Incidence, Risk Factors, and Outcomes of Incidental Durotomy during Lumbar Spine Decompression with or without Fusion

Does incidental durotomy affect clinical outcome in patients with lumbar degenerative diseases after posterior open lumbar interbody fusion? a multicenter observational study

BACKGROUND

Incidental durotomy (ID) during spinal surgery is common during spinal surgery. This study aimed to determine whether intraoperative ID affects the perioperative and long-term clinical outcomes in patients with degenerative lumbar disease (DLD) undergoing posterior open lumbar interbody fusion (POLIF).

METHODS

This multicenter observational study was conducted at two spinal centers between January 2020 and December 2022. The patients were divided into ID and non-ID groups according to whether ID occurred intraoperatively. Primary outcome measure was the length of hospital stay (LOS), while secondary outcome measures were 30-day readmission rate; hospital costs; postoperative visual analog scale (VAS) scores for low back pain (LBP) and leg pain (LP) at 1 day, 3, 7, and 15 days, 1 month, 3, 6, and 12 months; and Oswestry Disability Index (ODI) at 1 month, 3, 6, and 12 months.

RESULTS

Intraoperative ID occurred in 8.7% (36/415) patients. LOS, operative time, estimated blood loss, 30-day readmission rate, and hospital costs were significantly higher in the ID group. On average, the LOS increased by 2.9 days and hospital costs increased by 4800.2 yuan per patient. The ID group had significantly higher baseline VAS scores for LBP 15 days and 1 month postoperatively than the non-ID group. The ODI was significantly higher in the ID group than in the non-ID group 1 month postoperatively. No significant differences were noted in the VAS scores and ODI between the two groups at 3, 6, and 12 months postoperatively. Finally, we found that a higher BMI (P = 0.035, OR: 1.195, 95%CI: 1.012-1.412) and revision surgery (P = 0.022, OR: 2.901, 95%CI: 1.164-7.233) were risk factors for intraoperative ID.

CONCLUSIONS

Although ID does not significantly affect the long-term outcomes in patients with DLD after POLIF, it can lead to poorer perioperative clinical outcomes. Lumbar fusion surgery should be performed meticulously to minimize the incidence of intraoperative ID.

Incidental Durotomy During Transforaminal Lumbar Interbody Fusion (TLIF) Surgery with Expandable Interbody Spacers: A Retrospective, Single-Center Analysis of Complications and Outcomes

Study DesignRetrospective cohort study.ObjectivesTo evaluate the frequency, risk factors, and impact of incidental durotomy on adverse events and outcomes after TLIF with expandable interbody spacers.MethodsWe reviewed 433 consecutive patients treated by TLIF using expandable titanium interbody implants (ALTERA®, Globus Medical Inc) on 538 levels between December 2018 and September 2023. Patients with incidental durotomy (ID) and cerebrospinal fluid leakage were compared to patients without ID, focusing on patient-specific and surgery-related factors, adverse events, clinical outcomes (MacNab criteria), and radiological outcomes at discharge, 3, and 12 months.ResultsThe ID rate was 9.0% (39/433 patients). Patients with ID had lower BMI (26.1 ± 5.2 vs 28.0 ± 5.3 kg/m2, P = .03), longer surgery duration (358 ± 132 vs 305 ± 128 minutes, P = .01), and extended hospital stays (14.7 ± 12.8 vs 10.9 ± 8.2 days, P < .01). More postoperative adverse events (51.3% vs 28.7%, P = .004) with higher severity (28.2% vs 13.2% moderate to severe, P = .019) occurred at discharge. No differences were found in outcomes at 3 or 12 months. ID patients showed higher risks for impaired wound healing (adjusted OR, 4.39; 95% CI, 1.90-10.2; P = .001) and pulmonary embolism (adjusted OR, 3.52; 95% CI, 1.13-10.9; P = .029).ConclusionsIncidental durotomy was associated with longer surgery time, hospital stays, and increased early postoperative complications. While not affecting mid-to-long-term outcomes, ID increased risks for wound healing difficulties and pulmonary embolisms.

Impact of postoperative cauda equina clumping on recovery after biportal endoscopic decompression for severe lumbar stenosis

PURPOSE

This study determined the prevalence of cauda equina clumping among patients with Schizas grade C or higher central stenosis after decompression and compared the radiographic and clinical outcomes between patients with and without clumping.

METHODS

We conducted a single-center retrospective cohort study involving 98 patients who underwent biportal endoscopic spine surgery between January 2019 and June 2022. Based on postoperative magnetic resonance imaging findings, the patients were divided into the clumping (n = 40) and non-clumping (n = 58) groups. Clinical outcomes were assessed using the visual analog scale for back and leg pain, Oswestry Disability Index (ODI), and EuroQol 5-Dimension (EQ-5D-5 L) questionnaire at 1, 3, 6, and 12 months postoperatively. Radiographic evaluations included measuring the cross-sectional area of the dural sac preoperatively and 1 month postoperatively using the PACS software.

RESULTS

Postoperative cauda equina clumping was observed in 40.8% of the patients. Despite an average dural sac expansion of approximately 270%, the clumping group exhibited significantly higher radiating pain at 3 and 6 months (p < 0.05) than the non-clumping group. The ODI and EQ-5D scores were worse in the clumping group at 3 months (p < 0.05). At 12 months postoperatively, differences in clinical outcomes between the two groups were not significant. Patients in the clumping group required longer duration of postoperative medication than those in the non-clumping group (p = 0.024).

CONCLUSION

Post-decompression cauda equina clumping is commonly observed in patients with severe lumbar stenosis and impacts intermediate-term clinical recovery. Although long-term outcomes at 1 year are similar, tailored postoperative care is essential for patients exhibiting clumping to effectively manage prolonged symptoms.

Complications in Minimally Invasive Spine Surgery in the Last 10 Years: A Narrative Review

OBJECTIVE

Minimally invasive spine surgery (MISS) employs small incisions and advanced techniques to minimize tissue damage while achieving similar outcomes to open surgery. MISS offers benefits such as reduced blood loss, shorter hospital stays, and lower costs. This review analyzes complications associated with MISS over the last 10 years, highlighting common issues and the impact of technological advancements.

METHODS

A systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines was conducted using PubMed, MEDLINE, Embase via OVID, and Cochrane databases, covering publications from January 2013 to March 2024. Keywords related to MISS and complications were used. Studies on adult patients undergoing MISS with tubular, uniportal, or biportal endoscopy, reporting intraoperative or postoperative complications, were included. Non-English publications, abstracts, and small case series were excluded. Data on MISS approach, patient demographics, and complications were extracted and reviewed by 2 independent researchers.

RESULTS

The search identified 880 studies, with 137 included after screening and exclusions. Key complications in cervical MISS were hematomas, transient nerve root palsy, and dural tears. In thoracic MISS, complications included cerebrospinal fluid leaks and durotomy. In lumbar MISS, common complications were incidental dural injuries, postoperative neuropathic conditions, and disc herniation recurrences. Complications varied by surgical approach.

CONCLUSION

MISS offers reduced anatomical disruption compared to open surgery, potentially decreasing nerve injury risk. However, complications such as nerve injuries, durotomies, and hardware misplacement still occur. Intraoperative neuromonitoring and advanced technologies like navigation can help mitigate these risks. Despite variability in complication rates, MISS remains a safe, effective alternative with ongoing advancements enhancing its outcomes.

Full endoscopic surgery for calcium pyrophosphate deposition disease (CPPD) in the cervical ligamentum flavum: report of two cervical myelopathy cases

Calcium pyrophosphate deposition disease (CPPD), known as pseudogout, is characterized by the accumulation of calcium pyrophosphate crystals in musculoskeletal structures, primarily joints. While CPPD commonly affects various joints, involvement in the cervical spine leading to myelopathy is rare. Surgical intervention becomes necessary when conservative measures fail, but reports on full endoscopic surgeries are extremely rare. We present two successful cases where full endoscopic systems were used for CPPD removal in the cervical spine. The surgical technique involved a full endoscopic approach, adapting the previously reported technique for unilateral laminotomy bilateral decompression. Full-endoscopic removal of cervical CPPD inducing myelopathy were successfully removed with good clinical and radiologic outcomes. The scarcity of endoscopic cases for cervical ligamentum flavum CPPD is attributed to the condition's rarity. However, our successful cases advocate for endoscopic surgery as a potential primary treatment option for CPPD-induced cervical myelopathy, especially in elderly patients or those with previous cervical operation histories. This experience encourages the consideration of endoscopic surgery for managing cervical ligamentum flavum CPPD as a viable alternative.

Subfascial Lumbar Spine Drain Output Does Not Affect Outcomes After Incidental Durotomies in Elective Spine Surgery

OBJECTIVE

Postoperative drains have long been regarded as a preventive measure to mitigate the risks of complications such as neurological impairment by reducing fluid accumulation following spine surgery. Our study aims to contribute to the existing body of knowledge by examining the effects of postoperative drain output on the 90-day postoperative outcomes for patients who experienced an incidental durotomy after lumbar decompression procedures, with or without fusion.

METHODS

All patients aged ≥18 years with an incidental durotomy from spinal decompression with or without fusion surgery between 2017 and 2021 were retrospectively identified. The patient demographics, surgical characteristics, method of dural tear repair (DuraSeal, suture, and/or DuraGen), surgical outcomes, and drain data were collected via medical record review. Patients were grouped by readmission status and final 8-hour drain output. Those with a final 8-hour drain output of ≥40 mL were included in the high drain output (HDO) group and those with <40 mL were in the low drain output (LDO) group.

RESULTS

There were no statistically significant differences in preoperative patient demographics, surgical characteristics, method of dural tear repair, length of stay (HDO, 4.02 ± 1.90 days; vs. LDO, 4.26 ± 2.10 days; P = 0.269), hospital readmissions (HDO, 10.6%; vs. LDO, 7.96%; P = 0.744), or occurrence of reoperation during readmission (HDO, 6.06%; vs. LDO, 2.65%; P = 0.5944) between the 2 groups.

CONCLUSIONS

For patients undergoing primary lumbar decompression with or without fusion and experiencing an incidental durotomy, no significant association was found between the drain output and 90-day patient outcomes. Adequate fascial closure and the absence of symptoms may be satisfactory criteria for standard patient discharge regardless of drain output.