Incidence and Risk Factors of Gastrointestinal and Hepatobiliary Complications after Spinal Fusion Surgery: a Retrospective Cohort Study

BACKGROUND

Spinal surgery holds a higher chance of unpredicted postoperative medical complications among orthopedic surgeries. Several studies have analyzed the risk factors for diverse postoperative medical complications, but the majority investigated incidences of each complication qualitatively. Among gastrointestinal complications, reports regarding postoperative ileus were relatively frequent. However, risk factors or incidences of hepatobiliary complications have yet to be investigated. The purpose of this study was to examine the incidence of gastrointestinal complications after spinal surgery, quantitatively analyze the risk factors of frequent complications, and to determine cues requiring early approaches.

METHODS

In total, 234 consecutive patients who underwent spinal fusion surgery performed by one senior doctor at our institute in one-year period were retrospectively enrolled for analyses. The primary outcomes were presence of paralytic ileus, elevated serum alanine transaminase (ALT) and aspartate transaminase (AST) levels, and elevated total bilirubin levels. Univariate logistic regression analyses of all variables were performed. In turn, significant results were reanalyzed by multivariate logistic regression. The variables used were adjusted with age and gender.

RESULTS

Gastrointestinal complications were observed in 15.8% of patients. Upon the risk factors of postoperative ileus, duration of anesthesia (odds ratio [OR], 1.373; P = 0.015), number of fused segments (OR, 1.202; P = 0.047), and hepatobiliary diseases (OR, 2.976; P = 0.029) were significantly different. For elevated liver enzymes, men (OR, 2.717; P = 0.003), number of fused segments (OR, 1.234; P = 0.033), and underlying hepatobiliary (OR, 2.704; P = 0.031) and rheumatoid diseases (OR, 5.021; P = 0.012) had significantly different results. Lastly, risk factors for total bilirubin elevation were: duration of anesthesia (OR, 1.431; P = 0.008), number of fused segments (OR, 1.359; P = 0.001), underlying hepatobiliary diseases (OR, 3.426; P = 0.014), and thoracolumbar junction involving fusions (OR, 4.134; P = 0.002) compared to lumbar spine limited fusions.

CONCLUSION

Patients on postoperative care after spinal surgery should receive direct attention as soon as possible after manifesting abdominal symptoms. Laboratory and radiologic results must be carefully reviewed, and early consultation to gastroenterologists or general surgeons is recommended to avoid preventable complications.

Clinical Characteristics and Outcomes of Patients with Culture-Negative Pyogenic Spondylitis according to Empiric Glycopeptide Use

Background

The optimal choice of antibiotics is challenging in culture-negative pyogenic spondylitis (PS). The empiric use of glycopeptides is suggested depending on various risk factors, although clinical data are sparse. This study aimed to analyze the clinical characteristics and outcomes of patients with culture-negative PS and evaluate the effect of empiric glycopeptide use on clinical outcomes in these patients.

Materials and Methods

Data on the characteristics, treatment, and outcomes of 175 patients diagnosed with PS were retrospectively obtained from the electronic database of a tertiary referral hospital from 2009 to 2016. Patients with negative culture results were grouped by the duration of glycopeptide treatment: glycopeptide therapy <28 days (Group A) and glycopeptide therapy ≥28 days (Group B).

Results

Of 89 patients with negative culture results, 78 were included in the analysis (Group A, n = 66; Group B, n = 12). The mean age of patients with negative culture results was 65.5 years, and 52.6% were male. The median follow-up duration was 573 (interquartile range [IQR], 83 – 1,037) days. The duration of intravenous glycopeptide therapy was 0.0 (IQR, 0.0 – 0.0) days and 55.5 (IQR, 37.0 – 75.7) days for Groups A and B, respectively. Patients who used glycopeptide longer empirically (Group B) had more commonly undergone a previous spinal procedure, including surgery (P = 0.024). The length of hospitalization, erythrocyte sedimentation rate, and C-reactive protein level were significantly higher in Group B compared with those in Group A (P <0.001, P <0.001, and P = 0.006, respectively). Regarding treatment modalities, patients in Group B underwent surgery more frequently (P = 0.017). The duration of parenteral antibiotic treatment was longer in Group B (P <0.001). Recurrence was noted in 7 patients (9.0%), and the recurrence rate was not significantly different between the 2 groups (Group A, 5/66 [7.6%]; Group B, 2/12 [16.7%]; P = 0.293).

Conclusion

The recurrence rate among patients with culture-negative PS was not different based on the duration of empiric glycopeptide use. However, considering the small sample size and heterogeneity of our study population, we suggest that it is reasonable to administer glycopeptide antibiotics in these patients depending on clinical risk factors. Further large-scale prospective studies are needed to obtain more evidence for appropriate antibiotic treatment.

Transplantation of Mesenchymal Stem Cells for Acute Spinal Cord Injury in Rats: Comparative Study between Intralesional Injection and Scaffold Based Transplantation

Experimental stem cell therapy for spinal cord injury (SCI) has been extensively investigated. The selection of effective cell transplantation route is also an important issue. Although various types of scaffold have been widely tried as a carrier of stem cells to the injured spinal cord, there was little comparative study to investigate the efficacy of transplantation comparing with conventional transplantation route. A total of 48 Sprague-Dawley rats were subjected to standardized SCI, followed by transplantation of allogeneic mesenchymal stem cells (MSCs), either via intralesional injection (IL group), or via the poly (lactic-co-glycolic acid) (PLGA) scaffold (IP group) or chitosan scaffold (IC group). Engraftment and differentiation of the transplanted cells, expression of neurotrophic factors in the injured spinal cord, and functional recovery were compared with those of the control group. The mean numbers of engrafted MSCs in the IL, IP, and IC groups were 20.6 ± 0.7, 25.6 ± 1.7 and 26.7 ± 1.8 cells/high power filed (HPF), respectively. Results showed higher success rate of MSCs engraftment in the scaffold groups compared to the IL group. Expression of neuroprotective growth factors in the SCI lesions showed no significant differences between the IL, IP, and IC groups. The mean Basso, Beattie and Bresnahan locomotor scales at 6 weeks post-transplantation in the IL, IP, IC, and control groups were 7.9 ± 1.1, 7.9 ± 2.1, 8.7 ± 2.1, and 2.9 ± 1.0, respectively. The functional improvement was most excellent in the IC group. The scaffold based MSC transplantation for acute SCI presented the better cell engraftment and neuroprotective effect compared to the intralesional injection transplantation.

Risk factors affecting progressive collapse of acute osteoporotic spinal fractures

We prospectively investigated related clinical and radiological risk factors for progression following acute osteoporotic spinal fractures. Fracture location, morphological feature (mid-portion), and involvement of vertebral posterior wall were statistical significant risk factors considering increase of height loss and kyphotic angle, and occurrence of intravertebral cleft sign as a progressive collapse.

INTRODUCTION

This study was designed to investigate the clinical and radiological risk factors related to progressive collapse of acute osteoporotic spinal fractures (OSF).

METHODS

In total, 100 patients with acute OSF were prospectively enrolled at a single institute. Five pathological fractures were excluded. Twelve patients dropped out of the study because of conversion to surgical treatment during follow-up. Eight patients were excluded as follow-up losses. Thus, 75 patients were analyzed. Clinical data and radiological data were recorded and analyzed. As a definition of progressive OSF, height loss≥15%, kyphotic angle≥10°, and the occurrence of an intravertebral cleft sign at the 6-month follow-up compared to the initial values were adopted. Correlation analysis and multiple logistic regression analyses were performed to elucidate the related clinical or radiological factors for progressive OSF.

RESULTS

The occurrence of intravertebral cleft was not related to any significant differences in the clinical results and was only related to the fracture level in the regression analysis. A ≥15% increase in height loss and a ≥10° increase in kyphotic angle were related to worse clinical results. Mid-portion type fractures and involvement of the posterior wall were significant risk factors with relatively high odds ratios for progressive OSF under these criteria.

CONCLUSION

A thoracolumbar fracture, a mid-portion type fracture, and involvement of the vertebral posterior wall are relative risk factors for progressive collapse following acute OSF. More attention should be paid to patients with OSF and these risk factors during conservative management.

Miscellaneous tumour-like lesions of the ovary: cross-sectional imaging review

Miscellaneous tumour-like ovarian lesions are histobiologically diverse, and are often mistaken for the more common ovarian cancers, leading to aggressive management. Knowledge of characteristic clinical, laboratory and imaging findings of these select non-neoplastic ovarian entities allows correct diagnoses and permits optimal management.

Traumatic posterior atlantooccipital dislocation with Jefferson fracture and fracture-dislocation of C6-C7: a case report with survival

Atlantooccipital dislocation (AOD) is a rare and usually fatal injury. In the current study, the authors reported an extremely rare case of posterior AOD with Jefferson fracture and fracture-dislocation of C6-C7. The patient survived the injury and had only incomplete quadriplegia below the C7 segment with anterior cord syndrome. He was successfully managed with in situ occipitocervical fusion using the Cotrel-Dubousset rod system, corpectomy of C6, and anterior interbody fusion of C5-C7 with plating. To our knowledge, this is the first report of posterior AOD with two other non-contiguous cervical spine injuries. A high index of suspicion and careful examination of the upper cervical spine should be considered as the key to the diagnosis of AOD in cases that involve multiple or lower cervical spine injuries.

Fate of the facet joints after instrumented intertransverse process fusion

A success or failure of an intertransverse process fusion has been determined by the fusion status of the intertransverse fusion mass alone, and little consideration has been given to the fusion status of the facet joint. The purpose of this study was to assess the fusion status of the facet joints at the fusion level and its impact on the overall fusion outcome. Sixteen patients (19 levels) treated with decompression and intertransverse process fusion using pedicle screw fixation without facet arthrodesis were entered into a cross sectional study in which the fusion status of the intertransverse fusion masses and facet joints at each fusion level were evaluated and combined at an average duration of followup of 35 months (range, 22-61 months). Union rate of the intertransverse process fusion (58%, 22 of 38) was lower than the spontaneous fusion rate of the facet joint (68%, 26 of 38). However, the combination of the two fusion statuses at each fusion level generated 89% of the overall fusion rate (17 of 19 levels). With surgery, all patients had a good or excellent clinical outcome, but the outcome had no relation to the overall fusion status. The results suggest that the fusion status of the facet joint should be considered in determining overall fusion status after combined decompression with instrumented intertransverse process fusion.

Volumetric change of the graft bone after intertransverse fusion

STUDY DESIGN

Patients in whom good intertransverse fusion had been achieved were selected for the volumetric study of the fusion mass using sequential computed tomography scans.

OBJECTIVES

To assess the natural volumetric change of intertransverse fusion mass and the effect of the disease entity and spinal instrumentation on the fusion mass volume.

SUMMARY OF BACKGROUND DATA

The magnitude of volumetric change of the graft bone after intertransverse fusion is still inconclusive.

METHODS

Fifteen adult patients who underwent decompression surgery with single-level lumbar and lumbosacral intertransverse fusion were selected for this study. Preoperative diagnoses were degenerative spondylolisthesis in nine patients and isthmic spondylolisthesis in six. Seven of the 15 patients received pedicle screw fixation. They were categorized into two major groups: 1) instrumented and noninstrumented groups and 2) isthmic and degenerative groups. To assess the volumetric change of the graft bone, sequential computed tomography scans were obtained 2 weeks after surgery and again 18 months after surgery.

RESULTS

The overall initial mean graft volume was 6251 mm3, which decreased to 2842 mm3 by 18 months after surgery (P < 0.001). The overall mean volume loss between the two periods was 54.8% of the initial graft volume. Although there was no significant difference in the mean graft volume between the groups at either 2 weeks or 18 months after surgery (P > 0.05 in all comparisons), the mean graft volume in each group decreased significantly during the observation period (P < 0.01 in all comparisons). There was no significant difference in the mean volume loss or in the ratio of residual volume to the initial graft volume between the groups during the study period (P > 0.05 in all comparisons). The initial graft volume correlated positively with the graft volume at 18 months after surgery (r = 0.612, P < 0.01) and volume loss (r = 0.949, P < 0.01), but negatively with the residual volume ratio (r = -0.507, P < 0.01).

CONCLUSIONS

These results showed that more than one half of the initial graft bone volume was being absorbed during the consolidation processes of the graft bone, and that the volume loss during the period was not significantly affected by the spinal instrumentation or by the disease entity. It was also found that the greater the amount of the initial graft bone, the larger the fusion mass at 18 months after surgery. The volume loss, however, increased proportionally to an increase in the initial graft bone volume. The efficiency (ratio of residual volume to the initial graft volume) of the intertransverse fusion also tended to decline as the initial graft volume increased.

Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines

STUDY DESIGN

Thirty-nine adults and five children with active spinal tuberculosis and resulting kyphosis of the dorsal and lumbar spine who had combined posterior instrumentation and anterior interbody fusion were observed to determine whether the corrected spinal deformity could be maintained until solid fusion.

OBJECTIVE

To evaluate the effectiveness of the combined two-stage procedure for treating kyphosis due to active spinal tuberculosis.

SUMMARY OF BACKGROUND DATA

Until 1970, with all methods of treatment, kyphosis due to active spinal tuberculosis tended to increase during therapy. Most of the patients treated with these methods were not happy with this residual kyphosis, even though their disease was arrested or cured. Kyphosis became their main concern regarding further treatment.

METHODS

A combined two-stage procedure, under the cover of 18 months of triple chemotherapy, was used for all patients. For posterior stabilization, the Harrington distraction system, Rush nails or Steinmann pins and wires, and Texas Scottish Rite Hospital instrumentation were used. The diagnosis of successful interbody fusion was made if there was no loss of correction, no graft resorption or graft bed resorption, and if there was visible graft remodeling, such as trabeculation between the graft beds and graft and the graft hypertrophy.

RESULTS

In the 39 adults, average preoperative, immediate postoperative, and last follow-up kyphosis angles were 37 degrees, 16 degrees, and 18 degrees, respectively. In four children, the average preoperative, immediate postoperative, and last follow-up kyphosis angles were 55 degrees, 28 degrees, and 31 degrees, respectively. The loss of correction did not exceed 3 degrees. For one-segment spondylodesis, the average fusion times were 4 months in adults and 3.5 months in children. For a two-segment fusion, the average fusion times were 6 months in adults and 6.3 months in children.

CONCLUSION

Posterior instrumental stabilization and anterior interbody fusion were found helpful in arresting the disease early, providing early fusion, preventing progression of kyphosis, and correcting the kyphosis.

Effect of immobilization and configuration on lumbar adjacent-segment biomechanics

The motion and facet load changes at the adjacent segment after lumbosacral immobilization (with different angles) were quantified in vitro using canine spines. Changes were examined under flexion, extension, and lateral bending. An increase (extension: 62%; flexion: 85%; left bend: 30%; right bend 26%) in motion at the adjacent segment was found for all motions after immobilization. Adjacent-segment facet load remained constant under any load state or immobilized configuration. For all configurations, the facet contact site impinged in extension, remained unchanged in left bending, and moved superiorly in right bending. This study has shown that after immobilization the facet contact patterns at the adjacent segment changed, load was unchanged, and segmental motion increased when the lumbar spine reproduced the same range of motion. The configuration of the immobilized segments had no effect on these changes.

Tuberculosis of the ischiopubic ramus. A report of five cases

Five cases of tuberculosis of the ischiopubic ramus are reported. All presented with abscesses. Treatment by simple curettage and INH, rifampicin and ethambutol given for 18 to 24 months gave satisfactory results in the 4 patients who were children. The one adult had severe disruption of the symphysis pubis, and sacroiliac involvement; a good result was obtained after bone grafting and fixation with a plate.

The effect of posterior spinal fixation with acrylic cement on the vertebral growth plate and intervertebral disc in dogs

We have attempted to clarify the serial histological changes in the growing spine of dogs following posterior fixation with acrylic cement. Twenty-four male mongrel dogs aged 8 weeks were used for the study. The lumbar spine from L.3 to L.5 was fixed posteriorly with acrylic cement. Three dogs were then sacrificed every four weeks up to 32 weeks, and the histological changes of the vertebral disc, growth plate and vertebral bodies were observed by light microscopy. Thinning of the growth plate and distortion of the cartilage columns has been demonstrated, but premature fusion of the growth plate did not result and vertebral body growth continued. Anterior wedging of the intervertebral disc was seen with some thinning of the bony trabeculae of the vertebral body. Degeneration of the nucleus pulposus resulted, with replacement by fibrous tissue. The normal horizontal arrangement of the fibres of the annulus fibrosus altered to a vertical configuration by 32 weeks.