Effect of Ultrasonic Osteotome on Therapeutic Efficacy and Safety of Spinal Surgery: A System Review and Meta-Analysis

Background. A meta-analysis was performed to evaluate the effectiveness and safety of ultrasonic osteotomes in spine surgery to standard spinal surgery procedures. Methods. Using the search keywords “bone curette”, “cutter”, “scalpel”, “bone shaver”, “aspirator”, “osteotome”, “ultrasonic”, “piezosurgery”, and “ ${\text{dent}\hspace{0.17em}\hspace{0.17em}}^{\ast }$ ” in the databases of PubMed (1966-2021.12), Cochrane Library, Embase (1986-2018.12), Web of Science (1978-2021.12), and China Academic Journals Full-Text Database (CNKI, 1979-2021.12). Two researchers reviewed the literature, extracted and extensively assessed the data, and included information on the study quality. RevMan v5.3.5.0 was used for the meta-analysis. Results. A total of 10 trials with a total of 911 patients were included. The meta-analysis findings revealed that, when compared to traditional methods, ultrasonic osteotomes could save operation time ( $\text{OR}=-18.83$ , 95 percent CI (-22.76, -14.99), $P=0.03$ ) and reduce intraoperative bleeding ( $\text{OR}=-66.73$ , 95 percent CI (-75.70, -57.76), $P=0.04$ ) and postoperative complications ( $\text{OR}=0.38$ , 95 percent CI (0.21, 0.69), $P=0.001$ ). There was, however, no significant difference in the hospital stay ( $\text{OR}=-1.34$ , 95 percent CI (-1.90, -0.77), $P=0.23$ ) and symptom improvement rate ( $\text{OR}=1.03$ , 95 percent CI (0.73, 1.45), $P=0.86$ ). Conclusion. There is evidence that using an ultrasonic osteotome in spine surgery is safe and effective and may minimize intraoperative bleeding and save time. However, there is no significant difference in symptom improvement rate, hospital stay length, or postoperative complications compared to standard surgical equipment. Therefore, more high-quality investigations are needed to corroborate the initial results.

Bone-to-bone ligament preserving laminoplasty technique for reconstruction of laminae

Introduction

Laminoplasty is a method used in spinal intradural tumor surgery to reduce the possibility of iatrogenic deformity. In classic laminoplasty, the interspinous, supraspinous, and ligamentum flavum integrity may be impaired, thereby creating a risk of deformity despite the laminoplasty. The aim of this study was to review the outcomes of bone-to-bone ligament preserving laminoplasty (BLP laminoplasty) technique.

Materials and Methods

The data of 14 cases who underwent BLP laminoplasty for intradural spinal tumor between 2017 and 2019 were reviewed. Through examination of preoperative and postoperative computed tomography images and flexion-extension lateral X-rays, the fusion and kyphotic changes were evaluated in the laminas. An axial Visual Analog Scale (VAS) was used to evaluate clinical satisfaction.

Results

The cases comprised 10 females and 4 males, with a mean age of 39.2 years (range, 16-52 years). The masses were intramedullary in six cases and extramedullary in eight. Lumbar region localization was most frequent. Ependymoma was determined in 8 cases, schwannoma in 4, and meningioma in 2. Laminoplasty was applied at 43 levels (10 thoracic and 33 lumbar). No complications were observed, and fusion was obtained in all the cases at the end of 1 year. No segmental kyphotic changes were determined. In the clinical evaluation, the VAS scores improved from 3.4 ± 2.0 preoperatively to 1.8 ± 2.1 postoperatively.

Conclusion

BLP laminoplasty is a safe technique which preserves posterior ligamentous integrity. Furthermore, the use of ultrasonic bone scalpel provides a narrower gap between laminae and other bones, preventing dislocation, and allowing for more fusion, and consequently preventing kyphosis.

Resection of Spinal Meningioma Using Ultrasonic BoneScalpel Microshaver: Cases, Technique, and Review of the Literature

BACKGROUND

Meningiomas of the spinal canal comprise up to 40% of all spinal tumors. The standard management of these tumors is gross total resection. The outcome and extent of resection depends on location, size, patient's neurologic status, and experience of the surgeon. Heavily calcified spinal meningiomas often pose a challenge for achieving gross total resection without cord injury.

OBJECTIVE

To report our experience with the BoneScalpel Micro-shaver to resect heavily calcified areas of spinal meningiomas adherent to the spinal cord without significant cord manipulation, achieving gross total resection and outstanding clinical results.

METHODS

Seventy-nine and 82-yr-old females presented with progressive leg weakness, paresthesias, and gait instability. Magnetic resonance imaging of the thoracic spine showed a homogenous enhancing intradural extramedullary mass with mass effect on the spinal cord. Midline bilateral laminectomy was performed, and the dura was open in midline. The lateral portion of the tumor away from the spinal cord was resected with Cavitron Ultrasonic Surgical Aspirator while the BoneScalpel Micro-shaver (power level 5 and 30% irrigation) was brought into the field for the calcified portion of the tumor adherent to the spinal cord.

RESULTS

Gross total resection was achieved for both cases. At the 2-wk postoperative visit, both patients reported complete recovery of their leg weakness with significant improvement in paresthesias and ataxia.

CONCLUSION

The ultrasonic osteotome equipped with a microhook tip appears to be a safe surgical instrument allowing for effective resection of spinal meningiomas or other heavily calcified spinal masses not easily removed by usual surgical instrumentation.

Ultrasonic bone scalpel for thoracic spinal decompression: case series and technical note

Background

Thoracic spinal stenosis (TSS) is a rare but intractable disease that fails to respond to conservative treatment. Thoracic spinal decompression, which is traditionally performed using high-speed drills and Kerrison rongeurs, is a time-consuming and technically challenging task. Unfavorable outcomes and high incidence of complications are the major concerns. The development and adaptation of ultrasonic bone scalpel (UBS) have promoted its application in various spinal operations, but its application and standard operating procedure in thoracic decompression have not been fully clarified. Therefore, the purpose of this study is to describe our experience and technique note of using UBS and come up with a standard surgical procedure for thoracic spinal decompression.

Methods

A consecutive of 28 patients with TSS who underwent posterior thoracic spinal decompression surgery with UBS between December 2014 and May 2015 was enrolled in this study. The demographic data, perioperative complications, operation time, estimated blood loss, and pre- and postoperative neurological statuses were recorded and analyzed. Neurological status was evaluated with a modified Japanese Orthopaedic Association (JOA) scale, and the neurological recovery rate was calculated using the Hirabayashi’s Method.

Results

Thoracic spinal decompression surgery was successfully carried out in all cases via a single posterior approach. The average age at surgery was 49.7 ± 8.5 years. The mean operative time of single-segment laminectomy was 3.0 ± 1.4 min, and the blood loss was 108.3 ± 47.3 ml. In circumferential decompression, the average blood loss was 513.8 ± 217.0 ml. Two cases of instrument-related nerve root injury occurred during operation and were cured by conservative treatment. Six patients experienced cerebrospinal fluid (CSF) leakage postoperatively, but no related complications were observed. The mean follow-up period was 39.7 ± 8.9 months, the average JOA score increased from 4.7 before surgery to 10.1 postoperatively, and the average recovery rate was 85.8%.

Conclusions

The UBS is an optimal instrument for thoracic spinal decompression, and its application enables surgeons to decompress the thoracic spinal cord safely and effectively. This standard operating procedure is expected to help achieve favorable outcomes and can be used to treat various pathologies leading to TSS.

3D Real-Time Image-Guided Navigation Spine Corpectomy with Ultrasonic Bone Cutter: Technical Note

BACKGROUND

Surgical interventions for congenital scoliosis are challenging for spine surgeons. The coordination of 3-dimensional (3D), real-time, image-guided navigation with an ultrasonic bone cutter allows surgeons to localize the affected area of the spine accurately and remove the lesion without damaging soft tissue structures. The goal of this technical paper is to report a previously undescribed method of hemivertebrectomy that combines 3D, real-time, image-guided navigation and an ultrasonic bone cutter. We highlight the feasibility and safety of this method in spinal surgery.

METHODS

Three patients with congenital scoliosis were treated with this technique. We present three illustrative cases comprising hemivertebrectomies for congenital scoliosis. Intraoperative photos demonstrating the technique are also provided.

RESULTS

All surgeries were completed without complications. The hemivertebrae were completely removed, and marked correction of congenital scoliosis was noted.

CONCLUSIONS

We believe that the combination of 3D, real-time image navigation and an ultrasonic bone cutter improves hemivertebrectomy by increasing accuracy and avoiding dura laceration, major organ damage, or potential vessel damage.

Suitability of Administrative Databases for Durotomy Incidence Assessment: Comparison to the Incidence Associated With Bone-Removal Devices, Calculated Using a Systemic Literature Review and Clinical Data

Background

Durotomy is a major complication of spinal surgery, potentially leading to additional clinical complications, longer hospitalization, and increased costs. A reference durotomy incidence rate is useful for the evaluation of the safety of different surgical aspects. However, the literature offers a wide range of incidence rates, complicating this comparison. Theoretically, a reference incidence value can be extracted from administrative databases, containing a large number of procedures. However, it is suspected that these databases suffer from underreporting of complications. This study aims to evaluate durotomy incidence using several large-scale databases and to assess the ability to use it as a reference by comparison to durotomy incidences directly associated with 4 bone removal devices, including the commonly used high-speed drill.

Methods

Durotomy overall incidence was estimated from several administrative databases using different methods in order to achieve minimal and maximal estimations. Durotomy incidences for 3 bone removal devices were derived using literature meta-analysis, and the incidence for the fourth device was calculated using clinical data.

Results

The incidence range of durotomy according to the databases was 2.8-3.5%. The calculated incidence of durotomy for the studied devices was 0.4-2.91%. The highest rate, 2.91%, is associated with the commonly used high-speed drill combined with Kerrison Rongeur and bone punches. Since bone-removal devices are just one of the possible causes of dural tears, the general incidence is expected to be higher than the incidence associated with the devices, yet even the maximal estimation, 3.5%, was only slightly higher, suggesting that the speculation of underreporting of dural tears to these databases is probably true, as also supported by the mostly higher incidences reported in the literature.

Conclusions

Hospital administrative databases seem to show a lower-than-reasonable incidence of durotomy, suggesting possible underreporting. Researchers should therefore use this tool with caution. Reduction of the absolute durotomy incidence by approximately 2.5% can be achieved by improving the safety of bone-removal devices.

Alternative technique in atypical spinal decompression: the use of the ultrasonic scalpel in paediatric achondroplasia

Spinal stenosis can be a very disabling condition. Surgical decompression carries a risk of dural tear and neural injury, which is increased in patients with severe stenosis or an atypical anatomy. We present an unusual case of symptomatic stenosis secondary to achondroplasia presenting in a paediatric patient, and highlight a new surgical technique used to minimise the risk of dural and neural injury during decompression.

Technical note: Orbitozygomatic craniotomy using an ultrasonic osteotome for precise osteotomies

BACKGROUND

The orbitozygomatic craniotomy is a fundamental procedure in neurosurgery, allowing access to orbital and skull base pathology.

OBJECTIVE

Determine the feasibility of using an ultrasonic osteotome to safely perform orbitozygomatic osteotomies in patients with intracranial pathology.

METHODS

The medical records of patients undergoing orbitozygomatic craniotomy using an ultrasonic osteotome (Aesculap BoneScalpel™) for tumor resection at Johns Hopkins Hospital between November 2009 and March 2013 were retrospectively reviewed.

RESULTS

Six patients underwent orbitozygomatic craniotomy for tumor resection using an ultrasonic osteotome at the Johns Hopkins Hospital during the study period. All patients were female and the average age was 53.2 years. Patients were followed for an average of 375 days. There were two cases of transient diplopia. There were no cases of periorbital violation, orbital injury, enophthalmos, or orbital hematoma. Post-operative imaging showed the cuts were well opposed and no cosmetic issues were encountered.

CONCLUSION

Use of an ultrasonic osteotome allows for precise cuts under direct visualization with minimal risk to critical adjacent structures in our cohort of patients undergoing a two-piece orbitozygomatic craniotomy. This appears to be a safe instrument for osteotomy creation in skull base approaches.