Faculty Bibliography

BACKGROUND CONTEXT: While surgery has been shown on average to be superior to nonoperative (nonop) treatment for significant adult spinal deformity (ASD), nonop care remains a good option for many patients. However, failure to respond to this approach prolongs pain and disability which could have been relieved by surgery. Thus, it is important to establish an effective evaluation method for who will benefit from nonoperative treatment. PURPOSE: Our objective was to determine the outcome and risk factors of ASD patients who elected for nonop care. STUDY DESIGN/SETTING: Retrospective review of a nonop branch of a multicenter prospective database of ASD patients. PATIENT SAMPLE: Patients were drawn from a multicenter prospective database of ASD patients, derived from 10 sites across the United States. Specific inclusion criteria for the present study included nonoperative treatment and the availability of SRS-22 scores and radiographic data at baseline and at 1-year follow-up. OUTCOME MEASURES: Outcomes included health-related quality of life (HRQOL) measures assessed by the SRS-22 and radiographic data. METHODS: Changes in SRS-22 were evaluated by domain and expressed in number of minimum clinically important differences (MCIDs) gained/ lost; BL and 1Y scores were also compared to age- and gender-matched normative references (NR). RESULTS: 189 patients (53yo, 86%F) met inclusion criteria. At BL, Pain was the domain with the largest offset from NR for 44% of the patients, followed by Appearance (22%) and Activity (20%). On average there was a gain (improvement) of 0.2MCID in Pain but no gain or loss in Activity or Appearance at 1-year. Analysis of change in the Pain domain at follow-up revealed that 24% of patients gained>1MCID and 14.2% lost >1MCID. Percentages of patients with gain or loss for Activity were 20% and 24.9%, and for Appearance were 13.3% and 9.3%, respectively. Patients who gained>1MCID had more severe BL scores than those losing >1MCID (p p<0.001), but had no significant differenc!

BACKGROUND CONTEXT: Spine surgery may be associated with substantial blood loss necessitating transfusions. Blood loss-associated morbidity can be due to direct risks, such as hypotension and organ damage, or as result of blood transfusions. The antifibrinolytics tranexamic acid (TXA) and epsilon aminocaproic acid (EACA) are lysine analogues which inhibit activation of plasminogen and have been shown to reduce surgical blood loss. PURPOSE: The purpose of the meta-analysis is to consolidate findings of randomized controlled trials (RCTs) investigating the effects of these drugs on bleeding in spine surgery. STUDY DESIGN/SETTING: Meta-analysis. PATIENT SAMPLE: RCTs investigating effectiveness of intravenous TXA or EACA in reducing blood loss in spine surgery, compared to placebo. OUTCOME MEASURES: Outcome measures included intraoperative blood loss, total blood loss (TBL), transfusion rates and incidences of thromboembolism (TE), pulmonary embolism (PE) and myocardial infarction (MI). METHODS: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar were used to identify RCTs published before January 2013 that examined the effectiveness of intravenous TXA or EACA on reduction of blood loss and transfusions in spine surgery, compared to a placebo. Meta-analysis was performed using RevMan 5. Spine surgeries where blood loss was relatively small (<200ml) were excluded. Weighted mean difference was used to summarize findings across the trials for continuous outcomes. Dichotomous data were expressed as risk ratio with 95% confidence intervals (CI). Statistical significance was set at p<0.05. RESULTS: Eight RCTs were included for TXA (476 total patients) and two for EACA (218 total patients).TXA reduced intraoperative blood loss by an average of 398 ml ([-485, -311], p<0.05) and TBL by 431 ml ([-587, -275], p<0.05). TXA led to a reduction in the proportion of patients receiving a blood transfusion, RR 0.71 ([0.55, 0.92], p<0.05), relative to placebo. EACA reduced intraoperati!

BACKGROUND CONTEXT: Spine deformity surgery usually involves substantial blood loss. The antifibrinolytics tranexamic acid (TXA) and aminocaproic acid (EACA) have been shown to improve hemostasis in large blood loss surgeries. This study aimed to provide high-quality evidence regarding the relative efficacies of TXA, EACA and placebo in reducing blood loss and transfusion requirements in spine surgery. PURPOSE: To compare efficacies of TXA, EACA and placebo in patients undergoing posterior spinal fusion. STUDY DESIGN/SETTING: Prospective, double-blinded, randomized controlled trial. PATIENT SAMPLE: Patients (ages 18-80) undergoing posterior spinal fusion of at least five levels for correction of adult spinal deformity (AD) were enrolled. Patients with evidence of renal dysfunction, religious or other beliefs prohibiting transfusions, anti-coagulant use or abnormal baseline coagulation panels, or a medical history precluding use of TXA or EACA were excluded. OUTCOME MEASURES: Primary outcome measures included intraoperative, total blood loss (TBL) and transfusion rates. Secondary outcomes included change in hematocrit (Hct) and complications. METHODS: This is a prospective, randomized, double-blinded comparison of TXA, EACA and placebo used intra-operatively in patients with AD. Fifty-two patients were randomized to one of three treatment groups. TXA was given intravenously at 10 mg/kg loading dose followed by 1mg/ kg/h maintenance, while EACA was given at 100mg/kg loading dose followed by 10 mg/kg/h maintenance. Dosage calculation was based on previous studies and the rationale that TXA is 10 times more potent than EACA. Primary and secondary outcome measures were recorded as described above. ANOVA and Fisher's PLSD tests were used to compare continuous data and Fisher's exact test was used for categorical data. TBL was the sum of intraoperative blood loss and postoperative drain output. RESULTS: AD patients received TXA (n=19), EACA (n=19) or placebo (n=14) in the operating room (mean ages 60,!