Hemostats in Spine Surgery: Literature Review and Expert Panel Recommendations

Efficacy and safety of tranexamic acid in cervical spine surgery: a systematic review and meta-analysis

Background

Tranexamic acid (TXA) is an antifibrinolytic drug associated with reduced blood loss in a range of surgical specialties. This meta-analysis aimed to compare the efficacy and safety of TXA in cervical surgery, focusing on its effects on intraoperative blood loss and related outcomes.

Methods

We searched the PubMed, EMBASE, Medline, and Cochrane Library databases to identify all literature related to TXA used in cervical spinal surgery. Intraoperative blood loss, postoperative drainage volume, total blood loss, postoperative hematological variables, and complications were analyzed.

Results

Eight trials met the inclusion criteria. The pooled results showed that intraoperative blood loss, total blood loss, and postoperative drainage volume were significantly lower in the TXA group than in the control group. The hemoglobin and hematocrit on postoperative day 1 was significantly higher in the TXA group than in the control group. There was no significant difference in complications between the two groups.

Conclusion

The available evidence indicates that TXA effectively reduces blood loss in cervical spinal surgery while maintaining a favorable safety profile, without increasing associated risks.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023459652.

Expert panel recommendations for topical hemostatic agent use in varied bleeding sites and situations during neuro-spine surgeries

Intraoperative bleeding poses a substantial challenge, particularly in neuro-spine surgeries leading to complications such as hematomas, infections, and hemodynamic instability. Despite their proven efficacy, use of topical hemostatic agents (THAs) lacks comprehensive published literature and guidelines particularly in the Indian setting. The present study provides the first-ever Indian expert panel recommendations for effective adjunct THA use in different intraoperative bleeding sites and situations in neuro-spine surgeries. A comprehensive approach, encompassing a literature review, followed by experience sharing in a meeting using a survey helped integrate expert opinions in the form of practical algorithms to guide THA selection. Our survey results revealed a strong inclination towards specific THAs, flowable gelatin + thrombin being choice of THA for difficult to access and problematic bleeding situations during tumor removal/resection, transsphenoidal hypophysectomy and skull-based procedures. Both oxidized regenerated cellulose (ORC)/Fibrillar and flowable gelatin + thrombin were recommended for continuous oozing. ORC/Fibrillar was preferred for arteriovenous and cavernous malformations. This expert-panel guidance on THA use aims to optimize hemostat use practices and improve surgical outcomes in neuro-spine surgery.

Near infrared imaging system for preventing blood vision obstruction in endoscopy

Spinal endoscopy procedure is commonly used in the diagnosis and treatment of various health problems and is effective. Bleeding is one of the most common complications of spinal endoscopy procedures. Blood vision obstruction (BVO), that is, obstruction of the endoscopic camera lens caused by the accumulation of blood in the surgical field, is a serious problem in endoscopic procedures. This study presents what we believe to be a new approach to addressing BVO with external multispectral imaging. The study was completed using a BVO simulation model, and the results reveal that this technology can be used to effectively overcome BVO and provide clear images of the anatomy, enabling more effective diagnosis and treatment. This technique may enable improvement of the outcomes of endoscopic procedures and could have far-reaching implications in the field of endoscopy.

Limaprost and the Risk of Bleeding: A Self-Controlled Case Series Study

OBJECTIVE

To investigate the association between the use of limaprost and the risk of bleeding.

METHODS

A self-controlled case series analysis was conducted using the National Health Insurance Service-National Sample Cohort database in South Korea. We identified patients aged 18 years or older who had at least one prescription of limaprost and were diagnosed with at least one case of bleeding between 2003 and 2019. The incidence rate ratio (IRR) of bleeding was calculated by dividing the incidence rate in the exposed period to limaprost by that in the unexposed period and adjusted for age using conditional Poisson regression model.

RESULTS

Among 72,860 patients with limaprost prescriptions and bleeding diagnoses, there were 184,732 events of bleeding. After adjusting for age, the IRR was 1.47 (95% confidence interval [CI], 1.43-1.50), wherein the IRR was the highest during the 0-7 days after limaprost initiation (IRR, 2.11; 95% CI, 2.03-2.18). Risk of bleeding was higher when limaprost was concomitantly used with antithrombotics or other drugs for spinal stenosis treatment, and when higher daily doses of limaprost were administered.

CONCLUSION

Our findings suggest that the risk of bleeding increased by 1.5-fold in periods of limaprost exposure compared to unexposed periods, with particularly higher risks observed during the first week after limaprost initiation, with concomitant drugs related to bleeding, and with a higher daily dose. A careful risk-benefit assessment is warranted when initiating limaprost, especially when administered with other medications or in higher daily doses.

Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics

Short designer self-assembling peptide (dSAP) biomaterials are a new addition to the hemostat group. It may provide a diverse and robust toolbox for surgeons to integrate wound microenvironment with much safer and stronger hemostatic capacity than conventional materials and hemostatic agents. Especially in noncompressible torso hemorrhage (NCTH), diffuse mucosal surface bleeding, and internal medical bleeding (IMB), with respect to the optimal hemostatic formulation, dSAP biomaterials are the ingenious nanofiber alternatives to make bioactive neural scaffold, nasal packing, large mucosal surface coverage in gastrointestinal surgery (esophagus, gastric lesion, duodenum, and lower digestive tract), epicardiac cell-delivery carrier, transparent matrix barrier, and so on. Herein, in multiple surgical specialties, dSAP-biomaterial-based nano-hemostats achieve safe, effective, and immediate hemostasis, facile wound healing, and potentially reduce the risks in delayed bleeding, rebleeding, post-operative bleeding, or related complications. The biosafety in vivo, bleeding indications, tissue-sealing quality, surgical feasibility, and local usability are addressed comprehensively and sequentially and pursued to develop useful surgical techniques with better hemostatic performance. Here, the state of the art and all-round advancements of nano-hemostatic approaches in surgery are provided. Relevant critical insights will inspire exciting investigations on peptide nanotechnology, next-generation biomaterials, and better promising prospects in clinics.

Development and validation of a novel thoracic spinal stenosis surgical invasiveness index: a single-center study based on 989 patients

BACKGROUND CONTEXT

Surgical invasiveness indices have been established for general spine surgery (surgical invasiveness index [SII]), spine deformity, and metastatic spine tumors; however, a specific index for thoracic spinal stenosis (TSS) has not been developed.

PURPOSE

To develop and validate a novel invasiveness index, incorporating TSS-specific factors for open posterior TSS surgery, which may facilitate the prediction of operative duration and intraoperative blood loss, and the stratification of surgical risk.

STUDY DESIGN

A retrospective observational study.

PATIENT SAMPLE

Overall, 989 patients who underwent open posterior TSS surgeries at our institution during the past 5 years were included.

OUTCOME MEASURES

The operation duration, estimated blood loss, transfusion status, major surgical complications, length of hospital stay, and medical expenses.

METHODS

We retrospectively analyzed the data of 989 consecutive patients who underwent posterior surgery for TSS between March 2017 and February 2022. Among them, 70% (n=692) were randomly placed in a training cohort, and the remaining 30% (n=297) automatically constituted the validation cohort. Multivariate linear regression models of operative time and log-transformed estimated blood loss were created using TSS-specific factors. Beta coefficients derived from these models were used to construct a TSS invasiveness index (TII). The ability of the TII to predict surgical invasiveness was compared with that of the SII and assessed in a validation cohort.

RESULTS

The TII was more strongly correlated with operative time and estimated blood loss (p<.05) and explained more variability in operative time and estimated blood loss than the SII (p<.05). The TII explained 64.2% of operative time and 34.6% of estimated blood loss variation, whereas the SII explained 38.7% and 22.5%, respectively. In further verification, the TII was more strongly associated with transfusion rate, drainage time, and length of hospital stay than SII (p<.05).

CONCLUSIONS

By incorporating TSS-specific components, the newly developed TII more accurately predicts the invasiveness of open posterior TSS surgery than the previous index.

Long-term Outcomes of Posterior Multilevel Crack Osteotomy: Revisional Surgery for Scoliosis With a Fusion Mass

OBJECTIVE

Osteotomies are required for the mobilization of spinal segments in patients with revisional scoliosis surgery with a fusion mass; however, only a few techniques have shown efficacy and safety, and their mid- and long-term outcomes remain unelucidated. This study aimed to analyze long-term outcomes of the posterior multilevel crack osteotomy (PMCO) technique for revisional surgery for scoliosis with a fusion mass.

METHODS

Data from 18 patients who underwent revisional scoliosis surgery using PMCO between 2009 and 2015 and had more than 5-year follow-up were retrospectively reviewed. The Cobb angle and coronal and sagittal balance parameters were examined preoperatively, postoperatively, and during the final follow-up. Perioperative parameters and complications were also assessed.

RESULTS

Preoperative and postoperative Cobb angles were 60.5° and 29.9°, respectively (p < 0.001); this improvement was maintained until the final follow-up (33.4°, p = 0.058). The difference in preoperative and postoperative coronal balance was statistically significant (15.9 mm and 9.2 mm, respectively; p < 0.001); this was maintained until the final follow-up (p = 0.071). There was no change in sagittal balance parameters over the 3 measurement periods. Only 1 patient showed PMCO-related motor weakness, but he spontaneously recovered 3 months after postsurgery. Pseudarthrosis was not observed during the follow-up period.

CONCLUSION

Incomplete osteotomy using PMCO provided satisfactory deformity correction without severe complications during revisional surgery for scoliosis with a fusion mass. It may be a less invasive procedure that maintains cortical continuity, preserves soft tissues, and provides sufficient mobility for the correction of spinal segments.

The Role and Clinical Outcomes of Endoscopic Spine Surgery of Treating Spinal Metastases; Outcomes of 29 Cases From 8 Countries

OBJECTIVE

We aim to report the outcomes and feasibility of endoscopic spine surgery used to treat symptomatic spinal metastases patients. This is the most extensive series of spinal metastases patients who underwent endoscopic spine surgery.

METHODS

A worldwide collaborative network group of endoscopic spine surgeons, named 'ESSSORG,' was established. Patients diagnosed with spinal metastases who underwent endoscopic spine surgery from 2012 to 2022 were retrospectively reviewed. All related patient data and clinical outcomes were gathered and analyzed before the surgery and the followtime period of 2 weeks, 1 month, 3 months, and 6 months.

RESULTS

A total of 29 patients from South Korea, Thailand, Taiwan, Mexico, Brazil, Argentina, Chile, and India, were included. The mean age was 59.59 years, and 11 of them were female. The total number of decompressed levels was 40. The technique was relatively equal (15 uniportal; 14 biportal). The average length of admission was 4.41 days. Of all patients with an American Spinal Injury Association Impairment Scale of D or lower before surgery, 62.06% reported having at least one recovery grade after the surgery. Almost all clinical outcomes parameters statistically significantly improved and maintained from 2 weeks to 6 months after the surgery. Few surgical-related complications (4 cases) were reported.

CONCLUSION

Endoscopic spine surgery is a valid option for treating spinal metastases patients as it could yield comparable results to other minimally invasive spine surgery techniques. As the aim is to improve the quality of life, this procedure is valuable and holds value in palliative oncologic spine surgery.

Risk factors for perioperative hidden blood loss after one-segment posterior circumferential decompression surgery on thoracic ossification of the posterior longitudinal ligament: a finding of the double-layer sign on CT

BACKGROUND

Hidden blood loss (HBL) is of increasing interest to spine surgeons. This retrospective study aimed to evaluate perioperative HBL and its risk factors in patients undergoing one-segment posterior circumferential decompression surgery on thoracic ossification of the posterior longitudinal ligament (T-OPLL).

METHOD

We retrospectively studied 112 patients diagnosed with T-OPLL following posterior circumferential decompression surgery from August 2015 to June 2020. Patient demographics, blood loss-related parameters, surgery-related data and imaging parameters were extracted. Postoperative complications were also recorded. Pearson or Spearman correlation analysis was used to investigate the correlation between patient demographics and HBL. Multivariate linear regression analysis was performed to determine the independent risk factors associated with HBL.

RESULTS

Forty-five men and 67 women were involved in this research, with an average age of 56.4 ± 10.2 years. The mean HBL was 459.6 ± 275.4 ml, accounting for 56.5% of the total blood loss. Multiple linear regression analysis showed that double-layer sign (P = 0.000), ossification occupancy ratio (OOR) > 60% (P = 0.030), age (P = 0.010), hematocrit (Hct) loss (P = 0.034), and postoperative Hct (P = 0.016) were independent risk factors for HBL. However, OPLL morphology (P = 0.319), operation time (P = 0.587), hemoglobin (Hb) loss (P = 0.644), and postoperative Hb (P = 0.952) were not significantly different from HBL.

CONCLUSION

A high proportion of HBL was found after posterior circumferential decompression surgery on T-OPLL during the perioperative period, which should not be overlooked. Double-layer sign, OOR > 60%, age, Hct loss and postoperative Hct are independent risk factors for HBL.

Early Postoperative Iatrogenic Neuropraxia After Lumbar Disc Herniation Surgery: Analysis of 87 Cases

BACKGROUND

Postoperative early neuropraxia after lumbar disc herniation surgery is common. The emergence of new paresthesia findings with increased sensory and motor deficits in the postoperative period suggests iatrogenic neuropraxia. This study aimed to discuss the causes and prognosis of iatrogenic neuropraxia detected in the early postoperative period in patients who have been operated on for lumbar disc herniation.

METHODS

Cases with postoperative iatrogenic neuropraxia were determined retrospectively. Deficits were evaluated at intervals of 0-2 hours, 2-12 hours, 12-24 hours, and 24-48 hours. The cases were evaluated in 2 groups as those who underwent aggressive discectomy and simple discectomy. In addition, the treatment results were compared between the 2 groups as the cases that were treated and not treated with methylprednisolone.

RESULTS

The iatrogenic neuropraxia rate was significantly higher in patients who underwent aggressive discectomy. Although it was observed that paresthesia findings improved more rapidly in cases treated with methylprednisolone, no difference was found between the 2 groups in terms of its effects on the motor deficit.

CONCLUSIONS

Iatrogenic neuropraxia is a finding whose cause cannot be determined by quantitative criteria. It is common in patients who underwent aggressive discectomy. Methylprednisolone treatment is effective in recovering the paresthesia finding faster and may show that the radicular injury is in the neuropraxia stage in the early period.

Team management in complex posterior spinal surgery allows blood loss limitation

PURPOSE

The objective is to analyse peri-operative blood loss (BL) and hidden blood loss (HBL) rates in spinal deformity complex cases surgery, with a focus on the strategies to prevent major bleeding.

METHODS

We retrospectively analysed surgical and anaesthesiologic data of patients who had been operated for adolescent idiopathic scoliosis (AIS) or adult spinal deformities (ASD) with a minimum of five levels fused. A statistical comparison among AIS, ASD without a pedicle subtraction osteotomy (PSO) (ASD-PSO( -)) and ASD with PSO (ASD-PSO( +)) procedures was performed with a view to identifying patient- and/or surgical-related factors affecting peri-operative BL and HBL.

RESULTS

One-hundred patients were included with a mean 9.9 ± 2.8 fused vertebrae and a mean 264.2 ± 68.3 minutes operative time (OT) (28.3 ± 9 min per level). The mean perioperative BL was 641.2 ± 313.8 ml (68.9 ± 39.5 ml per level) and the mean HBL was 556.6 ± 381.8 ml (60.6 ± 42.8 ml per level), with the latter accounting for 51.5% of the estimated blood loss (EBL). On multivariate regression analysis, a longer OT (p < 0.05; OR 3.38) and performing a PSO (p < 0.05; OR 3.37) were related to higher peri-operative BL, while older age (p < 0.05; OR 2.48) and higher BMI (p < 0.05; OR 2.15) were associated to a more significant post-operative HBL.

CONCLUSION

With the correct use of modern technologies and patient management, BL in major spinal deformity surgery can be dramatically reduced. Nevertheless, it should be kept in mind that 50% of patients estimated losses are hidden and not directly controllable. Knowing the per-level BL allows anticipating global losses and, possibly, the need of allogenic transfusions.

Surgical Versus Conservative Management for Treating Unstable Atlas Fractures: A Multicenter Study

OBJECTIVE

This multicenter study compared radiological parameters and clinical outcomes between surgical and nonsurgical management and investigated treatment characteristics associated with the successful management of unstable atlas fractures.

METHODS

We retrospectively evaluated 53 consecutive patients with unstable atlas fracture who underwent halo-vest immobilization (HVI) or surgical fixation. Clinical outcomes were assessed using neck visual analogue scale and disability index. The radiological assessment included total lateral mass displacement (LMD) and the anterior atlantodental interval (AADI).

RESULTS

Thirty-two patients underwent surgical fixation and 21 received HVI (mean follow-up, 24.9 months). In the surgical fixation, but not in the HVI, LMD, and AADI showed statistically significant improvements at the last follow-up. The osseous healing rate and time-to-healing were 100% and 14.3 weeks with surgical fixation, compared with 71.43% and 20.0 weeks with HVI, respectively. Patients treated with HVI showed poorer neck pain and neck disability outcomes than those who received surgical treatment. LMD showed an association with osseous healing outcomes in nonoperative management. Clinical outcomes and osseous healing showed no significant differences according to Dickman's classification of transverse atlantal ligament injuries.

CONCLUSION

Surgical internal fixation had a higher fusion rate, shorter fracture healing time, more favorable clinical outcomes, and a more significant reduction in LMD and AADI compared to nonoperative management. The pitfalls of external immobilization are inadequate maintenance and a lower probability of reducing fractured lateral masses. Stabilization by surgical reduction with interconnected fixation proved to be a more practical management strategy than nonoperative treatment for unstable atlas fractures.