Surgical complications associated with spinal decompression surgery in a Japanese cohort

Clinical outcomes of unilateral biportal endoscopic discectomy (UBE) compared with conventional open lumbar discectomy with 3D microscope (OLDM) assisted

The open lumbar discectomy with 3D microscope (OLDM) is considered the most common surgical procedure for herniated or ruptured discs of the lumbar spine, while unilateral biportal endoscopic (UBE) technique is a rapidly growing surgical treatment for spinal surgery. UBE as a new endoscopic technique has been applied to conventional arthroscopic systems for treating the spinal disease. In this research, we aimed to evaluate and compare the perioperative parameters and clinical outcomes, including operative time, intraoperative, blood loss, pain and modification, hospital stay, patient's satisfaction, and complications, between OLDM and UBE for lumbar disc herniation. A total of 76 patients with lumbar disc herniation were included in this study from February 2019 to February 2022. All of them had received spinal surgery who underwent OLDM (42 cases) and UBE (34 cases) in Affiliated Hospital of Nantong University and Affiliated Nantong Hospital 3 of Nantong University. Respectively, all the patients had 1 level lumber disc herniation. Perioperative metrics were compared between the 2 groups: estimated blood loss, operation time, length of hospital stay, and complications of the patients. The visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI) and modified MacNab criteria were tested before surgery and 3 days, 3 months and 12 months following surgery. Compared with the OLDM group, the UBE group had obviously shorter operative time, less intraoperative blood loss, and shorter hospital stay. In addition, the VAS and ODI scores had a significantly reduction in 2 groups after operation. There was no great difference of VAS and ODI scores in preoperative and 3 days, 3 months, and 12 months after operation between the 2 groups. Meanwhile, there was no significant difference in the rate of operational conversion and complications between the 2 groups. Application of OLDM yielded similar clinical outcomes to UBE for treatment of lumbar disc herniation containing pain control and patient satisfaction. Nevertheless, UBE was associated with several advantages relative to OLDM in terms of surgical time, intraoperative blood loss, short-term postoperative pain relief and postoperative hospitalization.

Laminoplasty and In-Site Regrafting for the Treatment of Thoracic Ossification of the Ligamentum Flavum: A Surgical Technique

OBJECTIVE

Current surgical strategies for thoracic ossification of the ligamentum flavum (TOLF) are denounced by thoracic kyphosis, loss of spinal motion range, etc. A new surgical technique, laminoplasty and in-site regrafting (LPIR), was modified to address the problems. This study aimed to report the safety and feasibility of LPIR for TOLF treatment.

METHODS

This retrospective study reported the outcome of eight consecutive patients (3 males and 5 females, mean age 52.87 years) with TOLF who underwent LPIR surgery from January 2019 to March 2024. Pre- and post-operative data including x-ray, computerized tomography (CT), magnetic resonance imaging (MRI), the modified Japanese Orthopedic Association score (mJOA), the visual analog scale (VAS), and complications were collected to evaluate the outcome.

RESULTS

All surgeries were performed successfully, significantly alleviating symptoms postoperatively. During an average follow-up period of 28.63 months, the VAS score reduced from 4.50 ± 1.00 pre-operatively to 1.63 ± 0.48 on the third post-operative day and further reduced to 0.50 ± 0.70 during the last follow-up. The mJOA score increased from 3.63 ± 0.70 pre-operatively to 6.13 ± 0.78 on the third postoperative day and further increased to 8.88 ± 1.27 during the last follow-up. No severe complications were observed.

CONCLUSIONS

LPIR exhibited significant safety and feasibility for treating TOLF, offering a novel strategy for managing this problem.

Ultrasonic Bone Scalpel versus Conventional Technique for Thoracolumbar Spinal Decompression: A Prospective Randomized Controlled Trial

Objective  The purpose of the present study is to compare intraoperative blood loss, operating time, laminectomy time, hospital length of stay, and complications in thoracolumbar spinal decompression using ultrasonic bone scalpels (UBSs) with conventional procedures. Methods  Forty-two patients who underwent decompressive laminectomy and pedicular screw fusion with a surgical level of 1-5 levels between February 1, 2020, and June 30, 2022, in a single institution were evaluated for eligibility, and 11 were excluded due to a history of spinal surgery ( n  = 3), spinal tumor ( n  = 3), and spinal infection ( n  = 5). A total of 31 patients were randomly divided into the UBS group ( n =15) and the conventional group ( n =16). Intraoperative blood loss, operating time, laminectomy time, hospital length of stay, and complications were recorded. Results  Intraoperative blood loss and laminectomy time were significantly lower in the UBS group (656.0 ± 167.6 ml, 54.5 ± 27.4 minutes, respectively) than in the conventional group (936.9 ± 413.2 ml, 73.4 ± 28.1 minutes, respectively). Overall operation time, hospital length of stay, and complications were all similar between the groups. Conclusion  The UBS is a useful instrument for procedures performed near the dura mater or other neural tissue without excessive heat or mechanical injury. This device is recommended for various spinal surgeries in addition to high-speed burrs and Kerrison rongeurs.

The Gantry Crane Technique: A Novel Technique for Treating Severe Thoracic Spinal Stenosis and Myelopathy Caused by Ossification of the Ligamentum Flavum and Preliminary Clinical Results

STUDY DESIGN

Retrospective single-arm study.

OBJECTIVE

To propose a novel technique named the gantry crane technique for treating severe thoracic spinal stenosis and myelopathy caused by thoracic ossification of the ligamentum flavum (TOLF) and investigate its clinical results.

METHODS

From June 2017 to January 2019, 18 patients presenting with severe spinal stenosis and myelopathy caused by TOLF were included in our study. All patients were treated with gantry crane technique, pre-operative JOA score, as well as 3 days-, 3 months-, 6 months-, 12 months-, 24 months after operation, and Hirabayashi recovery rate were reported. Pre- and post-operative image were utilized for the assessment of post-operative effect. Peri-operative complications were recorded to assess the safety of the gantry crane technique.

RESULTS

The JOA score increased from 10.56 ± 3.76 preoperatively to 12.94 ± 3.33, 13.56 ± 3.48, 13.94 ± 3.32, 14.17 ± 3.70 and 14.06 ± 3.54 in 3 days, 3 months, 6 months, 12 months and 24 months after surgery, respectively. The post-operative JOA scores were improved with statistical significance at the level of P < 0.05. The recovery rate was (39.09 ± 33.85) %, (51.35 ± 42.60) %, (55.79 ± 36.10) %, (64.98 ± 29.24) % and (60.98 ± 35.96) % for 3 days, 3 months, 6 months, 12 months and 24 months after surgery, respectively. There were 2 cases of SSI (surgical site infection), 1 case of NI (neurovascular injury) and 1 case of cerebrospinal fluid (CSF) leakage.

CONCLUSIONS

This study highlights a safe and effective technique, the gantry crane technique, for treating severe thoracic spinal stenosis and myelopathy caused by TOLF.

Tibial nerve SEPs in diagnosing lumbar spinal stenosis: The utility of segmental evaluation using P15 and N21

Objective

To establish the utility of the additional evaluation of the P15 potential generated at the greater sciatic foramen in the tibial nerve somatosensory evoked potentials (SEPs) in diagnosing lumbar spinal stenosis (LSS).

Methods

We retrospectively reviewed tibial nerve SEP findings in patients having MRI-confirmed LSS at the cauda equina or conus/epiconus region. P15 and N21 potentials were recorded and the following findings were defined as localizing abnormalities: 1) normal P15 latency either with prolonged P15-N21 interval or with absent N21; 2) decreased ratio of the N21 amplitude to P15 amplitude. As non-localizing abnormalities, N21 and P38 latencies were also evaluated. Tibial nerve F-wave findings were also investigated.

Results

According to the entry criteria, 18 patients were included, 15 with cauda equina lesions and 3 with conus/epiconus lesions. Localizing abnormalities in SEPs were found in 67% of patients, achieving significantly higher sensitivity than delayed P38 latency (28%), and higher sensitivity than N21 abnormalities (39%), though this was not significant. Localizing abnormalities were observed even in 6 out of 11 patients lacking both sensory symptoms and signs. Tibial nerve F-wave was abnormal in 36% of 14 patients with F-wave examinations, whereas the localizing abnormalities in SEPs were found in 64% of the same patient population. P15 amplitude was depressed in 4 patients (22%), which may indicate the involvement of the dorsal root ganglion in LSS, although its latency was normal even for these patients.

Conclusions

Tibial nerve SEPs with the recording of P15 and N21 potentials achieved sufficiently high sensitivity in diagnosing LSS. They have the advantage over F-wave in that they can localize the lesion at the cauda equina or conus/epiconus level.

Significance

Tibial nerve SEPs are promising in evaluating LSS, especially in documenting sensory tract involvement in cases lacking sensory symptoms/signs.

Zoning laminectomy for the treatment of ossification of the thoracic ligamentum flavum

OBJECTIVE

Spinal cord injury is a common occurrence during spinal surgery. In this study, we proposed a zoning laminectomy, which could reduce the incidence of nerve injury. We also discussed the safety and clinical efficacy of the zoning laminectomy for thoracic ossification of the ligamentum flavum (TOLF).

METHODS

Forty-five patients with TOLF who underwent zoning laminectomy from October 2016 to February 2020 were included in the retrospective analysis. The Japan Orthopedic Association (JOA) score was used to evaluate clinical outcomes. Meanwhile, the occurrence of complications was recorded.

RESULTS

All 45 patients underwent the operation successfully, and the mean follow-up period was 25.3 months, the mean operation time was 160.2 min, the average blood loss was 474.2 ml, and the average hospital time was 8.0 days. At the final evaluation, the JOA score was significantly higher than the preoperative JOA score (P < 0.001) and the overall recovery rate of the JOA score averaged 69.6%. Seventeen patients were graded as excellent, twenty-six as good, and two as fair. The complications included dural tears in nine patients (20.0%), cerebrospinal fluid leakage in seven patients (15.6%), deep infection in one patient (2.2%), and epidural hematoma in one patient (2.2%). All patients recovered well after treatment. Besides, there was no neurological deterioration and thoracic kyphosis occurred.

CONCLUSIONS

Zoning laminectomy adopts a phased resection from "safe zone" to "danger zone" and defines the safe removal range of the lamina, which reduces the risks of spinal cord injury caused by instrument manipulation. Therefore, it is a safe and effective surgical option.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

BACKGROUND

The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.

METHODS

The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.

RESULTS

Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.

CONCLUSIONS

The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.

Complications of Spine Surgery in Elderly Japanese Patients: Implications for Future of World Population Aging

Objective

To analyze the relationship between age and perioperative complications of spine surgery in a Japanese cohort with the longest average life expectancy in the world.

Methods

Patients with spinal stenosis who underwent standard spine surgery without instrumented fusion were divided into 4 groups: adults (20–64 years), the young-old (65–74), the middle old (75–84), and the oldest-old (≥85). Data on medical complications, surgical complications, and deaths within 30 days of index surgery were compared across the groups. Risk factors for complications were identified through multivariate analysis.

Results

A total of 584 patients underwent 673 operations: 35% were performed on adult patients, 33% on the young-old, 27% on the middle old, and 5% on the oldest-old. The rates of total or [major] medical complications significantly increased with age (8% [0.8%], 11% [0.9%], 27% [3.9%], 45% [9.1%], respectively; p<0.001 [p=0.003]), whereas those of surgical complications did not differ (11%, 8.1%, 14%, 9.1%, respectively; p=0.25). Independent risk factors for medical complications were an age of 75 years or older (75–84: odds ratio [OR], 5.1; ≥85: OR, 6.2) and American Society of Anesthesiologists (ASA) physical status classification III (OR, 5.4). Two patients older than 85 years died from medical complications.

Conclusion

The complications of spine surgery increased in the middle and oldest-old patients because of medical complications; however, most were minor and treatable. Major complications were associated with preoperative medical comorbidities and their severities; therefore, most elderly patients with low ASA physical status classification (≤II) may benefit from spine surgery.

Comparative study of perioperative complication rates of cervical laminoplasty performed by residents and teaching neurosurgeons

Early surgical education is required for neurosurgical residents to learn many surgical procedures. However, the participation of less experienced residents may increase perioperative complication rates. Perioperative complication studies in the field of neurosurgery are being increasingly published; however, studies have not yet focused on cervical laminoplasty. The study population included 193 consecutive patients who underwent cervical laminoplasty in Tokyo Metropolitan Neurological Hospital between 2008 and 2014. Patient and surgeon background factors, as well as perioperative complication rates were retrospectively compared between resident and board-certified spine neurosurgeon groups. Deteriorated or newly developed neurological deficits and surgical site complications within 30days of cervical laminoplasty were defined as perioperative complications. Out of 193 patients, 123 (64%) were operated on by residents as the first operator and 70 (36%) by board-certified spine neurosurgeons. No significant differences were observed in patient and surgeon factors between the two groups, except for hyperlipidemia (13 vs 17, p=0.02). Furthermore, no significant differences were noted in perioperative complication rates between the two groups (7 [5.7%] vs 4 [5.7%], p=1). Cervical laminoplasty performed in a standardized manner by residents who received their surgical training in our hospital did not increase perioperative complication rates, and ensured the safety of patients.