Optimization of radiation doses for open lumbar spinal fusion using C-arm fluoroscopy and impact on radiation-induced cancer: a pilot study.

PURPOSE: Intraoperative fluoroscopy use is essential during spinal fusion procedures. The amount of radiation dose should always be minimized. This study aimed to determine the feasibility of halving the frame rate from 12.5 to 6.25 frames per second (fps) and to quantify the reduction in the risk of developing radiation-induced cancer. METHODS: This pilot study included 34 consecutive patients operated for open lumbar posterolateral fusion (PLF) with or without transforaminal lumbar interbody fusion (TLIF). C-arm modes were changed from half-dose (12.5 frames per second (fps), group I) to quarter-dose (6.25 fps, group II). Age, body mass index, surgical procedure, number of treated levels, and complications were collected. Kerma area product (KAP), cumulative air kerma (CAK), and fluoroscopy time were compared. Effective dose and radiation-induced cancer risk were estimated. RESULTS: Eighteen and 16 patients were, respectively, included in group I and II. Demographic, surgical data, and fluoroscopy time were similar in both groups. However, CAK, KAP, and effective dose were significantly lower in group II, respectively, 0.56 versus 0.41 mGy (p = 0.03), 0.09 versus 0.06 Gy cm2 (p = 0.04), and 0.03 versus 0.02 mSv (p = 0.04). Radiation-induced cancer risk decreased by 47.7% from 1.49 × 10-6 to 7.77 × 10-7 after optimization. No complications were recorded in either group. CONCLUSION: This study demonstrates the feasibility of setting 6.25 fps for TLIF with and without PLF. By halving the fps, radiation-induced cancer risk could be almost divided by two, without compromising surgical outcome. Finally, after optimization, the risk of developing radiation-induced cancer was less than one in a million.

Individual decontamination measures reduce by two the incidence of surgical site infections in spinal surgery.

BACKGROUND: In spinal surgery, incidence of surgical site infections (SSI) is estimated between 1 and 10%. It results in increased morbidity, mortality and cost of management. Individual Staphylococcus aureus (SA) decolonization has already proved efficiency to prevent those events in various surgical domains. The aim of this study was to evaluate a strategy of prevention of SSI and in particular the decolonization of the nasal carriage of SA by a protocol with Mupirocin application. METHODS: We conducted a bicentric observational study on 5314 spinal surgery patients over a seven-year period. In both center, we compared periods before and after implementation of two measures: modification of antibioprophylaxis and staphylococcus decolonization. Homogeneity of the different samples of patients was assessed through measure of individual and surgical variables. We measured monthly incidence of SSI and evaluated its evolution in order to assess efficiency of these interventions. RESULTS: The incidence of SSI decreased by half, from 7.3% to 3% at the Beaujon Hospital and from 8.3% to 3.9% at the Georges-Pompidou European Hospital (GPEH). We do not observe any significant decrease of SA rate in these SSI. CONCLUSION: We believe that Staphylococcus aureus decolonization should be recommended in spinal surgery, and should be combined with an overall improvement of the quality of care.

Successful 6-Week Antibiotic Treatment for Early Surgical-site Infections in Spinal Surgery.

BACKGROUND: The incidence of spinal surgical site infections (SSIs) remains stable at less than 10%. Surgical reinterventions may be hampered by decubitus, treatment-related adverse events, and cost. In the context of emergence of bacterial resistance, a short duration of antimicrobial treatment is of critical importance. If the duration of treatment for SSI is currently 12 weeks, the aim of our study was to assess the efficacy of an antimicrobial treatment shortened to 6 weeks. METHODS: This prospective study was carried out from November 2014 to July 2016 in an 827-bed teaching hospital. After surgical management of SSIs, patients received broad-spectrum antibiotics intravenously for 10 days and orally for the remainder, for a total of 6 weeks. Success was defined as absence of relapse, superinfection, or surgical failure at the end of treatment and at 1-year follow-up. RESULTS: Eighty-five patients were included in this study. The median delay between initial surgery and diagnosis of SSI was 16 days. In 65 cases (76.4%), SSIs were monomicrobial; among these, Staphylococcus aureus was found in 30 cases (46%). Failure was observed in 7 cases (8.2%), with more than half caused by anaerobic bacteria. CONCLUSIONS: Surgical management of SSI followed by a 6-week antibiotic treatment is associated with favorable outcome. Anaerobic bacteria seem to play a role in the occurrence of relapses. A 6-week reduction in antibiotic treatment leads to reduction in cost and, likely, also to reduction in the emergence and spread of resistant microorganisms.

Intra and inter-observer reliability of determining degree of pelvic obliquity in neuromuscular scoliosis using the EOS-CHAIR® protocol.

PURPOSE: Scoliosis with pelvic obliquity (PO) could be investigated with the EOS-CHAIR protocol as the most common deformity especially in patients with trunk hypotonia and quadriplegia. However, the intra-observer and inter-observer reliability of various angles assessing PO was not investigated with this new imaging protocol. METHODS: A retrospective cohort of 36 EOS frontal full-spine acquisitions made in sitting position was used. The sacroiliac pelvic obliquity angle, iliac crest pelvic obliquity angle, and ischiatic pelvic obliquity angle were assessed in an intra-observer and inter-observer study. RESULTS: The use of the EOS-CHAIR protocol was implemented satisfactory with a high acceptance rate by all caregivers and patients and their families. Intra-observer and inter-observer reliability was excellent for the three tested angular measurements. DISCUSSION: As for idiopathic scoliosis, we postulate the EOS system as being superior to standard radiographs to assess 3D spinal deformities in neuromuscular conditions. The EOS-CHAIR protocol improves preoperative comprehension of the lumbosacral junction anatomy in patients with poor standing or sitting postures. Our results show a very high reliability of three different angular measurements of the frontal pelvic obliquity in sitting position. Then it is possible to use one of these three angles as well as the others to assess frontal pelvic obliquity in neuromuscular patients. This frontal pelvic obliquity protocol in sitting position with the EOS-CHAIR is a validated measurement technique that needs to be used now to measure PO as a critical parameter of the global trunk balance in neuromuscular patients.