Eyal Behrbalk

Blood loss and complications following carotid endarterectomy in patients treated with clopidogrel

This study assessed the effect of uninterrupted antiplatelet therapy on perioperative blood loss and complications in patients undergoing carotid endarterectomy. The files of 107 consecutive patients (mean age 69.5 ± 9 years; range 47–88; 78 men) who underwent carotid endarterectomy were reviewed. Twenty-six patients had been treated with clopidogrel (16 of whom were on combined clopidogrel and aspirin treatment) and compared with non-clopidogrel patients. Antiplatelet treatment was continued until the day of surgery without interruption. Perioperative blood loss and complications were studied. The mean hemoglobin decrease was 1.64 ± 1.2 mg/dL and was not significantly affected by clopidogrel. Surgical time was significantly longer among patients treated with clopidogrel (205 ± 52 minutes on combined treatment and 201 ± 68 minutes on clopidogrel alone versus 165 ± 33 minutes, P < 0.0001). Postoperative complications were similar for all groups and included five strokes, five neck hematomas, one nerve injury and one wound infection. In conclusion, patients treated with clopidogrel before carotid endarterectomy can be expected to have prolonged surgical time. Large cohorts are required to determine whether these patients have more complications.

No gender-related bias in acute musculoskeletal pain management in the emergency department.

Introduction Patients’ gender remains a contributor for bias in pain management. Implementation of standardised analgesic protocols has been shown to minimise bias in analgesic care. The purpose of this study was to assess whether gender-related bias in pain management exists in our emergency department (ED) setting, where a standardised pain management protocol based on patients’ subjective pain rating is routinely used. Methods Pain management measures (ie, analgesia administration, waiting time for analgesia, pain relief and patients’ satisfaction) were prospectively assessed in 328 patients (150 women and 178 men, average age 36±18 years) who were treated in our ED for acute musculoskeletal pain. Results Patients’ subjective pain rating on arrival were similar for men and women (59±24 mm vs 61±26 mm, respectively; p=0.47). Interestingly, physicians using the same scale assessed the womens pain level to be higher than that of men (75±25 mm vs 63±22 mm, respectively; p<0.001) and higher than that of womens subjective pain rating (75±25 mm vs 61±26 mm respectively; p<0.001). Nevertheless, the rates of analgesia administration, waiting time for analgesia, pain relief and patient satisfaction were similar for both genders. Physicians’ own gender did not affect analgesic care. Conclusions Our findings suggest that a standardised pain management protocol based on patients’ subjective pain rating may reduce gender-related bias in acute musculoskeletal pain management.

A Comparison of Different Minimally Invasive and Open Posterior Spinal Procedures Using Volumetric Measurements of the Surgical Exposures.

Study Design: A Prospective observational study. Summary of the Background Data: Minimally invasive (MI) spine surgery techniques strive to minimize the damage to paraspinal soft tissues. Previous studies used only the length of the surgical incision to quantify the invasiveness of certain MI procedures. However, this method does not take into account the volume of muscle tissue that is dissected and retracted from the spine to achieve sufficient exposure. To date, no simple method has been reported to measure the volume of the surgical exposure and to quantify the degree of surgery invasiveness. Study Objectives: To obtain and compare volumetric measures of various MI and open posterior-approached spinal surgical exposures. Methods: The length, the depth, and the volume of the surgical exposure were obtained from 57 patients who underwent either open or MI posterior lumbar surgery. MI procedures included the following: tubular discectomy, laminotomy, and transforaminal interbody fusion. Open procedures included the following: discectomy, laminectomy, transforaminal interbody fusion, or posterior-lateral instrumented fusion. Four attending spine surgeons at our unit performed the surgeries. To reduce variability, only single-level procedures performed between L4 and S1 vertebrae were used. The volume of exposure was obtained by measuring the amount of saline needed to fill the surgical wound completely once the surgical retractors were deployed and opened. Results: The average volumes in mililiters of exposure for a single-level MI procedure ranged from 9.8±2.8 to 75±11.7 mL and were significantly smaller than the average volumes of exposure for a single level open procedures that ranged from 44± 21 to 277±47.9 P<0.001. The average skin-incision lengths for single-level MI procedures ranged from 1.7±0.2 to 7.7±1.6 cm and were significantly smaller than the average skin-incision lengths for open procedures [5.2±1.4 (Table 3) to 11.3±2 cm, P<0.001]. The measured surgical depths were similar in MI and open groups (P=0.138). MI decompression and posterior fusion procedures yielded 92% and 73% reductions in the volumes of exposure, respectively. However, absolute differences in exposure volumes were larger for fusion (202 mL) compared with decompression alone (110.7 mL). Conclusions: Direct volumetric measurement of the surgical exposure is obtained easily by measuring the amount of saline needed to fill the exposed cavity. Using this method, the needed surgical exposure of different spinal procedures can be quantified and compared. This volumetric measurement combined with the measure of retraction force, the duration of retraction, and the impact on soft tissue vascularity can help build a model that assesses the relative invasiveness of different spinal procedures.

Surgical correction of kyphotic deformity in a patient with Proteus syndrome

BACKGROUND CONTEXT Proteus syndrome (PS) is an extremely rare congenital disorder causing asymmetric overgrowth of different tissues. The etiology remains unclear. Limb deformities are common and often necessitate amputations. Only a few cases associated with spinal deformities have been described. PURPOSE The aim was to report a rare case of PS associated with spinal deformity and its surgical management. STUDY DESIGN A case of young boy with PS causing vertebral hypertrophy and kyphoscoliotic deformity, which was surgically corrected, is presented. METHODS The patient was assessed clinically and with whole spine plain radiographs, computed tomography, and magnetic resonance imaging. Surgical correction was performed. RESULTS Satisfactory correction of the deformity was achieved by posterior spinal fusion with instrumentation from T4-L5, five Ponte osteotomies T8-L1, and an L2 pedicle subtraction osteotomy. The kyphosis was corrected from 87° to 55°; there was improvement in all spinopelvic parameters. One year after surgery, there was maintenance of the deformity correction with no deterioration of the sagittal balance, and the patient was free of pain and had no loss of neurologic function. CONCLUSIONS Proteus syndrome can be associated with spinal stenosis and deformity. Although the syndrome can be progressive in nature, the symptomatic spinal pathology should be treated appropriately.

Interkorporelle Fusionsverfahren an der Wirbelsäule

ZusammenfassungHintergrundDie Entwicklung der interkorporellen Fusionsverfahren erstreckt sich mittlerweile über viele Jahrzehnte und ist noch immer nicht abgeschlossen.DiskussionAufgrund der Abwesenheit von entsprechenden Implantaten erfolgten die initialen Fusionen durch Dekortizierung der dorsalen und lateralen Strukturen der Wirbelsäule und anschließendes Anlagern von autologem Knochenmaterial. Trotz passabler Fusionsergebnisse manifestierte sich das Bestreben nach einer besseren Primärstabilität und höheren Fusionsraten. Zudem verbreitete sich auch das Verständnis, dass der primär lasttragende Anteil der Wirbelsäule ventral im Bereich des Corpus der Wirbelkörper liegt. Diese Überlegungen führten letztendlich zur Entwicklung der PLIF-Technik (posteriore lumbale interkorporelle Fusion), die unter Cloward 1953 deutlich an Popularität gewann. Nach Ausräumung des Bandscheibenfaches interpositionierte er Beckenkammknochenblöcke zwischen die Wirbelkörper, die sich entsprechend verklemmten. Basierend auf dieser Technik und diesen Überlegungen erfolgte in den 1970er Jahren die Entwicklung von intervertebralen Implantaten. Der sog. „Bagby Basket“ war der erste intervertebrale Cage, der zunächst bei Pferden mit „Wobbler-Syndrom“ eingesetzt wurde. Weitere Meilensteine in der Verbesserung des Cagedesigns schlossen sich an, was zur Herstellung vielzähliger Implantatformen und -materialien führte. Das Elastizitätsmodul der intersomatischen Implantate näherte sich durch moderne Werkstoffe immer mehr dem von Knochen an, so dass ein Einsintern der Cages reduziert und die Fusionen weiter gesteigert werden konnten. Durch den Einsatz von Schrauben-Stab-Systemen konnte die Primärstabilität zusätzlich weiter gesteigert werden, sodass die dorsale Instrumentierung heute den Standard im Rahmen von PLIF (posteriore lumbale interkorporelle Fusion)- und TLIF-Prozeduren (transforaminale lumbale interkorporelle Fusion) darstellt. Das von Harms beschriebene TLIF-Verfahren war eine neue Modifikation und konnte Komplikationen bei lumbalen Fusionen minimieren sowie die Invasivität des Eingriffs reduzieren.SchlussfolgerungHeutzutage steht uns eine Vielzahl unterschiedlichster Implantate und Implantationstechniken zur Verfügung, was die interkorporelle Fusion in PLIF- und TLIF-Technik zu sicheren und erfolgreichen Verfahren macht.AbstractBackgroundThe development of interbody fusion now stretches over many decades and is still not complete.DiscussionDue to the lack of appropriate implants, the initial fusions were performed via decortication of the dorsal and lateral structures of the spine, followed by placement of an autograft. Despite acceptable fusion results, better primary stability and higher fusion rates were desired. In addition, it became known that the primary load-bearing of the spine is located ventrally in the area of the corpus of the vertebrae. These considerations led to the development of the PLIF technique that was introduced by Cloward in 1953 and gained significantly in popularity. After removal of the intervertebral disc, he positioned iliac crest bone blocks between the vertebral bodies. Based on this technique and these considerations, intervertebral implants were developed in the 1970s. The so-called Bagby Basket was the first intervertebral cage that was initially used in horses with wobbler syndrome. Other milestones in the improvement of the cage designs followed, resulting in the production of different implant shapes and materials. The elastic modulus of the interbody implants approached by modern materials became more and more similar to bone, so that subsidence of cages reduced and the fusion rate could be further increased. The primary stability could be further increased with screw–rod systems, so that dorsal instrumentation became the standard in the context of PLIF and TLIF procedures today. The TLIF procedure described by Harms was a new modification and minimized complications of lumbar fusions and reduced the invasiveness of the procedure.ConclusionNowadays a wide variety of implants and implantation techniques are available, making interbody fusions in PLIF and TLIF techniques safe and successful procedures.BACKGROUND The development of interbody fusion now stretches over many decades and is still not complete. DISCUSSION Due to the lack of appropriate implants, the initial fusions were performed via decortication of the dorsal and lateral structures of the spine, followed by placement of an autograft. Despite acceptable fusion results, better primary stability and higher fusion rates were desired. In addition, it became known that the primary load-bearing of the spine is located ventrally in the area of the corpus of the vertebrae. These considerations led to the development of the PLIF technique that was introduced by Cloward in 1953 and gained significantly in popularity. After removal of the intervertebral disc, he positioned iliac crest bone blocks between the vertebral bodies. Based on this technique and these considerations, intervertebral implants were developed in the 1970s. The so-called Bagby Basket was the first intervertebral cage that was initially used in horses with wobbler syndrome. Other milestones in the improvement of the cage designs followed, resulting in the production of different implant shapes and materials. The elastic modulus of the interbody implants approached by modern materials became more and more similar to bone, so that subsidence of cages reduced and the fusion rate could be further increased. The primary stability could be further increased with screw-rod systems, so that dorsal instrumentation became the standard in the context of PLIF and TLIF procedures today. The TLIF procedure described by Harms was a new modification and minimized complications of lumbar fusions and reduced the invasiveness of the procedure. CONCLUSION Nowadays a wide variety of implants and implantation techniques are available, making interbody fusions in PLIF and TLIF techniques safe and successful procedures.

[Posterior lumbar interbody fusion implants. Software assisted planning--preliminary results].

BACKGROUND Sagittal imbalance, adjacent segment degeneration, and loss of correction due to cage sintering are the main reasons for revision surgery after lumbar fusion. Based on the experience from hip and knee replacement surgery, preoperative software-assisted planning combined with the corresponding cages is helpful to achieve better long-term results. OBJECTIVES Evaluation of the procedure regarding intraoperative application of preoperative planning and examination to what extent the planning was correct. MATERIALS AND METHODS In all, 30 patients were included in the period from September 2012 to May 2013 in an observational study, planned preoperatively with the planning software, and treated with the corresponding PLIF cages. The radiological evaluation was performed by thin-layer CT after 3 months. RESULTS A total of 24 (80%) patients were followed up after 3 months. In these 24 patients, the preoperative planning actually was correct in 17 cases with the intraoperatively implanted cage, which corresponds to a match of about 71%. The fusion rate for these 24 patients who underwent full examinations was 91.7%. CONCLUSION The results of this observational study to evaluate the planning of intervertebral cages show positive experience with this novel therapeutic concept. Despite the limited number of participants, good results were observed for the intraoperative implementation of the planned cages and an adequate fusion rate was obtained. Irrespective of this, a software-based surgical planning must be questioned critically any time. Ultimately, it is the surgeons responsibility to modify the planned procedure intraoperatively if necessary. Currently, the influence of this planning regarding the long-term course and the important question of adjacent segment instability remains unanswered.

Can MRI Predict Flexibility in Scheuermann Kyphosis Patients

Study Design: Retrospective, blinded analysis of imaging studies. Objective: The aim of this study is compare the use of magnetic resonance imaging (MRI) to lateral radiograph using bolster in the evaluation of Scheuermann kyphosis (SK) curve flexibility measurement. Summary and Background Data: The flexibility of the thoracic curve [thoracic kyphosis (TK)] in SK is of primary importance in its preoperative planning. Several methods have been described for SK curve flexibility measurement. The most commonly used method is lateral hyperextension radiography on hard bolster [hyperextension radiograph (HE)]. No current methods use MRI for flexibility assessment. Materials and Methods: Flexibility of TK in SK patients was measured as a difference between standing radiograph and bolster-assisted lateral HE or supine MRI. The sagittal Cobb angle of the TK was measured between the superior endplate of T4 and the inferior endplate of T12 vertebral body. Flexibilities measured by these 2 methods were compared and analyzed using the generalized estimating equation analysis and the correlation analysis. Results: We assessed 18 SK patients (14 males and 4 females) with mean age of 20.06±6.03 years. The standing TK x-rays showed 83.8±6.1 degrees. On HE, TK curve reduced by 39.3 degrees (95% confidence interval, 35.8–42.9) to 44.5±6.2 degrees (P<0.001). Preoperative MRI images showed TK of 53.8±5.9 degrees which means reduction by 30 degrees (95% confidence interval, 26.6–33.4) from the standing radiographs (P<0.001). Linear dependency between HE and MRI flexibility with a mean difference of 9.3 degrees was found (R2=0.61, P<0.001). Conclusions: Our study shows that preoperative MRI can be used for SK flexibility assessment with similar predictive value as routinely used bolster-assisted hyperextension lateral radiograph. Consequently, patient exposure to preoperative hyperextension ionizing radiation may be reduced.

Local implantation of autologous adipose-derived stem cells increases femoral strength and bone density in osteoporotic rats: A randomized controlled animal study

Background: Deficient osteogenic capacity of bone marrow stem cells plays a critical role in the pathophysiology of osteoporosis. Adipose-derived stem cells (ADSCs) have emerged as a promising source of skeletal progenitor cells. The capacity of ADSCs to undergo osteogenic differentiation and induce mineralized tissue formation may be beneficial in the treatment of osteoporosis. We question whether administration of autologous ADSCs into the proximal femur of osteoporotic rats will induce osteogenesis and enhance bone quality and strength. Materials and Methods: Thirty ovariectomized female rats were randomly assigned to one of the two treatment groups: (1) percutanous implantation of autogenous ADSCs-seeded scaffold into the proximal femur and (2) percutanous implantation of non-seeded scaffold. The contralateral untreated femur served as control. The effect of treatment on bone characteristics was assessed at 12-week follow-up by micro-computed tomography analysis, mechanical testing, and histological analysis. Results: The mean cortical thickness, total bone volume density, and bone load to failure in femora injected with autologous ADSCs-seeded scaffold was significantly higher compared to femora injected with non-seeded scaffold and compared to the untreated control femora (p < 0.01). Histological examination of the injected specimens revealed complete osseo-integration of the scaffolds with direct conversion of the ADSCs into osteoblasts and no inflammatory response. Conclusions: Autogenous ADSCs implantation into the proximal femur of rats with ovariectomy-related osteoporosis promoted bone regeneration and increased bone strength at short-term follow-up. These findings highlight the potential benefit of autogenous ADSCs in the treatment of osteoporosis. Level of Evidence: Level I, randomized controlled trial, animal study.

Interbody fusion procedures. Development from a historical perspective

ZusammenfassungHintergrundDie Entwicklung der interkorporellen Fusionsverfahren erstreckt sich mittlerweile über viele Jahrzehnte und ist noch immer nicht abgeschlossen.DiskussionAufgrund der Abwesenheit von entsprechenden Implantaten erfolgten die initialen Fusionen durch Dekortizierung der dorsalen und lateralen Strukturen der Wirbelsäule und anschließendes Anlagern von autologem Knochenmaterial. Trotz passabler Fusionsergebnisse manifestierte sich das Bestreben nach einer besseren Primärstabilität und höheren Fusionsraten. Zudem verbreitete sich auch das Verständnis, dass der primär lasttragende Anteil der Wirbelsäule ventral im Bereich des Corpus der Wirbelkörper liegt. Diese Überlegungen führten letztendlich zur Entwicklung der PLIF-Technik (posteriore lumbale interkorporelle Fusion), die unter Cloward 1953 deutlich an Popularität gewann. Nach Ausräumung des Bandscheibenfaches interpositionierte er Beckenkammknochenblöcke zwischen die Wirbelkörper, die sich entsprechend verklemmten. Basierend auf dieser Technik und diesen Überlegungen erfolgte in den 1970er Jahren die Entwicklung von intervertebralen Implantaten. Der sog. „Bagby Basket“ war der erste intervertebrale Cage, der zunächst bei Pferden mit „Wobbler-Syndrom“ eingesetzt wurde. Weitere Meilensteine in der Verbesserung des Cagedesigns schlossen sich an, was zur Herstellung vielzähliger Implantatformen und -materialien führte. Das Elastizitätsmodul der intersomatischen Implantate näherte sich durch moderne Werkstoffe immer mehr dem von Knochen an, so dass ein Einsintern der Cages reduziert und die Fusionen weiter gesteigert werden konnten. Durch den Einsatz von Schrauben-Stab-Systemen konnte die Primärstabilität zusätzlich weiter gesteigert werden, sodass die dorsale Instrumentierung heute den Standard im Rahmen von PLIF (posteriore lumbale interkorporelle Fusion)- und TLIF-Prozeduren (transforaminale lumbale interkorporelle Fusion) darstellt. Das von Harms beschriebene TLIF-Verfahren war eine neue Modifikation und konnte Komplikationen bei lumbalen Fusionen minimieren sowie die Invasivität des Eingriffs reduzieren.SchlussfolgerungHeutzutage steht uns eine Vielzahl unterschiedlichster Implantate und Implantationstechniken zur Verfügung, was die interkorporelle Fusion in PLIF- und TLIF-Technik zu sicheren und erfolgreichen Verfahren macht.AbstractBackgroundThe development of interbody fusion now stretches over many decades and is still not complete.DiscussionDue to the lack of appropriate implants, the initial fusions were performed via decortication of the dorsal and lateral structures of the spine, followed by placement of an autograft. Despite acceptable fusion results, better primary stability and higher fusion rates were desired. In addition, it became known that the primary load-bearing of the spine is located ventrally in the area of the corpus of the vertebrae. These considerations led to the development of the PLIF technique that was introduced by Cloward in 1953 and gained significantly in popularity. After removal of the intervertebral disc, he positioned iliac crest bone blocks between the vertebral bodies. Based on this technique and these considerations, intervertebral implants were developed in the 1970s. The so-called Bagby Basket was the first intervertebral cage that was initially used in horses with wobbler syndrome. Other milestones in the improvement of the cage designs followed, resulting in the production of different implant shapes and materials. The elastic modulus of the interbody implants approached by modern materials became more and more similar to bone, so that subsidence of cages reduced and the fusion rate could be further increased. The primary stability could be further increased with screw–rod systems, so that dorsal instrumentation became the standard in the context of PLIF and TLIF procedures today. The TLIF procedure described by Harms was a new modification and minimized complications of lumbar fusions and reduced the invasiveness of the procedure.ConclusionNowadays a wide variety of implants and implantation techniques are available, making interbody fusions in PLIF and TLIF techniques safe and successful procedures.BACKGROUND The development of interbody fusion now stretches over many decades and is still not complete. DISCUSSION Due to the lack of appropriate implants, the initial fusions were performed via decortication of the dorsal and lateral structures of the spine, followed by placement of an autograft. Despite acceptable fusion results, better primary stability and higher fusion rates were desired. In addition, it became known that the primary load-bearing of the spine is located ventrally in the area of the corpus of the vertebrae. These considerations led to the development of the PLIF technique that was introduced by Cloward in 1953 and gained significantly in popularity. After removal of the intervertebral disc, he positioned iliac crest bone blocks between the vertebral bodies. Based on this technique and these considerations, intervertebral implants were developed in the 1970s. The so-called Bagby Basket was the first intervertebral cage that was initially used in horses with wobbler syndrome. Other milestones in the improvement of the cage designs followed, resulting in the production of different implant shapes and materials. The elastic modulus of the interbody implants approached by modern materials became more and more similar to bone, so that subsidence of cages reduced and the fusion rate could be further increased. The primary stability could be further increased with screw-rod systems, so that dorsal instrumentation became the standard in the context of PLIF and TLIF procedures today. The TLIF procedure described by Harms was a new modification and minimized complications of lumbar fusions and reduced the invasiveness of the procedure. CONCLUSION Nowadays a wide variety of implants and implantation techniques are available, making interbody fusions in PLIF and TLIF techniques safe and successful procedures.

Is Hydronephrosis a Complication after Anterior Lumbar Surgery

Study Design Prospective follow-up design. Objective Ureteral injury is a recognized complication following gynecologic surgery and can result in hydronephrosis. Anterior lumbar surgery includes procedures like anterior lumbar interbody fusion (ALIF) and total disk replacement (TDR). Anterior approaches to the spine require mobilization of the great vessels and visceral organs. The vascular supply to the ureter arising from the iliac arteries may be compromised during midline retraction of the ureter, which could theoretically lead to ureter ischemia and stricture with subsequent hydronephrosis formation. Methods Potential candidates with previous ALIF or TDR via anterior retroperitoneal access between January 2008 and March 2012 were chosen from those operated on by a single surgeon in a university hospital setting (n = 85). Renal ultrasound evaluation of hydronephrosis was performed on all participants. Simple descriptive and inferential statistics were used to generate results. Results A total of 37 voluntary participants were recruited (23 male, 14 female subjects; average age 51.8 years). The prevalence of hydronephrosis in our population was 0.0% (95% confidence interval 0 to 8.1%). Conclusions Retraction of the ureter across the midline in ALIF and TDR does not result in an increase in hydronephrosis and appears to be a safe surgical technique.