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Martin A, Zahir J, Smith N, Raji O, Nelles D, Kondrashov D. High incidence of dural tears with 3-column osteotomies: a systematic review of adult spinal deformity surgery literature for the past decade. Spine Deform 2024:10.1007/s43390-024-00916-w. [PMID: 38914908 DOI: 10.1007/s43390-024-00916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/03/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE Dural tear (DT) is a well-known complication of spinal surgery. We aimed to systematically review the literature from the past decade and determine the incidence and risk factors for DT in the adult spinal deformity (ASD) population to improve both the surgical strategy and counseling of patients undergoing ASD correction. METHODS A systematic review from 2013 to 2023 utilizing PRISMA guidelines was performed. The MEDLINE database was used to collect primary English language articles. The inclusion criterion for patients was degenerative ASD. Pediatric studies, animal studies, review articles, case reports, studies investigating minimally invasive surgery (MIS), studies lacking data on DT incidence, and articles pertaining to infectious, metastatic or neoplastic, traumatic, or posttraumatic etiologies of ASD were excluded. RESULTS Our results demonstrate that the incidence of DT in ASD surgery ranges from 2.0% to 35.7%, which is a much broader range than the reported incidence for non deformity surgery. Moreover, the average rate of DT during ASD surgery stratified by surgical technique was greater for osteotomy overall (19.5% +/- 7.9%), especially for 3-column osteotomy (3CO), and lower for interbody fusion (14.3% +/- 9.9%). Risk factors for DT in the ASD surgery cohort included older age, revision surgery, chronic severe compression, higher-grade osteotomy, complexity of surgery, rheumatoid arthritis (RA), and higher Anesthesiology Society of America (ASA) grade. CONCLUSION To our knowledge, this is the first systematic review discussing the incidence of and risk factors for DT in the ASD population. We found that the risk factors for DT in ASD patients were older age, revision surgery, chronic severe compression, a greater degree of osteotomy, complexity of surgery, RA, and a higher ASA grade. These findings will help guide spine surgeons in patient counseling as well as surgical planning.
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Affiliation(s)
- Anna Martin
- Department of Orthopaedic Surgery, San Francisco Orthopaedic Residency Program, St. Mary's Spine Center, 450 Stanyan St, San Francisco, CA, 94117, USA
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA
| | - Jamal Zahir
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA
| | - Nathan Smith
- Penn State College of Medicine, Hershey, PA, USA
| | - Oluwatodimu Raji
- Department of Orthopaedic Surgery, San Francisco Orthopaedic Residency Program, St. Mary's Spine Center, 450 Stanyan St, San Francisco, CA, 94117, USA
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA
| | - David Nelles
- Department of Orthopaedic Surgery, San Francisco Orthopaedic Residency Program, St. Mary's Spine Center, 450 Stanyan St, San Francisco, CA, 94117, USA
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA
| | - Dimitriy Kondrashov
- Department of Orthopaedic Surgery, San Francisco Orthopaedic Residency Program, St. Mary's Spine Center, 450 Stanyan St, San Francisco, CA, 94117, USA.
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA.
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Okubo T, Nagoshi N, Kono H, Kobayashi Y, Tsuji O, Aoyama R, Isogai N, Ishihara S, Takeda K, Ozaki M, Suzuki S, Matsumoto M, Nakamura M, Watanabe K, Ishii K, Yamane J. Comparison of Surgical Outcomes After Posterior Decompression by Junior or Senior Surgeons for Patients With Cervical Ossification of the Posterior Longitudinal Ligament: Results From Retrospective Multicenter Cohort Study. Global Spine J 2024:21925682241260725. [PMID: 38831702 DOI: 10.1177/21925682241260725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES To investigate surgical outcomes following posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS We included 203 patients with cervical OPLL who were followed for a minimum of 1 year after surgery. Demographic information, medical history, and imaging findings were collected. Clinical outcomes were assessed preoperatively and at the final follow-up using the Japanese Orthopedic Association (JOA) score and the visual analog scale (VAS) for the neck. We compared outcomes between BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and NBCS surgeons. RESULTS BCS surgeons performed 124 out of 203 cases, while NBCS surgeons were primary in 79 cases, with 73.4% were directly supervised by a BCS surgeon. There was no statistically significant difference in surgical duration, estimated blood loss, and perioperative complication rates between the BCS and NBCS groups. Moreover, no statistically significant group differences were observed in each position of the C2-7 angle and cervical range of motion at preoperation and the final follow-up. Preoperative and final follow-up JOA scores, VAS for the neck, and JOA score recovery rate were comparable between the two groups. CONCLUSIONS Surgical outcomes, including functional recovery, complication rates, and cervical dynamics, were comparable between the BCS and NBCS groups. Consequently, posterior decompression for cervical OPLL is considered safe and effective when conducted by junior surgeons who have undergone training and supervision by experienced spine surgeons.
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Affiliation(s)
- Toshiki Okubo
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Hitoshi Kono
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Keiyu Orthopedic Hospital, Tatebayashi, Japan
| | - Yoshiomi Kobayashi
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Japan Red Cross Shizuoka Hospital, Shizuoka, Japan
- Department of Orthopedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Saitama Medical Center, Saitama, Japan
| | - Ryoma Aoyama
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Norihiro Isogai
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Tokyo, Japan
| | - Shinichi Ishihara
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Tokyo, Japan
- Department of Orthopedic Surgery, Subaru Health Insurance Society Ota Memorial Hospital, Ota, Japan
| | - Kazuki Takeda
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masahiro Ozaki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Ken Ishii
- Keio Spine Research Group (KSRG), Tokyo, Japan
- New Spine Clinic Tokyo, Tokyo, Japan
| | - Junichi Yamane
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan
- Department of Orthopedic Surgery, Kanagawa Prefectural Police Association Keiyu Hospital, Yokohama, Japan
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3
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Chi J, Zhang Y, Fontaine A, Zhang Z, Wang J, Labaran L, Li X. Pedicle Subtraction Osteotomy Versus Multilevel Anterior Lumbar Interbody Fusion and Lateral Lumbar Interbody Fusion in the Treatment of Adult Spinal Deformity: Trends, Outcomes, and Cost. Clin Spine Surg 2024; 37:E192-E200. [PMID: 38158597 DOI: 10.1097/bsd.0000000000001566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to compare the outcomes of pedicle subtraction osteotomy (PSO) with multilevel anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) in posterior long-segment fusion. BACKGROUND PSO and ALIF/LLIF are 2 techniques used to restore lumbar lordosis and correct sagittal alignment, with each holding its unique advantages and disadvantages. As there are situations where both techniques can be employed, it is important to compare the risks and benefits of both. PATIENTS AND METHODS Patients aged 18 years or older who underwent PSO or multilevel ALIF/LLIF with posterior fusion of 7-12 levels and pelvic fixation were identified. 1:1 propensity score was used to match PSO and ALIF/LLIF cohorts for age, sex, and relevant comorbidities, including smoking status. Logistic regression was used to compare medical and surgical outcomes. Trends and costs were generated for both groups as well. RESULTS ALIF/LLIF utilization in posterior long fusion has been steadily increasing since 2010, whereas PSO utilization has significantly dropped since 2017. PSO was associated with an increased risk of durotomy ( P < 0.001) and neurological injury ( P = 0.018). ALIF/LLIF was associated with increased rates of postoperative radiculopathy ( P = 0.005). Patients who underwent PSO had higher rates of pseudarthrosis within 1 and 2 years ( P = 0.015; P = 0.010), 1-year hardware failure ( P = 0.028), and 2-year reinsertion of instrumentation ( P = 0.009). Reoperation rates for both approaches were not statistically different at any time point throughout the 5-year period. In addition, there were no significant differences in both procedural and 90-day postoperative costs. CONCLUSIONS PSO was associated with higher rates of surgical complications compared with anterior approaches. However, there was no significant difference in overall reoperation rates. Spine surgeons should select the optimal technique for a given patient and the type of lordotic correction required.
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Affiliation(s)
- Jialun Chi
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Yi Zhang
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Andrew Fontaine
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Zhichang Zhang
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Jesse Wang
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Lawal Labaran
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Xudong Li
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
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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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Faldini C, Barile F, D'Antonio G, Rinaldi A, Manzetti M, Viroli G, Vita F, Traversari M, Cerasoli T, Ruffilli A. Incidental dural tears do not affect the overall patients' reported outcome of spine surgery at long-term follow-up: results of a systematic review. Musculoskelet Surg 2024; 108:47-61. [PMID: 36877336 DOI: 10.1007/s12306-023-00777-y] [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: 02/07/2023] [Accepted: 02/12/2023] [Indexed: 03/07/2023]
Abstract
To conduct a systematic review of the literature in order to establish if there is an overall adverse effect of accidental durotomy on the long-term patients' reported outcome after elective spine surgery. A systematic literature search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about pre- and postoperative clinical outcomes of patients with accidental durotomy and patients without were extracted and analysed. After screening, eleven studies were included with a total of 80,541 patients. About 4112 of these patients (5.10%) had incidental dural tear. When comparing patients with dural tear to patients without, 9/11 authors found no patients' reported differences at last follow-up. One author found a slightly worse VAS back pain in dural tear patients, and another author found inferior SF-36 and ODI scores in dural tear patients (both below minimal clinically important difference). Accidental dural tear did not have a significant adverse effect on clinical outcome of elective spine surgery. More studies are needed to better demonstrate this result.
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Affiliation(s)
- C Faldini
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - F Barile
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - G D'Antonio
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - A Rinaldi
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - M Manzetti
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - G Viroli
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - F Vita
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - M Traversari
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136.
| | - T Cerasoli
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - A Ruffilli
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Yu H, Zhao Q, Lv J, Liu J, Zhu B, Chen L, Jing J, Tian D. Unintended dural tears during unilateral biportal endoscopic lumbar surgery: incidence and risk factors. Acta Neurochir (Wien) 2024; 166:95. [PMID: 38381267 PMCID: PMC10881605 DOI: 10.1007/s00701-024-05965-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 12/31/2023] [Indexed: 02/22/2024]
Abstract
BACKGROUND An unintended dural tear (DT) is the most common intraoperative complication of lumbar spine surgery. The unilateral biportal endoscopic technique (UBE) has become increasingly popular for treating various degenerative diseases of the lumbar spine; however, the DT incidence and risk factors specific to UBE remain undetermined. Therefore, this study aimed to evaluate the incidence and risk factors of DTs in UBE. METHOD Data from all patients who underwent UBE for degenerative lumbar spinal diseases from November 2018 to December 2021 at our institution were used to assess the effects of demographics, diagnosis, and type of surgery on unintended DT risk. RESULTS Overall, 24/608 patients (3.95%) experienced DTs and were treated with primary suture repair or bed rest. Although several patients experienced mild symptoms of cerebrospinal fluid (CSF) leaks, no serious postoperative sequelae such as nerve root entrapment, meningitis, or intracranial hemorrhage occurred. Additionally, no significant correlations were identified between DT and sex (P = 0.882), body mass index (BMI) (P = 0.758), smoking status (P = 0.506), diabetes (P = 0.672), hypertension (P = 0.187), or surgeon experience (P = 0.442). However, older patients were more likely to experience DT than younger patients (P = 0.034), and patients with lumbar spinal stenosis (LSS) were more likely to experience DT than patients with lumbar disc herniation (LDH) (P = 0.035). Additionally, DT was more common in revision versus primary surgery (P < 0.0001) and in unilateral laminotomy with bilateral decompression (ULBD) versus unilateral decompression (P = 0.031). Univariate logistic regression analysis revealed that age, LSS, ULBD, and revision surgery were significant risk factors for DT. CONCLUSIONS In this UBE cohort, we found that the incidence of DT was 3.95%. Additionally, older age, LSS, ULBD, and revision surgery significantly increased the risk of DT in UBE surgery.
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Affiliation(s)
- Hang Yu
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
- Department of Orthopaedics, Huzhou Central Hospital, 313000, Huzhou, China
| | - Qingzhong Zhao
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Jianwei Lv
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Jianjun Liu
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Bin Zhu
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Lei Chen
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Juehua Jing
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China
| | - Dasheng Tian
- Department of Orthopaedics & Spine Surgery, The Second Hospital of Anhui Medical University, No.678 Furong Road, Economic and Technological Development Zone, Hefei, 230601, China.
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7
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Hamouda AM, Pennington Z, Astudillo Potes M, Mikula AL, Lakomkin N, Martini ML, Abode-Iyamah KO, Freedman BA, McClendon J, Nassr AN, Sebastian AS, Fogelson JL, Elder BD. The Predictors of Incidental Durotomy in Patients Undergoing Pedicle Subtraction Osteotomy for the Correction of Adult Spinal Deformity. J Clin Med 2024; 13:340. [PMID: 38256474 PMCID: PMC10816915 DOI: 10.3390/jcm13020340] [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: 10/23/2023] [Revised: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Background: Pedicle subtraction osteotomy (PSO) is a powerful tool for sagittal plane correction in patients with rigid adult spinal deformity (ASD); however, it is associated with high intraoperative blood loss and the increased risk of durotomy. The objective of the present study was to identify intraoperative techniques and baseline patient factors capable of predicting intraoperative durotomy. Methods: A tri-institutional database was retrospectively queried for all patients who underwent PSO for ASD. Data on baseline comorbidities, surgical history, surgeon characteristics and intraoperative maneuvers were gathered. PSO aggressiveness was defined as conventional (Schwab 3 PSO) or an extended PSO (Schwab type 4). The primary outcome of the study was the occurrence of durotomy intraoperatively. Univariable analyses were performed with Mann-Whitney U tests, Chi-squared analyses, and Fisher's exact tests. Statistical significance was defined by p < 0.05. Results: One hundred and sixteen patients were identified (mean age 61.9 ± 12.6 yr; 44.8% male), of whom 51 (44.0%) experienced intraoperative durotomy. There were no significant differences in baseline comorbidities between those who did and did not experience durotomy, with the exception that baseline weight and body mass index were higher in patients who did not suffer durotomy. Prior surgery (OR 2.73; 95% CI [1.13, 6.58]; p = 0.03) and, more specifically, prior decompression at the PSO level (OR 4.23; 95% CI [1.92, 9.34]; p < 0.001) was predictive of durotomy. A comparison of surgeon training showed no statistically significant difference in durotomy rate between fellowship and non-fellowship trained surgeons, or between orthopedic surgeons and neurosurgeons. The PSO level, PSO aggressiveness, the presence of stenosis at the PSO level, nor the surgical instrument used predicted the odds of durotomy occurrence. Those experiencing durotomy had similar hospitalization durations, rates of reoperation and rates of nonroutine discharge. Conclusions: In this large multisite series, a history of prior decompression at the PSO level was associated with a four-fold increase in intraoperative durotomy risk. Notably the use of extended (versus) standard PSO, surgical technique, nor baseline patient characteristics predicted durotomy. Durotomies occurred in 44% of patients and may prolong operative times. Additional prospective investigations are merited.
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Affiliation(s)
- Abdelrahman M. Hamouda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Zach Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Maria Astudillo Potes
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Anthony L. Mikula
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Nikita Lakomkin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Michael L. Martini
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | | | - Brett A. Freedman
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Jamal McClendon
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Ahmad N. Nassr
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Arjun S. Sebastian
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Jeremy L. Fogelson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
| | - Benjamin D. Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (A.M.H.); (M.A.P.)
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8
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Kögl N, Brawanski K, Thomé C, Petr O. Intraoperative application of triamcinolone - a risk factor for delayed CSF fistula formation? Acta Neurochir (Wien) 2023; 165:4105-4112. [PMID: 37910308 DOI: 10.1007/s00701-023-05844-8] [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: 08/27/2023] [Accepted: 10/15/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE Cerebrospinal fluid (CSF) leaks are a well-known complication in spinal surgery, caused mostly by incidental durotomy (ID). However, delayed pseudomeningocele formation has been described in patients following an unremarkable surgery - without ID. Intraoperative and epidural triamcinolone application has been suspected to be a potential risk factor. This study was conducted to evaluate the management of ID and identify further risk factors for secondary CSF fistula formation. METHODS After obtaining approval from the institutional ethics committee, a total of about 5512 patients, who underwent spine surgery between January 2014 and December 2017, were retrospectively reviewed. Of those, 139 cases with intraoperative ID and 15 with delayed pseudomeningocele formation were extracted and analyzed to identify potential risk factors for a late presenting dural injury (LPDI). RESULTS The incidence of delayed CSF fistulas was 0.27%, with 15 patients presenting with a secondary symptomatic CSF fistula following an unremarkable surgery. Triamcinolone was identified as a risk factor (p<0.001) for pseudomeningocele formation with an OR of 11.5, as it was applied in 80.0% (n=12) of these cases. Revision surgery was performed at a mean period of 6 weeks after initial surgery. CONCLUSION In our retrospective analysis, intraoperative application of triamcinolone was significantly associated with a high rate of delayed CSF fistulas. It should therefore be used with caution and only after weighing in potential negative side effects.
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Affiliation(s)
- Nikolaus Kögl
- Department of Neurosurgery, Medical University Innsbruck, Anichstrasse 35, MZA 3rd floor, 6020, Innsbruck, Tyrol, Austria.
| | - Konstantin Brawanski
- Department of Neurosurgery, Medical University Innsbruck, Anichstrasse 35, MZA 3rd floor, 6020, Innsbruck, Tyrol, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Anichstrasse 35, MZA 3rd floor, 6020, Innsbruck, Tyrol, Austria
| | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, Anichstrasse 35, MZA 3rd floor, 6020, Innsbruck, Tyrol, Austria
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AbdelFatah MAR. Acetazolamide, Short Bed Rest, and Subfascial Off-Suction Drainage in Preventing Persistent Spinal Fluid Leaks from Incidental Dural Tears. J Neurol Surg A Cent Eur Neurosurg 2023; 84:558-561. [PMID: 36693410 DOI: 10.1055/s-0042-1760228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Postoperative cerebrospinal fluid (CSF) leak might occur after the repair of dural tears. Acetazolamide lowers intradural pressure by decreasing CSF production. The aim of this study was to investigate the incidence of persistent CSF leak from incidental dural tears after using acetazolamide, short bed rest, and subfascial off-suction drainage. METHODS The medical records at the Ain Shams University hospital were examined retrospectively for this descriptive single-arm cohort study. Adult patients who underwent lumbar degenerative spine surgery from January 2011 through January 2021 were enrolled. The included patients experienced a CSF leak and were administered acetazolamide 1.5 g/d from postoperative day (POD) 1 to POD 7. Subfascial drainage was kept for a maximum of 5 days without suction. RESULTS Seventy-four patients met the inclusion criteria of the study. Fifty-nine patients (79.7%) had recurrent lumbar surgery. The average age of the patients was 55.7 years. In all patients, the quantity of fluid in the drain decreased on a daily basis. The subfascial drain was kept for 5 days in 26 patients (35.1%). There was no wound infection, collection, or persistent CSF leakage in any of the patients over the 6-month follow-up period. CONCLUSIONS In this study, acetazolamide was well tolerated by the patients and, in addition to short bed rest (72 hours) and off-suction subfascial drainage, did not result in persistent CSF leakage in any patient. A prospective placebo-controlled study is beneficial to confirm the efficacy of acetazolamide in preventing CSF leakage.
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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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Lyall MJ, Dear J, Simpson J, Lone N. Duration of consultant experience and patient outcome following acute medical unit admission: an observational cohort study. Clin Med (Lond) 2023; 23:458-466. [PMID: 37775159 PMCID: PMC10541280 DOI: 10.7861/clinmed.2022-0546] [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] [Indexed: 10/01/2023]
Abstract
BACKGROUND The effect of the duration of consultant experience on clinical outcomes in the acute medical unit (AMU) model remains unknown. METHODS Unscheduled AMU admissions (n=66,929) admitted by 56 consultant physicians between 2017 and 2020 to two large teaching hospital AMUs in Lothian, Scotland were examined. The associations of consultant experience on AMU with patient discharge, mortality, readmission and postdischarge death were calculated adjusting for clinical acuity, pathology and comorbidity. RESULTS Increasing consultant experience was associated with a continuous increase in likelihood of early AMU discharge (odds ratio (OR) 1.08; 95% confidence interval (CI) 1.07-1.10; p<0.001 per 5 years' experience), which persisted after adjustment for confounders (OR 1.06; 95% CI: 1.01-1.11; p=0.01). There was no association with early readmission, death after discharge or 30-day inpatient mortality. The marginal effect estimate translates into 31 (95% CI: 25-36), 41 (95% CI: 30-53) and 52 (95% CI: 35-71) additional safe discharges per 1,000 admissions for clinicians of 15, 20 and 25 years' experience, respectively compared with those recently completing training. CONCLUSIONS Increasing consultant physician experience associates with early safe discharge after AMU admission. These data suggest that the support and retention of experienced clinicians is vital if escalating pressures on unscheduled medical care are to be addressed.
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Affiliation(s)
- Marcus J Lyall
- Usher Institute for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - James Dear
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Johanne Simpson
- Department of Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nazir Lone
- Usher Institute for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Kumaar A, Ramachandraiah MK, Agarawal S, Shanthappa AH, Parmanantham M. Outcomes of Incidental Durotomy Repair in Thoracolumbar Spine Surgery: An Institutional Experience With Orthopedic Residents. Cureus 2023; 15:e41740. [PMID: 37575738 PMCID: PMC10415536 DOI: 10.7759/cureus.41740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
Background The occurrence of incidental durotomies (IDs) following spinal operations is a widely recognized issue. Complications such as poor outcomes, extended hospitalization, prolonged immobilization, infections, and revision surgeries are all potential consequences of inadequate durotomy management during the initial surgery. This study aims to describe the outcomes of ID repair in thoracolumbar spine surgery in terms of the Oswestry Disability Index (ODI) score and visual analog scale (VAS) when performed with the active involvement of orthopedic residents in the surgical procedure. Methodology Between April 2021 and April 2023, a hospital-based observational study was conducted among 110 patients hospitalized in the orthopedic ward at R.L. Jalappa Hospital and Research Center in Kolar, Karnataka, who required IDs due to an accidental dural tear or a postoperative CSF fluid leak following thoracolumbar spine procedures. Patients with a previous history of thoracolumbar spine surgery, vertebral tumors, spinal metastasis, infections, e.g., spondylodiscitis, or Pott's spine were excluded. The ODI score and VAS score were calculated on the postoperative day, one month, and three months following surgery. Results The mean age of the study participants was 62.81 + 10.49 years, with a male preponderance of 67.2% among the study participants. The mean BMI of study participants was 23.77 kg/m2. Approximately 24.5% of participants had a prior history of spinal surgery. Among 110 patients, 32 had postoperative complications. Six patients reported experiencing urinary retention, followed by five with CSF leakage and one with a postural headache (five cases). Based on the ODI score, mild disability was seen in 32.7% of the study samples at three months of follow-up. Based on the VAS score, moderate pain was seen among all the study samples at three months of follow-up. The ANOVA test revealed statistically significant differences in ODI and VAS score reductions between the immediate postoperative period and the one-month and three-month follow-up periods (p = 0.001 and p = 0.0247, respectively). Conclusion Less than one-third of the samples had postoperative complications. At three months, ODI scores showed mild disability in one-third of the study samples. At three months, all study samples had moderate VAS pain. The improvement in ODI and VAS scores from the day after surgery through the one-month and three-month follow-up periods was statistically significant.
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Affiliation(s)
- Arun Kumaar
- Orthopedics, Sri Devaraj Urs Medical College, Kolar, IND
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Giagkou N, Spanou I, Mitsikostas DD. Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes. Expert Rev Neurother 2022; 22:815-827. [PMID: 36453212 DOI: 10.1080/14737175.2022.2152674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Headaches occur when cerebrospinal fluid (CSF) pressure drops following dural puncture or trauma or spontaneously. As the features of these headaches and their accompanying symptoms might not be typical, low CSF pressure headache syndromes, and spontaneous intracranial hypotension in particular, are often misdiagnosed and underdiagnosed. AREAS COVERED The aim of this narrative review is to summarize the most recent evidence regarding the clinical presentation and the diagnosis of low CSF pressure headache syndromes. EXPERT OPINION The clinical spectrum low CSF pressure headache syndromes varies significantly and key signs might be missing. Low CSF pressure headache syndromes should be included in the differential diagnosis of any case of refractory headache, even when the headache is not orthostatic, or there are normal neuroimaging findings, and/or lumbar puncture opening pressure is within normal limits. Future research should focus on controlled interventional studies on the treatment of low CSF pressure headache syndromes, which are currently lacking.
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Affiliation(s)
- Nikolaos Giagkou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Spanou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Verma K, Freelin AH, Atkinson KA, Graham RS, Broaddus WC. Early mobilization versus bed rest for incidental durotomy: an institutional cohort study. J Neurosurg Spine 2022; 37:460-465. [PMID: 35303709 DOI: 10.3171/2022.1.spine211208] [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: 09/11/2021] [Accepted: 01/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to assess whether flat bed rest for > 24 hours after an incidental durotomy improves patient outcome or is a risk factor for medical and wound complications and longer hospital stay. METHODS Medical records of consecutive patients undergoing thoracic and lumbar decompression procedures from 2010 to 2020 were reviewed. Operative notes and progress notes were reviewed and searched to identify patients in whom incidental durotomies occurred. The need for revision surgery related to CSF leak or wound infection was recorded. The duration of bed rest, length of hospital stay, and complications (pulmonary, gastrointestinal, urinary, and wound) were recorded. The rates of complications were compared with regard to the duration of bed rest (≤ 24 hours vs > 24 hours). RESULTS A total of 420 incidental durotomies were identified, indicating a rate of 6.7% in the patient population. Of the 420 patients, 361 underwent primary repair of the dura; 254 patients were prescribed bed rest ≤ 24 hours, and 107 patients were prescribed bed rest > 24 hours. There was no statistically significant difference in the need for revision surgery (7.87% vs 8.41%, p = 0.86) between the two groups, but wound complications were increased in the prolonged bed rest group (8.66% vs 15.89%, p = 0.043). The average length of stay for patients with bed rest ≤ 24 hours was 4.47 ± 3.64 days versus 7.24 ± 4.23 days for patients with bed rest > 24 hours (p < 0.0001). There was a statistically significant increase in the frequency of ileus, urinary retention, urinary tract infections, pulmonary issues, and altered mental status in the group with prolonged bed rest after an incidental durotomy. The relative risk of complications in the group with bed rest ≤ 24 hours was 50% less than the group with > 24 hours of bed rest (RR 0.5, 95% CI 0.39-0.62; p < 0.0001). CONCLUSIONS In this retrospective study, the rate of revision surgery was not higher in patients with durotomy who underwent immediate mobilization, and medical complications were significantly decreased. Flat bed rest > 24 hours following incidental durotomy was associated with increased length of stay and increased rate of medical complications. After primary repair of an incidental durotomy, flat bed rest may not be necessary and appears to be associated with higher costs and complications.
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Ohrt-Nissen S, Carreon LY, Andresen AK, Andersen MØ, Udby P. Clinical and Patient-reported Outcomes After Posterior Versus Transforaminal Lumbar Interbody Fusion-A Propensity Score-matched Cohort Study on 422 Patients with 2-year Follow-up. Spine (Phila Pa 1976) 2022; 47:180-185. [PMID: 34474454 DOI: 10.1097/brs.0000000000004215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This was a dual-center study over an eight-year period on patients undergoing single level fusion surgery with either posterior- (PLIF) or transforaminal lumbar interbody fusion (TLIF). We analyzed prospectively collected pre- and postoperative data from the national Danish surgical spine database (DaneSpine). OBJECTIVE The aim of this study was to compare clinical and patient-reported outcome (PRO) 2 years after TLIF or PLIF in patients with symptomatic lumbar mechanical disc degeneration. SUMMARY OF BACKGROUND DATA PLIF and TLIF are well-described techniques for treating lumbar mechanical disc degeneration but whether the theoretical differences between the two techniques translate to different clinical outcomes is unknown. METHODS The primary outcome was Oswestry Disability Index (ODI) score at 2-year follow-up. Secondary outcome measures were scores on the European Quality of Life-5 Dimensions (EQ-5D) and visual analog scale (VAS) and the rate of intraoperative complications. To minimize baseline differences between the groups, propensity-score matching was employed in a 1:1 fashion, balancing the groups on preoperative factors including age, sex, back and leg pain, ODI, EQ-5D, and previous spine surgery. RESULT The matched cohort included 211 patients in each cohort. There was no significant difference between the groups in the mean score on the ODI at two years (PLIF: 33 ± 20 vs. TLIF: 35 ± 20, P = 0.328). We found no statistically significant differences in EQ-5D score (0.54 ± 0.35 vs. 0.51 ± 0.34, P = 0.327), VAS score for back pain (47 ± 32 vs. 48 ± 29, P = 0.570) or leg pain (42 ± 33 vs. 41 ± 32, P = 0.936) between the PLIF and TLIF groups, respectively, at 2-year follow-up. Dural tears occurred in 9.5% in the PLIF group and 1.9% in the TLIF group (P = 0.002) corresponding to a relative risk of 5.0 (95% CI 1.7-14.4). CONCLUSION We found no significant difference in PRO at 2-year follow-up between PLIF and TLIF for the treatment of lumbar disc degeneration. PLIF is associated with a five times higher risk of dural tears.Level of Evidence: 3.
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Affiliation(s)
- Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Leah Y Carreon
- Center for Spine Surgery and Research, Spine Center of Southern Denmark-part of Lillebaelt Hospital, Middelfart, Denmark
| | - Andreas K Andresen
- Center for Spine Surgery and Research, Spine Center of Southern Denmark-part of Lillebaelt Hospital, Middelfart, Denmark
| | - Mikkel Ø Andersen
- Center for Spine Surgery and Research, Spine Center of Southern Denmark-part of Lillebaelt Hospital, Middelfart, Denmark
| | - Peter Udby
- Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Køge, Denmark
- Center for Spine Surgery and Research, Spine Center of Southern Denmark-part of Lillebaelt Hospital, Middelfart, Denmark
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Abola MV, Du JY, Lin CC, Schreiber-Stainthorp W, Passias PG. Symptomatic Epidural Hematoma After Elective Cervical Spine Surgery: Incidence, Timing, Risk Factors, and Associated Complications. Oper Neurosurg (Hagerstown) 2021; 21:452-460. [PMID: 34624885 DOI: 10.1093/ons/opab344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/04/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND As the rate of elective cervical spine surgery increases, studies of complications may improve quality of care. Symptomatic postoperative cervical epidural hematomas (PCEH) are rare but result in significant morbidity. Because of their low incidence, the risk factors and complications associated with symptomatic PCEH remain unclear. OBJECTIVE To clarify the prevalence, timing, variables, and complications associated with PCEH following elective cervical spine surgery. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database, cervical spine surgeries performed between 2012 and 2016 were identified using Current Procedural Terminology codes. Symptomatic PCEH was defined as readmission or reoperation events specifically associated with International Classification of Diseases code diagnoses of postoperative hematoma within 30 d of index surgery. Multivariate models were created to assess the independent association of symptomatic PCEH with other postoperative complications. RESULTS There were 53233 patients included for analysis. The overall incidence of symptomatic PCEH was 0.4% (n = 198). Reoperation occurred in 158 cases (78.8%), of which 2 required a second reoperation (1.3%). The majority (91.8%) of hematomas occurred within 15 d of surgery. Multivariate analysis identified male gender, American Society of Anesthesiologists classes 3 to 5, bleeding disorder, increasing number of operative levels, revision surgery, dural repair, and perioperative transfusion as independent factors associated with PCEH. Upon controlling for those confounders, PCEH was independently associated with cardiac arrest, stroke, deep vein thrombosis, surgical site infection, and pneumonia. CONCLUSION Postoperative epidural hematomas requiring readmission or reoperation following elective cervical spine surgery occurred at an incidence of 0.4%. Symptomatic PCEHs are associated with increased rates of numerous major morbidities.
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Affiliation(s)
- Matthew V Abola
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
| | - Jerry Y Du
- Department of Orthopedics, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Charles C Lin
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
| | - William Schreiber-Stainthorp
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
| | - Peter G Passias
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
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Ajmi SC, Aase K. Physicians' clinical experience and its association with healthcare quality: a systematised review. BMJ Open Qual 2021; 10:e001545. [PMID: 34740896 PMCID: PMC8573657 DOI: 10.1136/bmjoq-2021-001545] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/22/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE There is conflicting evidence regarding whether physicians' clinical experience affects healthcare quality. Knowing whether an association exists and which dimensions of quality might be affected can help healthcare services close quality gaps by tailoring improvement initiatives according to physicians' clinical experience. Here, we present a systematised review that aims to assess the potential association between physicians' clinical experience and different dimensions of healthcare quality. METHODS We conducted a systematised literature review, including the databases MEDLINE, Embase, PsycINFO and PubMed. The search strategy involved combining predefined terms that describe physicians' clinical experience with terms that describe different dimensions of healthcare quality (ie, safety, clinical effectiveness, patient-centredness, timeliness, efficiency and equity). We included relevant, original research published from June 2004 to November 2020. RESULTS Fifty-two studies reporting 63 evaluations of the association between physicians' clinical experience and healthcare quality were included in the final analysis. Overall, 27 (43%) evaluations found a positive or partially positive association between physicians' clinical experience and healthcare quality; 22 (35%) found no association; and 14 (22%) evaluations reported a negative or partially negative association. We found a proportional association between physicians' clinical experience and quality regarding outcome measures that reflect safety, particularly in the surgical fields. For other dimensions of quality, no firm evidence was found. CONCLUSION We found no clear evidence of an association between measures of physicians' clinical experience and overall healthcare quality. For outcome measures related to safety, we found that physicians' clinical experience was proportional with safer care, particularly in surgical fields. Our findings support efforts to secure adequate training and supervision for early-career physicians regarding safety outcomes. Further research is needed to reveal the potential subgroups in which gaps in quality due to physicians' clinical experience might exist.
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Affiliation(s)
- Soffien Chadli Ajmi
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Karina Aase
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- SHARE Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Munakomi S. Letter to the Editor. Can an iatrogenic and self-limiting pseudomeningocele from a wide-bore spinal needle function as a safe lumbar drain substitute? J Neurosurg Pediatr 2021:1. [PMID: 34715666 DOI: 10.3171/2021.7.peds21375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Dural Tear Does not Increase the Rate of Venous Thromboembolic Disease in Patients Undergoing Elective Lumbar Decompression with Instrumented Fusion. World Neurosurg 2021; 154:e649-e655. [PMID: 34332152 DOI: 10.1016/j.wneu.2021.07.107] [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: 06/11/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Evaluate if dural tears (DTs) are an indirect risk factor for venous thromboembolic disease through increased recumbency in patients undergoing elective lumbar decompression and instrumented fusion. METHODS This was a retrospective cohort study of consecutive patients undergoing elective lumbar decompression and instrumented fusion at a single institution between 2016 and 2019. Patients were divided into cohorts: those who sustained a dural tear and those who did not. The cohorts were compared using Student's t-test or Wilcoxon Rank Sum for continuous variables and Fisher exact or chi-squared test for nominal variables. RESULTS Six-hundred and eleven patients met inclusion criteria, among which 144 patients (23.6%) sustained a DT. The DT cohort tended to be older (63.6 vs. 60.6 years, P = 0.0052) and have more comorbidities (Charlson Comorbidity Index 2.75 vs. 2.35, P = 0.0056). There was no significant difference in the rate of symptomatic deep vein thrombosis (2.1% vs. 2.6%, P = 1.0) or pulmonary embolus (1.4% vs. 1.50%, P = 1.0). Intraoperatively, DT was associated with increased blood loss (754 mL vs. 512 mL, P < 0.0001), operative time (224 vs. 195 minutes, P < 0.0001), and rate of transfusion (19.4% vs. 9.4%, P = 0.0018). Postoperatively, DT was associated with increased time to ambulation (2.6 vs. 1.4 days, P < 0.0001), length of stay (5.8 vs. 4.0 days, P < 0.0001), and rate of discharge to rehab (38.9 vs. 25.3%, P = 0.0021). CONCLUSIONS While DTs during elective lumbar decompression and instrumentation led to later ambulation and longer hospital stays, the increased recumbency did not significantly increase the rate of symptomatic venous thromboembolic disease.
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Masuda S, Fujibayashi S, Kimura H, Tanida S, Otsuki B, Murata K, Shimizu T, Matsuda S. Salvage Oblique Lateral Interbody Fusion for Pseudarthrosis after Posterior/Transforaminal Lumbar Interbody Fusion: A Technical Note. World Neurosurg 2021; 152:107-112. [PMID: 34129982 DOI: 10.1016/j.wneu.2021.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aims to demonstrate the efficacy of salvage oblique lumbar interbody fusion (OLIF) surgery for pseudarthrosis after posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). METHODS The study group were patients with leg or back pain induced by pseudarthrosis after PLIF/TLIF. These patients underwent salvage OLIF surgeries in our institutions between July 2015 and Oct 2019. We retrospectively evaluated their clinical and radiographic outcomes. RESULTS Seven consecutive patients (all male; mean age 68.4 ± 9.3 years, range 53-81 years) were included in this study. There was no intraoperative complications in all cases. Six of 7 patients achieved bone union (at average 33.4 months follow-up) and had a successful postoperative course. Only 1 patient failed to gain bony fusion and required additional revision surgery due to progression of sagittal and coronal malalignment at 18 months after salvage OLIF surgery. CONCLUSIONS The salvage OLIF approach was useful option for pseudarthrosis after PLIF/TLIF. It enabled us to build a rigid anterior support, allowed for extensive curettage of intervertebral scar tissue, and reduced the rate of the complications associated with dealing with posterior scar tissue.
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Affiliation(s)
- Soichiro Masuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Shunsuke Fujibayashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroaki Kimura
- Department of Orthopaedic Surgery, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Shimei Tanida
- Department of Orthopaedic Surgery, Shiga General Hospital, Shiga, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichi Murata
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takayoshi Shimizu
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Shahmohammadi M, Hajimohammadebrahim-Ketabforoush M, Behnaz F, Keykhosravi E, Zandpazandi S. Comparison of Transthecal Approach With Traditional Conservative Approach for Primary Closure After Incidental Durotomy in Anterior Lumbar Tear. Int J Spine Surg 2021; 15:429-435. [PMID: 33985999 DOI: 10.14444/8064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Incidental durotomies (IDs) are frequent complications of spinal surgeries which are mostly posterior or lateral. Anterior IDs are rare; however, they may lead to severe complications. We compared the transthecal approach with the conservative approach for primary closure after durotomy in anterior lumbar dural tear to assess the efficacy of these approaches to decrease postsurgical complications and clinical outcomes. METHODS A total of 21 patients undergoing L2-S1 laminectomy with anterior ID were randomly divided into a transthecal group (n = 9) and a conservative group (n = 12) based on the surgical dural closure technique. Postoperative pseudomeningocele, wound infection, rootlet herniation, pneumocephalus, cerebrospinal fluid (CSF) leakage, headache, meningitis, in addition to surgery duration and length of hospitalization were examined and compared in both groups. RESULTS The frequency of pseudomeningocele and CSF leakage in patients undergoing the transthecal approach was significantly lower than those undergoing the conservative approach (P = .045 and .008, respectively). Furthermore, although the differences in the frequency of meningitis, pneumocephalus, headache, and wound infection were not statistically significant between the 2 groups, the effect sizes of the comparison were obtained as 49.4, 19.8, 7.1, and 2.6, respectively. This indicated that the differences were clinically significant between the 2 groups. CONCLUSIONS We found that the transthecal approach was significantly more successful in managing CSF leakage as well as its complications and clinical outcomes. However, further clinical trials with bigger sample sizes are needed to substantiate this claim.
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Affiliation(s)
- Mohammadreza Shahmohammadi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Melika Hajimohammadebrahim-Ketabforoush
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Faranak Behnaz
- Anesthesiology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ehsan Keykhosravi
- Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sara Zandpazandi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Alshameeri ZAF, Jasani V. Risk Factors for Accidental Dural Tears in Spinal Surgery. Int J Spine Surg 2021; 15:536-548. [PMID: 33986000 DOI: 10.14444/8082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Accidental dural tears (DTs) are familiar complications of spinal surgery. Their reported incidence varies widely, and several risk factors have been proposed in the literature. The aim of this study was to conduct a systematic review and meta-analysis to determine the rate of DTs and assess their associated risk factors. METHODS A systematic literature search was conducted using specific MeSH and Text terms. Only articles with prospective data reporting the incidence and risk factors were selected and reviewed based on specific inclusion and exclusion criteria. RESULTS Twenty-three studies were included. The reported incidence rate ranged from 0.4% to 15.8%, giving an overall pooled incidence rate of 5.8% (95% confidence interval [CI] 4.4-7.3). The incidence rate varied in relation to the part of the spine and the type of surgery. Three factors were associated with a high rate of DTs: age (overall mean difference of 3.04, 95% CI 2.49-3.60), revision surgery (overall odds ratio of 2.28, 95% CI 1.84-2.83), and lumbar stenosis (overall odds ratio of 2.03, 95% CI 1.50-2.75). Diabetes was weakly associated with DTs, with an odds ratio of 1.40 (95% CI 1.01-1.93). The overall effects of sex and obesity were not statistically significant. CONCLUSION Advancing age, revision surgery, and lumbar stenosis were significantly associated with increased risk of DTs. These factors should be taken into consideration during the consenting process for spinal surgery. CLINICAL RELEVANCE Risk of dural tear during spine surgery.
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Affiliation(s)
- Zeiad A F Alshameeri
- University Hospital of North Midlands, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Vinay Jasani
- University Hospital of North Midlands, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
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Alshameeri ZAF, Ahmed EN, Jasani V. Clinical Outcome of Spine Surgery Complicated by Accidental Dural Tears: Meta-Analysis of the Literature. Global Spine J 2021; 11:400-409. [PMID: 32875884 PMCID: PMC8013939 DOI: 10.1177/2192568220914876] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
STUDY DESIGN Systemic review and meta-analysis. OBJECTIVES Several studies have reported the impact of accidental dural tears (DT) on the outcome of spinal surgery, some with conflicting results. Therefore, the aim of this study was to carry out a systemic review and meta-analysis of the literature to establish the overall clinical outcome of spinal surgery following accidental DT. METHOD A systemic literature search was carried out. Postoperative improvement in Oswestry Disability Index (ODI), Short-Form 36 survey (SF36), leg pain visual analogue scale (VAS), and back pain VAS were compared between patients with and without DT at different time intervals. RESULTS Eleven studies were included in this meta-analysis. There was a slightly better improvement in ODI and leg VAS score (standardized mean difference of -0.06, 95% confidence interval [CI] -0.12 to -0.01, and -0.06, 95% CI -0.09 to -0.02, respectively) in patients without DT at 12 months postsurgery, but this effect was not demonstrated at any other time intervals up to 4 years. There were no differences in the overall SF36 (function) score at any time interval or back pain VAS at 12 months. CONCLUSION Based on this study, accidental DT did not have an overall significant adverse impact on the short-term clinical outcome of spinal surgery. More studies are needed to address the long-term impact and other outcome measures including other immediate complications of DT.
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Affiliation(s)
- Zeiad A. F. Alshameeri
- University Hospital of North Midlands, Stoke-on-Trent, UK,Zeiad A. F. Alshameeri, Department of Spinal Surgery, University Hospital of North Midlands, Newcastle Road, Stoke-on-Trent ST4 6QG, UK.
| | - El-Nasri Ahmed
- University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Vinay Jasani
- University Hospital of North Midlands, Stoke-on-Trent, UK
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Choi EH, Chan AY, Brown NJ, Lien BV, Sahyouni R, Chan AK, Roufail J, Oh MY. Effectiveness of Repair Techniques for Spinal Dural Tears: A Systematic Review. World Neurosurg 2021; 149:140-147. [PMID: 33640528 DOI: 10.1016/j.wneu.2021.02.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Incidental or intentional durotomy in spine surgery is associated with a risk of cerebrospinal fluid (CSF) leakage and reoperation. Several strategies have been introduced, but the incomplete closure is still relatively frequent and troublesome. In this study, we review current evidence on spinal dural repair strategies and evaluate their efficacy. METHODS PubMed, Web of Science, and Scopus were used to search primary studies about the repair of the spinal dura with different techniques. Of 265 articles found, 11 studies, which specified repair techniques and postoperative outcomes, were included for qualitative and quantitative analysis. The primary outcomes were CSF leakage and postoperative infection. RESULTS The outcomes of different dural repair techniques were available in 776 cases. Pooled analysis of 11 studies demonstrated that the most commonly used technique was a combination of primary closure, patch or graft, and sealant (22.7%, 176/776). A combination of primary closure and patch or graft resulted in the lowest rate of CSF leakage (5.5%, 7/128). In this study, sealants as an adjunct to primary closure (13.7%, 18/131) did not significantly reduce the rate of CSF leakage compared with primary closure alone (17.6%, 18/102). The rates of infection and postoperative neurologic deficit were similar regardless of the repair techniques. CONCLUSIONS Although the use of sealants has become prevalent, available sealants as an adjunct to primary closure did not reduce the rate of CSF leakage compared with primary closure. The combination of primary closure and patches or grafts could be effective in decreasing postoperative CSF leakage.
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Affiliation(s)
- Elliot H Choi
- Department of Neurological Surgery, University of California, Irvine, California, USA; Medical Scientist Training Program, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alvin Y Chan
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California, San Diego, California, USA
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - John Roufail
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Michael Y Oh
- Department of Neurological Surgery, University of California, Irvine, California, USA.
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Tracking Scan to Incision Time in Patients with Emergent Operative Traumatic Brain Injuries as a Measure for Systems-Based Practice in Neurosurgical Trainees. World Neurosurg 2021; 149:e491-e497. [PMID: 33556603 DOI: 10.1016/j.wneu.2021.01.150] [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: 12/05/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Evaluation of trainee performance remains a challenge in resident education, particularly for systems-based practice (SysBP) metrics including care coordination and interdisciplinary teamwork. Time to intervention is an important modifiable outcome variable in severe traumatic brain injury (TBI) and may serve as a trackable metric for SysBP evaluation. METHODS We retrospectively studied time from computed tomography head scan to surgical incision (CTH-INC, minutes) among neurosurgical trainees treating patients with emergently operative TBI as a proxy SysBP measure. Our institutional operative database was utilized to identify all emergent TBI cases between July 2015 and June 2020. Patients evaluated by program year (PGY)-2 residents proceeding directly to the operating room from the emergency department were included. Statistical analysis was performed using linear regression. RESULTS One hundred sixty-six cases triaged by 14 PGY-2 neurosurgical trainees were analyzed. Median CTH-INC was 104 minutes (interquartile range, 82-136 minutes). CTH-INC improved 20.1% over the academic year (95% confidence interval, 4.3%-33.2%, P = 0.015). Between the first and second 6-month periods, the rate of CTH-INC within 90 minutes (29% vs. 46%, P = 0.04) improved. On a per-individual PGY-2 basis, median CTH-INC ranged from 83-127 minutes, 25th percentile CTH-INC ranged from 62-108 minutes, and fastest CTH-INC ranged from 45-92 minutes. CONCLUSIONS CTH-INC is an objective and trackable proxy measure for evaluating SysBP during neurosurgical training. Use of CTH-INC or other time metrics in resident evaluations should not supersede the safe and effective delivery of patient care.
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Iida J, Miyakoshi N, Hongo M, Sasaki H, Ito H, Kubota H, Sato T, Shimada Y. Herniation of the cauda equina into the facet joint through a pseudomeningocele: A case report and literature review. Surg Neurol Int 2021; 12:30. [PMID: 33598346 PMCID: PMC7881497 DOI: 10.25259/sni_893_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/25/2020] [Indexed: 11/04/2022] Open
Abstract
Background Incidental durotomy is a well-known complication of spinal surgery. It can lead to persistent cerebrospinal fluid leakage resulting in significant secondary complications. Here, we present a case in which the cauda equina herniated into a pseudomeningocele that penetrated a facet joint, leading to lower extremity radiculopathy warranting surgical correction. Case Description One year ago, a 67-year-old male underwent a partial left L4-L5 laminectomy. At surgery, a durotomy was repaired with a nylon suture and reinforced with a fat patch. He subsequently presented with severe left lower extremity radiculopathy and a partial cauda equina syndrome. On MR, the cauda equina had herniated into a pseudomeningocele that penetrated the left facet joint. Once the defect was repaired at surgery, the patient's symptoms improved. Conclusion It is critical to correctly repair an intraoperative durotomy to avoid further neurological deficits that may include cauda equina herniation into pseudomeningoceles penetrating facet joints.
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Affiliation(s)
- Jumpei Iida
- Department of Orthopedic Surgery, Noshiro Kosei Medical Center, Noshiro, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan
| | - Michio Hongo
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan
| | - Hiroshi Sasaki
- Department of Orthopedic Surgery, Noshiro Kosei Medical Center, Noshiro, Japan
| | - Hiroki Ito
- Department of Orthopedic Surgery, Noshiro Kosei Medical Center, Noshiro, Japan
| | - Hitoshi Kubota
- Department of Orthopedic Surgery, Noshiro Kosei Medical Center, Noshiro, Japan
| | - Takeshi Sato
- Department of Orthopedic Surgery, Noshiro Kosei Medical Center, Noshiro, Japan
| | - Yoichi Shimada
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan
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Kotaka S, Fujiwara Y, Ota R, Manabe H, Adachi N. Delayed symptomatic cerebrospinal fluid leakage after spine surgery with an intraoperative occult dural tear: An institutional experience and literature review. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Symptomatic Epidural Hematoma after Elective Posterior Lumbar Decompression: Incidence, Timing, Risk Factors, and Associated Complications. HSS J 2020; 16:230-237. [PMID: 33380952 PMCID: PMC7749891 DOI: 10.1007/s11420-019-09690-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/23/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Symptomatic post-operative lumbar epidural hematoma (PLEH) is a complication of lumbar spine surgery that can cause permanent neurologic consequences through compression of the cauda equina and nerve roots. QUESTIONS/PURPOSES We sought to investigate the incidence, timing, and risk factors for symptomatic epidural hematomas following posterior lumbar decompression, as well as to identify additional post-operative complications associated with symptomatic lumbar epidural hematomas. METHODS Elective lumbar spine procedures were identified in the National Surgical Quality Improvement Program (NSQIP) database between 2012 and 2016. Analyzed predictors of reoperation or readmission within 30 days for symptomatic PLEH included demographics, comorbidities, pre-operative laboratory values, peri-operative characteristics, and post-operative complications. RESULTS There were 75,878 cases included in the analysis. The incidence rate of symptomatic PLEH was 0.27% (n = 206), 54.4% (n = 112) of which occurred within 5 days of the procedure. Increased age, obesity (body mass index of 35 or higher), peri-operative transfusion, multilevel surgery (two or more levels), dural tear repair, and microscope use were independently associated with PLEH. Post-operative complications associated with PLEH included surgical site infection and urinary tract infection. CONCLUSIONS Readmission or reoperation for symptomatic PLEH following elective lumbar spine surgery is rare and can occur many days or weeks after a procedure. There are modifiable risk factors for PLEH and associated additional post-operative complications that physicians should be suspicious of following posterior lumbar decompression.
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Sun C, Chen G, Fan T, Li W, Guo Z, Qi Q, Zeng Y, Zhong W, Chen Z. Ultrasonic bone scalpel for thoracic spinal decompression: case series and technical note. J Orthop Surg Res 2020; 15:309. [PMID: 32771031 PMCID: PMC7414581 DOI: 10.1186/s13018-020-01838-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/29/2020] [Indexed: 11/25/2022] Open
Abstract
Background Thoracic spinal stenosis (TSS) is a rare but intractable disease that fails to respond to conservative treatment. Thoracic spinal decompression, which is traditionally performed using high-speed drills and Kerrison rongeurs, is a time-consuming and technically challenging task. Unfavorable outcomes and high incidence of complications are the major concerns. The development and adaptation of ultrasonic bone scalpel (UBS) have promoted its application in various spinal operations, but its application and standard operating procedure in thoracic decompression have not been fully clarified. Therefore, the purpose of this study is to describe our experience and technique note of using UBS and come up with a standard surgical procedure for thoracic spinal decompression. Methods A consecutive of 28 patients with TSS who underwent posterior thoracic spinal decompression surgery with UBS between December 2014 and May 2015 was enrolled in this study. The demographic data, perioperative complications, operation time, estimated blood loss, and pre- and postoperative neurological statuses were recorded and analyzed. Neurological status was evaluated with a modified Japanese Orthopaedic Association (JOA) scale, and the neurological recovery rate was calculated using the Hirabayashi’s Method. Results Thoracic spinal decompression surgery was successfully carried out in all cases via a single posterior approach. The average age at surgery was 49.7 ± 8.5 years. The mean operative time of single-segment laminectomy was 3.0 ± 1.4 min, and the blood loss was 108.3 ± 47.3 ml. In circumferential decompression, the average blood loss was 513.8 ± 217.0 ml. Two cases of instrument-related nerve root injury occurred during operation and were cured by conservative treatment. Six patients experienced cerebrospinal fluid (CSF) leakage postoperatively, but no related complications were observed. The mean follow-up period was 39.7 ± 8.9 months, the average JOA score increased from 4.7 before surgery to 10.1 postoperatively, and the average recovery rate was 85.8%. Conclusions The UBS is an optimal instrument for thoracic spinal decompression, and its application enables surgeons to decompress the thoracic spinal cord safely and effectively. This standard operating procedure is expected to help achieve favorable outcomes and can be used to treat various pathologies leading to TSS.
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Affiliation(s)
- Chuiguo Sun
- Department of orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Guanghui Chen
- Department of orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Tianqi Fan
- Department of orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Weishi Li
- Department of orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Zhaoqing Guo
- Department of orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Qiang Qi
- Department of orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Yan Zeng
- Department of orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Woquan Zhong
- Department of orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Zhongqiang Chen
- Department of orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China.
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Oshina M, Segawa T, Manabe N, Oshima Y, Tanaka S, Inanami H. Incidence, prognosis, and risk factors for bladder and bowel dysfunction due to incidental dural tears in lumbar microendoscopic surgery. Spine J 2020; 20:688-694. [PMID: 31863934 DOI: 10.1016/j.spinee.2019.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/12/2019] [Accepted: 12/13/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite the common occurrence of incidental dural tears, the incidence and prognosis of bladder and bowel dysfunction (BBD) due to incidental dural tears in lumbar spinal surgery are not well known because of the lack of reported cases. PURPOSE To analyze the incidence, prognosis, and risk factors for BBD after lumbar microendoscopic surgery with or without incidental dural tears. STUDY DESIGN/SETTING A retrospective cohort study. PATIENT SAMPLE We analyzed 2,421 patients who underwent lumbar microendoscopic surgery and investigated patients with BBD after an incidental durotomy during surgery. OUTCOME MEASURES Patients were divided into three groups on the basis of dysuria and defecation disorders: severe BBD, mild BBD, and no BBD. The post void residual volumes before and after surgery were compared using an ultrasound bladder scanner or bladder catheterization after confirmation of urination. Bowel dysfunction was evaluated by subjective symptomatic deterioration and the increase in the frequency and duration of postoperative medical care. METHODS Risk factors for BBD were analyzed using surgical video documentation to determine the dural tear site and cauda equina exposure from the dural sac. Patients with BBD were prospectively followed up for prognosis determination. The chi-square test was used to compare the incidence of BBD between patients with dural tears and those without. Propensity score-adjusted logistic regression analysis was performed to evaluate the effects of various factors on the incidence of postoperative BBD. RESULTS The incidence of dural tears was 6.9% (168/2,421). The overall incidence of BBD was 3.0% (73/2,421), while the incidences of BBD (mild+severe BBD) and severe BBD due to incidental dural tears were 1.2% (30/2,421) and 0.8% (20/2,421), respectively. The incidence of BBD in patients with dural tears and those without tears was 17.9% [30/168] and 1.9% [43/2,253; p<.001]), respectively. BBD rates at 1 week, 1 month, 3 months, 6 months, and 1 year after surgery were 64.0%, 44.0%, 40.0%, 28.0%, and 13.6%, respectively. Logistic regression analysis revealed that the male sex (odds ratio [OR], 4.20), dural tears in the central area (OR, 10.15), and exposure of the cauda equina (OR, 51.04) were significant risk factors. CONCLUSIONS The incidence of dural tears in lumbar microendoscopic surgeries are associated with an increased incidence of BBD. The recovery rate for BBD due to incidental dural tears is generally good; however, some patients experience long-term symptoms. Clinicians should be aware that incidental dural tears with cauda equina exposure can increase the risk of BBD.
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Affiliation(s)
- Masahito Oshina
- Inanami Spine and Joint Hospital, 3-17-5, Higashishinagawa, Shinagawa-Ku, Tokyo 140-0002, Japan.
| | - Tomohide Segawa
- Inanami Spine and Joint Hospital, 3-17-5, Higashishinagawa, Shinagawa-Ku, Tokyo 140-0002, Japan
| | - Nodoka Manabe
- Inanami Spine and Joint Hospital, 3-17-5, Higashishinagawa, Shinagawa-Ku, Tokyo 140-0002, Japan
| | - Yasushi Oshima
- Department of Orthopedic Surgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-Ku, Tokyo 113-8655, Japan
| | - Sakae Tanaka
- Department of Orthopedic Surgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-Ku, Tokyo 113-8655, Japan
| | - Hirohiko Inanami
- Inanami Spine and Joint Hospital, 3-17-5, Higashishinagawa, Shinagawa-Ku, Tokyo 140-0002, Japan
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Ehresman J, Pennington Z, Karhade AV, Huq S, Medikonda R, Schilling A, Feghali J, Hersh A, Ahmed AK, Cottrill E, Lubelski D, Westbroek EM, Schwab JH, Sciubba DM. Incidental durotomy: predictive risk model and external validation of natural language process identification algorithm. J Neurosurg Spine 2020; 33:342-348. [PMID: 32357334 DOI: 10.3171/2020.2.spine20127] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Incidental durotomy is a common complication of elective lumbar spine surgery seen in up to 11% of cases. Prior studies have suggested patient age and body habitus along with a history of prior surgery as being associated with an increased risk of dural tear. To date, no calculator has been developed for quantifying risk. Here, the authors' aim was to identify independent predictors of incidental durotomy, present a novel predictive calculator, and externally validate a novel method to identify incidental durotomies using natural language processing (NLP). METHODS The authors retrospectively reviewed all patients who underwent elective lumbar spine procedures at a tertiary academic hospital for degenerative pathologies between July 2016 and November 2018. Data were collected regarding surgical details, patient demographic information, and patient medical comorbidities. The primary outcome was incidental durotomy, which was identified both through manual extraction and the NLP algorithm. Multivariable logistic regression was used to identify independent predictors of incidental durotomy. Bootstrapping was then employed to estimate optimism in the model, which was corrected for; this model was converted to a calculator and deployed online. RESULTS Of the 1279 elective lumbar surgery patients included in this study, incidental durotomy occurred in 108 (8.4%). Risk factors for incidental durotomy on multivariable logistic regression were increased surgical duration, older age, revision versus index surgery, and case starts after 4 pm. This model had an area under curve (AUC) of 0.73 in predicting incidental durotomies. The previously established NLP method was used to identify cases of incidental durotomy, of which it demonstrated excellent discrimination (AUC 0.97). CONCLUSIONS Using multivariable analysis, the authors found that increased surgical duration, older patient age, cases started after 4 pm, and a history of prior spine surgery are all independent positive predictors of incidental durotomy in patients undergoing elective lumbar surgery. Additionally, the authors put forth the first version of a clinical calculator for durotomy risk that could be used prospectively by spine surgeons when counseling patients about their surgical risk. Lastly, the authors presented an external validation of an NLP algorithm used to identify incidental durotomies through the review of free-text operative notes. The authors believe that these tools can aid clinicians and researchers in their efforts to prevent this costly complication in spine surgery.
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Affiliation(s)
- Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Aditya V Karhade
- 2Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Sakibul Huq
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Ravi Medikonda
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Andrew Schilling
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - James Feghali
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Andrew Hersh
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - A Karim Ahmed
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Ethan Cottrill
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Daniel Lubelski
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Erick M Westbroek
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Joseph H Schwab
- 2Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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Alshameeri ZAF, El-Mubarak A, Kim E, Jasani V. A systematic review and meta-analysis on the management of accidental dural tears in spinal surgery: drowning in information but thirsty for a clear message. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1671-1685. [DOI: 10.1007/s00586-020-06401-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/21/2020] [Accepted: 03/28/2020] [Indexed: 12/29/2022]
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Gandhi J, DiMatteo A, Joshi G, Smith NL, Khan SA. Cerebrospinal fluid leaks secondary to dural tears: a review of etiology, clinical evaluation, and management. Int J Neurosci 2020; 131:689-695. [PMID: 32242448 DOI: 10.1080/00207454.2020.1751625] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Damage to the dura mater often occurs in trauma cases of the head and spine, surgical procedures, lumbar punctures, and meningeal diseases. The resulting damage from dural tears, or durotomy, causes cerebrospinal fluid (CSF) to leak out into the surrounding space. The CSF leak induces intracranial hypotension, which can clinically present with a range of symptoms not limited to positional headaches which can confound accurate diagnosis. Current methods of evaluation and management of dural tears are discussed herewith, as well as the present understanding of its etiology, which may be classified as related to surgery, procedure, trauma, or connective tissue disorder. METHODS We piloted a MEDLINE® database search of literature, with emphasis on the previous five years, combining keywords such as "cerebrospinal fluid leak," "surgery," "procedure," and "trauma" to yield original research articles and case reports for building a clinical profile. RESULTS Patients with suspected dural tears should be evaluated based on criteria set by the International Headache Society, radiological findings, and a differential diagnosis to accurately identify the tear and its potential secondary complications. Afflicted patients may be treated promptly with epidural blood patches, epidural infusions, epidural fibrin glue, or surgical repair. At this time, epidural blood patches are the first line of treatment. Dural tears can be prevented to an extent by utilizing minimally invasive techniques and certain positions for lumbar puncture. Surgical, trauma, lumbar puncture, and epidural injection patients should be observed very carefully for dural tears and CSF leaks as the presenting clinical manifestations can be highly individualized and misguiding. CONCLUSION Because studies have demonstrated a high frequency of dural tears, particularly in spinal surgery patients, there is a need for prospective studies so that clinicians can develop an elaborate prevention strategy and response to avoid serious, unseen complications.
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Affiliation(s)
- Jason Gandhi
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.,Medical Student Research Institute, St. George's University School of Medicine, Grenada, West Indies
| | - Andrew DiMatteo
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Gunjan Joshi
- Department of Internal Medicine, Stony Brook Southampton Hospital, Southampton, NY, USA
| | | | - Sardar Ali Khan
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.,Department of Urology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
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Costa F, Alves OL, Anania CD, Zileli M, Fornari M. Decompressive Surgery for Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations. World Neurosurg X 2020; 7:100076. [PMID: 32613189 PMCID: PMC7322794 DOI: 10.1016/j.wnsx.2020.100076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/02/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Lumbar spine stenosis is a common disease with a prevalence progressively increasing due to the aging of the population. Despite many papers having been published over the last decades, there still remain many doubts regarding its natural history and appropriate treatment. To overcome these problems and reach some globally accepted recommendations, the World Federation of Neurosurgical Society Spine Committee organized a consensus conference on this topic. This paper describes recommendations about the efficacy of surgical decompression, the difference between surgical techniques, and complications of surgery. Methods World Federation of Neurosurgical Society Spine Committee aimed to standardize clinical practice worldwide as much as possible and held a 2-round consensus conference on lumbar spinal stenosis. A team of expert spine surgeons reviewed literature regarding surgical treatment from over the last 10 years, and then drafted and voted on some statements based on the presented literature. Results Ten statements were voted. The committee agreed on the effectiveness of surgical decompression in patients with moderate-to-severe symptoms or with neurologic deficits. There was no consensus on the best surgical technique and, in particular, about the equivalence of microscopic techniques and an open approach. Regarding complications, we agreed that the most frequent complications are incidental durotomy and general complications in the elderly. Conclusions Surgical decompression represents the treatment of choice for symptomatic lumbar spinal stenosis with a low complication rate. However, which surgical technique is the best is still under debate. Further studies with standardized outcome measures are needed to understand the real complication rate and frequency of different unwanted events.
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Affiliation(s)
- Francesco Costa
- Neurosurgery Department, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
| | - Oscar L Alves
- Neurosurgery Department, Hospital Lusiadas Porto, Porto, Portugal
| | - Carla D Anania
- Neurosurgery Department, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University Faculty of Medicine, Bornova, Izmir, Turkey
| | - Maurizio Fornari
- Neurosurgery Department, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
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Nakashima H, Kanemura T, Satake K, Ito K, Ishikawa Y, Ouchida J, Segi N, Yamaguchi H, Imagama S. Indirect Decompression Using Lateral Lumbar Interbody Fusion for Restenosis after an Initial Decompression Surgery. Asian Spine J 2020; 14:305-311. [PMID: 31906613 PMCID: PMC7280913 DOI: 10.31616/asj.2019.0194] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 07/04/2019] [Indexed: 12/03/2022] Open
Abstract
Study Design Retrospective comparative study. Purpose We compared clinical and radiographical outcomes after lumbar decompression revision surgery for restenosis by lateral lumbar interbody fusion (LLIF) and posterior lumbar interbody fusion (PLIF). Overview of Literature Indirect lumbar decompression with LLIF was used to treat degenerative lumbar diseases requiring neural decompression. However, only a few studies have focused on the effectiveness of this technique for restenosis after lumbar decompression. Methods We retrospectively investigated 52 cases involving lumbar interbody fusions for restenosis with spondylolisthesis after lumbar decompressions; these cases consisted of 15 patients who underwent indirect decompression with LLIF and posterior fixation and 37 patients who underwent the same procedure with PLIF. We compared Japanese Orthopaedic Association (JOA) scores and perioperative complications between groups. The cross-sectional areas of the thecal sac on magnetic resonance imaging were measured before, immediately after, and 2 years after surgery. We conducted statistical analyses using unpaired t -test and Fisher’s exact tests, and a p-value <0.05 was considered statistically significant. Results The operative time was significantly shorter in the LLIF group than in the PLIF group (115.3±33.6 min vs. 186.2±34.2 min, respectively; p<0.001). In addition, the intraoperative blood loss was significantly lower in the LLIF group than in the PLIF group (58.2±32.7 mL vs. 303.2±140.1 mL, respectively; p<0.001). We found two cases of transient lateral thigh weakness (13.3%) in the LLIF group and five cases of incidental durotomy, one case of deep infection, and one case of neurological deterioration in the PLIF group—resulting in a higher complication incidence (18.9%), although it did not reach (p=0.63). The JOA scores improved significantly in both groups. Conclusions Indirect decompression using LLIF provided acceptable clinical and radiographical outcomes in patients with restenosis with spondylolisthesis after lumbar decompression; no revision-surgery-specific complications were found. Our results suggest that LLIF is a safe and minimally invasive procedure for revision surgery.
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Affiliation(s)
- Hiroaki Nakashima
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Tokumi Kanemura
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Kotaro Satake
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Kenyu Ito
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | | | - Jun Ouchida
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetoshi Yamaguchi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Nguyen T, Khanna K, Gornitzky AL, Diab M. Idiopathic stroke after syndromic and neuromuscular scoliosis surgery: a case report and literature review. AME Case Rep 2019; 3:28. [PMID: 31559384 DOI: 10.21037/acr.2019.07.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/27/2019] [Indexed: 11/06/2022]
Abstract
Children with syndromic and neuromuscular scoliosis undergoing corrective surgery experience higher complication rates than those with idiopathic scoliosis. A rare but devastating complication is stroke, which occurs in 0.57% of operations for neuromuscular scoliosis but accounts for 7.6% of deaths. Comorbidities associated with non-idiopathic scoliosis that increase risk of stroke include hypercoagulability, cardiac dysfunction, and contractures, which interfere with positioning and risk vascular compromise. Syndromic and neuromuscular diseases may predispose patients to intraoperative dural tears, either primarily (e.g., dural ectasia) or secondarily, in particular due to severity of deformity. We present the case of a perioperative, idiopathic stroke in a 15-year-old boy with scoliosis in the setting of neurofibromatosis type I, reviewing possible causes as well as strategies for preoperative assessment and postoperative monitoring.
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Affiliation(s)
- Thomas Nguyen
- School of Medicine, University of California - San Francisco, San Francisco, CA 94158, USA
| | - Krishn Khanna
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA 94158, USA
| | - Alex L Gornitzky
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA 94158, USA
| | - Mohammad Diab
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA 94158, USA
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Farshad M, Aichmair A, Wanivenhaus F, Betz M, Spirig J, Bauer DE. No benefit of early versus late ambulation after incidental durotomy in lumbar spine surgery: a randomized controlled trial. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:141-146. [PMID: 31552537 DOI: 10.1007/s00586-019-06144-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 07/29/2019] [Accepted: 09/07/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Incidental durotomy (ID) is a complication occurring in 4-17% of decompressive spinal surgeries. Persisting CSF leakage can occur even after ID repair and requires revision surgery. Prolonged flat bed rest (BR) to reduce the incidence of persisting CSF leakage is frequently applied but highly debated. A randomized controlled trial comparing prolonged BR versus early ambulation after ID repair is lacking. The aim of this study was to investigate the incidence of revision surgery as a result of persistent cerebro-spinal fluid (CSF) leakage and medical complications after immediate or late post-operative ambulation following ID during decompressive spinal surgery. METHODS Ninety-four of 1429 consecutive cases undergoing lumbar spine surgery (6.58%) were complicated by an ID. Sixty patients (mean age of 64 ± 13.28 years) were randomized to either early post-operative ambulation (EA, n = 30) or flat BR for 48 h (BR, n = 30). The incidence of CSF leakage resulting in revision surgery, medical complications and duration of hospitalization were compared between groups. RESULTS Two patients in the BR group and two patients in the EA group underwent revision surgery as a result of persisting CSF leakage. Four patients in the BR group experienced medical complications associated with prolonged immobilization. The duration of hospitalization was 7.25 ± 3.0 days in the BR group versus 6.56 ± 2.64 days in the EA group, p = 0.413. CONCLUSION The results of this study indicate no benefit of prolonged BR after an adequately repaired ID in lumbar spine surgery. LEVEL OF EVIDENCE Level 1b (individual randomized controlled trial). These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Mazda Farshad
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Alexander Aichmair
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Florian Wanivenhaus
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Michael Betz
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Jose Spirig
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - David Ephraim Bauer
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Kalidindi KKV, Bhat MR, Mannem A, Chhabra HS. Conservative Management for Late Presenting Dural Tears After Spine Surgery: An Institutional Experience and Literature Review. World Neurosurg 2019; 134:e82-e92. [PMID: 31542441 DOI: 10.1016/j.wneu.2019.09.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Symptoms and evidence of cerebrospinal fluid (CSF) leak after an uneventful intraoperative and immediate postoperative course are a rare entity in spine surgery. The literature is sparse on the description of such late presenting dural tears (LPDTs). They may need further admissions, wound management, and additional surgical procedures that add to the morbidity of the patient. METHODS A retrospective review of spine surgeries done at our institute for degenerative spinal conditions between January 2017 and January 2018 was conducted. A mini meta-analysis was performed on studies comparing conservative and surgical management of LPDTs. RESULTS Among 1929 patients, 6 cases (5 lumbar and 1 cervical) had an LPDT. Five of them had a CSF fistula and 1 patient had a pseudomeningocele. Two patients with CSF fistula were complicated by superficial surgical site infection (SSI). There was additional evidence of pneumocephalus and pneumorachis in 1 case. The SSI was managed by bedside debridement, regular dressing, and culture-sensitive antibiotics. CSF fistulas were managed by deep suturing, and pseudomeningocele was managed by excision of the sac and plication of the neck. All the patients had a good to an excellent outcome at the end of a 1-year follow-up. CONCLUSIONS One should be aware of the possibility of LPDTs. A combination of history, clinical examination, and imaging may aid in the diagnosis. It can be associated with complications like CSF fistula, pseudomeningocele, SSI, pneumocephalus, or pneumorachis. Conservative trial can have good to excellent outcomes in the management of such cases though there is insufficient evidence to establish it.
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Affiliation(s)
| | - Mohd Rafiq Bhat
- Department of Spine Service, Indian Spinal Injuries Center, Vasant Kunj, New Delhi, India
| | - Abhishek Mannem
- Department of Spine Service, Indian Spinal Injuries Center, Vasant Kunj, New Delhi, India
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Takenaka S, Makino T, Sakai Y, Kashii M, Iwasaki M, Yoshikawa H, Kaito T. Prognostic impact of intra- and postoperative management of dural tear on postoperative complications in primary degenerative lumbar diseases. Bone Joint J 2019; 101-B:1115-1121. [DOI: 10.1302/0301-620x.101b9.bjj-2019-0381.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to explore risk factors for complications associated with dural tear (DT), including the types of DT, and the intra- and postoperative management of DT. Patients and Methods Between 2012 and 2017, 12 171 patients with degenerative lumbar diseases underwent primary lumbar spine surgery. We investigated five categories of potential predictors: patient factors (sex, age, body mass index, and primary disease), surgical factors (surgical procedures, operative time, and estimated blood loss), types of DT (inaccessible for suturing/clipping and the presence of cauda equina/nerve root herniation), repair techniques (suturing, clipping, fibrin glue, polyethylene glycol (PEG) hydrogel, and polyglycolic acid sheet), and postoperative management (drainage duration). Postoperative complications were evaluated in terms of dural leak, prolonged bed rest, headache, nausea/vomiting, delayed wound healing, postoperative neurological deficit, surgical site infection (SSI), and reoperation for DT. We performed multivariable regression analyses to evaluate the predictors of postoperative complications associated with DT. Results In total, 429/12 171 patients (3.5%) had a DT. Multivariable analysis revealed that PEG hydrogel significantly reduced the incidence of dural leak and prolonged bed rest, and that patients treated with sealants (fibrin glue and PEG hydrogel) significantly less frequently suffered from headache. A longer drainage duration significantly increased the incidence of headache, nausea/vomiting, and delayed wound healing. Headache and nausea/vomiting were significantly more prevalent in younger female patients. Postoperative neurological deficit and reoperation for DT significantly depended on the presence of cauda equina/nerve root herniation. A longer operative time was the sole independent risk factor for SSI and was also a risk factor for dural leak, prolonged bed rest, and nausea/vomiting. Conclusion Sealants, particularly PEG hydrogel, may be useful in reducing symptoms related to cerebrospinal fluid leakage, whereas prolonged drainage may be unnecessary. Younger female patients should be carefully treated when DT occurs. Cite this article: Bone Joint J 2019;101-B:1115–1121.
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Affiliation(s)
- Shota Takenaka
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takahiro Makino
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Sakai
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masafumi Kashii
- Department of Orthopaedic Surgery, Toyonaka Municipal Hospital, Osaka, Japan
| | - Motoki Iwasaki
- Department of Orthopaedic Surgery, Osaka-Rosai Hospital, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Francavilla TL, Weiss MC, Davis R. Safe Discharge of Patients From an Ambulatory Care Center After Incidental Durotomy During Minimally Invasive Spine Surgery. Int J Spine Surg 2019; 13:386-391. [PMID: 31531289 DOI: 10.14444/6053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Incidental durotomy is a well-known complication of spinal surgery that may occur occasionally. Increasingly, minimally invasive techniques are being used for spinal decompressions in an ambulatory surgical center (ASC) setting. The management of this complication in an ASC setting has not been reported. Methods A total of 832 consecutive minimally invasive decompressive spinal surgeries were performed by a single surgeon in an ASC during the course of 1 year. Incidental durotomies with cerebrospinal fluid leakage were repaired and patients were discharged to home. Patients with a watertight suture dural repair did not receive any modifications to the usual discharge activities allowed. All other patients were treated with bed rest overnight and head of bed restrictions. A protocol for close patient follow-up after discharge was followed. The complications were collected prospectively and analyzed retrospectively. Results There were 30 incidental durotomies (3.6%), with all occurring in the lumbar spine. Suture repair was accomplished in 28 patients (93%). Patch repair was performed in 2 patients (7%). All patients were discharged to home from the ASC. There were 2 short-term complications noted after discharge. The patient safety protocols in place identified the complications and allowed timely interventions. Conclusions Incidental durotomy occurring during minimally invasive spinal decompressive surgery is an occasional event. Suture repair of the laceration is feasible in most instances. Lumbar spine patients may be safely discharged to home from the ASC. Patients can be stratified into those with, or without, a watertight suture dural closure. Those with such a closure, who are without symptoms of intracranial hypotension, do not require modification of their activities. A short period of bedrest with head of bed modification successfully treated the remainder. Hospitalization or routine prolonged bed rest is not necessary. Protocols must be put in place to identify and timely manage potentially serious sequelae.
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Affiliation(s)
- Thomas L Francavilla
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana
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Brazdzionis J, Ogunlade J, Elia C, Wacker MR, Menoni R, Miulli DE. Effectiveness of Method of Repair of Incidental Thoracic and Lumbar Durotomies: A Comparison of Direct Versus Indirect Repair. Cureus 2019; 11:e5224. [PMID: 31565626 PMCID: PMC6758957 DOI: 10.7759/cureus.5224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction Incidental durotomy (ID) is a well-known complication in spine surgery. Surveys have not identified a consensus for repair method among neurosurgeons. IDs may lead to complications such as cerebrospinal fluid (CSF) fistula, which may predispose patients to infection, additional procedures, increased length of stay and morbidity. This study aims to compare durotomy repair methods with clinical outcomes. Methods The neurosurgery database at a single institution, Arrowhead Regional Medical Center, was screened for all patients who underwent thoracic and lumbar spine surgery from 2007-2017. Retrospective chart review of operative reports identified patients with an ID. Data collection included: length of stay, infection, additional procedures, time lying flat, CSF fistula formation (primary endpoint) with analysis using t-tests. Results A total of 384 patients underwent initial analysis. Of the 384 patients, 25 had an incidental durotomy based on operative reports. Four patients were excluded from this subset: two were repaired with muscle graft (low N), two were excluded for unclear repair method. The remaining 21 were stratified into two groups, those repaired directly with suture with or without adjunct (N=9) and those repaired indirectly with sealant (N=12). No patients developed a CSF fistula. The indirect group had a length of stay of six days, while the direct group had a length of stay of four days, p=0.184. Two of the nine patients in the direct group and two of the twelve patients in the indirect group developed an infection, p=0.586. Conclusion No patients developed CSF fistulas. Secondary endpoints of length of stay and infection rate did not differ. This study was unable to determine if direct versus indirect repair was a more effective repair method for ID. It is possible that if an incidental durotomy is identified and repaired with a water-tight seal, the repair method does not affect the outcome. It is up to the surgeon to individualize repair based on ability and circumstances.
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Affiliation(s)
- James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - John Ogunlade
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Christopher Elia
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | | | - Rosalinda Menoni
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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Papavero L, Kothe R. [Incidental durotomy: intraoperative aid in ten steps]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:335-350. [PMID: 31324953 DOI: 10.1007/s00064-019-0618-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 01/23/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Management of the intradural structures safely, closure of the dura according to the tear, and minimizing the epidural dead space. INDICATIONS Incidental durotomy (ID). CONTRAINDICATIONS None. SURGICAL TECHNIQUE 1. Bone removal until whole dural tear is visible (if necessary); 2. intradural inspection; 3. reposition the fibers; 4. perform an inside patch (if ID > 5 mm); 5. dural closure; 6. outside patch; 7. Valsalva maneuver; 8. epidural pedicled muscle flap; 9. multilayer wound closure; 10. lumbar drainage of cerebrospinal fluid (if necessary). POSTOPERATIVE MANAGEMENT Bed rest up to 48 h; analgesics. RESULTS The intraspinal part of 4020 surgeries performed with the aid of a microscope were evaluated. The overall prevalence of ID was 4.4%. The prevalence was lowest in virgin microdiscectomies (1.7%) and varied from 3.6% in decompression for spinal canal stenosis up to 14.5% in revision procedures. Of the overall 195 IDs, 127 occurred in primary surgeries and 68 in revision surgeries. In 107 primary surgeries, the individual surgical technique (InT) achieved a single stage closure of the ID in 96 procedures (89.7%). Among 20 virgin surgeries, the ten-step technique (10 ST) was successful in all cases (P = 0.21). Among 42 revision procedures following failed attempts to stop the CSF leakage, the InT achieved single-stage closure in 36 procedures (85.7%), whereas after introduction of the 10 ST, closure was successful in all 26 cases (P = 0.03).
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Affiliation(s)
- L Papavero
- Klinik für Spinale Chirurgie, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Deutschland.
| | - R Kothe
- Klinik für Spinale Chirurgie, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Deutschland
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Kinaci A, Moayeri N, van der Zwan A, van Doormaal TP. Effectiveness of Sealants in Prevention of Cerebrospinal Fluid Leakage after Spine Surgery: A Systematic Review. World Neurosurg 2019; 127:567-575.e1. [DOI: 10.1016/j.wneu.2019.02.236] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/26/2019] [Indexed: 01/24/2023]
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Barber SM, Fridley JS, Konakondla S, Nakhla J, Oyelese AA, Telfeian AE, Gokaslan ZL. Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:217. [PMID: 31297382 DOI: 10.21037/atm.2019.01.04] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.
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Affiliation(s)
- Sean M Barber
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jared S Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Sanjay Konakondla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jonathan Nakhla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
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Wen BT, Chen ZQ, Sun CG, Jin KJ, Zhong J, Liu X, Tan L, Yang P, le G, Luo M. Three-dimensional navigation (O-arm) versus fluoroscopy in the treatment of thoracic spinal stenosis with ultrasonic bone curette: A retrospective comparative study. Medicine (Baltimore) 2019; 98:e15647. [PMID: 31096488 PMCID: PMC6531158 DOI: 10.1097/md.0000000000015647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Three-dimensional intraoperative navigation (O-arm) has been used for many years in spinal surgeries and has significantly improved its precision and safety. This retrospective study compared the efficacy and safety of spinal cord decompression surgeries performed with O-arm navigation and fluoroscopy. The clinical data of 56 patients with thoracic spinal stenosis treated from March 2015 to April 2017 were retrospectively analyzed. Spinal decompression was performed with O-arm navigation and ultrasonic bone curette in 29 patients, and with ultrasonic bone curette and fluoroscopy in 27 patients. Patients were followed-up at postoperative 1 month, 3 months, and the last clinic visit. The neurologic functions were assessed using the Japanese Orthopaedic Association (JOA) Back Pain Evaluation Questionnaire. The accuracy of screw placement was examined using three-dimensional computed tomography (CT) on postoperative day 5. There was no significant difference in the incidences of intraoperative dural tear, nerve root injury, and spinal cord injury between the two groups. The two groups showed no significant difference in postoperative JOA scores (P > .05). The O-arm navigation group had significantly higher screw placement accuracy than the fluoroscopy group (P < .05). O-arm navigation is superior to fluoroscopy in the treatment of thoracic spinal stenosis with ultrasonic bone curette in terms of screw placement accuracy. However, the two surgical modes have similar rates of intraoperative complications and postoperative neurologic functions.
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Affiliation(s)
- Bing-Tao Wen
- Department of Orthopedics, Peking University International Hospital
| | - Zhong-Qiang Chen
- Department of Orthopedics, Peking University International Hospital
| | - Chui-Guo Sun
- Department of Orthopedics, Peking University Third Hospital, Beijing
| | - Kai-Ji Jin
- Department of Orthopedics, Peking University International Hospital
| | - Jun Zhong
- Department of Orthopedics, Peking University International Hospital
| | - Xin Liu
- Department of Orthopedics, Peking University International Hospital
| | - Lei Tan
- Department of Orthopedics, Peking University International Hospital
| | - Peng Yang
- Department of Orthopedics, Peking University International Hospital
| | - Geri le
- Department of Orthopedics, Peking University International Hospital
| | - Man Luo
- Department of Orthopedics, Guangxi International Zhuang Medicine Hospital, Nanning, Guangxi, China
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Nagoshi N, Iwanami A, Isogai N, Ishikawa M, Nojiri K, Tsuji T, Daimon K, Takeuchi A, Tsuji O, Okada E, Fujita N, Yagi M, Watanabe K, Nakamura M, Matsumoto M, Ishii K, Yamane J. Does Posterior Cervical Decompression Conducted by Junior Surgeons Affect Clinical Outcomes in the Treatment of Cervical Spondylotic Myelopathy? Results From a Multicenter Study. Global Spine J 2019; 9:25-31. [PMID: 30775205 PMCID: PMC6362553 DOI: 10.1177/2192568218756329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES To evaluate the outcomes of posterior cervical decompression for cervical spondylotic myelopathy (CSM) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS We reviewed outcomes for 675 patients who underwent surgery for CSM, were followed at least 1 year after surgery, and were assessed preoperatively and at final follow-up by Japanese Orthopaedic Association (JOA) scores and by the visual analog scale (VAS) for the neck. Cervical alignment was assessed on radiographs by C2-C7 angles, and range of motion (ROM) by extension minus flexion C2-C7 angles. We compared outcomes for BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and for NBCS surgeons. RESULTS BCS surgeons performed 432 of 675 laminoplasties. NBCS surgeons were primary in 243 surgeries, of which 187 were directly supervised by a BCS surgeon. BCS surgeons required significantly less time in surgery (98.0 ± 39.5 vs 108.1 ± 49.7 min; P < .01). BCS and NBCS surgeons had comparable perioperative complications rates, and preoperative-to-postoperative changes in JOA scores (2.9 ± 2.1 vs 3.1 ± 2.3; P = .40) and VAS (-1.5 ± 2.9 vs -1.4 ± 2.5; P = .96). Lordotic cervical alignment and ROM were maintained after operations by both groups. CONCLUSIONS Surgical outcomes such as functional recovery, complication rates, and cervical dynamics were comparable between the BCS and NBCS groups. Thus, posterior cervical decompression for CSM is safe and effective when performed by junior surgeons who have been trained and supervised by experienced spine surgeons.
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Affiliation(s)
- Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Akio Iwanami
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Koga Hospital Spine Center, Koga, Japan
| | - Norihiro Isogai
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Minato-ku, Tokyo, Japan
| | - Masayuki Ishikawa
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Minato-ku, Tokyo, Japan
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Narita, Chiba, Japan
| | - Kenya Nojiri
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Isehara Kyodo Hospital, Isehara, Kanagawa, Japan
| | - Takashi Tsuji
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Fujita Health University, Toyoake, Mie, Japan
| | - Kenshi Daimon
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Ogikubo Hospital, Suginami, Tokyo, Japan
| | - Ayano Takeuchi
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Eijiro Okada
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Nobuyuki Fujita
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Ken Ishii
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Minato-ku, Tokyo, Japan
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Narita, Chiba, Japan
| | - Junichi Yamane
- Keio Spine Research Group (KSRG), Tokyo, Japan
- National Hospital Organization Murayama Medical Center, Musashimurayama City, Tokyo, Japan
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Surgical training in spine surgery: safety and patient-rated outcome. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:807-816. [DOI: 10.1007/s00586-019-05883-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
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Takenaka S, Makino T, Sakai Y, Kashii M, Iwasaki M, Yoshikawa H, Kaito T. Dural tear is associated with an increased rate of other perioperative complications in primary lumbar spine surgery for degenerative diseases. Medicine (Baltimore) 2019; 98:e13970. [PMID: 30608436 PMCID: PMC6344202 DOI: 10.1097/md.0000000000013970] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Shota Takenaka
- Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka
| | - Takahiro Makino
- Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka
| | - Yusuke Sakai
- Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka
| | - Masafumi Kashii
- Orthopaedic Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka
| | - Motoki Iwasaki
- Orthopaedic Surgery, Osaka-Rosai Hospital, Sakai, Osaka, Japan
| | - Hideki Yoshikawa
- Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka
| | - Takashi Kaito
- Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka
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Cerebrospinal Fluid Leak and Symptomatic Pseudomeningocele After Intradural Spine Surgery. World Neurosurg 2018; 120:e497-e502. [DOI: 10.1016/j.wneu.2018.08.112] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 11/24/2022]
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50
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Durand WM, DePasse JM, Kuris EO, Yang J, Daniels AH. Late-presenting dural tear: incidence, risk factors, and associated complications. Spine J 2018; 18:2043-2050. [PMID: 29679726 DOI: 10.1016/j.spinee.2018.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/28/2018] [Accepted: 04/09/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Unrecognized and inadequately repaired intraoperative durotomies may lead to cerebrospinal fluid leak, pseudomeningocele, and other complications. Few studies have investigated durotomy that is unrecognized intraoperatively and requires additional postoperative management (hereafter, late-presenting dural tear [LPDT]), although estimates of LPDT range from 0.6 to 8.3 per 1,000 spinal surgeries. These single-center studies are based on relatively small sample sizes for an event of this rarity, all with <10 patients experiencing LPDT. PURPOSE This investigation is the largest yet conducted on LPDT, and sought to identify incidence, risk factors for, and complications associated with LPDT. STUDY DESIGN/SETTING This observational cohort study employed the American College of Surgeons National Surgical Quality Improvement Program dataset (years 2012-2015). PATIENT SAMPLE Patients who underwent spine surgery were identified based on presence of primary listed Current Procedural Terminology (CPT) codes corresponding to spinal fusion or isolated posterior decompression without fusion. OUTCOME MEASURES The primary variable in this study was occurrence of LPDT, identified as reoperation or readmission with durotomy-specific CPT or International Classification of Diseases, Ninth Revision, Clinical Modification codes but without durotomy codes present for the index procedure. METHODS Descriptive statistics were generated. Bivariate and multivariate analyses were conducted using chi-square tests and multiple logistic regression, respectively, generating both risk factors for LPDT and independent association of LPDT with postoperative complications. Statistical significance was defined as p<.05. RESULTS In total, 86,212 patients were analyzed. The overall rate of reoperation or readmission without reoperation for LPDT was 2.0 per 1,000 patients (n=174). Of LPDT patients, 97.7% required one or more unplanned reoperations (n=170), and 5.7% of patients (n=10) required two reoperations. On multivariate analysis, lumbar procedures (odds ratio [OR] 2.79, p<.0001, vs. cervical), procedures involving both cervical and lumbar levels (OR 3.78, p=.0338, vs. cervical only), procedures with decompression only (OR 1.72, p=.0017, vs. fusion and decompression), and operative duration ≥250 minutes (OR 1.70, p=.0058, vs. <250 minutes) were associated with increased likelihood of LPDT. Late-presenting dural tear was significantly associated with surgical site infection (SSI) (OR 2.54, p<.0001), wound disruption (OR 2.24, p<.0001), sepsis (OR 2.19, p<.0001), thromboembolism (OR 1.71, p<.0001), acute kidney injury (OR 1.59, p=.0281), pneumonia (OR 1.14, p=.0269), and urinary tract infection (UTI) (OR 1.08, p=.0057). CONCLUSIONS Late-presenting dural tears occurred in 2.0 per 1,000 patients who underwent spine surgery. Patients who underwent lumbar procedures, decompression procedures, and procedures with operative duration ≥250 minutes were at increased risk for LPDT. Further, LPDT was independently associated with increased likelihood of SSI, sepsis, pneumonia, UTI, wound dehiscence, thromboembolism, and acute kidney injury. As LPDT is associated with markedly increased morbidity and potential liability risk, spine surgeons should be aware of best-practice management for LPDT and consider it a rare, but possible etiology for developing postoperative complications.
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Affiliation(s)
- Wesley M Durand
- Department of Orthopedics, Division of Spine Surgery, Brown University Warren Alpert Medical School, 100 Butler Drive, Providence, RI 02906, USA.
| | - J Mason DePasse
- Department of Orthopedics, Division of Spine Surgery, Brown University Warren Alpert Medical School, 100 Butler Drive, Providence, RI 02906, USA
| | - Eren O Kuris
- Department of Orthopedics, Division of Spine Surgery, Brown University Warren Alpert Medical School, 100 Butler Drive, Providence, RI 02906, USA
| | - JaeWon Yang
- Department of Orthopedics, Division of Spine Surgery, Brown University Warren Alpert Medical School, 100 Butler Drive, Providence, RI 02906, USA
| | - Alan H Daniels
- Department of Orthopedics, Division of Spine Surgery, Brown University Warren Alpert Medical School, 100 Butler Drive, Providence, RI 02906, USA
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