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Godino O, Fernandez-Carballal C, Català I, Moreno Á, Rimbau JM, Alvarez-Galovich L, Roldan H. A new hernia blocking system to prevent recurrent lumbar disc herniation: surgical technique, intraoperative findings and six-months post-operative outcomes. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2025; 34:1123-1133. [PMID: 39648196 DOI: 10.1007/s00586-024-08595-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 10/22/2024] [Accepted: 11/26/2024] [Indexed: 12/10/2024]
Abstract
PURPOSE The aim of this study was to evaluate the performance and safety of a new hernia blocking system (HBS), implanted after a limited discectomy, to prevent recurrence of lumbar disc herniation. METHODS Prospective, multicenter (6 sites), cohort clinical investigation. Thirty patients with a postero-lateral disc herniation between L4-S1 and large annular defects (> 6 mm wide), who underwent a limited discectomy and were treated with a new HBS (DISC care, NEOS Surgery S.L.), were included. This article presents details about the investigational device, its surgical technique, intraoperative parameters, and up to 6 months follow-up outcomes. The primary endpoint of the study was to assess the incidence of early symptomatic reherniation. In addition, disc height, leg and back pain (NRS 0-10), Oswestry Disability Index (ODI), quality of life (EQ-5D-5L) and device safety, were evaluated. CLINICALTRIALS gov: NCT04188236; date: 27th November 2019. RESULTS Thirty patients (43.3% female, 41.7 ± 10.9 years) were implanted with the device under evaluation in a mean of 16 ± 9.6 min. Six months after surgery, no symptomatic reherniation was detected and disc height was maintained in all patients included. All patients had a significant reduction in leg pain (> 2 points in the NRS), 92.9% improved > 15 points in the ODI and 82.6% significantly improved their quality of life (≥ 12 points in EQ VAS score). No product-related serious adverse events nor reoperations occurred. CONCLUSIONS The implantation of an HBS is a feasible and safe procedure that prevents early disc herniation recurrence in patients at high risk of reherniation.
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Affiliation(s)
- Oscar Godino
- Neurosurgery Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | | | - Ignasi Català
- Instituto Clavel, Hospital QuirónSalud Barcelona, Barcelona, Spain
| | - Ángela Moreno
- Neurosurgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jordi Manuel Rimbau
- Neurosurgery Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | - Héctor Roldan
- Neurosurgery Department, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
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Jalal MI, Santangelo G, Samodal J, Catanzaro S, Furst T, Singh R, Li H, Jain S, Singh A, Puvanesarajah V, Wensel A, Paul DA, Stone JJ. The Rochester Model for Spinal CSF Leak Repair Simulation and Scoring. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01424. [PMID: 39584831 DOI: 10.1227/ons.0000000000001458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 10/06/2024] [Indexed: 11/26/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Iatrogenic spinal durotomies occur at a rate of 1% to 17%. Surgical simulation for durotomy repair is needed to provide affordable, accessible, and validated practice. This study sought to design and validate a simple 3-dimensional printed model for spinal cerebrospinal fluid (CSF) leak repair and to introduce the Rochester original objective structured assessment of technical skills (OSATS) CSF leak (ROCL) repair criteria for assessment. METHODS A spinal model was designed to mimic a lumbar laminectomy with the L3-5 lamina removed and 3-dimensional printed using Vero polymers. The model was paired with a porcine collagen "dura" that was pressurized using IV saline and overlayed with gel-molded fascial, muscle, and skin layers with an opening. Participants were provided a training model with a 1.5-cm midline durotomy, surgical microinstrument set, microscope, and 6-0 prolene suture. The 25-point ROCL repair criteria were adapted from the original OSATS principles to assess proficiency in surgical repair by 2 blinded neurosurgeons not participating in the trials. Postsimulation survey data regarding model realism were collected. RESULTS Six residents and 4 attendings participated. Median operative time in minutes was 13 minutes among residents and 7 minutes among attendings. Moreover, the ROCL score was a median of 19/25 for attendings and 15/25 for residents. The suture angle was statistically more consistent among senior residents and attendings compared with junior residents. Participants agreed that the model was realistic (median 4/5), useful for improving the operative technique (median 5/5), and would increase comfort in spinal CSF leak repair procedures (median 5/5). Each reusable model had a cost of $19.99 if printed with polylactic acid and each replacement dura cost <3¢. CONCLUSION This study presents an affordable, realistic, and educational spinal CSF leak repair model and introduces ROCL for assessment.
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Affiliation(s)
- Muhammad I Jalal
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Gabrielle Santangelo
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Joshua Samodal
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Sandra Catanzaro
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Taylor Furst
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Rohin Singh
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Herman Li
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sameer Jain
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Aman Singh
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Andrew Wensel
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - David A Paul
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jonathan J Stone
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Kinoshita H, Hongo M, Kobayashi T, Kasukawa Y, Kikuchi K, Kudo D, Kimura R, Ono Y, Kasama F, Miyakoshi N. Dural Injury During Spinal Surgery and Postoperative Cerebrospinal Fluid Leakage: A Single-Center Experience. Cureus 2024; 16:e71878. [PMID: 39559681 PMCID: PMC11573356 DOI: 10.7759/cureus.71878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2024] [Indexed: 11/20/2024] Open
Abstract
BACKGROUND The incidence of dural injury during spinal surgery and postoperative cerebrospinal fluid leakage varies between studies. We examined these rates in our institution. METHODS Among 4014 patients who underwent a spinal operation between January 2012 and February 2020, 176 experienced an intraoperative dural injury (176 of 4014 cases, 4.3%). Among these, 22 (22 of 176 cases, 12.5%) developed postoperative cerebrospinal fluid leakage. RESULTS The cause of dural injury was identified in 74 of 176 patients (42%). The rates of dural injury associated with thoracic, cervical, and lumbar operations were 7.8% (25 of 321 cases), 3.2% (19 of 602 cases), and 4.3% (132 of 3091 cases), respectively. Corresponding rates of cerebrospinal fluid leakage were 28% (seven of 25 cases), 5.3% (one of 19 cases), and 11% (14 of 132 cases), respectively. Most patients who experienced cerebrospinal fluid leakage recovered with bed rest; however, cerebral hemorrhage occurred in two patients. CONCLUSIONS Although it was difficult to identify the cause of dural injury in more than half of patients, suturing the dura and using polyglycolic acid mesh with fibrin glue was effective. No patients required reoperation, even those who developed cerebrospinal fluid leakage.
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Affiliation(s)
| | - Michio Hongo
- Physical Therapy, Akita University Graduate School of Medicine, Akita, JPN
| | | | - Yuji Kasukawa
- Orthopaedic Surgery, Akita University Graduate School of Medicine, Akita, JPN
| | - Kazuma Kikuchi
- Orthopaedic Surgery, Yuri Kumiai General Hospital, Yurihonjo, JPN
| | - Daisuke Kudo
- Orthopaedic Surgery, Akita University Graduate School of Medicine, Akita, JPN
| | - Ryota Kimura
- Orthopaedic Surgery, Akita University Graduate School of Medicine, Akita, JPN
| | - Yuichi Ono
- Orthopaedic Surgery, Akita University Graduate School of Medicine, Akita, JPN
| | - Fumihito Kasama
- Orthopaedic Surgery, Akita Kousei Medical Center, Akita, JPN
| | - Naohisa Miyakoshi
- Orthopaedic Surgery, Akita University Graduate School of Medicine, Akita, JPN
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Guo Z, Wang P, Ye S, Li H, Bao J, Shi R, Yang S, Yin R, Wu X. Interpretable Machine Learning Models Based on Shapley Additive Explanations for Predicting the Risk of Cerebrospinal Fluid Leakage in Lumbar Fusion Surgery. Spine (Phila Pa 1976) 2024; 49:1281-1293. [PMID: 38963261 DOI: 10.1097/brs.0000000000005087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 06/17/2024] [Indexed: 07/05/2024]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES The objective of this investigation was to formulate and internally verify a customized machine learning (ML) framework for forecasting cerebrospinal fluid leakage (CSFL) in lumbar fusion surgery. This was accomplished by integrating imaging parameters and using the SHapley Additive exPlanation (SHAP) technique to elucidate the interpretability of the model. SUMMARY OF BACKGROUND DATA Given the increasing incidence and surgical volume of spinal degeneration worldwide, accurate predictions of postoperative complications are urgently needed. SHAP-based interpretable ML models have not been used for CSFL risk factor analysis in lumbar fusion surgery. METHODS Clinical and imaging data were retrospectively collected from 3505 patients who underwent lumbar fusion surgery. Six distinct machine learning models were formulated: extreme gradient boosting (XGBoost), decision tree (DT), random forest (RF), support vector machine (SVM), Gaussian naive Bayes (GaussianNB), and K-nearest neighbors (KNN) models. Evaluation of model performance on the test dataset was performed using performance metrics, and the analysis was executed through the SHAP framework. RESULTS CSFL was detected in 95 (2.71%) of 3505 patients. Notably, the XGBoost model exhibited outstanding accuracy in forecasting CSFLs, with high precision (0.9815), recall (0.6667), accuracy (0.8182), F1 score (0.7347), and AUC (0.7343). In addition, through SHAP analysis, significant predictors of CSFL were identified, including ligamentum flavum thickness, zygapophysial joint degeneration grade, central spinal stenosis grade, decompression segment count, decompression mode, intervertebral height difference, Cobb angle, intervertebral height index difference, operation mode, lumbar segment lordosis angle difference, Meyerding grade of lumbar spondylolisthesis, and revision surgery. CONCLUSIONS The combination of the XGBoost model with the SHAP is an effective tool for predicting the risk of CSFL during lumbar fusion surgery. Its implementation could aid clinicians in making informed decisions, potentially enhancing patient outcomes and lowering healthcare expenses. This study advocates for the adoption of this approach in clinical settings to enhance the evaluation of CSFL risk among patients undergoing lumbar fusion.
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Affiliation(s)
- ZongJie Guo
- Spine Surgery Center, Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - PeiYang Wang
- Spine Surgery Center, Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - SuHui Ye
- Department of Orthopedics, Yancheng Third People's Hospital, Yancheng, Jiangsu, People's Republic of China
| | - HaoYu Li
- Spine Surgery Center, Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - JunPing Bao
- Spine Surgery Center, Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Rui Shi
- Spine Surgery Center, Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Shu Yang
- Spine Surgery Center, Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Rui Yin
- Department of immunology, Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou, Jiangsu, People's Republic of China
| | - XiaoTao Wu
- Spine Surgery Center, Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu, People's Republic of China
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Bauerle L, Wessell JE, Bindner S, Saway BF, Wolgamott L, Kalhorn SP. Use of Subfascial Passive Bile Bag Drainage for the Management of Durotomies in Spine Surgery. Cureus 2024; 16:e68397. [PMID: 39224492 PMCID: PMC11366417 DOI: 10.7759/cureus.68397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Historically, the use of subfascial drains for the management of durotomies was avoided due to concerns about the creation of cerebrospinal fluid (CSF) fistulas. Currently, there are limited series utilizing subfascial drainage for CSF leak management, many of which utilize suction drainage. We report our experience with the use of subfascial passive drainage in the management of such leaks. OBJECTIVE To demonstrate the efficacy of a passive subfascial bile bag for diversion of CSF post-operatively in concert with a post-operative head of bed (HOB) protocol for the management of durotomies in spine surgery. METHODS We performed a retrospective chart review of patients who underwent spinal surgery at a single institution performed by one surgeon. Cases utilizing a passive subfascial bile bag for durotomies were identified. A total of 1,882 consecutive surgeries were reviewed, and 108 met the inclusion criteria. The primary outcome was return to the operating room (OR) and/or the need for lumbar drain placement. Patient sociodemographic information and pre-, intra-, and post-operative clinical characteristics were reviewed. RESULTS A total of 108 patients underwent subfascial bile bag CSF diversion after intra-operative durotomy. Four patients (3.7%) experienced post-operative CSF leakage requiring lumbar drain placement, while only two (1.9%) patients required a return to the OR. One patient returned to the OR for symptomatic pseudomeningocele and the other for ongoing CSF drainage from their wound. CONCLUSION Durotomies are known to increase complication rates, including reoperation. The use of subfascial passive bile bag drainage in concert with a post-operative HOB protocol is a safe and effective manner to manage durotomies while minimizing the need for reoperation.
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Affiliation(s)
- Luke Bauerle
- College of Medicine, Medical University of South Carolina, Charleston, USA
| | - Jeffrey E Wessell
- Department of Neurosurgery, Neurosurgical and Spine Institute of Savannah, Savannah, USA
| | - Samantha Bindner
- College of Medicine, Medical University of South Carolina, Charleston, USA
| | - Brian F Saway
- Department of Neurosurgery, Medical University of South Carolina, Charleston, USA
| | - Laura Wolgamott
- Department of Neurosurgery, Stanford Health Care, Palo Alto, USA
| | - Stephen P Kalhorn
- Department of Neurosurgery, Medical University of South Carolina, Charleston, USA
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Chan JL, Quintero-Consuegra MD, Kanim LE, Kropf MA, Bernstein R, Perry TG, Walker CT, Danielpour M, Tuchman A. Perioperative Complications Following Spine Surgery in Adult Patients with Achondroplasia. Global Spine J 2024; 14:1793-1799. [PMID: 36792924 PMCID: PMC11268303 DOI: 10.1177/21925682231157373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To describe the common types of complications and their risk factors during spine surgery in patients with achondroplasia. METHODS A retrospective review was performed of medical records of adult achondroplasia patients who underwent spine surgery at our institution between 2007 and 2021. Inclusion criteria were achondroplasia and age >16 years. Surgical encounters were evaluated for durotomy, postoperative neurologic deficit, wound compromise, medical complications, and return to the operating room. Statistical analysis included evaluation of relationships across complications and fisher exact test applied to bivariate/categorical variables and t-test/ANOVA for continuous variables. Multivariable analysis using logistic regression was performed to account for patient characteristics. RESULTS Fifty-five patients with achondroplasia underwent 95 surgeries. Forty-nine percent of the surgeries involved a complication. These included durotomy (33.7%), neurologic deficit (11.6%), wound compromise (6.3%), and other medical complications (6.3%). Thirteen percent of surgeries required return to the operating room. The greatest number of complications occurred in thoracolumbar region (60.0%) compared to cervicothoracic (18.2%) and craniocervical junction (33.3%). Chronologically later surgical encounters had decreased complications and durotomies only occurred in thoracolumbar surgeries (45.7%). CONCLUSIONS Adult patients with achondroplasia undergoing surgery chronologically later in this set of consecutive patients were at a decreased risk for complications. Thoracolumbar surgeries were at the greatest risk for durotomies. Male sex was a risk factor for durotomy, while age was a risk factor for neurologic deficit. The potential for adverse surgical events should be considered when evaluating patients with achondroplasia for spine surgery. .
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Affiliation(s)
- Julie L. Chan
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Linda E.A. Kanim
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael A. Kropf
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert Bernstein
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Portland, Portland, OR, USA
| | - Tiffany G. Perry
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Corey T. Walker
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Moise Danielpour
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Tuchman
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Song Z, Zhang Z, Zheng J, Zhang K, Wang F, Ran M, Luo J. Short-term and mid-term evaluation of three types of minimally invasive lumbar fusion surgery for treatment of L4/L5 degenerative spondylolisthesis. Sci Rep 2024; 14:4320. [PMID: 38383595 PMCID: PMC10881486 DOI: 10.1038/s41598-024-54970-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 02/19/2024] [Indexed: 02/23/2024] Open
Abstract
This was a single-centre retrospective study. Minimally invasive techniques for transforaminal lumbar interbody fusion (MIS-TLIF), oblique lumbar interbody fusion (OLIF), and percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) have been extensively used for lumbar degenerative diseases. The present study analyses the short-term and mid-term clinical effects of the above three minimally invasive techniques on L4/L5 degenerative spondylolisthesis. In this retrospective study, 98 patients with L4/L5 degenerative spondylolisthesis received MIS-TLIF, 107 received OLIF, and 114 received Endo-TLIF. All patients were followed up for at least one year. We compared patient data, including age, sex, body mass index (BMI), Oswestry disability index (ODI), visual analogue scale of low back pain (VAS-B), visual analogue scale of leg pain (VAS-L), surgical time, blood loss, drainage volume, hospital stay, complications, and neurological status. Moreover, we performed imaging evaluations, including lumbar lordosis angle (LLA), disc height (DH) and intervertebral fusion status. No significant differences were noted in age, sex, BMI, preoperative ODI, preoperative VAS-B, preoperative VAS-L, preoperative LLA, or preoperative DH. Patients who underwent OLIF had significantly decreased blood loss, a lower drainage volume, and a shorter hospital stay than those who underwent MIS-TLIF or Endo-TLIF (P < 0.05). The VAS-B in the OLIF group significantly decreased compared with in the MIS-TLIF and Endo-TLIF groups at 6 and 12 months postoperatively (P < 0.05). The VAS-L in the Endo-TLIF group significantly decreased compared with that in the MIS-TLIF and OLIF groups at 6 months postoperatively (P < 0.05). The ODI in the OLIF group was significantly better than that in the MIS-TLIF and Endo-TLIF groups at 6 months postoperatively (P < 0.05). No statistically significant differences in the incidence of complications and healthcare cost were found among the three groups. Follow-up LLA and DH changes were significantly lower in the OLIF group than in the other groups (P < 0.05). The intervertebral fusion rate was significantly higher in the OLIF group than in the other groups at 6 and 12 months postoperatively (P < 0.05). In conclusion, while MIS-TLIF, OLIF, and Endo-TLIF techniques can effectively treat patients with L4/5 degenerative spondylolisthesis, OLIF has more benefits, including less operative blood loss, a shorter hospital stay, a smaller drainage volume, efficacy for back pain, effective maintenance of lumbar lordosis angle and disc height, and a higher fusion rate. OLIF should be the preferred surgical treatment for patients with L4/5 degenerative spondylolisthesis.
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Affiliation(s)
- Zhaojun Song
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Zhi Zhang
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Jiazhuang Zheng
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Kai Zhang
- Operation Room of Suining Central Hospital, Sichuan, People's Republic of China
| | - Fandong Wang
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Maobo Ran
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Juan Luo
- Medical Record Department of Suining Central Hospital, Sichuan, People's Republic of China.
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Yu H, Zhao Q, Lv J, Liu J, Zhu B, Chen L, Jing J, Tian D. Unintended dural tears during unilateral biportal endoscopic lumbar surgery: incidence and risk factors. Acta Neurochir (Wien) 2024; 166:95. [PMID: 38381267 PMCID: PMC10881605 DOI: 10.1007/s00701-024-05965-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 12/31/2023] [Indexed: 02/22/2024]
Abstract
BACKGROUND An unintended dural tear (DT) is the most common intraoperative complication of lumbar spine surgery. The unilateral biportal endoscopic technique (UBE) has become increasingly popular for treating various degenerative diseases of the lumbar spine; however, the DT incidence and risk factors specific to UBE remain undetermined. Therefore, this study aimed to evaluate the incidence and risk factors of DTs in UBE. METHOD Data from all patients who underwent UBE for degenerative lumbar spinal diseases from November 2018 to December 2021 at our institution were used to assess the effects of demographics, diagnosis, and type of surgery on unintended DT risk. RESULTS Overall, 24/608 patients (3.95%) experienced DTs and were treated with primary suture repair or bed rest. Although several patients experienced mild symptoms of cerebrospinal fluid (CSF) leaks, no serious postoperative sequelae such as nerve root entrapment, meningitis, or intracranial hemorrhage occurred. Additionally, no significant correlations were identified between DT and sex (P = 0.882), body mass index (BMI) (P = 0.758), smoking status (P = 0.506), diabetes (P = 0.672), hypertension (P = 0.187), or surgeon experience (P = 0.442). However, older patients were more likely to experience DT than younger patients (P = 0.034), and patients with lumbar spinal stenosis (LSS) were more likely to experience DT than patients with lumbar disc herniation (LDH) (P = 0.035). Additionally, DT was more common in revision versus primary surgery (P < 0.0001) and in unilateral laminotomy with bilateral decompression (ULBD) versus unilateral decompression (P = 0.031). Univariate logistic regression analysis revealed that age, LSS, ULBD, and revision surgery were significant risk factors for DT. CONCLUSIONS In this UBE cohort, we found that the incidence of DT was 3.95%. Additionally, older age, LSS, ULBD, and revision surgery significantly increased the risk of DT in UBE surgery.
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Affiliation(s)
- Hang Yu
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
- Department of Orthopaedics, Huzhou Central Hospital, 313000, Huzhou, China
| | - Qingzhong Zhao
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Jianwei Lv
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Jianjun Liu
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Bin Zhu
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Lei Chen
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Juehua Jing
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Dasheng Tian
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China.
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Hamouda AM, Pennington Z, Astudillo Potes M, Mikula AL, Lakomkin N, Martini ML, Abode-Iyamah KO, Freedman BA, McClendon J, Nassr AN, Sebastian AS, Fogelson JL, Elder BD. The Predictors of Incidental Durotomy in Patients Undergoing Pedicle Subtraction Osteotomy for the Correction of Adult Spinal Deformity. J Clin Med 2024; 13:340. [PMID: 38256474 PMCID: PMC10816915 DOI: 10.3390/jcm13020340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Background: Pedicle subtraction osteotomy (PSO) is a powerful tool for sagittal plane correction in patients with rigid adult spinal deformity (ASD); however, it is associated with high intraoperative blood loss and the increased risk of durotomy. The objective of the present study was to identify intraoperative techniques and baseline patient factors capable of predicting intraoperative durotomy. Methods: A tri-institutional database was retrospectively queried for all patients who underwent PSO for ASD. Data on baseline comorbidities, surgical history, surgeon characteristics and intraoperative maneuvers were gathered. PSO aggressiveness was defined as conventional (Schwab 3 PSO) or an extended PSO (Schwab type 4). The primary outcome of the study was the occurrence of durotomy intraoperatively. Univariable analyses were performed with Mann-Whitney U tests, Chi-squared analyses, and Fisher's exact tests. Statistical significance was defined by p < 0.05. Results: One hundred and sixteen patients were identified (mean age 61.9 ± 12.6 yr; 44.8% male), of whom 51 (44.0%) experienced intraoperative durotomy. There were no significant differences in baseline comorbidities between those who did and did not experience durotomy, with the exception that baseline weight and body mass index were higher in patients who did not suffer durotomy. Prior surgery (OR 2.73; 95% CI [1.13, 6.58]; p = 0.03) and, more specifically, prior decompression at the PSO level (OR 4.23; 95% CI [1.92, 9.34]; p < 0.001) was predictive of durotomy. A comparison of surgeon training showed no statistically significant difference in durotomy rate between fellowship and non-fellowship trained surgeons, or between orthopedic surgeons and neurosurgeons. The PSO level, PSO aggressiveness, the presence of stenosis at the PSO level, nor the surgical instrument used predicted the odds of durotomy occurrence. Those experiencing durotomy had similar hospitalization durations, rates of reoperation and rates of nonroutine discharge. Conclusions: In this large multisite series, a history of prior decompression at the PSO level was associated with a four-fold increase in intraoperative durotomy risk. Notably the use of extended (versus) standard PSO, surgical technique, nor baseline patient characteristics predicted durotomy. Durotomies occurred in 44% of patients and may prolong operative times. Additional prospective investigations are merited.
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Affiliation(s)
- Abdelrahman M. Hamouda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Zach Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Maria Astudillo Potes
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Anthony L. Mikula
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Nikita Lakomkin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Michael L. Martini
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | | | - Brett A. Freedman
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Jamal McClendon
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Ahmad N. Nassr
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Arjun S. Sebastian
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Jeremy L. Fogelson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Benjamin D. Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
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10
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Johansen PM, Yerke Hansen P, Babici D, Miller TD. Management of Super-refractory Postoperative Lumbar Cerebrospinal Fluid Leak: A Case Report and Review of the Literature. Cureus 2023; 15:e48215. [PMID: 38050513 PMCID: PMC10693831 DOI: 10.7759/cureus.48215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/03/2023] [Indexed: 12/06/2023] Open
Abstract
One well-documented risk of spinal surgery is cerebrospinal fluid (CSF) leak in the immediate postoperative period. While the majority of CSF leaks occur due to an obvious intraoperative dural tear, several reports have documented delayed CSF leakage from occult intraoperative dural tears. There is a paucity of published literature regarding the true incidence of dural tears in minimally invasive spinal surgery. Furthermore, the types of dural tears that require closure are poorly understood. According to the limited existing literature available, the recommended treatment of dural tears includes primary repair, subarachnoid drainage catheters, and blood patches. However, there are no distinct treatment guidelines between the different etiologies of CSF leakage. The most important aspect in the management of CSF leakage is prevention, including preoperative risk assessment and meticulous intraoperative manipulation. One emerging treatment strategy is to alter the pressure gradient in a manner that stops CSF leakage. This method is based on one of two mechanisms: direct suture or augmented closure with dural substitute material and either reducing the subarachnoid fluid pressure or increasing the epidural space pressure. Bed rest is a key element in the treatment of persistent CSF leaks, as it can reduce the lumbar CSF pressure, thereby preventing CSF leakage. We describe the challenging case of a persistent CSF leak despite multiple attempts at direct repair, as well as our management strategies. Understanding the proper positioning techniques to reduce leakage is crucial for proper management, and orthopedic surgeons, neurosurgeons, and neurointensivists may consider being more aggressive in treating persistent CSF leaks.
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Affiliation(s)
| | - Payton Yerke Hansen
- Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Denis Babici
- Neurology, Marcus Neuroscience Institute, Boca Raton, USA
- Neurology, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Timothy D Miller
- Neurosurgery, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
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11
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Krahwinkel S, Schipmann S, Spille D, Maragno E, Al Barim B, Warneke N, Stummer W, Gallus M, Schwake M. The Role of Prolonged Bed Rest in Postoperative Cerebrospinal Fluid Leakage After Surgery of Intradural Pathology-A Retrospective Cohort Study. Neurosurgery 2023; 93:563-575. [PMID: 36883822 DOI: 10.1227/neu.0000000000002448] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/11/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Postoperative cerebrospinal fluid leakage (CSFL) is a feared complication after surgery on intradural pathologies and may cause postoperative complications and subsequently higher treatment costs. OBJECTIVE To assess whether prolonged bed rest may lower the risk of CSFL. METHODS We performed a retrospective cohort study including patients with intradural pathologies who underwent surgery at our department between 2013 and 2021. Cohorts included patients who completed 3 days of postoperative bed rest and patients who were mobilized earlier. The primary end point was the occurrence of clinically proven CSFL. RESULTS Four hundred and thirty-three patients were included (female [51.7%], male [48.3%]) with a mean age of 48 years (SD ±20). Bed rest was ordered in 315 cases (72.7%). In 7 cases (N = 7/433, 1.6%), we identified a postoperative CSFL. Four of them (N = 4/118) did not preserve bed rest, showing no significant difference to the bed rest cohort (N = 3/315; P = .091). In univariate analysis, laminectomy (N = 4/61; odds ratio [OR] 8.632, 95% CI 1.883-39.573), expansion duraplasty (N = 6/70; OR 33.938, 95% CI 4.019-286.615), and recurrent surgery (N = 5/66; OR 14.959, 95% CI 2.838-78.838) were significant risk factors for developing CSFL. In multivariate analysis, expansion duraplasty was confirmed as independent risk factor (OR 33.937, 95% CI 4.018-286.615, P = .001). In addition, patients with CSFL had significant higher risk for meningitis (N = 3/7; 42.8%, P = .001). CONCLUSION Prolonged bed rest did not protect patients from developing CSFL after surgery on intradural pathologies. Avoiding laminectomy, large voids, and minimal invasive approaches may play a role in preventing CSFL. Furthermore, special caution is indicated if expansion duraplasty was done.
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Affiliation(s)
- Sophia Krahwinkel
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
| | - Stephanie Schipmann
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
- Department of Neurosurgery, University Hospital Bergen, Bergen, Norway
| | - Dorothee Spille
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
| | - Emanuele Maragno
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
| | - Bilal Al Barim
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
| | - Marco Gallus
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Muenster, Muenster, Germany
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12
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Jiang L, Budu A, Khan MS, Goacher E, Kolias A, Trivedi R, Francis J. Predictors of Cerebrospinal Fluid Leak Following Dural Repair in Spinal Intradural Surgery. Neurospine 2023; 20:783-789. [PMID: 37798970 PMCID: PMC10562229 DOI: 10.14245/ns.2346432.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/01/2023] [Accepted: 07/20/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE We aim to compare the effectiveness of dural closure techniques in preventing cerebrospinal fluid (CSF) leaks following surgery for intradural lesions and seek to identify additional factors associated with CSF leaks. Surgical management of spinal intradural lesions involves durotomy which requires a robust repair to prevent postoperative CSF leakage. The ideal method of dural closure and the efficacy of sealants has not been established in literature. METHODS We performed a retrospective analysis of all intradural spinal cases performed at a tertiary spine centre from 1 April 2015 to 29 January 2020 and collected data on patient bio-profile, dural repair technique, and CSF leak rates. Multivariate analysis was performed to identify predictors for postoperative CSF leak. RESULTS A total of 169 cases were reported during the study period. There were 15 cases in which postoperative CSF leak was reported (8.87%). Multivariate analysis demonstrated that patient age (odds ratio [OR], 0.942; 95% confidence interval [CI], 0.891-0.996), surgical indication listed in the "others" category (OR, 44.608; 95% CI, 1.706-166.290) and dural closure with suture, sealant and patch (OR, 22.235; 95% CI, 2.578-191.798) were factors associated with CSF leak. Postoperative CSF leak was associated with the risk of surgical site infection with a likelihood ratio of 8.704 (χ² (1) = 14.633, p < 0.001). CONCLUSION Identifying predictors for CSF leaks can assist in the counselling of patients with regard to surgical risk and expected postoperative recovery.
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Affiliation(s)
- Lei Jiang
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - Muhammad Shuaib Khan
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Edward Goacher
- Department of Neurosurgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Rikin Trivedi
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Jibin Francis
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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13
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Toci G, Lambrechts MJ, Issa T, Karamian B, Siegel N, Antonio ND, Canseco J, Kurd M, Woods B, Kaye ID, Hilibrand A, Kepler C, Vaccaro A, Schroeder G. Incidence, Risk Factors, and Outcomes of Incidental Durotomy during Lumbar Spine Decompression with or without Fusion. Asian Spine J 2023; 17:647-655. [PMID: 37226383 PMCID: PMC10460661 DOI: 10.31616/asj.2022.0297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/14/2022] [Accepted: 10/16/2022] [Indexed: 05/26/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE The primary objective of this study was to determine the incidence and risk factors for incidental durotomies during lumbar decompression surgeries. In addition, we aimed to determine the changes in patient-reported outcome measures (PROMs) based on incidental durotomy status. OVERVIEW OF LITERATURE There is limited literature investigating the affect of incidental durotomy on patient reported outcome measures. While the majority of research does not suggest differences in complications, readmission, or revision rates, many studies rely on public databases, and their sensitivity and specificity for identifying incidental durotomies is unknown. METHODS Patients undergoing lumbar decompression with or without fusion at a single tertiary care center were grouped based on the presence of a durotomy. Multivariate analysis was performed for length of stay (LOS), hospital readmissions, and changes in PROMs. To identify surgical risk factors for durotomy, 3:1 propensity matching was performed using stepwise logistic regression. The sensitivity and specificity of the International Classification of Disease, 10th revision (ICD-10) codes (G96.11 and G97.41) were also assessed. RESULTS Of the 3,684 consecutive patients who underwent lumbar decompressions, 533 (14.5%) had durotomies, and a complete set of PROMs (preoperative and 1-year postoperative) were available for 737 patients (20.0%). Incidental durotomy was an independent predictor of increased LOS but not hospital readmission or worse PROMs. The durotomy repair method was not associated with hospital readmission or LOS. However, repair with collagen graft and suture predicted reduced improvement in Visual Analog Scale back (β =2.56, p=0.004). Independent risk factors for incidental durotomies included revisions (odds ratio [OR], 1.73; p<0.001), levels decompressed (OR, 1.11; p=0.005), and preoperative diagnosis of spondylolisthesis or thoracolumbar kyphosis. The sensitivity and specificity of ICD-10 codes were 5.4% and 99.9%, respectively, for identifying durotomies. CONCLUSIONS The durotomy rate for lumbar decompressions was 14.5%. No differences in outcomes were detected except for increased LOS. Database studies relying on ICD codes should be interpreted with caution due to the limited sensitivity in identifying incidental durotomies.
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Affiliation(s)
- Gregory Toci
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark James Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tariq Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas D' Antonio
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark Kurd
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Barrett Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
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14
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Xu C, Dong RP, Cheng XL, Zhao JW. Late presentation of dural tears: Two case reports and review of literature. World J Clin Cases 2023; 11:2464-2473. [PMID: 37123324 PMCID: PMC10130997 DOI: 10.12998/wjcc.v11.i11.2464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/23/2023] [Accepted: 03/21/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND The late presentation of dural tears (LPDT) has a low incidence rate and hidden symptoms and is easily ignored in clinical practice. If the disease is not treated in time, a series of complications may occur, including low intracranial pressure headache, infection, pseudodural cyst formation, and sinus formation. Here, we describe two cases of LPDT. CASE SUMMARY Two patients had sudden fever 1 wk after lumbar surgery. Physical examination showed obvious tenderness in the operation area. The patients were confirmed as having LPDT by lumbar magnetic resonance imaging and surgical exploration. One case was caused by continuous negative pressure suction and malnutrition, and the other was caused by decreased dural ductility and low postoperative nutritional status. The first symptom of both patients was fever, with occasional headache. Both patients underwent secondary surgery to treat the LPDT. Dural defects were observed and dural sealants were used to seal the dural defects, then drainage tubes were retained for drainage. After the operation, the patients were treated with antibiotics and the patients' surgical incisions healed well, without fever or incision tenderness. Both recovered and were discharged 1 wk after the operation. CONCLUSION LPDT is a rare complication of spinal surgery or neurosurgery that has hidden symptoms and can easily be overlooked. Since it may cause a series of complications, LPDT needs to be actively addressed in clinical practice.
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Affiliation(s)
- Chang Xu
- Department of Orthopedics, Jilin Provincial Armed Police Corps Hospital, Changchun 130000, Jilin Province, China
| | - Rong-Peng Dong
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130012, Jilin Province, China
| | - Xue-Liang Cheng
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130012, Jilin Province, China
| | - Jian-Wu Zhao
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130012, Jilin Province, China
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15
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Najjar E, Hassanin MA, Komaitis S, Karouni F, Quraishi N. Complications after early versus late mobilization after an incidental durotomy: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:778-786. [PMID: 36609888 DOI: 10.1007/s00586-023-07526-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/02/2023] [Indexed: 01/08/2023]
Abstract
BACKGROUND An incidental durotomy (IDT) is a frequent complication of spinal surgery. The conventional management involving a period of flat bed rest is highly debatable. Indeed, there are scanty data and no consensus regarding the need or ideal duration of post-operative bed rest following IDT. OBJECTIVE To systematically evaluate the literature regarding the outcomes of mobilization within 24 h and after 24 h following IDT in open lumbar or thoracic surgery with respect to the length of hospital stay, minor and major complications. METHODS A systematic review of the literature using PubMed, Embase and Cochrane and dating up until September 2022 was undertaken following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support. RESULTS Out of 532 articles, 6 studies met the inclusion criteria (1 Level-I, 4 level-III and 1 Level-IV evidence) and were analyzed. Overall, 398 patients of mean age 59.9 years were mobilized within 24 h. The average length of stay (LOS) for this group was 5.7 days. Thirty-four patients (8.5%) required reoperation while the rate of minor complications was 25.4%. Additionally, 265 patients of mean age 63 years with IDT were mobilized after 24 h. The average LOS was 7.8 days. Twenty patients (7.54%) required reoperation while the rate of minor complications was 55%. Meta-analysis comparing early to late mobilization, showed a significant reduction in the risk of minor complications and shorter overall LOS due to early mobilization, but no significant difference in major complications and reoperation rates. CONCLUSIONS Although early mobilization after repaired incidental dural tears in open lumbar and thoracic spinal surgery has a similar major complication/ reoperation rates compared to late mobilization, it significantly decreases the risk of minor complications and length of hospitalization.
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Affiliation(s)
- Elie Najjar
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Mohamed A Hassanin
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.,Department of Orthopedic Surgery, Assiut University, Asyut, Egypt
| | - Spyridon Komaitis
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - Faris Karouni
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Nasir Quraishi
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
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16
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Overweight increases perioperative spinal surgery complications: a single-center retrospective study. BMC Musculoskelet Disord 2023; 24:98. [PMID: 36740675 PMCID: PMC9900974 DOI: 10.1186/s12891-023-06217-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/01/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The World Health Organization (WHO) defines a person with a body mass index (BMI) greater than or equal to 25 kg/m2 as overweight. Being overweight is a lifestyle-related disease; however, little is known about the impact of overweight on the perioperative complications of orthopedic surgery. This study aimed to define the effect of overweight on the perioperative complications of spinal surgery. METHODS This retrospective case series study reviewed 269 consecutive patients who underwent spinal surgery. These patients were divided into the overweight (OW) and non-overweight (NOW) groups. Age, BMI, surgical time, blood loss, and perioperative complications were evaluated and compared between the groups. RESULTS There were 117 patients (43%) in the OW group and 152 (57%) in the NOW group. Cervical surgery was performed in 72 cases, thoracic surgery in 34, and lumbosacral surgery in 159. The surgical time was significantly longer in the OW group than in the NOW group (204.6 ± 98 min vs. 175 ± 75 min; p = 0.01). Blood loss was greater in the OW group than in the NOW group (446.8 ± 447.9 mL vs. 279 ± 296.5 mL; p = 0.00). Durotomy was more frequent in the OW group than in the NOW group (10 vs. 3 cases; p = 0.02). There was no difference in complications other than durotomy. CONCLUSIONS OW patients had longer surgical time, more blood loss, and more frequent durotomy than NOW patients. These findings indicate that overweight increases perioperative complications of spinal surgery.
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17
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Shi B, Zhu Z, He H, Jin A, Zhou C, Min S, Shu X, Cao Y, Chen Z, Zhu L. Effects of Pretreatment of the Dorsal Meningovertebral Ligaments on the Incidence of Intraoperative Cerebrospinal Fluid Leakage: A Comparative Study. Orthopedics 2023; 46:e66-e71. [PMID: 36206508 DOI: 10.3928/01477447-20221003-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cerebrospinal fluid leakage can lead to postoperative refractory headaches and meningitis. Dural injury is the main cause of postoperative cerebrospinal fluid leakage. Previously, we performed a comprehensive anatomic study on the dorsal meningovertebral ligaments in the lumbosacral regions and concluded that these ligaments are an anatomic factor leading to dural laceration. However, no clinical study has examined the relationship between dorsal meningovertebral ligaments and the incidence of intraoperative cerebrospinal fluid leakage. The goal of this study was to investigate the effect of prophylactic intraoperative pretreatment of the meningovertebral ligaments on the incidence of cerebrospinal fluid leakage during surgery. [Orthopedics. 2023;46(1):e66-e71.].
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Gao X, Du P, Xu J, Sun J, Ding W, Yang DL. Repair of cerebrospinal fluid leak during posterior thoracolumbar surgery using paraspinal muscle flap combined with fat graft. Front Surg 2022; 9:969954. [PMID: 36299572 PMCID: PMC9589508 DOI: 10.3389/fsurg.2022.969954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
Objective This study aimed to propose a novel surgical method via combination of fat graft and paraspinal muscle flap, in order to treat cerebrospinal fluid (CSF) leak during posterior thoracolumbar surgery. The clinical outcomes were also evaluated. Methods Data of a total of 71 patients who were diagnosed with intraoperative incidental durotomy and CSF leak after posterior thoracolumbar surgery in our hospital form January 2019 to January 2021 were retrospectively collected and analyzed. Among them, 34 and 37 patients were assigned into conventional suturing (CS) group and fat graft and paraspinal muscle flap (FPM) group, respectively. Patients’ demographic and clinical data were compared between the two groups. Results The average drainage tube time in the FPM group was 3.89 ± 1.17 days, which was shorter than that in the CS group (5.12 ± 1.56, P < 0.001). The drainage volume in the FPM group (281.08 ± 284.76 ml) was also smaller than that in the CS group (859.70 ± 553.11 ml, P < 0.001). Besides, 15 (44.11%) patients in the CS group complained of postural headache, which was more than that in the FPM group (7 patients, 18.91%). There was a statistically significant difference in postoperative visual analogue scale (VAS) score between the two groups (P = 0.013). Two patients underwent revision surgery resulting from incision nonunion and delayed meningeal cyst. Conclusion Fat graft combined with paraspinal muscle flap showed to be an effective method to repair CSF leak during posterior thoracolumbar surgery. The proposed method significantly reduced postoperative drainage tube time and postoperative drainage volume. It also decreased the incidence and the degree of postural headache. The proposed method showed satisfactory clinical outcomes, and it is worthy of promotion.
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19
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Verma K, Freelin AH, Atkinson KA, Graham RS, Broaddus WC. Early mobilization versus bed rest for incidental durotomy: an institutional cohort study. J Neurosurg Spine 2022; 37:460-465. [PMID: 35303709 DOI: 10.3171/2022.1.spine211208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 01/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to assess whether flat bed rest for > 24 hours after an incidental durotomy improves patient outcome or is a risk factor for medical and wound complications and longer hospital stay. METHODS Medical records of consecutive patients undergoing thoracic and lumbar decompression procedures from 2010 to 2020 were reviewed. Operative notes and progress notes were reviewed and searched to identify patients in whom incidental durotomies occurred. The need for revision surgery related to CSF leak or wound infection was recorded. The duration of bed rest, length of hospital stay, and complications (pulmonary, gastrointestinal, urinary, and wound) were recorded. The rates of complications were compared with regard to the duration of bed rest (≤ 24 hours vs > 24 hours). RESULTS A total of 420 incidental durotomies were identified, indicating a rate of 6.7% in the patient population. Of the 420 patients, 361 underwent primary repair of the dura; 254 patients were prescribed bed rest ≤ 24 hours, and 107 patients were prescribed bed rest > 24 hours. There was no statistically significant difference in the need for revision surgery (7.87% vs 8.41%, p = 0.86) between the two groups, but wound complications were increased in the prolonged bed rest group (8.66% vs 15.89%, p = 0.043). The average length of stay for patients with bed rest ≤ 24 hours was 4.47 ± 3.64 days versus 7.24 ± 4.23 days for patients with bed rest > 24 hours (p < 0.0001). There was a statistically significant increase in the frequency of ileus, urinary retention, urinary tract infections, pulmonary issues, and altered mental status in the group with prolonged bed rest after an incidental durotomy. The relative risk of complications in the group with bed rest ≤ 24 hours was 50% less than the group with > 24 hours of bed rest (RR 0.5, 95% CI 0.39-0.62; p < 0.0001). CONCLUSIONS In this retrospective study, the rate of revision surgery was not higher in patients with durotomy who underwent immediate mobilization, and medical complications were significantly decreased. Flat bed rest > 24 hours following incidental durotomy was associated with increased length of stay and increased rate of medical complications. After primary repair of an incidental durotomy, flat bed rest may not be necessary and appears to be associated with higher costs and complications.
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Jesse CM, Schermann H, Goldberg J, Gallus M, Häni L, Raabe A, Schär RT. Risk Factors for Postoperative Cerebrospinal Fluid Leakage After Intradural Spine Surgery. World Neurosurg 2022; 164:e1190-e1199. [PMID: 35659588 DOI: 10.1016/j.wneu.2022.05.129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Well-defined risk factors for cerebrospinal fluid leakage (CSFL) after intradural spine surgery are scarce in the literature. The aim of the present study was to identify patient- and surgery-related risk factors and the incidence of CSFL. METHODS For the present retrospective cohort study, we identified consecutive patients who had undergone intradural spine surgery between 2009 and 2021 at our department. The primary endpoint was the incidence of clinically or radiologically proven CSFL. The effects of the clinical and surgical factors on the occurrence of CSFL were analyzed. RESULTS A total of 375 patients (60.3% women; mean age, 54 ± 16.5 years) were included. Of the 375 patients, 30 (8%) had experienced postoperative CSFL and, thus, a significantly greater risk of wound healing disorders (odds ratio [OR], 24.9; 95% confidence interval [CI], 9.3-66.7) and surgical site infections (OR, 8.4; 95% CI, 2.6-27.7; P < 0.01 for each). No patient-related factors were associated with the development of CSFL. Previous surgery at the index level correlated significantly with the occurrence of postoperative CSFL (OR, 2.76; 95% CI, 1.1-6.8; P = 0.03) on multivariate analysis. Furthermore, patients with intradural tumors tended to have a greater risk of CSFL (OR, 2.3; 95% CI, 0.9-5.8; P = 0.07). Surgery-related factors did not influence the occurrence of CSFL. Surgery on the thoracic spine had resulted in a significantly lower postoperative CSFL rate compared with surgery on the cervical or lumbar spine (OR, -2.5; 95% CI, 1.3-4.9; P = 0.02). CONCLUSIONS Our study found no modifiable risk factors for preventing CSFL after intradural spine surgery. Patients with previous surgery at the index level had a greater risk of CSFL. The occurrence of CSFL resulted in significantly more wound healing disorders and surgical site infections, necessitating further therapy.
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Affiliation(s)
- Christopher Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Helena Schermann
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Gallus
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ralph T Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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21
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Nielsen TH, Rasmussen MM, Thygesen MM. Incidence and risk factors for incidental durotomy in spine surgery for lumbar stenosis and herniated disc. Acta Neurochir (Wien) 2022; 164:1883-1888. [PMID: 35641649 DOI: 10.1007/s00701-022-05259-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/02/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Incidental durotomy (ID) is one of the most common complications in degenerative surgery. Due to the negative consequences of ID, knowledge about incidence and risk factors is warranted. METHODS A total of 1,139 surgical procedures for lumbar spinal stenosis (LS) and lumbar herniated disc (LDH) were included from the spine surgery database: DaneSpine. Uni- and multivariate analyses were performed for the assessment of possible risk factors. RESULTS ID occurred in 10.4% of the surgical procedures. A multivariate regression analysis revealed an increased relative risk of ID by 2% per year of age, 58% by revision surgery, and 55% by decompression on multiple levels. CONCLUSION In our single-centre cohort study, one in ten patients experiences an ID. Increasing age, revision surgery and decompression of multiple levels are risk factors of ID in degenerative surgery of the lumbar spine.
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Affiliation(s)
- Teresa Haugaard Nielsen
- Cense Spine, Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.
- Comparative Medicine Lab, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | | | - Mathias Møller Thygesen
- Cense Spine, Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Comparative Medicine Lab, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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22
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Can Cervical and Lumbar Epidural Blood Patches Help Avoid Revision Surgery for Symptomatic Postoperative Dural Tears? World Neurosurg 2022; 164:e877-e883. [PMID: 35605941 DOI: 10.1016/j.wneu.2022.05.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/13/2022] [Accepted: 05/14/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Incidental durotomies resulting in symptomatic postoperative cerebrospinal fluid (CSF) leaks can be treated with bedrest, subarachnoid lumbar drain, and surgical re-exploration. Another option is an epidural blood patch, which forms a clot over the dural tear in a minimally invasive manner. Our objective was to describe our center's outcomes and complications following epidural blood patches for symptomatic postoperative durotomies. METHODS Patients undergoing spine surgeries at one institution from 2012-2020 were included. Patient charts were reviewed for demographic information, surgical data, rate of dural tear, type of repair, and use of blood patches postoperatively. RESULTS A total of 1392 patients (726 male, 666 female, average age: 56.3 ± 15.4 years), including 436 cervical and 956 posterior thoracolumbar/lumbar spine surgeries were screened. There were 6 (1.4%) cervical, 64 (6.7%) lumbar, and a total of 70 (5.0%) patients with incidental dural tears/blebs. Of these patients, we identified 2 cervical and 8 lumbar spine patients with persistent CSF leaks who received epidural blood patches postoperatively. Nine of 10 (90%) had resolution of symptoms. One lumbar patient failed both an initial blood patch and subsequent surgical re-exploration, but had successful relief after a second blood patch. CONCLUSIONS The incidence of dural tears/blebs was 1.4% in cervical, 6.7% in lumbar, and 5.0% in all spine surgeries. Of the 10 patients with symptomatic CSF leaks, 9 were successfully treated with blood patches. Targeted epidural blood patch is effective in treating symptomatic CSF leaks and minimizes the morbidity of surgical re-exploration.
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Perez-Roman RJ, Bryant JP, Tapamo HJ, Luther E, Levene HB. Use of an External Ventricular Drain for Treatment of a Thoracolumbar Cerebrospinal Fluid Leak: A Case Report and Review of Literature. Cureus 2022; 14:e24066. [PMID: 35573571 PMCID: PMC9097466 DOI: 10.7759/cureus.24066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/05/2022] Open
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West JL, Abode-Iyamah K, Chen SG, Fox WC, Bydon M, Miller DA, Clendenen SR. Application of Color Doppler Ultrasound to Identify and Repair Postoperative Cerebrospinal Fluid Leak: A Technical Note. Oper Neurosurg (Hagerstown) 2022; 22:e12-e17. [PMID: 34982905 DOI: 10.1227/ons.0000000000000007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Incidental durotomy is a known complication of spinal surgery. Persistent cerebrospinal fluid (CSF) leak after unrecognized durotomy may lead to prolonged hospitalization and significant morbidity. If initial bed rest fails, the surgeon must choose between nontargeted methods such as oversewing the wound and lumbar drain placement or return to the operating room. OBJECTIVE To report the novel use of color flow doppler (CFD) in conjunction with ultrasound (US) to localize the point of CSF leak, assist with aspiration of the pseudomeningocele, and direct the application of fibrin sealant or epidural blood patch. METHODS This article includes a description of the technique as a technical note. RESULTS A 72-year-old man underwent L2-5 laminectomies for spinal stenosis. During the index operation, a durotomy occurred and was repaired primarily. The patient subsequently developed leg weakness, back pain, and bulging of the incision. Using CFD, the site of durotomy was determined. Under direct visualization, 34 mL of CSF was aspirated from the pseudomeningocele and 20 mL of fibrin sealant was placed opposing the durotomy. At 2-month follow-up, CFD confirmed absent flow and MRI demonstrated pseudomeningocele resolution. CONCLUSION This article represents the first report highlighting the utility of CFD US to guide epidural patch placement for postsurgical CSF leaks. CFD allows localization of the durotomy and direct application of blood or fibrin sealant, potentially increasing the success rate of epidural blood patch in postoperative patients. This approach is less invasive than revision surgery and does not require the prolonged hospitalization of lumbar drainage or other nontargeted interventions.
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Affiliation(s)
- James L West
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Selby G Chen
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Miller
- Division of Neuroradiology, Mayo Clinic, Jacksonville, Florida, USA
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Dural tear repair surgery comparative analysis: a stitch in time saves nine. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:575-595. [PMID: 34889999 DOI: 10.1007/s00586-021-07081-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/14/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE A dural tear is a common iatrogenic complication of spinal surgery associated with a several post-operative adverse events. Despite their common occurrence, guidelines on how best to repair the defect remain unclear. This study uses five post-operative outcomes to the compare repair methods used to treat 106 dural tears to determine which method is clinically favourable. METHODS Data were retrospectively collected from Southampton General Hospital's online databases. 106 tears were identified and grouped per repair method. MANOVA was used to compare the following five outcomes: Length of stay, numbers of further admissions or revision surgeries, length of additional admissions, post-operative infection rate and dural tear associated neurological symptoms. Sub-analysis was conducted on patient demographics, primary vs non-primary closure and type of patch. Minimal clinically important difference (MCID) was calculated via the Delphi procedure. RESULTS Age had a significant impact on patient outcomes and BMI displayed positive correlation with three-fifth of the predefined outcome measures. No significant difference was observed between repair groups; however, primary closure ± a patch achieved an MCID percentage improvement with regards to length of original stay, rate of additional admissions/surgeries and post-operative infection rate. Artificial over autologous patches resulted in shorter hospital stays, fewer readmissions, infections and neurological symptoms. CONCLUSION This study reports primary closure ± dural patch as the most efficient repair method with regards to the five reported outcomes. This study provides limited evidence in favour of artificial over autologous patches and recommends that dural patches be used in conjunction with primary closure. LEVEL OF EVIDENCE I Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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26
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Bailey D, Lehman M, Tuohy K, Ko E, Hatten S, Rizk E. The Impact of Surgical Scheduling on Outcomes in Lumbar Laminectomy. Cureus 2021; 13:e20272. [PMID: 35018266 PMCID: PMC8741263 DOI: 10.7759/cureus.20272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/25/2022] Open
Abstract
Objective The purpose of this study was to determine whether surgical scheduling affected patient outcomes following lumbar laminectomy. Physician fatigue caused by prolonged work hours has been shown to worsen outcomes. Previous research has also established a relationship between surgical scheduling and outcomes. Methods This was a retrospective chart review of single-level lumbar laminectomy patients at the Penn State Milton S. Hershey Medical Center between 1992 and 2019. Patients who underwent a one-level laminectomy between 1992 and 2019 were included in the study. Patients with procedures defined as complex (>1 level, tumor or abscess removal, discectomy, implant removal) were excluded. The surgical complication rate [cerebrospinal fluid (CSF) leak, 30-day redo, 30-day ED visit, weakness, sensation loss, infection, urinary retention] was compared across surgical start times, day of the week, proximity to a holiday, and procedure length. Results Procedures that started between 9:01-11:00 were more likely to have a complication than those between 7:01-9:00 (p=0.04). For every 60-min increase in surgery length, odds of having a complication increased by 2.01 times (p=0.0041). Surgeries that started between 11:01-13:00 had a significantly longer median surgery length than those between 7:01-9:00. Conclusion The time of the day when the procedure was started was predictive of worse outcomes following laminectomy. This may be attributed to several factors, including fatigue and staff turnover. Additionally, increased surgical length was predictive of more complications. It remains unclear whether increased surgical time results from correction of noticed errors or a fatigue-related decline in speed and performance. These findings on one-level laminectomy warrant further investigations since they have implications for reducing systemic failures that impact patient outcomes.
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Affiliation(s)
- David Bailey
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Morgan Lehman
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Kyle Tuohy
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Elizabeth Ko
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Steven Hatten
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Elias Rizk
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Aspalter S, Senker W, Radl C, Aichholzer M, Aufschnaiter-Hießböck K, Leitner C, Stroh N, Trutschnig W, Gruber A, Stefanits H. Accidental Dural Tears in Minimally Invasive Spinal Surgery for Degenerative Lumbar Spine Disease. Front Surg 2021; 8:708243. [PMID: 34355019 PMCID: PMC8330378 DOI: 10.3389/fsurg.2021.708243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background: One of the most frequent complications of spinal surgery is accidental dural tears (ADTs). Minimal access surgical techniques (MAST) have been described as a promising approach to minimizing such complications. ADTs have been studied extensively in connection with open spinal surgery, but there is less literature on minimally invasive spinal surgery (MISS). Materials and Methods: We reviewed 187 patients who had undergone degenerative lumbar spinal surgery using minimally invasive spinal fusions techniques. We analyzed the influence of age, Body Mass Index (BMI), smoking, diabetes, and previous surgery on the rate of ADTs in MISS. Results: Twenty-two patients (11.764%) suffered from an ADT. We recommended bed rest for two and a half to 5 days, depending on the type of repair required and the amount of cerebrospinal fluid (CSF) leakage. We could not find any statistically significant correlation between ADTs and age (p = 0.34,), BMI (p = 0.92), smoking (p = 0.46), and diabetes (p = 0.71). ADTs were significantly more frequent in cases of previous surgery (p < 0.001). None of the patients developed a transcutaneous CSF leak or post-operative infection. Conclusions: The frequency of ADTs in MISS appears comparable to that encountered when using open surgical techniques. Additionally, MAST produces less dead space along the corridor to the spine. Such reduced dead space may not be enough for pseudomeningocele to occur, cerebrospinal fluid to accumulate, and fistula to form. MAST, therefore, provides a certain amount of protection.
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Affiliation(s)
- Stefan Aspalter
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Wolfgang Senker
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Christian Radl
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Martin Aichholzer
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | | | - Clemens Leitner
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | | | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Harald Stefanits
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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West JL, De Biase G, Abode-Iyamah K, Nottmeier EW, Deen HG, Chen SG, Huynh T, Fox WC, Bydon M, Miller DA, Clendenen SR. Initial Results of Precision Treatment of Postoperative Cerebrospinal Fluid Leak with Ultrasound-Guided Epidural Blood Patch. World Neurosurg 2021; 153:e204-e212. [PMID: 34175483 DOI: 10.1016/j.wneu.2021.06.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Incidental durotomy, a known complication of spinal surgery, can lead to persistent cerebrospinal fluid leak and pseudomeningocele if unrecognized or incompletely repaired. We describe the use of ultrasound to visualize the site of durotomy, observe the aspiration of the pseudomeningocele, and guide the precise application of an ultrasound-guided epidural blood patch (US-EBP), under direct visualization in real time. METHODS A retrospective review was performed to determine demographic, procedural, and outcome characteristics for patients who underwent US-EBP for symptomatic postoperative pseudomeningocele. RESULTS Overall, 48 patients who underwent 49 unique episodes of care were included. The average age and body mass index were 60.5 (±12.6) years and 27.8 (±4.50) kg/m2, respectively. The most frequent index operation was laminectomy (24.5%), and 36.7% of surgeries were revision operations. Durotomy was intended or recognized in 73.4% of cases, and the median time from surgery to symptom development was 7 (interquartile range 4-16) days. A total of 61 US-EBPs were performed, with 51.0% of patients experiencing resolution of their symptoms after the first US-EBP. An additional 20.4% were successful with multiple US-EBP attempts. Complications occurred in 14.3% of cases, and the median clinical follow-up was 4.3 (interquartile range 2.4-14.5) months. CONCLUSIONS This manuscript represents the largest series in the literature describing US-EBP for the treatment of postoperative pseudomeningocele. The success rate suggests that routine utilization of US-guided EBP may allow for targeted treatment of pseudomeningoceles, without the prolonged hospitalization associated with lumbar drains or the risks of general anesthesia and impaired wound healing associated with surgical revision.
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Affiliation(s)
- James L West
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Gaetano De Biase
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Eric W Nottmeier
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - H Gordon Deen
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Selby G Chen
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Thien Huynh
- Division of Neuroradiology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Miller
- Division of Neuroradiology, Mayo Clinic, Jacksonville, Florida, USA
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Alshameeri ZAF, Jasani V. Risk Factors for Accidental Dural Tears in Spinal Surgery. Int J Spine Surg 2021; 15:536-548. [PMID: 33986000 DOI: 10.14444/8082] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Accidental dural tears (DTs) are familiar complications of spinal surgery. Their reported incidence varies widely, and several risk factors have been proposed in the literature. The aim of this study was to conduct a systematic review and meta-analysis to determine the rate of DTs and assess their associated risk factors. METHODS A systematic literature search was conducted using specific MeSH and Text terms. Only articles with prospective data reporting the incidence and risk factors were selected and reviewed based on specific inclusion and exclusion criteria. RESULTS Twenty-three studies were included. The reported incidence rate ranged from 0.4% to 15.8%, giving an overall pooled incidence rate of 5.8% (95% confidence interval [CI] 4.4-7.3). The incidence rate varied in relation to the part of the spine and the type of surgery. Three factors were associated with a high rate of DTs: age (overall mean difference of 3.04, 95% CI 2.49-3.60), revision surgery (overall odds ratio of 2.28, 95% CI 1.84-2.83), and lumbar stenosis (overall odds ratio of 2.03, 95% CI 1.50-2.75). Diabetes was weakly associated with DTs, with an odds ratio of 1.40 (95% CI 1.01-1.93). The overall effects of sex and obesity were not statistically significant. CONCLUSION Advancing age, revision surgery, and lumbar stenosis were significantly associated with increased risk of DTs. These factors should be taken into consideration during the consenting process for spinal surgery. CLINICAL RELEVANCE Risk of dural tear during spine surgery.
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Affiliation(s)
- Zeiad A F Alshameeri
- University Hospital of North Midlands, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Vinay Jasani
- University Hospital of North Midlands, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
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Wach J, Yildiz ÖC, Sarikaya-Seiwert S, Vatter H, Haberl H. Predictors of postoperative complications after selective dorsal rhizotomy. Acta Neurochir (Wien) 2021; 163:463-474. [PMID: 32691268 DOI: 10.1007/s00701-020-04487-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/06/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy (CP). We analyzed potential preoperative predictors of complications after SDR via single-level laminectomy at the conus medullaris. METHODS One hundred and forty SDRs performed in children (2-17 years) with CP were included in this retrospective study (March 2016 to July 2019). Of these children, 69% were ambulatory (Gross Motor Functional Classification System (GMFCS) II and III). Variables associated with wound dehiscence and infections, cerebrospinal fluid (CSF) leaks, and prolonged epidural pain management were analyzed statistically. RESULTS Five children (3.6%) showed prolonged wound healing, which was associated with obesity (BMI z-score ≥ 1.64; odds ratio (OR) 24.4; 95% confidence interval (CI) 3-199; p = 0.003). Two cases (1.4%) had superficial surgical site infections (SSIs), which was associated with obesity (p = 0.004) and thrombocytopenia (< 180,000 G/l; p = 0.028). The area under the curve at ≥ 1.55 BMI z-score for SSI was 0.97 (95% CI 0.93-0.99, p = 0.024), with a sensitivity and specificity for SSI of 100 and 94.9%, respectively. CSF leaks occurred in four (2.9%) children, associated with age ≤ 5 years (p = 0.029). Fifteen (10.7%) children required prolonged (4-5 days) epidural pain treatment, which was associated with non-ambulatory GMFCS levels (IV and V) (OR 3.6; 95% CI 1.2-10.8; p = 0.008). CONCLUSIONS SDR is safe for all GMFCS levels. Obesity predicts prolonged wound healing and SSI. Prolonged pain management via epidural pain catheter is safe, but care should be taken with non-ambulatory children.
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Affiliation(s)
- Johannes Wach
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany.
| | - Ömer Can Yildiz
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| | - Sevgi Sarikaya-Seiwert
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| | - Hannes Haberl
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
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Dural Leak: Is It Deterrent to Outcomes in Spine Surgery?: 10 Years Retrospective Analysis of Incidence, Management Protocol, and Surgical Outcomes. Spine (Phila Pa 1976) 2020; 45:E1615-E1621. [PMID: 32833929 DOI: 10.1097/brs.0000000000003662] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVES To review the incidence of dural leaks, evaluate the efficacy of primary closure of durotomy and to study its effect on clinical outcome. The secondary aim is to classify the dural leaks and proposing a treatment algorithm for dural leaks. SUMMARY OF BACKGROUND DATA Dural leaks are described as one of the fearful complications in spine surgery. Literature evaluating the actual incidence, ideal treatment protocol, efficacy of primary repair techniques and its effects on long-term surgical outcomes are scanty. METHODS It was a retrospective analysis of 5390 consecutively operated spine cases over a period of 10 years. All cases were divided into two groups-study group (with dural leak-255) and control group (without dural leak-5135). Dural leaks were managed with the proposed treatment algorithm. Blood loss, surgical time, hospital stay, time for return to mobilization, pain free status, and clinical outcome score (ODI, VAS, NDI, and Wang criteria) were assessed in both groups at regular intervals. The statistical comparison between two groups was established with chi-square and t-tests. RESULTS The overall incidence of dural leaks was 4.73% with highest incidence in revision cases (27.61%). There was significant difference noted in mean surgical blood loss (P 0.001), mean hospital stay (P 0.001), time to achieve pain-free status after surgery, and return to mobilization between two groups. However, no significant difference was noted in operative time (P 0.372) and clinical outcome scores at final follow-up between the two groups. CONCLUSION Primary closure should be undertaken in all amenable major dural leak cases. Dural leaks managed as proposed by the author's treatment algorithm have shown a comparable clinical outcome as in patients without dural leaks. Dural leak is a friendly adverse event that does not prove a deterrent to long-term clinical outcome in spine surgeries. LEVEL OF EVIDENCE 4.
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Vinas-Rios JM, Rauschmann M, Medina-Govea F, Sellei R, Sobotke R, Arabmotlagh M. There is no difference in perioperative results between posterior instrumentation with and without interbody cage and debridement in primary spondylodiscitis in adults. A multicenter surveillance study from the German Spine Registry (DWG-Register). J Neurosurg Sci 2020; 66:187-192. [PMID: 32909418 DOI: 10.23736/s0390-5616.19.04869-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Primary spondylodiscitis is a medically challenging disease that can lead to recurrent back pain, progressive kyphotic deformity, and neurologic deficits. The incidence rate of primary non-tuberculosis spondylodiscitis has been estimated from 2.2 to 2.4 cases per 100,000 person-years, and it has been reported to be increasing because of the aging population. The objectives were to determine the safety and efficacy of posterior instrumentation (PI) with and without interbody cage, bony attachment and debridement in the treatment of primary spondylodiscitis by comparing perioperative data, functional outcomes, and overall infection-free survival. METHODS Analysis of data from the DWG registry on patients who have undergone posterior instrumentation with and without interbody cage, bony attachment and debridement in primary spondylodiscitis from the thoracolumbar junction to S1 (Th10-S1) at 10 institutions from January 2012 to December 2016. RESULTS In total, 420 posterior instrumentations with and without interbody cage, bony attachment and debridement in primary spondylodiscitis in the thoracolumbar junction to S1 were identified in the registry; n=138 were exclusively percutaneous posterior instrumented (PPI), while n=102 underwent open posterior instrumentation (OPI) without interbody cage, bony attachment and debridement and n=180 OPI with interbody cage, bony attachment and debridement. Clinical evaluation after surgery did not show a significant difference between groups including improvement of the mbilisation and infection-free survival. However, with PPI the duration of operation and blood loss was significantly less than OPI with and without interbody cage, bony attachment and debridement. CONCLUSIONS The results suggest interbody cage, bony attachment and debridement as not indispensable for treatment in primary spondylodiscitis. Therefore, we encourage the use of posterior stabilization alone in the treatment of spondylodiscitis as less invasive procedure reducing costs in instrumentation.
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Affiliation(s)
- Juan M Vinas-Rios
- Department of Spine Surgery Sanaklinik, Offenbach am Main, Germany -
| | | | - Fatima Medina-Govea
- Department of Epidemiology, Faculty of Medicine UASLP, San Luis Potosi, Mexico
| | - Richard Sellei
- Department of Traumatology Sanaklinik, Offenbach am Main, Germany
| | - Rolf Sobotke
- Department of Spine Surgery, Rhein-Maas Clinic, Aachen, Germany
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Incidental Durotomy During Endoscopic Stenosis Lumbar Decompression: Incidence, Classification, and Proposed Management Strategies. World Neurosurg 2020; 139:e13-e22. [DOI: 10.1016/j.wneu.2020.01.242] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/13/2022]
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Occurrence of multidrug-resistant tuberculous meningitis associated with injury during spinal surgery: A case report. J Infect Public Health 2020; 13:1586-1588. [PMID: 32554033 DOI: 10.1016/j.jiph.2020.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 05/01/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022] Open
Abstract
Here we describe a case of multidrug-resistant tuberculous meningitis associated with injury inflicted during spinal surgery. A 54-year-old man was diagnosed with multidrug-resistant spinal tuberculosis (TB). Anterior debridement and fusion with posterior fusion and instrumentation were conducted to remove damaged bone and TB-associated granulomatous tissue. After surgical decompression, a lancet wound (about 5mm in length) was discovered in the cerebral dura mater at the L3 position of the vertebral body. At four weeks post-surgery, the patient experienced fever, hemiparesis, and aphasia. Cerebrospinal fluid (CSF) findings were consistent with TB meningitis, while in vitro susceptibility test results confirmed that the patient had multidrug-resistant TB. Our data highlight a possible TBM infection associated with a surgical lesion in a spinal TB patient. Rapid molecular diagnostics are urgently needed to formulate efficacious regimens for treating these patients.
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Kulkarni AG, Tapashetti S, Patel PM. Use of Zipper Ratcheting Straps as a Bailout for Postoperative Cerebrospinal Fluid Leaks: Our Experience. Global Spine J 2020; 10:443-447. [PMID: 32435565 PMCID: PMC7222682 DOI: 10.1177/2192568219860463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Technical note. OBJECTIVES Management of postoperative cerebrospinal fluid (CSF) leaks is a challenge. Reexploration increases the morbidity risks. The main objective was to evaluate the outcomes of noninvasive zipper-like system (Zip surgical skin closure system, ZipLine Medical, Inc, Campbell, CA, USA) as a bailout technique for postoperative CSF leaks. METHODS Retrospective case series. Consecutive patients with postoperative CSF leaks that occurred secondary to spinal surgeries performed between January 2017 and September 2018 were part of the study. All these patients were managed conservatively by reinforcement with zipper ratcheting straps over the sutured surgical wound. Successful clinical outcomes included cessation of CSF leaks and adequate wound healing in the postoperative period and at follow-up. RESULTS Ten patients underwent the application of zipper ratcheting straps. The mean follow-up was 6 months (range 6 months to 1 year). In 7 cases, the dural tears were recognized postoperatively and in 3 cases, the tears were noted intraoperatively and repaired and reinforced with fibrin sealants. None of the patients developed wound soakage or subsequent CSF leak from the wound after the application of zipper ratcheting straps. CONCLUSIONS Zipper ratcheting straps as augmentation to sewing of the wound seem to be a good alternative and bailout in treating patients with postoperative CSF leaks. The ease of its application, the ability in minimizing the complications associated with CSF leaks, and negating the need of surgical reexploration makes it a worthy option.
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Affiliation(s)
- Arvind G. Kulkarni
- Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India,Arvind G. Kulkarni, Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai 400020, Maharashtra, India.
| | | | - Priyank M. Patel
- Lilavati Hospital, Mumbai, Maharashtra, India,Jupiter Hospital, Mumbai, Maharashtra, India,Breach Candy Hospital, Mumbai, Maharashtra, India
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Kim SK, Park SW, Lim BC, Lee SC. Comparison of Reoperation after Fusion and after Decompression for Degenerative Lumbar Spinal Stenosis: A Single-Center Experience of 987 Cases. J Neurol Surg A Cent Eur Neurosurg 2020; 81:392-398. [PMID: 32361983 DOI: 10.1055/s-0040-1709164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND STUDY AIM Reoperation for lumbar spinal stenosis (LSS) is technically challenging. Studies comparing preoperative risk factors and reoperation outcomes between spinal fusion and spinal decompression are limited. Thus this study compared fusion and decompression with respect to reoperation rates, preoperative factors related to re-surgery, and clinical outcomes. PATIENTS AND METHODS This retrospective cohort study included prospectively collected data from patients who underwent revision surgeries for degenerative LSS between May 2001 and March 2015. The reoperation rate, risk factors (proportional hazards analysis of index surgery), surgery type, main reason for revision, and final clinical outcomes (pain, quality-of-life modification, patient satisfaction, and complication rate) were analyzed and compared between the fusion and decompression surgeries. RESULTS Among 987 cases during 13 years, 25 cases of reoperation after fusion and 23 cases of reoperation after decompression were identified, accounting for reoperation rates of 5.88% and 4.00%, respectively. Combined comorbidities (hazard ratio [HR]: 1.98 for fusion; multilevel involvement [with fusion, HR: 2.92; decompression, HR: 1.95]) were strongly correlated with preoperative demographic risk factor for each procedure. The main reason for reoperation in fusion cases was proximal junctional kyphosis (40%) and implant failure (20%), and in decompression cases, recurrent lesions (48.8%) and incomplete surgery (17.4%) An additional fusion after initial fusion and re-decompression without fusion after initial decompression were the most common surgical procedure. Back pain and patient satisfaction after fusion were better compared with those after decompression. CONCLUSION The reoperation rate, preoperative risk factors, reason for revision, reoperation type, clinical outcomes, patient satisfaction, and time interval between index and re-surgery were different between the primary fusion and primary decompression. A better understanding of disease pathophysiology and surgical procedure characteristics will facilitate improvement in disease management and the development of treatment strategies.
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Affiliation(s)
- Seung-Kook Kim
- Himchan UHS Spine and Joint Centre, University Hospital Sharjah, Sharjah, United Arab Emirates.,Department of Pharmaceutical Medicine and Regulatory Sciences, College of Medicine and Pharmacy, Yonsei University, Incheon, Korea.,Joint and Arthritis Research, Orthopaedic Surgery, Himchan Hospital, Seoul, Korea
| | - Seoung-Woo Park
- Department of Neurosurgery, College of Medicine, Graduate School, Kangwon National University, Chuncheon, Korea
| | - Byun-Chul Lim
- Department of Neurosurgery, College of Medicine, Graduate School, Kangwon National University, Chuncheon, Korea
| | - Su-Chan Lee
- Joint and Arthritis Research, Orthopaedic Surgery, Himchan Hospital, Seoul, Korea
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Saiwai H, Okada S, Hayashida M, Harimaya K, Matsumoto Y, Kawaguchi KI, Kobayakawa K, Maeda T, Ohta H, Shirasawa K, Tsuchiya K, Terada K, Kaji K, Arizono T, Saito T, Fujiwara M, Iwamoto Y, Nakashima Y. Surgery-related predictable risk factors influencing postoperative clinical outcomes for thoracic myelopathy caused by ossification of the posterior longitudinal ligament: a multicenter retrospective study. J Neurosurg Spine 2020; 32:703-709. [PMID: 31881534 DOI: 10.3171/2019.10.spine19831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Compression of the spinal cord by thoracic ossification of the posterior longitudinal ligament (T-OPLL) often causes severe thoracic myelopathy. Although surgery is the most effective treatment for T-OPLL, problems associated with surgical intervention require resolution because surgical outcomes are not always favorable, and a small number of patients experience deterioration of their neurological status after surgery. The aim of the present study was to examine the surgery-related risk factors contributing to poor clinical outcomes for myelopathy caused by T-OPLL. METHODS Data were extracted from the records of 55 patients with thoracic myelopathy due to T-OPLL at institutions in the Fukuoka Spine Group. The mean follow-up period was 5.3 years. Surgical outcomes were assessed using the Japanese Orthopaedic Association (JOA) scale. To investigate the definitive factors associated with surgical outcomes, univariate and multivariate regression analyses were performed with several patient-related and surgery-related factors, including preoperative comorbidities, radiological findings, JOA score, surgical methods, surgical outcomes, and complications. RESULTS Neurological status improved in 33 patients (60.0%) and deteriorated in 10 patients (18.2%) after surgery. The use of instrumentation was significantly associated with an improved outcome. In the comparison of surgical approaches, posterior decompression and fusion resulted in a significantly higher neurological recovery rate than did anterior decompression via a posterior approach and fusion or decompression alone. It was also found that postoperative neurological status was significantly poorer when there were fewer instrumented spinal levels than decompression levels. CSF leakage was a predictable risk factor for deterioration following surgery. CONCLUSIONS It is important to identify preventable risk factors for poor surgical outcomes for T-OPLL. The findings of the present study suggest that intraoperative CSF leakage and a lower number of instrumented spinal fusion levels than decompression levels were exacerbating factors for the neurological improvement in T-OPLL surgery.
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Affiliation(s)
- Hirokazu Saiwai
- 1Department of Orthopedic Surgery, Graduate School of Medical Sciences
| | - Seiji Okada
- 1Department of Orthopedic Surgery, Graduate School of Medical Sciences
- 2Department of Immunobiology and Neuroscience, Medical Institute of Bioregulation, Kyushu University, Fukuoka
| | | | - Katsumi Harimaya
- 3Department of Orthopedic Surgery, Kyushu University Beppu Hospital, Oita
| | | | | | - Kazu Kobayakawa
- 4Department of Orthopedic Surgery, Spinal Injuries Center, Fukuoka
| | - Takeshi Maeda
- 4Department of Orthopedic Surgery, Spinal Injuries Center, Fukuoka
| | | | | | - Kuniyoshi Tsuchiya
- 7Department of Orthopedic Surgery, Japan Community Health Care Organization, Kyushu Hospital, Fukuoka
| | - Kazumasa Terada
- 8Department of Orthopedic Surgery, National Hospital Organization, Kyushu Medical Center, Fukuoka
| | - Kouzo Kaji
- 9Department of Orthopedic Surgery, Kyushu Rosai Hospital, Fukuoka
| | - Takeshi Arizono
- 10Department of Orthopedic Surgery, Kyushu Central Hospital, Fukuoka
| | - Taichi Saito
- 11Department of Orthopedic Surgery, Fukuoka City Hospital, Fukuoka; and
| | - Masami Fujiwara
- 12Department of Orthopedic Surgery, Sada Hospital, Fukuoka, Japan
| | - Yukihide Iwamoto
- 9Department of Orthopedic Surgery, Kyushu Rosai Hospital, Fukuoka
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Alshameeri ZAF, El-Mubarak A, Kim E, Jasani V. A systematic review and meta-analysis on the management of accidental dural tears in spinal surgery: drowning in information but thirsty for a clear message. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1671-1685. [DOI: 10.1007/s00586-020-06401-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/21/2020] [Accepted: 03/28/2020] [Indexed: 12/29/2022]
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Tonic-clonic seizures as a possible complication for cerebrospinal fluid leakage after intradural spinal surgery, a case report. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Koyama T, Sugita S, Hozumi T, Fujiwara M, Yamakawa K, Okuma T, Goto T. Incidence of Unrecognized Incidental Durotomy during Surgery for Malignant Spinal Tumor. Spine Surg Relat Res 2019; 4:159-163. [PMID: 32405563 PMCID: PMC7217675 DOI: 10.22603/ssrr.2019-0081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/03/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction Cerebral spinal fluid leak from durotomy is a well-known risk with spinal surgeries. The aim of this study is to identify the incidence of unrecognized incidental durotomy during posterior surgery for spinal metastases and its risk factors. Methods Participants comprised 75 patients who underwent posterior spine surgery for spinal metastases between January 2012 and December 2016. Cases with apparent durotomy noticed intraoperatively were excluded. Unrecognized durotomy was diagnosed as the presence of wide subcutaneous fluid retention on magnetic resonance imaging at least 3 months postoperatively. For comparison, 50 patients who underwent cervical laminoplasty due to cervical spondylotic myelopathy were examined using the same method. We also examined correlations between occurrence of durotomy and patient characteristics such as age, type of tumor, location of tumor (ventral or dorsal), extent of tumor, and history of radiotherapy before surgery. Results Unrecognized durotomy occurred in 21 cases of spinal metastasis (26.7%) and in 1 case of cervical spondylotic myelopathy (2%), representing a significant difference between groups. Age, type of tumor, location of tumor, extent of tumor, and history of radiotherapy before surgery did not correlate significantly with occurrence of durotomy. No local trouble was observed in durotomy cases, except in one case with subcutaneous local infection. Conclusions The incidence of unrecognized incidental durotomy is significantly higher during surgery for spinal metastases than that during surgery for degenerative disease.
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Affiliation(s)
- Takuma Koyama
- Department of Orthopaedic Surgery and Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Shurei Sugita
- Department of Orthopaedic Surgery and Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Takahiro Hozumi
- Department of Orthopaedic Surgery and Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Masanori Fujiwara
- Department of Orthopaedic Surgery and Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kiyofumi Yamakawa
- Department of Orthopaedic Surgery and Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Tomotake Okuma
- Department of Orthopaedic Surgery and Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Takahiro Goto
- Department of Orthopaedic Surgery and Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
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Vinas-Rios JM, Rauschmann M, Sellei R, Sanchez-Rodriguez JJ, Meyer F, Arabmotlagh M. Invasiveness has no influence on the rate of incidental durotomies in surgery for multisegmental lumbar spinal canal stenosis (≥ 3 levels) with and without fusion. Analysis from the German Spine Registry data (DWG-Register). J Neurosurg Sci 2019; 66:79-84. [PMID: 31601067 DOI: 10.23736/s0390-5616.19.04807-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Nowadays, perioperative complications as dural tear (DT) with subsequent neurological deficits are documented in independent registers. However, the relationship of these complications with the grade of invasiveness (≥3 levels) is still unclear. We attempted to evaluate perioperative complications, particularly DT with subsequent neurological deficits, between patients undergoing laminotomy and decompression and decompression and fusion in ≥3 levels. METHODS Retrospective analysis of the data pool of the DWG register based on cases described by 10 clinics between January 2012 and December 2016 was performed. Surgically treated LSS in ≥3 segments were divided into decompression with or without instrumentation and fusion. Cases with intraoperative DT in both subgroups were analysed for risk factor occurrence. The Surgical Invasive Index (SII) was used. RESULTS DT occurred in 102/941 (10.8%) patients. Difference in DT between groups was non- significant. The likelihood of DT increased by 2.12-fold with previous spinal surgery at the same level and by 1.9-fold for BMI 30-34 and >35 in comparison with BMI 26-29, respectively. Postoperative deep wound infection was increased by 2.39-fold after DT than without. Significance in outcomes between patients with/without DT was not found. The invasiveness index explained 48% of the variation in blood loss and 51% of the variation in surgery duration. CONCLUSIONS The rate of incidental DT during decompression for LSS with and without fusion in ≥3 levels was associated with BMI and previous surgery at the same spinal level. Invasivness (SII) is valid rather for variables proper to surgery such as bledding and Op-time but no with incidence for DT and subsequent CSF-leackage.
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Affiliation(s)
| | | | - Richard Sellei
- Department of Traumatology, Sanaklinik, Offenbach am Main, Germany
| | | | - Frerk Meyer
- Department of Spine Surgery, University Clinic for Neurosurgery, Evangelisches Krankenhaus, Oldenburg, Germany
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Kinaci A, Moayeri N, van der Zwan A, van Doormaal TPC. Effectiveness of Sealants in Prevention of Cerebrospinal Fluid Leakage after Spine Surgery: A Systematic Review. World Neurosurg 2019; 127:567-575.e1. [PMID: 30928579 DOI: 10.1016/j.wneu.2019.02.236] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/26/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Sealants are often used in spine surgery to prevent postoperative cerebrospinal fluid (CSF) leakage. OBJECTIVE To investigate the efficacy of sealants in preventing postoperative CSF leakage in spine surgery. METHODS The PubMed, Embase, and Cochrane databases were searched for articles reporting the outcome of patients treated with a sealant for spinal dural repair. The number of patients, indication of surgery, surgical site, applied technique, type of sealant used, and outcome in terms of postoperative CSF leakage were noted for each study. The primary outcome was CSF leakage in general and secondary outcome infection. RESULTS Forty-one articles were selected with a total of 2542 cases; there were 4 comparative studies with 540 sealed cases and 343 cases with primary suture closure only. The quantity of CSF leakage did not differ between the sealant group (50 of 540, 9.1%) and the group treated with sutures only (48 of 343, 13.8%) (risk ratio [RR], 0.58 [confidence interval [CI], 0.18-1.82]). The infection rate did also not differ between the sealant and primary suture groups (RR, 0.94 [CI, 0.55-1.61]). This result was found in both the intended and the unintended durotomy subgroups. Secondary analysis of all cases showed that endoscopic or minimally invasive surgery had lower CSF leakage rates compared with open surgery regardless of sealant use (RR, 0.18 [CI, 0.05-0.75]). CONCLUSIONS Currently available sealants seem not to reduce the rate of CSF leakage in spine surgery. In endoscopic and minimally invasive surgery, the CSF leakage rate is less frequent compared with open, conventional surgery regardless of sealant use.
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Affiliation(s)
- Ahmet Kinaci
- Department of Neurology and Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands; Brain Technology Institute, Utrecht, The Netherlands.
| | - Nizar Moayeri
- Department of Neurology and Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Albert van der Zwan
- Department of Neurology and Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands; Brain Technology Institute, Utrecht, The Netherlands
| | - Tristan P C van Doormaal
- Department of Neurology and Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
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Barber SM, Fridley JS, Konakondla S, Nakhla J, Oyelese AA, Telfeian AE, Gokaslan ZL. Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:217. [PMID: 31297382 DOI: 10.21037/atm.2019.01.04] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.
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Affiliation(s)
- Sean M Barber
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jared S Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Sanjay Konakondla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jonathan Nakhla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
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Buchanan IA, Min E, Pham MH, Donoho DA, Bakhsheshian J, Minneti M, Zada G, Giannotta SL, Hsieh PC, Liu JC. Simulation of Dural Repair in Minimally Invasive Spine Surgery With the Use of a Perfusion-Based Cadaveric Model. Oper Neurosurg (Hagerstown) 2019; 17:616-621. [DOI: 10.1093/ons/opz041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/14/2019] [Indexed: 01/22/2023] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
In an era of curtailed work hours and concerns over achieving technical proficiency in the repertoire of procedures necessary for independent practice, many residencies have turned to model simulation as an educational adjunct. Cerebrospinal fluid (CSF) leak repair after inadvertent durotomy in spine surgery is a fundamental skillset for any spine surgeon. While primary closure with suture is not always necessary for small durotomies, larger defects, on the other hand, must be repaired. However, the dire consequences of inadequate repair dictate that it is generally performed by the most experienced surgeon. Few intraoperative opportunities, therefore, exist for CSF leak repair by trainees.
OBJECTIVE
To simulate dural repair in spine surgery using minimal-access techniques.
METHODS
A cohort of 8 neurosurgery residents was evaluated on their durotomy repair efforts in a perfusion-based cadaveric model.
RESULTS
Study participants demonstrated consistent improvement across trials, with a significant reduction in closure times between their initial (12 min, 7 sec ± 4 min, 43 sec) and final attempts (7 min, 4 sec ± 2 min, 6 sec; P = .02). Moreover, all trainees—irrespective of postgraduate year—were able to accomplish robust dural closures resistant to simulated Valsalva maneuvers. Participants reported high degrees of model realism and exhibited significant increases in postprocedure confidence scores.
CONCLUSION
Our results support use of perfusion-based simulation models as a complement to neurosurgery training, as it affords unrestricted opportunities for honing psychomotor skillsets when resident learning is increasingly being challenged by work-hour limitations and stricter oversight in the context of value-based healthcare.
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Affiliation(s)
- Ian A Buchanan
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elliot Min
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Martin H Pham
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Daniel A Donoho
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael Minneti
- Department of General Surgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steven L Giannotta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Patrick C Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - John C Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Nagel SJ, Helland L, Woodroffe RW, Frizon LA, Holland MT, Machado AG, Yamaguchi S, Gillies GT, Howard MA, Wilson S. Durotomy Surrogate and Seals for Intradural Spinal Cord Stimulators: Apparatus and Review of Clinical Methods and Materials. Neuromodulation 2019; 22:916-929. [DOI: 10.1111/ner.12913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/14/2018] [Accepted: 11/14/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Sean J. Nagel
- Neurological SurgeryCleveland Clinic Cleveland, OH USA
| | - Logan Helland
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | - Royce W. Woodroffe
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | | | - Marshall T. Holland
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | | | - Satoshi Yamaguchi
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | - George T. Gillies
- Department of Mechanical and Aerospace EngineeringUniversity of Virginia Charlottesville VA USA
| | - Matthew A. Howard
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
| | - Saul Wilson
- Department of NeurosurgeryUniversity of Iowa Hospitals and Clinics Iowa City IA USA
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Cerebrospinal Fluid Leak and Symptomatic Pseudomeningocele After Intradural Spine Surgery. World Neurosurg 2018; 120:e497-e502. [DOI: 10.1016/j.wneu.2018.08.112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 11/24/2022]
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Faltings L, Kulason KO, Du V, Schneider JR, Chakraborty S, Kwan K, Pramanik B, Boockvar J. Early Epidural Blood Patch to Treat Intracranial Hypotension after Iatrogenic Cerebrospinal Fluid Leakage from Lumbar Tubular Microdiscectomy. Cureus 2018; 10:e3633. [PMID: 30705792 PMCID: PMC6349568 DOI: 10.7759/cureus.3633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Management of cerebrospinal fluid (CSF) leak during minimally invasive lumbar tubular microdiscectomy poses challenges unique to the surgical approach. Primary repair can be limited via tubular retractor systems, and onlay graft and dural sealant are often the treatment of choice intraoperatively. Postoperative persistent CSF leak may lead to intracranial hypotension (IH) and positional headaches. Early epidural blood patch (EBP) efficacy in the treatment of spinal CSF leaks of both spontaneous and iatrogenic origin is well-established in numerous studies. However, there is no consensus on treatment of persistent IH symptoms for patients undergoing lumbar tubular microdiscectomy. We describe the clinical courses of two patients who were treated with early EBP for IH symptoms following CSF leak during tubular microdiscectomy. Both patients underwent intraoperative repair with onlay autologous tissue graft followed by dural sealant after discectomy was completed without evidence of pseudomeningocele, but they developed postoperative positional headaches and presumed IH. Both patients received an early EBP with an immediate and complete resolution of positional headaches sparing them reoperation and/or lumbar drainage. EBP should be considered as a first-line treatment to treat postoperative IH symptoms without pseudomeningocele after iatrogenic CSF leak during tubular microdiscectomy.
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Affiliation(s)
- Lukas Faltings
- Neurosurgery, Brain Tumor Center, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, USA
| | - Kay O Kulason
- Neurosurgery, Brain Tumor Center, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, USA
| | - Victor Du
- Neurosurgery, Zucker School of Medicine at Hofstra / Northwell, Hempstead, USA
| | - Julia R Schneider
- Neurosurgery, Brain Tumor Center, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, USA
| | - Shamik Chakraborty
- Neurosurgery, Brain Tumor Center, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, USA
| | - Kevin Kwan
- Neurosurgery, Zucker School of Medicine at Hofstra / Northwell, Hempstead, USA
| | - Bidyut Pramanik
- Radiology, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, USA
| | - John Boockvar
- Neurosurgery, Brain Tumor Center, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, USA
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Sahu RN, Sardhara J, Singh AK, Sahu S, Chovatiya P, Srivastava AK, Jaiswal AK, Mehrotra A, Das KK, Bhaisora KS, Behari S. Efficacy of Double Drug Impregnated Autologous Coagulum Patch versus Single Drug Impregnated Autologous Coagulum Patch in Postoperative Pain Management after Spinal Surgery. Asian J Neurosurg 2018; 13:614-618. [PMID: 30283513 PMCID: PMC6159060 DOI: 10.4103/ajns.ajns_224_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Postoperative pain and cerebrospinal fluid (CSF) leak are common known complications of spinal surgery, both having a synergistic effect on each other. Thus, both need to be dealt simultaneously. Double drug impregnated autologous coagulum patch (DDIAC) is a novel method which reduced both incidences of postoperative CSF leaks as well as pain. Methodology: Twenty-seven patients undergoing lumbar disc surgery without instrumentation were included and randomized into DDIAC and single drug impregnated autologous coagulum patch (SDIAC) group. The patients were assessed postoperatively with visual analog scale (VAS). Results: There were 21 males and 6 females in the study. Seventeen (63%) patients got randomized for DDIAC patch application and other 10 (37%) patients entered the control arm group (SDIAC) patch use. Preoperative VAS was 5 in both the groups. The average postoperative VAS was 3.01 in DDIAC arm and 4.29 in control arm. The average analgesic shot required in the DDIAC group was 0.41 in 24 h and SDIAC group was 4.1 in 24 h. In DDIAC group, none of these patients had CSF leak from the surgical wound till discharge from the hospital. In the SDIAC group, one (10%, n = 10) patient had CSF leak. Conclusions: DDIAC patch was effective in controlling pain in the postoperative period; however, few patients may require analgesic shots for pain management. SDIAC patch may control some pain in the immediate postoperative period; however, this was not sufficient for a longer postoperative period.
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Affiliation(s)
| | - Jayesh Sardhara
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Amit Kumar Singh
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Sandeep Sahu
- Department of Anaesthesia, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Puja Chovatiya
- Department of Anaesthesia, Dr. Ram Manohar Lohia Combined Hospital, Lucknow, Uttar Pradesh, India
| | | | | | - Anant Mehrotra
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | - Sanjay Behari
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
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Pflugmacher R, Franzini A, Horovitz S, Guyer R, Ashkenazi E. Suitability of Administrative Databases for Durotomy Incidence Assessment: Comparison to the Incidence Associated With Bone-Removal Devices, Calculated Using a Systemic Literature Review and Clinical Data. Int J Spine Surg 2018; 12:498-509. [PMID: 30276111 DOI: 10.14444/5061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Durotomy is a major complication of spinal surgery, potentially leading to additional clinical complications, longer hospitalization, and increased costs. A reference durotomy incidence rate is useful for the evaluation of the safety of different surgical aspects. However, the literature offers a wide range of incidence rates, complicating this comparison. Theoretically, a reference incidence value can be extracted from administrative databases, containing a large number of procedures. However, it is suspected that these databases suffer from underreporting of complications. This study aims to evaluate durotomy incidence using several large-scale databases and to assess the ability to use it as a reference by comparison to durotomy incidences directly associated with 4 bone removal devices, including the commonly used high-speed drill. Methods Durotomy overall incidence was estimated from several administrative databases using different methods in order to achieve minimal and maximal estimations. Durotomy incidences for 3 bone removal devices were derived using literature meta-analysis, and the incidence for the fourth device was calculated using clinical data. Results The incidence range of durotomy according to the databases was 2.8-3.5%. The calculated incidence of durotomy for the studied devices was 0.4-2.91%. The highest rate, 2.91%, is associated with the commonly used high-speed drill combined with Kerrison Rongeur and bone punches. Since bone-removal devices are just one of the possible causes of dural tears, the general incidence is expected to be higher than the incidence associated with the devices, yet even the maximal estimation, 3.5%, was only slightly higher, suggesting that the speculation of underreporting of dural tears to these databases is probably true, as also supported by the mostly higher incidences reported in the literature. Conclusions Hospital administrative databases seem to show a lower-than-reasonable incidence of durotomy, suggesting possible underreporting. Researchers should therefore use this tool with caution. Reduction of the absolute durotomy incidence by approximately 2.5% can be achieved by improving the safety of bone-removal devices.
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Affiliation(s)
- Robert Pflugmacher
- Klinik und Poliklinik Für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Bonn, Germany
| | - Angelo Franzini
- Department of Neurosurgery, Fondazione Istituto Neurologico "Carlo Besta," Milan, Italy
| | | | | | - Ely Ashkenazi
- Israel Spine Center, Assuta Medical Center, Tel Aviv, Israel
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