An Innovative System to Facilitate Extension Osteotomy in the Prone Position for Chin-on-Chest Deformity of Ankylosing Spondylitis.

BACKGROUND: In the presence of chin-on-chest deformity of ankylosing spondylitis, positioning for extension osteotomy of the spine is a challenging endeavor. Conventional prone positioning equipment cannot safely accommodate all patients with advanced deformity where the chin brow angle approaches or exceeds 90°. Issues such as inability to accommodate the head and associated equipment while providing operative stability and venous congestion of the head represent significant perioperative risks. The sitting position has been advocated as an alternative but is suboptimal for surgical access and anesthetic care. We present a technical note for a positioning system developed to facilitate extension osteotomy in the prone position. METHODS: A positioning device was designed to accommodate patients with advanced deformity. A series of patients with chin brow angles of up to 89° were positioned using our new system. RESULTS: We were able to facilitate safe extension osteotomy in the prone position, for procedures lasting up to 14 hours. All our patients were discharged home without significant complication. CONCLUSIONS: Our device is simply constructed and may be easily replicated in other institutions engaging in complex spine surgery. We hope our system provides clinicians with greater freedom to provide optimal perioperative care to their patients.

An innovative prone positioning system for advanced deformity and frailty in complex spine surgery.

The authors present a technical note for a prone positioning system developed to facilitate cervical extension osteotomy for ankylosing spondylitis in the presence of severe deformity and frailty. Chin-on-chest deformity represents one of the most debilitating changes of ankylosing spondylitis. Where the chin-brow angle approaches or exceeds 90°, prone positioning becomes problematic due to the fixed position of the head. Furthermore, the challenge is compounded where physiological deconditioning leads to frailty, and the side effects of medical therapies decrease muscle mass and skin quality. Conventional prone positioning equipment is not able to cater to all patients. A versatile system was developed using a 3D reconstruction to enable a positioning simulation and verification tool. The tool was used to comprehensively plan the perioperative episode, including spatial orientation and associated equipment. Three-dimensional printing was used to manufacture a bespoke positioning device that precisely matched the contours of the patient, reducing contact pressure and risk of skin injury. The authors were able to safely facilitate surgery for a patient whose deformity and frailty may otherwise have precluded this possibility. The system has potential safety and economic implications that may be of significant utility to other institutions engaging in complex spinal surgery.

The implementation of enhanced recovery after surgery (ERAS) in complex spinal surgery.

BACKGROUND: This paper aims to review the introduction of an enhanced recovery after surgery (ERAS) service within complex spinal surgery, with an aim to assess if this is a cost effective way to improve the overall experience of such complex surgery. METHODS: The ERAS model was defined and followed within a regional centre for complex spinal surgery in the UK. Outcomes such as length of stay (LOS) and satisfaction were measured before and after implementation of the service. RESULTS: LOS was reduced and both patient and staff satisfaction improved following the implementation of the ERAS service. CONCLUSIONS: The ERAS model can successfully be implemented within complex spinal surgery, to help improve satisfaction and reduce cost.

The safety, efficacy, and cost-effectiveness of intraoperative cell salvage in metastatic spine tumor surgery.

BACKGROUND CONTEXT: Metastatic spine tumor surgery (MSTS) is associated with substantial blood loss, therefore leading to high morbidity and mortality. Although intraoperative cell salvage with leukocyte depletion filter (IOCS-LDF) has been studied as an effective means of reducing blood loss in other surgical settings, including the spine, no study has yet analyzed the efficacy of reinfusion of salvaged blood in reducing the need for allogenic blood transfusion in patients who have had surgery for MSTS. PURPOSE: This study aimed to analyze the efficacy, safety, and cost-effectiveness of using IOCS-LDF in MSTS. STUDY DESIGN: This is a retrospective controlled study. PATIENT SAMPLE: A total of 176 patients undergoing MSTS were included in the study. METHODS: All patients undergoing MSTS at a single center between February 2010 and December 2014 were included in the study. The primary outcome measure was the use of autologous blood transfusion. Secondary outcome measures included hospital stay, survival time, complications, and procedural costs. The key predictor variable was whether IOCS-LDF was used during surgery. Logistic and linear regression analyses were conducted by controlling variables such as tumor type, number of diseased vertebrae, approach, number and site of stabilized segments, operation time, preoperative anemia, American Society of Anesthesiologists (ASA) grade, age, gender, and body mass index (BMI). No funding was obtained and there are no conflicts of interest to be declared. RESULTS: Data included 63 cases (IOCS-LDF) and 113 controls (non-IOCS-LDF). Intraoperative cell salvage with LDF utilization was substantively and significantly associated with a lower likelihood of allogenic blood transfusion (OR=0.407, p=.03). Intraoperative cell salvage with LDF was cost neutral (p=.88). Average hospital stay was 3.76 days shorter among IOCS-LDF patients (p=.03). Patient survival and complication rates were comparable in both groups. CONCLUSIONS: We have demonstrated that the use of IOCS-LDF in MSTS reduces the need for postoperative allogenic blood transfusion while maintaining satisfactory postoperative hemoglobin. We recommend routine use of IOCS-LDF in MSTS for its safety, efficacy, and potential cost benefit.