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Description and Results of a Comprehensive Care Protocol for Overnight-Stay Spine Surgery in Adults. Spine (Phila Pa 1976) 2017; 42:E871-E875. [PMID: 27870808 DOI: 10.1097/brs.0000000000001987] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a prospective cohort study. OBJECTIVE The aim of this study was to define the probability of successful morning-after discharge after adult spine surgery achieved with a standard care protocol as applied to patients with a large variety of common degenerative spine disorders. SUMMARY OF BACKGROUND DATA Qualifying criteria for ambulatory or overnight-stay adult spine surgery are not well defined in either the spine or anesthesia literature. Most reports simply go to American Society of Anesthesiology risk classification or surgical technique alternatives and do not present a clearly defined patient care and case management protocol. METHODS A standardized protocol of patient preparation, preoperative comorbidities optimization, and perioperative care was applied in a prospective cohort of 126 patients including 83 lumbar and 41 cervical procedures. Office and hospital chart records were reviewed for relevant outcomes. RESULTS Fully 122 of 124 appropriately selected cases were able to successfully achieve uneventful same-day discharge without any need for readmission, unscheduled early emergency room or clinic visits, or other major complications. Both failures were for urinary retention in senior males and resolved after a single-day admission to the main hospital. CONCLUSION A wide variety of common degenerative spinal pathology in adults can be routinely and safely managed on an overnight-stay basis without requirement for formal hospital inpatient admission in patients appropriately selected and pre-educated to the experience and whose major comorbidities are preoperatively optimized. LEVEL OF EVIDENCE N/A.
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Abstract
This review includes a summary of contemporary theories of pain processing and advocates a multimodal analgesia approach for providing perioperative care. A summary of various medication classes and anesthetic techniques is provided that highlights evidence emerging from neurosurgical literature. This summary covers opioid management, acetaminophen, nonsteroidal antiinflammatories, ketamine, lidocaine, dexmedetomidine, corticosteroids, gabapentin, and regional anesthesia for neurosurgery. At present, there is not enough investigation into these areas to describe best practices for treating or preventing chronic pain in neurosurgery; but providers can identify a wider range of options available to personalize perioperative care strategies.
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Affiliation(s)
- Samuel Grodofsky
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street 5th Floor Dulles, Philadelphia, PA 19104, USA.
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Zoia C, Bongetta D, Poli JC, Verlotta M, Pugliese R, Gaetani P. Intraregional differences of perioperative management strategy for lumbar disc herniation: is the Devil really in the details? Int J Spine Surg 2017; 11:1. [PMID: 28377859 PMCID: PMC5375018 DOI: 10.14444/4001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This study intends to evaluate whether regional common habits or differences in case-volume between surgeons are significative variables in the perioperative management of patients undergoing surgery for lumbar disc herniation. METHODS An e-mail survey was sent to all neurosurgeons working in Lombardy, Italy's most populated region. The survey consisted of 17 questions about the perioperative management of lumbar disc herniation. RESULTS Forty-seven percent (47%) out of 206 Lombard neurosurgeons answered the survey. Although in some respects there is clear evidence in current literature on which is the best practice to adopt for an optimal management strategy, we noticed substantial differences between respondents, not only between hospitals but also between surgeons from the same hospital. Still, no differences were evident in a high vs low case-volume comparison. CONCLUSION We identified no regional clusterization as for practical principles in the perioperative management of lumbar disc herniation and neither was case-volume a significative variable. Other causes may be relevant in the variability between the perioperative management and the outcomes achieved by different specialists.
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Affiliation(s)
- Cesare Zoia
- Neurosurgery Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Daniele Bongetta
- Neurosurgery Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
- Neurosurgery, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Jacopo C. Poli
- Neurosurgery Unit, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Mariarosaria Verlotta
- Neurosurgery, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Università degli Studi di Pavia, Pavia, Italy
| | | | - Paolo Gaetani
- Neurosurgery Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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Mahesh B, Upendra B, Vijay S, Kumar GCA, Reddy S. Complication rate during multilevel lumbar fusion in patients above 60 years. Indian J Orthop 2017; 51:139-146. [PMID: 28400658 PMCID: PMC5361463 DOI: 10.4103/0019-5413.201704] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Spine surgery in elderly with comorbidities is reported to have higher complication rates and increased cost. However, the surgical outcome is good irrespective of the complications. Hence, it is essential to identify the factors affecting the complication rates in such patients and the measures to reduce them. This retrospective observational study determines the perioperative complications, their incidence and the measures to reduce complications in the elderly with comorbidities, operated by instrumented multilevel lumbar fusion. MATERIALS AND METHODS Patients aged 60 years and above with one or more comorbidities operated by multilevel instrumented lumbar fusion in our center between January 2012 and December 2013 were included in the study. Perioperative complications and their incidence were calculated. Age, number of levels fused, operative time, blood loss, and complication rates were correlated with the duration of stay and the incidence of perioperative complications using SPSS software. Measures to reduce complications are determined by these results and by review of literature. RESULTS Fifty two patients were included in the study (28 females and 24 males) with an average age of 69 years (range 60-84 years). Hypertension was the most common comorbidity followed by diabetes. Spondylolisthesis was the most common indication. Eleven complications were noted with an incidence of 21%. Three were systemic complications which required transfer to Intensive Care Unit. Local complications were incidental durotomy (three), transient root deficits (two), wound infections (one), and persistent radicular pain (two). Operative time and blood loss were significantly higher in patients with complications. CONCLUSION Complication rates strongly correlate with the blood loss and operative time. Reducing the operative time and blood loss by intraoperative tranexamic acid, laminectomy using osteotome, simultaneous bilateral exposure and instrumentation and reducing the number of interbody fusions can help in reducing the complications.
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Affiliation(s)
- Bijjawara Mahesh
- Department of Spine Surgery, Jain Institute of Spine Care and Research, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
| | - Bidre Upendra
- Department of Spine Surgery, Jain Institute of Spine Care and Research, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
| | - S Vijay
- Department of Spine Surgery, Jain Institute of Spine Care and Research, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India,Address for correspondence: Dr. S Vijay, Department of Spine Surgery, Jain Institute of Spine Care and Research, Bhagwan Mahaveer Jain Hospital, Millers Road, Vasanthnagar, Bengaluru - 560 052, Karnataka, India. E-mail:
| | - GC Arun Kumar
- Department of Spine Surgery, Jain Institute of Spine Care and Research, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
| | - Srinivas Reddy
- Department of Spine Surgery, Jain Institute of Spine Care and Research, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
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Meng T, Zhong Z, Meng L. Impact of spinal anaesthesia vs. general anaesthesia on peri-operative outcome in lumbar spine surgery: a systematic review and meta-analysis of randomised, controlled trials. Anaesthesia 2016; 72:391-401. [PMID: 27770448 DOI: 10.1111/anae.13702] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2016] [Indexed: 11/30/2022]
Affiliation(s)
- T. Meng
- Department of Anaesthesia; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong Province China
| | - Z. Zhong
- Department of Spine Surgery; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong Province China
| | - L. Meng
- Department of Anesthesiology; Yale University School of Medicine; New Haven Connecticut USA
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Epidural anesthesia for posterior spinal fusion and lumbar surgery in a patient with glanzmann's thrombasthenia – Case report and systematic review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rcae.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Anestesia epidural para artrodesis e instrumentación de columna lumbar por vía posterior en paciente con trombastenia de Glanzmann: informe de caso y revisión sistemática. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rca.2016.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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Agarwal P, Pierce J, Welch WC. Cost Analysis of Spinal Versus General Anesthesia for Lumbar Diskectomy and Laminectomy Spine Surgery. World Neurosurg 2016; 89:266-71. [PMID: 26875652 DOI: 10.1016/j.wneu.2016.02.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/03/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Lumbar spine surgery can be performed using various anesthetic modalities, most notably general or spinal anesthesia. Because data comparing the cost of these anesthetic modalities in spine surgery are scarce, this study asks whether spinal anesthesia is less costly than general anesthesia. METHODS A total of 542 patients who underwent elective lumbar diskectomy or laminectomy spine surgery between 2007 and 2011 were retrospectively identified, with 364 having received spinal anesthesia and 178 having received general anesthesia. Mean direct operating cost, indirect cost (general support staff, insurance, taxes, floor space, facility, and administrative costs), and total cost were compared among patients who received general and spinal anesthesia. Linear multiple regression analysis was used to identify the effect of anesthesia type on cost and determine the factors underlying this effect, while controlling for patient and procedure characteristics. RESULTS When controlling for patient and procedure characteristics, use of spinal anesthesia was associated with a 41.1% lower direct operating cost (-$3629 ± $343, P < 0.001), 36.6% lower indirect cost (-$1603 ± $168, P < 0.001), and 39.6% lower total cost (-$5232 ± $482, P < 0.001) compared with general anesthesia. Shorter hospital stay, shorter duration of anesthesia, shorter duration of operation, and lower estimated blood loss contributed to lower costs for spinal anesthesia, but other factors beyond these were also responsible for lower direct operating and total costs. CONCLUSIONS When comparing the benefits of spinal and general anesthesia, spinal anesthesia is less costly when used in patients undergoing lumbar diskectomy and laminectomy spine surgery.
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Affiliation(s)
- Prateek Agarwal
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - John Pierce
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William C Welch
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Epidural anesthesia for posterior spinal fusion and lumbar surgery in a patient with glanzmann’s thrombasthenia - Case report and systematic review☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1097/01819236-201644030-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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General versus epidural anesthesia for lumbar microdiscectomy. J Clin Neurosci 2015; 22:1309-13. [PMID: 26067543 DOI: 10.1016/j.jocn.2015.02.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 02/01/2015] [Accepted: 02/04/2015] [Indexed: 11/22/2022]
Abstract
This study was a retrospective analysis of 850 lumbar microdiscectomy (LMD) under epidural anesthesia (EA; n=573) or general anesthesia (GA; n=277) performed by the same surgeon and paid by invoice to the Social Security Institution of the Turkish Republic between April 2003 and May 2013. Although GA is the most frequently used method of anesthesia during LMD, the choice of regional anesthetia (epidural, spinal or a combination of these) differs between surgeons and anesthetists. Studies have reported that EA in surgery for lumbar disc herniation may be more reliable than GA, as it enables the surgeon to communicate with the patient during surgery, but few studies have compared the costs of these two anesthetic methods in LMD. We found that EA patient costs were significantly lower than GA patient costs (p<0.01) and there was a statistically significant difference between the two groups in terms of the time spent in the operating room (p<0.01). There was no difference in the duration of surgery (p>0.05). The anesthetic method used during LMD affected the complication rate, cost and efficiency of operating room use. We suggest that EA is an anesthetic method that can contribute to health care cost savings and enable LMD to be completed with less nerve root manipulation and more comfort, efficacy, reliability and cost efficiency without affecting the success rate of the surgical procedure.
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Pu C, Wang J, Tang Y, Yuan H, Li J, Bai Y, Wang X, Wei Q, Han P. The efficacy and safety of percutaneous nephrolithotomy under general versus regional anesthesia: a systematic review and meta-analysis. Urolithiasis 2015; 43:455-66. [PMID: 25926280 DOI: 10.1007/s00240-015-0776-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 04/13/2015] [Indexed: 02/05/2023]
Abstract
This meta-analysis was performed to evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL) under regional anesthesia (RA) vs. general anesthesia (GA). A systematic literature search in the electronic databases (Cochrane CENTRAL, Medline and EMBASE) was performed up to April 2014. Twelve trials, including 1954 patients, met the inclusion criteria and were included in the final analysis. Our pooled analysis showed that PCNL under RA could reduce surgical duration (MD, -2.47; 95 % CI, -3.51 to -1.44), hospitalization period (MD, -0.48; 95 % CI -0.93 to -0.04), fluoroscopy time (MD, -0.48; 95 % CI, -0.83 to -0.14), blood transfusion (OR, 0.59; 95 % CI, 0.38-0.92), postoperative pain (MD, -1.99; 95 % CI, -2.2 to -1.78), and analgesic requirements (MD, -19.14; 95 % CI, -26.64 to -11.63). However, there was no difference between RA and GA groups with regard to stone-free rate (OR, 1.09; 95 % CI, 0.86-1.37) and postoperative complications associated with PCNL (OR, 0.95; 95 % CI 0.58-1.54). Our results show that PCNL under RA offers several potential advantages over GA in terms of surgical duration, hospitalization period, fluoroscopy time, blood transfusion, postoperative pain, and analgesic requirements, but both anesthetic techniques appear to be equivalent with regard to the stone-free rate and complication rate. Along with the suggested favorable hemodynamic profile and lower cost, RA may prove a better alternative than GA.
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Affiliation(s)
- Chunxiao Pu
- Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jia Wang
- Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yin Tang
- Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Haichao Yuan
- Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jinhong Li
- Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yunjin Bai
- Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xiaoming Wang
- Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qiang Wei
- Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Ping Han
- Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
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Stundner O, Ortmaier R, Memtsoudis SG. Which outcomes related to regional anesthesia are most important for orthopedic surgery patients? Anesthesiol Clin 2014; 32:809-821. [PMID: 25453663 DOI: 10.1016/j.anclin.2014.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
An increasing body of evidence supports the benefits of regional anesthesia in orthopedic surgery. Compared with systemic anesthetic and analgesic approaches, these benefits include more focused and sustained pain control, less systemic side effects, improved patient comfort, earlier mobilization and hospital discharge, lower rates of advanced service requirements, and lower perioperative morbidity and mortality. However, there is discussion about the various outcomes as judged by patients and heath care practitioners. This article recapitulates the literature and presents an overview of endpoints.
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Affiliation(s)
- Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria
| | - Rainhold Ortmaier
- Department of Trauma Surgery and Sports Traumatology, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021, USA.
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Bajwa SJS, Haldar R. Endocrinological disorders affecting neurosurgical patients: An intensivists perspective. Indian J Endocrinol Metab 2014; 18:778-783. [PMID: 25364671 PMCID: PMC4192981 DOI: 10.4103/2230-8210.140240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Management of critically ill neurosurgical patients is often complicated by the presence or development of endocrinological ailments which complicate the clinical scenario and adversely affect the prognosis of these patients. The anatomical proximity to the vital centers regulating the endocrinological physiology and alteration in the neurotransmitter release causes disturbances in the hormonal homeostasis. This paves the way for development of diverse disorders where single or multiple hormones may be involved which can have deleterious effect on the different organ system. Understanding and awareness of these disorders is important for the treating intensivist to recognize these changes early in their course, so that appropriate and timely therapeutic measures can be initiated along with the treatment of the primary malady.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
| | - Rudrashish Haldar
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
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