Intraoperative blood loss in female patients with adolescent idiopathic scoliosis during different phases of the menstrual cycle

Supplementary decompression and extended surgical time contribute to hidden blood loss In percutaneous endoscopic lumbar discectomy

Background

It is widely believed that the Percutaneous endoscopic lumbar discectomy (PELD) is associated with minimal blood loss. However, significant perioperative hidden blood loss (HBL) is frequently unaccounted for. This study aimed to investigate HBL and peri-operative factors contributing to HBL in a series of individuals undergoing PELD.

Method

ology: A total of 156 consecutive patients with a mean age of 43.6 years (ranging from 18 to 80 years) who underwent PELD at our department from May 2019 to November 2020, were included in the study. Factors including gender, age, body mass index, symptom duration, operation approach/technique, operation duration, the presence of associated chronic diseases, and improvements in the Visual Analog Scale (VAS) score, Japanese Orthopaedic Association (JOA) score and the Oswestry Disability Index (ODI) were analyzed, and Gross's formula was applied to calculate blood loss, which was used to determine HBL.

Results

The average total blood loss (TBL) was 221.0 ± 126.2 mL, while the average HBL was 181.7 ± 119.0 mL (82.2 % of TBL). There was no statistically significant difference in HBL between the transverse surgical approach and the interlayer approach. Additionally, no significant differences were observed in improvements in VAS, JOA, and ODI scores between the two surgical approaches. However, the multivariate linear regression analysis revealed that longer surgical time and foraminal decompression were factors contributing to the increase in HBL, which subsequently led to the occurrence of post-operative anemia.

Conclusion

HBL is significant in PELD cases with long surgical time and lumbar foraminal decompression.

Does Progesterone Affect Perioperative Blood Loss during Posterior Spinal Fusion Surgeries in Female Patients with Adolescent Idiopathic Scoliosis? A Retrospective Study

OBJECTIVE

Menstruation is considered a contraindication for elective surgery for higher operative blood loss. Progesterone is often used to postpone menstruation to avoid surgery during menstruation. This study aimed to explore whether using progesterone to postpone menstruation affects perioperative blood loss and complications in female patients with adolescent idiopathic scoliosis (AIS) who underwent posterior spinal fusion (PSF) surgery.

METHODS

A retrospective study was performed for female patients diagnosed with AIS who underwent PSF surgery between March 2013 and January 2021. Patients scheduled to undergo PSF surgery from 2 days before menstruation to 3 days after menstruation were treated with progesterone preoperatively. The patients were divided into two groups according to progesterone use (progesterone injection group; control group). Demographic and surgical data including intraoperative blood loss (IBL), normalized blood loss (NBL), total blood loss (TBL), transfusion rate, perioperative complications, postoperative drainage time, postoperative hospital stay, and preoperative coagulation function data were collected.

RESULTS

A total of 206 patients were included in the study. Among them, the progesterone injection group included 41 patients, with an average age of 14.8 years. While the control group included 165 patients, with an average age of 14.9 years. The two groups were matched for age, height, weight, operation time, Risser sign, correction rate, mean curve Cobb angle, bending Cobb angle, number of internal fixations, and number of fused levels (all P > 0.05). Regarding coagulation function, no significant differences were found in thrombin time, activated partial thromboplastin time, fibrinogen, prothrombin time, and platelet count between the two groups (all P > 0.05). IBL, NBL, and TBL were higher in progesterone injection group; however, the difference was nonsignificant (all P > 0.05). Transfusion rate, perioperative complications, postoperative drainage time, and postoperative hospital stay were not statistically different between groups (all P > 0.05).

CONCLUSION

Intramuscular injection of progesterone to avoid menstruation during PSF surgery did not affect perioperative blood loss and complications in AIS patients. It may be a safe method for AIS patients to avoid menstrual problems affecting the operation time and receive PSF surgery as scheduled.

Does Menses Affect the Risk of Blood Loss in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion Surgeries?: A Propensity-Score Matching Study

STUDY DESIGN

Retrospective propensity score matching study.

OBJECTIVE

To investigate whether menses affect intraoperative blood loss in female adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) surgeries.

SUMMARY OF BACKGROUND DATA

There were concerns whether patients having menses will have higher intraoperative blood loss if surgery were to be done during this period.

METHODS

This study included 372 females who were operated between May 2016 to May 2019. Fifty-five patients had menses during surgery (Group 1, G1) and 317 patients did not have menses during surgery (Group 2, G2). Propensity score matching (PSM) analysis with one-to-one, nearest neighbor matching technique and with a match tolerance of 0.001 was used. The main outcome measures were intraoperative blood loss (IBL), volume of blood salvaged, transfusion rate, preoperative hemoglobin, preoperative platelet, preoperative prothrombin time, preoperative activated partial thromboplastin time (APTT), international normalized ratio (INR), and postoperative hemoglobin. Postoperative Cobb angle and correction rate were also documented.

RESULTS

At the end of PSM analysis, 46 patients from each group were matched and balanced. The average operation duration for G1 was 140.8 ± 43.0 minutes compared with 143.1 ± 48.3 minutes in G2 (P = 0.806). The intraoperative blood loss for G1 was 904.3 ± 496.3 mL and for G2 was 907.9 ± 482.8 mL (P = 0.972). There was no significant difference in terms of normalized blood loss (NBL), volume of blood salvaged during surgery, preoperative hemoglobin, postoperative hemoglobin, hemoglobin drift, estimated blood volume (EBV), IBL per EBV and IBL per level fused (P > 0.05). No postoperative complications were encountered in both groups. On average, the postoperative hospital stay was 3.5 ± 0.8 days for both groups (P = 0.143).

CONCLUSION

Performing corrective surgery during the menstrual phase in female AIS patients is safe without risk of increased blood loss.

LEVEL OF EVIDENCE

4.

Thoracic Lordosis, Especially in Males, Increases Blood Loss in Adolescent Idiopathic Scoliosis

BACKGROUND

Intraoperative blood loss during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been reportedly associated with multiple factors. This study aims to investigate the effect of thoracic kyphosis on blood loss in AIS spinal fusion.

METHODS

Patients with AIS who underwent posterior-only procedures for Lenke I and II type curves were identified. All included patients had intraoperative tranexamic acid. Difference in estimated blood loss per blood volume (EBL/BV) was identified between hypokyphotic curves (-), normal curves (N), and hyperkyphotic curves (+) classified based on Lenke sagittal modifier. Regression analysis was then performed with EBL/BV as dependent variable. Independent variables included radiographically measured T5-T12 kyphosis and calculated 3D T5-T12 kyphosis in addition to sex, body mass index (BMI), operative time, number of fused vertebrae, number of Ponte osteotomy levels, and main thoracic coronal curve.

RESULTS

In total, 837 patients were included. For female patients: EBL/BV was significantly higher for (-) (18%) compared with (N) (16%) and (+) (14%). A total of 29 female patients had T5-T12≤0 (-15 to 0 degree). EBL/BV was not significantly higher than patients with T5-T12>0 degree (18%±9% vs. 16%±11%; P=0.212). For male patients: EBL/BV was significantly higher in (-) (23%) compared with (+) (16%). In total, 14 male patients had T5-T12≤0 (-13 to 0) degree. EBL/BV was significantly higher than patients with T5-T12>0 degree (32%±18% vs. 18%±13%; P=0.015). Significant factors in predicting EBL/BV were sex, BMI, number of fused levels, and both 2D and 3D T5-T12 kyphosis. Male sex as well as every fused-level predicted an increase in EBL/BV~2%. Every 10-unit decrease in BMI predicted an increase in EBL/BV of 7%. Every 10-degree decrease in 2D or 3D T5-T12 kyphosis predicted an increase in EBL/BV~1%. The impact of the number of Ponte osteotomy levels was not significant.

CONCLUSIONS

This study supports the role of sagittal thoracic alignment in affecting EBL/BV in AIS surgery. Male patients with severe thoracic lordosis (T5-T12≤0 degree) are the highest risk group for intraoperative bleeding. These findings are helpful in predicting the intraoperative blood loss for patients with AIS undergoing posterior spinal fusion. In addition to sex and number of fused levels, decreased thoracic kyphosis is associated with increased blood loss.

LEVEL OF EVIDENCE

Level III-prognostic study.

Effect of intraoperative autologous transfusion techniques on perioperative hemoglobin level in idiopathic scoliosis patients undergoing posterior spinal fusion: A prospective randomized trial

BACKGROUND

Massive blood loss during posterior spinal fusion for adolescent idiopathic scoliosis remains a significant risk for patients. There is no consensus on the benefit of acute normovolemic hemodilution (ANH) or intraoperative cell salvage (ICS) in scoliosis surgery.

METHODS

Patients were randomized to one of two groups. Group A received ANH and ICS during operation, while group B received only ICS. Patients' age, sex, height, weight, body blood volume, number of fusion level, Cobb angle, number of screws, duration of surgery, and skin incision length were recorded. Hemoglobin and hematocrit levels were obtained preoperatively and postoperatively (0 h and 24 h).

RESULTS

There were 22 patients in each group. There was no significant difference in total blood loss. The perioperative decrease in hemoglobin levels between preoperation and postoperation 24 h (group A 2.79 ± 1.15 and group B 2.76 ± 1.00) showed no significant difference ( p = 0.93). Group A observed a larger decrease in hemoglobin levels at postoperative 0 h relative to preoperative level (2.57 ± 0.82 g/dl), followed by a smaller decrease within the next 24 h (0.22 ± 1.33 g/dl). Group B showed a continued drop in hemoglobin levels of similar magnitude at postoperation 0 h (1.60 ± 0.67 g/dl) and within the next 24 h (1.16 ± 0.78 g/dl). One patient from group B received 1 unit of allogenic blood transfusion ( p = 0.33).

CONCLUSIONS

The addition of ANH to ICS in posterior spinal fusion surgery for AIS resulted in a similar decrease in hemoglobin levels between preoperative values and at 24 h postoperatively.

Does spinal fusion to T2, T3, or T4 affects sagittal alignment of the cervical spine in Lenke 1 AIS patients: A retrospective study

The aim of this stusy was to investigate whether spinal fusion to T2, T3, or T4 affects sagittal alignment of the cervical spine in Lenke 1 adolescent idiopathic scoliosis (AIS) patients.A retrospective study comprised of 64 Lenke 1 AIS patients was performed to assess the radiographic and clinical outcome. According to the upper instrumented vertebrae (UIV) (T2, T3, or T4), the patients were divided into 3 groups. Comparison analyses were performed among these 3 groups of patients as between pre-op, immediate post-op, and final follow-up, as well as between these groups.Between groups, comparison analyses did not detect a statistical difference in cervical lordosis (CL) preoperatively (P = .501), immediately after surgery (P = .795), and at follow-up (P = .510). Immediately after surgery, CL increased significantly in all groups (T2, P = .004, T3, P < .001 and T4, P = .002 respectively). Compared with immediate postoperatively, CL at final follow-up increased in T2 group (P = .037), and T4 group (P = .010). Furthermore, CL at follow-up was significantly correlated with the following parameters: preoperative (coronal plane balance [r = .349, P = .004], pelvic tilt [r = 0.347, P = .004), pelvic incidence [r = 0.261, P = .031], and CL [r = 0.471, P < .001]) immediately postoperative (CL [r = 0.946, P < .001], T1-slope [r = -0.646, P < .001], and thoracic kyphosis [TK] [r = -0.353, P = .003]), and at follow-up (TK [r = -0.342, P = .004], and T1-slope [r = -0.821, P < .001]). However, there was no significant correlation between a selection of UIV and CL at follow-up (r = 0.031, P = .802). Moreover, Scoliosis Research Society (SRS-22) scores between groups were similar preoperatively (P = .242), immediately after surgery (P = .828), and at follow-up (P = .219).In Lenke 1 AIS patients, the selection of UIV mainly affects the coronal plane, especially shoulder balance. Fusion to T2, T3, or T4 did not affect the alignment of the cervical spine, and the SRS-22 score.

LEVEL OF EVIDENCE

Level IV.

Incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with neuromuscular scoliosis: A STROBE-compliant retrospective observational analysis

Factors influencing massive blood loss for neuromuscular scoliosis (NMS) patients.Despite advances in surgical and anesthetic techniques, scoliosis surgery is still associated with intraoperative massive blood loss, which can result in postoperative mortality and morbidity. The aim of this study was to assess the incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with NMS.A retrospective review of adolescents who underwent posterior spinal instrumentation and fusion for NMS was performed. Perioperative variables and data were recorded. Massive blood loss was defined as an estimated blood loss that exceeds 30% of total blood volume.We obtained data for 114 patients, of whom 63 (55%) had intraoperative massive blood loss. Compared with those without, patients with massive blood loss were more likely to be older, have lower body mass indexes (BMIs), larger Cobb angles, more fused levels, more osteotomy procedures, and prolonged duration of operation. Logistic regression analysis identified the number of fused levels to be more than 12 (P = 0.003, odds ratio = 6.614, 95% confidence interval [CI]: 1.891-23.131), BMI lower than 16.8 kg/m (P = 0.025, odds ratio = 3.293, 95% CI: 1.159-9.357), age greater than 15 years (P = 0.014, odds ratio = 3.505, 95% CI: 1.259-9.761), and duration of operation longer than 4.4 hours (P = 0.016, odds ratio = 3.746, 95% CI: 1.428-9.822) as influencing factors. Patients with massive blood loss are associated with more intraoperative colloids infusion and blood transfusions (red blood cell and fresh frozen plasma), as well as postoperative drainage volume.In adolescents with NMS who underwent posterior spinal instrumentation and fusion operations, intraoperative massive blood loss is common. The number of fused levels, BMI, age, and duration of operation are factors influencing intraoperative massive blood loss.

Assessment of Intraoperative Blood Loss at Different Surgical Stages During Posterior Spinal Fusion Surgery in the Treatment of Adolescent Idiopathic Scoliosis

STUDY DESIGN

Prospective clinical study.

OBJECTIVE

To analyze the amount of blood loss at different stages of Posterior Instrumented Spinal Fusion (PSF) surgery in adolescent idiopathic scoliosis (AIS) patients.

SUMMARY OF BACKGROUND DATA

Knowing the pattern of blood loss at different surgical stages may enable the surgical team to formulate a management strategy to reduce intraoperative blood loss.

METHODS

One hundred AIS patients who underwent PSF from January 2013 to December 2014 were recruited. The operation was divided into six stages; stage 1-exposure, stage 2-screw insertion, stage 3-release, stage 4-correction, stage 5-corticotomies and bone grafting, and stage 6-closure. The duration and blood loss at each stage was documented. The following values were calculated: total blood loss, blood loss per estimated blood volume, blood loss per minute, blood loss per vertebral level fused, and blood loss per minute per vertebral level fused.

RESULTS

There were 89 females and 11 males. The mean age was 17.0 ± 5.8 years old. Majority (50.0%) were Lenke 1 curve type. The mean preoperative major Cobb angle was 64.9 ± 15.0°. The mean number of levels fused was 9.5 ± 2.3 levels. The mean operating time was 188.5 ± 53.4 minutes with a mean total blood loss 951.0 ± 454.0 mLs. The highest mean blood loss occurred at stage 2 (301.0 ± 196.7 mL), followed by stage 4 (226.8 ± 171.2 mL) and stage 5 (161.5 ± 146.6 mL). The highest mean blood loss per minute was at stage 5 (17.1 ± 18.3 mL/min), followed by stage 3 (12.0 ± 10.8 mL/min). The highest mean blood loss per vertebral levels fused was at stage 2 (31.0 ± 17.7 mL/level), followed by stage 4 (23.9 ± 18.1 mL/level) and stage 5 (16.6 ± 13.3 mL/level).

CONCLUSION

All stages were significant contributors to the total blood loss except exposure (stage 1) and closure (stage 6). Blood loss per minute and blood loss per minute per level was highest during corticotomies (stage 5), followed by release (stage 3). However, the largest amount of total blood loss occurred during screw insertion (stage 2).

LEVEL OF EVIDENCE

2.