Use of a problem-based learning discussion format to teach anesthesiology residents research fundamentals.

STUDY OBJECTIVE: To present a new research problem-based learning discussion (PBLD) conference and to evaluate its effect on residents. DESIGN: Retrospective observational study of resident education before and after implementation of a research PBLD. SETTING: Large U.S. academic anesthesiology department. SUBJECTS: 93 anesthesiology residents with research PBLD exposure in the academic year (AY) 2010 and AY 2011, and 85 residents without research PBLD exposure in AY 2008 and AY 2009. MEASUREMENTS: Since AY 2010, a PBLD format has been used to teach residents clinical research fundamentals. The annual 90-minute PBLD addressed residents' perceived barriers to research and introduced research resources available via the Clinical and Translational Science Institute (CTSI). Data recorded were: 1) number of residents who made CTSI consultation solicitations as a new investigator, and 2) number of new research projects proposed by the residents and designed with CTSI consultation. Each outcome was compared between the prePBLD group (AY 2008 [n=43] and AY 2009 [n=42]) and the postPBLD group (AY 2010 [n=43] and AY 2011 [n=50]). MAIN RESULTS: The number of residents who consulted the CTSI as new investigators increased from 4 of 85 residents (4.7%) in the prePBLD group to 13 of 93 residents (14.0%) in the postPBLD group (P = 0.042). The number of new research projects for which the residents consulted CTSI increased from 10 to 20 (100% increase). CONCLUSION: A PBLD format for research education of anesthesiology residents is effective.

Safety and efficacy of a novel ultrasonic osteotome device in an ovine model.

The use of ultrasonic technology for bone removal offers the potential advantages over the use of traditional hand instruments or cutting burrs of more precise bone resection and reduced soft-tissue injury. While the use of modified ultrasonic aspirators has been described for bone removal in spinal surgery, none of these instruments has been systematically examined to evaluate safety and efficacy. Thus, we compared laminectomies using traditional instruments, and traditional instruments with an ultrasonic osteotome, in an ovine model. We used a combination of clinical examination, intra-operative and post-operative neuromonitoring and histological analysis to evaluate safety. The secondary endpoint of efficiency was assessed by examining operative times. No significant difference was found between groups in neurophysiology or the Tarlov clinical rating scale. Histology revealed inflammatory or reparative changes in 6/8 experimental animals and 2/4 control animals with a single section in an experimental animal revealing focal nerve root disruption and mild axonal loss. A single durotomy was noted in both the control and experimental groups. Operative time for the experimental group was significantly shorter than the operative time for the control group.

Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery.

Approximately one million spinal surgeries are performed in the United States each year. The risk of an incidental durotomy (ID) and resultant persistent cerebrospinal fluid (CSF) leakage is a significant concern for surgeons, as this complication has been associated with increased length of hospitalization, worse neurological outcome, and the development of CSF fistulae. Augmentation of standard dural suture repair with the application of fibrin glue has been suggested to reduce the frequency of these complications. This study examined unintended durotomies during lumbar spine surgery in a large surgical patient cohort and the impact of fibrin glue usage as part of the ID repair on the incidence of persistent CSF leakage. A retrospective analysis of 4,835 surgical procedures of the lumbar spine from a single institution over a 10-year period was performed to determine the rate of ID. The 90-day clinical course of these patients was evaluated. Clinical examination, B-2 transferrin assay, and radiographic imaging were utilized to determine the number of persistent CSF leaks after repair with or without fibrin glue. Five hundred forty-seven patients (11.3%) experienced a durotomy during surgery. Of this cohort, fibrin glue was used in the dural repair in 278 patients (50.8%). Logistic models evaluating age, sex, redo surgery, and the use of fibrin glue revealed that prior lumbar spinal surgery was the only univariate predictor of persistent CSF leak, conferring a 2.8-fold increase in risk. A persistent CSF leak, defined as continued drainage of CSF from the operative incision within 90 days of the surgery that required an intervention greater than simple bed rest or over-sewing of the wound, was noted in a total of 64 patients (11.7%). This persistent CSF leak rate was significantly higher (P < 0.001) in patients with prior lumbar surgery (21%) versus those undergoing their first spine surgery (9%). There was no statistical difference in persistent CSF leak between those cases in which fibrin glue was used at the time of surgery and those in which fibrin glue was not used. There were no complications associated with the use of fibrin glue. A history of prior surgery significantly increases the incidence of durotomy during elective lumbar spine surgery. In patients who experienced a durotomy during lumbar spine surgery, the use of fibrin glue for dural repair did not significantly decrease the incidence of a persistent CSF leak.