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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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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Controlled, deliberate hypotension during anesthesia for major spinal surgery reduces intraoperative blood loss and transfusion requirement. Hypotension may be achieved with increased doses of volatile anesthetic agents or by continuous infusion of vasodilating drugs. Safe application of this technique requires knowledge of the physiology of hemorrhagic shock and close intraoperative monitoring to avoid vasoconstriction and end-organ ischemia.
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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.
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A possible strategy to promote the wound-healing cascade in both soft and hard tissues is the preparation of an autologous platelet-rich plasma (PRP) to encourage the release of growth factors from activated platelets. In this process, PRP combines the advantage of an autologous fibrin clot that will aid in hemostasis as well as provide growth factors in high concentrations to the site of a tissue defect. The PRP preparation can be used as a biological enhancer in the healing of fractures and lumbar fusions. ⋯ This system provides a less costly alternative to other previously described augmentation techniques and also presents a patient-friendly and operator-safe alternative. Further experimental studies of the actual concentrations of the growth factors in the PRP samples are necessary in order to validate the platelet concentration and growth-factor activation by laboratory evidence. In further prospective clinical trials, the safety and efficacy of PRP, in combination with autologous bone or bone graft substitutes, must be evaluated.