ORCID Profile
0000-0002-9614-4695
Current Organisation
SPMM Hospital
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Publisher: Springer Science and Business Media LLC
Date: 27-01-2016
DOI: 10.1245/S10434-016-5092-8
Abstract: Metastatic spine tumor surgery (MSTS) can be associated with significant blood loss. Previous studies did not provide comprehensive data on blood loss in MSTS. Thorough study elaborating the blood loss, transfusion requirement, and their influencing factors is required. This study aimed to investigate the estimated blood loss and transfusion requirements associated with various surgical approaches and surgically managed vertebral levels for spinal metastases from different primary tumors. The study retrospectively evaluated 243 patients who underwent surgery for metastatic spine tumors at the authors' institution between 2005 and 2014. Estimated intraoperative blood loss and transfusion requirement were assessed for different primary tumors including lung, breast, prostate, gastrointestinal, renal, liver, thyroid, myeloma/lymphoma, and others types of surgical procedure (cervical corpectomy ± stabilization, thoracolumbar posterior decompression ± instrumentation, thoracolumbar corpectomy, minimally invasive surgery) and levels of instrumentation and decompression. Multivariate linear regression was attempted to investigate the factors influencing blood loss and transfusion requirements. The mean blood loss was 870 ± 720 ml, and the average blood transfusion was 1.5 ± 1.9 U. The mean blood loss was 1103 ml for patients who received blood transfusion and 597 ml for those who did not. Multivariate analysis showed that the significant factors influencing blood loss were primary tumor, type of surgery, and prolonged operative time. The influencing factors for blood transfusion were primary tumor, type of surgery, preoperative hemoglobin, and prolonged operative time. Significant variations in blood loss and transfusion requirement were based on primary tumor of spinal metastases, surgical approaches, and operative time. These findings will help clinicians in preoperative planning to address the problem of blood loss during MSTS.
Publisher: Wiley
Date: 22-11-2016
DOI: 10.1111/TRF.13912
Abstract: Despite advances in surgical techniques for spinal metastases, there is often substantial blood loss, resulting in patients requiring blood transfusion during the perioperative period. Allogeneic blood transfusion (ABT) has been the main replenishment method for lost blood. However, the impact of ABT on cancer‐related outcomes has been controversial in various studies. We aimed to evaluate the influence of perioperative ABT on disease progression and survival in patients undergoing metastatic spinal tumor surgery (MSTS). We conducted a retrospective study that included 247 patients who underwent MSTS at a single tertiary institution between 2005 and 2014. The impact of using perioperative ABT (either exposure to or quantities of transfusion) on disease progression and survival was assessed using Cox regression analyses while adjusting for potential confounding variables. Of 247 patients, 133 (54%) received ABT. The overall median number of blood units transfused was 2 (range, 0‐10 units). Neither blood transfusion exposure nor quantities of transfusion were associated with overall survival (hazard ratio [HR], 1.15 [p = 0.35] and 1.10 [p = 0.11], respectively) and progression‐free survival (HR, 0.87 [p = 0.18] and 0.98 [p = 0.11], respectively). The factors that influenced overall survival were primary tumor type and preoperative Eastern Cooperative Oncology Group performance status, whereas primary tumor type was the only factor that had an impact on progression‐free survival. This is the first study providing evidence that disease progression and survival in patients who undergo MSTS are less likely to be influenced by perioperative ABT. The worst oncologic outcomes are more likely to be caused by the clinical circumstances necessitating blood transfusion, but not transfusion itself. However, because ABT can have a propensity toward developing postoperative infections, including surgical site infection, the use of patient blood management interventions would be worthwhile rather than relying solely on ABTs for these patients, if and whenever possible.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2017
DOI: 10.1097/BSD.0000000000000400
Abstract: Prospective cohort study. Minimally invasive spinal surgery (MISS) has been gaining recognition in patients with metastatic spine disease (MSD). The advantages are reduction in blood loss, hospital stay, and postoperative morbidity. Most of the studies were case series with very few comparing the outcomes of MISS to open approaches. To evaluate and compare the clinical and perioperative outcomes of MISS versus open approach in patients with symptomatic MSD, who underwent posterior spinal stabilization and/or decompression. Our study included 45 MSD patients 27 managed by MISS and 18 by open approach. All patients had MSD presenting with symptoms of neurological deficit, spinal instability, or both. Preoperative, intraoperative, and postoperative data were collected for comparison of the 2 approaches. All patients were followed up until the end of study period (maximum up to 4 years from time of surgery) or till their demise. The clinical outcome measures were pain control, neurological and functional status, whereas perioperative outcomes were blood loss, operative time, length of hospital stay, and time taken to initiate radiotherapy/chemotherapy after index surgery. Majority of patients in both groups showed improvement in pain, neurological status, independent ambulation, and ECOG score in the postoperative period with no significant differences between the 2 groups. There was a significant reduction in intraoperative blood loss (621 mL less, P .001) in the MISS group. The average time to initiate radiotherapy after surgery was 13 days (range, 12–16 d) in MISS and 24 days (range, 16–40 d) in the open group. This difference was statistically significant ( P .001). Operative time and duration of hospital stay were also favorable in the MISS group, although the differences were not significant. MISS is comparable with open approach demonstrating similar improvements in clinical outcomes, that is pain control, neurological and functional status. MISS approaches have also shown promising results due to lesser intraoperative blood loss and allowing earlier radiotherapy/chemotherapy.
Publisher: Elsevier BV
Date: 2017
DOI: 10.1016/J.SPINEE.2016.09.009
Abstract: Osteoblastoma is rare and accounts for 3% of all benign tumors and 1% of all bone tumors. The spine is the most common site of occurrence, constituting 32% to 45% of all osteoblastomas. It has a strong predilection for the posterior elements, most often occurring in the lumbar spine. In this case report, we describe an unusual presentation of spinal osteoblastoma presenting as thoracic T9 vertebra plana in a 20-year-old female. She presented with discomfort over the midback with unsteadiness of gait. The patient underwent detailed investigations including computed tomography (CT), magnetic resonance imaging, and CT-guided biopsy. To our knowledge, this is the first case report of vertebra plana due to spinal osteoblastoma in the English literature. The patient successfully underwent posterior decompression of T9 with laminectomy followed by minimally invasive surgery posterior instrumentation from T7 to T11. Histopathology of the intraoperative specimen was consistent with osteoblastoma. The patient had an uneventful postoperative recovery and no evidence of tumor recurrence could be demonstrated on positron emission tomography scan at 15 months' follow-up. In conclusion, the differential diagnosis for vertebra plana is extensive and we add spinal osteoblastoma as another etiology to the existing list. Diagnosis and treatment of vertebra plana involve multimodality radiological imaging, and careful histological and surgical evaluation to identify the underlying etiology.
Publisher: Elsevier BV
Date: 09-2017
DOI: 10.1016/J.EJSO.2017.05.006
Abstract: The advent of minimally invasive surgery (MIS) in the surgical management armamentarium and stereotactic radiosurgery in the domain of radiotherapy, has led to a major evolution in treatment of metastatic spine disease (MSD). We reviewed the recent literature to discuss evolution from open to MIS approaches in MSD and the concurrent evolution in radiotherapy. This will provide a sound base for further development and understanding of treatment paradigms in MSD. Literature review showed that evolution of surgery can be traced from inappropriate open surgery (i.e. laminectomy) to appropriate open (i.e. posterior instrumentation and decompression) and further to minimally invasive surgery. This transition was concurrent with the introduction of radiotherapy and its evolution in management of MSD. Evidence shows that presently, the best clinical outcomes are achieved by surgery with timely postoperative radiotherapy. To make surgery an appealing choice in MSD, surgical morbidity needs to be minimized when planning postoperative oncological treatment. MIS approaches have advantages such as early wound healing enabling early introduction of radiotherapy, reduced intraoperative blood loss and shortened hospital stay. Pain reduction and neurological improvement are comparable to open surgery. A multidisciplinary team approach including spinal surgeons, medical & radiation oncologists is mandatory, as the treatment options are constantly evolving. Advancement in radiotherapy with introduction of MIS can be a game-changer in MSD due to reduced peri-operative morbidity, allowing earlier postoperative radiotherapy/chemotherapy. We also provide our treatment algorithm which relies on clinical presentation and radiological appearance of spinal cord compression, providing an overview of treatment strategy.
Publisher: Wiley
Date: 16-09-2017
DOI: 10.1111/TRF.14311
Abstract: The question of independent association between allogeneic blood transfusion (ABT) and postoperative complications in cancer surgeries has been controversial and remains so. In metastatic spine tumor surgery (MSTS), previous studies investigated the influence of ABT on survival, but not on postoperative complications. We aimed to evaluate the influence of perioperative ABT on postoperative complications and infections in patients undergoing MSTS. This retrospective study included 247 patients who underwent MSTS at a single tertiary institution between 2005 and 2014. The outcome measures were postoperative complications and infections within 30 days after MSTS. Multivariate logistic regression analyses were performed to assess influence of blood transfusion on the outcomes after adjusting for potential confounders. Of 247 patients, 133 (54%) received ABT with overall median (range) of 2 (0-10) units. The adjusted odds of developing any postoperative complication was 2.27 times higher in patients with transfusion (95% confidence interval [CI], 1.17-4.38 p = 0.01) and 1.24 times higher odds per every unit increase in blood transfusion (95% CI, 1.05-1.46 p < 0.01). Exposure to blood transfusion also increased the odds of having overall postoperative infections (odds ratio, 3.58 95% CI, 1.15-11.11 p = 0.02) and there were 1.24 times higher odds per every unit increase in transfusion (95% CI, 1.01-1.54 p = 0.04). This study adds evidence to the literature implicating ABT to be influential on postoperative complications and infections in patients undergoing MSTS. Appropriate blood management measures should, therefore, be given a crucial place in the care of these patients so as to reduce any putative effect of blood transfusion.
Publisher: Springer Science and Business Media LLC
Date: 11-03-2016
DOI: 10.1007/S00586-016-4494-4
Abstract: To determine the effect of preoperative embolization on intraoperative blood loss in surgery for metastatic spinal tumours stratified by tumour type, type of surgical approach and extent of surgery. We retrospectively analysed 218 patients undergoing open surgery for metastatic spine tumours in our institution between 2005 and 2014. The cohort was ided to those who underwent preoperative embolization and those who did not. The patients were further stratified into different subgroups by tumour types, types of surgical procedure, levels of instrumentation and levels of decompression. Estimated blood loss, duration of surgery and length of hospital stay were compared between embolized and non-embolized cases in each subgroup. The impact of embolization extent, the time gap between embolization and index surgery on blood loss were also studied. Preoperative embolization was performed in 45 out of 218 patients. Non-embolized cases had insignificantly lesser blood loss and shorter duration of surgery compared to embolized cases in all subgroups. Embolization, however, conferred reduction in length of hospital stay in some of the subgroups, yet the differences were not significant. The patients who achieved total embolization bled less than those who achieved subtotal or partial embolization. The effectiveness of the embolization procedure in reducing intraoperative blood loss was found to be profound when the gap between embolization and surgery was within 24 h. Our study demonstrated that success of embolization in reducing blood loss depends on the extent of embolization and time interval between embolization and index surgery.
Publisher: Springer Science and Business Media LLC
Date: 04-07-2013
Abstract: Early diagnosis of Acute Osteomyelitis (OM) and Septic Arthritis (SA) is of vital importance to avoid devastating complications. There is no single laboratory marker which is sensitive and specific in diagnosing these infections accurately. Total Count, ESR and CRP are not specific as they can also be elevated in non pyogenic causes of inflammation. Pus Culture and sensitivity is not a true gold standard due to its varied positivity rates (40 – 70%). Serum Procalcitonin (PCT), at 0.5 ng/ml is found to be an accurate marker for pyogenic infections. The objectives of this study were to show that PCT is an accurate marker in differentiating Acute Osteomyelitis and Septic Arthritis from viral and non infective inflammatory bone and joint conditions. Patients of all age groups (n = 82) with suspected Acute Osteomyelitis and Septic Arthritis were prospectively included in this study. All patients were subjected to TC, CRP, PCT, IgM Dengue, IgM Chikungunya, pus and blood culture and sensitivity. At the end of the study, patients were classified into 3 groups: Group 1 = Confirmed Pyogenic (n = 27) Group 2 = Presumed Pyogenic (n = 21) Group 3 = Non – infective inflammatory (n = 34). Group 1 has higher mean PCT levels than Group 2 and 3 ( p 0.05 ). PCT, at 0.4 ng/ml , was 85.2% sensitive and 87.3% specific in diagnosing Septic Arthritis and Acute Osteomyelitis. In comparison, PCT at conventional cut – off of 0.5 ng/ml is 66.7% sensitive and 91% specific. Serum Procalcitonin, at a cut – off of 0.4 ng/ml , is a sensitive and specific marker in the diagnosis of Septic Arthritis and Acute Osteomyelitis.
No related grants have been discovered for Karthikeyan Maharajan.