Incidental durotomy resulting in a postoperative lumbosacral nerve root with eventration into the adjacent facet joint: illustrative cases

BACKGROUND

Radicular pain after lumbar decompression surgery can result from epidural hematoma/seroma, recurrent disc herniation, incomplete decompression, or other rare complications. A less recognized complication is postoperative nerve root herniation, resulting from an initially unrecognized intraoperative or, more commonly, a spontaneous postoperative durotomy. Rarely, this nerve root herniation can become entrapped within local structures, including the facet joint. The aim of this study was to illustrate our experience with three cases of lumbosacral nerve root eventration into an adjacent facet joint and to describe our diagnostic and surgical approach to this rare complication.

OBSERVATIONS

Three patients who had undergone lumbar decompression surgery with or without fusion experienced postoperative radiculopathy. Exploratory revision surgery revealed all three had a durotomy with nerve root eventration into the facet joint. Significant symptom improvement was achieved in all patients following liberation of the neural elements from the facet joints.

LESSONS

Entrapment of herniated nerve roots into the facet joint may be a previously underappreciated complication and remains quite challenging to diagnose even with the highest-quality advanced imaging. Thus, clinicians must have a high index of suspicion to diagnose this issue and a low threshold for surgical exploration.

Economic implications of dural tears in lumbar microdiscectomies: a retrospective, observational study

STUDY DESIGN

Retrospective cohort study. Level of Evidence Level III. Dural tears (DT) are a frequent complication after lumbar spine surgery. With this study we sought to determine the incidence of DT and the related impact on healthcare expenditures after lumbar discectomies. All patients with first-time single level lumbar discectomies at our institution that underwent minimally-invasive surgery from 2015 to 2019 were reviewed. Age, sex, weight, height, body mass index (BMI), costs, revenues, length of stay (LOS), American Society of Anesthesiology (ASA) score, Charlson Comorbidity Index (CCI) and operation time (OT) were assessed. Exclusion criteria were age < 18 years, previous spine surgery, multiple or traumatic disc herniations but also malignant and infectious diseases. The follow-up time was at least 12 months postoperatively. 358 patients with lumbar discectomies were identified and 230 met the inclusion criteria. The DT incidence was 3.5%. The mean costs (p < 0.001), the loss (p < 0.01) and the operation time (p < 0.0001) were found to be significantly higher in the DT group when compared to the control group of patients without a DT. The revenues were not statistically different between both groups (p > 0.05). Further analysis of the control group by profit and loss revealed significantly higher BMI (p < 0.05), LOS (p < 0.0001) and OT (p < 0.0001) in the loss group. DT represent a significant socioeconomic burden in lumbar spine surgery and cause severe secondary complications. The DT-related impact on healthcare expenses is primarily based on significantly higher OT and a higher mean LOS.

Corrigendum: Infratentorial superficial siderosis: report of six cases and review of the literature

[This corrects the article DOI: 10.3389/fnins.2024.1373358.].

Infratentorial superficial siderosis: report of six cases and review of the literature

Objectives

To investigate the etiology, clinical manifestations, imaging features, and treatment of patients with infratentorial superficial siderosis (iSS), enhance clinicians' comprehension of this rare disease, and conduct oral deferiprone intervention and subsequent monitoring.

Methods

Six patients diagnosed with iSS based on magnetic resonance imaging (MRI) and susceptibility weighted imaging (SWI) were enrolled from 2021 to 2023 at the First Affiliated Hospital of Fujian Medical University. Their clinical datas were summarized, and the etiology and imaging characteristics were analyzed. Follow-up was conducted through telephone or outpatient visits.

Results

Among the 6 patients, there were 3 males and 3 females. The onset age ranged from 35 to 71 years, with an average onset age of 53 years. The clinical symptoms mainly included acoustic disturbances (6/6), gait imbalance (6/6), dysolfactory (6/6), cognitive impairment (2/6), epilepsy (2/6), and pyramidal tract sign (2/6). Evidence of superficial siderosis was observed on MRI across the cortex, brainstem, cerebellum, and spinal cord in all patients. T2-space sequence MRI revealed two instances of dural tear. During the follow-up period ranging from 1 month to 3 years, three patients who received oral deferiprone treatment showed improvement, whereas the remaining three patients who declined deferiprone treatment demonstrated progression.

Conclusion

The primary clinical manifestations of iSS include bilateral sensorineural hearing disturbances, progressive cerebellar ataxia, and spinal cord lesions. The key diagnostic criteria involve the presence of linear hypointensity on T2-WI in the surface region of the nervous system. Dural tear caused by various factors is considered to be the most common cause of iSS, and its treatment mainly involves surgical intervention for hemorrhagic primary diseases as well as pharmacotherapy with deferiprone.

Magnitude of dural tear and its associated factors among patients with depressed skull fracture

Introduction

Trauma is a huge problem seen in developed countries as well as developing countries. Head injury is a major factor responsible for mortality in young populations. Up to 6% of all head injuries and 11% of severe head traumas might result in a depressed skull fracture (DSF), a catastrophic injury. The aim of this study was to determine the prevalence of dural tear and to identify its predictors.

Method

A retrospective review of medical records of all patients operated on for DSFs at the University Comprehensive Specialized Hospital from 1 January 2021 to 1 January 2023 G.C. (Gregorian calendar) was conducted. A total of 163 patients were included in the study.

Results

A total of 163 patients [136 men (83.4%) and 27 women (16.6%)] had a mean age of 23.9 with a standard deviation of 14.8 (range from 3 to 65). Patients with penetrating injuries (missiles, axes) were excluded. The majority, 153 (93.9%) of the patients, were younger than 50 years of age. Physical assault accounted for 102 (62.5%) of the cases. Of the assaulted cases, 62 (38%) were assaulted by stone, 32 (19.6%) by stick, and 8 (5%) by other objects (beer bottle and shovel). Bleeding from the trauma site in 124 (76.1%), headache in 76 (46.6%), loss of consciousness in 75 (46%), and vomiting in 72 (44.2%) were the most common presentations. Based on the Glasgow Coma Scale (GCS), 123 (75%) patients had mild head injuries. Based on the site of fracture, frontal depressions are the most common (61, 37.4%), followed by parietal depressions (53, 32.5%). With regard to the associated injuries, brain contusion was seen in 52 (32%), epidural hematoma (EDH) in 26 (16%), subdural hematoma in 3 (1.8%), and intraventricular hemorrhage/subarachnoid hemorrhage (IVH/SAH) in 3 (1.8%). The median duration of presentation was 15 h, with an interquartile range (IQR) of 8-24 (1-96 h). From the multivariable logistic regression, brain contusion and EDH were significantly associated with dural tear.

Conclusion

The rules of our culture are reflected in the higher incidence of accidents and fractures among men. Physical assault, particularly with stones, was the most common cause of DSFs. Frontal depressions were the most common site of fracture, followed by parietal fractures. Brain contusion and EDH were significantly associated with dural tears. School-aged children are more vulnerable to injuries from horse or donkey kicks and falls.

Use of tissue sealant patch (TachoSil) in the management of cerebrospinal fluid leaks after anterior cervical spine discectomy and fusion

PURPOSE

The purpose of this study was to evaluate a fast, sutureless technique to repair anterior cervical dural tears. Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for the treatment of cervical degenerative diseases. Although uncommon, incidental durotomy with cerebrospinal fluid (CSF) leak during ACDF is a potentially serious complication. Yet, its technical management for the prevention of CSF leak is controversial.

METHODS

Between September 2012 and June 2018 we encountered seven cases (2 female/5 male) presenting with intraoperative CSF leaks secondary to incidental dural tears during ACDF surgery. All the cases were surgically treated using a topical fibrin sealant patch (TachoSil) with high adesive strength and fibrin glue (Tisseel). Intraoperative source of leakage, time to leakage control, quantity of Sealant Sponge used and postoperative complications were evaluated.

RESULTS

Dural tears were tipically the result of dissection of adherent posterior longitudinal ligament and/or calcified disc from the cervical dural sac to allow full decompression of the spinal cord. Effective repair of dural tear defined as cessation of CSF leak after topical sealant agents application was achieved no later than one minute in all cases. Evident clinical and/or radiological postoperative CSF leak was used to determine the patient's postoperative result. Postoperative CSF leak was not evident during a minimum 6 months follow up.

CONCLUSIONS

In the present study, we have reported our experience with a new sealing technique to manage CSF leaks from iatrogenic cervical dural lacerations. Tachosil tissue sealant patch is a rapid sutureless technique that may help in repairing introperatively incidental dural tears, thus reducing the risk of postoperative CSF leaks. To our knowledge, this is the first series to report the use of Tachosil adhesive sealant patch for the treatment of incidental dural tears during anterior cervical discectomy.

Superficial Cerebellar Siderosis and Spontaneous Intracranial Hypotension Secondary to Dural Tear

Spinal dural tears are being increasingly recongnized to cause superficial siderosis and intracranial hypotension. We report a patient with chronic headache who was detected to have cerebellar superficial siderosis and subtle signs of intracranial hypotension on imaging. Spinal imaging showed an upper thoracic dural tear secondary to a paradiscal osteophyte. She improved significantly with surgical repair of the tear. We highlight the importance of recognizing superficial sideorsis in patients with chronic headache as it serves as a marker for dural tear and intracranial hypotension.

Epidural Steroid Injection Prior to Spinal Surgery: A Step-Wise and Wise Approach

BACKGROUND

An epidural steroid injection (ESI) is used to treat a number of morbid central nervous system pathologies and is considered a reasonably safe procedure. This study aimed to determine the relative infection risk after spinal surgery by comparing outcomes in spinal surgery patients who received an ESI shortly prior to the surgery against those who did not receive an ESI shortly prior to the surgery.

METHODS

The present study is a retrospective cohort study using a multi-institutional healthcare database, TriNetX, to collect data on patients who received spinal surgery with and without having had ESIs six months before surgery. Two cohorts were generated: Cohort 1 included patients who had received an ESI in the six months prior to spinal surgery, and cohort 2 included patients who did not have an ESI in the six months prior to spinal surgery. The patients in cohort 2 had propensity scores matched 1:1 to those in cohort 1 using common baseline demographics, comorbidities and spinal procedure indications. The spinal procedures and surgeries considered for the analysis included open procedures for any purpose, including exploration, decompression, resection, revision or biopsy. Multiple outcomes were compared across these two cohorts in the three months following the spinal procedure/surgery, including the occurrence of death, surgical site infection, epidural and/or spinal abscess, and dural tear.

RESULTS

An ESI in the six months prior to spinal surgery was associated with a significant decrease in the likelihood epidural/spinal abscess in the three months after surgery. There was no change in mortality, wound infection or identification of dural tear in the three months after spinal surgery for those who received an ESI six months before spinal surgery.

CONCLUSION

This data suggests that epidural steroid injections' anti-inflammatory effects provide benefits before surgery beyond symptomatic relief. Given that the degeneration of spinal pathologies is typically advanced rather than corrected by the body's inflammatory response, it is likely that preventing hyperactivation of the body's immune system in the months preceding surgical intervention, a traumatic insult, is protective compared to no intervention and, importantly, without major adverse effects.

Temporary 6TH cranial nerve paralysis after accidental durotomy in endoscopic disc surgery

We present a unique case of 6th nerve palsy following accidental durotomy in endoscopic lumbar spine surgery, which has not been reported in the literature before. A 72- year-old female patient was admitted to our outpatient clinic complaining of right leg pain for 6 months. A 4/5 motor paresis was observed on her right toe with a positive Lasegue test at 45°. On her magnetic resonance imaging (MRI), a L5-S1 disc herniation was detected. The patient was planned for percutaneous endoscopic interlaminar disc surgery. The extruded disc was adherent to the dura. During removal, a dural tear was observed. She was relieved of her right leg pain immediately after surgery, but after 30 min postoperatively, she complained of double vision with left abducens nerve paralysis. On cranial MRI, no abnormality could be observed. Intravenous fluids were administered and the paralysis resolved on the postoperative 24th hour. The patient was discharged from the hospital and did not show any complaints on her follow-ups. A 6th nerve palsy can be caused due to alterations of intracranial pressure or mechanic injury. We believe that the durotomy following removing of the disc fragment caused a rapid drainage of CSF, leading to intracranial hypotension and injury of the abducens nerve. Intracranial pressure should be monitored perioperatively and brisk deteriorations has to result in immediate finishing of the surgery to avoid further secondary damage.

Thoracic Myelopathy in Ossified Ligamentum Flavum: Surgical Management and Long-Term Outcome Following 2 Different Techniques of Surgical Decompression

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Thoracic ossified ligamentum flavum (TOLF) has been reported to present with varying degrees of neuro-deficit and multiple factors have been purported to affect its outcome. Purpose of study was to analyze factors affecting outcome and impact of ultrasonic osteotome (UO).

METHODS

We retrospectively reviewed patients treated for thoracic myelopathy secondary to OLF between 2010 and 2017. 77 patients with complete clinico-radiological records and 2 years follow-up were included. Initial 45 patients, conventional high-speed burr (HSB-group A) was used for decompression. In others, UO was used in combination with HSB (group B). Myelopathy was graded using modified Japanese orthopaedic association grading pre-operatively and each postoperative visit. At final follow-up, recovery rate was calculated. Radiological details including location, morphology, dural ossification, signal change and spinal ossifications were recorded.

RESULTS

Mean mJOA at presentation and final follow-up were 4.3±1.8 and 7.6±1.9 respectively (p = 0.001). HRR was 49.9±23 at final follow-up. A significant reduction in dural tear (12.5%; 29%) and surgical time (125.8±49.5; 189.4±52.5) were observed in group B (p = 0.00). However, there was no statistically significant difference (p = 0.18) in recovery rates between groups A (44.8±26.1) and B (52.8±24.3). Symptom duration (p = 0.00), severity of myelopathy (p = 0.04) and cord signal changes on MRI (p = 0.02) were important predictors of outcome.

CONCLUSION

Use of UO significantly reduced operative time and dural tears, although resulted in similar recovery rate as compared with HSB. Pre-operative severity of myelopathy, symptom duration and presence of cord signal change were the most significant predictors of outcome.

Treatment of dural tear with nerve root herniation after unilateral biportal endoscopic decompression using an epidural blood patch: a case report

We present a case of a dural tear associated with nerve root herniation following unilateral biportal endoscopic decompression (UBED) that was successfully treated using a computed tomography-guided epidural blood patch. A 60-year-old man underwent UBED for radicular pain because of spinal stenosis at L4-5. A left partial hemilaminectomy and flavectomy were performed; however, the left dorsolateral side dura mater was torn during the procedure. TachoComb® was applied at the dural tear site, and the pain was relieved following UBED. However, 3 weeks post-UBED, the patient reported severe pain with an electric shock-like sensation in the left buttock and posterior thigh region with no other neurologic symptoms. The pain was aggravated by standing and spinal motion. Follow-up lumbar spinal magnetic resonance imaging was performed. Axial images indicated protrusion of the left S2 nerve root through the left dorsolateral side of the dura mater. The patient was further diagnosed with nerve root herniation following a dura mater tear. A computed tomography-guided epidural blood patch was performed, with successful therapeutic results. The outcome of this study indicates that a small dural tear that occurs during minimally invasive spinal surgery can be efficiently treated using an epidural blood patch prior to open surgery.

Diffuse symptomatic pneumocephalus after biportal endoscopic spinal surgery: illustrative case

BACKGROUND

Percutaneous endoscopic lumbar decompression is gaining attention as a minimally invasive surgery. Here, the authors report a rare complication of pneumocephalus caused by vacuum drain after biportal endoscopic spinal surgery (BESS) for lumbar stenosis.

OBSERVATIONS

A 79-year-old woman with spinal stenosis over the L4-5 level received BESS. No visible dural tear was encountered during surgery, and a vacuum drain was placed after surgery. Approximately 150 mL of cerebrospinal fluid was drained on postoperative day 1. Simultaneously, symptoms of intracranial hypotension were noted. Brain computed tomography (CT) revealed pneumocephalus. The patient was advised to have bed rest and hydration, and her symptoms improved subsequently. Follow-up brain CT indicated the resolution of pneumocephalus.

LESSONS

Pneumocephalus after endoscopic lumbar surgery is rare. Dural tear, high rate of normal saline irrigation, and vacuum drain placement are the associated risk factors.

Management of Large Dural Defect with CSF Leak in Hypertelorism Correction

The Rationale

Dural tear is a serious complication during hypertelorism corrective surgeries. Identifying the tear and managing requires considerable expertise. Managing large dural tears correctly is necessary to prevent cerebrospinal fluid (CSF)-related complications in craniofacial surgery.

Patient Concerns

The patient presented with hypertelorism as a part of the Tessier Cleft 0 and sought to correct the widely placed eyes.

Diagnosis

Large critical-sized dural tear during modified box osteotomy surgery.

Treatment

Besides successful modified box osteotomy surgery, the critical-sized dural tear was managed with fascia lata and fibrin glue.

Outcomes

There was no CSF leak or related complication postsurgically indicating successful sealing and healing of the dural tear.

Take-Away Lessons

The synergistic mechanism by which fascia lata graft and fibrin glue help to hermetically seal the critical-sized defect, especially when there are variable amounts of hydrostatic-hydrodynamic forces of CSF exerting pressure on the patched area, is discussed.

Anterior Dural Tear in Thoracic and Lumbar Spinal Fractures: Single-Center Experience with Coating Technique and Literature Review of the Available Strategies

Differently from the posterior, the anterior dural tears associated with spinal fractures are rarely reported and debated. We document our experience with a coating technique for repairing ventral dural lacerations, providing an associated literature review on the available strategies to seal off such dural defects. A PubMed search on watertight repair techniques of anterior dural lacerations focused on their association with spinal fractures was performed. Studies on animal or cadaveric models, on cervical spine, or based on seal/gelfoam or “not suturing” strategies were excluded. 10 studies were finally selected and our experience of three patients with thoracic/lumbar spinal fractures with associated ventral dural tear was integrated into the analysis of the surgical techniques. Among the described repair techniques for ventral dural lacerations a preference for primary suturing, mostly trans-dural, was noted (n = 6/10 papers). Other documented strategies were the plugging of the dural opening with a fat graft sutured to its margins, or stitched to the dura adjacent to the defect, and the closure of the dural tear with two patches, both trans-dural and epidural. Our coating techniques of the whole dural sac with the heterologous patch were revealed as safe and effective alternatives strategies, even when patch flaps wrapping nerve roots have to be cut and a fat graft has to be stitched in the patch respectively for sealing off antero-lateral and wide anterior dural tears. Compared to all the documented strategies for obtaining a watertight closure of an anterior dural laceration, the coating techniques revealed advantages of preserving neural structures, being adaptable to anterior and antero-lateral dural tears of any size.

Accidental Dural Tears in Minimally Invasive Spinal Surgery for Degenerative Lumbar Spine Disease

Background: One of the most frequent complications of spinal surgery is accidental dural tears (ADTs). Minimal access surgical techniques (MAST) have been described as a promising approach to minimizing such complications. ADTs have been studied extensively in connection with open spinal surgery, but there is less literature on minimally invasive spinal surgery (MISS).

Materials and Methods: We reviewed 187 patients who had undergone degenerative lumbar spinal surgery using minimally invasive spinal fusions techniques. We analyzed the influence of age, Body Mass Index (BMI), smoking, diabetes, and previous surgery on the rate of ADTs in MISS.

Results: Twenty-two patients (11.764%) suffered from an ADT. We recommended bed rest for two and a half to 5 days, depending on the type of repair required and the amount of cerebrospinal fluid (CSF) leakage. We could not find any statistically significant correlation between ADTs and age (p = 0.34,), BMI (p = 0.92), smoking (p = 0.46), and diabetes (p = 0.71). ADTs were significantly more frequent in cases of previous surgery (p < 0.001). None of the patients developed a transcutaneous CSF leak or post-operative infection.

Conclusions: The frequency of ADTs in MISS appears comparable to that encountered when using open surgical techniques. Additionally, MAST produces less dead space along the corridor to the spine. Such reduced dead space may not be enough for pseudomeningocele to occur, cerebrospinal fluid to accumulate, and fistula to form. MAST, therefore, provides a certain amount of protection.

An Investigation of a Novel Dural Repair Device for Intraoperative Incidental Durotomy Repair

Incidental durotomies, or dural tears, can be very difficult and time consuming to repair properly when they are encountered in confined spaces. A novel dural repair device was developed to address these situations. In this paper, the novel device was assessed against the use of traditional tools and techniques for dural repairs in two independent studies using an intricate clinical simulation model. The aim was to examine the results of the two assessments and link the outcomes to the clinical use of the novel device in the operating room. The novel device outperformed conventional techniques as measured by dural repair time, CSF leak pressure and nerve root avoidance in the simulation. The results were generally replicable clinically, however, numerous additional clinical scenarios were also encountered that the simulation model was unable to capture due to various inherent limitations. The simulation model design, potential contributors to watertightness, clinical experiences, and limitation are discussed.

Dural Tear During Thoracic Laminectomy Using Craniotome With Footplate Attachment

Laminectomy can be accomplished using the craniotome with a footplate attachment, and the technique has been advanced as a superior alternative to using a high-speed drill-driven burr and Kerrison rongeurs. Laminectomy can be accomplished more rapidly and with less bone destruction, an advantage when planning laminoplasty. There is, however, scant literature describing complications of dural laceration using this technique. A 48-year-old male underwent T7-10 laminectomy for resection of an intramedullary spinal cord tumor. During the upward cut of the hemi-lamina at T7-9, a dural laceration occurred that proved not amenable to direct suture closure. The dural was closed with a dural patch placed along the inner surface of the dura and a fat graft on the outer surface with adjunctive use of a lumbar drain. While the footplate laminectomy technique has merits touted in prior publications, including the ability to open the spinal canal quickly at numerous levels and an enhanced ability to achieve an osteoplastic laminoplasty, surgeons should be cognizant of the risk of associated dural laceration. We believe that it is important to emphasize that the initial placement of the lip of the footplate must be well-seated under the inferior aspect of the lowest lamina and over the ligamentum flavum and that the footplate should not be directed beyond the border of the laminae and facet, as this can result in dura and root injury.

Clinical Outcomes of Incidental Dural Tears During Lumbar Microdiscectomy

Background: A dural tear (DT) is the most commonly encountered complication during lumbar spine surgery. The incidence of DT increases depending on the complexity of the surgical procedure and the presence of a DT is related to a poor outcome and patient satisfaction.

Objectives: This study aimed to determine the incidence and clinical outcomes of DTs in those patients who undergo lumbar disc surgery.

Methods: We retrospectively reviewed consecutive patients who underwent surgery for the management of a primary single-level lumbar disc herniation at a single institution between 2004 and 2014. Among the studied population, those with DTs were included in the study group. An age- and sex-matched group of randomly selected patients who underwent the same level and type of lumbar spine surgery, but did not develop DTs, were assigned as the control group. The outcomes were compared at 12 months postoperatively between the groups.

Results: A total of 5,476 consecutive patients (2,608 female, 2,868 male; mean age, 54 ± 11.45 [range, 21-86] years) underwent surgery for primary single-level lumbar disc herniation. DT was noted in 192 (2.85%) cases. Of these, 102 patients with complete data were included in the DT group. The DT group had a significantly increased length of hospital stay (p = 0.001). Also, the duration of bed rest in the hospital was significantly higher in patients wherein DT was repaired using hemostatic material and fibrin glue, compared to the patients with primary closure with suturing of the tear.

Conclusion: Incidental DTs, if recognized and treated appropriately, will not lead to poor clinical results and do not adversely impact postoperative outcomes.

Severe Form of Bacterial Meningitis After Spine Surgery: A Case Report and Review of the Literature

Meningitis after spine surgery is a rare complication. In this report, we aim to discuss the case of a male patient who developed this rare condition after undergoing cervical spine surgery with devastating outcomes. We also engage in a review of the relevant literature. A 17-year-old boy presented with post-traumatic cervical kyphotic deformity with signs of cord compression. He was operated in three stages, all conducted in a single sitting. There was an incidental cerebrospinal fluid (CSF) leak, which was primarily repaired. On the fourth postoperative day, the patient developed altered sensorium and seizures. Evaluations for clinical signs of meningitis such as neck rigidity and Kernig's sign were inconclusive. CSF analysis confirmed the diagnosis of meningitis. Thereafter, the patient developed hydrocephalus and intractable infection, for which multiple procedures were done. Finally, we succeeded in controlling the infection, but the patient developed a neurological deficit, which did not resolve even after 2.5 years of follow-up. The clinical signs and symptoms of meningitis after cervical spine surgery are not very clear or suggestive. A strong index of suspicion should be maintained for the early detection of this condition to prevent devastating complications that result from it.

Risk factor analysis of surgery-related complications in primary cervical spine surgery for degenerative diseases using a surgeon-maintained database

AIMS

This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases.

METHODS

We studied 5,015 patients with degenerative cervical diseases who underwent primary cervical spine surgery from 2012 to 2018. We investigated the effects of diseases, surgical procedures, and patient demographics on surgery-related complications. As subcategories, the presence of cervical kyphosis ≥ 10°, the presence of ossification of the posterior longitudinal ligament (OPLL) with a canal-occupying ratio ≥ 50%, and foraminotomy were selected. The surgery-related complications examined were postoperative upper limb palsy (ULP) with a manual muscle test (MMT) grade of 0 to 2 or a reduction of two grade or more in the MMT, neurological deficit except ULP, dural tear, dural leakage, surgical-site infection (SSI), and postoperative haematoma. Multivariate logistic regression analysis was performed.

RESULTS

The significant risk factors (p < 0.050) for ULP were OPLL (odds ratio (OR) 1.88, 95% confidence interval (CI) 1.29 to 2.75), foraminotomy (OR 5.38, 95% CI 3.28 to 8.82), old age (per ten years, OR 1.18, 95% CI 1.03 to 1.36), anterior spinal fusion (OR 2.85, 95% CI 1.53 to 5.34), and the number of operated levels (OR 1.25, 95% CI 1.11 to 1.40). OPLL was also a risk factor for neurological deficit except ULP (OR 5.84, 95% CI 2.80 to 12.8), dural tear (OR 1.94, 95% CI 1.11 to 3.39), and dural leakage (OR 3.15, 95% CI 1.48 to 6.68). Among OPLL patients, dural tear and dural leakage were frequently observed in those with a canal-occupying ratio ≥ 50%. Cervical rheumatoid arthritis (RA) was a risk factor for SSI (OR 10.1, 95% CI 2.66 to 38.4).

CONCLUSION

The high risk of ULP, neurological deficit except ULP, dural tear, and dural leak should be acknowledged by clinicians and OPLL patients, especially in those patients with a canal-occupying ratio ≥ 50%. Foraminotomy and RA were dominant risk factors for ULP and SSI, respectively. An awareness of these risks may help surgeons to avoid surgery-related complications in these conditions. Cite this article: Bone Joint J 2021;103-B(1):157-163.

Remote Intracranial Hemorrhage after Cranio-Spinal Surgery. Report of Two Cases

Post-operative intracranial bleeding at a distance from the surgical site is a rare complication of both cranial and spinal surgeries and is referred to as remote intracranial hemorrhage (RIH). Bleeding typically occurs in the cerebellum. Simultaneous hemorrhages in different cranial compartments have been rarely observed. We herein report two cases of RIH, which showed different imaging patterns and clinical signs and symptoms. RIH are typically self-limiting and do not usually require treatment. Physicians must be aware of this benign entity which needs not be misdiagnosed with other conditions.

Teaching point: Remote intracranial hemorrhage is a rare but worthy of note complication of cranio-spinal surgery.

Microsurgical anatomy and treatment of dural defects in spontaneous spinal cerebrospinal fluid leaks

OBJECTIVE

Spontaneous spinal CSF leaks are caused by abnormalities of the spinal dura mater. Although most cases are treated conservatively or with an epidural blood patch, some intractable cases require neurosurgical treatment. However, previous reports are limited to a small number of cases. Preoperative detection and localization of spinal dural defects are difficult, and surgical repair of these defects is technically challenging. The authors present the anatomical characteristics of dural defects and surgical techniques in treating spontaneous CSF leaks.

METHODS

Among the consecutive patients who were diagnosed with spontaneous CSF leaks at the authors' institution between 2010 and 2020, those who required neurosurgical treatment were included in the study. All patients' clinical information, radiological studies, surgical notes, and outcomes were reviewed retrospectively. Outcomes of two different procedures in repairing dural defects were compared.

RESULTS

Among 77 patients diagnosed with spontaneous CSF leaks, 21 patients (15 men; mean age 57 years) underwent neurosurgery. Dural defects were detected by FIESTA MRI in 7 patients, by CT myelography in 12, by digital subtraction myelography in 1, and by dynamic CT myelography in 1. The spinal levels of the defects were localized at the cervicothoracic junction in 16 patients (76%) and thoracolumbar junction in 4 (19%). Intraoperative findings revealed that the dural defects were small, circumscribed longitudinal slits located at the ventral aspect of the dura mater. The median dural defect size was 5 × 2 mm. The presence of dural defects at the thoracolumbar junction was associated with manifestation of an altered mental status, which was an unusual manifestation of CSF leaks (p = 0.003). Eight patients were treated via the posterior transdural approach with watertight primary sutures of the ventral defects, and 13 were treated with muscle or fat grafting. Regardless of the two different procedures, postoperative MRI showed either complete disappearance or significant reduction of the extradural CSF collection. No patient experienced postoperative neurological deficits. Clinical symptoms improved or stabilized in 20 patients with a median follow-up of 12 months.

CONCLUSIONS

Dural defects in spontaneous CSF leaks were small, circumscribed longitudinal slits located ventral to the spinal cord at either the cervicothoracic or thoracolumbar junction. Muscle/fat grafting may be an alternative treatment to watertight primary sutures of ventral dural defects with a good outcome.

Subarachnoid Contrast Hyperdensity Following Pelvic Trauma Mimicking Diffuse Subarachnoid Hemorrhage

We present a case of a 54-year-old male who was involved in a motorcycle accident. His head computed tomography (CT) scan on arrival at our Level 1 institution was positive for hyperdensity suspicious for subarachnoid hemorrhage (SAH). Spine CT showed anterior compression fractures of T7-T9 vertebral bodies along with the presence of contrast within the subarachnoid space in the thoracic and lumbar spine, raising suspicion for a dural tear. CT of the chest, abdomen, and pelvis revealed open book pelvic fracture, left sacral ala fracture extending into the left sacroiliac joint and S1 neural foramen, coccygeal fracture, and extraperitoneal bladder rupture.

This rare case report highlights the possibility of a spinal meningeal tear in severe pelvic trauma with concomitant bladder injury as a pathway of contrast entry into the normally impermeable cerebrospinal fluid (CSF) space mimicking traumatic subarachnoid hemorrhage.

Dural tear is associated with an increased rate of other perioperative complications in primary lumbar spine surgery for degenerative diseases

Prospective case-control study.This study used a prospective multicenter database to investigate whether dural tear (DT) is associated with an increased rate of other perioperative complications.Few studies have had sufficient data accuracy and statistical power to evaluate the association between DT and other complications owing to a low incidence of occurrence.Between 2012 and 2017, 13,188 patients (7174 men and 6014 women) with degenerative lumbar diseases underwent primary lumbar spine surgery. The average age was 64.8 years for men and 68.7 years for women. DT was defined as a tear that was detected intraoperatively. Other investigated intraoperative surgery-related complications were massive hemorrhage (>2 L of blood loss), nerve injury, screw malposition, cage/graft dislocation, surgery performed at the wrong site, and vascular injury. The examined postoperative surgery-related complications were dural leak, surgical-site infection (SSI), postoperative neurological deficit, postoperative hematoma, wound dehiscence, screw/rod failure, and cage/graft failure. Information related to perioperative systemic complications was also collected for cardiovascular diseases, respiratory diseases, renal and urological diseases, cerebrovascular diseases, postoperative delirium, and sepsis.DTs occurred in 451/13,188 patients (3.4%, the DT group). In the DT group, dural leak was observed in 88 patients. After controlling for the potentially confounding variables of age, sex, primary disease, and type of procedure, the surgery-related complications that were more likely to occur in the DT group than in the non-DT group were SSI (odds ratio [OR] 2.68) and postoperative neurological deficit (OR 3.27). As for perioperative systemic complications, the incidence of postoperative delirium (OR 3.21) was significantly high in the DT group.This study demonstrated that DT was associated with higher incidences of postoperative SSI, postoperative neurological deficit, and postoperative delirium, in addition to directly DT-related dural leak.

Tension Pneumocephalus after Cervical Spine Surgery: A Case Report with Review of the Literature

This is the case of a 66-year-old male with cervical myelopathy secondary to severe cervical stenosis manifesting as worsening dexterity and numbness in his right hand. The patient underwent C3–C6 laminoplasty with bilateral foraminotomies. During the procedure an incidental durotomy occurred which was patched intraoperatively with Duragen and Tisseel. At 1 month follow-up, the patient reported that he was doing well and skin sutures were removed. Two days later, the patient presented to the emergency department with postoperative wound dehiscence, cerebrospinal fluid (CSF) drainage, altered mental status and lethargy. At that time, a computed tomography (CT) scan confirmed a tension pneumocephalus which was treated with a cranial burr hole and revision durotomy repair. The patient improved and was discharged to a rehabilitation facility with intact motor and cognitive function. At the 1-year follow-up appointment, he continued to do well without sequelae.

Three Level Thoracolumbar Spondylectomy for Recurrent Giant Cell Tumour of the Spine: A Case Report

Giant cell tumour (GCT) is a benign tumour but can be locally aggressive and with the potential to metastasise especially to the lungs. Successful treatments have been reported for long bone lesions; however, optimal surgical and medical treatment for spinal and sacral lesions are not well established. In treating spinal GCTs, the aim is to achieve complete tumour excision, restore spinal stability and decompress the neural tissues. The ideal surgical procedure is an en bloc spondylectomy or vertebrectomy, where all tumour cells are removed as recurrence is closely related to the extent of initial surgical excision. However, such a surgery has a high complication rate, such as dura tear and massive blood loss. We report a patient with a missed pathological fracture of T12 treated initially with a posterior subtraction osteotomy, who had recurrence three years after the index surgery and subsequently underwent a three level vertebrectomy and posterior spinal fusion.

Incidence of Remote Cerebellar Hemorrhage in Patients with a Dural Tear during Spinal Surgery: A Retrospective Observational Analysis

Introduction

The incidence of remote cerebellar hemorrhage (RCH) in patients with a dural tear during spinal surgery is unclear. The purpose of this study was to determine the incidence of RCH and the causative factors in these patients.

Methods

Two hundred and thirty-nine patients underwent spinal surgery at our institution between March 2015 and September 2016. Eleven of these patients needed dural suturing intraoperatively. All patients underwent CT of the head on the first postoperative day and were categorized according to whether they had RCH or not. The mean values for the amount of intraoperative bleeding, maximum perioperative blood pressure, postoperative drainage volume, and complaints of headache during the first 24 h postoperatively were compared between the two groups using the Welch's two-sample t-test and Fisher's exact test. The follow-up duration was 12 months.

Results

There were four patients in the RCH group and seven in the non-RCH group. The incidence of RCH was 36.4%. There were three cerebellar hemorrhages and one interhemispheric fissure hemorrhage in the RCH group. The mean intraoperative bleeding volume was 284 mL in the RCH group and 569 mL in the non-RCH group. The mean respective values for maximum perioperative blood pressure and postoperative drainage volume were 132 mmHg and 547 mL in the RCH group and 144 mmHg and 567 mL in the non-RCH group; none of the differences was statistically significant. However, complaints of headache in the first 24 h postoperatively were significantly more common in the RCH group than in the non-RCH group (100% vs. 14.3%; p = 0.01). All patients with intracranial bleeding had recovered 3 months after surgery.

Conclusions

The incidence of RCH following a dural tear during spinal surgery was 36.4%. There was a significant association between RCH and increased reporting of headache during the first 24 h postoperatively.

Cervical Myelopathy Secondary to Combined Ossification of Ligamentum Flavum and Posterior Longitudinal Ligament-A Case Report

In the cervical spine, the combined ossification of the ligamentum flavum (OLF) and posterior longitudinal ligament is rarely seen. Patients are usually treated with cervical laminectomy or laminoplasty with OLF resection. In most of the cases, OLF is adhered to the dura and there is a risk of dural tear or cerebrospinal fluid (CSF) leakage during its resection. In this case report, the authors present results of laminectomy with debulking instead of complete excision of OLF for spinal cord decompression in a cervical myelopathy case in which OLF was adhered to the dura. A 69-year-old man presented with insidious onset weakness in bilateral lower limbs and unsteady gait, which he had experienced 1 month. He has a history of neck pain with left upper limb radiation for the last 2 years. Magnetic resonance imaging showed C5-6 severe central canal stenosis with underlying myelomalacia. Computed tomography showed ossification posterior longitudinal ligament and OLF contributing to severe central canal stenosis at the C5-6 level. The patient underwent C4-C6 laminectomy, debulking of OLF, posterior instrumentation, and fusion with autogenous bone graft from C3 to C6. A histological specimen showed osseous tissue within the ligamentum flavum. After surgery the patient's symptoms improved and no recurrence was observed at 4 years after surgery. The symptoms of myelopathy were successfully treated with debulking instead of complete excision of OLF, thus reducing the risk of dural tear or CSF leakage.

Spinal Dural Repair: A Canadian Questionnaire

STUDY DESIGN

Questionnaire.

OBJECTIVES

Iatrogenic dural tear is a complication of spinal surgery with significant morbidity and cost to the health care system. The optimal management is unclear, and therefore we aimed to survey current practices among Canadian practitioners.

METHODS

A questionnaire was administered to members of the Canadian Neurological Surgical Society designed to explore methods of closure of iatrogenic durotomy.

RESULTS

Spinal surgeons were surveyed anonymously with a 55% response rate (n = 91). For pinhole-sized tears, there is no agreement in the methods of closure, with a trend toward sealant fixation (36.7%). Medium- and large-sized tears are predominantly closed with sutures and sealant (67% and 80%, respectively). Anterior tears are managed without primary closure (40.2%), or using sealant alone (48%). Posterior tears are treated with a combination of sutures and sealant (73.8%). Nerve root tears are treated with either sealant alone (50%), or sutures and sealant (37.8%). Tisseal is the preferred sealant (79.7%) over alternatives. With the exception of pin-hole sized tears (39.5%) most respondents recommended bed rest for at least 24 hours in the setting of medium (73.2%) and large (89.1%) dural tears.

CONCLUSIONS

This study elucidates the areas of uncertainty with regard to iatrogenic dural tear management. There is disagreement regarding management of anterior and nerve root tears, pinhole-sized tears in any location of the spine, and whether patients should be admitted to hospital or should be on bed rest following a pinhole-sized dural tear. There is a need for a robust comparative research study of dural repair strategies.

An Automated, Gravity-driven CSF Drainage System Decreases Complications and Lowers Costs

BACKGROUND

FlowSafe^TM (BeckerSmith Medical, Irvine, CA, USA) is a novel, robotic, external lumbar drainage (ELD) system, which was designed to control cerebrospinal fluid (CSF) drainage, reduce complications, and decrease treatment costs.

METHODS

 Forty-seven consecutive neurosurgical patients requiring ELD were treated using the FlowSafe system.

RESULTS

In 39 of 40 patients with traumatic and surgical dural openings, potential CSF leaks were avoided. In seven patients with suspected normal pressure hydrocephalus, post-infectious ventriculomegaly, or pseudotumor cerebrum, we were able to assess the likelihood of improvement with shunting. The system, therefore, produced what we considered to be the "desired result" in 46 of 47 patients (98%). Our one treatment failure (2%) involved a patient with unrecognized hydrocephalus who, following a Chiari repair with a dural patch graft, was drained for six days. A persistent CSF leak eventually required a reoperation. Two patients (4%) described low-pressure headaches during treatment. Both responded to temporarily suspending or reducing the drainage rate. We saw no complications. Required nursing interventions were minimal.  Conclusions: The FlowSafe system was safe and effective. In our experience, there were fewer complications compared to currently available ELD systems. The FlowSafe was well tolerated by our patients. The near elimination of nursing interventions should allow lumbar drainage to be delivered in less costly, non-intensive care unit settings. Larger trials will be needed.

Successful Treatment of Postdural Puncture Headache Using Epidural Fibrin Glue Patch after Persistent Failure of Epidural Blood Patches

OBJECTIVES

Epidural blood patch is the gold standard for the treatment of postdural puncture headache (PDPH) when conservative treatments have failed to provide any relief. However, alternative therapies are lacking when epidural blood patch persistently fails to improve symptoms. Failure to treat PDPH may lead to significant functional impairment of daily living. Alternative therapies should be sought to accelerate recovery from PDPH.

CASE REPORT

This case describes a woman who developed PDPH secondary to accidental dural puncture during a spinal cord stimulator trial. She was successfully treated with epidural fibrin glue patch after multiple trials of epidural blood patches.

CONCLUSION

Percutaneous injection of fibrin glue to seal the dural defect demonstrated promising outcomes for both immediate and long-lasting resolution of persistent PDPH in our patient. In the event of epidural blood patch failure, epidural fibrin glue patch may be a reasonable alternative for the treatment of persistent PDPH.

Neurosurgery: Skull Base Craniofacial Trauma

Much of craniofacial trauma involves the frontal sinuses. Because of its response to injury, the frontal sinus mucosa has an innate ability to develop mucoceles, and if infected, mucopyocoeles. This article presents a therapeutic algorithm for all forms of craniofacial trauma with concentration on the most severe injury-the through and through fracture and its surgical remediation.

Predisposing factors for dural tear in patients undergoing lumbar spine surgery

OBJECT The purpose of this prospective cohort study was to identify risk factors for incidental durotomies in lumbar spine surgery. The authors hypothesized that the incidence of durotomy would be higher in cases involving multiple operations. METHODS The authors prospectively evaluated 523 patients who underwent lumbar and thoracolumbar spine surgery. They compared data on patients in whom a dural tear occurred and those in whom a dural tear did not occur. Data from patients in whom a dural tear occurred were compared with data from patients who did not experience durotomy. The data included basic demographic information, intraoperative data, and clinical information from a medical record review. RESULTS One hundred thirty-one patients underwent discectomy and 392 patients underwent laminectomy. Among the 131 patients who underwent discectomy 6 patients had a dural tear. Among the 392 patients who underwent discectomy 49 patients had dural tear. Patients with incidental durotomy were older (mean 65 ± 13 vs 60 ± 14 years of age; p = 0.044, t-test), and had longer surgery (146 ± 59 vs 110 ± 54 minutes; p = 0.025, t-test), compared with the patients without dural tear. The incidence of dural tear was more common in patients with a history of previous spine surgery (p < 0.001). CONCLUSIONS In patients who underwent lumbar and thoracolumbar spine surgery for degenerative problems, previous surgery and older age were found to be predisposing factors for dural tear.