European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
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This article focuses on our current understanding of the role of activated coagulation factor VII (FVIIa) in coagulation, the current evidence regarding the efficacy and safety of recombinant FVIIa (rFVIIa), and thoughts regarding the use of rFVIIa in spine surgery. rFVIIa is approved in many countries (including the European Union and the USA) for patients with hemophilia and inhibitors (antibodies) to coagulation factors VIII or IX. High circulating concentrations of FVIIa, achieved by exogenous administration, initiate hemostasis by combining with tissue factor at the site of injury, producing thrombin, activating platelets and coagulation factors II, IX and X, thus providing for the full thrombin burst that is essential for hemostasis. This "bypass" therapy has led some clinicians to use rFVIIa "off-label" for disorders of hemostasis other than hemophilia. ⋯ Preliminary reports have indicated that rFVIIa does not increase the perioperative incidence of thromboembolic events. However, full reports from large clinical trials regarding the efficacy and safety of rFVIIa in settings other than hemophilia have yet to appear in peer-reviewed publications. Until adequate data demonstrating safety and efficacy are fully reported, it would seem appropriate to reserve the use of rFVIIa in spinal surgery to those instances where conventional therapy cannot provide adequate hemostasis, and "rescue" therapy is required.
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Spine surgery may be associated with profuse intraoperative bleeding that often requires blood transfusions. In recent years several techniques have been developed to avoid allogenic transfusions and their potential complications to surgical patients. In this study we review and analyse the role of preoperative recombinant human erythropoietin (rHuEPO) administration in spine surgery as a blood conservation strategy. Between 1998 and 2002, a total of 250 patients scheduled for spine surgery were included in our blood-sparing program: 114 patients (group 1), operated on before rHuEPO approval (2000), underwent preoperative autologous blood donation (ABD) alone, and 136 patients operated on after rHuEPO approval (groups 2 and 3) received rHuEPO while undergoing ABD. Adding rHuEPO to ABD resulted in higher haemoglobin and haematocrit values the day of surgery, more ABD units retrieved per patient and, consequently, reduced allogenic transfusion requirements. The effectiveness of rHuEPO as the only preoperative blood conservation technique was evaluated in ten patients with a predicted blood loss of less than 30% of their total volume, scheduled for lumbar surgery. Data from these patients were matched with those from a similar group of patients who had undergone ABD. Patients receiving rHuEPO alone had higher haemoglobin levels the day of surgery than did patients in the ABD program. Neither group required allogenic transfusions. ⋯ preoperative rHuEPO is useful for reducing allogenic blood requirements in elective spine surgery. In patients with an expected blood loss of around 50% of blood volume, rHuEPO improves ABD, minimising preoperative anaemia and increasing the number of ABD units collected. In patients with expected blood loss below 30% of total volume, rHuEPO administration may replace ABD.
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Review
An overview of blood-sparing techniques used in spine surgery during the perioperative period.
The problems linked to blood loss and blood-sparing techniques in spine surgery have been less studied than in other fields of orthopedics, such as joint-replacement procedures. Decreasing bleeding is not only important for keeping the patient's hemodynamic equilibrium but also for allowing a better view of the surgical field. In spine surgery the latter aspect is especially important because of the vicinity of major and highly fragile neurologic structures. ⋯ Various hemodynamic techniques, as well as systemic and local drugs and agents, can be used separately or in combination, and their use in the field of spine surgery is reported. The level of evidence for the efficacy of many of those methods in surgery as a whole is limited, and there is a lack of evidence for most of them in spine surgery. However, several blood-saving procedures and drugs, as well as promising new agents, appear to be efficient, although their efficacy has yet to be assessed by proper randomized controlled trials.
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Spinal surgery in adults can vary from simple to complex and can also have variable anticipated surgical blood loss. There are several factors that can put patients at increased risk for greater intraoperative blood loss. These factors, including a review of the literature, will be discussed.
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Clinical Trial
Kyphoplasty for treatment of osteoporotic vertebral fractures: a prospective non-randomized study.
Minimally invasive augmentation techniques of vertebral bodies have been advocated to treat osteoporotic vertebral body compression fractures (VBCFs). Kyphoplasty is designed to address both fracture-related pain as well as kyphotic deformity usually associated with fracture. Previous studies have indicated the potential of this technique for reduction of vertebral body height, but there has been little investigation into whether this has a lasting effect. The current study reports on our experience and the one-year results in 27 kyphoplasty procedures (24 patients) for osteoporotic VBCFs. ⋯ Kyphoplasty is an effective treatment of VBCFs in terms of pain relief and durable reduction of deformity. Whether spinal realignment results in an improved long-term clinical outcome remains to be investigated.