No abstract

OBJECTIVE One of the principal goals of minimally invasive surgery has been to speed postoperative recovery. In this case series, the authors used an endoscopic technique for interbody fusion combined with percutaneous screw fixation to obviate the need for general anesthesia. METHODS The first 10 consecutive patients treated with a minimum of 1 year's follow-up were included in this series. The patients were all treated using endoscopic access through Kambin's triangle to allow for neural decompression, discectomy, endplate preparation, and interbody fusion. This was followed by percutaneous pedicle screw and connecting rod placement using liposomal bupivacaine for long-acting analgesia. No narcotics or regional anesthetics were used during surgery. RESULTS All patients underwent the procedure successfully without conversion to open surgery. The patients' average age was 62.2 ± 9.0 years (range 52–78 years). All patients had severe disc height collapse, and 60% had a Grade I spondylolisthesis. The mean operative time was 113.5 ± 6.3 minutes (range 105–120 minutes), and blood loss was 65 ± 38 ml (range 30–190 ml). The mean length of hospital stay was 1.4 ± 1.3 nights. There were no intraoperative or postoperative complications. Comparison of preoperative and final clinical metrics demonstrated that the Oswestry Disability Index improved from 42 ± 11.8 to 13.3 ± 15.1; the 36-Item Short Form Health Survey (SF-36) Physical Component Summary improved from 47.6 ± 3.8 to 49.7 ± 5.4; the SF-36 Mental Component Summary decreased from 47 ± 3.9 to 46.7 ± 3.4; and the EQ-5D improved from 10.7 ± 9.5 to 14.2 ± 1.6. There were no cases of nonunion identified radiographically on follow-up imaging. CONCLUSIONS Endoscopic fusion under conscious sedation may represent a feasible alternative to traditional lumbar spine fusion in select patients. Larger clinical series are necessary to validate that clinical improvements are sustained and that arthrodesis rates are successful when compared with open surgery. This initial experience demonstrates the possible utility of this procedure.

For the management of mild-to-moderate asthma, salmeterol given twice daily is superior to albuterol given either four times daily or as needed.

OBJECTIVE Over the past decade, Enhancing Recovery After Surgery (ERAS) programs have been implemented throughout the world across multiple surgical disciplines. However, to date no spinal surgery equivalent has been described. In this report the authors review the development and implementation of a “fast track” surgical approach for lumbar fusion. METHODS The first 42 consecutive cases in which patients were treated with the new surgical procedure were reviewed. A combination of endoscopic decompression, expandable cage deployment, and percutaneous screw placement were performed with liposomal bupivacaine anesthesia to allow the surgery to be performed without general endotracheal anesthesia. RESULTS In all cases the surgical procedure was performed successfully without conversion to an open operation. The patients' mean age (± SD) was 66.1 ± 11.7 years, the male/female ratio was 20:22, and a total of 47 levels were treated. The mean operative time was 94.6 ± 22.4 minutes, the mean intraoperative blood loss was 66 ± 30 ml, and the mean hospital length of stay was 1.29 ± 0.9 nights. Early follow-up showed a significant improvement in the mean Oswestry Disability Index score (from 40 ± 13 to 17 ± 11, p = 0.0001). Return to the operating room was required in 2 cases due to infection and in 1 case due to cage displacement. An iterative quality improvement program demonstrated areas of improvement, including steps to minimize infection, improve postoperative analgesia, and reduce cage osteolysis. CONCLUSIONS ERAS programs for improving spinal fusion surgery are possible and necessary. This report demonstrates a first foray to apply these principles through 1) a patient-focused approach, 2) reducing the stress of the operation, and 3) an iterative improvement process.

The bronchoprotective effect of montelukast was maintained throughout 8 weeks of study. In contrast, significant loss of bronchoprotection at weeks 4 and 8 was seen with salmeterol. Long-term administration of montelukast provided consistent inhibition of exercise-induced bronchoconstriction at the end of the 8-week dosing interval without tolerance.