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Chanbour H, Gardocki RJ, Zuckerman SL. Commentary: Keyhole Fenestration for Cerebrospinal Fluid Leaks in the Thoracic Spine: Quantification of Bone Removal and Microsurgical Anatomy. Oper Neurosurg (Hagerstown) 2024; 27:12-13. [PMID: 38648850 DOI: 10.1227/ons.0000000000001169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 04/25/2024] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
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Hinsen K, Huynh P, Shilling M, Luo H, Ehsanian R, Shin P. Contrast enhancing epidural fluid accumulation after percutaneous endoscopic lumbar discectomy: A case report of recurrent disc herniation within pseudocyst secondary to irrigation fluid. Int J Surg Case Rep 2024; 120:109884. [PMID: 38875830 PMCID: PMC11226958 DOI: 10.1016/j.ijscr.2024.109884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/16/2024] Open
Abstract
INTRODUCTION Percutaneous endoscopic lumbar discectomy (PELD) is increasingly being utilized to treat patients with lumbar disc herniation. PELD is unique in that it uses a single working port endoscope with constant irrigation of the surgical field to visualize pathology. The current report is of a case of postoperative epidural irrigation fluid accumulation presenting as peripherally enhancing epidural lesions, masking an underlying re-herniation. PRESENTATION OF CASE A patient with a Lumbar 5-Sacral 1 level disc herniation presenting with radiculopathy was treated using PELD. Following the operation, the patient experienced recurrent pain, prompting a repeat MRI of the lumbar spine. Multiple ring-enhancing lesions within the epidural space were observed, creating diagnostic dilemmas. The differential diagnoses included epidural abscess, pseudomeningocele from unintended durotomy, epidural hematoma, or trapped epidural fluid collection presenting as a pseudocyst with or without recurrent disc herniation. A repeat endoscopic discectomy was performed to confirm the diagnosis of pseudocyst, revealing a recurrent disc herniation. DISCUSSION Pseudocysts are not an uncommon complication of PELD, typically believed to be due to an inflammatory response to disc fragments. However, in this case, the epidural fluid collection was likely the result of trapped irrigation fluid from continuous irrigation during the procedure, which masked an underlying re-herniation on imaging. CONCLUSION With the increasing utilization of PELD, it is important to acknowledge unique complications such as fluid accumulation from irrigation within the epidural space. Fluid accumulation can lead to contrast-enhancing pseudocyst formation, which can theoretically lead to mass effect or increased intracranial and intraspinal pressure and may mask additional underlying pathology.
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Affiliation(s)
- Kristin Hinsen
- University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Pearl Huynh
- University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Mark Shilling
- Department of Anesthesiology and Critical Care, University of New Mexico Hospitals, Albuquerque, NM, USA
| | - Henry Luo
- University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Reza Ehsanian
- Department of Anesthesiology and Critical Care, University of New Mexico Hospitals, Albuquerque, NM, USA.
| | - Peter Shin
- Department of Neurosurgery, University of New Mexico Hospitals, Albuquerque, NM, USA
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Wu PH, Kim HS, Grasso G, An JW, Kim M, Lee I, Park JS, Lee JH, Kang S, Lee J, Yi Y, Lee JH, Park JH, Lim JH, Jang IT. Remodeling of Epidural Fluid Hematoma after Uniportal Lumbar Endoscopic Unilateral Laminotomy with Bilateral Decompression: Comparative Clinical and Radiological Outcomes with a Minimum Follow-up of 2 Years. Asian Spine J 2023; 17:118-129. [PMID: 35785910 PMCID: PMC9977969 DOI: 10.31616/asj.2021.0366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/23/2022] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE To evaluate the clinical and radiological effects of epidural fluid hematoma in the medium term after lumbar endoscopic decompression. OVERVIEW OF LITERATURE There is limited literature comparing the effect of postoperative epidural fluid hematoma after uniportal endoscopic decompression. METHODS Magnetic resonance imaging (MRI) and clinical evaluation were performed for patients with single-level uniportal endoscopic lumbar decompression with a minimum follow-up of 2 years. RESULTS A total of 126 patients were recruited with a minimum follow-up of 26 months. The incidence of epidural fluid hematoma was 27%. Postoperative MRI revealed a significant improvement in the postoperative dura sac area at postoperative day 1 and at the upper endplate at 6 months in the hematoma cohort (39.69±15.72 and 26.89±16.58 mm2) as compared with the nonhematoma cohort (48.92±21.36 and 35.1±20.44 mm2), respectively (p <0.05); and at the lower endplate on postoperative 1 day in the hematoma cohort (51.18±24.69 mm2) compared to the nonhematoma cohort (63.91±27.92 mm2) (p <0.05). No significant difference was observed in the dura sac area at postoperative 1 year in both cohorts. The hematoma cohort had statistically significant higher postoperative 1-week Visual Analog Scale (VAS; 3.32±0.68) pain and Oswestry Disability Index (ODI; 32.65±5.56) scores than the nonhematoma cohort (2.99±0.50 and 30.02±4.84, respectively; p <0.05). No significant difference was found at the final follow-up VAS, ODI, and MRI dura sac area. CONCLUSIONS Epidural fluid hematoma is a common early postoperative MRI finding in lumbar endoscopic unilateral laminotomy with bilateral decompression. Conservative management is the preferred treatment option for patients who do not have a neurological deficit. Symptoms last only a few days and are self-limiting. A common endpoint is a remodeled fluid hematoma and the subsequent expansion of the dura sac area.
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Affiliation(s)
- Pang Hung Wu
- Spine Surgery, Nanoori Gangnam Hospital, Seoul,
Korea,Department of Orthopaedic Surgery, Juronghealth Campus, National University Health System,
Singapore
| | | | - Giovanni Grasso
- Neurosurgical Clinic, Department of Biomedicine, Neurosciences and Advanced Diagnostics University for Palermo, Palermo,
Italy
| | - Jin Woo An
- Nanoori Spine and Joint Clinic with Saudi German Hospital in Dubai, Dubai,
United Arab Emirates
| | - Myeonghun Kim
- Spine Surgery, Nanoori Gangnam Hospital, Seoul,
Korea
| | - Inkyung Lee
- Spine Surgery, Nanoori Gangnam Hospital, Seoul,
Korea
| | | | | | - Sangsoo Kang
- Spine Surgery, Nanoori Gangnam Hospital, Seoul,
Korea
| | - Jeongshik Lee
- Spine Surgery, Nanoori Gangnam Hospital, Seoul,
Korea
| | - Yeonjin Yi
- Spine Surgery, Nanoori Gangnam Hospital, Seoul,
Korea
| | - Jun Hyung Lee
- Department of Internal Medicine, Chosun University College of Medicine, Gwangju,
Korea
| | - Jun Hwan Park
- Faculty of Medicine, University of Debrecen, Debrecen,
Hungary
| | - Jae Hyeon Lim
- Spine Surgery, Nanoori Gangnam Hospital, Seoul,
Korea
| | - Il-Tae Jang
- Spine Surgery, Nanoori Gangnam Hospital, Seoul,
Korea
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Treatment, Outcome, and Relapse of Spontaneous and Nonspontaneous Cerebrospinal Fluid Leak. Brain Sci 2022; 12:brainsci12030340. [PMID: 35326296 PMCID: PMC8945904 DOI: 10.3390/brainsci12030340] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 02/05/2023] Open
Abstract
Cerebrospinal fluid (CSF) leak can be spontaneous or nonspontaneous. The management options include conservative treatments, blood patch, and surgical repairs. We compared clinical symptoms, image findings, management options, hospitalization, and relapse rates among different causes of CSF leaks. Eighty-one patients were recruited: 20 with spontaneous and 61 with nonspontaneous CSF leaks. Nonspontaneous causes included lumbar puncture, surgery, and trauma. Surgery sites comprised sphenoid, spine, skull base, and calvaria. Spontaneous CSF leak came from the sphenoid or spine. Age, gender, body mass index, initial symptoms, hospitalization, treatment courses, and recurrence rates showed no difference between the groups. The spontaneous group had higher CSF accumulations on their MRIs. MRI pachymeninge enhancement showed the highest sensitivity (78.6%) for intracranial hypotension. Meningitis occurred in 1/3 of sphenoid, skull base, and calvarian surgeries. Earlier reoperation was correlated with shorter hospitalization (r = 0.651), but the recurrence rates were similar. Longer intervals between surgery and CSF leak encouraged reoperation. Among the spontaneous spine and lumbar puncture-related CSF leaks, 57.1% of them responded to 4 days of conservative treatment. Among the trauma-related CSF leaks, 90.9% of them required surgical repair. The demographic data and symptoms were similar in various groups of CSF leak. The symptom onset durations and treatment strategies were different. However, the recurrence rates were similar.
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Safety Evaluation of Biportal Endoscopic Lumbar Discectomy: Assessment of Cervical Epidural Pressure During Surgery. Spine (Phila Pa 1976) 2020; 45:E1349-E1356. [PMID: 32969993 DOI: 10.1097/brs.0000000000003585] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective study. OBJECTIVE To evaluate the change in cervical epidural pressure (CEP) during biportal endoscopic lumbar discectomy (BELD). SUMMARY OF BACKGROUND DATA In percutaneous uniportal endoscopic lumbar discectomy, irrigation fluid (IF) introduced into the spinal canal during surgery can compress the thecal sac, and act as a potential risk for neurological complications by disturbing cerebrospinal fluid (CSF) circulation and increasing intracranial pressure. METHODS Thirty consecutive patients, who underwent BELD, which was performed under automated pump system, an infusion pressure of 30 mmHg were enrolled. The change in CEP on C7-T1 level was measured. CEP was measured in each of the five phases of the procedure (1st phase-making surgical portals; 2nd phase-creating a workspace; 3rd phase-performing neural decompression and discectomy; 4th phase-factitious increase of pressure by clogging the outflow; 5th phase-dismission from fluid irrigation system). Neurological complications and independent risk factors were evaluated. RESULTS In the final 27 patients, changes in CEP during surgery were similar. The baseline CEP was 14.8 ± 2.8 mmHg, and the mean CEP in the 3rd phase 18.8 ± 5.1 mmHg was not significantly higher. In the 4th phase, however, the CEPs rose with linear correlation as the pressure increased. In the 5th phase, the elevated CEP returned to baseline in 2.5 ± 5.6 minutes. No patient had neurological complications. No statistically significant risk factors were observed. CONCLUSION In BELD, which is performed to allow continuous lavage with infusion pressure set to 30 mmHg, CEP does not increase beyond the physiological range. Therefore, BELD may be considered as a potentially safe technique. LEVEL OF EVIDENCE 4.
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Mahatthanatrakul A, Kotheeranurak V, Lin GX, Hur JW, Chung HJ, Kim JS. Comparative analysis of the intervertebral disc signal and annulus changes between immediate and 1-year postoperative MRI after transforaminal endoscopic lumbar discectomy and annuloplasty. Neuroradiology 2019; 61:411-419. [DOI: 10.1007/s00234-019-02174-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/16/2019] [Indexed: 12/19/2022]
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Quillo-Olvera J, Akbary K, Lin GX, Kim JS. Delayed Infected Pseudomeningocele After Percutaneous Endoscopic Lumbar Diskectomy. World Neurosurg 2018; 119:315-320. [PMID: 30144597 DOI: 10.1016/j.wneu.2018.08.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Percutaneous endoscopic lumbar diskectomy (PELD) has evolved over the last decades and has become an effective treatment for soft disk herniations. However, while its use increases, newer complications have been discovered. CASE DESCRIPTION We present the unique case of a woman who underwent PELD/foraminotomy to treat right-side foraminal disk herniations on L4-5 and L5-S1 in the same procedure. Ten days after surgery, the patient developed fever and severe low back pain radiated down her right leg. Magnetic resonance imaging showed a right pseudomeningocele arising from L4-5 and a nerve root herniated through the dural sac at the same lumbar segment. Blood cultures and fluid culture obtained from pseudomeningocele drainage depicted infection. Specific antibiotics were administrated, direct dura repair under the microscope was performed, and the patient improved symptomatically. CONCLUSIONS PELD combined with foraminotomy is a relatively new and skill-demanding surgery which is indicated only in cases where foraminal disk herniation is combined with foraminal stenosis. This surgical strategy requires experience by the endoscopic surgeon to prevent procedure-related complications. Although rare, these complications can lead to increased morbidity.
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Affiliation(s)
- Javier Quillo-Olvera
- The Brain and Spine Care, Minimally Invasive Spine Surgery Center, Queretaro City, Mexico
| | - Kutbuddin Akbary
- Seoul St. Mary's Hospital, Spine Center, Department of Neurosurgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Guang-Xun Lin
- Seoul St. Mary's Hospital, Spine Center, Department of Neurosurgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jin-Sung Kim
- Seoul St. Mary's Hospital, Spine Center, Department of Neurosurgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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