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Anderson B, Mozaffari K, Foster CH, Jaco AA, Rosner MK. The Ultrasonic Bone Scalpel does not Outperform the High-Speed Drill: A Single Academic Experience. World Neurosurg 2024; 185:e387-e396. [PMID: 38350596 DOI: 10.1016/j.wneu.2024.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND Spinal decompression and osteotomies are conventionally performed using high-speed drills (HSDs) and rongeurs. The ultrasonic bone scalpel (UBS) is a tissue-specific osteotome that preferentially cuts bone while sparing the surrounding soft tissues. There is ongoing investigation into its ability to optimize peri- and postoperative outcomes in spine surgery. The purpose of this study was to compare the intraoperative metrics and complications during a transition period from HSD to UBS. METHODS A single-institution, single-surgeon retrospective analysis was conducted of patients undergoing spine surgery from January 2020 to December 2021. Statistical analyses were performed to detect associations between the surgical technique and outcomes of interest. A P value < 0.05 was considered statistically significant. RESULTS A total of 193 patients met the inclusion criteria (HSD, n = 100; UBS, n = 93). Multivariate logistic regression revealed similar durotomy (P = 0.10), nerve injury (P = 0.20), and reoperation (P = 0.68) rates. Although the estimated blood loss (EBL) and length of stay were similar, the operative time was significantly longer with the UBS (192.81 vs. 204.72 minutes; P = 0.03). Each subsequent surgery using the UBS revealed a 3.1% decrease in the probability of nerve injury (P = 0.026) but had no significant effects on the operative time, EBL, or probability of durotomy or reoperation. CONCLUSIONS The UBS achieves outcomes on par with conventional tools, with a trend toward a lower incidence of neurologic injury. The expected reductions in EBL and durotomy were not realized in our cohort, perhaps because of a high proportion of revision surgeries, although these might be dependent on surgeon familiarity, among other operative factors. Future prospective studies are needed to validate our results and further refine the optimal application of this device in spine surgery.
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Affiliation(s)
- Bradley Anderson
- Department of Neurological Surgery, The George Washington University Hospital, Washington, District of Columbia, USA.
| | - Khashayar Mozaffari
- Department of Neurological Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Chase H Foster
- Department of Neurological Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Alejandro A Jaco
- Department of Neurological Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Michael K Rosner
- Department of Neurological Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
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Rodríguez D, Amin U, Bartolomé D, Pont A, Del Arco A, Saló G, Vilá G, Isart A, Manzano D, Lafuente J. Management of incidental durotomies in an integrated Orthopaedic and Neurosurgical Spinal Unit. BRAIN & SPINE 2023; 3:102682. [PMID: 38020997 PMCID: PMC10668103 DOI: 10.1016/j.bas.2023.102682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 08/23/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023]
Abstract
Introduction Incidental durotomy (ID) is an intraoperative event associated to prolonged bed rest and hospital stay, antibiotic use, higher patient dissatisfaction, and leg pain among other complications of its postoperative course. Several repair techniques and postsurgical care have been proposed for its management. This study was designed to develop an agreed protocol in cases of ID among Orthopaedic Surgeons (OS) and Neurosurgeons (NS) integrated into a Spinal Surgery Unit. Research question Incidental durotomies management protocol. Materials and methods From 997 eligible cases operated in Hospital del Mar (Barcelona, Spain) from April 2018 to March 2022, demographic, clinical, surgical and postoperative data was collected for statistical analysis from the morbidity and mortality database, with 79 identified IDs. Redo procedures were significantly associated to OS, and cervical and anterior/lateral approaches to NS, both groups were not comparable. Results ID occurred in 7.9% of cases, more frequently after the lockdown (p=0.03), in females (p=0.04), during posterior approaches (p=0.003), and less frequently in the cervical spine (p=0.009). IDs were linked to postoperative infections (p< 0.001) and nerve root damage (p< 0.001). Patients without ID evolved more satisfactorily during the postoperative period (p=0.002), and those with CSF leak (20/79) spent on bed rest more than twice the time as those without (p<0.001). Multivariable logistic regression showed strong association between posterior approaches and ID, between complicated postoperative courses and ID. Discussion and conclusions ID is linked to an adverse postoperative recovery, and it should be primarily repaired under microscope, with early mobilization of patients after surgery.
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Affiliation(s)
- D. Rodríguez
- Spinal Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - U. Amin
- Universitat Pompeu Fabra, Barcelona, Spain
| | - D. Bartolomé
- Instituto de Investigaciones Médicas del Hospital del Mar, Barcelona, Spain
| | - A. Pont
- Instituto de Investigaciones Médicas del Hospital del Mar, Barcelona, Spain
| | - A. Del Arco
- Spinal Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - G. Saló
- Spinal Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - G. Vilá
- Spinal Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - A. Isart
- Spinal Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - D. Manzano
- Spinal Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - J. Lafuente
- Spinal Surgery Unit, Hospital del Mar, Barcelona, Spain
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Lewandrowski KU, Hellinger S, De Carvalho PST, Freitas Ramos MR, Soriano-SáNchez JA, Xifeng Z, Calderaro AL, Dos Santos TS, Ramírez León JF, de Lima E SilvA MS, Dowling Á, DataR G, Kim JS, Yeung A. Dural Tears During Lumbar Spinal Endoscopy: Surgeon Skill, Training, Incidence, Risk Factors, and Management. Int J Spine Surg 2021; 15:280-294. [PMID: 33900986 DOI: 10.14444/8038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Incidental dural tears during lumbar endoscopy can be challenging to manage. There is limited literature on their appropriate management, risk factors, and the clinical consequences of this typically uncommon complication. MATERIALS AND METHODS To improve the statistical power of studying durotomy with lumbar endoscopy, we performed a retrospective survey study among endoscopic spine surgeons by email and chat groups on social media networks, including WhatsApp and WeChat. Descriptive and correlative statistics were done on the surgeons' recorded responses to multiple-choice questions. Surgeons were asked about their clinical experience with spinal endoscopy, training background, the types of lumbar endoscopic decompression they perform by approach, the decompression instruments they use, and incidental durotomy incidence with routine lumbar endoscopy. RESULTS There were 689 dural tears in 64 470 lumbar endoscopies, resulting in an incidental durotomy incidence of 1.07%. Seventy percent of the durotomies were reported by 20.4% of the surgeons. Eliminating these 19 outlier surgeons yielded an adjusted durotomy rate of 0.32. Endoscopic stenosis decompression (54.8%; P < .0001), rather than endoscopic discectomy (44.1%; 41/93), was significantly more associated with durotomy. Medium-sized dural tears (1-10 mm) were the most common (52.2%; 48/93). Small pinhole durotomies (less than 1 mm) were the second most common type (46.7%; 43/93). Rootlet herniations were seen by 46.2% (43/93) of responding surgeons. The posterior dural sac injury during the interlaminar approach (57%; 53/93) occurred more frequently than traversing nerve-root injuries (31.2%) or anterior dural sac (23.7%; 22/93). Exiting nerve-root injuries (10.8%;10/93) were less common. Over half of surgeons did not attempt any repair or closure (52.2%; 47/90). Forty percent (36/90) used sealants. Only 7.8% (7/90) of surgeons attempted an endoscopic repair or sutures (11.1%; 10/90). DuralSeal was the most commonly used brand of commercially available sealant used (42.7%; 35/82). However, other sealants such as Tisseal (15.9%; 13/82), Evicel (2.4%2/82), and additional no-brand sealants (38; 32/82) were also used. Nearly half of the patients (48.3%; 43/89) were treated with 24-48 hours of bed rest. The majority of participating surgeons (64%; 57/89) reported that the long-term outcome was unaffected. Only 18% of surgeons reported having seen the development of a postoperative cerebrospinal fluid (CSF)-fistula (18%;16/89). However, the absolute incidence of CSF fistula was only 0.025% (16/64 470). Severe radiculopathy with dysesthesia; sensory loss; and motor weakness in association with an incidental durotomy were reported by 12.4% (11/89), 3.4% (3/89), and 2.2% (2/89) of surgeons, respectively. CONCLUSIONS The incidence of dural tears with lumbar endoscopy is about 1%. The incidence of durotomy is higher with the use of power drills and the interlaminar approach. Stenosis decompression that typically requires the more aggressive use of these power instruments has a slightly higher incidence of dural tears than does endoscopic decompression for a herniated disc. Most dural tears are small and can be successfully managed with mechanical compression with Gelfoam and sealants. Two-thirds of patients with incidental dural tears had an entirely uneventful postoperative course. The remaining one-third of patients may develop a persistent CSF leak, radiculopathy with dysesthesia, sensory loss, or motor function loss. Patients should be educated preoperatively and reassured. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tucson, Arizona.,Department of Neurosurgery, UNIRIO, Rio de Janeiro, Brazil
| | | | | | - Max Rogério Freitas Ramos
- Orthopedics and Traumatology, Federal University of the Rio de Janeiro State UNIRIO, Brazil.,Orthopedic Clinics, Gaffrée Guinle University Hospital, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Zhang Xifeng
- The Chinese PLA General Hospital, Beijing, China
| | - André Luiz Calderaro
- Centro Ortopedico Valqueire, Departamento de Full Endoscopia da Coluna Vertebral, Rio de Janeiro, Brazil
| | | | - Jorge Felipe Ramírez León
- Reina Sofía Clinic and Center of Minimally Invasive Spine Surgery, Bogotá, Colombia.,Spine Surgery Program, Universidad Sanitas, Bogotá, Colombia
| | | | - Álvaro Dowling
- Endoscopic Spine Clinic, Santiago, Chile.,Department of Orthopaedic Surgery, USP, Ribeirão Preto, Brazil
| | - Girish DataR
- Center for Endoscopic Spine Surgery, Sushruta Hospital for Orthopaedics and Traumatology, Miraj, Sangli, Maharashtra, India
| | - Jin-Sung Kim
- Seoul Saint Mary's Hospital, Seocho-gu, Seoul, Republic of Korea
| | - Anthony Yeung
- University of New Mexico School of Medicine, Albuquerque, New Mexico.,Desert Institute for Spine Care, Phoenix, AZ
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