Seizure After Percutaneous Endoscopic Surgery-Incidence, Risk Factors, Prevention, and Management

Intracranial Pressure Evaluation in Swine During Full-Endoscopic Lumbar Spine Surgery

BACKGROUND

Neurological complications during full-endoscopic spine surgery (FESS) might be attributed to intracranial pressure (ICP) increase due to continuous saline infusion (CSI). Understanding CSI and ICP correlation might modify irrigation pump usage. This study aimed to evaluate invasive ICP during interlaminar FESS; correlate ICP with irrigation pump parameters (IPPs); evaluate ICP during saline outflow occlusion, commonly used to control bleeding and improve the surgeon's view; and, after durotomy, simulate accidental dural tear.

METHODS

Five swine were monitored, submitted to total intravenous anesthesia, and positioned ventrally. A parenchymal catheter was installed through a skull burr for ICP monitoring. Lumbar interlaminar FESS was performed until exposure of neural structures. CSI was used within progressively higher IPPs (A [60 mm Hg, 350 mL/minute] to D [150 mm Hg, 700 mL/minute]), and ICP was documented. During each IPP, different situations were grouped: intact dura with open channels (A1-D1) or occlusion test (A2-D2); dural tear with open channels (Ax1-Dx1) or occlusion test (Ax2-Dx2). ICP <20 mm Hg was defined as safe.

RESULTS

Basal average ICP was 8.1 mm Hg. Adjustment in total intravenous anesthesia or suspension of tests was necessary due to critical ICP or animal discomfort. It was safe to operate with all IPPs with opened drainage channels (A1-D1) even with dural tear (Ax1-Dx1). Several occlusion tests (A2-D2, Ax2-Dx2) caused ICP increase (e.g., 86.1 mm Hg) influenced by anesthetic state and hemodynamics.

CONCLUSIONS

During FESS, CSI might critically raise ICP. Keeping drainage channels open, with ideal anesthetic state, ICP remains safe even with high IPPs, despite dural tear. Drainage occlusions can quickly raise ICP, being even more severe with higher IPPs. Total intravenous anesthesia may protect from ICP increase and may allow longer drainage occlusion or higher IPPs.

Clinical Features and Management of Seizure After Percutaneous Endoscopic Spine Surgery: A Retrospective Case Series Analysis

OBJECTIVE

To describe the perioperative clinical features, management, and outcomes of patients with seizure after percutaneous endoscopic spine surgery (PESS).

METHODS

Patients who experienced seizure after PESS in a tertiary orthopedic hospital between January 2016 and June 2022 were retrospectively recruited, and patient charts were reviewed.

RESULTS

Twenty-nine patients were recruited, and the incidence of seizure after PESS was 0.52%. The operation time was 110.0 minutes (interquartile range [IQR], 82.5-235.0 minutes) and the irrigation speed was 109.0 mL/minute (IQR, 86.5-145.5 mL/minute). Definitive dural tears were reported in 15 patients (51.7%). In addition to agitation and myotonia, significant increased respiratory rate (29.9 ± 6.5 breaths/minute), tachycardia (112.1 ± 20.6 beats/minute), and hypertension (systolic, 189.5 ± 21.9 mm Hg; diastolic, 98.3 ± 10.6 mm Hg) were observed. Arterial blood gas analysis showed hypocapnia, metabolic acidosis, and hyperlactatemia. All patients received analgesia and sedation as well as hyperosmolar therapy. The estimated duration of seizure was 3.0 hours (IQR, 2.5-4.0 hours) and the postoperative length of hospital stay was 3.0 (IQR, 3.0-5.5) days. The Japanese Orthopaedic Association score and visual analog scale score improved markedly within 6 months after surgery.

CONCLUSIONS

Despite the low incidence and short duration, seizure after PESS should be considered a critical and urgent syndrome. Management strategies for seizure mainly involve intensive care, securing the airway, analgesia and sedation, hyperosmolar therapy, and negative fluid balance. No significant adverse effects of seizure on clinical outcomes were observed during 6 months of follow-up.

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.

Anesthesia considerations for patients with epilepsy: Findings of a qualitative study in the Palestinian practice

OBJECTIVE

This qualitative exploratory study was conducted to explore how anesthesiologists in Palestine provide perioperative care for patients with epilepsy and how they account for the unique challenges relevant to epilepsy while planning perioperative care for patients with epilepsy.

METHODS

This study was conducted in an explorative qualitative design. Purposive and snowball sampling approaches were used to recruit the study participants. Qualitative semi-structured in-depth interviews were conducted with anesthesiologists (n = 10) and a neurologist (n = 1). The qualitative data collected in this study were thematically analyzed using the interpretive description methodology to generate themes, subthemes, and patterns.

RESULTS

Three major themes emerged from the collected qualitative data with a total of 18 subthemes. The 3 themes were: 1) considerations/challenges while assessing patients, 2) anesthetic considerations, and 3) recovery considerations. Lack of epilepsy-specific assessment and anesthesia protocols, underuse of neurology referral services, and lack of neuromonitoring were identified.

CONCLUSION

Findings of this study highlighted the need to develop specific anesthesia protocols for patients with epilepsy. Anesthesiologists and planners of perioperative care should improve collection of patient information and assessment methods, ensure control over seizures, reduce triggers of seizures, and improve patient monitoring approaches. Findings of this study might be used to inform anesthesiologists and decision makers in professional groups, patient advocacy groups, and healthcare authorities to benchmark and improve anesthesia care and services offered to patients with epilepsy. More studies are still needed to quantitatively assess the quality of anesthesia care and services provided to patients with epilepsy.