Spontaneous pneumomediastinum and subcutaneous emphysema as a complication of asthma in children: case report and literature review.

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Spontaneous pneumomediastinum and subcutaneous emphysema as a complication of asthma in children: case report and literature review.

Ther Adv Respir Dis. 2016 Oct;10(5):402-9

Authors: Tortajada-Girbés M, Moreno-Prat M, Ainsa-Laguna D, Mas S

Abstract
BACKGROUND: Spontaneous pneumomediastinum (SPM) is an uncommon disorder. It is rarely reported in paediatric patients and may be accompanied by subcutaneous emphysema. It is usually benign and self-limiting, with only supportive therapy being needed, but severe cases may require invasive measures. Asthma exacerbations have classically been described as a cause of SPM. However, detailed descriptions in asthmatic children are scarce. We aimed at improving the current understanding of the features of SPM and subcutaneous emphysema, and outcomes, by means of a case report and a systematic review.
METHODS: For the systematic review a literature search was performed in PubMed to identify reported cases of SPM in asthmatic children.
RESULTS: The case a 10-year-old asthmatic girl with SPM is reported. The patient received an inhaled corticosteroid and long-acting beta2 agonist, in addition to sublingual immunotherapy (SLIT) with eventual control of asthma symptoms.
REVIEW: A total of 114 published cases were found since 1995, most of them in teenagers; no sex differences were observed. Clinical presentation was associated with an asthma exacerbation in a number of cases. Other presenting features were chest pain, dyspnoea, cough, and particularly acute swelling of the face, neck, and upper chest. Subcutaneous emphysema was present in most patients. Overall, three cases of pneumothorax and two cases of pneumorrhachis were reported. Therapy was mainly based on supportive care, rest, oxygen therapy, analgesics, steroids, and bronchodilators. All patients recovered spontaneously, in spite of a small initial increase in SPM in a few cases.
CONCLUSIONS: Early identification of patients at risk of SPM would avoid the high number of under-diagnosed cases. Patients should be treated not only with supportive therapy but also with measures to achieve control of the underlying cause (such as poorly controlled asthma).

PMID: 27585598 [PubMed – indexed for MEDLINE]

Improvements in Neck and Arm Pain Following an Anterior Cervical Discectomy and Fusion.

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Improvements in Neck and Arm Pain Following an Anterior Cervical Discectomy and Fusion.

Spine (Phila Pa 1976). 2017 Jul 15;42(14):E825-E832

Authors: Massel DH, Mayo BC, Bohl DD, Narain AS, Hijji FY, Fineberg SJ, Louie PK, Basques BA, Long WW, Modi KD, Singh K

Abstract
STUDY DESIGN: A retrospective analysis.
OBJECTIVE: The aim of this study was to quantify improvements in Visual Analogue Scale (VAS) neck and arm pain, Neck Disability Index (NDI), and Short Form-12 (SF-12) Mental (MCS) and Physical (PCS) Composite scores following an anterior cervical discectomy and fusion (ACDF).
SUMMARY OF BACKGROUND DATA: ACDF is evaluated with patient-reported outcomes. However, the extent to which these outcomes improve following ACDF remains poorly defined.
METHODS: A surgical registry of patients who underwent primary, one- or two-level ACDF during 2013 to 2015 was reviewed. Comparisons of VAS neck and arm, NDI, and SF-12 MCS and PCS scores were performed using paired t tests from preoperative to each postoperative time point. Analysis of variance (ANOVA) was used to estimate the reduction in neck and arm pain over the first postoperative year. Subgroup analyses were performed for patients with predominant neck (pNP) or arm (pAP) pain, as well as for one- versus two-level ACDF.
RESULTS: Eighty-nine patients were identified. VAS neck and arm, NDI, and SF-12 PCS improved from preoperative scores at all postoperative time points (P < 0.05 for each). Across the first postoperative year, patients reported a 2.7-point (44.2%) reduction in neck and a 3.1-point (54.0%) reduction in arm pain (P < 0.05 for each). Sixty-one patients with pNP and 28 patients with pAP reported reductions in neck and arm pain over the first 6 months and 12 weeks postoperatively, respectively (P < 0.05 for each). Patients who underwent one-level ACDFs experienced a 47.2% reduction in neck pain and 55.1% reduction in arm pain over the first postoperative year (P < 0.05 for each), while those undergoing two-level ACDF experienced 39.7% and 49.2% for neck and arm, respectively (P < 0.05 for each).
CONCLUSION: This study suggests that patients experience significant improvements in neck and arm pain following ACDF regardless of presenting symptom. In addition, patients undergoing one-level ACDF report greater reductions in neck and arm pain than patients undergoing two-level fusion.
LEVEL OF EVIDENCE: 4.

PMID: 27851659 [PubMed – indexed for MEDLINE]

Which Technique Is Better Option for C3 Segment in Multilevel Open-Door Laminoplasty of the Cervical Spine?: Laminectomy Versus Laminoplasty.

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Which Technique Is Better Option for C3 Segment in Multilevel Open-Door Laminoplasty of the Cervical Spine?: Laminectomy Versus Laminoplasty.

Spine (Phila Pa 1976). 2017 Jul 15;42(14):E833-E840

Authors: Lee GW, Cho CW, Shin JH, Ahn MW

Abstract
STUDY DESIGN: A post-hoc comparative study.
OBJECTIVE: To evaluate postoperative clinical, radiological, and surgical outcomes after laminoplasty (LP) involving the C3 segment and to compare outcomes with those of patients who underwent LP with C3 laminectomy (LN).
SUMMARY OF BACKGROUND DATA: In many of the pathologies that require LP involving C3 segment, most spine surgeons perform LP at C3 and other cervical segments. Considering the peculiarities of the C2-C3 level, spine surgeons should take into account those in LP involving the C3 segment, but the particular aspects of the C2-C3 levels have not been fully evaluated.
METHODS: Of 93 patients, 66 patients (39 in group A, LP involving C3; 27 in group B, LP with C3 LN) were enrolled in the study. The primary outcome measure was pain intensity of the posterior neck measured with visual analog scale. Secondary endpoints included the following: (1) radiologic outcomes based on the cervical range of motion and rate of bony impingement and spontaneous fusion between C2 and C3, (2) clinical outcomes based on the 12-item short-form health survey and Japanese Orthopedic Association scale, and (3) surgical outcomes.
RESULTS: The primary end-point of the present study, posterior neck pain, exhibited a greater improvement in the group with C3 LN than in the group with C3 LP at 6 months and 1 year after surgery (P = 0.03 and 0.01, respectively). The cervical range of motion of C3 LN group was significantly greater than C3 LP group at postoperative 1 year (P = 0.02). Radiologic evidences of bony impingement and spontaneous fusion between C2 and C3 were significantly greater in C3 LP group than in C3 LN group. Clinical outcomes and surgical outcomes did not differ significantly between groups.
CONCLUSION: We recommend performing LN instead of LP for the C3 segment in cases requiring multilevel LP surgery involving C3.
LEVEL OF EVIDENCE: 3.

PMID: 27851661 [PubMed – indexed for MEDLINE]

Radiographic Predictors for Mechanical Failure After Adult Spinal Deformity Surgery: A Retrospective Cohort Study in 138 Patients.

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Radiographic Predictors for Mechanical Failure After Adult Spinal Deformity Surgery: A Retrospective Cohort Study in 138 Patients.

Spine (Phila Pa 1976). 2017 Jul 15;42(14):E855-E863

Authors: Hallager DW, Karstensen S, Bukhari N, Gehrchen M, Dahl B

Abstract
STUDY DESIGN: Retrospective cohort study at a single institution.
OBJECTIVE: We aimed at estimating the rate of revision procedures and identify radiographic predictors of mechanical failure after adult spinal deformity surgery.
SUMMARY OF BACKGROUND DATA: Mechanical failure rates after adult spinal deformity surgery range 12% to 37% in literature. Although the importance of spinal and spino-pelvic alignment is well documented for surgical outcome and ideal alignment has been proposed as sagittal vertical axis (SVA) < 5 cm, pelvic tilt < 20° and lumbar lordosis (LL) = pelvic incidence ± 9°, the role of radiographic sagittal spine parameters and alignment targets as predictors for mechanical failure remains uncertain.
METHODS: A consecutive cohort of adult spinal deformity patients who underwent corrective surgery with at least 5 levels of instrumentation between January 2008 and December 2012 at a single tertiary spine unit were followed for at least 2 years. Time to death or failure was recorded and cause-specific Cox regressions were applied to evaluate predictors for mechanical failure or death.
RESULTS: A total of 138 patients with median age of 61 years were included for analysis. Follow up ranged 2.1 to 6.8 years. In total 47% had revision and estimated failure rates were 16% at 1 year increasing to 56% at 5 years. A multivariate analysis adjusting for age at surgery showed increased hazard of failure from LL change > 30°, postoperative TK > 50°, and SS ≤30°. LL change was mostly because of 3-column osteotomy and ending the instrumentation at L5 or S1 increased the hazard of failure more than 6 fold compared with more cranial lumbar levels.
CONCLUSION: Mechanical failure rate was 47% after adult spinal deformity corrective surgery. LL change > 30°, postoperative TK > 50°, and postoperative SS ≤30° were independent radiographic predictors associated with increased hazard of failure.
LEVEL OF EVIDENCE: 4.

PMID: 27879571 [PubMed – indexed for MEDLINE]

Lateral lumbar interbody fusion with unilateral pedicle screw fixation for the treatment of adjacent segment disease: a preliminary report.

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Lateral lumbar interbody fusion with unilateral pedicle screw fixation for the treatment of adjacent segment disease: a preliminary report.

J Spine Surg. 2017 Sep;3(3):330-337

Authors: Du JY, Kiely PD, Al Maaieh M, Aichmair A, Huang RC

Abstract
BACKGROUND: To assess the clinical outcomes of 20 patients who underwent single level unilateral pedicle screw fixation following lateral lumbar interbody fusion (LLIF) for treatment of lumbar adjacent segment disease (ASD).
METHODS: Demographic, comorbidity, clinical assessment, peri-operative, and complication data were assessed. Visual analog scale (VAS), Oswestry disability index (ODI), and short form-12 (SF-12) were used to assess clinical outcomes. Post-operative radiographs were assessed for subsidence, cage migration, and fusion.
RESULTS: Average age of patients was 63.2±13.7 years (range, 41-86 years), with 8 males and 12 females. Recombinant human bone morphogenic protein-2 (rhBMP-2) was utilized in 18 LLIF cages (90%) and 12 posterolateral fusions (60%). Mean operation time was 214.1±47.2 minutes (range, 146-342 minutes), mean estimated blood loss of 187.5±90.1 cc (range, 50-400 cc). No patients received a blood transfusion. There were no intra-operative complications. Mean hospital length of stay was 4.4±1.7 days (range, 2-9 days). At final follow-up (mean: 13.0±12.7 months after surgery), there was significant improvement in post-op VAS (P=0.006) score compared to pre-op, but not ODI (P=0.181), SF-12 PC (P=0.480), and SF-12 MC (P=0.937). Patients with >6 months of post-operative imaging (14/20, 70%) demonstrated successful fusion in 13 out of 14 cases (93%). There was grade 0 subsidence of adjacent cranial vertebra in all cases (100%). There was grade 0 subsidence of the adjacent caudal vertebra in 13 cases (93%) and grade 1 subsidence in 1 case (7%). There was evidence of cage migration in 3 cases (21%). There were 4 patients (20%) who experienced transient neurological deficits that eventually resolved. Two patients required surgery for further ASD.
CONCLUSIONS: In conclusion, this pilot study suggests that patients who undergo LLIF with unilateral pedicle screw fixation for treatment of ASD may have significantly reduced pain and favorable radiographic results. Further investigation in techniques for treatment of ASD is warranted.

PMID: 29057340 [PubMed]

Early clinical and radiological results of unilateral posterior pedicle instrumentation through a Wiltse approach with lateral lumbar interbody fusion.

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Early clinical and radiological results of unilateral posterior pedicle instrumentation through a Wiltse approach with lateral lumbar interbody fusion.

J Spine Surg. 2017 Sep;3(3):338-348

Authors: Du JY, Kiely PD, Bogner E, Al Maaieh M, Aichmair A, Salzmann SN, Huang RC

Abstract
BACKGROUND: To assess the clinical outcomes of 44 patients who underwent single-level lateral lumbar interbody fusion (LLIF) with unilateral pedicle screw instrumentation through a paramedian Wiltse approach.
METHODS: Demographic, comorbidity, clinical assessment, peri-operative, and complication data were assessed. Visual analog scale (VAS), Oswestry disability index (ODI), and short form-12 (SF-12) were used to assess clinical outcomes. Post-operative plain radiographs were assessed for subsidence, cage migration, and fusion.
RESULTS: Average age of patients at surgery was 60.8±10.6 years (range, 32-79 years), with 15 males and 29 females. Recombinant human bone morphogenic protein-2 (rhBMP-2) was used in 32 cases (73%) and 13 posterolateral fusions (30%). Average duration of surgery was 195.2±36.9 minutes (range: 111-295 minutes), with an estimated blood loss of 159.3±90.8 cc (range, 50-500 cc). There were no intra-operative complications. Average length of hospital stay was 4.2±2.5 days (range, 2-13 days). Four patients (9%) experienced neurological deficit, 2 of which resolved by 3-month follow-up and 2 of which improved but did not resolve by final follow-up at 11 and 16 months. There was significant improvement in VAS (P<0.001), ODI (P<0.001), and SF-12 physical component (P<0.001), but not for SF-12 mental component (P=0.053). Patients with minimum 6 months radiographic follow-up demonstrated successful fusion in 90% of cases (35/39), with 2 cases of grade 1 (5%) subsidence of the adjacent cranial vertebra, and no cases higher than grade 0 subsidence of the adjacent caudal vertebra.
CONCLUSIONS: Unilateral pedicle screw instrumentation following LLIF was associated with significant improvement in clinical outcomes and favorable radiographic outcomes.

PMID: 29057341 [PubMed]

Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis.

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Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis.

Spine (Phila Pa 1976). 2017 Jul 15;42(14):1088-1095

Authors: Perera AP, Chari A, Kostusiak M, Khan AA, Luoma AM, Casey ATH

Abstract
STUDY DESIGN: Systematic Review and Meta-Analysis OBJECTIVE.: To identify whether intramuscular local anesthetic infiltration prior to wound closure was effective in reducing postoperative pain and facilitating early discharge following lumbar spine surgery.
SUMMARY OF BACKGROUND DATA: Local anesthetic infiltration prior to wound closure may form part of the multimodal strategy for postoperative analgesia, facilitating early mobilization and discharge. Although there are a number of small studies investigating its utility, a quantitative meta-analysis of the data has never been performed.
METHODS: This review was conducted according the PRISMA statement and was registered with the PROSPERO database. Only randomized controlled trials were eligible for inclusion. Key outcomes of interest included time to first analgesic demand, total postoperative opiate usage in the first 24 hours, visual analogue score (VAS) at 1, 12 and 24 hours and postoperative length of stay.
RESULTS: Eleven publications fulfilled the inclusion criteria. A total of 438 patients were include; 212 in the control group and 226 in the intervention group. Local anesthetic infiltration resulted in a prolonged time to first analgesic demand (mean difference (MD) 65.88 minutes, 95% confidence interval (95% CI) 23.70 to 108.06, P.0.002) as well as a significantly reduced postoperative opiate demand (M.D. -9.71 mg, 95% CI -15.07, -4.34, p = 0.0004). There was a small but statistically significant reduction in postoperative visual analogue score (VAS) at 1 hour (M.D. -0.87 95%CI -1.55, -0.20, p = 0.01), but no significant reduction at 12 or 24 hours (p = 0.93 and 0.85 respectively).
CONCLUSION: This systematic review and meta-analysis provides evidence that postoperative intramuscular local anaesthetic infiltration reduces postoperative analgesic requirements and the time to first analgesic demands for patients undergoing lumbar spine surgery. Key research priorities include optimization of the choice and strength of local anaesthetic agent and health-economic analyses to strengthen the case for routine use of postoperative local anesthetics in lumbar spine surgery.
LEVEL OF EVIDENCE: 1.

PMID: 28426530 [PubMed – indexed for MEDLINE]