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Shah VN, Kosanam AR, Patel M, Kasliwal MK. Rate and fate of incidental durotomies in spine surgery. J Clin Neurosci 2025; 136:111184. [PMID: 40174550 DOI: 10.1016/j.jocn.2025.111184] [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: 12/18/2024] [Revised: 02/23/2025] [Accepted: 03/11/2025] [Indexed: 04/04/2025]
Abstract
BACKGROUND Incidental Durotomy (ID) is a well-recognized complication from spine surgery and its occurrence is often linked to negative outcomes following spine surgery. However, there is conflicting evidence in the literature regarding the risk factors, incidence and outcome following ID. This study aims to assess the rate and fate of ID in spine surgery. METHODS A retrospective review of a prospectively maintained database all adult patients who underwent spinal surgery by a single board certified neurospine surgeon between January 2016 and October 2024 was performed to identify all patients who sustained ID. For open spinal surgeries, the intraoperative management strategy involved direct repair of durotomies using a reinforced closure technique. In minimally invasive surgery (MIS) cases, direct repair of the durotomy was not performed; however, other reinforcement steps were identical to those used in the open approach. The primary outcomes assessed included the occurrence of intraoperative durotomies and any postoperative and perioperative complications associated with durotomy. Secondary outcomes included the analysis of durotomy rates based on surgical approach, surgical instrumentation, primary versus revision surgery, and the surgeon's years of experience. The postoperative management remained unchanged between patients with and without ID. RESULTS Among 1,155 patients who underwent spinal surgeries during the study period, 56 (4.8 %) experienced ID. The overall association between age group and durotomy rate was not statistically significant (p = 0.12). Analysis showed no significant differences in the occurrence of durotomies between MIS (4.9 %) and open surgeries (4.8 %) (p = 1) and instrumented cases (5.2 %) versus non-instrumented cases (3.5 %) (p = 0.34). Durotomy rates were higher in revision surgeries (8.7 %) compared to primary surgeries (4.6 %), but this difference was not statistically significant (p = 0.21). A statistically significant difference was found between primary diagnosis and durotomy rate, with the highest chances of durotomies in patients undergoing surgery for adult spinal deformity (p < 0.0001) with a 50 % rate (8 of 16) of ID in patients who underwent three-column osteotomies. There was no significant relationship between the surgeon's years of experience as an attending and durotomy rates (p = 0.543). No patient required revision surgery for any complication related to ID. CONCLUSIONS This study provides real-world clinical data demonstrating the rate and fate of ID following spine surgery that spine surgeons can utilize during preoperative counseling and setting expectations. Surgery for adult spinal deformity, especially those involving three-column osteotomies, is associated with the highest incidence of ID. While this study suggests ID as a benign event, given possible serious postoperative sequelae, it remains essential for surgeons to employ techniques to avoid ID and, if it occurs, monitor patients closely and employ best practices to mitigate potential risks.
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Affiliation(s)
- Varunil N Shah
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Anish R Kosanam
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Mohit Patel
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Manish K Kasliwal
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Irwan N, Takahashi Y, Saito K, Ito A, Nishizawa T, Sasaki T, Faried A, Endo T. Successful management of interdural spinal cysts presenting as radiculopathy caused by epidural venous enlargement: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2025; 9:CASE24533. [PMID: 39761565 PMCID: PMC11705673 DOI: 10.3171/case24533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Accepted: 10/31/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND The authors report the first case of thoracic interdural spinal cysts presenting as radiculopathy attributed to overdrainage-related cervical venous plexus enlargement. This case emphasizes the importance of considering interdural spinal cysts and cerebrospinal fluid overdrainage in the differential diagnosis of radiculopathy. OBSERVATIONS A 37-year-old male patient with a history of orthostatic headache presented with bilateral deltoid muscle atrophy consistent with C5 radiculopathy. Postcontrast magnetic resonance imaging (MRI) revealed cervical epidural venous plexus enlargement and nerve root compression. Thoracic MRI showed an interdural cyst extending from C7 to T11. In addition, a small defect in the inner layer of the dura, which connects the subarachnoid space to the cyst at the T10 level, was detected on thin-slice MRI. Surgery was performed to close the dural defect, with endoscopic assistance facilitating definitive treatment. Postoperative MRI confirmed the resolution of the spinal cyst and epidural venous enlargement. Furthermore, the patient's symptoms improved. LESSONS Evaluating the cervical spinal pathology is the common approach for cervical radiculopathy. However, in the authors' case, the presence of thoracic lesions could have been an underlying cause. Hence, identifying this unique clinical presentation can raise awareness among neurosurgeons and lead to better patient outcomes by addressing the underlying pathology in a timely manner. https://thejns.org/doi/10.3171/CASE24533.
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Affiliation(s)
- Nuradi Irwan
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan;
- Department of Neurosurgery, Universitas Padjadjaran, Bandung, Indonesia
| | - Yoshiharu Takahashi
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan;
| | - Kyohei Saito
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan;
| | - Akira Ito
- Department of Neurosurgery, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
| | - Taketo Nishizawa
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan;
| | - Tatsuya Sasaki
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan;
| | - Ahmad Faried
- Department of Neurosurgery, Universitas Padjadjaran, Bandung, Indonesia
| | - Toshiki Endo
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan;
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Faldini C, Barile F, D'Antonio G, Rinaldi A, Manzetti M, Viroli G, Vita F, Traversari M, Cerasoli T, Ruffilli A. Incidental dural tears do not affect the overall patients' reported outcome of spine surgery at long-term follow-up: results of a systematic review. Musculoskelet Surg 2024; 108:47-61. [PMID: 36877336 DOI: 10.1007/s12306-023-00777-y] [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: 02/07/2023] [Accepted: 02/12/2023] [Indexed: 03/07/2023]
Abstract
To conduct a systematic review of the literature in order to establish if there is an overall adverse effect of accidental durotomy on the long-term patients' reported outcome after elective spine surgery. A systematic literature search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about pre- and postoperative clinical outcomes of patients with accidental durotomy and patients without were extracted and analysed. After screening, eleven studies were included with a total of 80,541 patients. About 4112 of these patients (5.10%) had incidental dural tear. When comparing patients with dural tear to patients without, 9/11 authors found no patients' reported differences at last follow-up. One author found a slightly worse VAS back pain in dural tear patients, and another author found inferior SF-36 and ODI scores in dural tear patients (both below minimal clinically important difference). Accidental dural tear did not have a significant adverse effect on clinical outcome of elective spine surgery. More studies are needed to better demonstrate this result.
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Affiliation(s)
- C Faldini
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - F Barile
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - G D'Antonio
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - A Rinaldi
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - M Manzetti
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - G Viroli
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - F Vita
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - M Traversari
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136.
| | - T Cerasoli
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - A Ruffilli
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Xin JH, Che JJ, Wang Z, Chen YM, Leng B, Wang DL. Effectiveness and safety of interspinous spacer versus decompressive surgery for lumbar spinal stenosis: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2023; 102:e36048. [PMID: 37986330 PMCID: PMC10659713 DOI: 10.1097/md.0000000000036048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/19/2023] [Accepted: 10/19/2023] [Indexed: 11/22/2023] Open
Abstract
STUDY DESIGN A meta-analysis of randomized controlled trials. OBJECTIVE Our meta-analysis was conducted to investigate whether interspinous spacer (IS) results in better performance for patients with lumbar spinal stenosis (LSS) when compared with decompressive surgery (DS). BACKGROUND DATA DS and IS are common surgeries for the treatment of LSS. However, controversy remains as to whether the IS is superior to DS. METHODS We comprehensively searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for prospective randomized controlled trials that compared IS versus DS for LSS. The retrieved results were last updated on July 30, 2023. RESULTS Eight studies involving 852 individuals were included in the meta-analysis. The pooled data indicated that IS was superior to DS considering shorter operation time (P = .003), lower dural violation rate (P = .002), better Zurich Claudication Questionnaire Physical function score (P = .03), and smaller foraminal height decrease (P = .004), but inferior to DS considering the higher rate of reoperation (P < .0001). There was no significant difference between the 2 groups regarding hospital stay (P = .26), blood loss (P = .23), spinous process fracture (P = .09), disc height decrease (P = .87), VAS leg pain score (P = .43), VAS back pain score (P = .26), Oswestry Disability Index score (P = .08), and Zurich Claudication Questionnaire symptom severity (P = .50). CONCLUSIONS In summary, we considered that IS had similar effects with DS in hospital stay, blood loss, spinous process fracture, disc height decrease, VAS score, Oswestry Disability Index score, and Zurich Claudication Questionnaire Symptom severity, and was better in some indices such as operation time, dural violation, Zurich Claudication Questionnaire Physical function, and foraminal height decrease than DS. However, due to the higher rate of reoperation in the IS group, we considered that both IS and DS were acceptable strategies for treating LSS. As a novel technique, further well-designed studies with longer-term follow-up are needed to evaluate the effectiveness and safety of IS.
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Affiliation(s)
- Jian-Hai Xin
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Jia-Ju Che
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Zhe Wang
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Yu-Ming Chen
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Bing Leng
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Da-Lin Wang
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
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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: 6] [Impact Index Per Article: 3.0] [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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Dong RP, Zhang Q, Yang LL, Cheng XL, Zhao JW. Clinical management of dural defects: A review. World J Clin Cases 2023; 11:2903-2915. [PMID: 37215425 PMCID: PMC10198091 DOI: 10.12998/wjcc.v11.i13.2903] [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: 12/28/2022] [Revised: 03/03/2023] [Accepted: 04/04/2023] [Indexed: 04/25/2023] Open
Abstract
Dural defects are common in spinal and cranial neurosurgery. A series of complications, such as cerebrospinal fluid leakage, occur after rupture of the dura. Therefore, treatment strategies are necessary to reduce or avoid complications. This review comprehensively summarizes the common causes, risk factors, clinical complications, and repair methods of dural defects. The latest research progress on dural repair methods and materials is summarized, including direct sutures, grafts, biomaterials, non-biomaterial materials, and composites formed by different materials. The characteristics and efficacy of these dural substitutes are reviewed, and these materials and methods are systematically evaluated. Finally, the best methods for dural repair and the challenges and future prospects of new dural repair materials are discussed.
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Affiliation(s)
- Rong-Peng Dong
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Qi Zhang
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Li-Li Yang
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Xue-Liang Cheng
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Jian-Wu Zhao
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
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Spencer Fox E, McDonnell JM, Cunniffe GM, Darwish S, Butler JS. Is a Standardized Treatment Plan for Incidental Durotomy Plausible? Clin Spine Surg 2023; 36:37-39. [PMID: 36728306 DOI: 10.1097/bsd.0000000000001424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 12/01/2022] [Indexed: 02/03/2023]
Affiliation(s)
- E Spencer Fox
- National Spinal Injuries Unit, Mater Misericordiae University Hospital
- UCD School of Medicine, Dublin, Ireland
| | - Jake M McDonnell
- National Spinal Injuries Unit, Mater Misericordiae University Hospital
| | | | - Stacey Darwish
- National Spinal Injuries Unit, Mater Misericordiae University Hospital
| | - Joseph S Butler
- National Spinal Injuries Unit, Mater Misericordiae University Hospital
- UCD School of Medicine, Dublin, Ireland
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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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Banerjee C, Cross B, Rumley J, Devine J, Ritter E, Vender J. Multiple-Layer Lumbosacral Pseudomeningocele Repair with Bilateral Paraspinous Muscle Flaps and Literature Review. World Neurosurg 2020; 144:e693-e700. [PMID: 32942058 DOI: 10.1016/j.wneu.2020.09.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pseudomeningocele is an uncommon but widely recognized complication of spinal surgery that can be challenging to correct. When conservative measures fail, patients frequently require reoperation to attempt primary closure of the durotomy, yet attempts at true watertight closures of the dura or fascia sometimes fall short. We describe a technique of lumbosacral pseudomeningocele repair involving a 2-layer pants-over-vest closure of the pseudomeningocele coupled with mobilization of bilateral paraspinal musculature to create a Z-plasty, or a Z-shaped flap. We have demonstrated a high success rate with our small series. METHODS The technique used meticulous manipulation of the pseudomeningocele to make a 2-layer pants-over-vest closure. This closure coupled with wide mobilization and importation of paraspinous muscle into the wound effectively obliterated dead space with simultaneous tamponade of the dural tear. The lateral row perforators were left intact, providing excellent vascularity with adequate mobility to the patient. RESULTS This technique was incorporated into the care of 10 patients between 2004 and July 2019. All wounds were closed in a single stage after careful flap section based on the wound's needs. We demonstrated successful pseudomeningocele resolution in all 10 patients with no observed clinical recurrence of symptomatic pseudomeningocele after at least 6 months of follow-up. CONCLUSIONS This technique provides a straightforward option for the spine surgeon to manage these challenging spinal wounds with minimal, if any, need for further laminectomy as well as a high fistula control rate with minimal morbidity.
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Affiliation(s)
- Christopher Banerjee
- Department of Neurological Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA.
| | - Brandy Cross
- Department of General Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Jacob Rumley
- Department of Orthopedic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - John Devine
- Department of Orthopedic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Edmond Ritter
- Department of Plastic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - John Vender
- Department of Neurological Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
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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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Høy K, Grycel B, Andersen T, Bünger C. Does transforaminal lumbar interbody fusion produce leg pain?-Results from a RCT. J Orthop Surg (Hong Kong) 2020; 27:2309499019869469. [PMID: 31530081 DOI: 10.1177/2309499019869469] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Transforaminal lumbar interbody fusion (TLIF) is presently the most used method to achieve lumbar interbody fusion worldwide. The special preparation and cage insertion imply a risk of an undesirable side effect in the form of residual neurogenic pain. This issue has not been investigated prior in a randomized clinical trial (RCT) set up. AIM To test whether TLIFs had a higher incidence of leg pain in comparison to a common instrumented posterolateral fusion (PLF) and to test whether a higher occurrence of leg pain on the ipsilateral side in the TLIF group was present. METHODS One hundred patients included in a RCT comparing TLIF and PLF fulfilled pain drawings and numeric rating scale (NRS) scale from 0 to 10 preoperatively, after 1 year, and after 2 years. Difference in pain appearance, type, localization, and intensity was compared between groups. RESULTS A slightly higher number of patients in the TLIF group reported leg pain at 2 years follow-up: no leg pain, 47% (PLF) and 37% (TLIF); unilateral leg pain, 31% (PLF) and 25% (TLIF); bilateral leg pain, 22% (PLF) and 37% (TLIF), p = 0.270. Numbness and pins and needles on the anterior aspect of the lower leg were marked by 10% and 12% of TLIF patients compared to 6% and 4% in PLF patients p = 0.498/0.197. The ipsilateral side of cage insertion in the TLIF group was not a place for new leg pain compared to the contralateral side. CONCLUSION The special surgical preparation used in TLIFs does not result in the development of new ipsilateral leg pain. However, a higher percentage of the patients in the TLIF group had new leg pain in comparison to PLF after 2 years.
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Affiliation(s)
- Kristian Høy
- Department of Orthopedics, Spine Section, Aarhus University Hospital, Aarhus, Denmark
| | - Blazej Grycel
- Department of Orthopedics, Spine Section, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Andersen
- Department of Orthopedics, Spine Section, Aarhus University Hospital, Aarhus, Denmark
| | - Cody Bünger
- Department of Orthopedics, Spine Section, Aarhus University Hospital, Aarhus, Denmark
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12
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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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13
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Strömqvist F, Sigmundsson FG, Strömqvist B, Jönsson B, Karlsson MK. Incidental durotomy in degenerative lumbar spine surgery - a register study of 64,431 operations. Spine J 2019; 19:624-630. [PMID: 30172899 DOI: 10.1016/j.spinee.2018.08.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Incidental durotomy (ID) is one of the most common intraoperative complications seen in spine surgery. Conflicting evidence has been presented regarding whether or not outcomes are affected by the presence of an ID. PURPOSE To evaluate whether outcomes following degenerative spine surgery are affected by ID and the incidence of ID with different diagnoses and different surgical procedures. MATERIALS By using SweSpine, the national Swedish Spine Surgery Register, preoperative, surgical and postoperative 1-year follow-up data were obtained for 64,431 surgeries. All patients were surgically treated due to lumbar spinal stenosis (LSS) without or with concomitant degenerative spondylolisthesis (DS) or lumbar disc herniation (LDH) between 2000 and 2015. Gender, age, smoking habits, walking distance, consumption of analgesics, back and leg pain (Visual Analogue Scale [VAS]), quality of life (EuroQol [EQ5D] and Short Form 36 [SF-36]), and disability (Oswestry Disability Index [ODI]) were recorded. RESULTS Overall, incidence of ID during the study period was 5.0%. For the LDH, LSS, and DS subgroups, it was 2.8%, 6.5%, and 6.5%, respectively. Laminectomy was associated with a higher incidence of ID than discectomy (p<.001). ID was more common in all three subgroups if the patient had previously been subjected to spine surgery and with increasing age of the patients (p<.001). LDH patients with an ID reported a higher degree of residual leg pain, inferior mental quality of life (SF-36 MCS), and higher disability (ODI) than LDH patients without ID (all p<.001) 1-year after surgery. LSS patients with an ID reported inferior SF-36 MCS (p<.001) and DS patients with an ID had inferior SF-36 MCS and higher ODI compared to patients with the same diagnosis but without an ID (p<.001). However, these numerical differences are well below references for MCID, for all three subgroups. ID was associated with a higher frequency of patients being dissatisfied with the surgical outcome at 1-year follow-up. In patients who did not improve in back and leg pain following surgery (delta-value), ID was less common than in patients reporting improved back and leg pain from before as compared to following surgery. CONCLUSIONS The overall occurrence of ID in the present study was 5%, with higher figures in LSS and DS and lower figures in LDH. Higher age of the patient and previous surgery were associated with higher frequencies of ID. The outcome at 1 year following surgery was not affected to a clinically relevant extent when an ID was obtained. However, ID was associated with a higher degree of patient dissatisfaction and a longer hospital length of stay.
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Affiliation(s)
- Fredrik Strömqvist
- Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Akutgatan 4, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Inga Marie Nilssons gata 22, SE-205 02 Malmö, Sweden.
| | - Freyr Gauti Sigmundsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Akutgatan 4, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Inga Marie Nilssons gata 22, SE-205 02 Malmö, Sweden
| | - Björn Strömqvist
- Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Akutgatan 4, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Inga Marie Nilssons gata 22, SE-205 02 Malmö, Sweden
| | - Bo Jönsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Akutgatan 4, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Inga Marie Nilssons gata 22, SE-205 02 Malmö, Sweden
| | - Magnus K Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Akutgatan 4, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Inga Marie Nilssons gata 22, SE-205 02 Malmö, Sweden
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14
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Zavodska M, Galik J, Marsala M, Papcunova S, Pavel J, Racekova E, Martoncikova M, Sulla I, Gajdos M, Lukac I, Kafka J, Ledecky V, Sulla I, Reichel P, Trbolova A, Capik I, Bimbova K, Bacova M, Stropkovska A, Kisucka A, Miklisova D, Lukacova N. Hypothermic treatment after computer-controlled compression in minipig: A preliminary report on the effect of epidural vs. direct spinal cord cooling. Exp Ther Med 2018; 16:4927-4942. [PMID: 30542449 PMCID: PMC6257352 DOI: 10.3892/etm.2018.6831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 06/29/2018] [Indexed: 11/24/2022] Open
Abstract
The aim of the present study was to investigate the therapeutic efficacy of local hypothermia (beginning 30 min post-injury persisting for 5 h) on tissue preservation along the rostro-caudal axis of the spinal cord (3 cm cranially and caudally from the lesion site), and the prevention of injury-induced functional loss in a newly developed computer-controlled compression model in minipig (force of impact 18N at L3 level), which mimics severe spinal cord injury (SCI). Minipigs underwent SCI with two post-injury modifications (durotomy vs. intact dura mater) followed by hypothermia through a perfusion chamber with cold (epidural t≈15°C) saline, DMEM/F12 or enriched DMEM/F12 (SCI/durotomy group) and with room temperature (t≈24°C) saline (SCI-only group). Minipigs treated with post-SCI durotomy demonstrated slower development of spontaneous neurological improvement at the early postinjury time points, although the outcome at 9 weeks of survival did not differ significantly between the two SCI groups. Hypothermia with saline (t≈15°C) applied after SCI-durotomy improved white matter integrity in the dorsal and lateral columns in almost all rostro-caudal segments, whereas treatment with medium/enriched medium affected white matter integrity only in the rostral segments. Furthermore, regeneration of neurofilaments in the spinal cord after SCI-durotomy and hypothermic treatments indicated an important role of local saline hypothermia in the functional outcome. Although saline hypothermia (24°C) in the SCI-only group exhibited a profound histological outcome (regarding the gray and white matter integrity and the number of motoneurons) and neurofilament protection in general, none of the tested treatments resulted in significant improvement of neurological status. The findings suggest that clinically-proven medical treatments for SCI combined with early 5 h-long saline hypothermia treatment without opening the dural sac could be more beneficial for tissue preservation and neurological outcome compared with hypothermia applied after durotomy.
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Affiliation(s)
- Monika Zavodska
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Jan Galik
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Martin Marsala
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia.,Department of Anesthesiology, Neuroregeneration Laboratory, University of California-San Diego, San Diego, CA 92093, USA
| | - Stefania Papcunova
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Jaroslav Pavel
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Eniko Racekova
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Marcela Martoncikova
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Igor Sulla
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia.,Hospital of Slovak Railways, 040 01 Košice, Slovakia
| | - Miroslav Gajdos
- Department of Neurosurgery, Faculty of Medicine, University of Pavol Jozef Safarik, 040 66 Košice, Slovakia
| | - Imrich Lukac
- Department of Neurosurgery, Faculty of Medicine, University of Pavol Jozef Safarik, 040 66 Košice, Slovakia
| | - Jozef Kafka
- Department of Neurosurgery, Faculty of Medicine, University of Pavol Jozef Safarik, 040 66 Košice, Slovakia
| | - Valent Ledecky
- Department of Small Animal Clinic, University of Veterinary Medicine and Pharmacy, 041 81 Košice, Slovakia
| | - Igor Sulla
- Department of Small Animal Clinic, University of Veterinary Medicine and Pharmacy, 041 81 Košice, Slovakia
| | - Peter Reichel
- Department of Small Animal Clinic, University of Veterinary Medicine and Pharmacy, 041 81 Košice, Slovakia
| | - Alexandra Trbolova
- Department of Small Animal Clinic, University of Veterinary Medicine and Pharmacy, 041 81 Košice, Slovakia
| | - Igor Capik
- Department of Small Animal Clinic, University of Veterinary Medicine and Pharmacy, 041 81 Košice, Slovakia
| | - Katarina Bimbova
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Maria Bacova
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Andrea Stropkovska
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Alexandra Kisucka
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Dana Miklisova
- Department of Vector-borne Diseases, Institute of Parasitology, Slovak Academy of Sciences, 040 01 Košice, Slovakia
| | - Nadezda Lukacova
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, 040 01 Košice, Slovakia
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15
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Pendi A, Lee YP, Farhan SADB, Acosta FL, Bederman SS, Sahyouni R, Gerrick ER, Bhatia NN. Complications associated with intrathecal morphine in spine surgery: a retrospective study. JOURNAL OF SPINE SURGERY 2018; 4:287-294. [PMID: 30069520 DOI: 10.21037/jss.2018.05.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Supplemental intrathecal morphine (ITM) represents an option to manage postoperative pain after spine surgery due to ease of administration and ability to confer effective short-term analgesia at low dosages. However, whether ITM increases risk of surgical site infections (SSI), cerebrospinal fluid (CSF) leak, and incidental dural tears (IDT) has not been investigated. Therefore, this study was performed to determine the rates of SSI, CSF leak, and IDT in patients that received ITM. Methods Patients that underwent posterior instrumented fusion from January 2010 to 2016 that received ITM were compared to controls with respect to demographic, medical, surgical, and outcome data. Fisher's exact test was used to compare rates of SSI, CSF leak, and IDT between groups. Poisson regression was used to analyze complication rates after adjusting for the influence of covariates and potential confounders. Results A total of 512 records were analyzed. ITM was administered to 78 patients prior to wound closure. The remaining 434 patients compromised the control group. IDT was significantly more common among patients receiving ITM (P=0.009). Differences in rates of CSF leak and SSI were not statistically significant (P=0.373 and P=0.564, respectively). After compensating for additional variables, Poisson regression revealed a significant increase in rates of IDT (P=0.007) according to ITM injection and advanced age (P=0.014). There was no significant difference in rates of CSF leak or SSI after accounting for the additional variables (P>0.05). Conclusions ITM for pain control in posterior instrumented spinal fusion surgery was linked to increased likelihood of IDT but not CSF leaks or SSI. Age was also noted to be a significant predictor of IDT. Spine surgeons should weigh potential risks against benefits when deciding whether to administer ITM for postoperative pain management following spine surgery.
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Affiliation(s)
- Arif Pendi
- School of Medicine, Wayne State University, Detroit, MI, USA
| | - Yu-Po Lee
- Department of Orthopaedic Surgery, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Saif Al-Deen B Farhan
- Department of Orthopaedic Surgery, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Frank L Acosta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Ronald Sahyouni
- School of Medicine, University of California Irvine, CA, USA
| | - Elias R Gerrick
- TH Chan School of Public Health, Harvard University, Harvard, Cambridge, MA, USA
| | - Nitin N Bhatia
- Department of Orthopaedic Surgery, School of Medicine, University of California Irvine, Orange, CA, USA
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16
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Abstract
STUDY DESIGN This is a retrospective study analysis. OBJECTIVE In this retrospective study we evaluated risk factors for incidental durotomy and its impact on the postoperative course. SUMMARY OF BACKGROUND DATA Lumbar interbody fusion (LIF) is increasingly applied for the treatment of degenerative instability. A known complication is incidental durotomy. MATERIALS AND METHODS A cohort of 541 patients who underwent primary LIF surgery between 2005 and 2015 was analyzed. Previous lumbar surgery, age, surgeon's experience, intraoperative use of a microscope, and the number of operated levels were assessed and the risk for incidental durotomy was estimated using the Log-likelihood test and Wald test, respectively. The association of incidental durotomy and outcome parameters was analyzed using the quantile regression model. RESULTS In 77 (14.2%) patients intraoperative cerebrospinal fluid (CSF) fistula was observed. Previous lumbar surgery (P<0.001), number of operated levels (P=0.03), and surgeon's experience (P=0.01) were significantly associated with incidental durotomy. Incidental durotomy was significantly associated with a prolonged bed rest (P<0.001), hospital stay (P=0.041), and an increased use of postoperative antibiotics (P<0.001). Eleven of 77 patients with incidental durotomy (14.3%) developed postoperative CSF fistula of whom 10 (91%) needed revision surgery for dural repair. CONCLUSIONS We could identify important risk factors for incidental durotomy in LIF surgery. In patients who had undergone previous lumbar surgery and those with multilevel disease particular precaution is required. Furthermore, we were able to verify the morbidity associated with CSF fistula as shown by increased immobilization and follow-up surgeries for postoperative CSF fistula which emphasizes the importance to develop strategies to minimize the risk for incidental durotomy.
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17
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Herren C, Sobottke R, Mannion AF, Zweig T, Munting E, Otten P, Pigott T, Siewe J, Aghayev E. Incidental durotomy in decompression for lumbar spinal stenosis: incidence, risk factors and effect on outcomes in the Spine Tango registry. 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 2017. [PMID: 28634709 DOI: 10.1007/s00586-017-5197-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE The three aims of this Spine Tango registry study of patients undergoing decompression for spinal stenosis were to: report the rate of dural tear (DT) stratified by treatment centre; find factors associated with an increased likelihood of incurring a DT; and compare treatment outcomes in relation to DT (none vs. repaired vs. unrepaired DT). METHODS Multivariate logistic regression was used to assess the association between DT and patient and treatment characteristics. Patient-rated and surgical outcomes were compared in patients with no DT, repaired DT, and unrepaired DT, while adjusting for case-mix. RESULTS DT occurred in 328/3254 (10.1%) of included patients. The rate for all 29 contributing hospitals was within 95% confidence intervals of the average. The likelihood of DT increased by 2% per year of age, 1.78 times with previous spine surgery, 1.67 for a minimally/less invasive surgery, 1.58 times with laminectomy, and 1.40, and 2.12 times for BMI 31-35, and >35 in comparison with BMI 26-30, respectively. The majority of DTs (272/328; 82.9%) were repaired. Repairing the DT was associated with a longer duration of surgery (p < 0.001). More patients with repaired than with unrepaired DTs were satisfied with treatment, but the difference was not statistically significant. There was no association between DT and patient-reported outcomes. CONCLUSION The unadjusted rate of incidental DT during decompression for LSS was homogeneous across the participating centres and was associated with age, BMI, previous surgery at the same spinal level, minimally/less invasive surgery, and laminectomy. Non-repair of DTs had no negative association with treatment outcome; however, the unrepaired DTs may have been those that were smaller in size.
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Affiliation(s)
- Christian Herren
- Department for Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Rolf Sobottke
- Department of Orthopaedic and Trauma Surgery, University of Cologne, Joseph-Stelzmann-Straße 9, 50924, Cologne, Germany.,Department of Orthopaedic Surgery, Medizinisches Zentrum StädteRegion Aachen, Mauerfeldchen 25, 52146, Würselen, Germany
| | - Anne F Mannion
- Spine Centre Division, Department of Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Thomas Zweig
- Spinecenter, Schänzlistrasse 39, 3025, Bern, Switzerland.,Institute for Social and Preventive Medicine, Finkenhubelweg 11, 3012, Bern, Switzerland
| | - Everard Munting
- Clinique Saint Pierre, Av. Reine Fabiola 9, 1340 Ottignies, Belgium
| | - Philippe Otten
- Clinique Générale de Fribourg, Rue Hans-Geiler 6, 1700, Fribourg, Switzerland
| | - Tim Pigott
- Department of Neurosurgery, Walton Centre for Neurosurgery, Lower Lane, L9 7LJ, Liverpool, UK
| | - Jan Siewe
- Department of Orthopaedic and Trauma Surgery, University of Cologne, Joseph-Stelzmann-Straße 9, 50924, Cologne, Germany
| | - Emin Aghayev
- Spine Centre Division, Department of Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
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Schöller K, Steingrüber T, Stein M, Vogt N, Müller T, Pons-Kühnemann J, Uhl E. Microsurgical unilateral laminotomy for decompression of lumbar spinal stenosis: long-term results and predictive factors. Acta Neurochir (Wien) 2016; 158:1103-13. [PMID: 27084380 DOI: 10.1007/s00701-016-2804-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/04/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The microsurgical unilateral laminotomy (MUL) technique for bilateral decompression of lumbar spinal stenosis (LSS) is a less destabilizing alternative to laminectomy and leads to good short-term outcomes. However, little is known about the long-term results including predictive factors. METHODS Medical records of patients who underwent MUL for LSS decompression between 2005 and 2010 were reviewed, and a questionnaire was distributed to complement the long-term outcome data. The study population consisted of 176 patients including 17 patients with stable grade I spondylolisthesis. Complications and reoperations were meticulously analyzed. Clinical outcome was measured using a modified Prolo scale and was further dichotomized in good vs. poor outcome. Predictive factors were obtained from uni- and multivariate analyses. RESULTS The median age of the cohort was 70.0 years and the follow-up 71.7 months. Complications occurred in 5.1 % of the patients. The overall reoperation rate was 17.0 %, including surgery, which was exclusively performed at other levels in 4.0 %. The reoperation rate for fusion was 4.5 %. Good neurogenic claudication outcome faded from 98.3 % at hospital discharge to 47.2 % at 6 years. Multivariate analysis identified previous lumbar operation as a potential independent predictor of a reoperation; potential independent predictors of poor long-term claudication outcome were older age, female gender, higher body mass index (BMI) and tobacco smoking. CONCLUSIONS In our experience, the long-term reoperation rate after MUL for LSS is not negligible and higher in previously operated patients. It seems like the good initial clinical results after MUL may fade over time, and several patient-related predictive factors including potentially modifiable obesity and tobacco smoking seem to play an important role.
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Affiliation(s)
- Karsten Schöller
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany.
| | - Thomas Steingrüber
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Marco Stein
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Nina Vogt
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Tilman Müller
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Jörn Pons-Kühnemann
- Institute for Medical Informatics, Medical Statistics Study Group, Justus-Liebig-University, Giessen, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
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19
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Adam D, Hornea I, Burduşa G, Iftimie D, Moisescu C. A retrospective comparison of laminectomy and unilateral fenestration with foraminotomy on outcome of patients with lumbar spinal stenosis. ROMANIAN NEUROSURGERY 2016. [DOI: 10.1515/romneu-2016-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background: Neural decompression for lumbar spinal stenosis (LSS) can be performed, besides conventional lumbar laminectomy, by many other surgical techniques.
Objective: The goal of this study is to analyze the results of laminectomy versus unilateral fenestration and foraminotomy with bilateral neural decompression in LSS patients.
Methods: A number of 58 patients with lumbar spinal stenosis were divided into two groups: group A (no.=22) consists of patients that underwent a laminectomy procedure and group B (no.=36) of cases where unilateral fenestration with foraminotomy was used. Outcome was assessed at 1, 6 and 12 months postoperatively. Two parameters were evaluated: level of pain with the VAS (Visual Analogue Scale) score and the ODI (Oswestry Disability Index) scale for functional improvement.
Results: The level of pain was reduced in both patient groups. Cases in group A maintained higher levels of back pain in the first postoperative month versus group B. Improvement was faster for those operated by unilateral approach. At 6 months and 1 year follow-ups, VAS values were very similar. All patients presented functional recovery evaluated with the ODI scale, that showed continuous improvement at 6 months and 1 year.
Conclusions: Bilateral decompression by unilateral approach is an efficient method that represents the first option of treatment for patients with lateral lumbar spinal stenosis with unilateral or predominantly unilateral symptoms. For patients with severe central stenosis, classic laminectomy remains the first surgical choice.
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20
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Moussa WMM, Aboul-Enein HA. Combined thrombin and autologous blood for repair of lumbar durotomy. Neurosurg Rev 2016; 39:591-7. [PMID: 26864189 DOI: 10.1007/s10143-016-0707-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/03/2015] [Accepted: 01/27/2016] [Indexed: 12/27/2022]
Abstract
Lumbar durotomy can be intended or unintended and can result in persistent cerebrospinal fluid (CSF) leak. Several methods are used to manage this complication including bed rest and CSF diversion. In this study, we theorize that the use of thrombin-soaked gel foam together with autologous blood laid on the sutured dural tear can prevent persistent CSF leak. A retrospective review of the records of patients who underwent lumbar surgery and had an unintended dural tear with CSF leak, comparing the outcome of patients who were submitted to thrombin-soaked gel foam together with autologous blood (group A) to patients treated by subfacial drain, tight bandage, and bed rest (group B). A total of 1371 patients had lumbar surgery, of whom 131 had dural tear. Group A included 62 patients, while group B included 69 patients. 8.1 % of group A patients had CSF leak as compared to 17.4 % of group B patients at postoperative day 14. The incidence of postoperative CSF leak and duration of postoperative hospital stay were statistically lower in group A than in group B (p < 0.05). Combining thrombin and autologous blood for repair of lumbar durotomy is an effective and a relatively cheap way to decrease CSF leak in the early postoperative period as well as decreasing postoperative hospital stay. It also resulted in decreased complications rate in the late postoperative period.
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Affiliation(s)
| | - Hisham A Aboul-Enein
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery: Let's tell someone. Surg Neurol Int 2016; 7:S96-S101. [PMID: 26904373 PMCID: PMC4743264 DOI: 10.4103/2152-7806.174896] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 01/23/2023] Open
Abstract
Background: In a recent study entitled: “More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion (XLIF): A review”, Epstein documented that more nerve root injuries occurred utilizing minimally invasive surgery (MIS) versus open lumbar surgery for diskectomy, decompression of stenosis (laminectomy), and/or fusion for instability. Methods: In large multicenter Spine Patient Outcomes Research Trial reviews performed by Desai et al., nerve root injury with open diskectomy occurred in 0.13–0.25% of cases, occurred in 0% of laminectomy/stenosis with/without fusion cases, and just 2% for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion. Results: In another MIS series performed largely for disc disease (often contained nonsurgical disc herniations, therefore unnecessary procedures) or spondylolisthesis, the risk of root injury was 2% for transforaminal lumbar interbody fusion (TLIF) versus 7.8% for posterior lumbar interbody fusion (PLIF). Furthermore, the high frequencies of radiculitis/nerve root/plexus injuries incurring during anterior lumbar interbody fusions (ALIF: 15.8%) versus extreme lumbar interbody fusions (XLIF: 23.8%), addressing disc disease, failed back surgery, and spondylolisthesis, were far from acceptable. Conclusions: The incidence of nerve root injuries following any of the multiple MIS lumbar surgical techniques (TLIF/PLIF/ALIF/XLIF) resulted in more nerve root injuries when compared with open conventional lumbar surgical techniques. Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients?
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Affiliation(s)
- Nancy E Epstein
- Department of Winthrop NeuroScience, Winthrop University Hospital, Mineola, New York, USA
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Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion: A review. Surg Neurol Int 2016; 7:S83-95. [PMID: 26904372 PMCID: PMC4743267 DOI: 10.4103/2152-7806.174895] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 11/02/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In the lumbar spine, do more nerve root injuries occur utilizing minimally invasive surgery (MIS) techniques versus open lumbar procedures? To answer this question, we compared the frequency of nerve root injuries for multiple open versus MIS operations including diskectomy, laminectomy with/without fusion addressing degenerative disc disease, stenosis, and/or degenerative spondylolisthesis. METHODS Several of Desai et al. large Spine Patient Outcomes Research Trial studies showed the frequency for nerve root injury following an open diskectomy ranged from 0.13% to 0.25%, for open laminectomy/stenosis with/without fusion it was 0%, and for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion it was 2%. RESULTS Alternatively, one study compared the incidence of root injuries utilizing MIS transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) techniques; 7.8% of PLIF versus 2% of TLIF patients sustained root injuries. Furthermore, even higher frequencies of radiculitis and nerve root injuries occurred during anterior lumbar interbody fusions (ALIFs) versus extreme lateral interbody fusions (XLIFs). These high frequencies were far from acceptable; 15.8% following ALIF experienced postoperative radiculitis, while 23.8% undergoing XLIF sustained root/plexus deficits. CONCLUSIONS This review indicates that MIS (TLIF/PLIF/ALIF/XLIF) lumbar surgery resulted in a higher incidence of root injuries, radiculitis, or plexopathy versus open lumbar surgical techniques. Furthermore, even a cursory look at the XLIF data demonstrated the greater danger posed to neural tissue by this newest addition to the MIS lumbar surgical armamentariu. The latter should prompt us as spine surgeons to question why the XLIF procedure is still being offered to our patients?
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Affiliation(s)
- Nancy E Epstein
- Department of Neurousrgery, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
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Kamenova M, Leu S, Mariani L, Schaeren S, Soleman J. Management of Incidental Dural Tear During Lumbar Spine Surgery. To Suture or Not to Suture? World Neurosurg 2015; 87:455-62. [PMID: 26700751 DOI: 10.1016/j.wneu.2015.11.045] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 11/17/2015] [Accepted: 11/18/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Incidental durotomy (ID) during lumbar spine surgery is a frequent complication of growing clinical relevance as the number and complexity of spinal procedures increases. Yet, there is still a lack of guidelines for the treatment of ID with a large heterogeneity of established surgical techniques. The aim of this study was to investigate the efficacy of dural suturing in patients having ID during degenerative lumbar spine surgery, compared with other dural closure techniques. METHODS Of 1173 consecutive patients undergoing degenerative lumbar spine surgery from July 2013 to March 2015, in 64 (5.4%) patients 69 (5.8%) IDs occurred. The patients were divided into 3 groups depending on the dural closure technique used: group A, sole dural suture (n = 12, 19%); group B, patch only (TachoSil and/or muscle and/or fat) (n = 22, 32%); group C, dural suture in combination with a patch (n = 34, 49%). The primary end point was revision surgery caused by complications of cerebrospinal fluid leakage after 6 weeks. The secondary end points were operation time and hospitalization time, as well as surgical morbidity. RESULTS The 3 groups showed no significant difference in rates of revision surgery (group A: n = 1, 1.4%; group B: n = 4, 5.8%; group C: n = 3; 4.3%; P = 0.5). Furthermore, no significant difference for hospitalization time, operation time, and clinical outcome was found. Extent of ID, American Society of Anesthesiology score, postoperative immobilization, and insertion of a drainage tube were not associated with higher rates of revision surgery. Applying suction once a drainage tube was placed was found to be a significant risk factor for revision surgery (P = 0.003). Furthermore, patients undergoing revision surgery had a significantly higher body mass index (33 kg/m(2) vs. 26.37 kg/m(2); P = 0.006; odds ratio 1.252; P = 0.004). CONCLUSIONS Based on our results, the dural closure technique after ID does not seem to influence revision surgery rates due to cerebrospinal fluid leakage and its complications. Further prospective randomized studies are needed to confirm our results.
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Affiliation(s)
- Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland; Department of Spine Surgery, University Hospital of Basel, Basel, Switzerland.
| | - Severina Leu
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland; Department of Spine Surgery, University Hospital of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Stefan Schaeren
- Department of Spine Surgery, University Hospital of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland; Department of Spine Surgery, University Hospital of Basel, Basel, Switzerland
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Lopes M, Faillot T. [Dural tears: Regarding a series of 100 cases]. Neurochirurgie 2015; 61:329-32. [PMID: 26409571 DOI: 10.1016/j.neuchi.2015.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 06/05/2015] [Accepted: 06/07/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Dural tears are a dreaded surgical incident because they are difficult to anticipate and may lead to serious complications. MATERIALS AND METHODS The French College of Neurosurgery analyzed 100 cases of dural tears declared on the physicians accreditation website from the Haute Autorité de santé (Regional Health Authority). A questionnaire on drainage, type of dural repair and bed rest duration was sent to 87 French neurosurgeons. RESULTS Thirty-six percent of patients with dural tears had a history of previous spinal surgery and the most common cause of tear was surgical fibrosis into the operative field for 30% of cases. Sixty-four percent had no history of spinal surgery and, in 33% of cases, the dural tear occurred during a surgery for herniated disc. Drainage was proposed case by case in 76% of cases, the patient was allowed to stand up at day 1 in 48% of cases. The treatment of dural tears combined different techniques including in situ injection of biological glue in 86% of cases. The most common complication was the need of wound repair procedure in 59.5% of cases, which was complicated by meningitis in 21.5% of cases. CONCLUSION This study shows the lack of formal consensus about the procedure of repair, the method of drainage or the need to keep the patient bed ridden. This study highlights a relatively high frequency of dural tears, its potentially serious complications and stresses the need for prospective studies in order to define the appropriate action to undertake when faced with this type of incident.
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Affiliation(s)
- M Lopes
- Service de neurochirurgie, clinique d'Argonay, 385, route de Menthonnex, 74370 Argonay, France.
| | - T Faillot
- Service de neurochirurgie, hôpital Beaujon, 100, boulevard du Général-Leclerc, 92118 Clichy cedex, France
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Incidence of Pinhole Type Durotomy and Subsequent Cerebrospinal Fluid Leakage Following Simple Laminectomy. Asian Spine J 2015; 9:529-34. [PMID: 26240710 PMCID: PMC4522441 DOI: 10.4184/asj.2015.9.4.529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 12/01/2014] [Accepted: 12/18/2014] [Indexed: 11/25/2022] Open
Abstract
Study Design Cross sectional study. Purpose The purpose of this study was to determine the incidence and the associated risk factors of pinhole type of durotomy and cerebrospinal fluid (CSF) leakage following a simple laminectomy for spinal stenosis. Overview of Literature The incidence of spinal stenosis is expected to rise with increasing life expectancy. Moreover, lumbar spinal stenosis is the most common indication for spinal injury in the geriatric population. It is therefore important to identify and prevent the risks associated with laminectomy, the most widely used surgical procedure for spinal stenosis. The serious complication of incidental dural tear or durotomy and subsequent CSF leakage has not been studied in the region of Southeast Asia. Methods In this cross sectional study, we included 138 adult patients (age>18 years), who underwent a simple laminectomy for lumbar stenosis between 2011 and 2012. CSF leakage was the main outcome variable. Patients' wounds were examined for CSF leakage up to 1 week postoperatively. Results The incidence of pinhole type durotomy and subsequent CSF leakage in our region was 8.7%. Univariate analysis showed that hypertension, diabetes and smoking were significantly associated with durotomy and increased CSF leakage by 16.72, 44.25, and 33.71 times, respectively. Multivariate analysis showed that only smoking and diabetes significantly increased the chances of leakage. Conclusions Glycemic control and cessation of smoking prior to a simple laminectomy procedure reduced the incidence of a dural tear. Larger clinical studies on this lethal complication are required.
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Giannadakis C, Hammersbøen LE, Feyling C, Solheim O, Jakola AS, Nerland US, Nygaard ØP, Solberg TK, Gulati S. Microsurgical decompression for central lumbar spinal stenosis: a single-center observational study. Acta Neurochir (Wien) 2015; 157:1165-71. [PMID: 26002712 DOI: 10.1007/s00701-015-2450-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 05/07/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess outcomes and complications in patients undergoing microsurgical decompression for central lumbar spinal stenosis (LSS) without radiologic instability. METHODS Prospective data for patients operated at the Department of Neurosurgery, St. Olavs University Hospital, Norway, were obtained from the Norwegian Registry for Spine Surgery (NORspine) from 2007 to 2012. The primary outcome was change in Oswestry disability index (ODI) at 1 year. The secondary endpoint was perioperative complications. Complications were graded according to the Ibanez classification system. RESULTS For all patients (n = 125), the mean improvement in ODI at 1 year was 16.9 points (95% CI 13.5-20.2, p < 0.001). Seventy-six (71.7%) patients achieved a minimal clinically important difference in ODI (defined as ≥8 points improvement). The total number of complications within 3 months of surgery was 22 (17.6%). There were 14 medical and eight surgical complications, and all were Ibanez grade I or II (mild or moderate) complications. Four (3.2%) complications occurred while being admitted to the hospital and 18 (14.4%) occurred within 3 months following hospital discharge. The most common complication was urinary tract infection (n = 11, 8.8%). CONCLUSIONS Microsurgical decompression for central LSS in the absence of radiological instability is an effective and safe treatment.
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Papavero L, Engler N, Kothe R. Incidental durotomy in spine surgery: first aid in ten steps. 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 2015; 24:2077-84. [DOI: 10.1007/s00586-015-3837-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 01/18/2015] [Accepted: 02/23/2015] [Indexed: 11/24/2022]
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Radcliff KE, Neusner AD, Millhouse PW, Harrop JD, Kepler CK, Rasouli MR, Albert TJ, Vaccaro AR. What is new in the diagnosis and prevention of spine surgical site infections. Spine J 2015; 15:336-47. [PMID: 25264181 DOI: 10.1016/j.spinee.2014.09.022] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 05/06/2014] [Accepted: 09/15/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical site infection (SSI) after spinal surgery can result in several serious secondary complications, such as pseudoarthrosis, neurological injury, paralysis, sepsis, and death. There is an increasing body of literature on risk factors, diagnosis, and specific intraoperative interventions, including attention to sterility of instrumentation, application of minimally invasive fusion techniques, intraoperative irrigation, and application of topical antibiotics, that hold the most promise for reduction of SSI. PURPOSE The purpose of this review is to identify and summarize the recent literature on the incidence, risk factors, diagnosis, prevention, and treatment of SSIs after adult spine surgery. STUDY DESIGN The study design included systematic review and literature synthesis. METHODS For the systematic reviews, a search was performed in Medline and Scopus using keywords derived from a preliminary review of the literature and Medline MeSH terms. These studies were then manually filtered to meet the study criteria outlined in each section. Studies were excluded via predetermined criteria, and the majority of articles reviewed were excluded. RESULTS There are a number of patient- and procedure-specific risk factors for SSI. Surgical site infection appears to have significant implications from the patients' perspective on outcome of care. Diagnosis of SSI appears to rely primarily on clinical factors, while laboratory values such as C-reactive protein are not universally sensitive. Similarly, novel methods of perioperative infection prophylaxis such as local antibiotic administration appear to be modestly effective. CONCLUSIONS Surgical site infections are a common multifactorial problem after spine surgery. There is compelling evidence that improved risk stratification, detection, and prevention will reduce SSIs.
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Affiliation(s)
- Kris E Radcliff
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
| | - Alexander D Neusner
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA; Department of Surgery, Temple University Hospital, 3401 N. Broad St, Suite 400, Philadelphia, PA 19140, USA
| | - Paul W Millhouse
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - James D Harrop
- Department of Neurosurgery, Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Mohammad R Rasouli
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Todd J Albert
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
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Gautschi OP, Stienen MN, Smoll NR, Corniola MV, Tessitore E, Schaller K. Incidental durotomy in lumbar spine surgery--a three-nation survey to evaluate its management. Acta Neurochir (Wien) 2014; 156:1813-20. [PMID: 25047813 DOI: 10.1007/s00701-014-2177-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 07/08/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although it is generally accepted that incidental durotomies (ID) should be primarily repaired, the current literature shows no consensus regarding the peri- and postoperative management in case of ID during lumbar spine surgery. Because ID is a rather frequent complication and may be associated with significant disability, we were interested to analyze the current handling of ID in three European countries. METHODS In March 2014, members of the Swiss, German, and Austrian neurosurgical and spine societies were asked to complete an online questionnaire regarding the management of ID during and after lumbar spine surgery. Two, respectively 4 weeks after the first invitation, reminder requests were sent to all invitees, who had not already responded at that time. RESULTS There were 175 responses from 397 requests (44.1 %). Responders were predominantly neurosurgeons (89.7 %; 10.3 % were orthopedic surgeons), of which 45.7, 40.0, and 17.8 % work in a non-university hospital, university hospital, and private clinic, respectively. As for the perioperative management of ID, 19.4 % of the responders suggest only bed rest, while, depending on the extent of the ID, 84.0 % suggest additional actions, TachoSil/Spongostan with fibrin glue or a similar product and single suture repair being the most mentioned. Concerning epidural wound drainage in case of ID, 37.2 % desist from placing an epidural wound drainage with or without aspiration, 30.9 % place it sometimes, and 33.7 % place it regularly, but only without aspiration. Most responders prescribe bed rest for 24 (34.9 %) or 48 h (28.0 %), with much fewer prescribing bed rest for 72 h (6.3 %) and none more than 72 h, and 14.9 % of participants never prescribe bed rest. The vast majority of physicians (82.9 %, n = 145) always inform their patients after the operation in case of ID. CONCLUSIONS There is substantial heterogeneity in the management of incidental durotomies. The majority of spine surgeons today aim at complete/sufficient primary repair of the ID with varying recommendations concerning postoperative bed rest. Still, there is a trend towards early mobilization if the incidental durotomy has been closed completely/sufficiently with no participant favoring bed rest for more than 72 h.
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Affiliation(s)
- Oliver P Gautschi
- Département de Neurosciences cliniques, Service de Neurochirurgie, Faculté de Médecine, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland,
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Health care costs of incidental durotomies and postoperative cerebrospinal fluid leaks after elective spinal surgery. 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 2014; 24:2065-8. [PMID: 25099874 DOI: 10.1007/s00586-014-3504-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/29/2014] [Accepted: 07/30/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE To explore the additional health care costs of incidental durotomies and cerebrospinal fluid (CSF) leaks after elective surgery for degenerative spinal disorders. METHODS Prospective, observational single-center study including all patients operated for a degenerative condition of the spine over a 13-month period. Incidental durotomies and cerebrospinal fluid leaks were registered prospectively and a detailed analysis of health care costs of each case was performed. RESULTS In total 239 patients were included; an incidental durotomy occured in ten patients and a postoperative cerebrospinal fluid leak occured in one patient causing significantly higher hospital costs, as well as significantly longer hospital stay and operation time. While the hospital costs increased by nearly 50% the hospitals reimbursement increased only by 21% and this resulted in an average financial loss of 730 <euro> per case. CONCLUSION Incidental durotomy or postoperative cerebrospinal fluid leak after elective surgery for degenerative spinal disorders causes significantly higher health care costs.
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Complications of minimally invasive, tubular access surgery for cervical, thoracic, and lumbar surgery. Minim Invasive Surg 2014; 2014:451637. [PMID: 25097785 PMCID: PMC4109131 DOI: 10.1155/2014/451637] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 06/23/2014] [Indexed: 11/17/2022] Open
Abstract
The object of the study was to review the author's large series of minimally invasive spine surgeries for complication rates. The author reviewed a personal operative database for minimally access spine surgeries done through nonexpandable tubular retractors for extradural, nonfusion procedures. Consecutive cases (n = 1231) were reviewed for complications. There were no wound infections. Durotomy occurred in 33 cases (2.7% overall or 3.4% of lumbar cases). There were no external or symptomatic internal cerebrospinal fluid leaks or pseudomeningoceles requiring additional treatment. The only motor injuries were 3 C5 root palsies, 2 of which resolved. Minimally invasive spine surgery performed through tubular retractors can result in a low wound infection rate when compared to open surgery. Durotomy is no more common than open procedures and does not often result in the need for secondary procedures. New neurologic deficits are uncommon, with most observed at the C5 root. Minimally invasive spine surgery, even without benefits such as less pain or shorter hospital stays, can result in considerably lower complication rates than open surgery.
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Li Y, Walker CL, Zhang YP, Shields CB, Xu XM. Surgical decompression in acute spinal cord injury: A review of clinical evidence, animal model studies, and potential future directions of investigation. FRONTIERS IN BIOLOGY 2014; 9:127-136. [PMID: 24899887 PMCID: PMC4041293 DOI: 10.1007/s11515-014-1297-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The goal for treatment in acute spinal cord injury (SCI) is to reduce the extent of secondary damage and facilitate neurologic regeneration and functional recovery. Although multiple studies have investigated potential new therapies for the treatment of acute SCI, outcomes and management protocols aimed at ameliorating neurologic injury in patients remain ineffective. More recent clinical and basic science research have shown surgical interventions to be a potentially valuable modality for treatment; however, the role and timing of surgical decompression, in addition to the optimal surgical intervention, remain one of the most controversial topics pertaining to surgical treatment of acute SCI. As an increasing number of potential treatment modalities emerge, animal models are pivotal for investigating its clinical application and translation into human trials. This review critically appraises the available literature for both clinical and basic science studies to highlight the extent of investigation that has occurred, specific therapies considered, and potential areas for future research.
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Affiliation(s)
- Yiping Li
- Spinal Cord and Brain Injury Research Group, Stark Neurosciences Research Institute, Department of Neurological Surgery and Goodman and Campbell Brain and Spine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Chandler L. Walker
- Spinal Cord and Brain Injury Research Group, Stark Neurosciences Research Institute, Department of Neurological Surgery and Goodman and Campbell Brain and Spine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yi Ping Zhang
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY 40202, USA
| | | | - Xiao-Ming Xu
- Spinal Cord and Brain Injury Research Group, Stark Neurosciences Research Institute, Department of Neurological Surgery and Goodman and Campbell Brain and Spine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Incidental dural tear in lumbar spinal decompression and discectomy: analysis of a nationwide database. Arch Orthop Trauma Surg 2013; 133:1501-8. [PMID: 24002253 DOI: 10.1007/s00402-013-1843-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION An incidental dural tear (DT) is one of the most common intraoperative complications in lumbar spine surgery. The purpose of this study was to report the incidence of DT in lumbar spinal decompression (LSD) and lumbar discectomy (LD), risk factors, and patient outcomes on a national level. MATERIALS AND METHODS Clinical data were obtained from the Nationwide Inpatient Sample for 2009. Patients who underwent LSD for lumbar spinal stenosis and LD for lumbar disc herniation were identified and divided into those with and without DT, according to the International Classification of Diseases, 9th revision, Clinical Modification codes. Patient and healthcare system-related demographic data were retrieved. The incidence of DT and patient outcomes were analyzed. Multiple logistic regression analysis was performed to identify the risk factors for DT. RESULTS The incidence of DT was 6.3 % (4,255/67,982) in LSD and 1.9 % (2,564/136,482) in LD. Multivariate analysis revealed that significant risk factors for DT were hypertension and surgery in a teaching hospital for LSD, and older age and male gender for LD. DT was associated with significantly higher overall in-hospital complications (16.4 vs. 8.6 % for LSD, 9.1 vs. 8.0 % for LD). DT increased in-hospital mortality rate for LSD (0.7 vs. 0.1 %), however, not for LD (0.4 vs. 0.2 %). DT was associated with significantly longer hospital stay for LSD (4.6 vs. 3.0 days), however, not for LD (3.24 vs. 3.16 days). DT significantly increased hospital costs ($52,783 vs. $40,454 for LSD, and $32,307 vs. $27,787 for LD). CONCLUSIONS The incidence of DT was higher in LSD (6.3 %) than in LD (1.9 %), based on a national database. The effect of DT on in-hospital morbidity and mortality and health care burdens was more significant in LSD than in LD.
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Mannion AF, Fekete TF, O'Riordan D, Porchet F, Mutter UM, Jeszenszky D, Lattig F, Grob D, Kleinstueck FS. The assessment of complications after spine surgery: time for a paradigm shift? Spine J 2013; 13:615-24. [PMID: 23523445 DOI: 10.1016/j.spinee.2013.01.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 09/03/2012] [Accepted: 01/25/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Recent years have witnessed a shift in the assessment of spine surgical outcomes with a greater focus on the patient's perspective. However, this approach has not been widely extended to the assessment of complications. PURPOSE The present study sought to quantify the patient-rated impact/severity of complications of spine surgery and directly compare the incidences of surgeon-rated and patient-reported complications. STUDY DESIGN Prospective study of patients undergoing surgery for painful degenerative lumbar disorders, being operated in the Spine Center of an orthopedic hospital. PATIENT SAMPLE A total of 2,303 patients (mean [standard deviation] age, 61.9 [15.1] years; 1,136 [49.3%] women and 1,167 [50.7%] men). PATIENTS Core Outcome Measures Index, self-rated complications, bothersomeness of complications, global treatment outcome, and satisfaction. Surgeons: Spine Tango surgery and follow-up documentation forms registering surgical details and complications. METHODS PATIENTS completed questionnaires before and 3 months after surgery. Surgeons documented complications before discharge and at the first postoperative follow-up, 6 to 12 weeks after surgery. RESULTS In total, 615 out of 2,303 (27%) patients reported complications, with "bothersomeness" ratings of 1%, not at all; 22%, slightly; 26%, moderately; 34%, very; and 17%, extremely bothersome. PATIENTS most commonly reported sensory disturbances (35% of those reporting a complication) or ongoing/new pain (27%) followed by wound healing problems (11%) and motor disturbances (8%). The surgeons documented complications in 19% of patients. There was a minimal overlap regarding the presence or absence of complications in any given patient. CONCLUSIONS Most complications reported by the patient are perceived to be at least moderately bothersome and are, hence, not inconsequential. Surgeons reported lower complication rates than the patients did, and there was only moderate agreement between the ratings of the two. As with treatment outcome, complications and their severity should be assessed from both the patient's and the surgeon's perspectives.
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Affiliation(s)
- Anne F Mannion
- Spine Center, Schulthess Klinik, Lennghalde 2, 8008 Zürich, Switzerland.
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Epstein NE. A review article on the diagnosis and treatment of cerebrospinal fluid fistulas and dural tears occurring during spinal surgery. Surg Neurol Int 2013; 4:S301-17. [PMID: 24163783 PMCID: PMC3801173 DOI: 10.4103/2152-7806.111427] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/25/2013] [Indexed: 02/06/2023] Open
Abstract
Background: In spinal surgery, cerebrospinal fluid (CSF) fistulas attributed to deliberate dural opening (e.g., for tumors, shunts, marsupialization of cysts) or inadvertent/traumatic dural tears (DTs) need to be readily recognized, and appropriately treated. Methods: During spinal surgery, the dura may be deliberately opened to resect intradural lesions/tumors, to perform shunts, or to open/marsupialize cysts. DTs, however, may inadvertently occur during primary, but are seen more frequently during revision spinal surgery often attributed to epidural scarring. Other etiologies of CSF fistulas/DTs include; epidural steroid injections, and resection of ossification of the posterior longitudinal ligament (OPLL) or ossification of the yellow ligament (OYL). Whatever the etiology of CSF fistulas or DTs, they must be diagnosed utilizing radioisotope cisternography (RIC), magnetic resonance imaging (MRI), computed axial tomography (CT) studies, and expeditiously repaired. Results: DTs should be repaired utilizing interrupted 7-0 Gore-Tex (W.L. Gore and Associates Inc., Elkton, MD, USA) sutures, as the suture itself is larger than the needle; the larger suture occludes the dural puncture site. Closure may also include muscle patch grafts, dural patches/substitutes (bovine pericardium), microfibrillar collagen (Duragen: Integra Life Sciences Holdings Corporation, Plainsboro, NJ), and fibrin glues or dural sealants (Tisseel: Baxter Healthcare Corporation, Deerfield, IL, USA). Only rarely are lumbar drains and wound-peritoneal and/or lumboperitoneal shunts warranted. Conclusion: DTs or CSF fistulas attributed to primary/secondary spinal surgery, trauma, epidural injections, OPLL, OYL, and other factors, require timely diagnosis (MRI/CT/Cisternography), and appropriate reconstruction.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurological Surgery, Department of Neurosurgery, The Albert Einstein College of Medicine, Bronx, NY, 10461, and Chief of Neurosurgical Spine and Education, Department of Neurosurgery, Winthrop University Hospital, Mineola, NY, 11501, USA
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Papadakis M, Aggeliki L, Papadopoulos EC, Girardi FP. Common surgical complications in degenerative spinal surgery. World J Orthop 2013; 4:62-6. [PMID: 23610753 PMCID: PMC3631953 DOI: 10.5312/wjo.v4.i2.62] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 11/26/2012] [Accepted: 12/23/2012] [Indexed: 02/06/2023] Open
Abstract
The rapid growth of spine degenerative surgery has led to unrelenting efforts to define and prevent possible complications, the incidence of which is probably higher than that reported and varies according to the region of the spine involved (cervical and thoracolumbar) and the severity of the surgery. Several issues are becoming progressively clearer, such as complication rates in primary versus revision spinal surgery, complications in the elderly, the contribution of minimally invasive surgery to the reduction of complication rate. In this paper the most common surgical complications in degenerative spinal surgery are outlined and discussed.
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Time spent per patient in lumbar spinal stenosis surgery. 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 2013; 22:1868-76. [PMID: 23397190 DOI: 10.1007/s00586-013-2691-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 12/09/2012] [Accepted: 01/25/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE To examine the time needed from a surgeon's viewpoint to treat a patient operated for lumbar spinal stenosis. We firstly aimed to give evidence of the wide ranging duration of standardized procedure. Secondly, we investigated factors affecting the time allocated to each patient. METHODS 438 medical records of patients operated on for lumbar decompression without fusion (2005-2011) were retrospectively examined. Primary data were operative time (OT, min), length of stay (LoS, days) and number of postoperative visits. A fourth parameter was calculated, the time spent per patient (TSPP, min) by summing the time spent in surgery, during inpatient and outpatient follow-up visits. Factors that influenced these medical resources were examined. RESULTS Median (5th-95th percentile) LoS was 5 days (2-15), OT 106 min (60-194), number of medical visits 5 (2-11) and TSPP 329 min (206-533). In descending order, factors predicting LoS were age, no. of levels, sex, operative technique, cardiovascular risk index, dural tear and haematoma. Factors predicting OT were number of levels, dural tear, foraminotomy, synovial cyst and body mass index. The statistical model could predict 36% of the TSPP variance. We recommend that surgeons add 35 min for each level, 29 min for patients over 65 years, 30 min for women, 132 min for dural tear and 108 min for epidural haematoma. CONCLUSION TSPP treated for lumbar spinal stenosis is highly variable, yet partially predictable. These data may help individual surgeons or heads of departments to plan their activities.
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McMahon P, Dididze M, Levi AD. Incidental durotomy after spinal surgery: a prospective study in an academic institution. J Neurosurg Spine 2012; 17:30-6. [DOI: 10.3171/2012.3.spine11939] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Incidental durotomies (IDs) are an unfortunate but anticipated potential complication of spinal surgery. The authors surveyed the frequency of IDs for a single spine surgeon and analyzed the major risk factors as well as the impact on long-term patient outcomes.
Methods
The authors conducted a prospective review of elective spinal surgeries performed over a 15-year period. Any surgery involving peripheral nerve only, intradural procedures, or dural tears due to trauma were excluded from analysis. The incidence of ID was categorized by surgery type including primary surgery, revision surgery, and so forth. Incidence of ID was also examined in the context of years of physician experience and training. Furthermore, the incidence and types of sequelae were examined in patients with an ID.
Results
Among 3000 elective spinal surgery cases, 3.5% (104) had an ID. The incidence of ID during minimally invasive procedures (3.3%) was similar, but no patients experienced long-term sequelae. The incidence of ID during revision surgery (6.5%) was higher. There was a marked difference in incidence between cervical (1.3%) and thoracolumbar (5.1%) cases. The incidence was lower for cases involving instrumentation (2.4%). When physician training was examined, residents were responsible for 49% of all IDs, whereas fellows were responsible for 26% and the attending for 25%. Among all of the cases that involved an ID, 7.7% of patients went on to experience a neurological deficit as compared with 1.5% of those without an ID. The overall failure rate of dural repair was 6.9%, and failure was almost 3 times higher (13%) in revision surgery as compared with a primary procedure (5%).
Conclusions
The authors established a reliable baseline incidence for durotomy after spine surgery: 3.5%. They also identified risk factors that can increase the likelihood of a durotomy, including location of the spinal procedure, type of procedure performed, and the implementation of a new procedure. The years of physician training or resident experience did not appear to be a major risk for ID.
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Mannion AF, Mutter UM, Fekete FT, O'Riordan D, Jeszenszky D, Kleinstueck FS, Lattig F, Grob D, Porchet F. The bothersomeness of patient self-rated "complications" reported 1 year after spine surgery. 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 2012; 21:1625-32. [PMID: 22481548 DOI: 10.1007/s00586-012-2261-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 02/25/2012] [Accepted: 03/04/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE The last few decades have witnessed a paradigm shift in the assessment of outcome in spine surgery, with patient-centred questionnaires superseding traditional surgeon-based assessments. The assessment of complications after surgery and their impact on the patient has not enjoyed this same enlightened approach. This study sought to quantify the incidence and bothersomeness of patient-rated complications 1 year after surgery. METHODS Patients with lumbar degenerative disorders, operated with the goal of pain relief between October 2006 and September 2010, completed a questionnaire 1 year postoperatively enquiring about complications arising as a consequence of their operation. They rated the bothersomeness of any such complications on a 5-point scale. Global outcome of surgery and satisfaction at the 12-month follow-up were also rated on 5-point Likert scales. The multidimensional Core Outcome Measures Index (COMI) was completed preoperatively and at the 12-month follow-up. RESULTS Of 2,282 patients completing the questionnaire (92% completion rate), 687 (30.1%) reported complications, most commonly sensory disturbances (36% of those with complications) or ongoing/new pain (26%), followed by motor problems (8%), pain plus neurological disturbances (11%), and problems with wound healing (6%). The corresponding "bothersomeness" ratings for these were: 1% not at all, 23% slightly, 27% moderately, 31% very, and 18% extremely bothersome. The greater the bothersomeness, the worse the global outcome (Rho = 0.51, p < 0.0001), patient satisfaction (Rho = 0.44, p < 0.0001) and change in COMI score (Rho = 0.52, p < 0.0001). CONCLUSION Most complications reported by the patient are perceived to be at least moderately bothersome and hence are not inconsequential. Complications and their severity should be assessed from both the patient's and the surgeon's perspectives--not least to better understand the reasons for poor outcome and dissatisfaction with treatment.
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Affiliation(s)
- A F Mannion
- Spine Center Division, Department of Research and Development, Schulthess Klinik, Zurich, Switzerland.
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Ruban D, O'Toole JE. Management of incidental durotomy in minimally invasive spine surgery. Neurosurg Focus 2011; 31:E15. [DOI: 10.3171/2011.7.focus11122] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Unintended durotomy is one of the most common complications in spine surgery that may lead to serious complications if not recognized or treated properly. There are few reports on the management of durotomies incurred during minimally invasive spine surgery (MISS). The authors describe their experience in a series of consecutive MISS patients with unintended durotomies.
Methods
All patients who underwent MISS by the senior author between August 2006 and February 2011 were retrospectively reviewed, and cases with unintended durotomies were identified. A case-control study was carried out comparing patient demographics and perioperative data between patients with and without durotomy. Surgical technique, including a proposed algorithm for management of durotomies, is described.
Results
Unintended durotomy occurred in 53 (9.4%) of 563 patients. The mean age at surgery was 60.7 years (range 30–85 years). Previous surgery at the same level was performed in 5 patients (9.4%). Two patients underwent posterior cervical surgery, and 51 patients underwent posterior lumbar surgery. Decompression alone was performed in 32 patients (60.4%), and fusion was performed in 21 patients (39.6%). The mean operative time was 105 minutes in the decompression group and 310 minutes in the fusion group (p < 0.001). Estimated blood loss was 60 ml in the decompression group and 381 ml in the fusion group (p < 0.001). The hospital length of stay was 52 hours in the decompression group and 106 hours in the fusion group (p < 0.001). The mean follow-up was 310 days, and there were no cases of cutaneous CSF fistula, pseudomeningocele, or other complications referable to durotomy in either group. Risk factors identified for durotomy included previous operation at the same level (p = 0.019) and operation in the lumbar spine region (p = 0.001).
Conclusions
In the authors' consecutive series of patients undergoing MISS, an unintended durotomy was associated with fewer complications than previously reported for open spinal surgery. The authors propose a simple management algorithm that includes early mobilization and results in excellent clinical outcomes with no incidence of postoperative cutaneous CSF fistula or other complications.
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