Perioperative red blood cell salvage in spine surgery. A prospective analysis.

Reinfusion of perioperative blood loss was studied in 150 spinal surgery patients to evaluate its efficacy in reducing transfusion requirements. Three groups of 50 consecutive patients were observed. Group A had no blood salvage and served as a control group, Group B used Cell Saver for intraoperative blood salvage, and Group C used Cell Saver intraoperatively and Solcotrans postoperatively for salvage of postoperative drainage. The three groups had similar demographics, preoperative hematocrits (HCT), operative blood loss, and postoperative drainage. Serial HCTs through the fifth postoperative day showed no significant difference between groups. Total transfusion requirements of homologous and prebanked autologous blood were reduced 35% in Group B and 68% in Group C when compared to control group A. These differences are statistically significant. The combination of intraoperative and postoperative blood salvage was highly effective in reducing the need for transfused blood.

Intraoperative and postoperative red blood cell salvage.

The risks associated with homologous blood transfusions include hepatitis, transfusion reactions, and AIDS. Intraoperative and postoperative red blood cell salvage and reinfusion are techniques available to decrease the need for homologous transfusions. In this article the techniques of red blood cell salvage are described and the benefits and potential risks of these methods are discussed.

Somatosensory evoked potentials as an aid in the diagnosis and intraoperative management of spinal stenosis.

The use of somatosensory evoked potentials (SEPs) in localizing the level, extent, and laterality of nerve root entrapment is clinically important. In patients with lumbar spinal stenosis, this is especially true. This study defines a prospective investigation of 20 patients with preoperative SEPs of which 11 patients had intraoperative SEPs correlated with their computed tomographic (CT) scan and/or myelographic findings. The results confirm a high incidence of 4th and 5th lumbar and 1st sacral nerve root involvement. The posterior tibial nerve was abnormal in 95%, the peroneal in 90%, and the sural in 60% in the symptomatical lower extremity. Upper lumbar segments were barely affected as evident by the low incidence of saphenous nerve abnormality in only 12% of the patients. The posterior tibial nerve had the highest yield and was useful for screening. Bilateral lower extremity abnormalities were found in seven of 20 cases studied with two patients having bilateral symptoms and findings. Therefore, bilateral lower extremity SEP evaluation can reveal previously unsuspected pathology and is strongly recommended in preoperative evaluations. SEPs can serve as a useful intraoperative tool to guide the surgeon during a decompressive surgical procedure. SEPs are specifically helpful in spinal stenosis with a paucity of clinical findings and equivocal CT scan or myelographic studies. SEPs seem much more sensitive and effective than conventional electrodiagnostic tests in detecting spinal nerve root compression secondary to spinal stenosis.

Respiratory mechanics in adolescents with idiopathic scoliosis.

Mechanisms causing the reduction in lung capacity commonly found in adolescents with idiopathic scoliosis (IS) have not been understood. In 29 patients with typical thoracic curvatures of mild to moderate degree (less than 60 degrees), total lung capacity (TLC) was a mean 75 +/- 13% (SD) of predicted. The patients could generate only -70 +/- 26 cm H2O (SD) maximal inspiratory airway pressure at function residual capacity, as compared with -102 +/- 28 cm H2O in 21 normal control subjects (p less than 0.001). Studies of lung mechanics in 15 of the patients showed that maximal transpulmonary pressure at TLC was also reduced. Static pressure volume curves were shifted to the right, and both static and dynamic lung compliance were significantly reduced. Although both upstream conductance per TLC and anatomic dead space per TLC were abnormally high, relationships between maximal expiratory flow and static lung recoil were appropriate for age, indicating a normal growth of airway dimensions. From results of the single-breath nitrogen washout procedure, amounts of trapped nitrogen were also normal, indicating that the low lung compliance is not caused by airway closure. After a 5-min period of positive pressure (25 cm H2O) breathing, dynamic compliance increased by a mean of 34% in subjects with low TLC, and by a significantly smaller (p less than 0.05) mean increase of 14% in subjects with normal TLC. The 15 patients were restudied 1 yr after corrective surgery by the Harrington procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

The electrocardiogram in patients with scoliosis.

Electrocardiograms of 802 patients with isolated scoliosis followed and/or operated at Columbia Presbyterian Medical Center were reviewed. There were 586 patients younger than 18 years and 216 patients older than 18 years of age. There were 86 males and 716 females. Eleven patients had associated congenital heart disease. Effects of age, site of scoliosis, side of convexity and severity of curvature on multiple electrocardiographic variables were analysed. Electrocardiographic variables such as heart rate, Q-Tc, P wave amplitude, P-R interval, amplitude of R and S waves in V1 and V6 were similar to data reported in the normal population without scoliosis. The effect of age on these electrocardiographic variables was similar to changes reported in the normal population and were not affected by site of scoliosis or side of curvature. The frontal QRS axis was within normal limits of 94% in patients under 18 years of age with right-sided thoracic scoliosis and in 87% of patients over 18 years. Evidence of right axis deviation (5%) and right ventricular hypertrophy (2%) were present equally in patients younger and older than 18 years of age and 8% of patients over 18 years old. Since in our patient population the degree of scoliosis severity increased with age it is likely that the increasing incidence of left axis deviation found in patients over 18 years of age with scoliosis is related to scoliosis severity and the altered intrathoracic cardiac orientation. Because right axis deviation and right ventricular hypertrophy are noted occasionally in patients with scoliosis and because congenital heart disease and pulmonary disease are more prevalent in this patient population, it is recommended that the presence of right axis deviation and right ventricular hypertrophy on the ECG should lead to a complete cardiopulmonary evaluation and exclusion of possible additional cardiac or pulmonary anomalies.

Diagnostic problems in the lumbar spine.

In summary then, the diagnostic problems of the lumbar spine are myriad. They can include conditions which are congenital, tumorous, traumatic, toxic, metabolic, inflammatory, degenerative, infectious, circulatory, mechanical, or psychoneurotic. In addition many of these combinations can be found in the problem now alluded to as "spinal stenosis". Even under this condition, spinal stenosis is classified as congenital and acquired. Under the acquired forms of stenosis there are degenerative, combined stenosis, spondylotic, postoperative, posttraumatic, and miscellaneous types such as that due to Paget's disease or fluorosis. A diagnosis of these conditions can best be made by an experienced historian and examiner since they are never clear-cut and sometimes it is a "sixth sense" of the physician which helps him make the diagnosis. The diagnosis, once suspected, can best be confirmed with proper laboratory tests including myelography and tomography. The treatment, of course, depends specifically on the pathology which is diagnosed. The surgical approach to lumbar spinal stenosis and nerve root entrapment is discussed in Chapter 15. Due to the work of Verbiest and others, much has been done to elucidate this confusing diagnostic area (1, 9). However, much more needs to be learned. We do not completely understand the pain receptors for discogenic pain as well as reasons why various forms of treatment seem to have a 60% success rate no matter what is done. One of the reasons that long-term results are so difficult to come by in this type of work is the fact that these patients cannot be easily categorized by a simple method such as the study of a long bone fracture and the acquisition of a large series with one type of treatment. There are so many psychogenic factors as well as multifaceted treatment regimes used by experts throughout the world that a perfect follow-up with controls is practically impossible. Hopefully, better standardization of diagnostic procedures, nonoperative and operative treatment forms, and analysis of long-term end results may be forthcoming in the future as we elucidate this confusing problem called "low back pain".

Osteoid osteoma of the cervical spine.

Four cases of cervical osteoid osteoma occurred predominantly in the adolescent age group with either pain, pain with scoliosis, or radicular pain usually without neurological signs. The initial X-rays did not demonstrate the lesions but a high index of suspicion led to additional roentgenographic as well as tomography examinations and eventually an accurate diagnosis. The lesions were located in the posterior elements in all 4 cases. Treatment consisted of excision in 3 cases and excision and fusion in one case and resulted in cure with no recurrence.

Displaced fractures of the major pelvis: a method of management.

Fractures of the bony pelvis occur with such violence that associated non-musculo-skeletal injury is common. The patients require an aggressive team approach if they are to leave the hospital alive. After the visceral injuries are treated, the bony pelvis should be aligned to minimize secondary sacroiliac arthritis. Following initial pelvic sling management, the reduction of these fractures is accomplished by using the Keim-Surcingle table coupled with a pantaloon spica cast to maintain the reduction. The patient is then managed by bedrest at home until 12 weeks post-injury at which time the plaster is removed and ambulation is progressed as tolerated. The pubic diastasis may increase if plaster immobilization is discontinued too early. We hope that an aggressive initial evaluation and team approach coupled with this method of reduction and immobilization will decrease significantly the mortality and morbidity associated with displaces fractures of the major pelvis.

Osteoid-osteoma as a cause of scoliosis.

In nine cases of osteoid-osteoma causing scoliosis, all lesions were in the spine and several led to significant structural spine changes. One patient had two distinct spine lesions two years apart. Almost all cases were misdiagnosed and improperly treated at first. Prompt recognition should lead to early surgical excision without spine fusion.