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Patel RV, Yearley AG, Isaac H, Chalif EJ, Chalif JI, Zaidi HA. Advances and Evolving Challenges in Spinal Deformity Surgery. J Clin Med 2023; 12:6386. [PMID: 37835030 PMCID: PMC10573859 DOI: 10.3390/jcm12196386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Surgical intervention is a critical tool to address adult spinal deformity (ASD). Given the evolution of spinal surgical techniques, we sought to characterize developments in ASD correction and barriers impacting clinical outcomes. METHODS We conducted a literature review utilizing PubMed, Embase, Web of Science, and Google Scholar to examine advances in ASD surgical correction and ongoing challenges from patient and clinician perspectives. ASD procedures were examined across pre-, intra-, and post-operative phases. RESULTS Several factors influence the effectiveness of ASD correction. Standardized radiographic parameters and three-dimensional modeling have been used to guide operative planning. Complex minimally invasive procedures, targeted corrections, and staged procedures can tailor surgical approaches while minimizing operative time. Further, improvements in osteotomy technique, intraoperative navigation, and enhanced hardware have increased patient safety. However, challenges remain. Variability in patient selection and deformity undercorrection have resulted in heterogenous clinical responses. Surgical complications, including blood loss, infection, hardware failure, proximal junction kyphosis/failure, and pseudarthroses, pose barriers. Although minimally invasive approaches are being utilized more often, clinical validation is needed. CONCLUSIONS The growing prevalence of ASD requires surgical solutions that can lead to sustained symptom resolution. Leveraging computational and imaging advances will be necessary as we seek to provide comprehensive treatment plans for patients.
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Affiliation(s)
- Ruchit V. Patel
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Alexander G. Yearley
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Hannah Isaac
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
| | - Eric J. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Joshua I. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Hasan A. Zaidi
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
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Terada R, Stewart K, Hansen S, Shettar SS, Butt A, Vallurupalli S, Martin M, Tanaka K. Temporal changes and predictors of perioperative blood transfusion in elective spine surgery: a retrospective analysis of a large surgical database. Br J Anaesth 2023; 130:421-429. [PMID: 36586804 DOI: 10.1016/j.bja.2022.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/09/2022] [Accepted: 11/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Allogeneic blood transfusion used to be common in spine surgery. Patient blood management has been widely adopted, and it is important to reassess transfusion predictors in contemporary practice. METHODS A retrospective study of inpatient spine surgery was performed using National Surgical Quality Improvement Program (NSQIP) data from 2011 to 2019. The primary outcome was perioperative transfusion within 72 h of surgery. Multivariable logistic regression and recursive partitioning were used to assess up to 15 variables including patient and surgical data, surgical specialty (orthopaedic surgery vs neurosurgery), and year of surgery. RESULTS The study population included 251 971 US surgical patients; 6.9% of these patients received perioperative blood transfusion. Perioperative transfusions declined over time with the steepest decline from 2011 to 2015. The greatest reduction was seen among orthopaedic cases where the transfusion rate declined from 16.0% to 8.7% between 2011 and 2015. Eight variables were predictive factors in a reduced model: operative time, preoperative haemoglobin, vertebral level, number of vertebral levels, older age, surgeon specialty, arthrodesis, and year of surgery (area under the curve [AUC]=0.880; 95% confidence interval [CI], 0.878-0.883). Overall, longer operative time (>144 min) and greater numbers of vertebral levels had greater associations with transfusion than surgical specialty after adjustments. Prevalence of anaemia (15%) has not substantially declined. CONCLUSIONS Perioperative blood transfusion rate in spine surgery has declined over the past decade. The extent and duration of surgery and preoperative haemoglobin level remain important factors associated with increased odds for perioperative blood transfusion.
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Affiliation(s)
- Rui Terada
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Kenneth Stewart
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA; Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Sandra Hansen
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Shashank S Shettar
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Amir Butt
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Santaram Vallurupalli
- Department of Orthopedic Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Michael Martin
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Kenichi Tanaka
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
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Bildik C, Pehlivanoglu T. Arthroscopic rotator cuff repair performed with intra-articular tranexamic acid: could it provide improved visual clarity and less postoperative pain? A prospective, double-blind, randomized study of 63 patients. J Shoulder Elbow Surg 2023; 32:223-231. [PMID: 36403924 DOI: 10.1016/j.jse.2022.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) has been widely used in orthopedic surgery with the aim of reducing intraoperative and postoperative bleeding, as well as bleeding-related complications. The purpose of this study was to assess whether intra-articular use of TXA during arthroscopic rotator cuff tear (RCT) repair could improve visual clarity, shorten the duration of the operation, and provide superior pain management as compared with placebo. METHODS We conducted a prospective, randomized, double-blind, placebo-controlled study. Patients aged ≥18 years with a magnetic resonance imaging-confirmed RCT and a history of failed conservative treatment for ≥6 months were included. Patients with a history of coagulopathy; a history of cardiac, renal, or hepatic disease; a history of conservative treatment for <6 months; and/or acute RCTs were excluded. Visual clarity as the primary outcome was assessed using an arthroscopic visual scale comprising 5 grades-ranging from grade 1, best visual clarity, to grade 5, worst visual clarity (requiring conversion to open surgery)-after the procedure by the operating surgeon every 10 minutes throughout the video of the operation. Secondary outcomes were operative duration and postoperative pain scores. RESULTS A total of 63 patients with similar demographic data (age and sex) and intraoperative mean arterial pressure were enrolled and randomized into 2 groups: The TXA group comprised 32 patients with a mean age of 56.46 years, and the placebo group comprised 31 patients with a mean age of 57.83 years. The TXA group was reported to have significantly superior visual clarity (mean arthroscopic visual scale score, 1.5 ± 0.5 vs. 2.86 ± 1.7; P < .001), with a significantly higher percentage of grade 1 visual clarity (78.1% vs. 32.2%, P < .001) and a significantly lower percentage of grade 4 visual clarity (0% vs. 3.2%, P = .003). Grade 5 visual clarity was not recorded in any patient in either group. The TXA group showed a significantly shorter operative duration (55.73 minutes vs. 67.26 minutes, P = .001) and superior pain scores at 8 hours (2.3 vs. 3.6, P = .002) and 24 hours (1.6 vs. 2.4, P < .001) postoperatively. No complications were recorded in either group. CONCLUSIONS This study showed that during arthroscopic rotator cuff repair procedures, intra-articular use of TXA was able to provide superior arthroscopic visual clarity while shortening the total operative duration significantly and providing significantly superior pain management in the first 8 and 24 hours postoperatively as compared with placebo. This study underlines the safety and efficacy of intra-articular TXA use in arthroscopic rotator cuff repair.
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Affiliation(s)
- Celaleddin Bildik
- Orthopedic Surgery and Traumatology, Faculty of Health Sciences, Yeni Yüzyıl University, Istanbul, Turkey
| | - Tuna Pehlivanoglu
- Orthopedic Surgery and Traumatology, Faculty of Health Sciences, Yeni Yüzyıl University, Istanbul, Turkey; Department of Orthopaedic Surgery, Liv Hospital Ulus, Istanbul, Turkey.
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Kanhere AP, Lambrechts MJ, Issa TZ, Karamian BA, Hendow CJ, Reddy YC, Slota PJ, D'Antonio ND, Kaye ID, Canseco JA, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The Effect of Tranexamic Acid on Operative and Postoperative Blood Loss in Transforaminal Lumbar Interbody Fusions. World Neurosurg 2022; 166:e443-e450. [PMID: 35840090 DOI: 10.1016/j.wneu.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this retrospective cohort study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF). Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for patients who undergo 1- to 3-level TLIF. METHODS All patients requiring 1- to 3-level TLIF who received a preoperative loading dose of TXA were grouped and compared with patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with χ2, Kruskal-Wallis, or analysis of variance tests, depending on normality and data type. Multiple linear regressions were developed to determine independent predictors of the estimated blood loss (EBL), total blood loss, drain output, and length of stay. Statistical significance was set at P < 0.05. RESULTS Patients who received preoperative TXA had more comorbidities (P = 0.006), longer surgery length (P < 0.001), and longer length of stay (P = 0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (P < 0.001, P = 0.001, P = 0.007, P < 0.001, respectively), but was not associated with a change in EBL, total blood loss, or length of stay. CONCLUSIONS The application of preoperative TXA for patients undergoing 1- to 3-level TLIF reduced drain output in the first 2 postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL.
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Affiliation(s)
- Arun P Kanhere
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Tariq Ziad Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chelsea J Hendow
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yashas C Reddy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul J Slota
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Adeyemo EA, Aoun SG, Barrie U, Nguyen ML, Badejo O, Pernik MN, Christian Z, Dosselman LJ, El Ahmadieh TY, Hall K, Reyes VP, McDonagh DL, Bagley CA. Enhanced Recovery After Surgery Reduces Postoperative Opioid Use and 90-Day Readmission Rates After Open Thoracolumbar Fusion for Adult Degenerative Deformity. Neurosurgery 2021; 88:295-300. [PMID: 32893863 DOI: 10.1093/neuros/nyaa399] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/02/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The role of enhanced recovery after surgery (ERAS) pathways implementation has not been previously explored in adult deformity patients. OBJECTIVE To determine the impact of ERAS pathways implementation in adult patients undergoing open thoraco-lumbar-pelvic fusion for degenerative scoliosis on postoperative outcome, opioid consumption, and unplanned readmission rates. METHODS In this retrospective single-center study, we included 124 consecutive patients who underwent open thoraco-lumbar-pelvic fusion from October 2016 to February 2019 for degenerative scoliosis. Primary outcomes consisted of postoperative supplementary opioid consumption in morphine equivalent dose (MED), postoperative complications, and readmission rates within the postoperative 90-d window. RESULTS There were 67 patients in the ERAS group, and 57 patients served as pre-ERAS controls. Average patient age was 69 yr. The groups had comparable demographic and intraoperative variables. ERAS patients had a significantly lower rate of postoperative supplemental opioid consumption (248.05 vs 314.05 MED, P = .04), a lower rate of urinary retention requiring catheterization (5.97% vs 19.3%, P = .024) and of severe constipation (1.49% vs 31.57%, P < .0001), and fewer readmissions after their surgery (2.98% vs 28.07%, P = .0001). CONCLUSION A comprehensive multidisciplinary approach to complex spine surgery can reduce opioid intake, postoperative urinary retention and severe constipation, and unplanned 90-d readmissions in the elderly adult population.
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Affiliation(s)
- Emmanuel A Adeyemo
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Salah G Aoun
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Umaru Barrie
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Madelina L Nguyen
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Olatunde Badejo
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Mark N Pernik
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Zachary Christian
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Luke J Dosselman
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Kristen Hall
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Valery Peinado Reyes
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - David L McDonagh
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, Texas
| | - Carlos A Bagley
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas.,Department of Orthopedic Surgery, UT Southwestern Medical Center, Dallas, Texas
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