Spinal subdural hematoma (SDH) is a rare complication after spinal surgery. Only a few cases are reported on spinal SDH following open lumbar spinal decompression or fusion surgery. Moreover, there has been no case report on spinal SDH following percutaneous transforaminal endoscopic lumbar discectomy. We report a case of spinal SDH following endoscopic discectomy, review the literature of this complication and discuss the etiology to it and methods to prevent it. A 63-year-old woman presented with severe radiating pain. Pain was not improved with conservative management. Lumbar magnetic resonance imaging (MRI) was checked and revealed right L3-4 ruptured disc with severe L4 root compression. Percutaneous transforaminal endoscopic decompression was performed and the pain subsided promptly after the endoscopic procedure. On 7th post-operative day, pain on Rt. buttock, anterior thigh was deteriorated severely, more than in pre-operatively. Deteriorated pain was not controlled by oral medications and epidural block. Repeat MRI showed no definite recurrence of disc herniation at decompressed level but spinal SDH, severely compressing cauda equina was seen on T12-sacral area. Spinal SDH is a rare complication following spine surgery, including percutaneous endoscopic surgery. A spine surgeon should be aware of the possibility of spinal subdural hematoma, having severe sequel.
Lumbar fusion surgery for lumbar degenerative diseases has increased in the past several decades and many techniques for fusion surgery have been introduced. Recently lateral lumbar interbody fusion with minimally invasive technique was introduced and accepted as a useful method for various lumbar degenerative disease. It can produce good correction for sagittal and coronal imbalance with relatively decreased morbidity. The advantage of lateral lumbar interbody fusion is that it can avoid injury to the abdominal large vessels and neural structures which is more common during posterior approaches. However various complications had been reported. Complications related with lateral lumbar interbody fusion include neurologic complications including thigh pain and numbness, vascular complications including arterial injury, cage related complication such as cage subsidence and vertebral body fractures. Therefore special care should be taken to avoid possible complications in lateral lumbar interbody fusion surgery.
Introduction We describe the complications that can occur after percutaneous vertebroplasty using bone cement for osteoporosis vertebral compression fracture.
Main subject: The most common complication of percutaneous vertebroplasty is the leakage of bone cement.
Leakage of bone cement has been reported variously and could leak into the spinal or neural foramen, adjacent intervertebral disc and soft tissues around the spine, and venous systems. The most serious complications are neurologic symptoms due to spinal cord and nerve root compression and complications associated with death due to heart and pulmonary embolism. In addition, recompression fracture or adjacent vertebral compression fracture might occur and various treatment methods have been proposed.
Conclusion The complications that can occur after percutaneous vertebroplasty have been reported variously, including neurologic deficits due to the leakage of bone cement and lung and heart embolism. In addition, there is a possibility of recompression fracture or adjacent compression fracture. Therefore, you should be careful about percutaneous vertebroplasty. Finally, patients with many risk factors regarding complications of vertebroplasty would need close observation and follow-up.
Background Endoscopic spinal surgery for lumbar foraminal lesions comes to be more popular recently. Bleedings around the foramen during extraforaminal endoscopic approach could make surgical filed turbid and more difficult to perform procedures safely. There were, however, few reports and insufficient information about vascular geometry around the foramen.
Purpose: To report lumbar foraminal vascular geometry to help endoscopic spinal surgery underwent well and decrease technical complications by control of bleeding.
Materials and Methods We reviewed operating record movie clips of extraforaminal approach using biportal endoscopic spine surgery (BESS). Several bleeding foci were matched with previously reported vascular anatomy and vascular geometry was modified to adapt to endoscopic view.
Results There were four main arterial branches coming out from the lumbar segmental artery. Inferior articular artery, superior articular artery, inter-articular artery and radicular artery could be faced in order during extraforaminal approach using BESS. To escape heavy bleeding from the inferior articular artery and superior articular artery, the dorso-distal surface of transverse process (TP) should be exposed to make a working space without scratching the proximal area of the TP and dorsal surface of the facet. Inter-articular artery was hidden and covered under the capsule overlying superior articular process. Radicular artery was running along the midline of the root under the foraminal ligamentum flavum.
Conclusion The information of the geometric location of the four arterial branches could help to escape heavy bleeding on extra-foraminal approach and control the bleeding foci to prevent postoperative hematoma.
Seventy-four-year female patient presented back pain, radiating pain from both posterior thigh and intermittent claudication for two years. Preoperative radiography and MRI demonstrated L2~S1 spinal stenosis. She underwent OLIF and posterior instrumentation L2-S1. At 3 days postoperatively, she presented nausea, abdominal discomfort and showed low SpO2 and drowsy mental state with abrupt vomiting. Abdomen X-ray and CT demonstrated severe paralytic ileus and Chest CT and bronchoscopy demonstrated aspiration pneumonia and ARDS. She transferred to respiratory internal medicine in intensive care unit. She recovered for one month of ICU care and was possible to wheelchair ambulation. Approximately 3.5% of patients undergoing elective spine surgery develop paralytic ileus.
Especially, anterior or lateral access spine surgery, gastroesophageal reflux disease and posterior instrumentation have a high risk of ileus. If patients present nausea, vomiting, abdominal discomfort, constipation, doctor must be evaluated paralytic ileus and treat it by NPO, early ambulation, nasogastric tube and possible pharmacological agents.
Many techniques have been introduced and performed, with different strengths and benefits. The lateral lumbar interbody fusion techniques (direct lateral lumbar interbody fusion [DLIF] and oblique lateral interbody fusion [OLIF]) have yielded good results for elderly patients. These are useful options for elderly patients with high risk of complications with traditional approaches.
Purpose The purpose of this retrospective study was to evaluate the results and complications of lateral mass screw fixation on C7 in a single spinal center.
Materials and Methods During a 7-year period, a total of 104 lateral mass screws were placed on C7 in 56 patients with cervical disorders. A review of the hospital records and radiographs of these patients was conducted. Followup plain X-rays and computed tomography (CT) including sagittal reconstruction were obtained to analyze screw positions.
Results A total of 104 screws were placed on C7 lateral mass using the modified Magerl’s method. Most patients had two screws on both lateral masses, but eight underwent unilateral lateral mass screw fixation due to fracture (n=4), lateral mass deficit due to tumor removal (n=1), and unilateral fixation for additional stabilization of an anterior fixation (n=3). Most cases were connected to the subaxial spine (91.1%). All patients underwent more than 1 year of follow-up. The only complication was one wound infection. On follow-up CT, one transverse foramen invasion (2 mm), one spinal canal invasion, and four facet joint violations developed post-operatively. However, no symptoms related to these issues were occurred, so reoperations for instrument repositioning were not required. Screw loosening and pseudoarthrosis did not develop during the follow-up period. Also, there was no case of vertebral artery or neural injury requiring reoperation due to the position of the lateral mass screw. Almost patients showed successful bone fusion on follow-up images, with the exception of one patient.
Conclusion Despite the small size of the lateral mass, risk of pseudoarthrosis, and steep angle of the lamina, lateral mass screw fixation can be a safe, easy and less complicated method of posterior cervical stabilization. If the lateral mass is suitable, lateral mass screw fixation may enable C7 stabilization during posterior subaxial cervical surgery.
Purpose The purpose of this review is the current understanding of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following adult spinal deformity (ASD) surgery.
Materials and Methods We carried out a systematic search of PubMed for literatures published up to September 2016 with “proximal junctional kyphosis” and “proximal junctional failure” as search terms. A total of 57 literatures were searched.
Finally, the 33 articles were included in this review.
Result PJK and PJF are recognized complications after long instrumented posterior fusion in ASD surgery. PJK is multifactorial in origin and likely results from surgical, radiographic, and patient related risk factors. PJF is a progressive form of the PJK spectrum including bony fracture of uppermost instrumented vertebra (UIV) or UIV+1, subluxation between UIV and UIV+1, failure of fixation, neurological deficit, which may require revision surgery for proximal extension of fusion.
Variable risk factors for PJK and PJF have been investigated, and they can be categorized into surgical, radiographic, and patient-related factors. There are several strategies to minimize PJK and PJF. Soft tissue protections, adequate selection of the UIV, prophylactic rib fixation, hybrid instrumentation such as hooks, vertebral cement augmentation at UIV and UIV+1, and age-appropriate spinopelvic alignment goals are worth consideration.
Conclusion The ability to perform aggressive global realignment of spinal deformities has also led to the discovery of new complications such as PJK and PJF. Continuous research on PJK and PJF should be proceeded in order to comprehend the pathophysiology of these complications.
Background Owing to its new introduction, there are few documents on pit-falls of biportal endoscopic spine surgery (BESS) clinically. The authors reported etiologies in need of early exploration after BESS for lumbar degenerative diseases and strategies to overcome them.
Methods BESS were performed for lumbar spine diseases (LSDs) by two spine surgeons from December 2013 to March 2016. Postoperative MRI was checked for all cases and following-up MRIs in the case in need of revision surgery within six months after the first surgery due to pain intolerable, sustained or recurred. The complicated cases were reviewed and classified as radiographic and operative findings to reveal the main reasons for early explorations.
Results The 562 cases (M:295, F:267, Age 58.5±14.1 yrs, 20~88 yrs) included lumbar disc herniation (LDH) (255 cases), extraforaminal disc herniation (22 cases), spinal stenosis (218 cases), degenerative spondylolisthesis (27 cases), revision surgery after recurred disc herniation or restenosis after open surgery (24 cases), juxtafacet cyst (11 cases), adjacent segment stenosis with fusion surgery (3 cases), and spondylolytic spondylolisthesis (2 cases). Early explorations were needed in 43 cases (7.7%) at 26.1±31.5 days after the initial operations. Causative etiologies were listed as recurred LDH (12 cases, 27.9%), remnant stenosis (7 cases, 16.3%), remained ruptured disc fragment (6 cases, 14.0%), root edema (5 cases, 11.6%), synovitis (4 cases, 9.3%), hematoma (3 cases, 7.0%), dura tear (2 cases, 4.7%), recurred stenosis (2 cases. 4.7%), wrong level (1 case, 2.3%) and postoperative fungal infection (1 case, 2.3%).
Thirty-one cases (72.1%) were revised within 4 weeks and most conditions (40 cases, 93.0%) were improved after early exploration using BESS. Two cases of dura tear were conversed to open repair. One case of fungal infection was suspected to related with the patient’s medical illness including long-term steroid use for chronic lung disease with pulmonary fibrosis and Diabetes mellitus.
Conclusions Preoperative planning should be prepared carefully to decrease early exploration. It was helpful to comparing MRIs immediately postoperative and early following-up to find the reasons. Don’t hesitate to explore the operated site again using BESS, because most etiologies are supposed to be controlled by early exploration without need of converting to open surgery except in the case of dura tear in need of dural repair.
Minimally invasive TLIF has been reported to be a useful treatment option for the patients with various degenerative lumbar diseases. Many studies have reported the favorable clinical results of MIS TLIF. However it remains technically demanding, leading to higher complication rates and longer operative times during the early period of the learning curve. It showed some potential complications due to small working space and visual field. In this study, authors tried to find out various possible complications and some tips avoiding these complications through the review of various articles and authors’ clinical experiences. In many studies, the general complication fusion rates of MIS TLIF have been reported to be similar to that of open fusion. The technical difficulty of the procedure, combined with inadequate training, is evident in initial studies of MIS TLIF. A difficult learning curve of MIS TLIF demands that surgeons have sufficient preclinical training, and education is obtained before the application of MIS TLIF in clinical practice.
Purpose Higher viscous cement can be injected through larger-diametered tubes with lower pressure. The lower the cement modulus is, the less the stress-transfer would be. The lower-pressure percutaneous vertebroplasty with blood-mixed cement(LP-PVPblood ) was devised to overcome technical problems in conventional percutaneous vertebroplasty(C-PVP). We would like to prove the validity of technical modifications to increase viscosity of cement being injected and reduce final modulus of cement.
Methods Nineteen C-PVPs, 51 kyphoplasty (KPs), 23 LP-PVPs and 70 LP-PVPblood s were analyzed in radiologic point of view. The successful cases with sufficient cement volume(≥ 5ml) were also analyzed as a subgroup.
Results Asymptomatic cement leakage(CL) showed a similar tendency in LP-PVblood (17.1%) compared to other groups(21.1~27.5%, p=0.514), even though the injected cement volume in LP-PVPblood (6.9ml) was much more than that of C-PVP(3.5ml, p=0.000). Vertebral height restoration(VHR) was significantly higher(11.7%) than C-PVP(4.7%, p=0.024). Vertebral body subsidence(VS) was less in KP(1.1%) than others(2.1~5.9%, p=0.000). But, adjacent vertebral compression fractures(VCFs) happened more frequently in KP(15.7%) than others (0~5.3%, p=0.001).
In subgroup analysis, the rates of successful cases were significantly higher in LP-PVPblood (85.7%) than in C-PVP(5.3%, p=0.000). CLs and VHRs showed no significant differences. VS was significantly less in KP(1.0%, p=0.000) but adjacent VCF developed more frequently in KP(21.1%) than LP-PVPblood (0%, p=0.001).
Conclusions The LP-PVPblood which stands for larger diameter tubes for injecting sufficient volume of higher viscous cement and more interdigitation by omitting balloon and lower modulus blood-mixed cement was appraised to reduce risk of cement leakage than C-PVP and decrease stress transfer to adjacent vertebrae than KP.
Neurological complications related to spinal surgery are not common, but can result in catastrophic clinical failures.
The ultimate goal during the operation should be to try to reduce and prevent a severe neurologic complication by careful preoperative planning and attention to trivial details related to the patients and their pathologies. It is very critical and important to understand the potential neurological complications that can occur during the operation and to manage them if they should happen. In our review article, general principles associated with various neurologic complications are reviewed and discussed.
Purpose The purpose of this study is to decrease the frequency of the perioperative complication and improve the clinical outcomes of multilevel lumbar degenerative disease by multilevel minimally invasive transforaminal lumbar interbody fusion.
Materials and Methods 317 patients(Minimally invasive transforaminal lumbar interbody fusion : 161, Conventional open surgery : 156) were followed up for more than 1 year. The age of each patient, the amount of intraoperative blood loss, the postoperative drainage, the transfusion requirement, surgery time, using of Intensive care unit, ambulation day, admission day and perioperative complications were investigated and analyzed.
Results Minimally invasive transforaminal lumbar interbody fusion was found to have a less blood loss, less using of Intensive care unit. And as the levels of union increase, disparities were increased(p<0.05).
But, surgery time of Minimally invasive transforaminal lumbar interbody fusion was longer, and as the levels of union increase, disparities were increased(p<0.05).
Conclusions Multilevel Minimally invasive transforaminal lumbar interbody fusion can be the better way, If surgery time of Multilevel Minimally invasive transforaminal lumbar interbody fusion can be reduced.
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