Sarcopenia predicts perioperative adverse events following complex revision surgery for the thoracolumbar spine.

BACKGROUND CONTEXT: Sarcopenia measured by psoas muscle index (PMI) has been shown to predict perioperative mortality and adverse events (AEs) after various surgical procedures. However, this relationship has not been studied in complex revision thoracolumbar spine surgery. PURPOSE: This study aimed to determine the relationship between sarcopenia and perioperative AEs among patients undergoing complex revision thoracolumbar spine surgery. STUDY DESIGN: Retrospective cohort study PATIENT SAMPLE: A retrospective analysis was performed at a single institution between May 2016 and February 2020 of patients undergoing complex revision thoracolumbar spine surgery by three board certified fellowship-trained orthopaedic spine surgeons. OUTCOME MEASURES: Perioperative adverse events including postoperative anemia requiring transfusion, cardiac complication, sepsis, wound complication, delirium, intra-operative dural tear, acute kidney injury, pneumonia, urinary tract infection, urinary retention, epidural hematoma, and deep vein thrombosis. Secondary outcome measures were 30-day readmission rates, 30-day re-operation rates, in-hospital mortality rates, discharge disposition, and postoperative length of stay (LOS). METHODS: Sarcopenia was analyzed using PMI, calculated at the L3 vertebral body measured on preoperative magnetic resonance imaging (MRI) or computed tomography (CT) normalized to height2 (mm2/m2). Receiver operating characteristic (ROC) curve analysis and Youden index were used to determine gender-specific PMI cut-off values for predicting perioperative AEs. Sarcopenia was defined as PMI below the cut-off values. Complex revision surgery was defined as Spine Surgical Invasiveness Index >10. RESULTS: A total of 114 consecutive patients were included in the study. ROC curve analysis demonstrated PMI <500 mm2/m2 for males and <412 mm2/m2 for females as predictors for perioperative AEs. 49 patients were in the sarcopenia cohort and 65 patients in the nonsarcopenia cohort. The sarcopenia group had higher overall perioperative AEs (75.5% vs 27.7%, p<.001) and individual AEs including: postoperative anemia requiring transfusion, wound complication, delirium, acute kidney injury, pneumonia, urinary tract infection, and deep vein thrombosis. The sarcopenia group had higher 30-day reoperation rate (14.3% vs 3.1%, p=.037), 30-day readmission rate (16.3% vs 3.1%, p=.018), rate of discharge to a facility (83.7% vs 50.8%, p<.001), and longer length of stay (LOS) (7.3±4.2 days vs 5.6±3.5 days, p=.023). CONCLUSIONS: Sarcopenia measured by PMI is associated with higher perioperative AEs, 30-day readmission rates, 30-day reoperation rates, rate of discharge to a facility, and longer LOS among patients undergoing complex revision thoracolumbar spine surgery.

Outcomes of Negative Pressure Wound Therapies in the Management of Spine Surgical Site Wound Infections.

BACKGROUND: Many studies report benefits using negative pressure wound therapy (NPWT) in surgical site infections (SSIs). We measured and compared efficacy and complications associated with NPWT for traditional versus suprafascial vacuum-assisted closures (VACs). METHODS: This is a retrospective chart review of consecutive SSIs managed with negative wound therapy after spinal procedures between 2012 and 2015 from a single, academic center. Patients were collected through International Classification of Diseases, Ninth Revision, procedure codes. Inclusion criteria were patients with spine SSIs managed by irrigation and debridement with a VAC device; infection occurring after spinal surgeries; and age over 18. A total of 23 consecutive patients met the criteria. We reviewed demographic data, surgical data, infectious disease data, discharge summaries, and postoperative follow-up charts. We compared and analyzed demographics, duration of VAC therapy, and reoperation rates between VAC groups. Statistical analysis was completed using analysis of variance and χ2 tests; P ≤ 0.05 was considered statistically significant. RESULTS: A total of 7 patients had traditional VACs (Group 1), and 16 patients had suprafascial VACs (Group 2). Average blood loss and number of levels involved during index surgery were not statistically significant between groups. Locations of infection occurrence were cervical spine = 3, thoracic spine = 1, and lumbar spine = 19. Reoperation rate after initial wound VAC placement was 34%, with rates significantly higher for Group 1 (71%) than Group 2 (16%), P = 0.02. Average duration of wound therapy was longer in Group 1 (77 days) than Group 2 (33 days), P = 0.08. Average number of operating room visits after initial wound VAC implantation were 0.7 for Group 1 and 0.3 for Group 2, P = 0.26, before obtaining a clean wound closure. CONCLUSIONS: Small sample size and retrospective nature were limitations. Negative pressure wound therapy may be useful for managing spinal infections, and suprafascial VAC had less time duration, lower risk of sponge fragment retainment, and fewer procedures to ultimately achieve wound closure. LEVEL OF EVIDENCE: 3.

Guillain-Barré Syndrome After Revision Lumbar Surgery: A Case Report.

Guillain-Barré syndrome (GBS) is a term that is used to describe a group of immune-mediated peripheral neuropathies, with the most common feature being rapid polyradiculoneuropathy. The exact etiology of this syndrome is unknown. In the field of orthopedics, GBS has been reported to occur after total hip arthroplasty, orthopedic trauma, and spine surgery. We report a unique case of GBS after elective revision lumbar spine surgery. A 62-year-old female presented with persistent low back pain and radiculopathy and elected to have revision lumbar spine surgery. Approximately 24 to 36 hours after hospital discharge, she returned to the hospital with weakness in her legs. After an electromyography (EMG), the patient was diagnosed with GBS and placed on intravenous immunoglobulin (IVIG). She developed respiratory failure, which required intubation and eventually converted to a tracheostomy and was finally decannulated. Over the course of 12 months, she improved to her pre-surgical baseline, gaining 5/5 strength in her upper and lower extremities and was able to ambulate independently without any aids. This was a case of GBS that occurred in a patient approximately two weeks after revision lumbar surgery. GBS is a poorly understood and rare complication of lumbar spine surgery that needs to be recognized quickly to be effectively treated.

Factors associated with emergency department length of stay for patients with hip fracture.

Time to surgery, which includes time in the emergency department (ED), is important for all patients with hip fracture. We hypothesized that patients with hip fracture spend significantly more time in the ED than do patients with the top 5 most common conditions. In addition, we hypothesized that there are patient, physician, and hospital factors that affect the length of time spent in the ED. We retrospectively reviewed our institution's hip fracture database and identified 147 elderly patients with hip fractures who presented to our ED from December 18, 2005, through April 30, 2009. We reviewed their records for patient, practitioner, and hospital factors of interest associated with ED time and for 6 specified time intervals. Average working, boarding (waiting for an inpatient room), and total times were calculated and compared with respective averages for admitted ED patients with the top 5 most common conditions. Univariate and multivariate analyses were performed before and after adjusting for confounders (significance, P = .05). The mean total ED time (7 hours and 25 minutes) and working time (4 hours and 31 minutes) for patients with hip fracture were similar to the respective overall averages for admitted ED patients. However, the average boarding time for patients with hip fracture was 2 hours 44 minutes, longer than that for other patients admitted through the ED. Factors significantly associated with longer ED times were a history of hypertension, history of atrial fibrillation, the number of computed tomography scans ordered, and the occupancy rate. Admission to the hip fracture service decreased working time but not overall time. Substantial multidisciplinary work among the ED, hospital admission services, and physicians is needed to dramatically decrease the boarding time and thus the overall time to surgery.

Reliability and reproducibility of spectral and time domain optical coherence tomography images before and after correction for patients with age-related macular degeneration.

PURPOSE: To evaluate the reproducibility and reliability of Optical Coherence Tomography scans (OCT) obtained using the Time Domain (TD-OCT) StratusTM OCT, and the Spectral Domain (SD-OCT) SpectralisTM and CirrusTM OCT devices before and after manual correction in eyes with either Neovascular (NV-AMD) or Non-Neovascular (NNV-AMD) Age-related Macular Degeneration. METHODS: We conducted a prospective observational study of 36 patients (50 eyes) with NV-AMD or NNV-AMD at a university-based retina practice. OCT scans were taken simultaneously using one TD-OCT and two SD-OCT devices. Macular thickness measurements were assessed before and after correction of the OCT algorithm by constructing Bland-Altman plots for agreement and calculating intraclass correlation coefficients (ICCs) and coefficients of repeatability (COR) to evaluate intraclass repeatability. RESULTS: The Spectralis device had the highest number of images needing manual correction. All machines had high ICCs, with Spectralis having the highest. Bland-Altman plots indicated that there was low agreement between both Cirrus™ and Stratus™ and Spectralis™ and Stratus™, while there was good agreement between the Cirrus™ and Spectralis™ devices. The CORs were lowest for SpectralisTM and similar with each other and had higher values for CirrusTM and StratusTM. Agreement, CORs, and ICCs generally improved after manual correction, but only minimally.   CONCLUSION: Agreement is low between devices, except between both SD-OCT machines. Manual correction tends to improve results.

Retinal nitric oxide and malonyldialdehyde levels following photodynamic therapy.

BACKGROUND: To determine the retinal nitric oxide (NO) and malonyldialdehyde (MDA) levels following photodynamic therapy (PDT). MATERIALS AND METHODS: Seven Dutch-belted rabbits received dextrose, while seven others received 2 mg/kg verteporfin infusion over a period of 15 minutes in a dim-lit room. Irradiation to a 1.5 mm diameter intact chorioretinal area in the right eye of verteporfin-infused rabbits, was started 5 minutes after the end of infusion. Three groups were control (dextrose infusion), infusion with verteporfin (left eyes were not irradiated), and irradiation after verteporfin injection (right eyes were irradiated). On the fifth day of the experiment, the eyes were enucleated. The retinas were subsequently frozen and homogenized. Nitrite, a stable end-product of NO and MDA, was measured using the spectrophotometer. Protein concentrations were measured by the Lowry method. Tissue NO and MDA levels were expressed as µmol/gprt and nmol/mgprt, respectively. RESULTS: The mean retinal NO and MDA levels of the control, infusion, and irradiation groups were 24.67 ± 6.66, 0.11 ± 0.02; 45.90 ± 15.52, 0.21 ± 0.09; and 84.43 ± 14.96 µmol/gprt, 0.58 ± 0.14 nmol/mgprt, respectively. The mean retinal NO levels were significantly elevated in the infusion and irradiation groups compared with the control group ( p :0.004; p :0.001). The mean retinal MDA levels were significantly elevated in the infusion and irradiation groups compared to the control one ( p :0.026; p :0.001). Also the mean retinal NO and MDA levels in the irradiation group were found to be significantly higher than the infusion group ( p :0.018; p :0.018). CONCLUSION: Not only PDT, but also verteporfin infusion alone resulted in NO and MDA level increments in the retina, which might be toxic.

Blockade of sphingosine-1-phosphate reduces macrophage influx and retinal and choroidal neovascularization.

Sphingosine-1-phosphate (S1P) is a bioactive lipid molecule that stimulates endothelial cell migration, proliferation, and survival in vitro, and tumor angiogenesis in vivo. In this study, we used a humanized monoclonal antibody (sonepcizumab) that selectively binds S1P to investigate its role in retinal and choroidal neovascularization (NV). Intraocular injection of sonepcizumab significantly reduced macrophage influx into ischemic retina and strongly suppressed retinal NV in mice with oxygen-induced ischemic retinopathy. In mice with laser-induced rupture sites in Bruch's membrane, intraocular injection of sonepcizumab significantly reduced the area of choroidal NV and concomitantly reduced fluorescein leakage from the remaining choroidal NV. Four weeks after intraocular injection of up to 1.8 mg of the sonepcizumab in non-human primates, electroretinograms and fluorescein angiograms were normal, and light microscopy of ocular sections showed no evidence of structural damage. These data show for the first time that S1P stimulates both choroidal and retinal NV and suggest that sonepcizumab could be considered for evaluation in patients with choroidal or retinal NV.