Efficacy of antifibrinolytic agents on surgical bleeding and transfusion requirements in spine surgery: a meta-analysis.

PURPOSE: Spine surgery is usually associated with large amount of blood loss and blood transfusion. Excessive blood loss may cause hypotension, inadequate oxygenation of organs, necessitate allogeneic blood transfusion, and spinal epidural hematoma formation. Aprotinin, TXA, and EACA are antifibrinolytics currently offered as prophylactic agents to reduce surgery-associated blood loss. The purpose of this study was to assess the efficacy of using antifibrinolytic agents in reducing blood loss and blood transfusions in spine surgery. METHODS: PubMed, Embase, and Cochrane-controlled trials register were used to identify RCTs published before April 2015 that examined the effectiveness of intravenous aprotinin, tranexamic acid (TXA), and epsilon-aminocaproic acid (EACA) on reduction of blood loss and blood transfusions, compared with placebo in spine surgery. Randomized controlled trials reported the primary outcome that included total blood loss, intra-operative blood loss, post-operative blood loss, blood transfusion requirements, blood transfusion rate, and incidence of deep vein thrombosis. Meta-analysis was performed using the Stata12.0. Weighted mean difference with 95 % confidence intervals was used to summarize the findings across the trials for continuous outcomes. Dichotomous data were expressed as risk ratios with 95 % confidence intervals. A P < 0.05 was considered statistically significant. RESULTS: 17 studies involving 1191 patients were identified. Among them, 13 RCTs with 943 patients were included for the evaluation of total blood loss. Compared with the control group, the antifibrinolytic agents reduced total blood loss (SMD = -0.62; 95 % CI -0.75, -0.48; P = 0.000), The aprotinin group (SMD = -0.80; 95 % CI -1.22, -0.37; P = 0.938), The TXA group (SMD = -0.75; 95 % CI -0.93, -0.57; P = 0.000), and the EACA group (SMD = -0.28; 95 % CI -0.54, -0.01; P = 0.185). Thirteen RCTs with eight hundred and ninety four patients were included for the evaluation of intra-operative blood loss. Compared with the control group, the antifibrinolytic agents reduced intra-operative blood loss (SMD = -0.41; 95 % CI -0.55, -0.28; P = 0.010), The aprotinin group (SMD = -0.62; 95 % CI -0.93, -0.30; P = 0.862), The TXA group (SMD = -0.47; 95 % CI -0.64, -0.29; P = 0.005), and the EACA group (SMD = -0.16; 95 % CI -0.42, -0.11; P = 0.897). Eight RCTs with six hundred and seven patients were included for the evaluation of post-operative blood loss. Compared with the control group, the antifibrinolytic agents reduced post-operative blood loss (SMD = -0.68; 95 % CI -0.85, -0.51; P = 0.000), the aprotinin group (SMD = -0.48; 95 % CI -0.85, -0.12; P = 0.036), the TXA group (SMD = -0.80; 95 % CI -1.01, -0.59; P = 0.000), and the EACA group (SMD = -0.32; 95 % CI -0.68, -0.04; P = 0.009). Ten RCTs with seven hundred and twenty twopatients were included for the evaluation of blood transfusion. Compared with the control group, the antifibrinolytic agents reduced blood transfusion (SMD = -0.68; 95 % CI -0.85, -0.51; P = 0.000), the aprotinin group (SMD = -0.80; 95 % CI -1.22, -0.37; P = 0.938), the TXA group (SMD = -0.38; 95 % CI -0.58, -0.18; P = 0.000), and the EACA group (SMD = -0.28; 95 % CI -0.54, -0.01; P = 0.185). Twelve RCTs with eight hundred and fifteenpatients were included for the evaluation of blood transfusion rate. The transfusion rate was 35.6 % in the patients with antifibrinolytic agents and 55.2 % in the patients with placebo (RR = 0.75; 95 % CI 0.63, 0.89; P = 0.939). All studies were included for the evaluation of safety, with a total of eight thromboembolic events reported overall (two in the experimental group and six in the control group). CONCLUSIONS: The antifibrinolytic agents were able to reduce perioperative blood loss and transfusion requirements in spine surgery. TXA appeared more effective than aprotinin and EACA in reducing total blood loss, intra-operative blood loss, and blood transfusion according to the results of this analysis. The three groups in reducing the post-operative blood loss are significantly better than control groups. There was no evidence that the use of antifibrinolytic agents was a risk factor for thromboembolism in spine surgery. Further multicenter, large-sample, double-blind RCTs are required to confirm the efficacy and safety of the three antifibrinolytic agents in spine surgery.

Expansion Open-door Laminoplasty With Foraminotomy Versus Anterior Cervical Discectomy and Fusion for Coexisting Multilevel Cervical Myelopathy and Unilateral Radiculopathy.

STUDY DESIGN: This was a clinical prospective study. OBJECTIVE: To assess whether clinical and radiologic outcomes differ between expansion open-door laminoplasty with foraminotomy (EOLF) and anterior cervical discectomy and fusion (ACDF) in the treatment of coexisting multilevel cervical myelopathy and unilateral radiculopathy (CMUR). SUMMARY OF BACKGROUND DATA: No reports to date have compared clinical outcomes between anterior and posterior decompression for CMUR. MATERIALS AND METHODS: We prospectively performed ACDF (n=59) in 2004, 2006, and 2008 and EOLF (n=62) in 2005, 2007, and 2009. The Japanese Orthopedic Association (JOA) score and recovery rate were evaluated. For radiographic evaluation, the lordotic angle and range of motion at C2-C7 were investigated. RESULTS: Only 110 patients could be followed for >3 years (EOLF/ACDF: 56/54; follow-up rate, 90.9%). Demographics were similar between the 2 groups. Compared with ACDF, in EOLF group there were shorter operating time (144 vs. 178 min), less bleeding (175 vs. 192 mL), and fewer complications (P<0.05). Results of JOA score and recovery rate, at 3-year postoperative follow-up, showed no statistical difference for the 2 groups. Cervical lordosis of ACDF increased from 13.7 to 16.2 degrees, whereas that of EOLF group decreased from 14.6 to 13.3 degrees (P<0.05). The percentage of range of motion declined in the 2 groups (ACDF/EOLF), 57.4% versus 74.7% (P<0.05). CONCLUSIONS: The 2 surgical procedures have similar clinical effects in treating multisegmental CMUR. However, the EOLF group demonstrated shorter operative time, less blood loss, and fewer complications; therefore, it proved to be a more effective and safer method.

[The analysis of prognostic factors in patients with thoracic ossification of the ligamentum flavum and thoracic ossification of posterior longitudinal ligament by posterior decompression].

OBJECTIVE: To investigate the prognostic factors for patients with thoracic ossification of the ligamentum flavum (OLF) and thoracic ossification of posterior longitudinal ligament (OPLL). METHODS: Clinical information of 83 patients suffering from thoracic OLF and OPLL was reviewed retrospectively from January 2006 to June 2010. The related factors such as gender, age, preoperative and postoperative Japanese Orthopedic Association (JOA) score, pathological segment, type of thoracic OPLL, degree of thoracic kyphosis, anteroposterior diameter of OPLL, range of circumferential decompression, cerebrospinal fluid leakage or not and dysfunction or not and carotid lumbar disorders or not were analyzed by Chi-square and Logistic regression. RESULTS: All cases were classified into desirable group (58 cases) and undesirable group (25 cases) based on the postoperative JOA score improvement rate. Comparison of physical characteristics between two groups of age, preoperative JOA and the course of the disease had not statistically significant (P > 0.05). Two groups in pathological segment of thoracic OPLL (χ(2) = 6.290, P = 0.043), the ossification type of OPLL (χ(2) = 5.361, P = 0.021) and dysfunction or not in preoperative (χ(2) = 27.711, P = 0.000) had significant difference. Logistic regression analysis showed that the upper thoracic segments (P = 0.044), beak type ossification (P = 0.023) and with dysfunction in preoperative (P = 0.009) were risk factors. There were 24 patients (28.9%) with cerebrospinal fluid leakage, 3 patients with early postoperative deep infection and neurological deterioration of 2 cases in postoperative. CONCLUSIONS: Patients with ossification on the upper section of thoracic have a better prognosis, but the beaked localized longitudinal ligament ossification in patients and associated with preoperative dysfunction show a poor prognosis, combined jumping segmental ossification and cervical or lumbar severe disorders are the influencing factor for poor prognosis.

[Distribution patterns of PAHs in soils from coking plant and the particle-size cut points of soil washing].

Soil particle size distribution and contaminants distribution patterns in different soil size fractions are the basis of soil treatability using soil washing method. Soil particle-size cut points are important parameters of soil washing process. According to ex situ soil washing technology, soil samples were collected in a former coking plant. The soil particle size distribution and the concentrations of 16 polycyclic aromatic hydrocarbons (PAHs) in USEPA priority list were analyzed. Tween 80 and Triton X-100 solutions were used to clean the polluted soil with different particle size. Results showed that the total concentrations of 16 PAHs ranged from 6.27 to 40.18 mg/kg dry weight in the six soil size fractions and present a bimodal distribution. The maximum individual PAH concentration mostly occurred in the 250-500 microm size fraction. The lowest individual PAH concentration was in the 50-75 microm size fraction. The removal efficiencies of PAHs in different soil size fractions depended on their initial concentrations and the characteristics of soil. The PAHs removal efficiencies in coarser size fractions were lower than that in the finer size fractions owing to their higher organic carbon content. Based on the removal efficiency of PAHs in each soil size fractions by surfactant solution and the requirements of waste volume reduction, 50 microm was determined as the particle-size cut point. Then, 82.95% volume reduction can be achieved.

[Bone turnover markers in the detection of bone metastases in primary lung cancer].

OBJECTIVE: To study which markers can be applied to monitor the presence of the bone metastases in primary lung cancer without bone lesion during the follow-up period. METHODS: Based on the criteria for inclusion, we screened and selected 10 cases of lung cancer with bone metastases, 10 cases of lung cancer without bone metastases and 10 healthy subjects. Then we measured their serum bone alkaline phosphatases (bALP) by chemiluminescence immunoassay, their serum beta-carboxyterminal telopeptide of type I collagen (sCTX) and their serum N-terminal midfragment osteoclacin (N-MID) by electro-chemiluminescence immunoassay, and their serum total alkaline phosphatases (tALP) by flurorescence enzyme immunoassay. RESULTS: The individuality indices (II) of all biochemical markers were less than 0.6 in the healthy group and the primary lung cancer without bone metastases group. sCTX was the marker showing the highest critical difference (CD) in these groups, whereas N-MID was the marker displaying the lowest CD. Comparison on the means of these markers between the healthy group and the primary lung cancer without bone metastases group showed that P value for N-MID, tALP, bALP and sCTX was higher than 0.05. The means of these markers between the primary lung cancer without bone metastases group and the primary lung cancer with bone metastases group showed that the P value for N-MID was 0.08, and the P values for tALP, bALP and sCTX were less than 0.05. CONCLUSION: These results support the use of bALP and sCTX as a tool to follow up the lung cancer patients without bone metastases in order to monitor the presence or absence of bone metastases.