Patient Positioning in Spine Surgery: What Spine Surgeons Should Know?

Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.

How to start an awake spine program: Protocol and illustrative cases.

Surgical techniques and technology are steadily improving, thereby expanding the pool of patients amenable for spine surgery. The growing and aging population in the United States further contributes to the increase in spine surgery cases. Traditionally, spine surgery is performed under general anesthesia. However, awake spinal surgery has recently gained traction due to evidence of decreased perioperative risks, postoperative opioid consumption, and costs, specifically in lumbar spine procedures. Despite the potential for improving outcomes, awake spine surgery has received resistance and has yet to become adopted at many healthcare systems. We aim to provide the fundamental steps in facilitating the initiation of awake spine surgery programs. We also present case reports of two patients who underwent awake spine surgery and reported improved clinical outcomes.

Enhanced recovery after surgery (ERAS) protocol in spine surgery.

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.

Perioperative outcomes of general versus spinal anesthesia in the lumbar spine surgery population: A systematic review and meta-analysis of data from 2005 through 2021.

Study design: Meta-analysis. Objectives: Perform a systematic review and meta-analysis to determine the perioperative utility of general versus spinal anesthesia in the lumbar spine surgery population. Methods: PubMed and Embase were queried for manuscripts reporting perioperative outcomes for patients undergoing one to three-level lumbar spine surgery (including decompression, fusion, and decompression with fusion) using either general or spinal anesthesia. Inclusion criteria included studies published from 2005 to 2021, in English, involving primary data from human subjects. Studies were further screened for data on total operative time, blood loss, intraoperative hypotension, pain scores, postoperative nausea and vomiting, time required in post-anesthesia care unit (PACU), PACU pain anesthetic requirement, and length of stay. Risk of bias for each study was assessed using standardized tools (i.e., RoB 2, ROBINS-I, NOS, as appropriate). Potential predictors of outcome were compared using univariate analysis, and variables potentially associated with outcome were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to produce standard mean differences (SMD) or odds ratios (OR) and 95% confidence intervals (CI). Results: In total, 12 studies totaling 2796 patients met inclusion criteria. 1414 (50.6%) and 1382 (49.4%) patients underwent lumbar spine surgery with general anesthesia and spinal anesthesia, respectively. Patients undergoing spinal anesthesia were statistically more likely to have coronary artery disease and respiratory dysfunction. Total operative time (SMD: 12.62 min, 95% CI -18.65 to -6.59), estimated blood loss (SMD: 0.57 mL, 95% CI -0.68 to -0.46), postoperative nausea and vomiting (OR = 0.20, 95% CI 0.15 to 0.26), time required in PACU (SMD = -0.20 min, 95% CI -0.32 to -0.08), and length of stay (SMD = -0.14 day, 95% CI -0.18 to -0.10), all statistically significantly favored spinal anesthesia over general anesthesia (p < 0.05). Conclusion: In one to three-level lumbar spine surgery, current literature supports spinal anesthesia as a viable alternative to general anesthesia. As this was a heterogeneous patient population, prospective randomized trials are needed to corroborate findings.

Regional Anesthesia for Spine Surgery.

Current advancements in spine surgery have led to a recent interest in regional anesthesia for spine surgery. Spinal anesthesia, epidural anesthesia, and their combination are commonly used modalities for regional anesthesia in spine surgeries. The successful use of regional anesthesia has led to the emergence of several new concepts such as awake spinal fusion and outpatient spinal surgery. Regarding analgesic techniques, several new modalities have been described recently such as erector spinae and thoracolumbar interfascial plane blocks. These regional analgesic modalities are aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. This narrative review focuses on the techniques, indications and contraindications, benefits, and complications of regional anesthesia in the context of spine surgery.

Awake Spinal Fusion.

¼: Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints. ¼: ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia. ¼: The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia.

Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery.

INTRODUCTION: Spinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies, discectomies, and microdiscectomies. However, the use of SA in spinal fusion surgery has been very scarcely documented in the current literature. Here we present a comparison of SA to GA in lumbar fusion surgery in terms of perioperative outcomes and cost. METHODS: The authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015 to 2018. Data collected included demographics, operative and recovery times, nausea/vomiting, postoperative pain, and opioid requirement. Costs were included in the analysis if they were: 1) non-fixed; 2) incurred in the operating room (OR); and 3) directly related to patient care. All cost data represents net costs and was obtained from the hospital revenue cycle team. Patients were grouped for statistical analysis based on anesthetic modality. RESULTS: A total of 29 patients received SA and 46 received GA. Both groups were similar in terms of age, gender, BMI, number of levels operated upon, preoperative diagnosis, and medical comorbidities. The SA group spent less time in the OR (163.86 ± 9.02 vs. 195.63 ± 11.27 min, p < 0.05), PACU (82.00 ± 7.17 vs. 102.98 ± 8.46 min, p < 0.05), and under anesthesia (175.03 ± 9.31 vs. 204.98 ± 10.15 min, p < 0.05) than the GA group. Post-surgery OR time was significantly less with SA than with GA (6.00 ± 1.09 vs. 17.26 ± 3.05 min, p < 0.05); however, pre-surgery OR time was similar between groups (50.17 ± 3.08 vs. 56.17 ± 5.34 min, p = 0.061). The SA group also experienced less maximum postoperative pain (3.31 ± 1.41 out of 10 vs. 5.96 ± 0.84/10, p < 0.05) and required less opioid analgesics (2.38 ± 1.37 vs. 5.39 ± 0.84 doses, p < 0.05). Both groups experienced similar nausea or vomiting rates and adverse events postoperatively. Net operative cost was found to be $812.31 (5.6%) less with SA than with GA, although this difference was not significant (p = 0.225). DISCUSSION/CONCLUSION: To our knowledge, SA is almost never used in lumbar fusion, and a cost-effectiveness comparison with GA has not been recorded. In this retrospective study, we demonstrate that the use of SA in lumbar fusion surgery leads to significantly shorter operative and recovery times, less postoperative pain and opioid usage, and slight cost savings over GA. Thus, we conclude that this anesthetic modality represents a safe and cost-effective alternative to GA in lumbar fusion.

Regional Anesthesia for Spine Surgery.

Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. In this narrative review we discuss the characteristics of regional anesthesia including its types, indications, contraindications, benefits, and potential complications along with new modalities of regional analgesia.

Awake spinal fusion.

'Awake spinal fusion' is a novel approach to spine surgery that combines modern anaesthetic and surgical technique resulting in improved patient satisfaction and overall outcomes. Along with techniques of regional anaesthesia, minimally invasive or endoscopic surgical techniques are used to minimize surgical dissection and blood loss. Although, it is a relatively new concept with limited supporting evidence till date, it may prove to be highly effective in reducing post-operative hospital stays, in-hospital complications and cost of surgery while at the same time expediting recovery and rehabilitation. The current review focuses on techniques, advantages, limitations and the available evidence on awake spinal fusion.

Biogenic Silver Nanoparticles Decorated with Methylene Blue Potentiated the Photodynamic Inactivation of Pseudomonas aeruginosa and Staphylococcus aureus.

The persistence of multidrug resistance among microorganisms has directed a mandate towards a hunt for the development of alternative therapeutic modalities. In this context, antimicrobial photodynamic therapy (aPDT) is sprouted as a novel strategy to mitigate biofilms and planktonic cells of pathogens. Nanoparticles (NPs) are reported with unique intrinsic and antimicrobial properties. Therefore, silver NPs (AgNPs) were investigated in this study to determine their ability to potentiate the aPDT of photosensitizer against Staphylococcus aureus and Pseudomonas aeruginosa. Biologically synthesized AgNPs were surface coated with methylene blue (MB) and studied for their aPDT against planktonic cells and biofilms of bacteria. The nano-conjugates (MB-AgNPs) were characterized for their size, shape and coated materials. MB-AgNPs showed significant phototoxicity against both forms of test bacteria and no toxicity was observed in the dark. Moreover, activity of MB-AgNPs was comparatively higher than that of the free MB, which concludes that MB-AgNPs could be an excellent alternative to combat antibiotic resistant bacteria.

Antimicrobial photodynamic therapy on Staphylococcus aureus and Escherichia coli using malachite green encapsulated mesoporous silica nanoparticles: an in vitro study.

BACKGROUND: Rise in the number of healthcare associated or hospital acquired infections is a major problem affecting the global healthcare sector. We evaluated superior antibacterial and antibiofilm photodynamic therapy (aPDT) using malachite green encapsulated mesoporous silica nanoparticles (MG-MSN) against Staphylococcus aureus and Escherichia coli, which are known to be major causative agents of nosocomial infections. METHODS: Malachite green (MG) was encapsulated on mesoporous silica nanoparticles (MSN). Fourier-transform infrared spectroscopy, Transmission electron microscopy, and spectroscopic analysis were performed to characterize the MG-MSN. The antimicrobial efficacies of MSN, MG, and MG-MSN were investigated and the results were recorded. RESULTS: MG-MSN was effective against both the tested bacteria. S. aureus was more phototoxic to MG-MSN compared to E. coli. The antibiofilm efficacy of MG-MSN on E. coli and S. aureus was also studied. Biofilm inhibition was 65.68 ± 2.62% in E. coli and 79.66 ± 3.82% in S. aureus. Cell viability assay, exopolysaccharides quantification, and confocal laser scanning microscopy studies also revealed the enhanced antibiofilm activity of MG-MSN when used as a potential photosensitizer for aPDT. This study can be extended to eradicate these strains from localized superficial infections and medical appliances, preventing nosocomial infections.

Malachite green-conjugated multi-walled carbon nanotubes potentiate antimicrobial photodynamic inactivation of planktonic cells and biofilms of Pseudomonas aeruginosa and Staphylococcus aureus.

Purpose: Infections associated with medical devices that are caused by biofilms remain a considerable challenge for health care systems owing to their multidrug resistance patterns. Biofilms of Pseudomonas aeruginosa and Staphylococcus aureus can result in life-threatening situations which are tough to eliminate by traditional methods. Antimicrobial photodynamic inactivation (aPDT) constitutes an alternative method of killing deadly pathogens and their biofilms using reactive oxygen species (ROS). This study investigated the efficacy of enhanced in vitro aPDT of P. aeruginosa and S. aureus using malachite green conjugated to carboxyl-functionalized multi-walled carbon nanotubes (MGCNT). Both the planktonic cells and biofilms of test bacteria were demonstrated to be susceptible to the MGCNT conjugate. These MGCNT conjugates may thus be employed as a facile strategy for designing antibacterial and anti-biofilm coatings to prevent the infections associated with medical devices. Methods: Conjugation of the cationic dye malachite green to carbon nanotube was studied by UV-visible spectroscopy, high-resolution transmission electron microscopy, and Fourier transform infrared spectrometry. P. aeruginosa and S. aureus photodestruction were studied using MGCNT conjugate irradiated for 3 mins with a red laser of wavelength 660 nm and radiant exposure of 58.49 J cm-2. Results: Upon MGCNT treatment, S. aureus and P. aeruginosa were reduced by 5.16 and 5.55 log10 , respectively. Compared to free dye, treatment with MGCNT afforded improved phototoxicity against test bacteria, concomitant with greater ROS production. The results revealed improved biofilm inhibition, exopolysaccharide inhibition, and reduced cell viability in test bacteria treated with MGCNT conjugate. P. aeruginosa and S. aureus biofilms were considerably reduced to 60.20±2.48% and 67.59±3.53%, respectively. Enhanced relative MGCNT phototoxicity in test bacteria was confirmed using confocal laser scanning microscopy. Conclusion: The findings indicated that MGCNT conjugate could be useful to eliminate the biofilms formed on medical devices by S. aureus and P. aeruginosa.

An Analysis of the Cost-Effectiveness of Spinal Versus General Anesthesia for Lumbar Spine Surgery in Various Hospital Settings.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To determine the relative cost-effectiveness of spinal anesthesia and general anesthesia for lumbar laminectomy and microdiscectomy surgery performed in an academic versus private practice hospital setting. METHODS: The authors retrospectively reviewed charts of 188 consecutive patients who underwent lumbar laminectomy or microdiscectomy by a single surgeon from 2012 to 2016 at either an academic or a private practice hospital setting. Intraoperative and postoperative outcomes were recorded and direct variable costs were calculated. RESULTS: At the academic institution, the direct cost of a lumbar laminectomy or microdiscectomy surgery under general anesthesia was determined to be 9.93% greater than with spinal anesthesia (P = .040). The greatest difference was seen with operating room costs, in which general anesthesia was associated with 18.74% greater costs than spinal anesthesia (P = .016). There was no significant difference in cost at the private practice hospital setting. CONCLUSIONS: We conclude that use of spinal anesthesia for lumbar laminectomy leads to less operating room, postanesthesia care unit, and anesthesia times, lower levels of postoperative pain, and no increased rate of other complications compared with general anesthesia at an academic institution as compared to a private practice setting. Spinal anesthesia is 9.93% less expensive than general anesthesia, indicating substantial cost-saving potential. With no sacrifice of patient outcomes and the added benefit of less pain and recovery time, Spinal anesthesia represents a more cost-effective alternative to general anesthesia in lumbar spine surgery in the academic hospital setting.

Antimicrobial photodynamic activity of toluidine blue-carbon nanotube conjugate against Pseudomonas aeruginosa and Staphylococcus aureus - Understanding the mechanism of action.

BACKGROUND: The emergence of drug-resistant bacterial strains has raised the need to develop alternative treatment modalities to combat infectious diseases. Antimicrobial photodynamic therapy (aPDT) is an alternative to conventional treatment modalities. aPDT integrates a photosensitizer, which, after exposure to light of an appropriate wavelength, leads to the generation of cytotoxic reactive oxygen species (ROS). METHODS: The aim of the present study was to synthesize a toluidine blue/multiwalled carbon nanotube conjugate (TBCNT) for enhanced photoinactivation of Pseudomonas aeruginosa and Staphylococcus aureus. Synthesized TBCNT conjugate was characterized and its antibacterial and antibiofilm activity was determined. RESULTS: During TBCNT synthesis, dye loading, and entrapment efficiency of the CNT were 12.04 ±â€¯0.55% and 48.99 ±â€¯2.33%, respectively. The photo-destruction of planktonic cells of the test bacteria was performed by exposure to a 125 mW red laser with a wavelength of 670 nm (radiant exposure of 58.49 J/cm2) for 3 min. Photoinactivation using TBCNT resulted in a 4.91- and 5.47-log10 reduction in P. aeruginosa and S. aureus, respectively. The mechanism of this aPDT was studied by measuring intracellular ROS generation, protein leakage, and lipid peroxidation in the test bacteria after light irradiation. The antibiofilm activity of TBCNT after light exposure was 69.94% and 75.54% for P. aeruginosa and S. aureus, respectively. Photoinactivation of test bacteria treated with TBCNT reduced cell viability and exopolysaccharide production. Confocal laser-scanning microscopy revealed a significant biofilm inhibition efficacy of the TBCNT conjugate. CONCLUSION: Therefore, TBCNT conjugates may be used for the eradication of P. aeruginosa and S. aureus biofilms.

Antimicrobial photodynamic activity of toluidine blue encapsulated in mesoporous silica nanoparticles against Pseudomonas aeruginosa and Staphylococcus aureus.

In the present study, the antimicrobial and antibiofilm efficacy of toluidine blue (TB) encapsulated in mesoporous silica nanoparticles (MSN) was investigated against Pseudomonas aeruginosa and Staphylococcus aureus treated with antimicrobial photodynamic therapy (aPDT) using a red diode laser 670 nm wavelength, 97.65 J cm-2 radiant exposure, 5 min). Physico-chemical techniques (UV-visible (UV-vis) absorption, photoluminescence emission, excitation, and FTIR) and high-resolution transmission electron microscopy (HR-TEM) were employed to characterize the conjugate of TB encapsulated in MSN (TB MSN). TB MSN showed maximum antimicrobial activities corresponding to 5.03 and 5.56 log CFU ml-1 reductions against P. aeruginosa and S. aureus, respectively, whereas samples treated with TB alone showed 2.36 and 2.66 log CFU ml-1 reductions. Anti-biofilm studies confirmed that TB MSN effectively inhibits biofilm formation and production of extracellular polymeric substances by P. aeruginosa and S. aureus.

The Prevalence of Asymptomatic Cervical and Lumbar Facet Arthropathy: A Computed Tomography Study.

STUDY DESIGN: Case control study. PURPOSE: To determine the prevalence and degree of asymptomatic cervical and lumbar facet joint arthritis. We retrospectively reviewed 500 computed tomography (CT) scans of cervical facet joints obtained from 50 subjects. Moreover, 500 lumbar facet joints obtained from an additional 50 subjects were reviewed. OVERVIEW OF LITERATURE: Numerous reports in the literature indicate that joint arthritis is a major source of axial neck and low back pain. However, the diagnostic value of this condition, based on degenerative changes seen on radiological studies, remains controversial because significant imaging findings may not correlate with corresponding symptoms. The CT scan is a sensitive method for facet joint evaluation and may reveal degenerative abnormalities. Previous studies have described the prevalence of facet arthropathy in symptomatic patients, according to radiological findings; however, no study to date has assessed its prevalence in asymptomatic patients. METHODS: We retrospectively reviewed the neck and abdominal CT scans of patients had been examined for non-spinal pathologies (i.e., thyroid disease, rule out cancer, ascites). Electronic medical records were reviewed to exclude patients with histories of either neck or back pain. Arthritis severity was graded using a previously published four-point CT scale. RESULTS: The prevalence of asymptomatic cervical facet arthritis (grade 1-3) was 33% (grade 1, 19%; grade 2, 11%; and grade 3, 3%). Among asymptomatic patients, 37% had scalable lumbar facet join arthritis (grade 1, 24%; grade 2, 9%; and grade 3, 4%). There was a statistically significant difference (chi-square test, p<0.0001) in the number of older individuals with arthritic degeneration at the cervical and lumbar levels compared with that of younger individuals. The C6-C7 and L5-S1 levels were the most likely to show arthritic changes. CONCLUSIONS: Arthritic changes to the cervical and lumbar facet joints are prevalent among patients, and in some cases are asymptomatic. These findings were more common in older patients and at lower spinal levels.

Correction: Synthesis and antimicrobial photodynamic effect of methylene blue conjugated carbon nanotubes on E. coli and S. aureus.

Correction for 'Synthesis and antimicrobial photodynamic effect of methylene blue conjugated carbon nanotubes on E. coli and S. aureus' by Paramanantham Parasuraman et al., Photochem. Photobiol. Sci., 2019, DOI: 10.1039/c8pp00369f.

Synthesis and antimicrobial photodynamic effect of methylene blue conjugated carbon nanotubes on E. coli and S. aureus.

Catheter-related bloodstream infections (CRBSIs) are one of the leading causes of high morbidity and mortality in hospitalized patients. The proper management, prevention and treatment of CRBSIs rely on the understanding of these highly resistant bacterial infections. The emergence of such a challenge to public health has resulted in the development of an alternative antimicrobial strategy called antimicrobial photodynamic therapy (aPDT). In the presence of a photosensitizer (PS), light of the appropriate wavelength, and molecular oxygen, aPDT generates reactive oxygen species (ROS) which lead to microbial cell death and cell damage. We investigated the enhanced antibacterial and antibiofilm activities of methylene blue conjugated carbon nanotubes (MBCNTs) on biofilms of E. coli and S. aureus using a laser light source at 670 nm with radiant exposure of 58.49 J cm-2. Photodynamic inactivation in test cultures showed 4.86 and 5.55 log10 reductions in E. coli and S. aureus, respectively. Biofilm inhibition assays, cell viability assays and EPS reduction assays showed higher inhibition in S. aureus than in E. coli, suggesting that pronounced ROS generation occurred due to photodynamic therapy in S. aureus. Results from a study into the mechanism of action proved that the cell membrane is the main target for photodynamic inactivation. Comparatively higher photodynamic inactivation was observed in Gram positive bacteria due to the increased production of free radicals inside these cells. From this study, we conclude that MBCNT can be used as a promising nanocomposite for the eradication of dangerous pathogens on medical devices.

Antimicrobial photodynamic activity of rose bengal conjugated multi walled carbon nanotubes against planktonic cells and biofilm of Escherichia coli.

BACKGROUND: The global threat of antimicrobial resistance especially due to the bacterial biofilms has engaged researchers in the search of new treatment modalities. Antimicrobial photodynamic inactivation (aPDI) is one of the alternative treatment modalities which kills bacteria by generating endogenous reactive oxygen species (ROS). In this work authors evaluated the antibacterial and antibiofilm efficacy of rose Bengal (RB) conjugated to CNT against E. coli. METHODS: The interaction of anionic dye to the CNT was studied using UV-vis spectroscopy, HRTEM, FTIR and spectrofluorometry. Phototoxicity of RBCNT conjugate against E. coli was studied using a green light of 50 mW and radiant exposure of 1674.7 J/ cm2 for 10 min. The antibiofilm activity and mechanism of action of RBCNT conjugate in presence of light was evaluated. RESULTS: The loading and encapsulation was found to be 15.46 ± 1.05 and 61.85 ± 4.23% respectively. The photodynamic inactivation of planktonic cells of E. coli was found to 5.46 and 3.56 log10 CFU/ml reduction on treatment with RBCNT and RB respectively. The conjugate also exhibited efficient and enhanced antibiofilm activity against E. coli. The study of mechanism of action has confirmed cell membrane and DNA damage were the two main targets of aPDI. CONCLUSION: This report has concluded the efficient photodynamic inactivation occurred in Gram negative bacteria E. coli due to the increased production of ROS inside the bacterial cells. Hence, the newly synthesized RBCNT conjugate can be efficiently utilized to control infections caused by E. coli.