Minimally Invasive versus Conventional Open Surgery for Fixation of Spinal Fracture in Ankylosed Spine

@#Introduction: This was a retrospective study aimed to investigate the perioperative outcomes of long construct minimally invasive spinal stabilisation (MISt) using percutaneous pedicle screws (PPS) versus conventional open spinal surgery in the treatment of spinal fracture in ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH). Material and Methods: Twenty-one patients with AS and DISH who were surgically treated between 2009 and 2017 were recruited. Outcomes of interest included operative time, intra-operative blood loss, complications, duration of hospital stay and fracture union rate. Results: Mean age was 69.2 ± 9.9 years. Seven patients had AS and 14 patients had DISH. 17 patients sustained AO type B3 fracture and 4 patients had type B1 fracture. Spinal trauma among these patients mostly involved thoracic spine (61.9%), followed by lumbar (28.6%) and cervical spine (9.5%). MISt using PPS was performed in 14 patients (66.7%) whereas open surgery in 7 patients (33.3%). Mean number of instrumentation level was 7.9 ± 1.6. Mean operative time in MISt and open group was 179.3 ± 42.3 minutes and 253.6 ± 98.7 minutes, respectively (p=0.028). Mean intra-operative blood loss in MISt and open group was 185.7 ± 86.4ml and 885.7 ± 338.8ml, respectively (p<0.001). Complications and union rate were comparable between both groups. Conclusion: MISt using PPS lowers the operative time and reduces intra-operative blood loss in vertebral fractures in ankylosed disorders. However, it does not reduce the perioperative complication rate due to the premorbid status of the patients. There was no significant difference in the union rate between MISt and open surgery.

Spinal Anesthesia with Isobaric Tetracaine in Patients with Previous Lumbar Spinal Surgery

PURPOSE: Previous lumbar spinal surgery (PLSS) is not currently considered as a contraindication for regional anesthesia. However, there are still problems that make spinal anesthesia more difficult with a possibility of worsening the patient's back pain. Spinal anesthesia using combined spinal-epidural anesthesia (CSEA) in elderly patients with or without PLSS was investigated and the anesthetic characteristics, success rates, and possible complications were evaluated. MATERIALS AND METHODS: Fifty patients without PLSS (Control group) and 45 patients with PLSS (PLSS group) who were scheduled for total knee arthroplasty were studied prospectively. A CSEA was performed with patients in the left lateral position, and 10 mg of 0.5% isobaric tetracaine was injected through a 27 G spinal needle. An epidural catheter was then inserted for patient controlled analgesia. Successful spinal anesthesia was defined as adequate sensory block level more than T12. The number of skin punctures and the onset time were recorded, and maximal sensory block level (MSBL), time to 2-segment regression, success rate and complications were observed. RESULTS: The success rate of CSEA in Control group and PLSS group was 98.0%, and 93.3%, respectively. The median MSBL in PLSS group was higher than Control group [T4 (T2-L1) vs. T6 (T3-T12)] (p < 0.001). There was a significant difference in the number of patients who required ephedrine for the treatment of hypotension in PLSS group (p = 0.028). CONCLUSION: The success rate of CSEA in patients with PLSS was 93.3%, and patients experienced no significant neurological complications. The MSBL can be higher in PLSS group than Control group.

Alternative Result of Wake-up Test according to Position Change during a Spinal Fusion / 대한마취과학회지

There are rare but serious complications-especially risk of paraplegia when instrumentation by surgery is used to correct a spinal deformity. Wake-up tests may be necessary during scoliosis or kyphosis surgery to ensure that spinal function remains intact. We tried four spinal fusions for ankylosing spondylitis of a 62 year-old woman. We were not able to fix the rod for fusion because of a presenting positive wake-up test in the previous two prone-positioned operations. In last operation we decided on normotensive anesthesia with fentanyl-propofol in a lateral decubitus position, and then surgical instrumentation was completed after we made sure of a negative weak-up test. There were no postoperative sequelae. The lateral approach to the thoracic disc space during spinal fusion may produce minimum disruption of the normal spinal musculoskeletal anatomy, avoid retraction of the spinal cord and preserve the neurovascular bundle and the segmental radicular arteries to the spinal cord.

A Retrospective Study of Efficacy of Autotransfusion in Spinal Surgery / 대한마취과학회지

BACKGROUND: To avoid complications of homologous transfusion, many methods are used in patients who undergo an operation, but the autologous transfusion is most popular. This retrospective study was done to evaluate the applicability of an autologous transfusion in an orthopedic spinal surgery. METHODS: The cases of 239 autologous transfusion and 85 homologous transfusions in patients who had spinal surgery due to spinal stenosis were reviewed, and the differences in homologous transfusion, postoperative drainage and complications in both groups were compared. Both groups were analysed and compared by the T-test and Mann-Whitmann rank sum test. RESULTS: In the homologous transfusion group, 4.6 +/- 2.7 units of RBC products were used in 85 patients. In the autologous transfusion group more than 2 techniques of preoperative deposit, intraoperative autotansfusion by cell saver, acute normovolemic hemodilution, and postoperative autotransfusion were used, and 3.6 +/- 2.4 units of RBC products were infused to 49 out of 239 patients (P < 0.001). A postoperative hematoma occured in 2 patients after a homologous transfusion but there were no cases in autologous transfusions. CONCLUSION: Consequently much of the homologous transfusion could be saved by using an autologous transfusion, and smaller amounts of postoperative drainge occured, so the author could confirm the benefit of autologous transfusion.

Induced Hypotension Using Esmolol in Spinal Surgery / 대한마취과학회지

Background: Esmolol as a drug for induced hypotension can, not only avoid many drawbacks of nitroprusside, but reduce the amount of intraoperative bleeding and make better operative field. This study was performed to evalute cardiovascular changes during esmolol-induced controlled hypotension. Methods: Induced hypotension using esmolol was applied to 18 adult patients receiving spinal surgery under the diagnosis of spinal stenosis or scoliosis. After prehydraion of 2,000 ml of crystalloid solution, 0.5 mg/kg esmolol was used as loading dose once, twice or three times until mean blood pressure (MBP) fell below 70 mmHg, followed by continuous infusion (50~300 microg/kg/min) of esmolol. MBP and heart rate (HR) were measured before, 5, 10, 15, 30, 60 and 90 min after esmolol administration, and 5, 10 and 15 minutes after discontinuation of esmolol. In 8 patients, cardiac output (CO) and mixed venous oxygen tension and saturation were measured before, during and after esmolol use. Results: MBP was decreased from 91+/-12 mmHg to 67+/-7 mmHg after 15 min (P<0.05). HR(BPM) was decreased from 76+/-17 to about 60 after 15 min (P<0.05). CO was decreased about 30% during induced hypotension but recoverd to initial level 15 min after esmolol discontinuation. While oxygen transport was reduced significantly during induced hypotension (P<0.05), oxygen consumption was maintained all the time. Conclusion: With the use of esmolol, stable hypotension could be achieved. Although oxygen transport decreased possibly due to reduction of CO, but oxygen consumption was maintained.

Responses of Pro-Inflammatory and Anti-Inflammatory Cytokines with Clonidine Premedication in Patients Undergoing Spinal Surgery / 대한마취과학회지

BACKGROUND: As immune mediators, cytokines are thought to regulate many biological functions. Changes in cytokine response were found in stressful conditions including surgery. Our aim was to study the effects of oral clonidine premedication on the proinflammatory and antiinflammatory cytokines in patients undergoing spinal fusion. METHODS: Thirty patients (ASA I and II) were selected and randomly assigned to one of the three groups. Group 1, 2, and 3 received no premedication, clonidine 0.15 mg and 0.3 mg orally, respectively. Blood concentrations of proinflammatory cytokines, tumor necrosis factor-alpha (TNF-alpha), Interleukin-1beta (IL-1beta), IL-6, and antiinflammatory cytokines IL-10, IL-13 were determined as following intervals: before induction, immediate, 1 h, 3 h and 5 h after incision. For cytokines assay, commercially available ELISA kits were used. RESULTS: Compared to baseline values, TNF-alpha , IL-6 and IL-10 concnetrations at 3 h and 5 h after incision increased significantly in all the individual groups. IL-1beta increased significantly at 3 h and 5 h after incision in group 1 and 3, and at immediate, 1 h and 3 h after incision in group 2. At the same times sampled, TNF-alpha, IL-1beta, IL-6, IL-13 concentrations were not statistically different among three groups. However, IL-10 concentration increased significantly at 5 h after incision in group 2 and 3 compared to group 1. In addition, IL-10 level at 5 h after incision in group 2 was significantly different from group 3. CONCLUSIONS: Oral clonidine premedication increased release of antiinflammatory cytokine IL-10 significantly during spinal fusion surgery.