle injury in patients undergoing posterior lumbar spinal surgery and the clearance of postoperative biochemical changes following lumbar fusion and secondarily to evaluate the timing for monitoring postoperative biochemical serum levels and potential clinical correlation.

METHODS

The study prospectively enrolled 39 patients with degenerative disease of the lumbar spine. Biochemical markers (creatine phosphokinase [CPK], creatinine, and hemoglobin) were analyzed in 5 predefined stages. All relevant clinical data were collected. Rhabdomyolysis (RML) was defined as a postoperative 5-fold increase of the baseline CPK value.

RESULTS

Patients from the lumbar fusion group had the highest postoperative CPK ratio. Overall, the rate of RML was 43.6%. CPK and creatinine activity reached their maximum on the first postoperative day in 69.2% and 87.5% of patients, respectively. Lumbar fusion (P = 0.005), surgical time >270 minutes (P = 0.028), and fall in hemoglobin levels >3 g/dL (P = 0.034) were identified as independent factors associated with higher risk of RML.

CONCLUSIONS

The risk of RML increases with prolonged and invasive surgery with higher bleeding potential. Knowing the clearance of postoperative biochemical changes permits a standardized strategy with measurements in precise intervals, thereby avoiding unnecessary costs. The clinical significance is still undetermined.

Defining the Normal Trends of Serum Creatine Kinase Levels Following Spinal Surgery

Study Design

Prospective, prognostic study, level II evidence.

Purpose

To define the normal change in the creatine kinase (CK) levels in patients undergoing prone or supine lumbar or cervical spine surgery and to determine if positioning influences the postoperative changes in the CK levels.

Overview of Literature

Spine surgery is one of the most commonly performed and fastest growing areas of surgery in the United States. Thus, the various possible complications need to be understood, and risk factors for these complications need to be mitigated. One of the rare complications, reported in the literature as small case series and case reports, is rhabdomyolysis, diagnosed by high CK levels. Thus far, very few studies have examined the rise in CK levels following spine surgery, and to our knowledge, none has assessed the potential association of surgical positioning and the rise in CK levels.

Methods

We retrospectively analyzed 94 patients. We obtained their preoperative CK levels, and re-assessed their CK levels at postoperative day (POD) 1, 2, and 3, as well as at their 2-week follow-up. The data were analyzed with respect to the spine level and positioning to determine if positioning had any effect on the postoperative rise in the CK level.

Results

Total 94 consecutive patients were enrolled in this study. The average preoperative CK level was 179.64, and the average CK level was 847.04 on POD 1. Prone positioning showed a greater rise in the CK levels following surgery than the supine positioning. In a similar manner, lumbar procedures led to a larger rise in the CK levels than cervical surgery. Prone/lumbar surgery showed the largest increase among all groups. Finally, revision surgery and instrumentation both increased the postoperative CK levels.

Conclusions

This study demonstrated that positioning can affect the postoperative CK level rise, with patients undergoing prone/lumbar surgery showing the greatest rise in the postoperative CK levels. This rise, however, may be related to paraspinal muscle damage, rather than the positioning itself.

Recent Advances in Technique and Clinical Outcomes of Minimally Invasive Spine Surgery in Adult Scoliosis

Objective:

Conventional open spinal surgery of adult scoliosis can be performed from anterior, posterior, or combined approach. Minimally invasive spine surgery (MISS) was developed for the purpose of reducing the undesirable effects and complications. This review aimed to make a brief summary of recent studies of the approach and clinical outcomes of MISS in adult scoliosis.

Data Sources:

We conducted a systematic search from PubMed, Medline, EMBASE, and other literature databases to collect reports of surgical methods and clinical outcomes of MISS in treatment of adult scoliosis. Those reports were published up to March 2017 with the following key terms: “minimally invasive,” “spine,” “surgery,” and “scoliosis.”

Study Selection:

The inclusion criteria of the articles were as followings: diagnosed with adult degenerative scoliosis (DS) or adult idiopathic scoliosis; underwent MISS or open surgery; with follow-up data. The articles involving patients with congenital scoliosis or unknown type were excluded and those without any follow-up data were also excluded from the study. The initial search yielded 233 articles. After title and abstract extraction, 29 English articles were selected for full-text review. Of those, 20 studies with 831 patients diagnosed with adult DS or adult idiopathic scoliosis were reviewed. Seventeen were retrospective studies, and three were prospective studies.

Results:

The surgical technique reported in these articles was direct or extreme lateral interbody fusion, axial lumbar interbody fusion, and transforaminal lumbar interbody fusion. Among the clinical outcomes of these studies, the operated levels was 3–7, operative time was 2.3–8.5 h. Both the Cobb angle of coronal major curve and evaluation of Oswestry Disability Index and Visual Analog Scale decreased after surgery. There were 323 complications reported in the 831 (38.9%) patients, including 150 (18.1%) motor or sensory deficits, and 111 (13.4%) implant-related complications.

Conclusions:

MISS can provide good radiological and self-evaluation improvement in treatment of adult scoliosis. More prospective studies will be needed before it is widely used.

Limitations and complications of minimally invasive spinal surgery in adult deformity

Minimally invasive spine (MIS) surgery has rapidly progressed from simple short segment fusions to large adult deformity corrections, with radiographic and clinical outcomes as good as those of open surgery. Anterior longitudinal ligament release (ALLR) and anterior column realignment (ACR) have been key advancements in the ability to correct deformity using MIS techniques. However, patient selection and appropriate preoperative workup is critical to obtain good outcomes and for complication avoidance. Despite favorable outcomes in spinal deformity surgery, MIS techniques are limited in (I) pronounced cervical or thoracic deformity; (II) patients with prior fusion mass; and (III) severe sagittal imbalance necessitating Schwab 5 osteotomy or higher. Guidelines for proper patient selection are needed to guide MIS spine surgeons in choosing the right candidate.

Rhabdomyolysis following minimally invasive transforaminal lumbar interbody fusion: Case report

Background:

Rhabdomyolysis results from the release of large quantities of muscle cell contents into plasma resulting in a classic triad of symptoms – muscle pain, weakness, and brown urine. Only a handful of rhabdomyolysis cases occurring after spinal surgery have been reported.

Case Description:

A 36-year-old male underwent an uneventful right-sided, minimally invasive transforaminal lumbar interbody fusion (miTLIF) for intractable lower back pain and right lower extremity radiculopathy attributed to L4-S1 degenerative spondylosis (DS). Postoperatively, the patient complained of intractable lower extremity pain resistant to medical management. He was subsequently diagnosed with rhabdomyolysis, and aggressive intravenous fluid resuscitation resulted in complete recovery.

Conclusions:

Rhabdomyolysis should be diagnosed and treated promptly with aggressive intravenous fluid resuscitation to avoid acute kidney injury following miTLIF surgery.

The Impact of Kidney Disease on Acute Tubular Necrosis and Surgical Site Infection After Lumbar Fusion

BACKGROUND

Kidney disease in spine surgery can be associated with serious complications.

OBJECTIVE

To investigate the rate of acute tubular necrosis (ATN) and surgical site infection (SSI) after lumbar fusion in patients with kidney disease.

METHODS

A review of the U.S. Nationwide Inpatient Sample from 2002 to 2011 was performed to identify patients who underwent lumbar fusion for degenerative spine disease or disk herniation. Four groups were established: no kidney disease, chronic kidney disease (CKD), end-stage renal disease (ESRD), and posttransplant. A multivariate analysis was performed to control for age, sex, and comorbidities.

RESULTS

A total of 268,158 patients met the criteria; 263,757 with no kidney disease (98.4%), 3576 with CKD (1.3%), 586 with ESRD (0.2%), and 239 posttransplant (0.1%). Rates of ATN were 0.1%, 2.9%, 3.6%, and 0.0% for the 4 groups, respectively (P < 0.001). Rates of SSI were 0.3%, 0.4%, 1.0%, and 0.0%, respectively (P = 0.002). After controlling for patient age, sex, and medical comorbidities, patients with CKD (odds ratio [OR], 5.42; 95% confidence interval [CI], 4.14-7.09; P < 0.001) and ESRD (OR, 6.32; 95% CI, 3.89-10.33; P < 0.001) were significantly more likely to develop ATN compared with patients without kidney disease. However, CKD (OR, 0.80; 95% CI, 0.20-3.12; P = 0.754) or ESRD (OR, 1.96; 95% CI, 0.38-10.00; P = 0.415) did not increase the risk for SSI on multivariate analysis.

DISCUSSION

The rate of ATN significantly increases based on severity of kidney disease. However, patients with transplants have ATN and SSI rates comparable with patients without kidney disease.

Is rhabdomyolysis an anaesthetic complication in patients undergoing robot-assisted radical prostatectomy?

BACKGROUND:

In patients undergoing robot-assisted radical prostatectomy (RARP), pneumoperitoneum, intraoperative fluid restriction and prolonged Trendelenburg position may cause rhabdomyolysis (RM) due to hypoperfusion in gluteal muscles and lower extremities. In this study, it was aimed to assess effects of body mass index (BMI), comorbidities, intra-operative positioning, fluid restriction and length of surgery on the development of RM in RARP patients during the perioperative period.

SUBJECTS AND METHODS:

The study included 52 American Society of Anesthesiologists I–II patients aged 50–80 years with BMI >25 kg/m², who underwent RARP. Fluid therapy with normal saline (1 ml/kg/h) and 6% hydroxyethyl starch 200/05 (1 ml/kg/h) was given during the surgery. Charlson comorbidity index (CCI), operation time (OT) and Trendelenburg time (TT) were recorded. Blood samples for creatine phosphokinase (CPK), blood urea nitrogen, creatinine (Cr), aspartate aminotransferase (AST), alanine transferase (ALT), lactate dehydrogenase (LDH), creatinine kinase-MB, cardiac troponin I and arterial blood gases were drawn at baseline and on 6, 12, 24 and 48 h. RM was defined by serum CPK level exceeding 5000 IU/L.

RESULTS:

Seven patients met predefined criteria for RM. There were positive correlations among serum CPK and Cr, AST, ALT and LDH levels. However, there was no significant difference in BMI, OT and TT between patients with or without RM (P > 0.05). CCI scores were higher in patients with RM than those without (3.00 ± 0.58 vs. 2.07 ± 0.62; P < 0.01). No renal impairment was detected among patients with RM at the post-operative period.

CONCLUSIONS:

It was found that comorbid conditions are more important in the development of RM during RARP rather than BMI, OT or TT. Patients with higher comorbidity are at risk for RM development and that this should be kept in mind at follow-up and when informing patients.

The Potentially Fatal Ogilvie's Syndrome in Lateral Transpsoas Access Surgery: A Multi-Institutional Experience with 2930 Patients

BACKGROUND

Ogilvie's syndrome (OS) is a relatively uncommon pathology characterized by significant colonic dilation in the absence of mechanical obstruction. If unrecognized and untreated, cecal perforation resulting in a mortality rate of 25%-71% may occur. It is a potentially underdiagnosed condition in the lateral transpsoas approach population because of its uncommon nature and imitation of other well-known pathologies.

METHODS

Two thousand nine hundred and thirty patients from 6 separate institutions were retrospectively reviewed since 2007 and screened for OS. All patients underwent a minimum of single-level lateral transpsoas fusion. Diagnostic criteria included signs of a postoperative paralytic ileus combined with abdominal computed tomography showing a cecal diameter greater than 9 cm. Treatment modalities and outcomes were recorded.

RESULTS

Eight cases (0.22%) of OS were diagnosed at 6 separate institutions. Most institutions recorded more than 350 lateral access procedures. Four cases were initially diagnosed as a routine postoperative ileus; however, they failed conservative therapy and underwent abdominal CT imaging. Neostigmine treatment was required for 1 patient in the intensive care unit setting, and 3 patients were managed conservatively without complications. Four other patients demonstrated bowel perforation at least 48 hours after surgery and required laparotomy with diversion ileostomy.

CONCLUSION

Ogilvie's syndrome is a rare but potentially fatal complication that can mimic a postoperative ileus. It is likely underdiagnosed in the lateral transpsoas approach population because of its uncommon nature and a high index of suspicion should remain. Neostigmine can be administered safely under close observation with immediate and successful outcomes. Patients with perforation require urgent laparotomy and primary repair.

Contralateral psoas hematoma after minimally invasive, lateral retroperitoneal transpsoas lumbar interbody fusion: a multicenter review of 3950 lumbar levels

OBJECTIVE Minimally invasive lateral lumbar interbody fusion (LLIF) via the retroperitoneal transpsoas approach is a technically demanding procedure with a multitude of potential complications. A relatively unknown complication is the contralateral psoas hematoma. The authors speculate that injury occurs from segmental vessel injury at the time of contralateral annulus release; however, this is not fully understood. In this multicenter retrospective review, the authors report the incidence of this contralateral complication and its neurological sequelae. METHODS This study was a retrospective chart review of all minimally invasive LLIF performed at participating institutions from 2008 to 2014. Exclusion criteria included an underlying diagnosis of trauma or neoplasia as well as lateral corpectomies or anterior column releases. Single-level, multilevel, and stand-alone constructs were included. All patients underwent preoperative MRI. Follow-up was at least 12 months. All complications and clinical outcomes were self-reported by each surgeon. RESULTS There were 3950 lumbar interbody cages placed via the retroperitoneal transpsoas approach, with 7 cases (0.18% incidence) of symptomatic contralateral psoas hematoma, 3 of which required reoperation for hematoma evacuation. Neurological outcome did not improve after reoperation. Reoperation occurred an average of 1 month after the initial operation due to a delay in diagnosis. In 1 case, segmental artery injury was confirmed at the time of surgery; in the others, segmental vessel injury was suspected, although it could not be confirmed. Neurological deficits persisted in 3 patients while the others remained neurologically intact. Two patients were receiving antiplatelet therapy prior to the procedure. CONCLUSIONS The contralateral psoas hematoma is a rare complication suspected to occur from segmental vessel injury during contralateral annulus release. Detailed review of preoperative imaging for aberrant vessel anatomy may prevent injury and subsequent neurological deficit.

Lateral Pressure and VAS Pain Score Analysis for the Lateral Lumbar Interbody Fusion Procedure

BACKGROUND

The lateral lumbar interbody fusion (LLIF) procedure is a minimally invasive procedure that has become widely utilized. The LLIF procedure typically involves bending the table to access the disc spaces of interest due to anatomical constraints. It is unknown if this bending process is painful or what pressures are exhibited on the downside part of the body. The goal of the study was to determine whether sex, height, weight, body mass index, bed angle, or positioning relative to the break of the bed affects the downside skin pressures and VAS pain scores in awake volunteers.

METHODS

Fifty-six volunteers were placed in the lateral decubitus position and pressure sensors were placed at the downside part of their anatomy (shoulder, T10 rib , iliac crest, and greater trochanter). The pressures were checked with the iliac crest or greater trochanter at 0, 10, 20, 30, 40 degree bed angles. VAS scores were checked when the iliac crest or greater trochanter were at the maximum bed break angles.

RESULTS

A significant positive association was found between increased bed angle and pressure at all five areas on the downside body locations (p<0.0001). The greatest pressures were located at the iliac crest and greater trochanter when these specific locations were centered over the break of the bed (p<0.0001). When the iliac crest was placed at maximal bed break, each unit increase in BMI increased the VAS pain by 0.13 (p<0.0001)and men had 1.96 (p=0.0009)higher VAS scores then women. When the greater trochanter was placed at the maximal bed break, each unit increase in BMI decreased VAS pain by 0.19 (p<0.0001) and women had 1.55 (p=0.0002)higher VAS pain scores then men.

CONCLUSIONS

In awake volunteers, the pressure at the iliac crest or greater trochanter at the break of the bed increases by increasing the bed angle. Women with a lower BMI had high VAS pain scores when their greater trochanter was at maximal bed break. Men with higher BMI had high VAS pain scores when their iliac crest was at maximal bed break. An awareness of the iliac crest or greater trochanter at the break of the bed should be considered to prevent pain and increased pressure based on the patient's sex and BMI.

Supra-psoas shallow docking in lateral interbody fusion

BACKGROUND

Lateral interbody fusion techniques have been linked with considerable postoperative morbidity, often the outcome of direct psoas trauma. The most common neurological postoperative complications are transient motor weakness/palsy and sensory dysesthesia, which can be permanent. It appears that these neural complications are a result of passing through the psoas muscle where the potential for nerve injury is significant. The supra-psoas shallow docking method may be a safer alternative and may help minimize morbidities by eliminating or reducing direct psoas injury.

OBJECTIVE

To describe the operative technique of performing lateral interbody fusion using supra-psoas retractor docking.

METHODS

The authors describe the surgical technique including side selection, positioning, and patient outcomes.

RESULTS

Fifteen patients were treated with the supra-psoas shallow docking method. Specifically, no patient reported weakness, numbness, and/or pain on the side that underwent the surgery. In these cases, performing lateral transpsoas interbody fusion using supra-psoas shallow docking appeared to minimize the most common neurological postoperative complications of the surgery, motor weakness/palsy and sensory dysesthesia, which may be a result of dilation of the psoas muscle.

CONCLUSION

The shallow docking technique may decrease postoperative morbidities by docking on top of psoas muscle instead of passing through it. An important potential benefit of this approach is direct visualization of the lumbosacral plexus, which may potentially minimize the postoperative neurological morbidity often encountered in patients after this surgery.

[Application of vancomycin powder into the wound during spine surgery: systematic review and meta-analysis]

OBJECTIVE

To determine the effects of applying vancomycin powder within the surgical wound on the risk of surgical infections, pseudo-arthrosis and adverse events, in patients undergoing spinal surgery.

MATERIAL AND METHODS

A meta-analysis was carried out, including controlled studies that evaluated the risk of postoperative infections and/or pseudo-arthrosis in patients undergoing spinal surgery in which vancomycin powder was applied within the surgical wound.

RESULTS

were presented as pooled relative risks, with its 95% confidence intervals. Additionally, the frequency of complications attributable to vancomycin was also assessed.

RESULTS

A total of six controlled studies (3,379 subjects) were included. Pooled relative risks were: surgical site infection, 0.11 (95%CI: 0.05-0.25; P<.00001), and pseudo-arthrosis, 0.87 (95%CI; 0.34-2.21; P=.77). No statistically significant heterogeneity was found in both analyses. In 1,437 patients treated with vancomycin, there were no recorded vancomycin-related adverse events.

CONCLUSIONS

Application of vancomycin powder into the wound was associated with a significantly reduced risk of surgical site infections, without increasing pseudo-arthrosis or adverse events. However, randomized controlled trials are needed, in order to confirm the present results and make recommendations with more certainty.

Rhabdomyolysis in bariatric surgery: a systematic review

BACKGROUND

Rhabdomyolysis (RML) is a rare complication of bariatric surgery. A systematic review was performed to identify risk factors and patient outcomes in morbidly obese patients undergoing bariatric surgery who develop RML.

METHODS

A comprehensive search was performed between January 1990 and March 2012 using relevant MeSH terms. Studies were chosen based on predefined inclusion criteria. RML was defined as a creatine kinase of more than 1,000 IU/L. The parameters assessed included patient characteristics of the RML population, type of bariatric surgery performed, operating time, complications, presentation and diagnosis of RML.

RESULTS

Twenty-two studies were analysed which included 11 case reports, two case series, six prospective and three retrospective comparative studies. Overall 145 patients with RML were reported following bariatric surgery. Acute renal failure was found in 20 patients (14 %) and was significantly more likely to occur in patients with postoperative muscle pain (p < 0.05). The mortality rate after renal failure was 25 % (n = 5). In the comparative studies, 87 RML patients were compared with 325 non-RML patients. The RML patients were more likely to be male, had a greater mean body mass index (BMI) (52 vs 48 kg/m(2), p < 0.01) and underwent a longer operation (255 vs 207 min, p < 0.01) compared to non-RML patients.

CONCLUSIONS

Risk factors of developing RML following bariatric surgery include male gender, elevated BMI and prolonged operating time. Patients with a biochemical diagnosis of RML and postoperative myalgia after bariatric surgery are at increased risk of developing acute renal failure and mortality. These patients must be identified and treated promptly.

Rhabdomyolysis

Rhabdomyolysis is a well-known clinical syndrome of muscle injury associated with myoglobinuria, electrolyte abnormalities, and often acute kidney injury (AKI). The pathophysiology involves injury to the myocyte membrane and/or altered energy production that results in increased intracellular calcium concentrations and initiation of destructive processes. Myoglobin has been identified as the primary muscle constituent contributing to renal damage in rhabdomyolysis. Although rhabdomyolysis was first described with crush injuries and trauma, more common causes in hospitalized patients at present include prescription and over-the-counter medications, alcohol, and illicit drugs. The diagnosis is confirmed by elevated creatine kinase levels, but additional testing is needed to evaluate for potential causes, electrolyte abnormalities, and AKI. Treatment is aimed at discontinuation of further skeletal muscle damage, prevention of acute renal failure, and rapid identification of potentially life-threatening complications. Review of existing published data reveals a lack of high-quality evidence to support many interventions that are often recommended for treating rhabdomyolysis. Early and aggressive fluid resuscitation to restore renal perfusion and increase urine flow is agreed on as the main intervention for preventing and treating AKI. There is little evidence other than from animal studies, retrospective observational studies, and case series to support the routine use of bicarbonate-containing fluids, mannitol, and loop diuretics. Hyperkalemia and compartment syndrome are additional complications of rhabdomyolysis that must be treated effectively. A definite need exists for well-designed prospective studies to determine the optimal management of rhabdomyolysis.

Rhabdomyolysis is a Potential Complication of Total Hip Arthroplasty in the Morbidly Obese

Rhabdomyolysis (RML) can complicate prolonged surgery and may lead to renal failure and death. Obese patients are at high risk for this complication. This complication has been recently described in bariatric surgery and prolonged spine surgery, but it is not well recognized in patients undergoing THA. We present an obese patient (BMI = 50) who developed RML and acute kidney injury after a total hip arthroplasty.

Rhabdomyolysis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a case report

Gastric cancer with peritoneal carcinomatosis is a disease with a poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) can improve prognosis, although in most cases this should still be considered as a palliative treatment. Therefore, morbidity has to be avoided at all cost as quality of life is of utmost importance. We describe the case of a 64-year-old female with an adenocarcinoma of the stomach that was initially treated with a Billroth II gastrectomy, adjuvant chemotherapy and radiotherapy. During follow-up, the diagnosis of peritoneal carcinomatosis was made, and the patient was referred for CRS and HIPEC. Postoperatively, she developed rhabdomyolysis in both gastrocnemius muscles. Renal function remained within normal limits, but ultrasonography of the lower legs suggested the presence of bilateral abscesses. Drainage with pigtail catheters was necessary for more than 1 month, significantly impairing quality of life. The objective of this case report is to heighten awareness for this complication. Rhabdomyolysis is a rare complication of CRS and HIPEC, with a significant impact on quality of life. Prevention is necessary and can be achieved by adequate surgical positioning, using the altered lithotomy position, sufficient padding and by preventing hypovolemia.

Urological injury as a complication of the transpsoas approach for discectomy and interbody fusion

Transpsoas discectomy and interbody fusion has become an increasingly popular method of achieving lumbar interbody fusion, but reports of neurological, vascular, and gastrointestinal complications associated with this procedure have been described in the literature. To date, however, ureteral complications have not been reported with this procedure. The authors report 2 cases of ureteral injury and 1 case of renal injury following this procedure. A low index of suspicion is warranted to work up any patient having flank or abdominal symptoms after undergoing transpsoas discectomy and interbody fusion.

Rhabdomyolysis after neurosurgery: a review and a framework for prevention

Rhabdomyolysis (RM) is a potentially fatal or disabling clinical syndrome resulting in muscle necrosis and leakage of muscle constituents into the blood. Lactic acidosis and more serious complications such as acute renal failure may occur in up to half of recognized cases, so accurate diagnosis is required. We present three cases in which RM occurred in patients undergoing neurosurgical procedures performed in the lateral position. A review of the literature is provided together with a framework for the prevention of this surgical complication. Three patients underwent neurosurgical procedures in the lateral position for left facial/glossopharyngeal neuralgia, for jugular foramen tumor, and for a petroclival meningioma, respectively. All patients were obese and all three showed massive postoperative elevation in creatine kinase (CK) levels characteristic of RM. Myoglobinuria was identified in two patients and all three showed hyperintensity of the hip gird muscles in the short tau inversion recovery sequence magnetic resonance imaging. All recovered spontaneously and none went on to develop renal failure. A literature review showed that RM has been rarely reported after neurosurgery. However, the duration of procedures of the cases of reported RM indicates that the prevalence of the condition is likely highly under-recognized in neurosurgery. This is particularly important given the rising obesity rates seen in many countries. Obese patients undergoing long neurosurgical procedures, particularly in the lateral position, should be suspected of RM and should be closely monitored for CK levels, myoglobinuria, and acidosis. We outline a framework of strategies for the prevention of the condition.