The Role of Drains in Lumbar Spine Fusion

Do Superficial Drains Make a Difference After Lumbar Fusion Surgery? A Prospective, Randomized Trial

STUDY DESIGN

A prospective, randomized study.

OBJECTIVE

The goal of this study was to evaluate the impact that subcutaneous drains have on patient satisfaction and postoperative recovery after a lumbar fusion surgery.

SUMMARY OF BACKGROUND DATA

The use of drains following lumbar fusion surgery is controversial. Current literature shows that there are both benefits and drawbacks to using deep drains, however, there are no reports on the utility of superficial drains.

METHODS

One hundred ten patients undergoing a 1 to 3-level fusion by a single surgeon were randomly selected to receive either a subcutaneous drain (55 patients) or no drain (55 patients). Drain output was collected 1, 3, and 5 days after the procedure. Drains were removed 5 days after the surgery so long as the output was <50 ccs in a 24-hour period. Patient demographics, drain outputs, and questionnaire data from 10, 30, and 60 days after the procedure were compared.

RESULTS

Patients receiving a superficial drain were significantly less likely to have incisional drainage (P<0.01) and tended to be less anxious about their wound healing (P=0.06). There was no difference between drain and no drain groups in terms of postoperative complications, wound care satisfaction, level of independence, or need for outside medical assistance. Body mass index (BMI) and wound thickness did not impact the volume of drain output or other results.

CONCLUSIONS

Subcutaneous drains significantly decrease incisional leakage and tend to decrease patient anxiety regarding wound healing. The presence of a postoperative drain does not diminish patient satisfaction with wound healing.

Advancing the timing of drainage removal: a comprehensive analysis of different drainage removal criteria in patients undergoing short-level lumbar fusion surgery

OBJECTIVE

To specifically evaluate the safety and benefit of different drainage removal criteria (50 ml and 100 ml per 24 h) in patients undergoing short-level lumbar fusion surgery.

METHODS

Patients with degenerative lumbar diseases who underwent short level lumbar fusion with instrumentation between January 2021 and January 2023 were retrospectively recruited in the study. Based on the different criteria for drainage removal, the patients were divided into 2 groups (group A and group B). To control for confounding factors, a 1:1 nearest propensity score matching of significant variation, especially age, gender, BMI, number of fused levels, intraoperative blood loss, and surgical duration, were performed between groups. Perioperative outcomes were compared between groups. Multivariate logistic regression was performed to determine the risk factors for overall complications.

RESULTS

A total of 1004 eligible patients were reviewed in this study with 676 patients in group A and 328 patients in group B. After propensity score matching, 616 patients, 308 in each group were included in the final analysis. There were significantly more patients getting drainage removed on POD 2 (23.1% vs. 32.1%, p = 0.012) and POD 3 (37.0% vs., 45.1%, p = 0.041) in group B. In addition, patients in group B had earlier postoperative timing of ambulation (3.87 ± 1.12 vs. 2.41 ± 1.34, p = 0.012). No significant difference in symptomatic hematoma and surgical site infection was observed, but there were significant fewer overall complications (10.39% vs. 5.19%, p = 0.016) in the group B. Multivariate logistic regression indicated that postoperative timing of ambulation (OR 2.38, 95% CI 1.19-3.97, p < 0.001) was independently associated with overall complications.

CONCLUSION

In this study, we found that the relaxation of the criteria for drainage removal could significantly shorten the length of stay, in addition, it could promote early postoperative ambulation of patients and thus reduce the occurrence of perioperative overall complications.

Role of Spinal Surgery Drainage Techniques in Postoperative Outcomes: Insights From a Comprehensive Literature Review

Postoperative management often demands the introduction of several strategies in an attempt to minimize complication rates. One of the routine strategies includes the use of spinal drains, which have been questioned for their efficacy in improving postoperative outcomes. However, its role in postoperative outcomes is still debated. In general, this elucidation of an extensive literature review supports the synthesis of current evidence regarding the role of spinal drains in infection rates, hematoma formation, and overall patient recovery. A comprehensive search of PubMed from 2000 to 2024 was performed, focusing on studies investigating the use of spinal drains in spinal surgeries and their associated postoperative outcomes. It followed the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The inclusion criteria were studies related to spinal surgeries, excluding case reports, reviews, and editorials, and limited to articles published in English. Quality assessment was performed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. A total of 19 studies were included, with different designs and varied sample sizes. The sample size was from 25 to 2,446 patients. Findings on infection rates were mixed; while one group of studies showed no significant differences in patients with and without drains, another group showed a reduced rate of reoperation for surgical site infections in patients with drains. In general, hematoma formation rates were reported to be the same across groups, while a few studies indicated that drains were more effective in managing wound exudates compared to no drains. Recovery outcomes indicated that patients who had a wound drain were more likely to stay in the hospital longer, although an improvement was noticed with time-driven wound drain removal, which resulted in shorter hospital stays and earlier ambulation. The use of spinal drains in postoperative spinal surgery presents both benefits and drawbacks. Spinal drains can assist in the management of wound exudates, and earlier detection of infection complications increases hospital stays and complications. Indeed, whether to use spinal drains or not should be an individual decision, weighing the potential benefits and risks. Future studies need to be done in order to establish clear guidelines for the use of drainage systems in various spinal surgical cases.

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.

Similar Short-Term Outcomes of Adolescent Idiopathic Scoliosis Surgery with or without Drainage: A Systematic Review of the Literature and Meta-Analysis

The use of closed suction drains post posterior spinal fusion for adolescent idiopathic scoliosis (AIS) is common practice, although evidence on its impact is limited compared to that for knee and hip arthroplasty. This study aimed to assess the effect of closed suction drainage on short-term post-operative outcomes in AIS surgery. A systematic review following PRISMA guidelines was conducted, including studies comparing outcomes with and without drainage. Data on blood loss, transfusions, hospital stay, and complications were collected and subjected to meta-analysis. Five studies involving 772 patients were analyzed. The meta-analysis found no significant difference in blood transfusion rates (p = 0.107) or hospital stay (p = 0.457) between groups. Complications, including surgical site infections, were more common without drainage, though not statistically significant (p = 0.356). Reintervention rates were higher in the no-drainage group, but not significantly (p = 0.260). Overall, this review found no significant short-term outcome differences, suggesting clinical judgment should guide drainage decisions. Further research, particularly with enhanced recovery protocols, is warranted to clarify drainage's role in AIS surgery.

Effect of wound drainage on the wound infection and healing in patients undergoing spinal surgery: A meta-analysis

A meta-analysis was conducted to comprehensively evaluate the impact of wound drainage on postoperative wound infection and healing in patients undergoing spinal surgery. Computer searches were performed, from database inception to October 2023, in EMBASE, Google Scholar, Cochrane Library, PubMed, Wanfang and China National Knowledge Infrastructure databases for studies related to the application of wound drainage in spinal surgery. Two researchers independently screened the literature, extracted data and conducted quality assessments. Stata 17.0 software was employed for data analysis. Overall, 11 articles involving 2102 spinal surgery patients were included. The analysis showed that, compared to other treatment methods, the use of wound drainage in spinal surgery patients significantly shortened the wound healing time (standardized mean difference [SMD]: -1.35, 95% confidence intervals [CI]: -1.91 to -0.79, p < 0.001). However, there was no statistical difference in the incidence of wound infection (odds ratio: 1.35, 95% CI: 0.83-2.19, p = 0.226). This study indicates that wound drainage in patients undergoing spinal surgery is effective, can accelerate wound healing and is worth promoting in clinical practice.

Natural language processing for the automated detection of intra-operative elements in lumbar spine surgery

Background

The aim of this study was to develop natural language processing (NLP) algorithms to conduct automated identification of incidental durotomy, wound drains, and the use of sutures or skin clips for wound closure, in free text operative notes of patients following lumbar surgery.

Methods

A single-centre retrospective case series analysis was conducted between January 2015 and June 2022, analysing operative notes of patients aged >18 years who underwent a primary lumbar discectomy and/or decompression at any lumbar level. Extreme gradient-boosting NLP algorithms were developed and assessed on five performance metrics: accuracy, area under receiver-operating curve (AUC), positive predictive value (PPV), specificity, and Brier score.

Results

A total of 942 patients were used in the training set and 235 patients, in the testing set. The average age of the cohort was 53.900 ± 16.153 years, with a female predominance of 616 patients (52.3%). The models achieved an aggregate accuracy of >91%, a specificity of >91%, a PPV of >84%, an AUC of >0.933, and a Brier score loss of ≤0.082. The decision curve analysis also revealed that these NLP algorithms possessed great clinical net benefit at all possible threshold probabilities. Global and local model interpretation analyses further highlighted relevant clinically useful features (words) important in classifying the presence of each entity appropriately.

Conclusions

These NLP algorithms can help monitor surgical performance and complications in an automated fashion by identifying and classifying the presence of various intra-operative elements in lumbar spine surgery.

Reducing drain use with paraspinal muscle flaps for spinal closures: A retrospective cohort study

BACKGROUND

Paraspinal muscle (PSM) flaps can be mobilized with superficial undermining and lateral release from the thoracolumbar fascia and/or deep undermining and medial release from the transverse processes and ribs. The objective of the study was to compare the effect of the PSM flap technique on drain use, retention, and complication rates.

METHODS

A retrospective chart review was performed for patients who underwent spinal coverage with PSM flaps at a single institution from April 2020 to June 2021. Patient demographics, preoperative comorbidities, surgical technique, drain usage, and postoperative complications were analyzed to compare the effects of different PSM flap surgical techniques on postoperative drain use and complications.

RESULTS

Sixty patients were included. Both superficial and deep releases were performed in half (47%) of the cases, while the remainder was split between superficial (25%) and deep (28%) releases. Drains were used less frequently for the deep release (35%) than the superficial (93%) or both releases (96%, p < 0.01). The deep release had shorter mean drain retention time (5.8 days) than the superficial (30.3 days) or both releases (24.8 days, p < 0.01). There were no significant differences between the techniques in terms of complications. For the deep release, the use of drains was not associated with a reduction in complications (odds ratio 0.91 [0.84 - 0.98], p = 0.97).

CONCLUSIONS

In a selected patient population, a "deep release only" PSM flap technique may allow for drainless spinal closure without an increased risk of seroma or other complications.

Treatment of cerebrospinal fluid leakage with prolonged use of subfascial epidural drain and antibiotics in patients of thoracic myelopathy after posterior decompression surgery

Background

Cerebrospinal fluid leakage (CSFL) is a prevalent and vexing complication associated with spine surgery. No standard protocol is available guiding CSFL management, especially for thoracic CSFL. The aim of this study was to retrospectively evaluate the efficacy of prolonged use of subfascial epidural drain and antibiotics to treat CSFL after posterior thoracic decompression surgery.

Methods

Fifty-six patients with an average age of 52.3 years (24-76 years), who underwent thoracic decompression with CSFL (group A) and 65 patients with an average age of 54.9 years (25-80 years) without CSFL (group B) were retrospectively reviewed. Patients in group A had prolonged use of subfascial drainage and antibiotics and patients in group B were treated with conventional methods. The surgical results and rate of wound related complications was compared between the two groups.

Results

The average subfascial drainage time was 7.0 ± 2.7 days (2-16 days) and 3.8 ± 1.4 days (2-7 days) in group A and B, respectively. Higher occupation rate (>49%), presence of dural ossification and higher MRI grade (>2) were more likely to presented with CSFL. In group A, four patients (7.1%) presented with deep wound infection and were successfully managed with wound debridement or intravenous antibiotics. In group B, one patient (1.5%) had a superficial wound infection and was treated with antibiotics. No patients presented with wound dehiscence, wound exudation or CSF fistulation.

Conclusion

The occupation rate of ossified mass and presence of dural ossification were the major risk factors of CSFL. No significant difference in infection rates was observed between the patients in group A and B.

Natural pressure drainage versus negative pressure drainage following transforaminal lumbar interbody fusion (TLIF) for the treatment of lumbar degeneration disease: a prospective cohort study

OBJECTIVE

To comprehensively compare the perioperative data and clinical outcomes of natural pressure drainage (NAPD) and negative pressure drainage (NEPD) following transforaminal lumbar interbody fusion (TLIF) for the treatment of lumbar degeneration disease.

METHODS

Between January 2021 and December 2021, 203 patients in our hospital who underwent single- or two-segment TLIF were assigned to the NAPD group (112 patients) or the NEPD group (91 patients) based on different postoperative drainage methods. Between the two groups, comparisons were made regarding the demographics, intraoperative and postoperative data, patient-reported outcomes, and complications.

RESULTS

The NAPD group experienced less overall drainage and fewer postoperative drainage days (157.89 vs. 318.49 ml/249.54 vs. 589.43 ml, 2.00 vs. 2.67 days/2.04 vs. 2.74 days, P < 0.001) than the NEPD group. The NAPD group has a higher rate of overall hidden blood loss (HBL) than the NEPD group (63.98% vs. 51.90%/65.80% vs. 48.11%, P < 0.001); HBL, however, did not significantly differ between the two groups (P > 0.05). In two-segment surgery, the postoperative hemoglobin (HGB) levels were higher in the NAPD group (99.67 vs. 92.69 g/L, P < 0.05), but there was no difference in single-segment surgery (P > 0.05). Regardless of whether single- or two-segment surgery was performed, the NAPD group had a lower HGB level loss (18.81% vs. 21.63%/26.35% vs. 32.08%, P < 0.05). There was no discernible difference between the two groups in the visual analog scale (VAS) scores for symptomatic epidural hematoma, postoperative body temperature, low back and leg pain, or incision infection (P > 0.05).

CONCLUSION

NAPD did not increase postoperative complications but did significantly reduce postoperative drainage volume and the risk of anemia. We show that, when compared to NEPD, NAPD may be a better option for patients following TLIF.

Comparative study on the selection of drainage methods in posterior lumbar interbody fusion

OBJECTIVE

To compare and analyze the clinical effects of bilateral natural pressure drainage and negative pressure drainage after posterior lumbar interbody fusion (PLIF) to provide a reference for selecting drainage methods after lumbar surgery.

METHODS

A retrospective cohort study, 281 patients who underwent single-segment PLIF in our hospital from January 2017 to December 2020 and met the inclusion and exclusion criteria were included in the study, including 132 males and 149 females, aged 22-85 years, with an average of (53.62 ± 11.23) years. According to different postoperative incision drainage methods determined by the random number table method before surgery, they were divided into the natural pressure drainage group and negative pressure drainage group, both of which were bilateral drainage. The general observation indexes and perioperative-related indexes were recorded and analyzed.

RESULTS

There were 143 cases in the natural pressure drainage group and 138 cases in the negative pressure drainage group. There was no significant difference in age, gender, body mass index, disease type, blood pressure on the day of surgery, preoperative albumin, hemoglobin, platelet, prothrombin time, and intraoperative bleeding between the two groups (P > 0.05). The albumin on the first postoperative day in the natural pressure drainage group was higher than that in the negative pressure drainage group [(33.24 ± 3.52) vs. (32.17 ± 5.03), P < 0.05]; The hemoglobin on the first postoperative day in the natural pressure drainage group was higher than that in the negative pressure drainage group [(126.01 ± 15.03) vs. (115.19 ± 16.25), P < 0.01]; The drainage volume on the first postoperative day in the natural pressure drainage group was lower than that in the negative pressure drainage group [(93.25 ± 63.58) ml vs. (119.46 ± 54.48) ml, P < 0.01]; The total postoperative drainage volume in the natural pressure drainage group was lower than that in the negative pressure drainage group [(355.60 ± 189.69) ml vs. (434.37 ± 149.12) ml, P < 0.01]; The indwelling time of drainage tube in the natural pressure drainage group was lower than that in the negative pressure drainage group [(3.29 ± 1.17) d vs. (3.45 ± 0.97) d, P < 0.05]. There was no significant difference in platelet count on the first postoperative day, postoperative hospital stays, and complications (incision infection and hematoma) between the two groups (P > 0.05).

CONCLUSION

Bilateral natural pressure drainage and negative pressure drainage can achieve good drainage effects after PLIF, but patients with natural pressure drainage have less loss of albumin and hemoglobin, less drainage volume, and shorter drainage tube indwelling time, which is worthy of clinical application.

The Influence of Systolic Blood Pressure at the Time of Extubation on the Development of Postoperative Spinal Epidural Hematoma

Background

The most common cause of neurological complications after a biportal endoscopic spine surgery (BESS) is postoperative spinal epidural hematomas (POSEH). The objective of this study was to determine the influence of systolic blood pressure at extubation (e-SBP) on POSEH.

Methods

A total of 352 patients who underwent single-level decompression surgery including laminectomy and/or discectomy with BESS under the diagnosis of spinal stenosis and herniated nucleus pulposus between August 1, 2018, and June 30, 2021, were reviewed retrospectively. The patients were divided into two, a POSEH group and a normal group without POSEH (no neurological complication). The e-SBP, demographic factors, and the preoperative and intraoperative factors suspected to influence the POSEH were analyzed. The e-SBP was converted to a categorical variable by the threshold level that was decided by maximum area under the curve (AUC) in receiver operating characteristic (ROC) curve analysis. Antiplatelet drugs (APDs) were taken in 21 patients (6.0%), discontinued in 24 patients (6.8%), and not taken in 307 patients (87.2%). Tranexamic acid (TXA) was used in 292 patients (83.0%) in the perioperative period.

Results

Of the 352 patients, 18 patients (5.1%) underwent revision surgery for the removal of POSEH. The POSEH and normal groups were homogenous in age, sex, diagnosis, operation segments, operation time, and lab findings that were related to blood clotting, whereas there were differences in e-SBP (163.7 ± 15.7 mmHg in POSEH group and 154.1 ± 18.3 mmHg in normal group), APD (4 takers, 2 stoppers, 12 non-takers in POSEH group and 16 takers, 22 stoppers, 296 non-takers in normal group), and TXA (12 use, 6 not use in POSEH group and 280 use, 54 not use in normal group) in single variable analysis. The highest AUC in the ROC curve analysis was 0.652 for 170 mmHg e-SBP (p < 0.05). There were 94 patients in the high e-SBP group (≥ 170 mmHg) and 258 patients in the low e-SBP group. In multivariable logistic regression analysis, only high e-SBP was a significant risk factor for POSEH (p = 0.013; odds ratio, 3.434).

Conclusions

High e-SBP (≥ 170 mmHg) can influence the development of POSEH in biportal endoscopic spine surgery.

Wound drain in lumbar arthrodesis for degenerative disease: an experimental, multicenter, randomized controlled trial

INTRODUCTION

Drains for surgical wound management are frequently used in spine surgery. They are often used to decrease the incidence of postoperative hematoma and decrease wound tension. No conclusive evidence in the literature supports using drains to avoid complications in degenerative lumbar spine surgery.

PURPOSE

We aimed to evaluate wound drains in patients with lumbar arthrodesis for degenerative disorders based on clinical outcomes, complications, hematocrit, and length of stay.

STUDY DESIGN

A multicenter randomized prospective controlled clinical trial.

PATIENT SAMPLE

We enrolled surgical candidates for posterior lumbar decompression and fusion surgery for degenerative disorders from October 2019 to August 2021. Patients were randomized into the drain or nondrain group at nine hospitals. The inclusion criteria were as follows: patients aged 40 to 80 years with lumbar and radicular pain, lumbar degenerative disorder, and primary surgery up to three levels. The exclusion criteria were bleeding abnormalities, bleeding >2,500 mL and dural tears.

OUTCOME MEASURES

Preoperative data including Oswestry disability index (ODI), SF-36, lumbar and lower extremity visual analog scale (VAS), body mass index (BMI), hematocrit, and temperature were recorded. Surgical parameters, including surgical time, complications, estimated blood loss (EBL), postoperative temperature and hematocrit (days 1 and 4), dressing saturation, and length of hospital stay (LOS), were registered.

METHODS

The two groups were assessed preoperatively, perioperatively and at the 1-month follow-up. A REDCap database was used for registration. Data analysis was performed using classical statistics.

RESULTS

One hundred one patients were enrolled using the Redcap database, and 93 patients were evaluated at the final follow-up. Forty-five patients were randomized to the drain group, and 48 were randomized to the nondrain group. The preoperative characteristics were equivalent in both groups: demographic aspects, pain, ODI, SF-36, BMI, hematocrit, and spine pathology. Surgical time, EBL and complications were similar, with no difference between the groups. No difference was found between BMI and complications. No difference was observed in dressing saturation or postoperative temperature between the groups. The postoperative day 4 hematocrit was higher in the nondrain group [36.4% (32-39)] than in the drain group [34% (29.7-37.6)] without statistically differences (p=.054). The LOS was higher in the drain group [4 (3-5) days] than in the nondrain group [3 (2-4) days] (p=.007). The quality-of-life score, SF-36, was higher in the nondrain group [67.9 (53.6-79.2)] than in the drain group [56.7 (49.1-66)] (p=.043).

CONCLUSIONS

Nondrain patients presented shorter LOS and better outcomes, with similar complication rates. No difference was found between BMI and complications. Based on this study, in patients undergoing primary posterior spinal decompression and fusion up to three levels for degenerative lumbar disorders, we do not recommend the use of postoperative drains.

Negative versus natural drainage after single-level posterior lumbar interbody fusion. A prospective randomized study

Introduction

Despite of their extensive use, drains remain controversial without clear guidelines, and there is unclear evidence on drain use in spine procedures. Negative pressure drainage is theoretically more effective in preventing postoperative hematomas. On the contrary, it may result in excessive drainage and blood loss.The aim of this study was to compare the outcome between the uses of negative versus natural drainage in single level posterior lumbar interbody fusion (PLIF).

Research question

The aim is to compare between negative versus natural drainage after single-level PLIF as regard to postoperative wound infection, wound healing, temperature, pain and neurological deficits.

Materials and methods

A prospective randomized study of consecutive PLIF patients at a single level for lumbar disc prolapse was performed between January 2019 and January 2020. The patients were randomly assigned to either the negative suction drainage group or natural drainage group. Negative suction was created by maximum compression of the reservoir to create negative pressure. In the other group, natural pressure drainage was kept without any negative pressure.Our study included a total of 62 patients who met the inclusion criteria. They were divided into two groups; 33 patients had negative suction drains and 29 patients had natural drainage. There were 32 female (51.6%) and 30 male (48.4%). Their ages ranged between of 23-69 years, with a mean age of 42.11 ​± ​8.89 years.

Results

Drainage volume was statistically higher in the negative group on the day of surgery (day 0) as well as the 1st and second days after. However, no significant differences were observed as regards to postoperative temperature, pain, wound infection, temperature, or neurological deficits.

Discussion &conclusion

In this prospective randomized study, our results revealed that natural drainage in short term can reduce the total amount of blood in the drain, and therefore the blood loss without significant differences in postoperative wound infection, wound healing, temperature, pain, or neurological deficits in single-level PLIF.

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.

Symptomatic Postoperative Epidural Hematoma in the Lumbar Spine

A symptomatic postoperative epidural hematoma (SPEH) in the lumbar spine is a complication with variable presentation and the potential to rapidly cause an irrecoverable neurological injury. Significant heterogeneity exists among current case series reporting SPEH in the literature. This review attempts to clarify the known incidence, risk factors, and management pearls. Currently, literature does not support the efficacy of subfascial drains in reducing the incidence of SPEHs and possibly suggests that medication for thromboembolism prophylaxis may increase risk. Acute back pain and progressing lower extremity motor weakness are the most common presenting symptoms of SPEH. Magnetic resonance imaging is the mainstay of diagnostic imaging necessary to confirm the diagnosis, but if not acutely available, an immediate return to the operative theater for exploration without advanced imaging is justified. Treatment of a SPEH consists of emergent hematoma evacuation as a delay in repeat surgery has a deleterious effect on neurological recovery. Outcomes are poorly defined, though a significant portion of patients will have lasting neurological impairments even when appropriately recognized and managed.

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

PURPOSE

The considered benefit of surgical drain use after spinal surgery is to prevent local accumulation of a haematoma by decompressing the closed space in the approach of the surgical site. In this context, the aim of the present systematic review was to prove the benefit of the routine use of closed-suction drains.

METHODS

We conducted a comprehensive systematic review of the literature according to the Preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist and algorithm.

RESULTS

Following the literature search, 401 potentially eligible investigations were identified. Eventually, a total of 24 studies with 8579 participants were included. Negative suction drainage led to a significantly higher volume of drainage fluid. Drainage duration longer than 72 h may be associated with a higher incidence of Surgical side infections (SSI); however, accompanying antibiotic treatment is unnecessary. Regarding postoperative haematoma and neurological complications, no evidence exists concerning their prevention. Hospital stay length and related costs may be elevated in patients with drainage but appear to depend on surgery type.

CONCLUSIONS

With regard to the existing literature, the use of closed-suction drainage in elective thoracolumbar spinal surgery is not associated with any proven benefit for patients and cannot decrease postoperative complications.

Lumbar surgical drains do not increase the risk of infections in patients undergoing spine surgery

PURPOSE

The aim of this study was to characterize if the use of surgical drains or length of drain placement following spine surgery increases the risk of post-operative infection.

METHODS

Records of patients undergoing elective spinal surgery at a tertiary care center were collected between May 5, 2016 and August 16, 2018. Pre-operative baseline characteristics were recorded including patient's demographics and comorbidities. Intraoperative procedure information was documented related to procedure type, blood loss, and antibiotics used. Following surgery, patients were then further subdivided into two groups: patients who were discharged with a spinal surgical site drain and patients who did not receive a drain. Post-operative surgical variables included length of stay (LOS), drain length, number of antibiotics given, and type of post-operative infection. Univariate and multivariate statistical analysis was conducted.

RESULTS

A total of 671 patients were included in the current study, 386 (57.5%) with and 285 (42.5%) without the drain. The overall infection rate was 5.7% with 6.22% among patients with the drain compared to 4.91% in patients without drain. The univariate analysis identified the following variables to be significantly associated with the infection: total number of surgical levels, spinal region, blood loss, redosing of antibiotics, length of stay, length of drain placement, and number of antibiotics (P < 0.05). However, the multivariate analysis none of the predictors was significant.

CONCLUSIONS

The current study shows that the placement of drain does not increase rate of infection, irrespective of levels, length of surgery, or approach.

Risk Factors for Increased Surgical Drain Output After Transforaminal Lumbar Interbody Fusion

OBJECTIVE

To investigate the risk factors for increased surgical drain output after transforaminal lumbar interbody fusion (TLIF).

METHODS

Patients who underwent TLIF in a single center from June 2017 to January 2020 were included in this study. They were divided into the increased surgical drain output group and no increased surgical drain output group according to the boundary of the median drain output. Patients' demographic and clinical parameters were compared between the 2 groups. Risk factors for increased surgical drain output were identified by univariate and multivariate logistic regression analysis.

RESULTS

This study enrolled 368 patients who underwent TLIF. Among them, 187 patients had increased surgical drain output (drain output ≥50th percentile or 480 mL). Univariate analysis showed that age (P < 0.001), smoking status (P = 0.002), number of fused levels (P < 0.001), intraoperative blood loss (P < 0.001), intraoperative end plate injury (P < 0.001), administration of tranexamic acid (TXA) (P = 0.002), and surgical duration (P < 0.001) were significantly associated with increased surgical drain output. Multiple logistic regression analysis revealed that older age (P = 0.001), smoking (P = 0.005), more fused levels (P < 0.001), and intraoperative end plate injury (P = 0.017) were the independent risk factors, while administration of TXA (P = 0.012) was a protective factor.

CONCLUSIONS

This study showed that older age, smoking, more fused levels, and intraoperative end plate injury were the independent risk factors, while administration of TXA was a protective factor for increased surgical drain output after TLIF.

Which Criterion for Wound Drain Removal is Better Following Posterior 1-Level or 2-Level Lumbar Fusion With Instrumentation: Time Driven or Output Driven?

STUDY DESIGN

Case-control study.

OBJECTIVES

To compare the outcomes of 2 different criteria (time driven and output driven) for wound drain removal and identify which one is better.

METHODS

743 patients who underwent posterior lumbar fusion with instrumentation involving 1 or 2 motion segments were enrolled in this study. Based on the different criteria for drain removal, the patients were divided into 2 groups. The drains were discontinued by time driven (postoperative day 2) in group I and output driven (<50 ml per day) in group II. Demographic characteristics, perioperative parameters and clinical outcomes were compared between the 2 groups.

RESULTS

The demographic characteristics in both groups were comparable. The postoperative drain output, total blood loss, postoperative timing of ambulation, and postoperative duration of hospital stay in group I were lower than those in group II (P < 0.001). There was a higher proportion of patients requiring postoperative blood transfusion in group II, but not to a level of statistical significance (P = 0.054). There was no statistical significant difference in the incidence of surgical site infection (SSI) or symptomatic spinal epidural hematoma (SEH) between the 2 groups (P > 0.05).

CONCLUSIONS

This study reveals that there are more benefits of wound drain removal by time driven than that by output driven for patients undergoing posterior 1-level or 2-level lumbar fusion with instrumentation, including less postoperative drain output, less total blood loss, earlier postoperative timing of ambulation and less postoperative duration of hospital stay without increasing the incidence of postoperative SSI or symptomatic SEH.

Epidural hemostasis by autologous fat graft in minimally invasive surgery for lumbar spinal stenosis: In vivo experimental study

BACKGROUND

Epidural hemostasis needs to use small, adapted material in minimally invasive surgery, including bilateral decompression via a unilateral approach for lumbar spinal stenosis. Most surgeons avoid external material for hemostasis because of possible neural tissue damage or complications. We compared epidural hemostasis in minimally invasive surgery by fat graft versus gelatin sponge.

METHODS

The design was a prospective randomized controlled in-vivo human experimental study. The 24 levels operated on for lumbar spinal stenosis were evaluated in two groups: Group A (control group: gelatin sponge) and Group B (experimental group: fat graft). International Normalized Ratio and Prothrombin Time were assessed preoperatively. Number of cotton hemostats and systolic and diastolic blood pressure were assessed intraoperatively. Epidural hemorrhage area, spinal cord size and ratio of epidural hemorrhage area to spinal cord size were evaluated on early postoperative lumbar MRI.

RESULTS

Mean epidural hemorrhage area in groups A and B was respectively 1.3±0.5 and 1.2±0.6cm², and mean spinal cord size 1.2±0.6 and 1.8±0.6cm² on early postoperative axial lumbar MRI. The two groups did not significantly differ in ratio of epidural hemorrhage/spinal cord size or number of intraoperative hemostats (P=0.36, and P=0.71).

CONCLUSIONS

The autologous fat graft ensured sufficient and safe epidural hemostasis without serious adverse events in minimally invasive spinal surgery, and is preferable as autologous tissue is easily and quickly harvested. The surgeon feels safe with this technique and does not need external hemostatic agents.

Risk-benefit analysis of wound drain usage in spine surgery: a systematic review and meta-analysis with evidence summary

STUDY DESIGN

Systematic review, meta-analysis, evidence synthesis.

OBJECTIVES

To analyse the literature evidence available to support the usage of wound drain in various scenarios of spine surgery and provide an evidence summary on the surgical practice.

MATERIALS AND METHODS

We conducted independent and duplicate electronic database searches adhering to PRISMA guidelines in PubMed, Embase, and Cochrane Library till April 2020. Quality appraisal was done as per Cochrane ROB tool, and evidence synthesis was done as per GRADE approach. Five domains of spine surgery with associated key questions were identified. Evidence tables were generated for each question and critical appraisal done as per the GRADE approach.

RESULTS

Twenty-three studies (9-RCTs, 4-prospective studies, 10-retrospective studies) were included. Analysis of studies in cervical spine either by anterior or posterior approach and single/multilevel thoracolumbar spinal surgeries did not show any evidence of reduction in surgical site infection (SSI) or haematoma formation with the use of drain. Deformity correction surgeries and surgeries done for trauma or tumour involving spine also did not find any added benefit from the use of wound drains despite increasing the total blood loss.

CONCLUSION

Evidence from this review suggests that routine use of drain in various domains of spine surgery does not reduce the risk of SSI and their absence did not increase the risk of haematoma formation. The current best evidence is presented with its limitations. High-quality studies to address their use in spine surgeries in cervical, trauma, and tumour domains are required to further strengthen the evidence synthesised from available literature.

Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary

BACKGROUND CONTEXT

There are three phases in prophylaxis of surgical site infections (SSI): preoperative, intraoperative and postoperative. There is lack of consensus and paucity of evidence with SSI prophylaxis in the postoperative period.

PURPOSE

To systematically evaluate the literature, and provide evidence-based summaries on postoperative measures for SSI prophylaxis in spine surgery.

STUDY DESIGN

Systematic review, meta-analysis, evidence synthesis.

METHODS

A systematic review conforming to PRIMSA guidelines was performed utilizing PubMed (MEDLINE), EMBASE, and the Cochrane Database from inception to January 2019. The GRADE approach was used for quality appraisal and synthesis of evidence. Six postoperative care domains with associated key questions were identified. Included studies were extracted into evidence tables, data synthesized quantitatively and qualitatively, and evidence appraised per GRADE approach.

RESULTS

Forty-one studies (nine RCT, 32 cohort studies) were included. In the setting of preincisional antimicrobial prophylaxis (AMP) administration, use of postoperative AMP for SSI reduction has not been found to reduce rate of SSI in lumbosacral spine surgery. Prolonged administration of AMP for more than 48 hours postoperatively does not seem to reduce the rate of SSI in decompression-only or lumbar spine fusion surgery. Utilization of wound drainage systems in lumbosacral spine and adolescent idiopathic scoliosis corrective surgery does not seem to alter the overall rate of SSI in spine surgery. Concomitant administration of AMP in the presence of a wound drain does not seem to reduce the overall rate of SSI, deep SSI, or superficial SSI in thoracolumbar fusion performed for degenerative and deformity spine pathologies, and in adolescent idiopathic scoliosis corrective surgery. Enhanced-recovery after surgery clinical pathways and infection-specific protocols do not seem to reduce rate of SSI in spine surgery. Insufficient evidence exists for other types of spine surgery not mentioned above, and also for non-AMP pharmacological measures, dressing type and duration, suture and staple management, and postoperative nutrition for SSI prophylaxis in spine surgery.

CONCLUSIONS

Despite the postoperative period being key in SSI prophylaxis, the literature is sparse and without consensus on optimum postoperative care for SSI prevention in spine surgery. The current best evidence is presented with its limitations. High quality studies addressing high risk cohorts such as the elderly, obese, and diabetic populations, and for traumatic and oncological indications are urgently required.

The role of drains in adolescent idiopathic scoliosis surgery: Is it necessary?

Close suction drainage systems are widely used in orthopedics and spine surgeries. There are less studies investigating the outcomes of using subfascial closed suction drains in adolescent patients who had undergone idiopathic scoliosis surgery. We evaluated the outcomes of patients with and without closed suction drainage and to investigate whether close suction drainage is needed after adolescent idiopathic scoliosis (AIS) surgery.We retrospectively investigated 63 patients, who underwent posterior spinal surgery for AIS from January 2015 to January 2018. The patients were divided into the following groups: Groups A (drainage group) and B (nondrainage group). We evaluated the wound drainage (wound oozing), need for transfusion, preoperative and postoperative hemoglobin levels, length of hospital stay, and postoperative blood loss from closed suction drains. Patients' scoliosis was categorized according to the Lenke Classification System for Scoliosis. The level of instrumentations was also evaluated.The median postoperative hemoglobin level was lower in group A than in group B. Postoperatively, group A underwent more blood transfusions than group B. Postoperative hospital stay was also significantly longer in group A than in group B. There was no statistical difference in the infection rate between the two groups.Using drains after AIS surgery increases hospital stay duration, blood transfusion rate and patients' anxiety of drain tube removal. Thus, closed suction drainage may not be suitable after AIS surgery.

Closed Wound Subfascial Suction Drainage in Posterior Fusion Surgery for Adolescent Idiopathic Scoliosis: A Prospective Randomized Control Study

STUDY DESIGN

A prospective randomized control study.

OBJECTIVE

The aim of this study was to compare the complication rate in adolescent idiopathic scoliosis (AIS) posterior spinal fusion (PSF) surgery with and without drainage.

SUMMARY OF BACKGROUND DATA

PSF is the mainstay of surgical treatment for AIS. Drains are commonly used despite contradictory findings in the literature for their having any clear advantage.

METHODS

A total of 100 AIS patients undergoing instrumented PSF were blindly randomized into two groups of either a deep drain or no drain. The collected data included wound follow-up findings, hemoglobin, hematocrit, vital signs and fever levels, and mean 20 months follow-up.

RESULTS

Fifty-two patients were randomly allocated to the "no drain" group and 48 to the "drain" group. There were no differences in patient characteristics, surgical data, and hemoglobin and hematocrit levels between the two groups. Only 4 units of packed cells were given in total. Fever during the first postoperative 1 to 3 days was equal, but increased in the no drain group on day 6 (P = 0.017). Length of hospitalization was equal (6 days) for all the patients. The mean follow-up period was 20 months [8.5-30.7 (SD 6.4)]. Complications included one case (1.9%) of pneumonia in the "no-drain" group, wound dehiscence in two cases (3.8%) in the "no-drain" group and in one case (2.1%) in the "drain" group, and two cases (3.8%) of superficial wound infection in the "no-drain" group. There was no case of deep infection in either group.

CONCLUSION

The current results indicate that there is no advantage to deep drainage in AIS patients undergoing PSF. The number of wound healing complications was low and identical for both the drain and no-drain groups.

LEVEL OF EVIDENCE

2.

The use of subfascial drains after multi-level anterior cervical discectomy and fusion: does the data support its use?

Background

Subfascial drains are routinely used after multi-level anterior cervical discectomy and fusion (ACDF) procedures despite little evidence to support their use. Proponents of drain use argue that drain placement reduces the incidence of post-operative hematomas and surgical site infections (SSI). The aim of this study is to determine whether the use of subfascial drains after multi-level ACDFs are associated with a decreased incidence of hematomas and SSIs.

Methods

This is a retrospective study of 321 consecutive adult patients (18 years and older) with degenerative cervical stenosis that undergoing an index multi-level ACDF procedure. Only patients undergoing multilevel ACDF were included in the study. Patients were separated into one of two groups depending whether a subfascial drain was placed during surgery. The decision to place a drain was based on surgeon preference. Baseline characteristics, operative details, as well as rates of hematoma formation and SSIs were gathered by direct medical record review.

Results

Of the 321 patients enrolled in the study, 58 (18%) patients had subfascial drains placed at the time of surgery. Baseline demographics and co-morbidities were similar between both cohorts; however, on average, patients in the "Drain Use" cohort were older when compared to those in the "No Drain" cohort (64 vs. 56 years old, P<0.0001). There was no observed difference between both groups in the incidence of post-operative hematoma formation (P=0.99) or SSI (P=0.99). Five percent of patients in the "Drain Use" cohort required a post-operative allogenic blood transfusion compared to less than 1% (0.4%) in the comparison cohort. The duration of hospital stay was almost 2-fold longer in the in the "Drain use" cohort compared to the comparison cohort ("Drain Use": 2.82 days vs. "No Drain": 1.58 days, P<0.0001).

Conclusions

The use of subfascial drains after multi-level ACDF procedures were not associated with a decreased incidence of hematoma formation or SSIs. In fact, patients in which a subfascial drain was used were 14 times more likely to require a post-operative blood transfusion and with an almost 2-fold increase in the duration of in-hospital stay.

Prognostic Factors of Neurological Complications in Spinal Surgeries

Study Design

Retrospective study.

Purpose

To determine prognostic factors of neurological complications (NCs) of posterior thoracolumbar surgeries.

Overview of Literature

There have been few reports on the prognosis of NCs according to the causes and treatment methods.

Methods

The subjects were 65 patients who had NCs for 19 years (1995–2013) after posterior thoracolumbar surgeries in Seoul Sacred Heart General Hospital. The degree of neurological injury was assessed using numeric scales as follows: G1, increased leg pain or sensory loss; G2, hemiparesis; G3, paraparesis; G4, cauda equine syndrome; and G5, complete paraplegia. The relative degree of neurological recovery was evaluated using four numeric scales as follows: Gr1, complete recovery; Gr2, almost complete recovery with residual sensory loss or numbness; Gr3, partial recovery with apparent neurological deficit; and Gr4, no recovery. The prognostic factors were investigated in terms of demographic and surgical variables that were available in a retrospective review.

Results

The causes were as follows: epidural hematoma (EH), 25 patients (38.5%); insufficient decompression and fusion, 14 patients (21.5%); mechanical injury, 11 patients (16.9%); insufficient discectomy, four patients (6.2%); and unknown, 11 patients (23.1%). The grade of neurological injury was as follows: G1, 11 patients (16.9%); G2, 34 patients (52.3%); G3, 15 patients (23.1%); G4, three patients (4.6%); and G5, two patients (3.1%). Thirteen patients received conservative treatment, and 52 underwent revision surgeries. Neurological recovery was as follows: Gr1, 21 patients (32.3%); Gr2, 17 patients (26.2%); Gr3, 20 patients (30.8%); and Gr4, seven patients (10.8%). The prognosis depended on the causes (p =0.041). The subgroup analysis of the revision group revealed a significant correlation between the degree of neurological recovery and the timing of revision, irrespective of causes (r =0.413, p =0.002).

Conclusions

The prognosis of NC depended on the causes. EH was the best and unknown was the worst prognostic factor. Revision should be performed as soon as possible for a better prognosis.

Post-operative drain use in patients undergoing decompression and fusion: incidence of complications and symptomatic hematoma

Background

Surgical drains are commonly used after spine surgery to minimize infection and hematoma formation. The aim of this study was to determine the incidence of post-operative complications after spinal decompression and fusion with and without a subfascial drain.

Methods

The medical records of 139 adult (≥18 years old) spinal deformity patients undergoing elective spinal decompression and fusion at a major academic institution were reviewed. We identified 116 (83.5%) who had a post-operative drain and 23 (16.5%) who did not have a postoperative drain (No-Drain: n=23; Drain-Use: n=116). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was the rate of post-operative complications, specifically surgical site infections (SSI) and hematoma formation.

Results

Patient demographics and comorbidities were similar between both cohorts, with the body mass index (BMI) slightly higher in the Drain-Use cohort (No-Drain: 26.1 kg/m²vs. Drain-Use: 29.1 kg/m², P=0.02). Operative time and the median number of levels fused were similar between the cohorts. The postoperative complications profile was similar between both cohorts, including deep and superficial SSIs (P=0.52 and P=0.66, respectively), and incidence of hematoma formation (P=0.66). Length of hospital stay (LOS) was significantly higher for the Drain-use cohort compared to the No-Drain cohort (5.0 vs. 2.8 days, P<0.0001). There were no significant differences in the 30-day hospital readmission rate or incidence of 30-day wound dehiscence, draining wound, incision & drainage (I & D), or bleeding between both patient groups.

Conclusions

Our study suggests that the use of postoperative subfascial drains in patients undergoing spinal decompression with fusion may not be associated with a reduction in SSIs or hematoma formation.

A systematic review and meta-analysis of wound drains in non-instrumented lumbar decompression surgery

Wound drains are routinely used in lumbar decompressive surgery (LDS). However, it remains unclear whether this practice helps to prevent symptomatic epidural hematoma formation and associated complications, particularly following non-instrumented procedures. A systematic review and meta-analysis was therefore completed to critically appraise the literature. The search protocol was conducted using the Ovid MEDLINE, EMBASE, Scopus, Cochrane Library, and Google Scholar databases. Articles meeting the following criteria were included: (i) examined patients undergoing LDS; (ii) included cases receiving post-operative wound drains; (iii) detailed adverse outcomes including symptomatic epidural hematomas or wound infection; and (iv) were published in English in a peer-reviewed journal. Pooled risk differences (RD) for adverse outcomes were calculated using Comprehensive Meta-Analysis software. Three Level 1b prospective randomized studies and five Level 2b retrospective cohort studies were included, from which 5327 cases were identified as having received a surgical drain and 773 were identified as having received no drainage following non-instrumented LDS. There was no difference between groups in the risk of symptomatic epidural hematoma (RD = 0.02; 95% CI -0.02 - 0.06, p = 0.28) or post-operative infection (RD = 0.00; 95% CI -0.01 - 0.01, p = 0.91). In conclusion, symptomatic epidural hematomas and infection are rare following non-instrumented LDS, with incidence rates unaffected by the routine use of wound drainage.

Postoperative Spinal Epidural Hematoma: The Danger Caused by the Misuse of Thrombin-Containing Local Hemostatics

Study Design

Retrospective case-control study.

Purpose

To examine the hypothesis that the misuse of thrombin-containing local hemostatics (TCLH) increases the risk of postoperative spinal epidural hematoma (POSEH).

Overview of Literature

Many studies have focused on hypocoagulability as a risk factor for POSEH. However, there are no prior reports on the increased risk of POSEH in hypercoagulable states.

Methods

Posterior instrumented lumbar spine surgery cases over 2 consecutive years were divided into two groups: a study group (98 patients in whom TCLH was used) and a control group (176 patients in whom TCLH was not used). The excess TCLH matrix that was not associated with blood clot was not removed from the patients in the study group. The senior author decided whether to use TCLH or not. Suction drains were used in all patients. The demographics, coagulation-related factors, and intraoperative factors of the patients in the two groups were analyzed. The development of POSEH was compared between the two groups.

Results

The two groups were homogenous in demographics (age and sex), coagulation-related factors (platelet count, prothrombin time, activated partial thromboplastin time, and platelet function analysis), and surgical factors (total blood loss, operation time, blood loss/10 minutes, number of fusion segments, posterolateral fusion/posterior lumbar interbody fusion, and virgin or revision surgery). POSEH developed more frequently in the patients in the study group than in those in the control group (14/98 patients, 14.3% vs. 3/176 patients, 1.7%, respectively; p=0.001; odds ratio, 17.1).

Conclusions

TCLH causes blood clot not only at the edge of damaged vessels but also at the site of extravascular blood. Excess TCLH matrix not associated with blood clot at the epidural space can enhance POSEH development because early clotted hematomas do not drain through suction drains.

Perioperative Management of Blood Loss in Spine Surgery

Spine procedures are associated with high rates of blood loss which can result in a greater need for transfusions. Repeated exposure to blood products is associated with risks and adverse reactions such as transfusion-related acute lung injury, fluid shifting, and infections. With the higher number of spine procedures and the increasing open surgery times associated with difficult procedures, excessive blood loss has become more prevalent. Perioperative methods have been established to combat the excessive blood loss and decrease the need for blood products. Preoperatively, anemia and coagulopathy screening is standard at least 4 weeks before elective procedures. Erythropoietin, iron loading or transfusions are used to decrease preoperative anemia, a predisposing factor for blood loss. Autologous predonation of blood has been shown to be ineffective and decreases preoperative hemoglobin levels. Intraoperatively, antifibrinolytics such as tranexamic acid and aminocaproic acid are used to decrease blood loss. In addition, fibrinogen concentrates, thromboelastometry, acute normovolemic hemodilution, controlled hypotension, and temperature regulation are some of the techniques used to decrease blood loss and the need for transfusions. Postoperatively, fibrin sealants, shed blood salvage, and erythropoietin or intravenous iron are used in management of blood loss, especially in instances when the patient refuses blood products.

Decreasing hospital length of stay following lumbar fusion utilizing multidisciplinary committee meetings involving surgeons and other caretakers

Background:

Although hospital length of stay (LOS) following lumbar fusion has decreased for a variety of reasons, different institutions find their LOS over the benchmarks published by the national Agency for Healthcare Research and Quality (AHRQ). Over a 3-year period, this prospective study introduced utilization of multidisciplinary committee meetings between surgeons and other caretakers to decrease LOS following spinal fusion surgery without compromising the quality of care.

Methods:

A multidisciplinary committee was established to assess factors and institute recommendations that influence hospital LOS following lumbar fusion compared to the national compared to the national AHRQ benchmark at baseline and at 1 and 2 years after adjusting our standard practice. We also analyzed re-admission rates at 7 and 30 days and determined the average variable direct cost.

Results:

While the national AHRQ benchmark average LOS (ALOS) was statistically better for DRGs 459 and 460 for all three years except for DRG 459 in the baseline year compared to our ALOS, we observed improvement in the ALOS for both DRG 459 and 460 throughout the 3 years of the study. ALOS for DRG 460 was statistically different for 2011–2012 vs 2013–2014 (P < 0.001) and 2012–2013 vs 2013–2014 (P < 0.001). There was a statistically significant improvement in cost initially for 2012–2013 vs 2011–2012 (P < 0.001) and for 2013–2014 vs 2011–2012 (P = 0.001).

Conclusions:

This study established an effective patient discharge plan, patient education, partnerships with rehabilitation facilities, and study review and discussion among physicians and staff. Further monitoring of factors that impact hospital LOS following lumbar fusion is warranted to curtail patient complications and organizational expenditures while providing superior medical care.

A randomized controlled trial on effects of different hemostatic sponges in posterior spinal fusion surgeries

Background

Spinal fusion surgery is associated with significant blood loss, which may result in potential clinical complications, it is necessary to take safe and effective measures to reduce blood loss in surgery. We perform this study to assess the impact of three different hemostatic materials on perioperative blood loss.

Methods

We performed a Randomized Controlled Trial research and recruited patients with lumbar disease into the study between November 2013 and March 2015. All the participants were randomly assigned to 3 groups using a simple equal probability randomization scheme: Group A (Stypro hemostatic sponge), Group B (Collagen hemostatic sponge) and Group C (gelatin sponge). We compared postoperative blood loss between these 3 groups.

Results

In our study, drainage volume in the first 24 h of patients in Group A and B is significantly smaller, as well as total postoperative volumes of drainage (p < 0.05) during their hospital stay. The drainage volumes in the second 24 h were similar in the 3 groups. We also found that the average drainage Hematocrit (HCT) reduced over time, the average HCT of drainage is 18.04% and 11.72% on the first day and on the second day respectively.

Conclusions

Hemostatic collagen sponge demonstrated better hemostasis effects than gelatin sponge with lower volume of postoperative drainage volume and blood loss in posterior spinal fusion surgery.

Trial registration

The trial registration number (TRN) of the study is ISRCTN29254316 and date of registration is 25/10/2016. Our trial was registered retrospectively.

Improved Intermittent-clamped Drainage in Lower Lumbar Internal Fixation: A Randomized Prospective Study

Background:

Continuous negative pressure drainage (CNPD) is widely used after lower lumbar internal fixation; however, it may cause tremendous blood loss and lead to postoperative hemorrhagic anemia. The present study explored the efficacy and safety of improved intermittent-clamped drainage (ICD) for lower lumbar internal fixation.

Methods:

This was a prospective study that included 156 patients with decompression of the spinal canal and internal fixation for the first time from January 2012 to December 2014. The patients were randomly divided into ICD group and CNPD group, and each group had 78 cases. A drainage tube was placed under the deep fascia in all patients within 10 min after the commencement of wound closure. The postoperative drainage amount at different time points, the hemoglobin level, and postoperative complications were recorded and compared between the two groups. Shapiro-Wilk test, independent samples t-test, and Mann-Whitney U-test were used in this study.

Results:

The drainage amount was significantly reduced in the ICD group, as compared with the CNPD group (Z = 10.74, P < 0.01). The mean total drainage amount (in ml) of the single-segment and two-segment procedures was significantly greater in the CNPD group than the ICD group (Z = 10.63 and 10.75, respectively; P < 0.01). For the adverse events, there was no significant difference in postoperative temperature, wound problem, and complications between the two groups.

Conclusions:

The present study showed a statistically significant reduction in postoperative drainage amount between ICD and CNPD groups, and ICD is an effective, convenient, and safe method for routine use in lower lumbar surgery. It is essential to focus on the effect of clamping drainage with long-segment surgical procedure and complex lumbar disease in the further investigation, as well as the effect of clamping on long-term functional outcomes.

Postoperative Cerebrospinal Fluid Leak Rates with Subfascial Epidural Drain Placement after Intentional Durotomy in Spine Surgery

Study Design Retrospective chart review. Objective Postoperative cerebrospinal fluid (CSF) leak is a known complication of intraoperative durotomy. Intraoperative placement of subfascial epidural drains following primary dural repair has been proposed as a potential management strategy to prevent formation of CSF cutaneous fistula and symptomatic pseudomeningocele. Here we describe our experience with subfascial drain after intentional durotomy. Methods Medical records of patients who underwent placement of subfascial epidural drains during spinal procedures with intentional intraoperative durotomies over a 4-year period at two institutions were retrospectively reviewed. Primary outcomes of interest were postoperative CSF cutaneous fistula or symptomatic pseudomeningocele formation. Results Twenty-five patients were included. Mean length of follow-up was 9.5 months. Twelve patients (48%) underwent simultaneous arthrodesis. The average duration of the drain was 5.3 days with average daily output of 126.5 mL. Subgroup analyses revealed that average drain duration for the arthrodesis group was 6.33 days, which is significantly greater than that of the nonfused group, which was 3.7 days (p = 0.016). Similarly, the average daily drain output for the arthrodesis subgroup at 153.1 mL was significantly higher than that of the nonfused subgroup (86.8 mL, p = 0.04). No patient developed postoperative CSF cutaneous fistula or symptomatic pseudomeningocele or had negative sequelae associated with overdrainage of CSF. One patient had a delayed wound infection. Conclusions The intraoperative placement of subfascial epidural drains was not associated with postoperative development of CSF cutaneous fistula, symptomatic pseudomeningocele, overdrainage, or subdural hematoma in the cases reviewed. Subfascial closed wound drain placement is a safe and efficacious management method after intentional spinal durotomies. It is particularly helpful in those who undergo simultaneous arthrodesis, as those patients have statistically higher daily drain output and longer drain durations.

Why Cannot Suction Drains Prevent Postoperative Spinal Epidural Hematoma?

BACKGROUND

Postoperative spinal epidural hematoma (POSEH) is different from spontaneous or post-spinal procedure hematoma because of the application of suction drains. However, it appeared that suction drains were not effective for prevention of POSEH in previous studies. The purpose of this study was to test our hypothesis that POSEH can be caused by hypercoagulability.

METHODS

This was an experimental study. One hundred fifty milliliters of blood was donated from each of the 12 consecutive patients who underwent spine surgery and infused into 3 saline bags of 50 mL each. One of the 3 bags in each set contained 5,000 units of thrombin. All of them were connected to 120 ± 30 mmHg vacuum suctions: drainage was started 8 minutes after connection to the vacuum system for 12 normal blood bags (BV8) and 12 thrombin-containing blood bags (TBV8) and 15 minutes after connection for the remaining 12 normal blood bags (BV15). The amount of initial and remaining hematoma at 20 minutes, 120 minutes, and 24 hours after vacuum application were measured by their weight (g). The primary endpoint was the difference between BV8 and TBV8. The secondary end point was the difference between BV8 and BV15.

RESULTS

The remaining hematoma in TBV8 was significantly greater than that in BV8 at all measurement points: 46.3 ± 12.4 vs. 17.0 ± 1.3 (p = 0.000) at 20 minutes; 33.0 ± 8.2 vs. 16.3 ± 1.2 (p = 0.000) at 120 minutes; and 26.1 ± 4.0 vs. 15.8 ± 1.6 (p = 0.000) at 24 hours after vacuum application. The remaining hematoma of BV15 was significantly greater than that of BV8 at all measurement points: 30.0 ± 12.0 vs. 17.0 ± 1.3 (p = 0.002) at 20 minutes; 24.2 ± 7.6 vs. 16.3 ± 1.2 at 120 minutes (p = 0.002); and 22.2 ± 6.6 vs. 15.8 ± 1.6 (p = 0.004) at 24 hours after vacuum application.

CONCLUSIONS

With a suction drain in place, the amount of remaining hematoma could be affected by coagulability. Thrombin-containing local hemostatics and the length of time elapsed before the commencement of suction resulted in hypercoagulability, indicating these two factors could be causes of POSEH.

Can We Prevent a Postoperative Spinal Epidural Hematoma by Using Larger Diameter Suction Drains?

Background

Epidural hematoma is a rare but serious complication. According to previous studies, it is not prevented by suction drains. This study evaluated the following alternative hypothesis: the larger the diameter of a suction drain, the less the remaining epidural hematoma after spinal surgery.

Methods

This was a randomized prospective study. Patients who underwent posterior lumbar decompression and instrumented fusion were divided into two groups: the large drain (LD, 2.8-mm-diameter tube) and small drain (SD, 1.6-mm-diameter tube) groups according to the diameter of the suction drains. All patients were consecutive and allocated alternately according to the date of operations. Suction drains were removed on day 3 and magnetic resonance imaging was performed on day 7 postoperatively. The size of remaining hematomas was measured by the degree of thecal sac compression in cross section using the following 4-point numeric scale: G1, less than one quarter; G2, between one quarter and half; G3, more than half; and G4, more than subtotal obstruction.

Results

There were 39 patients with LDs and 38 with SDs. They did not differ significantly in terms of sex, number of fusion segments, revision or not, antiplatelet medication, intraoperative injection of tranexamic acid. However, patient age differed significantly between the two groups (LD, 63.3 years and < SD, 68.6 years; p = 0.007). The two groups did not differ significantly in terms of prothrombin time, activated partial thromboplastin time, platelet number, blood loss, or operation duration. However, platelet function analysis exhibited a significant difference (LD, 164.7 seconds and < SD, 222.3 seconds; p = 0.002). The two blinded readers showed high consistency (Kappa value = 0.740; p = 0.000). The results of reader 1 were as follows: LD and SD had 21 and 21 cases of G1, 9 and 11 cases of G2, 6 and 6 cases of G3, and 3 and 0 cases of G4, respectively. The results of reader 2 were as follows: LD and SD had 22 and 23 cases of G1, 7 and 9 cases of G2, 7 and 6 cases of G3, and 3 and 0 cases of G4, respectively. There was no difference between the two groups (reader 1, p = 0.636; reader 2, p = 0.466).

Conclusions

The alternative hypothesis was rejected. Therefore, postoperative spinal epidural hematoma would not be prevented by LD.

Wound drains in posterior spinal surgery: a meta-analysis

Background

The use of drains following posterior spinal surgery is controversial. Thus, the aim of this meta-analysis was to review the advantages and adverse effects of closed suction drainage systems in posterior spinal surgery.

Methods

All randomized and non-randomized controlled trials comparing the use of closed suction drainage with no drainage in posterior spinal surgery were sought in PubMed, Medicine, Embase, and other Internet databases. All of the literature was searched and assessed by two independent reviewers, according to the standards of Cochrane systematic reviews. Data on functional and radiological outcomes in the two groups were pooled, which were then analyzed with RevMan software, version 5.2.

Results

Four randomized controlled trials (RCTs) and four non-RCTs met the inclusion criteria. Meta-analysis revealed that no significant differences were found regarding wound infection (P = 0.83), hematoma (P = 0.48), neurological injury (P = 0.21), estimated blood loss (P = 0.59), or dry and moderate dressing drainage between the groups. The number of patients with saturated dressings was larger in the no drainage group (P = 0.002).

Conclusions

There is no obvious evidence to support the application of closed suction drains for posterior spinal surgery. Because of the limited quality of the evidence currently available, more high-quality RCTs with better experimental designs and larger patient samples should be performed.

The Outcome of Using Closed Suction Wound Drains in Patients Undergoing Lumbar Spine Surgery: A Systematic Review

Study Design Systematic review. Objective Determine whether closed suction wound drains decrease the incidence of postoperative complications compared with no drain use in patients undergoing spine surgery for lumbar degenerative conditions. Methods Electronic databases and reference lists of key articles were searched up through January 22, 2015, to identify studies comparing the use of closed suction wound drains with no drains in spine surgery for lumbar degenerative conditions. Outcomes assessed included the cumulative incidence of epidural hematoma, superficial and deep wound infection, and postoperative blood transfusion. The overall strength of evidence across studies was based on precepts outlined by the Grades of Recommendation Assessment, Development and Evaluation Working Group. Results Five heterogeneous studies, three randomized controlled trials, and two cohort studies form the evidence basis for this report. There was no difference in the incidence of hematoma, superficial wound infection, or deep infection in patients with compared with patients without closed suction wound drains after lumbar surgery. The upper bounds of the 95% confidence interval for hematoma ranged from 1.1 to 16.7%; for superficial infection, 1.0 to 7.3%; and for deep infection, 1.0 to 7.1%. One observational study reported a 3.5-fold increase in the risk of blood transfusion in patients with a drain. The overall strength of evidence for these findings is considered low or insufficient. Conclusions Conclusions from this systematic review are limited by the quality of included studies that assessed the use of closed suction wound drains in lumbar spine surgeries for degenerative conditions. We believe that spine surgeons should not routinely rely on closed suction wound drains in lumbar spine surgery until a higher level of evidence becomes available to support its use.

Necessity of Surgical Site Closed Suction Drain for Pterional Craniotomy

Objective

The aim of this study was to assess the benefit of using a prophylactic surgical site closed suction drain in pterional craniotomy.

Materials and Methods

A retrospective review was conducted on 607 consecutive patients who underwent a pterional craniotomy for treatment of intracranial anterior circulation aneurysms over a 5-year period. Between January 2000 and December 2004, 607 patients were divided into two groups, those who had a prophylactic suction drain during closure of the surgical site (drain group, DG) and those who did not (non-drain group, NDG). Head computed tomography (CT) was taken routinely on postoperative day (POD) 1, 7, and 14. Patients' demographics, incidence of surgical site complications, and courses of surgical site healing which were evaluated radiologically by the thickness of the surgical site myocutaneous layer, were analyzed between DG and NDG.

Results

Patients' demographics and characteristics did not differ significantly between the two groups. The head CT showed that the degree of changes in the postoperative surgical site thickness was 148% at POD 1, 209% at POD 7, and 198% at POD 14 in DG, and 118% at POD 1, 152% at POD 7, and 158% at POD 14 in NDG compared to the preoperative value. Postoperative surgical site hematoma was 7.9% (22/274) in DG and 2.4% (8/333) in NDG.

Conclusion

Prophylactic use of an epidural and/or subgaleal closed suction drain does not appear to be necessary for prevention of postoperative surgical site hematoma as well as for promotion of surgical site healing in pterional craniotomy.

Dressings and drains in posterior spine surgery and their effect on wound complications

The purpose of this study was to systematically search, critically appraise and summarize published randomized control trials (RCT) and non-RCT examining the effect of drains and dressings on wound healing rates and complications in posterior spine surgery. The use of post-operative drains and the type of post-operative dressing is at the discretion of the treating surgeon with no available clinical guidelines. Drains will theoretically decrease incidence of post-operative hematoma and therefore, potentially decrease the risk of neurologic compromise when the neural elements have been exposed. Occlusive dressings have more recently been advocated, potentially maintaining a sterile barrier for longer time periods post-operatively. A systematic review of databases from 1969-2013 was undertaken. All papers examining drains in spine surgery and dressings in primary healing of surgical wounds were included. Revman (version 5.2; The Nordic Cochrane Centre, The Cochrane Collaboration, Oxford, UK) was used to test for overall treatment effect, clinical heterogeneity and risk of bias. Of the papers identified, 1348 examined post-operative drains in spine surgery and 979 wound dressings for primary wound healing of all surgical wounds. Seven studies were included for analysis for post-operative drains and 10 studies were analyzed for primary wound healing. The use of a post-operative drain did not influence healing rates and had no effect secondarily on infection (odds ratio [OR] 1.33; 95% confidence interval [CI] 0.76-2.30). We were not able to establish whether surgical drains prevent hematomas causing neurologic compromise. There was a slight advantage to using occlusive dressings versus non-occlusive dressings in wound healing (OR 2.09; 95% CI 1.44-3.02). Incisional vacuum dressings as both an occlusive barrier and superficial drainage system have shown promise for wounds at risk of dehiscence. There is a relatively high risk of bias in the methodology of many of the studies reviewed. We recommend favoring of occlusive dressings based on heterogeneous and potentially biased evidence. Drain use does not affect wound healing based on similar evidence. Incisional vacuum dressings have shown promise in managing potentially vulnerable wounds.