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PubMedDate not supplied

Wound infection after spinal fusion in children with cerebral palsy.

One hundred and seventy-two children with cerebral palsy were operated on for neuromuscular scoliosis by spinal fusion with unit rod instrumentation between January 1988 and June 1996. There were 15 (8.7%) postoperative wound infections (seven deep, eight superficial) in 15 patients (five males, 10 females) who had a mean age of 13.9 years. The mean follow-up after diagnosis of infection was 3.3 years (range, 1-7.2). Twelve of the 15 infected cases, including all seven deep infections, occurred in the distal portion of the incision. In 14 patients, the wound infections were diagnosed within the first 2 months of the original spinal fusion. All the superficial wound infections were treated successfully by local wound care and intravenous antibiotics. The removal of hardware was necessary in the one late deep wound infection that occurred 2 years after the spinal fusion. The remaining six deep infections were treated by irrigation and debridement with the wound left open, allowing it to heal by secondary intention. One patient's wound was closed over suction-irrigation drains; however, due to a recurrent abscess, the wound was reopened and allowed to granulate. All the wound infections occurred in severely neurologically involved spastic quadriplegics who were nonambulatory and severely mentally retarded and had seizure disorders.

Adolescent↗

PubMed1997

Unexplained visual loss after lumbar spinal fusion.

Two cases of visual loss after spinal fusion surgery are described. In both cases, surgery was lengthy, the patient's head was placed in a dependent position, and hemodilution and deliberate hypotension were combined. One patient was achondroplastic, the other obese. Possible risk factors associated with ischemic optic neuropathy after anesthesia and surgery are discussed.

Achondroplasia↗

PubMed1998

Persistent Horner's syndrome after spinal fusion and epidural analgesia. A case report.

STUDY DESIGN: A case report of a clinical observation. OBJECTIVES: To present the clinical findings of an unusual complication of spinal fusion and epidural analgesia. SUMMARY OF BACKGROUND DATA: A 13-year-old girl developed Horner's syndrome after posterior thoracic spinal fusion and epidural analgesia. METHODS: By clinical examination and pupillary pharmacologic testing, the diagnosis of Horner's syndrome was confirmed. RESULTS: Examination and testing confirmed the presence of central or preganglionic Horner's syndrome. The specific cause of the Horner's syndrome was not determined. Horner's syndrome persisted, and the blepharoptosis was corrected surgically. CONCLUSIONS: This is the first reported case of Horner's syndrome occurring after posterior spinal fusion and epidural analgesia.

Anesthesia, Epidural↗

PubMed2002

Resorbable posterolateral graft containment in a rabbit spinal fusion model.

OBJECT: The authors studied the effect of a resorbable graft containment device in a rabbit posterolateral lumbar spinal fusion model. METHODS: Twenty rabbits were divided into four groups: autologous bone graft (ABG), ABG with the MacroPore containment device (ABG + MP), demineralized bone matrix (DBM), and DBM with the containment device (DBM + MP). Fusion mass was assessed at 6 weeks with high-resolution radiography and volumetric computerized tomography. The graft containment device was associated with alteration of the fusion mass structure and significant enhancement of fusion mass volume (ABG versus ABG + MP, p = 0.027; DBM versus DBM + MP, p = 0.043). CONCLUSIONS: A bioabsorbable protective graft containment device successfully enhanced posterolateral spinal fusion mass volume.

Absorbable Implants↗

PubMed2004

Spinal fusion using an autologous growth factor gel and a porous resorbable ceramic.

Augmenting healing through a single application of an exogenous growth factor or bone morphogenetic protein is not a new concept. The use of autologous growth factors through platelet isolation and concentration provides multiple endogenous growth factors to the healing site. A posterolateral fusion model in aged sheep (5- to 6-year-old ewes) was used to examine the effects of the addition of growth factors through autologous platelet isolation on the biomechanic and histologic properties of the fusion using a resorbable coral bone graft substitute. At 6 months the combination of autologous growth factors to the Pro Osteon 500R plus aspirated bone marrow resulted in the greatest bending stiffness but not ultimate load. Autologous growth factors can be isolated from platelets and concentrated to provide multiple growth factors to the fusion site to aid in spinal fusion.

Animals↗

PubMed1992

Acute normovolemic hemodilution combined with hypotensive anesthesia and other techniques to avoid homologous transfusion in spinal fusion surgery.

To avoid homologous transfusion in spinal fusion surgery, acute normovolemic hemodilution was combined with controlled hypotensive anesthesia. Patients were kept hemodiluted, not only during surgery, but also after surgery by delaying transfusion until the next morning or later. Transfusion decisions were made by clinical judgment rather than by preset value (ie, 10 g/dl). Other techniques used in this protocol were preoperative autologous blood donation and intraoperative salvage of shed blood. Only 4 of 119 patients (3.4%) required homologous blood, compared to 25 of 29 patients (86%) in 1982, at which time none of these techniques were used. The average hemoglobin on the seventh postoperative day was similar in both groups; 11.5 g/dl in the current series compared to 11.1 g/dl in the 1982 series.

Adolescent↗

PubMed1999

Experimental spinal fusion using sintered bovine bone coated with type I collagen and recombinant human bone morphogenetic protein-2.

STUDY DESIGN: Posterolateral lumbar transverse process fusion using recombinant human bone morphogenetic protein (rhBMP)-2 carried by sintered bovine bone and Type I collagen complex was compared with fusion achieved using autogeneous bone graft or sintered bovine bone alone. OBJECTIVES: This study examined the efficacy of sintered bovine bone coated with Type I collagen as a carrier of rhBMP-2 for lumbar intertransverse process arthrodesis. SUMMARY OF BACKGROUND DATA: Posterolateral intertransverse process arthrodesis using osteoinductive growth factors is performed experimentally in the lumbar spine. The previous studies revealed the efficacy of osteoinductive factors applied to carriers having no bony structures, such as collagen sheet or polylactic acid polymer, for the spinal fusion. However, in their studies, a large amount of osteoinductive proteins have been applied for the spinal fusion. We used the sintered bovine bone "True Bone Ceramics" (TBC; Koken Co., Tokyo, Japan) coated with type I collagen as the carrier. True Bone Ceramics is the only biomaterial possessing a natural trabecular structure and an organized crystal of bone minerals. METHODS: Twenty-two adult rabbits underwent bilateral lumbar intertransverse process arthrodesis at L4-L5. The animals were divided into four groups and had materials implanted as follows: autologous bone group, grafted autologous corticocancellous bone harvested from the posterior iliac crest; implanted TBC group; TBC collagen group, implanted TBC coated with Type I collagen infiltrating into the porous space; and BMP group, implanted sintered bovine bone coated with Type I collagen infiltrated with 100 micrograms of rhBMP-2. Spinal fusion was evaluated by radiographic analysis, manual palpation, biomechanical testing, and histologic examination 6 weeks after surgery. RESULTS: Two rabbits were killed because of infection and lumbar plexus palsy. Radiographs of the BMP group showed a homogeneous fusion mass at the intertransverse area, and stability was confirmed by dynamic radiographs at 3 and 6 weeks after surgery. In the BMP group, a bony mass in the intertransverse area was more prominent than in the other groups. The BMP group had a higher fusion rate based on manual palpation than the-other groups, and BMP fusions showed significantly higher tensile strength and stiffer fusion. The histologic findings in the BMP group demonstrated membranous bone and endochondral bone formations between the transverse process and the fusion mass. In the other groups, continuous trabecular bone formation was observed in the area surrounding the transverse process, but gaps between grafted fragments and less mature bone formation were present in the intertransverse area. CONCLUSIONS: Sintered bovine bone coated with Type I collagen and rhBMP-2 resulted in a higher fusion rate than the autograft and can be used as a carrier for rhBMP-2 in spinal fusion.

Animals↗

PubMed1988

Additive effects of dihydralazine during enflurane or isoflurane hypotensive anaesthesia for spinal fusion.

Sixteen patients (13-38 yr) undergoing spinal fusion for scoliosis under controlled hypotension were studied to determine the haemodynamic and neuroendocrine responses to IV dihydralazine (1.0 mg.kg-1) followed by 0.5 and 1 MAC of enflurane or isoflurane. Twenty minutes after dihydralazine administration mean arterial pressure (-20 per cent) and systemic vascular resistance (-50 per cent) decreased, and cardiac index (+57 per cent), heart rate (+37 per cent) and intrapulmonary shunt increased. Plasma renin activity and aldosterone and norepinephrine levels increased. Further decreases in mean arterial pressure and in systemic vascular resistance were observed when 0.5 MAC enflurane or isoflurane were added. With 1 MAC anaesthetic levels a further decrease in mean arterial pressure was observed in both groups, but pressure fell to a lower level with isoflurane than with enflurane (p less than 0.01). The reduction of arterial blood pressure to a level of 50-60 mmHg for three to four hours was easy to control and was free of complications. The preliminary IV administration of dihydralazine allowed a reduced volatile agent concentration which attenuated undesirable haemodynamic effects, in spite of renin and norepinephrine release, and permitted a rapid intraoperative awakening.

Adolescent↗

PubMed1993

Anterior and posterior spinal fusion: comparison of one-stage and two-stage procedures.

OBJECTIVE: To compare postoperative morbidity and length of hospital stay after combined anterior and posterior spinal fusion for patients treated by a one-stage procedure and those treated in two stages, 1 to 2 weeks apart. DESIGN: Retrospective review of all cases handled by the first author between July 1989 and November 1991. The patients had been referred for treatment of severe spinal deformity, scoliosis or kyphosis by combined anterior and posterior spinal fusion. SETTING: The operations were performed at McMaster University Medical Centre, Hamilton, Ont., by the first author, who was assisted by another specialist in spinal surgery and a fellow or resident. PATIENTS: Eleven operations of each type were performed. The mean age of the 22 patients was 16.6 and 14.6 years for those who underwent the one-stage and the two-stage procedures respectively. The diagnoses included neuromuscular disease, neurofibromatosis, spina bifida, congenital kyphoscoliosis and severe idiopathic spinal curvature. The one-stage procedure was used after the surgical team became able to provide the care associated with this type of major surgery; selection of patients also involved preoperative risk assessment and the feasibility of combining two surgical procedures that would take a maximum of 9 hours. The preoperative plan was to spend a maximum of 9 hours in performing the one-stage procedure. INTERVENTIONS: Similar surgical procedures were performed in both groups. The average number of intervertebral levels fused during the anterior component of the operation was 4.6 in the one-stage procedure and 6.0 in the two-stage procedure. Thoracolaparotomy was performed in four patients who underwent the two-stage procedure. During the posterior component of the operation, instrumentation was inserted through an average of 11.6 and 12.6 intervertebral levels in the groups undergoing the one-stage and the two-stage procedures respectively. Total operating time averaged 7 hours and 15 minutes for the one-stage procedure and 11 hours for the two-stage procedure. Mean blood loss was 1830 mL for the one-stage procedure and 2270 mL for the two-stage procedure. MAIN OUTCOME MEASURES: The number of days spent in the intensive care unit (ICU) and the total number of days spent in hospital, as well as morbidity after the operation, were determined. RESULTS: Postoperative morbidity included five minor complications in patients who underwent a one-stage procedure; all of these complications resolved well. Among those who underwent the two-stage procedure there were 11 complications; in two patients further surgery was required. The patients' stay in the ICU averaged 2.6 and 7.7 days respectively for one-stage and two-stage procedures, and the total stay in hospital averaged 14 and 33 days respectively. CONCLUSIONS: When possible, the one-stage procedure for anterior and posterior spinal fusion is preferred over the two-stage procedure because of a significant reduction in the length of stay in the ICU and in hospital, as well as reduced morbidity. However, this analysis should be interpreted cautiously because of the small number of cases and the variables encountered in treating this type of spinal deformity.

Adolescent↗

PubMed1999

Aerobic and anaerobic microbiology of surgical-site infection following spinal fusion.

The aerobic and anaerobic microbiology of surgical-site infections (SSI) following spinal fusion was retrospectively studied. This was done by reviewing the clinical and microbiological records at the Naval Hospital in Bethesda, Md., from 1980 to 1992. Aspirates of pus from 25 infection sites showed bacterial growth. Aerobic bacteria only were recovered from 9 (36%) specimens, anaerobic bacteria only were recovered from 4 (16%), and mixed aerobic and anaerobic bacteria were recovered from 12 (48%). Sixty isolates were recovered: 38 aerobes (1.5 isolates per specimen) and 22 anaerobes (0.9 isolate per specimen). The predominant aerobes were Escherichia coli (n = 8) and Proteus sp. (n = 7). The predominant anaerobes were Bacteroides fragilis group (n = 9) and Peptostreptococcus sp. (n = 6) isolates. An increase in recovery of E. coli and B. fragilis was noted in patients with bowel or bladder incontinence. This study highlights the polymicrobial nature of SSI and the importance of anaerobic bacteria in SSI following spinal fusion.

Bacteria, Anaerobic↗

PubMedDate not supplied

Comparison of disk excision and combined disk excision and spinal fusion for lumbar disk ruptures.

In a series of private patients 77 per cent over-all satisfactory results were obtained from surgical disk excision performed without spinal fusion. Patients in whom spinal fusion combined with discectomy has been recommended by other authors are not much more satisfied than patients with discectomy alone without fusion (81% versus 74% satisfactory). Patients in whom the third party influence prevails were significantly more dissatisfied (only 59% satisfactory). Findings of a definite disk rupture at the time of surgery result in a higher incidence of satisfactory rating than those with degenerative changes or with normal findings.

Adolescent↗

PubMed1999

Factors affecting lumbar spinal fusion.

There is little information on the effect of nonsurgical factors or postoperative anemia on achieving spinal fusion. In a prospective cohort study of 184 consecutive lumbar spinal fusions, we obtained data on socioeconomic, clinical, radiologic, and traditional surgical factors and analyzed associations between these factors and fusion status at 6 months post surgery. The overall fusion rate was 74%. Among the surgical factors, use of pedicle screw fixation (p = 0.005) predicted fusion success; postoperative anemia (hematocrit < 30%; p = 0.003) and a history of smoking (p = 0.050) predicted fusion failure. However, when the surgical factors were analyzed together with clinical and socioeconomic factors, back pain greater than or equal to leg pain (p < 0.001) and patients working at the initial visit (p = 0.001) predicted fusion success; shoulder pain at the initial visit (p < 0.001) and a family history of back surgery (p = 0.006) predicted fusion failure. These factors were stronger predictors of fusion status than were traditional surgical factors.

Adolescent↗

PubMedDate not supplied

Children's use of PCA following spinal fusion.

PURPOSE: The purpose of this study was to examine the effectiveness of patient-controlled analgesia (PCA) in relieving postoperative pain for children and adolescents following spinal fusion. DESIGN/SAMPLE: A one-group, descriptive design was used with a convenience sample of 93 children (ages 8 to 21 years) who had undergone spinal fusion over a 2-year period. METHODS: All of the patients were using PCA postoperatively with morphine sulfate, the most common opioid analgesic prescribed for use in the infusion pump. Data were collected for the first 4 postoperative days on four outcome variables: use of PCA, self-report of pain, observed pain-related behaviors, and satisfaction with PCA. FINDINGS: Despite aggressive pain management, findings showed that neither children's pain nor their analgesic use diminished significantly over time. Children continued to report moderate-to-severe pain over the 4-day measurement period. Likewise, children reported their satisfaction with PCA for pain relieve as "fair" to "good." CONCLUSION: The use of high technology and aggressive pharmacologic treatment alone may not be adequate for managing severe pain following spinal fusion. As proposed by the Gate Control Theory, pain stimuli produce not only physiologic, but also psychologic and emotional responses. Relief for severe pain, therefore, may require multidimensional therapies that include nonpharmacologic approaches together with precise titration of available pharmacologic agents.

Adolescent↗

PubMed2001

Serum magnesium, copper, and zinc alterations following spinal fusion.

Changes in serum magnesium, copper and zinc values were evaluated in spinal fusion patients at four monitorings. For magnesium and copper individually, a significant difference was found between the mean values at each monitoring (p < 0.05), whereas the changes of zinc values between four monitorings were insignificant. There was no statistical difference between the changes of each trace element values and gender, age, operative time, intraoperative blood loss, blood replacement, number of the vertebral levels fused, and antibiotic type used. As a result, magnesium can be suggested to be more important than the other two elements in the postoperative period. Alterations of serum magnesium, copper, and zinc values do not have any correlation with the fusion of the spinal column, either with the width of the fused area or operative time and blood loss. This study cannot confirm the exact reason for this entity and the etiology remains speculative. There is no need for magnesium, copper, or zinc supplementation during the surgical period for the patients. It will be worthy to evaluate the patients who were sent to the intensive care unit after spinal surgery and compare their results with the other intensive care patients.

Adolescent↗

PubMed2000

The biomechanical significance of anterior column support in a simulated single-level spinal fusion.

This study examines the biomechanical effects of interbody cages and variations in posterior rod diameter in a simulated single-level spinal fusion. A single-level spinal fusion model composed of polyethylene cylinders, posterior pedicular instrumentation, and variously positioned single or dual interbody cages was used for biomechanical testing. Constructs were tested under compressive flexural load, with measurement of stiffness, rod strain, cage strain, and intracage pressure. A strong linear correlation emerged between the mean construct stiffness and cage positioning within the sagittal plane that was inversely related to posterior rod strain. Two small titanium mesh cages were equivalent to one large cage. In a single-level spine model, the presence of and sagittal position of interbody cages significantly influences overall construct stiffness. Cage strain increased with more anterior positions and was inversely related to rod strain.

Humans↗

PubMed2001

The Effect of epsilon-aminocaproic acid on perioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion: a preliminary prospective study.

STUDY DESIGN: A prospective study evaluating the efficacy of epsilon-aminocaproic acid (EACA) in decreasing perioperative blood loss in idiopathic scoliosis. OBJECTIVES: To compare the perioperative blood loss and need for blood replacement in two groups of patients undergoing surgery for idiopathic scoliosis. One group received intraoperative EACA; the other did not and served as controls. SUMMARY OF BACKGROUND DATA: Excessive blood loss increases the operative time, risk for blood product disease transmission, postoperative complications, and costs associated with posterior spinal fusion and instrumentation. EACA is an antifibrinolytic agent that has been shown to be effective in reducing perioperative blood loss during pediatric cardiothoracic surgical procedures. We hypothesized that it would also be effective in lowering blood loss during posterior spinal fusion for idiopathic scoliosis. METHODS: We compared the perioperative blood loss of 28 consecutive pediatric patients with idiopathic scoliosis who underwent posterior spinal fusion and received intraoperative EACA with 31 consecutive patients who did not receive this medication and served as a control group. RESULTS: The patients in both groups were similar. Patients in the EACA group demonstrated statistically significant decreases in total estimated perioperative blood loss and the need for autologous blood transfusion. The patients in the EACA group had no intraoperative or postoperative complications related to the use of this medication. CONCLUSIONS: Based on these preliminary findings, we believe that EACA is helpful in decreasing blood loss in patients undergoing posterior spinal fusion and instrumentation, and may decrease the number of autologous units needed to maintain safe perioperative hemoglobin levels, thereby improving safety and lowering cost associated with scoliosis surgery.

Adolescent↗

PubMed1997

RF heating of implanted spinal fusion stimulator during magnetic resonance imaging.

Radio frequency (RF) heating of an implanted spinal fusion stimulator (SpF) during magnetic resonance imaging (MRI) was studied on a full-size human phantom. Heating during MRI scans (GE Signa 4X, 1.5 T) was measured with RF-transparent fiberoptic sensors. With the implant correctly connected, the maximum temperature rises were less than 2 degrees C during the 26 min that the scans were at maximum RF power. At the tip of a broken stimulator lead (connecting the SpF generator and its electrodes), the maximum temperature rise was 11-14 degrees C. Regular 4-min scans of the spinal cord produced similar temperature rises at the broken tip. After the generator and the leads were removed, heating at the electrode connector tip was less than 1.5 degrees C. The control temperature rises at the same locations, without the stimulator, were less than 0.5 degree C. This study shows that spinal fusion stimulator heating is within the Food and Drug Administration safety guideline of 2 degrees C. However, if a lead wire is broken, it is unsafe during MRI scans. Radiological examinations will be necessary to ensure the integrity of the implant.

Electric Stimulation↗

PubMed1994

Vertebral growth after posterior spinal fusion for idiopathic scoliosis in skeletally immature adolescents. The effect of growth on spinal deformity.

We studied 29 girls and one boy with adolescent idiopathic scoliosis who were at Risser grade 0 at the time of posterior spinal fusion and were followed until maturity (mean 7.8 years). We used serial radiographs to measure the ratio of disc to vertebral height in the fused segments and to detect differential anterior spinal growth and assess its effect on scoliosis, vertebral rotation, kyphosis, and rib-vertebral-angle difference (RVAD). From one year after surgery to the latest review, the percentage anterior disc height decreased by nearly one-half and the percentage posterior disc height by nearly one-third in the fused segments (p < 0.001). There was a 4 degree increase in mean Cobb angle (p < 0.001), 11 patients (37%) having an increase of between 6 degrees and 10 degrees. There was a significant increase in mean apical rotation by 2 degrees (p = 0.003), and four patients (13%) had an increase of between 6 degrees and 16 degrees. There was little change in kyphosis. There was an increase in mean RVAD by 4 degrees (p = 0.003), seven patients (23%) showing a reduction by 1 degree to 7 degrees, and 11 (37%) increases of between 6 degrees and 16 degrees. Spinal growth occurs after posterior fusion in adolescents who are skeletally immature, as a result of continued anterior vertebral growth. There is some progression of scoliosis, vertebral rotation, and RVAD, but little change in kyphosis. The increase in deformity is not enough to warrant the use of combined anterior and posterior fusion. The findings are relevant to the management of progressive curves, the timing and extent of surgery, and the prognosis for progression of deformity in this group of patients.

Adolescent↗