Study Design: Review article. Objective: A review of the literature on postoperative initiation of thrombophylactic agents following spine surgery. Methods: A review of the literature and synthesis of the data to provide an update on venous thromboprophylaxis following spine surgery. Results: Postoperative regimens of venous thromboprophylaxis measures following spine surgery remain a controversial issue. Recommendations regarding mechanical versus chemical prophylaxis vary greatly among institutions. Conclusion: Postoperative spine surgery initiation of thromboprophylaxis remains controversial regarding optimal timing and agent selection. The benefits of deep vein thrombosis/pulmonary embolism prophylaxis must be weighed against the possible postoperative complications associated with spine surgery.
Glioependymal cysts are rare congenital lesions of the central nervous system. Reported surgical treatments of these lesions have varied and yielded mixed results, and the optimal surgical strategy is still controversial. The authors here report the clinical and surgical outcomes for three adult patients successfully treated with neuroendoscopic fenestration into the ventricular system. The patients had presented with symptomatic glioependymal cysts in the period from 2013 to 2016 at the authors’ institution. All underwent minimally invasive neuroendoscopic fenestration of the glioependymal cyst into the lateral ventricle via a stereotactically guided burr hole. Presenting clinical and radiological findings, operative courses, and postintervention outcomes were evaluated.All three patients initially presented with symptoms related to regional mass effect of the underlying glioependymal cyst, including headaches, visual disturbances, and hemiparesis. All patients were successfully treated with endoscopic fenestration of the cyst wall into the lateral ventricle, where the wall was thinnest. Postoperatively, all patients reported improvement in their presenting symptoms, and neuroimaging demonstrated decompression of the cyst. Clinical follow-up ranged from 4 months to 5 years without evidence of reexpansion of the cyst or shunt requirement.Compared to open resection and shunting of the cyst contents, minimally invasive endoscopic fenestration of a glioependymal cyst into the ventricular system is a safe and effective surgical option. This approach is practical, is less invasive than open resection, and appears to provide a long-term solution.
The authors report 2 cases of sacral dural arteriovenous fistula (AVF) presenting with gradual neurologic decline characterized by progressive lower extremity weakness and bowel and bladder incontinence. Spinal angiography demonstrated a sacral dural AVF with perimedullary vein engorgement and drainage extending to the level of the cervical spine in both cases. The fistulas were completely obliterated with n-BCA (n-butyl cyanoacrylate) embolic agent in one case, and with ethylene vinyl alcohol (Onyx) in the second, resulting in improvement of the symptoms in both patients. The unique features of this case report include the rare location of the fistula's origin, the necessity for complete spinal angiography, and the use of intraoperative monitoring in one case to guide embolization treatment.
Study Design: Literature review. Objective: Preoperative management of therapeutic anticoagulation in spine surgery is critical to minimize risk of thromboembolic events yet prevent postsurgical complications. Limited research is available, and most guidelines are based on drug half-lives. We aim to clarify current guidelines and available evidence for safe practice of spine surgery in this patient population. Methods: A literature search in PubMed was done encompassing comprehensive search terms to locate published literature on anticoagulation and spine surgery. Predefined inclusion and exclusion criteria were applied and data extraction was performed. Results: A total of 17 articles met the final inclusion criteria. Of these, 12 articles were retrospective chart reviews, 3 were prospective observational studies, and 2 were systematic reviews. Current practice suggests holding warfarin until international normalized ratio <1.4, anti-Xa drugs for 48 to 72 hours, 12 to 24 hours for low-molecular-weight heparin, and 4 to 24 hours for heparin, before surgery. Antiplatelet agents can be stopped for 1 to 3 days prior to operation (81-500 mg) but must be stopped for 1 week for doses >1 g/d. For Plavix, 5 to 7 days of discontinuation advised to prevent complications. Conclusions: This review provides an overview of main anticoagulation agents seen in preoperative setting for spine patients. Although data is mixed and no true randomized control trials are available, there is growing evidence suggesting the aforementioned guidelines are needed to optimize anticoagulation in setting of spine surgery. Further studies are needed to elucidate risk of complications while operating under therapeutic levels of anticoagulation for a variety of comorbid conditions.
Objective To examine heart rate recovery (HRR) as an indicator of autonomic nervous system (ANS) dysfunction following maximal exercise testing in children and young adults with sickle cell anemia (SCA). Study design Recovery phase heart rate (HR) in the first 5 minutes following maximal exercise testing in 60 subjects with SCA and 30 matched controls without SCA was assessed. The difference between maximal HR and HR at both 1-minute (ΔHR1min) and 2-minute (ΔHR2min) recovery was our primary outcome. Results Compared with controls, subjects with SCA demonstrated significantly smaller mean ΔHR1min (23 bpm, 95% CI [20, 26] vs. 32 bpm, 95% CI [26, 37], p = 0.006) and ΔHR2min (39 bpm, 95% CI [36, 43] vs. 48 bpm, 95% CI [42, 53], p = 0.011). Subjects with SCA also showed smaller mean changes in HR from peak HR to 1 minute, from 1 minute to 2 minutes and from 2 through 5 minutes of recovery by repeated measures testing. In a multivariable regression model, older age was independently associated with smaller ΔHR1min in subjects with SCA. Cardiopulmonary fitness and hydroxyurea use, however, were not independent predictors of ΔHR1min. Conclusions Children with SCA demonstrate impaired HRR following maximal exercise. Reduced post-exercise HRR in SCA suggests impaired parasympathetic function, which may become progressively worse with age, in this population.
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