There is currently no consensus about the mean
volume of blood lost during spinal tumour surgery and surgery for metastatic
spinal disease. We conducted a systematic review of papers published
in the English language between 31 January 1992 and 31 January 2012.
Only papers that clearly presented blood loss data in spinal surgery
for metastatic disease were included. The random effects model was
used to obtain the pooled estimate of mean blood loss. We selected 18 papers, including six case series, ten retrospective
reviews and two prospective studies. Altogether, there were 760
patients who had undergone spinal tumour surgery and surgery for
metastatic spinal disease. The pooled estimate of peri-operative
blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic
blood loss as high as 5000 ml, which is rare. Aside from two studies
that reported large amounts of mean blood loss (>
5500 ml), the
resulting funnel plot suggested an absence of publication bias.
This was confirmed by Egger’s test, which did not show any small-study
effects
(p = 0.119). However, there was strong evidence of heterogeneity
between studies (I2 = 90%; p <
0.001). Spinal surgery for metastatic disease is associated with significant
blood loss and the possibility of catastrophic blood loss. There
is a need to establish standardised methods of calculating and reporting
this blood loss. Analysis should include assessment by area of the
spine, primary pathology and nature of surgery so that the amount
of blood loss can be predicted. Consideration should be given to
autotransfusion in these patients. Cite this article:
Patients with neurogenic claudication from lumbar canal stenosis non-responsive to non-surgical treatment are usually managed with spinal decompression with or without fusion. Flexion at stenotic segments relieves symptoms by increasing canal cross-sectional area, intervertebral foraminal height. Interspinous spacers work by causing flexion at the treated segement. We used COFLEX¯ [Paradigm Spine] a titanium interspinous spacer along with interlaminar decompression where indicated. To compare the clinical and radiological results of patients undergoing interlaminar decompression with or without use of COFLEX¯. Pre and post-operative assessment and comparison of clinical outcomes of Oswestry disability index(ODI), Visual analog Scale(VAS), Short Form-36(SF-36) and radiological outcomes of disc heights of operated and adjacent levels, intervertebral foraminal heights, sagittal angles of the operated segment. All consecutive patients undergoing spinal decompression at one or more levels from Jan to Dec 2008 were included. Patients with clinically symptomatic back pain for a duration longer than claudication pain were offered interspinous spacer at L4/5 level or above. In first group(n-20), patients were treated with inter-laminar decompression and COFLEX¯ with a standard posterior approach. In second group(n-25) inter-laminar decompression for the involved segment was performed. All patients are on follow-up. Clinical and radiological outcomes were compared at 6 months and 1 year. Statistically significant(p<0.001) improvements in ODI, VAS(back), VAS(leg) and SF-36 in patients in whom COFLEX¯ was used. Radiological parameters also showed significant improvements(p<0.05). Use of COFLEX¯ spacer is justified in patients with symptomatic disc degeneration with neurogenic claudication when treated operatively.
Although success has been achieved with implantation of bone marrow mesenchymal stem cells (bMSCs) in degenerative discs, its full potential may not be achieved if the harsh environment of the degenerative disc remains. Axial distraction has been shown to increase hydration and nutrition. Combining both therapies may have a synergistic effect in reversing degenerative disc disease. In order to evaluate the effect of bMSC implantation, axial distraction and combination therapy in stimulating regeneration and retarding degeneration in degenerative discs, we first induced disc degeneration by axial loading in a rabbit model. The rabbits in the intervention groups performed better with respect to disc height, morphological grading, histological scoring and average dead cell count. The groups with distraction performed better than those without on all criteria except the average dead cell count. Our findings suggest that bMSC implantation and distraction stimulate regenerative changes in degenerative discs in a rabbit model.
Video-assisted thoracoscopic surgery (VATS) has been in use since the 1980s for surgery of the spine. Initially it was used for anterior release of the thoracic spine in order to facilitate posterior instrumentation. With increasing experience, it has been applied to perform definitive correction and instrumentation. Video-assisted thoracoscopic spine surgery allows the surgeon to perform anterior thoracic spine operations with fewer levels of instrumentation, reducing the crankshaft effect and removing the morbidity associated with thoracotomy. From 1996 to November 2000, our center performed 19 such operations. 18 of them were completed successfully endoscopically and one was converted to an open procedure. An initial group of 10 patients underwent thoracoscopic anterior release and fusion followed by same day posterior instrumentation and fusion. Subsequently, 6 patients underwent anterior discectomies, fusion with instrumentation via thoracoscopic approach. For the initial 10 patients, the average operative time was 190 minutes. The average post-operative correction was 62 % and blood loss was 350 mLs. For the 6 patients who underwent anterior discectomies, fusion and instrumentation via the thoracoscopic approach, the average operative time was 360 minutes; average post-operative correction was 70% and blood loss was 400 mLs. Complications encountered were minor and included one case ofcontralateral pneumothorax, one patient complained of transient limb numbness which resolved within 6 weeks. It is our conclusion that thoracoscopic anterior spinal surgery, though with learning curve, a safe and effective procedure.
