Closed-suction drainage in thoracolumbar spinal surgery-clinical routine without evidence? a systematic review

Evaluation of postoperative drainage necessity in posterior atlantoaxial fixation via intermuscular approach for odontoid fracture

The necessity of routinely placing closed suction wound drainage in spinal surgery has been questioned. This study aims to assess if closed suction wound drainage is necessary for posterior atlantoaxial fixation via intermuscular approach. The functional outcomes of these 40 patients who underwent posterior atlantoaxial fixation via intermuscular approach without drainage tube (Group A) were compared with that of a control group, which consisted of 68 randomly enrolled cases with posterior atlantoaxial fixation via intermuscular approach with drainage tube (Group B). Outcome assessments included American Spinal Injury Association (ASIA) scoring grade and Visual Analog Scale Score for Neck Pain (VASSNP). The postoperative analgesic consumption, the incidence of subcutaneous and surrounding ecchymosis and the time of ambulation were compared between two groups. Bone fusion was evaluated through computed tomography (CT) reconstruction. Postoperative paravertebral tissue edema was evaluated by the edema coefficient. The use of drainage tube had no significant influence on the postoperative analgesic consumption, wound ecchymosis, the time of ambulation and paravertebral tissue edema (P > 0.05). There were no statistically significant differences in the VASSNP and bone fusion rates during the follow-up period between the two groups (P > 0.05). All patients achieved ASIA grade E 3 months after surgery. No complications such as wound infection occurred in either group. Posterior atlantoaxial fixation via intermuscular approach does not necessitate postoperative drainage tube placement if there is no accidental vascular injury or excessive muscle bleeding occurs intraoperatively.

Incidence, Risk Factors, and Functional Outcomes of Symptomatic Postoperative Spinal Epidural Hematoma: A Case-Control Study

BACKGROUND

Symptomatic postoperative spinal epidural hematomas (PEDHs) are rare complications, with significant implications on patients' functional outcomes. Strategies for PEDH prevention are poorly understood. This study sought to evaluate preoperative and intraoperative variables predicting the risk of PEDH and patients' functional outcomes after PEDH evacuation.

METHODS

This is a single institution study of all patients with PEDH requiring reoperation and matched controls over a 6-year period. The incidence of PEDH was calculated by region and operative technique. The preoperative and intraoperative parameters of 40 patients and 40 matched controls were compared.

RESULTS

A total of 5941 spine surgeries and 40 patients with symptomatic PEDH requiring reoperation were identified (0.67% overall incidence). The highest incidence of PEDH was observed after minimally invasive lumbar laminectomies. Higher preoperative diastolic blood pressure was a risk factor for PEDH. Of the 17 PEDH patients in whom a drain was placed at the time of index surgery, 8 patients (47%) still had the drain in place at the time of diagnosis of PEDH. Among the posterior index approaches, 18 patients (51.43%) (1 cervicothoracic and 17 lumbar) did not develop paresis at the time of PEDH diagnosis. Seventeen patients (48.57%) (9 cervicothoracic and 8 lumbar) developed paresis. Ten of the patients with paresis had complete resolution of motor weakness, whereas 7 never achieved complete resolution.

CONCLUSIONS

Although the incidence of PEDH was less than 1%, nearly half of the patients developed motor weakness as a presenting symptom and a third of the patients never had resolution of the weakness.

The utility of surgical drains in adult and pediatric posterior spinal fusion: systematic review and meta-analysis

Surgical drains are utilized in spinal surgery to reduce the incidence of epidural hematomas (EDHs) and to facilitate optimal wound healing. Despite their widespread use, there is a paucity of data to support their utility. The goal of this systematic review and meta-analysis is to compare the effect of using drains versus no drains on postoperative outcomes in adult and pediatric patients undergoing posterior spinal fusions for deformity or degenerative conditions. The following outcomes were assessed: SSIs, EDHs, reoperations, transfusions, and length of stay (LOS). A systematic review of the literature in databases was conducted for all relevant literature. Exclusion criteria included single level decompressions, minimally invasive fusions, anterior-only approaches, and any surgical procedures performed for tumor, trauma, and osteomyelitis. Forest plots for Odds Ratios (ORs) and Mean Differences (MDs) were generated using random effects model. The search identified 2,210 titles, of which 11 studies were chosen for final analysis. 5 studies involved pediatric patients, while 6 included adult patients. A total of 3293 patients were analyzed-2,060 had a drain, and 1,233 had no drain. There were no statistically significant differences in the ORs of SSIs, EDHs, reoperations, and transfusions. LOS in adults was higher in the Drain group (MD 1.36 days 95% CI 0.25 - 2.47). This meta-analysis found no benefit in surgical drains in posterior spinal fusion in reducing the incidence of SSI, EDH, and reoperation. Drains may be associated with longer LOS in the adult population. PROSPERO registration number: CRD42023417315.

The safety of perioperative antiplatelet continuation without selection biases in microsurgical decompression surgery for single level lumbar spinal stenosis and lumbar disc herniotomy

PURPOSE

Each institution or physician has to decide on an individual basis whether to continue or discontinue antiplatelet (AP) therapy before spinal surgery. The purpose of this study was to determine if perioperative AP continuation is safe during single-level microsurgical decompression (MSD) for treating lumbar spinal stenosis (LSS) and lumbar disc hernia (LDH) without selection bias.

METHODS

Patients who underwent single-level MSD for LSS and LDH between April 2018 to December 2022 at our institute were included in this retrospective study. We collected data regarding baseline characteristics, medical history/comorbidities, epidural hematoma (EDH) volume, reoperation for EDH, differences between preoperative and one-day postoperative blood cell counts (ΔRBC), hemoglobin (ΔHGB), and hematocrits (ΔHCT), and perioperative thromboembolic complications. Patients were divided into two groups: the AP continuation group received AP treatment before surgery and the control group did not receive antiplatelet medication before surgery. Propensity scores for receiving AP agents were calculated, with one-to-one matching of estimated propensity scores to adjust for patient baseline characteristics and past histories. Reoperation for EDH, EDH volume, ΔRBC, ΔHGB, ΔHCT, and perioperative thromboembolic complications were compared between the groups.

RESULTS

The 303 enrolled patients included 41 patients in the AP continuation group. After propensity score matching, the rate of reoperation for EDH, the EDH volume, ΔRBC, ΔHGB, ΔHCT, and perioperative thromboembolic complication rates were not significantly different between the groups.

CONCLUSION

Perioperative AP continuation is safe for single-level lumbar MSD, even without biases.

Thoracolumbar fractures patients undergoing posterior pedicle screw fixation can benefit from drainage

PURPOSE

To explore whether it is necessary to put drain tubes after posterior pedicle screw fixation of thoracolumbar fractures.

METHODS

From April 2020 to January 2023, a total of 291 patients with recent thoracolumbar fractures (AO type-A or type-B) who received the pedicle screw fixation operation were enrolled retrospectively. In 77 patients, drain tubes were used in the pedicle screw fixation surgery, while no drain tubes were placed in the other group. After gleaning demographic information and results of lab examination and imageology examination, all data were put into a database. Independent-sample t-tests, Pearson Chi-Square tests, Linear regression analysis, and correlation analysis were then performed.

RESULTS

Compared to the control group, the drainage group had significantly lower postoperative CRP levels (P = 0.047), less use of antipyretics (P = 0.035), higher ADL scores (P = 0.001), and lower NRS scores (P < 0.001) on the 6th day after surgery. Other investigation items, such as demographic information, operation time, intraoperative blood loss, body temperature, and other preoperative and postoperative lab results, showed no significant differences.

CONCLUSIONS

The use of a drain tube in the pedicle screw fixation of thoracolumbar fractures is correlated with the improvement of patients' living and activity ability and the reduction of inflammation, postoperative fever and pain.

Development of a Modified Bayonet Forceps for Improving Steerability of Paddle Lead Electrodes During Spinal Cord Stimulator Surgery: A Technical Note

BACKGROUND AND OBJECTIVE

Despite recent advancements in spinal cord stimulation (SCS) technology, the surgical instrumentation for placement of SCS paddle leads remains suboptimal. Therefore, we developed a novel instrument to improve the steerability of SCS paddle leads during surgical placement.

METHODS

A review of existing literature was performed to analyze workflow deficiencies in the standard instrumentation of SCS paddle lead placement. After a period of adaptation and iterative feedback with a medical instrument company, a new instrument was developed, tested at benchtop, and successfully incorporated into the surgical routine.

RESULTS

A standard bayonet forceps was modified to include hooked ends and a ribbed surface, providing the surgeon with greater control over the paddle lead. The new instrument also included bilateral metal tubes starting approximately 4 cm proximal from the edge of the forceps. The bilateral metal tubes, through which the SCS paddle lead wires are passed, serve as anchors to keep the wires away from the incision site. In addition, it permitted the paddle lead to assume a bent configuration, reducing its overall size and allowing it to be placed through a smaller incision and laminectomy. The modified bayonet forceps was successfully used intraoperatively for placement of SCS paddle lead electrodes in several surgeries.

CONCLUSION

The proposed modified bayonet forceps increased steerability of the paddle lead, facilitating optimal midline placement. The bent configuration of the device facilitated a more minimally invasive surgical approach. Future studies are needed to validate our single-provider experience and evaluate the impact of this new instrument on operating room efficiency.

Complications associated to wound drainages in tumor spine surgery: a multicenter surveillance study from the German Spine Registry (DWG-Register)

There is an ongoing debate whether a surgical drainage is beneficial to prevent local accumulation of hematoma and to reduce the rate of wound infections, and neurological deficits. Data from the German Spine Society (DWG) registry were filtered for surgically treated spine tumor cases between 2017 and 2021. Cases were categorized into with (Group I) and without (Group II) placement of a surgical drainage. Subgroups were compared for demographic data, type of surgery, experience of the surgeon and postoperative surgical complications. 10,029 cases were included into final analysis (Group I: 3007; Group II: 7022). There was no significant difference between both groups regarding age or gender distribution. Average morbidity of patients was significantly elevated in Group I (p < 0.05) and the rates of invasive surgery were significantly increased in this group (p < 0.001). Overall complication rates were reported with 12.0% (Group I) and 8.5% (Group II). There were significantly more epidural hematoma (p < 0.001) and motor dysfunction (p = 0.049) as well as deep wound infections (p < 0.001) and implant failures (p = 0.02) in Group I. A surgical wound drainage cannot prevent epidural hematoma.

The Effect of Tranexamic Acid on Operative and Postoperative Blood Loss in Transforaminal Lumbar Interbody Fusions

OBJECTIVE

The purpose of this retrospective cohort study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF). Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for patients who undergo 1- to 3-level TLIF.

METHODS

All patients requiring 1- to 3-level TLIF who received a preoperative loading dose of TXA were grouped and compared with patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with χ², Kruskal-Wallis, or analysis of variance tests, depending on normality and data type. Multiple linear regressions were developed to determine independent predictors of the estimated blood loss (EBL), total blood loss, drain output, and length of stay. Statistical significance was set at P < 0.05.

RESULTS

Patients who received preoperative TXA had more comorbidities (P = 0.006), longer surgery length (P < 0.001), and longer length of stay (P = 0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (P < 0.001, P = 0.001, P = 0.007, P < 0.001, respectively), but was not associated with a change in EBL, total blood loss, or length of stay.

CONCLUSIONS

The application of preoperative TXA for patients undergoing 1- to 3-level TLIF reduced drain output in the first 2 postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL.