Exposición a radiación del cirujano de columna / Radiation exposure of the spine surgeon

Resumen: Introducción: en general, los cirujanos de columna buscan minimizar el daño a tejidos blandos empleando abordajes menos invasivos, lo que ocasiona que utilicen imágenes intraoperatorias de una manera mucho más habitual que el resto de las especialidades quirúrgicas; por lo tanto, están en mayor riesgo de exposición de radiación. Objetivo: el propósito del trabajo es analizar la cantidad de radiación a la cual está expuesto el cirujano de columna en diferentes escenarios. Material y métodos: estudio prospectivo con una fuente de datos descriptiva, longitudinal, no aleatorizada. Se llevó a cabo el estudio en el período del año 2015 al 2019; la protección radiológica consistió en chaleco plomado, protector de tiroides y lentes plomados; se usaron 10 dosímetros. Resultados: cuatro dosímetros fueron incluidos en el estudio, los otros seis fueron excluidos. Durante el estudio, un cirujano sufrió de cáncer de tiroides y otro de liposarcoma. En el grupo de protegidos se incluyeron dos cirujanos, en el grupo de protección aleatorizada se incluyó un cirujano y en el grupo sin protección se incluyó un cirujano. El dosímetro del grupo sin protección recibió mayor cantidad de radiación en todos los años, se realizó un análisis inferencial por año relacionado con el número de cirugías no encontrando correlación significativa, atribuimos este resultado a que no clasificamos el tipo de cirugía realizada por cada cirujano. Conclusión: el cirujano de columna debe de aplicar los métodos primarios de protección radiológica, ya que los cirujanos de columna sin equipo de protección reciben mayor cantidad de radiación en comparación con los protegidos.

Abstract: Introduction: in general, spine surgeons seek to minimize soft tissue damage by using less invasive approaches, which causes them to use intraoperative images much more frequently than other surgical specialties; therefore, they are at increased risk of radiation exposure. Objective: the aim of this work was to analyse the amount of radiation to which the spine surgeon is exposed in different scenarios. Material and methods: a prospective study with a descriptive, longitudinal non-randomized data source. We carried out this study in the period from 2015 to 2019, the radiologic protection consisted in lead apron, thyroid shield and leaded glasses, there were 10 badge dosimeters. Results: only 4 dosimeters were included in the study, the other six were excluded. During the study period one surgeon suffered thyroid cancer and other suffered of liposarcoma. In the protected group were two surgeons, in the group of aleatory exposition was one surgeon and in the unprotected group was one surgeon. In the study the dosimeter in the unprotected group received more amount of radiation in all the years, we did an inferential analysis per year related with the number of surgeries without significant correlation, we attribute this result because we didn't classified the type of surgery realized by each surgeon. Conclusion: we conclude that the spine surgeon must apply the primary methods of radiological protection and that the unprotected spine surgeon receives more amount of radiation in comparison of the protected ones.

Acute subdural hematoma secondary to sacral arachnoid cyst surgery: a case report / 中华神经科杂志

Sacral cyst usually occurs around the nerve root, which is the accumulation of cerebrospinal fluid between the intima and the perineurium at the junction of the posterior spinal nerve root and the dorsal root ganglion. Its typical clinical manifestations include low back pain, lower limb radiation pain, rectal/bladder dysfunction and so on. Complications of acute subdural hematoma with cerebral hernia after posterior midline cystectomy of sacral cyst are rare. A middle-aged female patient with sacral cyst was admitted to Gansu Provincial Hospital. After the operation, acute subdural hematoma occurred in the right frontoparietal temporal occipital region, and cerebral herniation was formed. After the operation, the patient was given rehabilitation exercise and discharged well. No neurological deficits were observed during follow-up.

Effects of remimazolam tosilate combined with remifentanil anesthesia on hemodynamics, serum IL-1β, CXCL8 levels in elderly patients undergoing spinal surgery / 中国临床药理学与治疗学

AIM: To investigate the anesthetic effect of remimazolam tosilate combined with remifentanil in elderly patients undergoing spinal surgery, and its impacts on hemodynamics, serum interleukin-1β (IL-1β) and C-X-C motif chemokine ligand 8 (CXCL8) level. METHODS: A total of 88 elderly patients who underwent spinal surgery in our hospital from May 2022 to May 2023 were randomly separated into an experimental group and a control group. The control group was given remifentanil, and the experimental group was anesthetized with remimazolam tosilate on the basis of the control group. The anesthesia effect, hemodynamic indicators, serum IL-1β and CXCL8 levels, and complication rate were compared between two groups. RESULTS: After different anesthesia regimens, the recovery time of spontaneous respiration, extubation time, and recovery time of the two groups were compared, and the experimental group were obviously shorter than the control group (P0.05). CONCLUSION: The combined anesthesia of remimazolam tosilate and remifentanil has an ideal effect and high clinical application value for elderly patients undergoing spinal surgery.

Research status of dural injury types and repair / 中国修复重建外科杂志

OBJECTIVE@#To evaluate the current status of classification and repair methods for dural injury caused by spinal surgery or trauma, providing new strategies and ideas for the clinical repair of dural injury and the development of related materials.@*METHODS@#The literature related to dural injury both at home and abroad in recent years was thoroughly reviewed and analyzed in order to draw meaningful conclusions.@*RESULTS@#There have been numerous retrospective studies on dural injury, but there is a scarcity of prospective and multi-center studies, resulting in a low level of evidence-based research. The incidence and risk factors of dural injury have primarily been studied in relation to common degenerative spinal diseases of the cervical and lumbar spine, with insufficient research on thoracic spine-related diseases. Currently, a universally recognized method for grading and classifying dural injury has not been established, which hampers the development of clinical guidelines for their repair. Furthermore, although there are repair materials and surgical strategies available to address clinical issues such as suture leakage and surgical repair of dural injury in complex locations, there is a lack of comprehensive clinical research and evidence-based data to validate their scientificity and reliability.@*CONCLUSION@#Regardless of the classification of dural injury, suture remains the most important repair method. It is important to further develop new patches or sealants that can meet clinical needs and reduce the difficulty of repair.

Effects of in-house made heat preservation socks on body temperature maintenance in elderly patients undergoing spinal surgery / 中华老年医学杂志

Objective:To examine the effects of in-house made heat preservation socks on body temperature maintenance in elderly patients undergoing posterior approach spinal surgery.Methods:This was a randomized, controlled trial.A total of 84 patients aged 65-75 years treated with posterior approach spinal surgery under general anesthesia were enrolled.Patients were randomly divided into two groups: the experimental group(n=42)and the control group(n=42). The two groups were treated with the same anesthesia procedure.The control group was given routine temperature management, while the experimental group used in-house made heat preservation socks in addition to routine temperature management during the entire surgical process.The anal temperature of patients was dynamically monitored with a disposable body temperature probe, and body temperature, heart rate, mean arterial pressure and oxygen saturation were recorded at the time of anesthesia induction and intubation(T 0), skin incision(T 1), 1 hour into surgery(T 2), 2 hours into surgery(T 3), the end of surgery(T 4), arrival at the post-anesthesia care unit(T 5), immediately after extubation(T 6)and 1 hour after extubation(T 7). The occurrence of intraoperative body temperature lower than 36℃, postoperative extubation time, incidence of shivering, postoperative incision infection rate and average length of stay were recorded.Changes in C-reactive protein and procalctonin levels were recorded. Results:There was no significant difference in sex composition, age, height, weight, body mass index and operative time between the two groups(all P>0.05). From T 2 to T 7, the body temperature of the experimental group was higher than that of the control group[T 2: (36.5±0.5)℃ vs.(36.3±0.3)℃, (36.6±0.6)℃ vs.(36.2±0.4)℃, (36.6±0.6)℃ vs.(36.2±0.4)℃, (36.6±0.6)℃ vs.(36.2±0.4)℃, (36.6±0.6)℃ vs.(36.2±0.4)℃, (36.6±0.5)℃ vs.(36.2±0.3)℃, t=2.229, 3.514, 3.823, 3.790, 3.722, 4.408, P=0.029, 0.001, 0.001, 0.001, 0.001, 0.000]. The incidence of intraoperative body temperature lower than 36 ℃ in the control group was higher than that in the experimental group(47.6% vs.21.4%, χ2=6.372, P=0.012). The incidence of postoperative shivering in the experimental group was lower than that in the control group(21.4% vs.59.5%, χ2=12.649, P<0.001). There was no significant difference between the two groups in postoperative incision infection rate, average length of stay and postoperative inflammatory infection indicators(all P>0.05). Conclusions:For elderly patients undergoing posterior spinal surgery, the in-house made heat preservation socks have favorable effects on body temperature maintenance and help reduce the occurrence of hypothermia and postoperative shivering.

Effect of iliac crest on L5-S1 transforaminal puncture and catheterization evaluated by CT scan and 3D reconstruction / 西安交通大学学报(医学版)

【Objective】 To analyze the effect of iliac crest on the difficulty of L5-S1 transforaminal puncture and catheterization by using CT images and oblique sagittal reconstruction images. 【Methods】 We made a retrospective analysis of the CT images and oblique sagittal reconstruction images of the adults aged from 30 to 50 years who underwent abdominopelvic CT examination in Affiliated Hospital of Nantong University. Based on the feasibility of puncture and catheterization， all the subjects were divided into two groups： group Ⅰ （suitable for puncture and catheterization） and group Ⅱ （unsuitable for puncture and catheterization）. We compared and analyzed differences in the rostral puncture inclination angle （α）， the abaxial angle of iliac crest （β）， the distance between the highest iliac crests （a）， the distance between sacroiliac joints （b）， the height of the superior articular process of sacral （c）， the height of iliac crest （d）， and the height of the superior articular process of sacral （c’） in the oblique sagittal images between the two groups. We explored the effect of anatomical indexes and iliac crests in oblique sagittal images on puncture and catheterization. 【Results】 The number of high/low iliac crests for group Ⅰ and group Ⅱ was （117/58 vs. 63/0）， and the number of men/women was 64/111 vs. 56/7， respectively. Variables α， b and c were higher in group Ⅰ than in group Ⅱ （34.77±4.86 vs. 31.11±5.16， P<0.001； 137.19±19.24 vs. 128.56±20.73， P = 0.003； 14.34±2.38 vs. 13.02±2.68， P<0.001）， and d was lower than that in group Ⅱ （27.51±6.73 vs. 37.65±6.35， P<0.001）. In addition， no statistically significant difference was found in the height of c of coronal CT scan and c’ of oblique sagittal reconstruction images （13.99±2.53 vs. 13.93±2.40， P = 0.465）. 【Conclusion】 It is more comprehensive and effective to evaluate preoperatively the influence of iliac crest on L5-S1 puncture and catheterization of TF-PELD by using CT scan and CT 3D reconstruction oblique sagittal images. The key factors in the evaluation of iliac crest are the degree of “cohesion” and the height. It is more easily to successfully puncture and catheterize when the shape of iliac crest is wider and lower. Therefore， it has higher probability to successfully puncture and catheterize in women.

Progress and future prospects of endoscopic spine surgery / 西安交通大学学报(医学版)

Spinal endoscopic surgery is a minimally invasive technique that has developed rapidly in recent years.As spinal endoscopic techniques continue to develop， their indications are expanding and they are beginning to gradually replace traditional open spine surgery.This article compares the differences between various spinal endoscopic procedures and other open and minimally invasive spine procedures， summarizes the current state of development of the main common techniques of spinal endoscopic surgery， and provides an overview of the advantages， disadvantages， and future developments of this technique.

Incidence of Deep Venous Thrombosis and Sickle Cell Disease in Patients Undergoing Spinal Surgery in South Gujarat, India: A Prospective Observational Study

@#Introduction: Our objective of this study was to assess the incidence of Deep Venous Thrombosis in patients including those with sickle cell disease who underwent spine surgery, and also to determine the association of Sickle Cell Disease as a clinical predictor for Deep Venous Thrombosis in spinal surgery patients. Materials and methods: All patients who underwent spinal surgery from January 2016 to October 2016 were included in this study. Detailed history, demographic data, physical findings, pre-operative haematological and radiological investigations were documented. All the patients underwent daily clinical evaluation for clinical signs of Deep Venous Thrombosis and also underwent a post-operative venous Doppler and D-dimer test. Results: Seventy-nine consecutive patients were included in the study with the mean age of 41 years. All patients had normal venous Doppler pre-operatively. A total of 2.5% patients had deep vein thrombosis in bilateral lower limbs while 2 patients (2.5%) had evidence of venous stasis but no thrombosis on Doppler ultrasound done post-operatively. Nine patients (11.4%) were sickle cell positive from which 4 patients showed evidence of Deep Venous Thrombosis or Venous Stasis. D-dimer was positive in 5 (8.3%) patients which included 4 patients with Sickle Cell Disease. Conclusion: This study concludes that Sickle Cell Disease is a risk factor for developing Deep Venous Thrombosis in patients undergoing spinal surgery. The study also concludes the effectiveness of mechanical prophylaxis in preventing Deep Venous Thrombosis and recommends pharmacological prophylaxis after assessing the risk profile or positive Ddimer test.

Subdural hematoma following lumbar spine surgery

Abstract The occurrence of subdural hematomas following lumbar spine surgical procedures is a rare complication, but one with a high burden of morbidity and mortality, and despite an incidence rate of around 1%, it is a complication which must be considered in this group of patients. We present the case of a male patient, in the fourth decade of life, with a history of neurofibromatosis and spastic quadriparesis, who developed an altered state of consciousness following lumbar tumor resection, ending in a coma. A simple cranial CAT showed evidence of an acute right subdural hematoma which had to be drained via a craniotomy. He had an unsatisfactory postoperative course and died in the intensive care unit due to ARDS. The national literature has little information on this complication, therefore we believe that this case is an important contribution to the literature. (Acta Med Colomb 2021; 46. DOI:https://doi.org/10.36104/amc.2021.2094).

Cervical arthroplasty in a professional kick-boxing fighter, 7 years follow-up / Artroplastia cervical en un luchador profesional de kick-boxing, 7 años de seguimiento

Abstract: Spinal surgery in professional athletes is a topic of much discussion. Anterior cervical discectomy and fusion (ACDF) is the standard procedure used by surgeons, and other techniques used to treat athletes includes foraminotomies, laminoplasties and total disc replacement. Total disc replacement is an unusual technique used to treat athletes in general and is becoming a more important issue in full contact sports. This case report illustrates a 34 years old professional fighter that suffered a cervical injury that evolved with cervical axial pain and irradiated pain and numbness. She was submitted to total disc replacement (TDR) at the C5-6 level, returning to competitive sports after and with a seven-year follow-up. To the date she remains symptom free and besides having an anterior foramen, the spine was able to keep movement at that level. TDR may be a safe and trustworthy technique when treating elite athletes.

Resumen: La cirugía de columna en atletas profesionales es un tema de mucha discusión. La discectomía y fusión cervical anterior es el procedimiento estándar utilizado por los cirujanos, y otras técnicas utilizadas para tratar a los atletas incluyen foraminotomías, laminoplastías y reemplazo total de disco. El reemplazo total del disco es una técnica inusual utilizada para tratar a los atletas en general y se está convirtiendo en un tema más importante en los deportes de contacto completo. Este informe de caso ilustra a una luchadora profesional de 34 años que sufrió una lesión cervical que evolucionó con dolor axial cervical y dolor irradiado y entumecimiento. Fue sometida a colocación de prótesis de disco en el nivel C5-6, regresando a los deportes competitivos y con un seguimiento de siete años. Hasta la fecha permanece libre de síntomas y además de tener un foramen anterior, la columna vertebral fue capaz de mantener el movimiento a ese nivel. La cirugía puede ser una técnica segura y confiable cuando se trata a atletas de élite.

Association between smoking and surgical site infection after spine surgery: a meta-analysis / 国际生物医学工程杂志

Objective:To investigate the effect of smoking on surgical site infection (SSI) after spinal surgery, and to provide evidence-based information for preventing the occurrence of SSI after spinal surgery.Methods:Literature searches were independently conducted in PubMed, EMBASE, CNKI, Wanfang and other databases from January 2000 to June 2020 by two researchers. Stata13.0 software was used to analyze the included literatures. Statistical analysis and subgroup analysis were preformed based on different population, research types, and adjustments.Results:44 literatures were finally included, involving 79 601 samples including 3 016 cases in the infected group. Compared with non-smokers, the combined odds ratio ( OR) of SSI in smokers after spinal surgery was 1.45 (95% CI: 1.25~1.68). The results of subgroup analysis showed that the risk of SSI in the yellow population and smokers after spinal surgery was 1.69 times that of the control group (95% CI: 1.35~2.12), and no such association was found in the white population. Smokers in the case-control studies and cohort studies had a higher risk of SSI after spinal surgery than that of the control group. Regardless of whether the effect size was adjusted, smokers had a higher risk of SSI after spinal surgery than that of the control group. Conclusions:This study has the advantages of using the latest data, including more literature, and analyzing ethnicity for the first time. The results show that smokers have a higher risk of SSI after spinal surgery. Clinically, patients should be encouraged to quit smoking to reduce the risk of SSI after spinal surgery. However, when to quit smoking to achieve the maximum benefit still needs further research.

Hemostatic effect of single infusion of tranexamic acid with different loading dose before spinal surgery: a comparative study / 中国输血杂志

【Objective】 To compare the hemostatic effect and safety of single infusion of tranexamic acid with different loading dose before spinal surgery. 【Methods】 150 patients with scoliosis orthopaedic surgery were randomly divided into group C, group H and group L with 50 cases in each group. Before skin incision, group H and group L received intravenous loading dose TXA of 20 mg/kg and 10 mg/kg, respectively, followed by continuous intravenous pumping of TXA of 10 mg/kg/h until the end of the operation. Group C received intravenous infusion of 0.9% sodium chloride injection at the same time. Intraoperative infusion volume, blood loss, red blood cell transfusion volume, urine volume and postoperative drainage volume were recorded. Prothrombin time (PT), activated partial prothrombin time (APTT), D-dimer (D-D), blood platelet count (BPC), hemoglobin (Hb), hematocrit (HCT), tissue plasminogen activator (t-PA) and plasminogen activator inhibitor -1(PAI-1) were detected before and after surgery. Adverse events such as lower extremity deep vein thrombosis (DVT), pulmonary embolism, acute kidney injury (AKI), epilepsy and myocardial infarction were followed. 【Results】 The amount of blood loss and transfusion in group H and group L was lower than that in group C (P0.05), while there was a significant decrease in PAI-1 in group C (P<0.05). B-ultrasonography of both lower limbs showed no DVT formation on 1d, 7d and 28d after surgery, and no adverse events such as pulmonary embolism, AKI, epilepsy and myocardial infarction were found after 28 d follow-up. 【Conclusion】 The application of high load dose of TXA in spinal surgery produces better hemostasis, and it has no effect on the incidence of near and long term postoperative adverse events.

Advances in tissue state recognition in spinal surgery: a review / 医学前沿

Spinal disease is an important cause of cervical discomfort, low back pain, radiating pain in the limbs, and neurogenic intermittent claudication, and its incidence is increasing annually. From the etiological viewpoint, these symptoms are directly caused by the compression of the spinal cord, nerve roots, and blood vessels and are most effectively treated with surgery. Spinal surgeries are primarily performed using two different techniques: spinal canal decompression and internal fixation. In the past, tactile sensation was the primary method used by surgeons to understand the state of the tissue within the operating area. However, this method has several disadvantages because of its subjectivity. Therefore, it has become the focus of spinal surgery research so as to strengthen the objectivity of tissue state recognition, improve the accuracy of safe area location, and avoid surgical injury to tissues. Aside from traditional imaging methods, surgical sensing techniques based on force, bioelectrical impedance, and other methods have been gradually developed and tested in the clinical setting. This article reviews the progress of different tissue state recognition methods in spinal surgery and summarizes their advantages and disadvantages.

Reanimación cardiopulmonar en prono a propósito de un caso / Case report cardiopulmonary resuscitation in prone position

Prone position is necessary for some neurosurgical and othopedic procedures. Cardiopulmonary resuscitation (CPR) in prone position was first described by McNeil in 1989, since then several successful cases have been published. We report the case of a 72-year-old patient with history of stage IV breast cancer who presented acute spinal cord compression due to a vertebral fracture at T10 level. Surgical spinal cord decompression and posterior arthrodesis was performed. After three hours of surgery, cardiorespiratory arrest occur while patient was in prone position. Unestable spine and fixed head made turning the patient into supine position very difficult, consequently prone CPR manoeuvres were started with recovery of spontaneous circulation. In case of cardiorespiratory arrest in prone position, the intense fixation and the extent of the surgical incision make the change to supine a time-consuming and technically complex procedure. If cardiorespiratory arrest occurs in the prone position, CPR in the prone position might be reasonable.

La posición de decúbito prono es necesaria para la realización de algunos procedimientos neuroquirúrgicos y traumatológicos. La reanimación cardiopulmonar (RCP) en prono fue descrita por primera vez por McNeil en 1989, desde entonces se han publicado varios casos de RCP en prono con buen resultado. Presentamos el caso de una paciente de 72 años con antecedentes de carcinoma de mama estadio IV que presenta síndrome de compresión medular por fractura patológica a nivel de T10. Se decide realizar descompresión medular y artrodesis por vía posterior. A las 3 horas de la cirugía se produjo parada cardiorrespiratoria en prono. Dada la inestabilidad espinal y la fijación de la paciente, el cambio a supino era complejo por lo que se iniciaron maniobras de RCP en prono con posterior recuperación de circulación espontánea. En caso de parda cardiorrespiratoria en prono, la intensa fijación y la extensión de la incisión quirúrgica hace que el cambio a supino consuma tiempo y sea técnicamente complejo. Si la PCR ocurre en prono, está justificado iniciar las maniobras de RCP en esta posición.

Infusión intravenosa de ketamina a bajas dosis durante cirugía de artrodesis de columna. Una estrategia en el manejo del dolor agudo posoperatorio / Intravenous ketamine infusión at low doses during spinal arthodesis surgery. A strategy in acute postoperative pain management

INTRODUCTION: Acute postoperative pain is a complex problem given the pathophysiological characteristics, increasing health costs and complications and hindering recovery[1],[2]. Spinal arthrodesis is one of the most painful surgical procedures, presenting intense and disabling pain[3],[4]. Multimodal analgesia has been the tool with the best results, based on opioids; however, the combined use of drugs and dependence on opiates are important consequences. Therefore, the analgesic behavior during the use of subanesthetic doses of ketamine is described in the patients undergoing this procedure. METHODOLOGY: A prospective case series study was conducted from January-December 2019, with patients undergoing spinal arthrodesis who met the inclusion criteria, at the Hernando Moncaleano Perdomo University Hospital, Neiva. A univariate statistical analysis of all the variables is performed, with a joint interpretation of the results. RESULTS: A total of 17 patients underwent surgery, one of whom was excluded due to complications related to the surgical material. 88% of the patients showed evaluations of mild or absent pain in at least 4 times, with a number of morphine rescues in 24 hours of 1-2 per patient and patient ambulation in 90% on the first day. CONCLUSIONS. Postoperative spinal arthrodesis patients receiving intravenous ketamine infusion-based analgesia at subanesthetic doses showed mild or absent pain scores at almost all times.

INTRODUCCIÓN: El dolor agudo postoperatorio es un problema complejo dada las características fisiopatológicas, aumentando los costos en salud y las complicaciones y dificultando la recuperación[1],[2]. La artrodesis de columna, es uno de los procedimientos quirúrgicos más dolorosos, presentando un dolor intenso e incapacitante[3],[4]. La analgesia multimodal ha sido la herramienta con mejores resultados, tomando como base los opioides; sin embargo, el uso combinado de fármacos y la dependencia a opiáceos son consecuencias importantes. Por lo anterior, se describe el comportamiento analgésico durante el uso de dosis subanestésicas de ketamina en los pacientes llevados a dicho procedimiento. METODOLOGÍA: Se realiza un estudio tipo serie de casos, prospectivo de enero-diciembre de 2019, con los pacientes llevados a artrodesis de columna que cumplieron con los criterios de inclusión en el Hospital Universitario Hernando Moncaleano Perdomo, Neiva. Se realiza un análisis estadístico univariado de la totalidad de las variables, con una interpretación conjunta de los resultados. RESULTADOS: Se intervinieron un total de 17 pacientes, uno de los cuales fue excluido por complicaciones relacionadas con el material quirúrgico. El 88% de los pacientes mostraron valoraciones de dolor leve o ausente en al menos 4 tiempos, con número de rescates de morfina en 24 h de 1-2 por paciente y deambulación de los pacientes en el 90% en el primer día. CONCLUSIONES: Los pacientes posoperatorios de artrodesis de columna que recibieron analgesia basada en infusión endovenosa de ketamina a dosis subanestésicas mostraron valoraciones de dolor leve o ausente, en casi todos los tiempos.

Discectomía Endoscópica Lumbar Percutánea: presentación de 110 casos intervenidos en Argentina y revisión de la técnica quirúrgica / Percutaneous Lumbar Endoscopic Discectomy: presentation of 110 operated cases in Argentina and review of the surgical technique

Introducción: La Discectomía Endoscópica Lumbar Percutánea (DELP) es una técnica mínimamente invasiva que se usa en distintos países desde finales de los ochenta para el tratamiento de las Hernias Discales. Objetivo: El propósito del presente artículo es presentar los resultados de la evolución clínica de 110 pacientes operados de distintas hernias discales lumbares por técnica endoscópica percutánea, con seis meses de seguimiento. Asimismo, describir la técnica realizada y los aspectos más relevantes del planning preoperatorio, entre ellos el punto de ingreso percutáneo. Materiales y Métodos: En un grupo de 110 pacientes y 141 discos operados entre abril de 2016 y octubre de 2019, se recogieron datos como la edad, el sexo, la clínica, las imágenes de RMN y el planning del ingreso (Skin Entry Point) con target en el fragmento discal herniado. Se realizó en todos los casos una fragmentectomía dirigida, y luego se complementó con técnica In-Out. Se registró, como dato principal, la diferencia en los puntajes de Oswestry (ODI) pre y postquirúrgico a los 6 meses del procedimiento. También se constató la duración de la operación, el tiempo de hospitalización, y la necesidad de reintervención. Todos los pacientes se operaron despiertos, recibiendo anestesia peridural y sedación. Resultados: Se operaron 110 pacientes y 141 hernias discales. El promedio de reducción en ODI a los 6 meses fue 47,5 puntos (SD=5,7), representando un porcentaje medio de reducción de 85% (SD=9,5). Desde el punto de vista técnico se logró promediar la distancia de línea media al ingreso o Skin Entry Point, según el nivel operado y el abordaje elegido. Conclusión: a la luz de los resultados en nuestra serie de 110 pacientes con hernias discales lumbares, operados despiertos por endoscopía percutánea, se obtuvieron mejorías en el dolor promedio del 85% a seis meses. La técnica endoscópica puede ser considerada como un procedimiento efectivo para pacientes con hernias foraminales, extraforaminales y centrales en los niveles L3L4, L4L5 y L5S1.

Introduction: Introduction: PELD is a minimally invasive technique that has been used in different countries since the late 1980s for the treatment of Herniated Discs. Objective: to describe the surgical method from the Approach point of view and PELD results in a series of 110 patients. Materials and Methods: In a group of 110 patients who together had 141 discs operated on between April 2016 and October 2019, data were collected on patients age and gender, clinical presentation, MRI abnormalities and Skin Entry Point (SEP) with target in the herniated disc fragment. A focused fragmentectomy was performed in all cases, and then it was complemented with an In-Out technique. The main result was the difference in the pre and postoperative Oswestry Disability Index (ODI) scores 6 months after the procedure. The operation duration, the lenght of hospitalization, and the need for reoperation were also recorded. All patients underwent surgery awake, receiving epidural anesthesia and sedation. Results: Respecting the SEP of the endoscope according to the MRI planning focused in the herniated fragment, the evolution of the patients was very favorable. The average reduction in ODI at 6 months was 47.5 points (SD = 5.7), representing an average percentage reduction of 85% (SD = 9.5). The average surgery time was 58 minutes, and the hospitalization time 8.5 hours. Conclusions: In our series of surgical patients with lumbar disc herniations, PELD with focused fragmentectomy in awake patients proved to be a technique with very good results, especially with prior planning of the SEP to achieve effective root decompression

Hipotensión controlada en cirugía espinal / Controlled Hypotension in Spinal Surgery

RESUMEN Introducción: La hipotensión controlada implica a cualquier técnica que, utilizada de forma única o combinada, disminuya intencionalmente los valores de tensión arterial durante el período intraoperatorio, con la finalidad de reducir el sangramiento y mejorar la visibilidad del campo quirúrgico. Objetivo: Describir los fundamentos fisiológicos, definiciones, técnicas y complicaciones de la hipotensión controlada aplicada en la cirugía espinal. Métodos: Se realizó una revisión de la literatura, en bases de datos científicas como Cochrane Database of Systematic Reviews, Pubmed/Medline, EMBASE, SCOPUS, Web of Science, Ebsco Host, ScienceDirect, OVID y el buscador académico Google Scholar, en el mes de junio del 2020. Conclusiones: La hipotensión controlada aplicada en la cirugía espinal presenta limitados beneficios quirúrgicos. Sin embargo, no existe un consenso preciso sobre los umbrales hemodinámicos y límites de tiempo requeridos para su utilización, y se asocia a un elevado riesgo de potenciales complicaciones como el delirium, disfunción cognitiva posoperatoria, accidente cerebrovascular isquémico, pérdida visual posoperatoria, lesión renal aguda, lesión miocárdica, déficit neurológico posoperatorio tardío y dolor neuropático crónico; por lo cual no se recomienda su empleo rutinario durante el período intraoperatorio(AU)

ABSTRACT Introduction: Controlled hypotension implies any technique that, used alone or in combination, intentionally lowers blood pressure values during the intraoperative period, in order to reduce bleeding and improve the visibility of the surgical field. Objective: To describe the physiological foundations, definitions, techniques and complications of controlled hypotension in spinal surgery. Methods: A literature review was carried out in scientific databases such as Cochrane Database of Systematic Reviews, Pubmed/Medline, EMBASE, SCOPUS, Web of Science, Ebsco Host, ScienceDirect, OVID and the academic search engine Google Scholar, in June 2020. Conclusion: Controlled hypotension in spinal surgery has limited surgical benefits. However, there is no precise consensus on the hemodynamic thresholds and time limits required for its use, and it is associated with a high risk of potential complications as delirium, postoperative cognitive dysfunction, ischemic stroke, postoperative visual loss, acute kidney injury, myocardial injury, late postoperative neurological deficit and chronic neuropathic pain; therefore, its routine use during the intraoperative period is not recommended(AU)

Intraoperative intravenous application of tranexamic acid reduces perioperative bleeding in multilevel posterior spinal surgery: A meta-analysis / 中国组织工程研究

OBJECTIVE: Tranexamic acid as a synthetic antifibrinolytic agent has been used in hip replacement, gastrointestinal surgery, neurosurgery, obstetrics and gynecology, cardiac surgery, and various nasal operations to reduce bleeding. In recent years, tranexamic acid has also been used in spinal surgery. Meta-analysis was used to evaluate whether intraoperative intravenous tranexamic acid reduced the incidence of perioperative bleeding and transfusion events in multilevel posterior spinal surgery compared with placebo. METHODS: The randomized controlled trials of tranexamic acid in the use of PubMed, Cochrane Library and EMBASE in multi-segment posterior spinal surgery were searched by computer. Tranexamic acid was used intravenously in the experimental group and placebo was used in the control group. Two reviewers screened all the retrieved literature according to the inclusion and exclusion criteria. The literature quality was evaluated with the modified Jadad scale and meta-analysis was performed with the Review Manager 5.3 software. RESULTS: (1) A total of nine randomized controlled trials were included in this study. The score of the modified Jadad scale showed 7 points in 6 articles, 6 points in 1 article, 4 points in 1 article and 3 points in 1 article. (2) Meta-analysis showed that the amount of postoperative drainage, intraoperative blood loss, intraoperative erythrocyte recovery, incidence of transfusion events, and total perioperative blood loss in the tranexamic acid group were all lower than those in the placebo group [MD=-102.70, 95%CI(-141.25,-64.15), Z=5.22, P 0.05). CONCLUSION: Intravenous tranexamic acid can reduce the total perioperative blood loss, intraoperative blood loss, postoperative drainage, intraoperative erythrocyte recovery and the incidence of transfusion events in posterior spinal multilevel surgery. However, due to the limited quantity and quality of the included studies, the above conclusions still need to be verified by more high-quality large-sample studies.

Meta-analysis of independent risk factors for surgical site infection after spinal surgery / 中国组织工程研究

BACKGROUND: The risk factors of surgical site infection after spinal surgery are diverse and complex. At present, there is still a great controversy on the study of the risk factors of postoperative infection of spine. OBJECTIVE: To systematically evaluate the independent risk factors of surgical site infection after spinal surgery, and to provide theoretical basis for the prevention and treatment of surgical site infection. METHODS: Between January 2004 and June 2019, the Chinese and foreign databases were retrieved. According to the inclusion and exclusion criteria, we collected case-control and cohort studies on independent risk factors for surgical site infection after surgery. After extraction of available data, independent risk factors (hypertension, diabetes, obesity, smoking, history of surgery) for the merger OR value and 95%CI were calculated by using the fixed effect model and random effect model for meta-analysis. The consistency of the results was compared. The reliability of the merge result was analyzed. RESULTS AND CONCLUSION: (1) A total of 19 articles were included, with 1 008 cases of surgical site infection, and the control group contained 7 527 cases. (2) The independent risk factors for merger OR value (95%CI) from high to low in turn were diabetes (OR=3.24, 95%CI: 2.09-5.02), obesity (OR=2.99, 95%CI: 1.77-5.05), surgical history (OR=2.12, 95%CI: 1.79-2.50), hypertension (OR=1.90, 95%CI: 1.34-2.69), and smoking (OR=1.85, 95%CI: 1.39-2.48). (3) Results indicated that diabetes, hypertension, obesity, smoking and surgical history are all independent risk factors for the occurrence of surgical site infection after spinal surgery, and each independent risk factor is positively correlated with the occurrence of surgical site infection after spinal surgery.

Delayed Post-operative Spinal Epidural Haematoma after Posterior Spinal Surgery: Report of Two Cases

@#Delayed post-operative spinal epidural haematoma (DPSEH) is diagnosed when the onset of symptoms is more than three days from the index surgery. DPSEH is a rare but serious complication of spinal surgery. Missed diagnosis will result in irreversible neurological deficit which may lead to permanent disabilities. We report two cases of DPSEH who presented with worsening neurological deficit four days after the index surgery. Magnetic resonance imaging (MRI) showed the presence of an epidural haematoma compressing the spinal cord. Surgical evacuation of haematoma were performed for both patients. Both patients experienced neurological improvement. Surgeons should have high index of suspicion to identify delayed onset of spinal epidural haematoma (SEH) and timely intervention should be taken to avoid irreversible neurological damage.