Objective: The surgical treatment of an upper cervical spinal tumor (UCST) at C1-2/C1-3 is challenging due to anterior exposure and reconstruction. Limited information has been published concerning the effective approach and reconstruction for an anterior procedure after C1-2/C1-3 UCST resection. The authors attempted to introduce a novel, customized, anterior craniocervical reconstruction between the occipital condyles and inferior vertebrae through a modified high-cervical retropharyngeal approach (mHCRA) in addressing C1-2/C1-3 spinal tumors.
Methods: Seven consecutive patients underwent 2-stage UCST resection with circumferential reconstruction. Posterior decompression and occiput-cervical instrumentation was conducted at the stage 1 operation, and anterior craniocervical reconstruction using a 3D-printed implant was performed between the occipital condyles and inferior vertebrae via an mHCRA. The clinical characteristics, perioperative complications, and radiological outcomes were reviewed, and the rationale for anterior craniocervical reconstruction was also clarified.
Results: The mean age of the 7 patients in the study was 47.6 ± 19.0 years (range 12-72 years) when referred to the authors' center. Six patients (85.7%) had recurrent tumor status, and the interval from primary to recurrence status was 53.0 ± 33.7 months (range 24-105 months). Four patients (57.1%) were diagnosed with a spinal tumor involving C1-3, and 3 patients (42.9%) with a C1-2 tumor. For the anterior procedure, the mean surgical duration and average blood loss were 4.1 ± 0.9 hours (range 3.0-6.0 hours) and 558.3 ± 400.5 ml (range 100-1300 ml), respectively. No severe perioperative complications occurred, except 1 patient with transient dysphagia. The mean pre- and postoperative visual analog scale scores were 8.0 ± 0.8 (range 7-9) and 2.4 ± 0.5 (range 2.0-3.0; p < 0.001), respectively, and the mean improvement rate of cervical spinal cord function was 54.7% ± 13.8% (range 42.9%-83.3%) based on the modified Japanese Orthopaedic Association scale score (p < 0.001). Circumferential instrumentation was in good position and no evidence of disease was found at the mean follow-up of 14.8 months (range 7.3-24.2 months).
Conclusions: The mHCRA provides optimal access to the surgical field at the C0-3 level. Customized anterior craniocervical fixation between the occipital condyles and inferior vertebrae can be feasible and effective in managing anterior reconstruction after UCST resection.
Background: Peripheral arterial disease (PAD) in pregnancy has serious implications and requires multidisciplinary management. This becomes even more complicated in the setting of active disease and history of prior vascular grafts.
Case: A woman presented with increasing left lower extremity pain at 18 weeks of gestation with a complex history of PAD and a previous bifurcated aorta-left femoral, -right iliac bypass. CT angiogram demonstrated known occluded bypass graft. A multidisciplinary team of providers developed guidelines for potential surgical intervention based upon clinical symptoms.
Conclusion: Pelvic PAD can worsen in pregnancy in the setting of the enlarging uterus, which can potentially deplete perfusion of existing collateral vessels. Symptomatic approach to worsening disease provided an effective management strategy in this case.
Background: Multimodal analgesia is a fundamental part of modern surgery and enhanced recovery pathways. Duloxetine, a serotonin and norepinephrine reuptake inhibitor, has been validated for the treatment of chronic neuropathic pain. The evidence for duloxetine as an adjunct for the treatment of acute postoperative pain remains controversial. We conducted a meta-analysis to determine the efficacy of duloxetine in the acute perioperative setting.
Methods: A literature search was conducted in the major databases (PubMed, EMBASE and Google Scholar) for randomized controlled trials (RCTs) evaluating duloxetine compared with placebo control for acute postoperative pain. The primary outcome was postoperative pain assessed at 2, 4, 6, 24 and 48 hours time frames. Secondary outcomes included postoperative opioid administration, as well as side effects, such as postoperative nausea/vomiting (PONV), pruritus, dizziness and headache.
Results: 574 patients (n=9 RCTs) were included in the analysis, divided between duloxetine (n=285 patients) and placebo (n=289 patients). Duloxetine use was associated with a significant reduction in pain scores as early as 4 (mean difference (MD) -0.9, 95% CI -1.33 to -0.47) and as late as 48 (MD -0.94, 95% CI -1.56 to -0.33) hours postoperatively compared with placebo. In addition, duloxetine was associated with a significant reduction in opioid administration at 24 (standardized MD (SMD) -2.24, 95% CI -4.28 to -0.19) and 48 (SMD -2.21, 95% CI -4.13 to -0.28) hours as well as a significant reduction in PONV (risk ratio 0.69, 95% CI 0.49 to 0.95, p=0.03) compared with placebo. There was no difference between groups in other side effects.
Conclusion: Duloxetine, a non-opioid neuromodulator, may provide efficacy for the treatment of acute perioperative pain. Additional prospective studies are required to establish optimal perioperative dosing regimens, role in the setting of a comprehensive multimodal analgesic plan and impact on chronic postsurgical pain.
Prospero registration number: CRD42019121416.
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