(Press-News.org) Charlottesville, VA (May 21, 2013). Physicians at Monash University and The Alfred Hospital in Melbourne, Australia describe the logistic, medical, and societal challenges faced in treating spine trauma in morbidly obese patients. Based on a case series of six patients injured in high-speed motor vehicle accidents, the authors categorize difficulties faced in the care of morbidly obese patients from on-scene immobilization and medical transport through spinal imaging, surgery, and postoperative care. Details of the six cases and a thorough discussion of challenges posed by morbid obesity and possible solutions are covered in "Challenges in the surgical management of spine trauma in the morbidly obese patient: a case series. Clinical article," by Hannah E. Rosenfeld and colleagues, published today online, ahead of print, in the Journal of Neurosurgery: Spine.
The obesity epidemic is spreading worldwide. When patients who are morbidly obese suffer spinal injury or other major trauma, they face greater risks of complications and death compared with non-obese individuals.
The patients described in this article—five women and one man, ages 18–69 years—ranged in weight from 276 pounds (125 kilograms) to 410 pounds (186 kilograms). All six patients had a body-mass index greater than 40. These particular patients were selected because of the problems posed by their large body mass before, during, and after spine sugery.
The authors describe each case separately and then break down the obstacles faced during care of these patients into separate categories, specifically
Transport and transfer. Hailing from Australia, the authors are well aware of difficulties in transporting trauma victims from rural areas to tertiary trauma hospitals. At times, air ambulances may be the optimal choice, but these helicopters and planes have limited cabin sizes and/or weight capacities that can exclude conveyance of morbidly obese patients. This necessitates travel by road, which significantly delays diagnosis and treatment, and can have a deleterious effect on outcome. The use of a cervical collar during transport may be complicated by the large circumference of the patient's neck. Alternative stabilizers, such as sandbags and head taping, may be required.
Anesthesia and resuscitation. Intubation is difficult because the anatomy makes it difficult to identify internal structures. Once intubation has been achieved, the endotracheal tube may become easily dislodged. Mechanical ventilation is problematic. Because of excess subcutaneous tissue, intravenous or intra-arterial access is difficult, as is placement of a draining tube in the urinary bladder. Monitoring of blood pressure and heart function is not always accurate in these patients.
Imaging. Preoperative and intraoperative imaging is more difficult in morbidly obese patients. Some patients are too large to fit comfortably in closed MRI magnets. Expansive adipose tissue results in poor x-ray penetration and unclear CT and MRI images. In attempts to obtain better images, the patient may be subjected to greater radiation doses.
Surgical positioning. The researchers point out that standard operating tables may not be wide enough or strong enough to hold morbidly obese patients. Turning these patients and transferring them to another table can be challenging and potentially harmful to the staff. Positioning these patients on a spinal frame may be difficult, because they may exceed the size limits of the frame.
Surgical approaches and techniques. As mentioned earlier, intraoperative imaging is not as dependable in morbidly obese patients. Localization of spinal levels is thus much more difficult. Due to the depth of subcutaneous fat in these patients, the authors state that a longer incision may be necessary and longer instruments required. Retraction can be difficult, and harvesting of bone autografts may pose technical challenges and greater risks of morbidity.
Venous problems. There can be greater venous bleeding, impaired venous return of blood to the heart, and increased events of venous thromboembolism.
Postoperative wound care and pulmonary care. Morbidly obese patients face a higher incidence of wound breakdown, surgical site infection, and pressure sores than patients of lower weight. They should also be monitored to ascertain if those with cervical spine injuries are at risk for aspiration.
In addition to alerting other physicians about the many obstacles impeding quick and efficient health care in morbidly obese patients with spinal injuries, the authors offer commonsense suggestions for how to overcome many of the obstacles they describe. Some examples include: fashioning makeshift cervical collar extenders; increased vigilance in monitoring airways; use of open MRI units when available; clamping together two operating tables when a large table is not available; using hoist systems in the operating room and training staff in moving obese patients; selecting nonstandard surgical approaches, when appropriate, to provide adequate access to the spine while allowing morbidly obese patients to be positioned safely for the entire operation; creation of longer surgical instruments; additional use of Cell Saver, which lessens overall blood loss during surgery; adjusting the dose of prophylactic heparin; and use of adequately sized pneumatic calf compressors. The authors also suggest that new hospital guidelines and management techniques should be developed to improve overall outcomes in obese patients, as their number is on the rise.
###
Rosenfeld HE, Limb R, Chan P. Fitzgerald M, Bradley WPL, Rosenfeld JV. Challenges in the surgical management of spine trauma in the morbidly obese patient: a case series. Clinical article. Journal of Neurosurgery: Spine, published online, ahead of print, May 21, 2013; DOI: 10.3171/2013.4.SPINE12876.
Disclosure: The authors report no conflict of interest concerning the materials
or methods used in this study or the findings specified in this paper.
For additional information, please contact:
Ms. Jo Ann M. Eliason, Communications Manager
Journal of Neurosurgery Publishing Group
One Morton Drive
Charlottesville, Virginia 22903
Fax 434-924-2702
The Journal of Neurosurgery: Spine is a monthly peer-reviewed journal focused on neurosurgical approaches to treatment of diseases and disorders of the spine. It contains a variety of articles, including descriptions of preclinical and clinical research as well as case reports and technical notes. The Journal of Neurosurgery: Spine is one of four monthly journals published by the JNS Publishing Group, the scholarly journal division of the American Association of Neurological Surgeons. Other peer-reviewed journals published by the JNS Publishing Group each month include the Journal of Neurosurgery, Neurosurgical Focus, and the Journal of Neurosurgery: Pediatrics. All four journals can be accessed at http://www.thejns.org.
Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 8,300 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the entire nervous system including the brain, spinal column, spinal cord, and peripheral nerves. For more information, visit http://www.AANS.org.
Challenges encountered in surgical management of spine trauma in morbidly obese patients
2013-05-21
ELSE PRESS RELEASES FROM THIS DATE:
Study shows COPD is associated with significant and persistent pain
2013-05-21
ATS 2013, PHILADELPHIA – Chronic obstructive pulmonary disease (COPD) is primarily associated with the respiratory symptoms that are its hallmark, but in fact, patients who struggle with the disease also experience significant amounts of chronic pain. A new study conducted by researchers in Pennsylvania and New Mexico estimates the degree of pain suffered by these patients to be close to that experienced by patients with osteoarthritis and rheumatoid arthritis.
The research results will be presented at the ATS 2013 International Conference.
"Several studies have found ...
Inflammation is associated with depression in COPD patients
2013-05-21
ATS 2013, PHILADELPHIA ─ Depression is common in patients with chronic obstructive pulmonary disease (COPD) and has been linked with disease severity and impaired quality of life. Now, for the first time, researchers at the University of Pittsburgh have linked the systemic inflammation associated with COPD with depression in these patients.
"Systemic inflammation is thought to be an important mediator of comorbidities in COPD, but the relationship between inflammation and depression has not been explored," said researcher Hilary Strollo, M.S., a graduate of the ...
Sexual function in older adults with thoracolumbar–pelvic instrumentation
2013-05-21
Charlottesville, VA (May 21, 2013). Surgeons investigated sexual function in 62 patients, 50 years and older, who had received extensive spinal–pelvic instrumentation for spinal deformity at the University of Virginia Health Center. Based on their results, the surgeons found that it is very possible for older people to achieve satisfactory sexual function despite having extensive spinal–pelvic instrumentation. Details of this study are disclosed in "Sexual function in older adults following thoracolumbar to pelvic instrumentation for spinal deformity. Clinical article," ...
Exercise levels may predict hospitalizations in COPD population
2013-05-21
ATS 2013, PHILADELPHIA ─ Clinical measurement of physical activity appears to be an independent predictor of whether or not patients with chronic obstructive pulmonary disease (COPD) will end up being hospitalized, according to a new study conducted by researchers in Connecticut. The study also corroborates an earlier investigation that linked higher levels of inactivity with an increased incidence of hospitalizations among patients with COPD.
The results of the study will be presented at the ATS 2013 International Conference.
"Physical inactivity is common in ...
Monoclonal antibody appears effective and safe in asthma Phase IIa trial
2013-05-21
ATS 2013, PHILADELPHIA ─ A novel approach to obstructing the runaway inflammatory response implicated in some types of asthma has shown promise in a Phase IIa clinical trial, according to U. S. researchers.
Their research will be presented at the American Thoracic Society 2013 International Conference and published simultaneously online in the New England Journal of Medicine.
The randomized, double-blind, placebo-controlled trial tested the efficacy and safety of the monoclonal antibody, dupilumab, in patients with "persistent, moderate-to-severe asthma" and elevated ...
Teens exposed to schoolmate's death by suicide much more likely to consider or attempt suicide
2013-05-21
Youth who had a schoolmate die by suicide are significantly more likely to consider or attempt suicide, according to a study in published in CMAJ (Canadian Medical Association Journal). This effect can last 2 years or more, which has implications for strategies following schoolmate suicides.
"We found that exposure to suicide predicts suicidality," writes senior author Dr. Ian Colman, Canada Research Chair in Mental Health Epidemiology and Assistant Professor, University of Ottawa, with lead author Sonja Swanson, from Harvard School of Public Health, Boston. "This was ...
Treatment with A1-PI slows the progression of emphysema in Alpha-1 antitrypsin deficiency
2013-05-21
ATS 2013, PHILADELPHIA─Treatment with an Alpha-1 proteinase inhibitor (A1-PI), a naturally occurring protein that protects lung tissue from breakdown and protects the lung's elasticity, is effective in slowing the progression of emphysema in patients with Alpha-1 antitrypsin deficiency (AATD), a life-threatening genetic disorder, according to a new study presented at the 2013 American Thoracic Society International Conference.
The study showed the efficacy of A1-PIin preventing the loss of lung tissue as measured by computed tomography (CT) scan lung density at ...
Small but speedy: Short plants live in the evolutionary fast lane
2013-05-21
Durham, NC — Biologists have known for a long time that some creatures evolve more quickly than others. Exactly why isn't well understood, particularly for plants. But it may be that height plays a role, says Robert Lanfear of Australian National University and the U. S. National Evolutionary Synthesis Center.
In a study to be published 21 May in the journal Nature Communications, Lanfear and colleagues report that shorter plants have faster-changing genomes.
Drawing from a database of global patterns in plant height for more than 20,000 species, the researchers estimated ...
Genetic predictors of postpartum depression uncovered by Hopkins researchers
2013-05-21
The epigenetic modifications, which alter the way genes function without changing the underlying DNA sequence, can apparently be detected in the blood of pregnant women during any trimester, potentially providing a simple way to foretell depression in the weeks after giving birth, and an opportunity to intervene before symptoms become debilitating.
The findings of the small study involving 52 pregnant women are described online in the journal Molecular Psychiatry.
"Postpartum depression can be harmful to both mother and child," says study leader Zachary Kaminsky, Ph.D., ...
Child maltreatment increases risk of adult obesity
2013-05-21
Children who have suffered maltreatment are 36% more likely to be obese in adulthood compared to non-maltreated children, according to a new study by King's College London. The authors estimate that the prevention or effective treatment of 7 cases of child maltreatment could avoid 1 case of adult obesity.
The findings come from the combined analysis of data from 190,285 individuals from 41 studies worldwide, published this week in Molecular Psychiatry.
Severe childhood maltreatment (physical, sexual or emotional abuse or neglect) affects approximately 1 in 5 children ...