Does intraoperative fluid management in spine surgery predict intensive care unit length of stay?

STUDY OBJECTIVE

To determine whether intraoperative fluid management in spine surgery predicts postoperative intensive care unit length of stay (ICU LOS).

DESIGN

Retrospective case series.

SETTING

University-affiliated medical center.

PATIENTS

103 adult ASA physical status I, II, and III patients undergoing spine surgery.

INTERVENTIONS

Patients were divided into three LOS groups: no ICU stay (LOS0) (n = 26), 1 day ICU stay (LOS1) (n = 48), and ICU stay > 1 day (LOS2) (n = 29). Measurements were analyzed by groups using the Kruskal-Wallis and Mann-Whitney tests, and linear regression.

MEASUREMENTS

Demographics, comorbidity, length of surgery, surgical procedure, and intraoperative fluids were recorded.

MAIN RESULTS

The important differences in perioperative fluid management among the three groups included estimated blood loss (612 +/- 480 mL, 1853 +/- 1175 mL, 2702 +/- 1771 mL, means +/- SD); total crystalloid administration (2715 +/- 1396 mL, 5717 +/- 2574 mL, 7281 +/- 3417 mL); and total blood administration (92 +/- 279 mL, 935 +/- 757 mL, 1542 +/- 1230 mL) in LOS0, LOS1, and LOS2, respectively. The mixture of surgical procedures was similar in LOS1 and LOS2; and differed from LOS0. Predictors of ICU LOS included age, ASA physical status, surgical procedure, total crystalloid administration, and platelet administration. Surgical procedure and total crystalloid administration correlated (Pearson correlation coefficient = 0.441; p = 0.000) and were not related to age or ASA physical status.

CONCLUSIONS

Total crystalloid administration during spine surgery does predict ICU LOS. In addition, total crystalloid administration is closely related to the surgical procedure. Given that the mixture of surgical procedures was similar in LOS1 and LOS2, but differed in estimated blood loss, total crystalloid administration, and total blood administration; intraoperative fluid management during spine surgery only predicts ICU LOS insofar as total crystalloid administration is related to the surgical procedure.

Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes

STUDY DESIGN

A meta-analysis of surgical outcomes of cauda equina syndrome secondary to lumbar disc herniation.

OBJECTIVES

To determine the relationship between time to decompression after onset of cauda equina syndrome and clinical outcome, and to identify preoperative variables that were associated with outcomes.

SUMMARY OF BACKGROUND DATA

The timing of surgical decompression for cauda equina syndrome is controversial. Although most surgeons recommend emergent decompression, results in certain studies show that delayed surgery may provide a satisfactory outcome.

METHODS

A meta-analysis was performed to determine the correlation between timing of decompression and clinical outcome. One hundred four citations were reviewed, and 42 met the inclusion criteria. Preoperative and postoperative data were recorded. Length of time to surgery was broken down into five groups: less than 24 hours, 24-48 hours, 2-10 days, 11 days to 1 month, and more than 1 month. Logistic regression was used to determine the association between preoperative variables and postoperative outcomes.

RESULTS

Outcomes were analyzed in 322 patients. Preoperative chronic back pain was associated with poorer outcomes in urinary and rectal function, and preoperative rectal dysfunction was associated with worsened outcome in urinary continence. In addition, increasing age was associated with poorer postoperative sexual function. No significant improvement in surgical outcome was identified with intervention less than 24 hours from the onset of cauda equina syndrome compared with patients treated within 24-48 hours. Similarly, no difference in outcome occurred in patients treated more than 48 hours after the onset of symptoms. Significant differences, however, were found in resolution of sensory and motor deficits as well as urinary and rectal function in patients treated within 48 hours compared with those treated more than 48 hours after onset of symptoms.

CONCLUSIONS

There was a significant advantage to treating patients within 48 hours versus more than 48 hours after the onset of cauda equina syndrome. A significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patients who underwent decompression within 48 hours versus after 48 hours.

Pseudarthrosis repair. Autogenous iliac crest versus femoral ring allograft

Pseudarthrosis repair in the lumbar spine is one of the most challenging problems faced by spine surgeons. Historically high failure rates with posterior repair have led to the use of anterior lumbar interbody fusion with tricortical iliac crest autograft in these difficult cases. More recently, femoral ring allografts packed with autograft bone have been advocated as another method that would decrease donor site morbidity. Two series of patients underwent anterior lumbar interbody fusion with anterior instrumentation to repair pseudarthrosis (Group I, 33 patients with tricortical autogenous iliac crest and Group II, 20 patients with femoral ring allografts). At minimum 2-year followup, there was no difference in fusion rates (Group I, 32 of 33 versus Group II, 20 of 20). Patients in Group I had radiographic fusion develop more rapidly than patients in Group II (12 months versus 18 months), but a significant proportion of patients in Group I (35%) had an average of 2 mm of graft subsidence. Despite excellent fusion rates in both groups, functional outcomes were not as good with only 28% of patients in Group I and 36% of patients in Group II returning to work. Using anterior instrumentation, anterior interbody fusion offers an excellent method to repair pseudarthrosis using femoral ring allografts or autogenous iliac crest. However, femoral ring allografts offer the potential to decrease donor site morbidity, allowing the surgeon to treat multiple spine levels.

Complications of spinal fusion in adult patients more than 60 years of age

This article describes the overall rate, characteristics, and predictive factors for major and minor complications in spinal fusion patients over 60 years of age (or greater) cared for in the authors' institution. Special emphasis is placed on establishing the most valid incidence of complications after spinal fusion by extracting the information directly from the pateint's permanent medical or clinical database record. Once the spinal surgery risk profile for the elderly patient is established, treatment interventions to modify these risks can be implemented and evaluated prospectively and longitudinally to maximize spinal surgery outcomes.