Intraoperative blood loss in oncological spine surgery

Promoting postoperative recovery in patients with metastatic epidural spinal cord compression based on the concept of ERAS: a multicenter analysis of 304 patients

BACKGROUND CONTEXT

Enhanced recovery after surgery (ERAS) has proven beneficial for patients undergoing orthopedic surgery. However, the application of ERAS in the context of metastatic epidural spinal cord compression (MESCC) remains undefined.

PURPOSE

This study aims to establish a medical pathway rooted in the ERAS concept, with the ultimate goal of scrutinizing its efficacy in enhancing postoperative outcomes among patients suffering from MESCC.

STUDY DESIGN/SETTING

An observational cohort study.

PATIENT SAMPLE

A total of 304 patients with MESCC who underwent surgery were collected between January 2016 and January 2023 at two large tertiary hospitals.

OUTCOME MEASURES

Surgery-related variables, patient quality of life, and pain outcomes. Surgery-related variables in the study included surgery time, surgery site, intraoperative blood loss, and complication.

METHODS

From January 2020 onwards, ERAS therapies were implemented for MESCC patients in both institutions. Thus, the ERAS cohort included 138 patients with MESCC who underwent surgery from January 2020 to January 2023, whereas the traditional cohort consisted of 166 patients with MESCC who underwent surgery from January 2016 to December 2019. Clinical baseline characteristics, surgery-related features, and surgical outcomes were collected. Patient quality of life was evaluated using the Functional Assessment of Cancer Therapy-General Scale (FACT-G), and pain outcomes were assessed using the Visual Analogue Scale (VAS).

RESULTS

Comparison of baseline characteristics revealed that the two cohorts were similar (all p>.050), indicating comparable distribution of clinical characteristics. In terms of surgical outcomes, patients in the ERAS cohort exhibited lower intraoperative blood loss (p<.001), shorter postoperative hospital stays (p<.001), lower perioperative complication rates (p=.020), as well as significantly shorter time to ambulation (P<0.001), resumption of regular diet (p<.001), removal of urinary catheter (p<.001), initiation of radiation therapy (p<.001), and initiation of systemic internal therapy (p<.001) compared with patients in the traditional cohort. Regarding pain outcomes and quality of life, patients undergoing the ERAS program demonstrated significantly lower VAS scores (p<.010) and higher scores for physical (p<.001), social (p<.001), emotional (p<.001), and functional (p<.001) well-being compared with patients in the traditional cohort.

CONCLUSIONS

The ERAS program, renowned for its ability to expedite postoperative recuperation, emerges as a promising approach to ameliorate the recovery process in MESCC patients. Not only does it exhibit potential in enhancing pain management outcomes, but it also holds the promise of elevating the overall quality of life for these individuals. Future investigations should delve deeper into the intricate components of the ERAS program, aiming to unravel the precise mechanisms that underlie its remarkable impact on patient outcomes.

Is perioperative blood transfusion associated with postoperative thromboembolism or infection after metastatic spinal tumor surgery?

STUDY DESIGN

Retrospective cohort.

SUMMARY OF BACKGROUND DATA

Patients with metastatic spine disease who undergo surgical intervention have a high risk of requiring red blood cell (RBC) transfusion. Perioperative transfusion has been independently associated with increased risk of venous thromboembolic (VTE) and infectious complications following orthopedic procedures and degenerative spinal intervention; however, literature within spine oncology is limited.

OBJECTIVE

To determine the association between perioperative RBC transfusion and postoperative VTE or infection following spinal tumor surgery.

METHODS

A total of 153 patients who underwent surgery for spinal metastases between April 2012 and April 2022 were included. Medical records were reviewed to identify RBC transfusion administered either intraoperatively or within 96 h following surgery. The primary endpoints were: 1) development of any VTE or 2) development of any infection within 30 days following surgery. Any VTE was defined as deep vein thrombosis or pulmonary embolism, and any infection was defined as pneumonia, meningitis, Clostridium difficile infection, urinary tract infection, surgical site infection, or sepsis. Logistic regression analyses were performed.

RESULTS

Of the 153 patients included in the study, 43 % received a perioperative RBC transfusion. The overall incidence of postoperative VTE and infection was 15 % and 22 %, respectively. In univariate analysis, perioperative transfusion was not associated with postoperative VTE (odds ratio [OR] 2.41; 95 % confidence interval [CI] 0.97-6.00; p = 0.058) but was associated with infection (OR 3.02; 95 % CI 1.36-6.73; p = 0.007). After adjusting for confounders such as performance status, operative time, and surgical extent, transfusion was not associated with both VTE (OR 1.25; 95 % CI 0.36-4.32; p = 0.727) or infection (OR 1.86; 95 % CI 0.70-4.92; p = 0.210). While not statistically significant, sub-analyses demonstrated a trend towards increased VTE incidence in patients requiring transfusion earlier (within 24 h) as opposed to later postoperatively.

CONCLUSIONS

We found that perioperative transfusion was not an independent predictor of 30-day postoperative VTE or infection in patients undergoing metastatic spinal surgery. Further exploration of time-dependent transfusion outcomes is warranted.

Quantile regression-based prediction of intraoperative blood loss in patients with spinal metastases: model development and validation

PURPOSE

To develop and evaluate a quantile regression-based blood loss prediction model for open surgery of spinal metastases.

METHODS

This was a multicenter retrospective cohort study. Over a 11-year period, patients underwent open surgery for spinal metastases at 6 different institutions were reviewed. The outcome measure is intraoperative blood loss (in mL). The effects of baseline, histology of primary tumor and surgical procedure on blood loss were evaluated by univariate and multivariate analysis to determine the predictors. Multivariate ordinary least squares (OLS) regression and 0.75 quantile regression were used to establish two prediction models. The performance of the two models was evaluated in the training set and the test set, respectively.

RESULTS

528 patients were included in this study. Mean age was 57.6 ± 11.2 years, with a range of 20-86 years. Mean blood loss was 1280.1 ± 1181.6 mL, with a range of 10 ~ 10,000 mL. Body mass index (BMI), tumor vascularization, surgical site, surgical extent, total en bloc spondylectomy and microwave ablation use were significant predictors of intraoperative blood loss. Hypervascular tumor, higher BMI, and broader surgical extent were related with massive blood loss. Microwave ablation is more beneficial in surgery with substantial blood loss. Compared to the OLS regression model, the 0.75 quantile regression model may decrease blood loss underestimate.

CONCLUSION

In this study, we developed and evaluated a prediction model for blood loss in open surgery for spinal metastases based on 0.75 quantile regression, which may minimize blood loss underestimate.

Is Tranexamic Acid Beneficial in Open Spine Surgery? and its Effects Vary by Dosage, Age, Sites, and Locations: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

The role of tranexamic acid (TXA) in controlling blood loss during spine surgery remains unclear. With the publication of new randomized controlled trials (RCTs), we conducted a meta-analysis to determine the safety and efficacy of TXA in spine surgery.

METHODS

PubMed, Embase, Web of Science, and Cochrane databases were searched for relevant studies through 2022. Only RCTs were eligible for this study. The extracted data were analyzed using RevMan 5.3 software for meta-analysis.

RESULTS

Twenty RCTs including 1497 patients undergoing spine surgery were included in this systematic evaluation. Compared with the control group, TXA significantly reduced total blood loss (mean difference [MD] = - 218.96, 95% confidence interval [CI] = - 309.77 to - 128.14, P < 0.00001), perioperative blood loss (MD = - 90.54, 95% CI = - 139.33 to - 41.75, P = 0.0003), postoperative drainage (MD = - 102.60, 95% CI = - 139.51 to - 65.70, P < 0.00001)，reduced hospital stay (MD = - 1.42, 95% CI = - 2.71 to - 0.14, P = 0.03), reduced total blood transfusion volume (MD = - 551.06, 95% CI = - 755.90 to - 346.22, P < 0.00001), and international normalized ratio (MD = -0.03, 95% CI = -0.04 to -0.02, P < 0.00001).

CONCLUSIONS

Based on the meta-analysis of 20 RCTs, we demonstrated that TXA reduces blood loss in open spine surgery, decreases transfusion rates, and shortens hospital stays. The TXA administration during the perioperative period does not increase the incidence of postoperative complications.

Preoperative embolization of hypervascular spinal tumors: Two case reports

The performance of preoperative embolization on a spinal tumor can be a useful adjunctive procedure that minimizes blood loss and complications, particularly for both metastatic and non-metastatic hypervascular tumors. We discuss two cases of hypervascular spinal tumors that were successfully treated with preoperative embolization and surgery. The first patient was an 18-year-old man who presented with cervical and shoulder pain for two months without paralysis or weakness. Magnetic resonance imaging revealed a tumor located in the D2 posterior vertebral arch that extended into the spinal canal and compressed the spinal cord. The second patient was a 68-year-old man with back pain that radiated to the legs for ten days. Magnetic resonance imaging revealed a mass in the L4 vertebral body. Both patients received tumor embolization and surgery. After surgery, neither patient experienced any major complications. Histological examination revealed osteoblastoma in the first patient and plasmacytoma in the second patient.

Complication Avoidance in Surgical Management of Vertebral Column Tumors

The surgical management of spinal tumors has grown increasingly complex as treatment algorithms for both primary bone tumors of the spine and metastatic spinal disease have evolved in response to novel surgical techniques, rising complication rates, and additional data concerning adjunct therapies. In this review, we discuss actionable interventions for improved patient safety in the operative care for spinal tumors. Strategies for complication avoidance in the preoperative, intraoperative, and postoperative settings are discussed for approach-related morbidities, intraoperative hemorrhage, wound healing complications, cerebrospinal fluid (CSF) leak, thromboembolism, and failure of instrumentation and fusion. These strategies center on themes such as pre-operative imaging review and medical optimization, surgical dissection informed by meticulous attention to anatomic boundaries, and fastidious wound closure followed by thorough post-operative care.