Although autologous bone graft from the iliac crest is the gold standard for most spinal fusion applications, it is known to cause significant graft-site morbidity. Unlike the traditional corticocancellous allograft, the intracortical method leaves the iliac crest in continuity and decreases the surgical incision and overall area of dissection. We hypothesized this modified technique would decrease pain and complication rate. We first performed an extensive literature review to ascertain which questions, variables, and results were found to be statistically significant regarding the postoperative course and complication rates in patients who underwent iliac crest bone grafting. We then created an Iliac Crest Bone Graft survey that was mailed to 293 patients who had undergone intracortical iliac crest bone graft at our institution to assess postoperative pain and complications.One hundred one (34.5%) surveys were returned. Differences in chronic pain between the surgical types (cervical, lumbosacral, traumatic, and scoliosis) using the intracortical technique showed a trend toward statistical significance (F=2.42, P<.071); this trend was mostly due to no chronic pain reported in the cervical and traumatic groups. Patients experiencing chronic pain at their graft site using the intracortical technique had a statistically significant difference in pain between the same incision versus a separate incision (F=5.05, P<.027), with a separate incision having lower reported pain. After meta-analyses were performed with articles obtained in the literature search using the traditional corticocancellous technique and compared to our results, the only variable that obtained statistical significance was decreased chronic pain at 2 years with the intracortical method in our study (P<.001).
Patients with pulmonary hypertension (PH) are at an increased risk of perioperative morbidity and mortality when undergoing non-cardiac surgery. We present a case of a 57-year-old patient with severe PH, who developed cardiac arrest as the result of right heart failure, undergoing a revision total hip arthroplasty under combined spinal epidural anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was undertaken as rescue therapy during the pulmonary hypertensive crisis and a temporizing measure to provide circulatory support in an intensive care unit (ICU). We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery. The review goes through the updated hemodynamic definition, clinical classification of PH, perioperative morbidity, and mortality associated with PH in non-cardiac surgery. Pre-operative assessment evaluates the type of surgery, the severity of PH, and comorbidities. General anesthesia (GA) is discussed in detail for patients with PH regarding the benefits of and unsubstantiated arguments against GA in non-cardiac surgery. The literature on risks and benefits of regional anesthesia (RA) in terms of neuraxial, deep plexus, and peripheral nerve block with or without sedation in patients with PH undergoing non-cardiac surgery is reviewed. The choice of anesthesia technique depends on the type of surgery, right ventricle (RV) function, pulmonary artery (PA) pressure, and comorbidities. Given the differences in pathophysiology and mechanical circulatory support (MCS) between the RV and left ventricle (LV), the indications, goals, and contraindications of VA-ECMO as a rescue in cardiopulmonary arrest and pulmonary hypertensive crisis in patients with PH are discussed. Given the significant morbidity and mortality associated with PH, multidisciplinary teams including anesthesiologists, surgeons, cardiologists, pulmonologists, and psychological and social worker support should provide perioperative management.
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