Background: Awake surgery is performed in multiple surgical specialties, but historically, awake surgery in the field of neurosurgery was limited to craniotomies. Over the past two decades, spinal surgeons have pushed for techniques that only require regional anesthesia as they may provide reduced financial burdens on patients, faster recovery times, and better outcomes. The list of awake spine surgeries that have been found in the literature include: laminectomies/discectomies, anterior cervical discectomy and fusions (ACDFs), lumbar fusions, and dorsal column (DC) stimulator placement. Methods: An extensive review of the published literature was conducted through PubMed database with articles containing the search term “awake spine surgery.” No date restrictions were used. Results: The search yielded 293 related articles. Cross-checking of articles was conducted to exclude of duplicate articles. The articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic. Findings have shown that lumbar laminectomies performed with local anesthesia have shown shorter operating time, less postoperative nausea, lower incidence of urinary retention and spinal headache, and shorter hospital stays when compared to those performed under general anesthesia. Lumbar fusions with local anesthesia showed similar outcomes as patients reported better postoperative function and fewer side effects of general anesthesia. DC stimulator placement performed with local anesthesia is advantageous as it allows real time patient feedback for surgeons as they directly test affected nerves. However, spontaneous movement during the placement of DC stimulators is associated with higher failure rates when compared to general anesthesia (29.7% vs. 14.9%). Studies have shown that the use of local anesthesia during ACDFs has no significant differences when compared to general anesthesia, and patient’s report better tolerated pain with general anesthesia. Conclusion: The use of awake spine surgery is beneficial for those who cannot undergo general anesthesia. However, it is limited to patients who can tolerate prone positioning with no central airway (i.e., normal BMI with a healthy airway), have no pre-existing mental health conditions (e.g., anxiety), and require a minimally invasive procedure with a short operating time. Future studies should focus on long-term efficacies of these procedures that provide further insight on the indications and limitations of awake spine surgery.
Degenerative disc disease (DDD) is the leading cause of chronic back pain. It is a pathologic condition associated with aging and is believed to result from catabolic excess in the intervertebral discs’ (IVD) extracellular matrix. Two new treatment options are intradiscal cellular transplantation and growth factor therapy. Recent investigations on the use of these therapies are discussed and compared with emerging evidence supporting novel cellular injections. At present, human and animal studies provide a compelling rationale for the use of cellular injections in the treatment of discogenic pain. Since DDD results from the IVD extracellular matrix’s unmitigated catabolism, cellular injections are used to induce regeneration and homeostasis in the IVD. Here, we review intervertebral disc anatomy, DDD pathophysiology and clinical considerations, as well as the current and emerging literature investigating outcomes associated with cellular transplantation and platelet-rich plasma for discogenic pain. Further high-quality trials are certainly warranted.
ObjectivesThe COVID-19 pandemic highlighted concerns regarding the equity of medical care. We evaluated associations between race/ethnicity, timing of hospital presentation and outcomes of acute appendicitis (AP) and acute cholecystitis (AC) during the initial pandemic peak.MethodsAnalysis was performed on a prospective, observational, multicenter study of adults with AP or AC. Patients were categorized as pre-pandemic (pre-CoV: October 2019–January 2020) or during the first pandemic peak (CoV: April 2020 through 4 months following the end of local pandemic restrictions). Patient demographics, American Association for the Surgery of Trauma (AAST) imaging/pathology grade, duration of symptoms before triage, time from triage to intervention and hospital length of stay were collected.ResultsA total of 2165 patients (1496 pre-CoV, 669 CoV) were included from 19 centers. Asian and Hispanic patients with AC had a longer duration of symptoms prior to presentation during CoV than pre-CoV (100.6 hours vs 37.5 hours, p<0.01 and 85.7 hours vs 52.5 hours, p<0.05, respectively) and presented later during CoV than Black or White patients (34.3 and 37.9 hours, p<0.01). During CoV, Asian patients presented with higher AAST pathology grade for AP compared with pre-CoV (1.90 vs 1.26, p<0.01). Asian and Hispanic patients presented with higher AAST pathology grade for AC during CoV versus pre-CoV (2.57 vs 1.45, p<0.01, and 1.57 vs 1.20, p<0.05, respectively). Patients with AC and an AAST pathology grade of ≥3 were at higher odds of postoperative complications (OR 4.4, 95% CI 1.0 to 18.4) and AP (OR 2.8, 95% CI 1.3 to 6.0). Asian and Hispanic patients with AC had a higher risk of postoperative complications compared to White patients (Asian: OR 3.9, 95% CI 1.2 to 12.7; Hispanic: OR 3.3, 95% CI 1.2 to 8.9).ConclusionAsian and Hispanic patients had a longer duration of symptoms before hospital presentation during the initial COVID-19 peak, had higher odds of postoperative complications and more advanced pathologic disease.Level of evidenceIII, Prognostic/epidemiological.
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