Nonsteroidal Anti-inflammatory Drugs (NSAID) Do Not Increase Blood Loss or the Incidence of Postoperative Epidural Hematomas When Using Minimally Invasive Fusion Techniques in the Degenerative Lumbar Spine

Objective: Nonsteroidal anti-inflammatory drugs (NSAID) are essential in surgeons’ armamentarium for pain relief and antiphlogistic effects. However, spine surgeons are concerned about the drugs’ impact on coagulation, fearing hemodynamic instability due to blood loss and neurological complications due to postoperative hematoma. Furthermore, there are no clear guidelines for the use of these drugs.Materials and methods: In this retrospective subgroup analysis of a prospective observational study, we investigated 181 patients who underwent minimally invasive spinal fusions in degenerative lumbar spine pathologies. 83 patients were given NSAID perioperatively, 54 of which were female and 29 male. Of these patients who took NSAID, 39 were on NSAID until at least one day before surgery or perioperatively, whilst the others discontinued their NSAID medication at least three days before surgery. Differences in perioperative blood loss, as well as complication rates between patients with and without NSAID treatment, were investigated.Results: A significantly higher amount of blood loss during surgery and the monitoring period was encountered in patients whose spine was fused in more than one level, regardless of whether NSAID medication was taken or not and up until what point. Furthermore, it was found that taking NSAID medication had no effect on the incidence of postoperative epidural hematomas.Conclusion: Perioperatively taking NSAID medication does not increase blood loss or the incidence of postoperative hematoma in patients undergoing minimally invasive lumbar spinal fusion surgery.

Antithrombotic Effects of Montelukast by Targeting Coagulation Factor XIa

Current oral anticoagulants prescribed for the prevention of thrombosis suffer from severe hemorrhagic problems. Coagulation factor XIa (FXIa) has been confirmed as a safer antithrombotic target as intervention with FXIa causes lower hemorrhagic risks. In this study, by a high-throughput virtual screening, we identified Montelukast (MK), an oral antiasthmatic drug, as a potent and specific FXIa inhibitor (IC50 = 0.17 µM). Compared with the two mostly prescribed anticoagulants (Warfarin and Apixaban), MK demonstrated comparable or even higher antithrombotic effects in three independent animal models. More importantly, in contrast to the severe hemorrhage caused by Warfarin or Apixaban, MK did not measurably increase blood loss in vivo. In addition, MK did not affect the hemostatic function in plasma from healthy individuals. In contrast, MK suppressed clot formation in clinical hypercoagulable plasma samples. This study provides a lead compound of anticoagulants targeting FXIa, and suggests the exploratory clinical researches on antithrombotic therapies using MK.

M. M. Mironov. - Warm and hot baths during menstruation. - (Weekly, 1895, No. 22).

Wanting to test Makaveev's observations on the indifferent and beneficial action of warm baths during the month, the author exposed the action of salty baths in 27 -28 menstruating women on the Slavic mineral waters and describes briefly seven such baths. Conclusions from the last ones are as follows: common salt baths at 27 -28 R. With the addition of several buckets of lye, they do not produce any bad effects, on the contrary, they even quench pain, and the amount of blood lost either does not change, or decreases. Another series of observations by the author dulal with general or zone warm baths at 31 -33 R., without the addition of salt; From five observations the author concludes: in women with a normal sexual apparatus, baths at 32 -33 R., lasting 20 minutes, do not produce any harmful effects on the course of regulation and even reduce the amount of blood lost. In the third row (21 cases), the observation of the effect of baths on menstruating, with inflammatory changes in the pelvic organs, the same result was obtained: baths do not increase blood loss, sometimes they reduce the amount of blood lost, and what is most important, they are effective.

P.016 Bimanual psychomotor performance in neurosurgical resident applicants assessed using NeuroVR (formerly NeuroTouch), a virtual reality simulator

Background: Current selection methods for neurosurgical residents lack objective measurements of psychomotor performance. This pilot study was designed to answer three questions: 1) What are the differences in bimanual psychomotor performance among neurosurgical residency applicants using the NeuroVR (formerly NeuroTouch) neurosurgical simulator? 2) Are there exceptionally skilled medical student applicants? 3) Does previous surgical exposure influence surgical performance? Methods: Medical students attending neurosurgery residency interviews at McGill University were asked to participate. Participants were instructed to remove 3 simulated brain tumors. Validated tier 1, tier 2, and advanced tier 2 metrics were utilized to assess bimanual psychomotor performance. Demographic data included weeks of neurosurgical elective and prior operative exposure. Results: Sixteen of 17 neurosurgical applicants (94%) participated. Performances clustered in definable top, middle, and bottom groups with significant differences for all metrics. Increased time spent playing music, increase applicant self-evaluated technical skills, high self-ratings of confidence and increased skin closures statistically influenced performance on univariate analysis. A trend for both self-rated increased operating room confidence and increased weeks of neurosurgical exposure to increase blood loss was seen in multivariate analysis. Conclusions: Simulation technology identifies neurosurgical residency applicants at the extremes of technical ability and extrinsic and intrinsic applicant factors appear to influence performance.

Brief intraoperative heparinization and blood loss in anterior lumbar spine surgery

OBJECT The anterior approach to the lumbar spine may be associated with iliac artery thrombosis. Intraoperative heparin can be administered to prevent thrombosis; however, there is a concern that this will increase the procedural blood loss. The aim of this study was to examine whether intraoperative heparin can be administered without increasing blood loss in anterior lumbar spine surgery. METHODS A prospective study of consecutive anterior approaches for lumbar spine surgery was performed between January 2009 and June 2014 by a single vascular surgeon and a single spine surgeon. Patients underwent an anterior lumbar interbody fusion (ALIF) at L4–5 and/or L5–S1, a total disc replacement (TDR) at L4–5 and/or L5–S1, or a hybrid procedure with a TDR at L4–5 and an ALIF at L5–S1. Heparin was administered intravenously when arterial flow to the lower limbs was interrupted during the procedure. Heparin was usually reversed on removal of the causative retraction. RESULTS The cohort consisted of 188 patients with a mean age of 41.7 years; 96 (51.1%) were male. Eighty-four patients (44.7%) had an ALIF, 57 (30.3%) had a TDR, and 47 (25.0%) had a hybrid operation with a TDR at L4–5 and an ALIF at L5–S1. One hundred thirty-four patients (71.3%) underwent a single-level procedure (26.9% L4–5 and 73.1% L5–S1) and 54 (28.7%) underwent a 2-level procedure (L4–5 and L5–S1). Seventy-two patients (38.3%) received heparinization intraoperatively. Heparin was predominantly administered during hybrid operations (68.1%), 2-level procedures (70.4%), and procedures involving the L4–5 level (80.6%). There were no intraoperative ischemic vascular complications reported in this series. There was 1 postoperative deep venous thrombosis. The overall mean estimated blood loss (EBL) for the heparin group (389.7 ml) was significantly higher than for the nonheparin group (160.5 ml) (p < 0.0001). However, when all variables were analyzed with multiple linear regression, only the prosthesis used and level treated were found to be significant in blood loss (p < 0.05). The highest blood loss occurred in hybrid procedures (448.1 ml), followed by TDR (302.5 ml) and ALIF (99.7 ml). There were statistically significant differences between the EBL during ALIF compared with TDR and hybrid (p < 0.0001), but not between TDR and hybrid. The L4–5 level was associated with significantly higher blood loss (384.9 ml) compared with L5–S1 (111.4 ml) (p < 0.0001). CONCLUSIONS During an anterior exposure for lumbar spine surgery, the administration of heparin does not significantly increase blood loss. The prosthesis used and level treated were found to significantly increase blood loss, with TDR and the L4–5 level having greater blood loss compared with ALIF and L5–S1, respectively. Heparin can be administered safely to help prevent thrombotic intraoperative vascular complications without increasing blood loss.