Incidental Durotomy Research Articles

Development and validation of a novel AI framework using NLP with LLM integration for relevant clinical data extraction through automated chart review.

The accurate extraction of surgical data from electronic health records (EHRs), particularly operative notes through manual chart review (MCR), is complex, crucial, and time-intensive, limited by human error due to fatigue and the level of training. This study aimed to develop and validate a novel Natural Language Processing (NLP) algorithm integrated with a Large Language Model (LLM; GPT4-Turbo) to automate the extraction of spinal surgery data from EHRs. The algorithm employed a two-stage approach. Initially, a rule-based NLP framework reviewed and classified candidate segments from the text, preserving their reference segments. These segments were then verified in the second stage through the LLM. The primary outcomes of this study were the accurate extraction of surgical data, including the type of surgery, levels operated, number of disks removed, and presence of intraoperative incidental durotomies. Secondary objectives explored time efficiency, tokenization lengths, and costs. The performance of the algorithm was assessed across two validation databases, analyzing metrics such as accuracy, sensitivity, discrimination, F1-score, and precision, with 95% confidence intervals calculated using percentile-based bootstrapping. The NLP + LLM algorithm markedly outperformed all performance metrics, demonstrating significant improvements in time and cost efficiency. These results suggest the potential for widespread adoption of this technology.

Open vs tubular rate of re-operation for incidental durotomies after lumbar microdiscectomies: a propensity matched analysis.

Incidental durotomy (ID) is a common complication in spine surgery and can lead to increase in length of stay, decreased satisfaction with surgery and pseudomeningocele formation. Here, we describe a retrospective study comparing ID occurrences and repairs between patients receiving traditional open versus tubular minimally invasive spine (MIS) microdiscectomy. A retrospective comparative cohort-matched analysis was performed to study ID and its complications in MIS versus open lumbar microdiscectomies. The study included 192 patients in the tubular MIS cohort and 2902 patients in the open microdiscectomy cohort. Propensity scores were estimated by age and Elixhauser comorbidity score. After cohort matching, 156 patients were included in the open cohort. The difference in proportion for incidental durotomies, re-operation for pseudomeningocele, and levels were calculated using a Fisher's exact test. The total incidence of durotomy in our cohort of 348 patients was 3.1% (n = 11), 5 (3.2%) in the open cohort and 6 (3.1%) in the tubular cohort. Various ID repair techniques were used including primary repair and dural sealants. One patient in the open cohort required re-operation for pseudomeningocele formation while none required re-operation in the MIS cohort. This result was not significant (p = 0.45). Pseudomeningocele formation after ID is rare. The rates of ID were similar between cohorts. We found no significant difference between re-operation rate for pseudomeningocele between the two cohorts. Larger, cohort-matched, prospective studies are needed to determine the true difference between rates of re-operation for pseudomeningocele formation after lumbar microdiscectomies.

Intraoperative Management of Iatrogenic Durotomy in Endoscopic Spine Surgery: A Systematic Review.

This review aims to systematically evaluate the incidence, management strategies, and clinical outcomes of iatrogenic durotomy (ID) in endoscopic spine surgery and to propose a management flowchart based on the tear size and associated complications. A comprehensive literature search was conducted, focusing on studies involving endoscopic spinal procedures and incidental durotomy. The selected studies were analyzed for management techniques and outcomes, particularly in relation to the size of the dural tear and the presence of nerve root herniation. Based on these findings, a flowchart for intraoperative management was developed. A total of 14 studies were included, encompassing 68,546 patients. Varying incidences of ID, with management strategies largely dependent on the size of the dural tear, were found. Small tears (less than 5 mm) were often left untreated or managed with absorbable hemostatic agents, while medium (5-10 mm) and large tears (greater than 10 mm) required more complex approaches like endoscopic patch repair or open surgery. The presence of nerve root herniation necessitated immediate action, often influencing the decision to convert to open repair. Effective management of ID in endoscopic spine surgery requires a nuanced approach tailored to the size of the tear and specific intraoperative challenges, such as nerve root herniation. The proposed flowchart offers a structured approach to these complexities, potentially enhancing clinical outcomes and reducing complication rates. Future research with more rigorous methodologies is necessary to refine these management strategies further and broaden the applications of endoscopic spine surgery.

Incidental durotomy during tubular microdiscectomy does not preclude same-day discharge.

One of the major advantages of a minimally invasive microdiscectomy is that when CSF leak occurs, there is minimal anatomic dead space for ongoing leakage following removal of the tubular retractor. However, there are no published reports that address the safety and long-term outcomes of same-day discharge for CSF leak after tubular microdiscectomy. This is a retrospective compartive study of 30 patients with incidental durotomy during minimally invasive tubular microdiscectomy occurring between January 1, 2009 to August 31, 2023 at our institution. There were 16 patients (53%) admitted to hospital and 14 (47%) patients discharged home the same day following CSF leak. There were no differences in patient demographics between the two groups at baseline. Twenty-nine out of 30 (97%) of the patients had onlay duraplasty, and one (3%) patient was repaired using sutures through the tubular retractor. None were converted to an open approach. The hospitalized group was kept on bed rest overnight or for 24 h. The discharge group was kept on best rest for 2 h or mobilized immediately after surgery. No patients in either group required readmission or revision surgery for CSF leak. The average length of admission for the hospitalized group was 2.4 ± 4.0 days. Patients with CSF leak during minimally invasive tubular microdiscectomy can be safely discharged home the same day.

Expandable versus static transforaminal lumbar interbody fusion (TLIF) cages: comparing radiographic outcomes and complication profiles

Background ContextExpandable transforaminal lumbar interbody fusion (TLIF) cages have become popular in recent years due to anticipated advantages of increased disc height, improved segmental lordosis, and ease of implantation. Such benefits have not been conclusively demonstrated in the literature. PurposeTo determine whether expandable cages increase disc height and segmental lordosis in a durable way following surgery and compare complication profiles between cage types. Study Design/SettingRetrospective cohort study conducted within a large academic health system involving 31 different spine surgeons. Patient SampleAdults undergoing single-level TLIF for an indication other than infection, tumor, trauma, or revision instrumentation from 2021 to 2023. Outcome MeasuresOur primary outcomes were changes in segmental disc height, segmental lordosis, and L4-S1 lordosis at 2 weeks, 6 months, and 1 year following surgery relative to baseline. Our secondary outcomes were frequencies of incidental durotomies, surgical site infections, readmissions, death, subsidence, and unplanned return to the operating room. MethodsRadiographic variables were collected from our institutional imaging registry. Demographics and surgical characteristics were abstracted from chart review. Generalized linear modeling was used for each primary outcome, with cage type (expandable vs. static) as our primary predictor and age, biologic sex, race, CCI, year of surgery, duration of surgery, invasiveness of surgery, surgeon specialty (Orthopedics vs. Neurosurgery), and level of surgery as covariates. ResultsOur cohort consisted of 417 patients with a mean age of 62. Static cages were used in 306 patients and expandable cages in 111. Expandable cages were associated with increased changes in disc height relative to static cages at 2 weeks (1.1 mm [0.2–1.9]; p=.01) and 6 months (1.2 mm [0.2–2.3]; p=.02) following surgery, but differences were no longer significant at 1 year (0.4 mm [−0.9–1.8]; p=.4). Expandable cages were found to subside more commonly than static cages (14.1% vs. 6.6%; p=.04). No significant differences between cage types were identified in lordotic parameters at any timepoint (p=0.25 to p=0.97). ConclusionsExpandable cages were associated with an initial increase in disc height relative to static cages, but this difference diminished with the first year of surgery, likely due to a higher rate of subsidence within the expandable cohort.

Application of Using Gore Preclude MVP Dura Substitute for Intraoperative Durotomy Repair in Lumbar Spine Surgery: Case Series and A Technical Note

AbstractDurotomy is an intraoperative complication in lumbar surgery, which can result in refractory cerebrospinal leakage. Therefore, intraoperative durotomy in lumbar surgery should be appropriately repaired. The aim of the study was to describe our method to repair intraoperative durotomy using the Gore Preclude MVP Dura Substitute (MVP). The MVP is an artificial dural substitute of three layers. Its surfaces are composed of expanded polytetrafluoroethylene, and the intermittent layer is made of a proprietary fluoroelastomer. After an incidental durotomy during surgery, the MVP was cut and designed bigger than the size of the durotomy site. The MVP was inserted into the space between the dura and the arachnoid membrane. The MVP was unfolded in the inserted space and fixed to the dura using four nodes of 6–0 nylon yarn. Intraoperative dural repair was achieved, and cerebrospinal fluid leakage did not persist. No complications were observed. Our method to repair intraoperative durotomy using the MVP can be simple and useful.

P.143 Safety of same-day discharge following incidental durotomy in tubular microdiscectomy: a retrospective cohort study

Background: Cerebrospinal fluid (CSF) leak is a common complication of minimally invasive tubular microdiscectomy (MIM). However, it is not known whether patients with CSF leak can be safely discharged home the same day. Methods: This is a retrospective cohort study of patients with incidental durotomy after MIM from January, 2009 to August, 2023. Patient demographic information, surgery information, CSF leak management, and postoperative outcomes were recorded. Results: There were 16 patients (53%) who were admitted to hospital and 14 (47%) patients discharged home the same day post CSF leak. There were no differences in patient demographics between the two groups at baseline. Twenty-nine out of 30 (97%) of the patients had onlay duraplasty, and one (3%) patient was repaired using sutures. The hospitalized group was kept on bed rest overnight or 24 hours. The discharge group was kept on best rest for 2 hours or mobilized immediately after surgery. The average length of admission for the hospitalized group was 2.4 ± 4.0 days. No patients in either group required readmission or revision surgery for CSF leak. Conclusions: Patients with CSF leak post minimally invasive tubular microdiscectomy can be safely discharged home the same day provided that duraplasty or primary repair was performed intraoperatively.

The Use of Cranial Aneurysm Clips for Repair of Incidental Lumbar Durotomy: Operative Technique and Case Series

BackgroundIncidental durotomy is a common complication of posterior lumbar spine surgery, however effective and durable methods for primary repair remain elusive. Multiple existing techniques have previously been reported and extensively described including sutured repair and non-penetrating titanium clips. The use of cranial aneurysm clips for primary repair of lumbar durotomy serves as a safe and effective alternative to obtain watertight closure of a dural tear. MethodsWe performed a retrospective review of patients at a single institution who underwent primary repair of an incidental lumbar durotomy with use of an aneurysm clip during open posterior lumbar surgery between 2012 and 2023. Patient demographics, operative details, and postoperative metrics were collected and examined to evaluate the safety and efficacy of the novel technique. ResultsA total of 51 patients were included for analysis. Four patients underwent durotomy repair with aneurysm clip alone, 27 patients were repaired with aneurysm clip and fibrin glue, and 20 patients had repair with aneurysm clip, fibrin glue, and a collagen dural substitute. Three (5.9%) patients reported headaches, 2 (3.9%) with psuedomeningocele, and 1 (2%) with wound leakage. Two (3.9%) patients had treatment failure with return to OR for repair of CSF leak. ConclusionWe report the largest series of patients undergoing primary repair of incidental durotomy with the use of an aneurysm clip. Utilization of an aneurysm clip is noted to be a safe, quick and effective method of primary repair when compared to existing repair techniques such as sutured repair or non-penetrating titanium clips.

Clinical Outcomes Following Decompression of Central Canal and Lateral Recess Simultaneous Stenosis, with a Focus on Multilevel Stenosis: A Randomized Comparison of Microscopic Bilateral Laminotomy versus Total Laminectomy with Posterior Spinal Fusion

In patients with simultaneous lumbar central spinal stenosis (LCSS) and lateral recess stenosis (LRS) at multiple levels, spinal decompression using microscopic bilateral laminotomy was compared to total laminectomy plus medial facetectomy and fusion (LF). From 2017 to 2022, this trial was performed to examine 96 patients with concomitant LCS and LRS at multilevel. Of the 96 patients, 48 were allocated to the following groups: LF (group I) or microscopic bilateral laminotomy (group II). However, 76 patients completed the study. We compared the outcomes in these 2 groups. Microscopic bilateral laminotomy was superior in most outcome measures. Delta-visual analog scale leg pain in group II was significantly greater than in group I (mean-group I: 4.368 vs. group II: 5.368, P value=0.001). Complication and revision rates were lower in the microscopic bilateral laminotomy than in group I, except for incidental durotomy occurrence (group II: 31.58% -group I: 7.89%, P value=0.0190). The rate of revision surgery for group I compared with group II was 44.74% versus 13.16% (P value=0.0047), indicating the superiority of laminotomy over LF. The mean length of hospital stay was 3.551±0.6349 in group II versus 6.774±1.197 in group I (P value <0.0001). Also, blood loss during surgery was significantly lower in group II (P value <0.0001). The findings indicate that microscopic bilateral laminotomy provides favorable clinical and radiological outcomes for individuals experiencing multilevel lumbar central canal and LRS. However, a higher frequency of durotomy may occur during microsurgical procedures.

Incidental durotomy resulting in a postoperative lumbosacral nerve root with eventration into the adjacent facet joint: illustrative cases.

Radicular pain after lumbar decompression surgery can result from epidural hematoma/seroma, recurrent disc herniation, incomplete decompression, or other rare complications. A less recognized complication is postoperative nerve root herniation, resulting from an initially unrecognized intraoperative or, more commonly, a spontaneous postoperative durotomy. Rarely, this nerve root herniation can become entrapped within local structures, including the facet joint. The aim of this study was to illustrate our experience with three cases of lumbosacral nerve root eventration into an adjacent facet joint and to describe our diagnostic and surgical approach to this rare complication. Three patients who had undergone lumbar decompression surgery with or without fusion experienced postoperative radiculopathy. Exploratory revision surgery revealed all three had a durotomy with nerve root eventration into the facet joint. Significant symptom improvement was achieved in all patients following liberation of the neural elements from the facet joints. Entrapment of herniated nerve roots into the facet joint may be a previously underappreciated complication and remains quite challenging to diagnose even with the highest-quality advanced imaging. Thus, clinicians must have a high index of suspicion to diagnose this issue and a low threshold for surgical exploration.

The Predictors of Incidental Durotomy in Patients Undergoing Pedicle Subtraction Osteotomy for the Correction of Adult Spinal Deformity.

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.

Natural language processing for the automated detection of intra-operative elements in lumbar spine surgery.

The aim of this study was to develop natural language processing (NLP) algorithms to conduct automated identification of incidental durotomy, wound drains, and the use of sutures or skin clips for wound closure, in free text operative notes of patients following lumbar surgery. A single-centre retrospective case series analysis was conducted between January 2015 and June 2022, analysing operative notes of patients aged >18 years who underwent a primary lumbar discectomy and/or decompression at any lumbar level. Extreme gradient-boosting NLP algorithms were developed and assessed on five performance metrics: accuracy, area under receiver-operating curve (AUC), positive predictive value (PPV), specificity, and Brier score. A total of 942 patients were used in the training set and 235 patients, in the testing set. The average age of the cohort was 53.900 ± 16.153 years, with a female predominance of 616 patients (52.3%). The models achieved an aggregate accuracy of >91%, a specificity of >91%, a PPV of >84%, an AUC of >0.933, and a Brier score loss of ≤0.082. The decision curve analysis also revealed that these NLP algorithms possessed great clinical net benefit at all possible threshold probabilities. Global and local model interpretation analyses further highlighted relevant clinically useful features (words) important in classifying the presence of each entity appropriately. These NLP algorithms can help monitor surgical performance and complications in an automated fashion by identifying and classifying the presence of various intra-operative elements in lumbar spine surgery.

Enhanced Dural Repair Using Biodegradable Sealants Based on Photocurable Hyaluronic Acid.

Cerebrospinal fluid (CSF) leakage is a common complication of intradural surgery or incidental durotomy in neurosurgery. Dural suturing is a common method for durotomy repair, but this technique requires a long operation time and includes the risk of CSF leakage by incomplete sealing. Glue-type sealants are effective for watertight dural closure. However, unresolved shortcomings include insufficient sealing performance, poor biocompatibility, and excessive swelling. Here, a dural sealant using light-activated hyaluronic acid (HA) with multi-networks (HA photosealant) that provides fast sealing performance and high biocompatibility is reported. The HA photosealants form a watertight hydrogel barrier with multilength networks under low-energy visible light exposure (405nm, <1Jcm-2) for 5s and allow firm tissue adhesion on the wet dural surface. In a rabbit model of craniectomy and durotomy, HA photosealants exhibit the faster sealing performance of dural tears and enhance dural repair with accelerated bone formation compared to commercial surgical glues, with no degenerative changes, such as inflammation or necrosis, in histopathological evaluation. This biocompatible HA photosealant can be applied in a variety of clinical settings that require fast wound closure as a promising potential.

Functional Outcomes After Discectomy for Recurrent Lumbar Herniation Using the Destandau Endospine System: A Retrospective Study of 44 Patients.

Background Recurrent disc herniation is a major cause of morbidity and surgical failure after disc surgery. This study aimed to investigate the feasibility, safety, and effectiveness of the Destandau endospine system (DES) for treating recurrent lumbar disc herniation (LDH). Methodology A total of 44 patients who underwent minimally invasive Destandau endoscopic lumbar discectomy (DELD) for recurrent LDH were included in this study. All data were collected retrospectively. The preoperative and postoperative visual analog scale (VAS) score was used for the evaluation and gradation of pain. The clinical outcome was analyzed according to modified MacNab criteria. The minimum follow-up was two years. Preoperative and postoperative VAS scores were compared using the paired Student's t-test. Statistical significance was set at a p-value <0.05. Results The mean surgical time was 30 ± 20 minutes. The VAS score for leg pain was improved in all cases from 5.9 ± 2.1 to 1.7 ± 1.3 (p< 0.001). In 98% of cases, a successful outcome was noted (excellent or good outcome according to MacNab criteria). In three (7%) patients, incidental durotomy occurred, but there was no neurological worsening, cerebrospinal fluid fistula, or negative influence on the clinical outcome. No recurrence or instability occurred in our series. Conclusions The clinical outcomes of minimally invasive DES for LDH were found to be comparable with the reported success rates of other minimally invasive techniques reported in the existing literature. The dural tear rate was independent of postoperative morbidity and functional outcome. The technique is a safe and effective treatment option for recurrent LDH.

Early ambulation versus prolonged bed rest for incidental durotomies in spine procedures: a systematic review and meta-analysis.

Incidental durotomies are frequent complications of spine surgery associated with cerebrospinal fluid (CSF) leak-related symptoms. Management typically involves prolonged bed rest to reduce CSF pressure at the durotomy site. However, early ambulation may be a safer, effective alternative. PubMed, Web of Science, Embase, Cochrane, and Scopus were systematically searched for studies comparing early ambulation (bed rest ≤ 24h) with prolonged bed rest (> 24h) for patients with incidental durotomies in spine surgeries. The outcomes of interest were CSF leak, hypotensive headache, additional surgical repair, pseudomeningocele, and pulmonary complications. Systematic reviews and meta-analysis were performed following the Cochrane Handbook for Systematic Reviews of Interventions. We included a total of 704 patients from 6 studies. There was a significant reduction in the incidence of pulmonary complications (RR 0.23; 95% CI 0.08-0.67; p = 0.007) in the early mobilization group. The incidence of CSF leak (RR 1.34; 95% CI 0.83-2.14; p = 0.23), hypotensive headache (RR 0.72; 95% CI 0.27-1.90; p = 0.50), additional repair surgery (RR 1.29; 95% CI 0.76-2.2; p = 0.35), and pseudomeningocele (RR 1.29; 95% CI 0.20-8.48; p = 0.79) did not differ significantly. In patients with incidental durotomy following spinal surgery, early mobilization was associated with a lower incidence of pulmonary complications as compared with prolonged bed rest. There was no significant difference between groups in terms of CSF leak, need for additional repair, pseudomeningocele, and hypotensive headache.

Subfascial Lumbar Spine Drain Output Does Not Affect Outcomes After Incidental Durotomies in Elective Spine Surgery

Postoperative drains have long been regarded as a preventive measure to mitigate the risks of complications such as neurological impairment by reducing fluid accumulation following spine surgery. Our study aims to contribute to the existing body of knowledge by examining the effects of postoperative drain output on the 90-day postoperative outcomes for patients who experienced an incidental durotomy after lumbar decompression procedures, with or without fusion. All patients aged ≥18 years with an incidental durotomy from spinal decompression with or without fusion surgery between 2017 and 2021 were retrospectively identified. The patient demographics, surgical characteristics, method of dural tear repair (DuraSeal, suture, and/or DuraGen), surgical outcomes, and drain data were collected via medical record review. Patients were grouped by readmission status and final 8-hour drain output. Those with a final 8-hour drain output of ≥40 mL were included in the high drain output (HDO) group and those with <40 mL were in the low drain output (LDO) group. There were no statistically significant differences in preoperative patient demographics, surgical characteristics, method of dural tear repair, length of stay (HDO, 4.02 ± 1.90 days; vs. LDO, 4.26 ± 2.10 days; P= 0.269), hospital readmissions (HDO, 10.6%; vs. LDO, 7.96%; P= 0.744), or occurrence of reoperation during readmission (HDO, 6.06%; vs. LDO, 2.65%; P= 0.5944) between the 2 groups. For patients undergoing primary lumbar decompression with or without fusion and experiencing an incidental durotomy, no significant association was found between the drain output and 90-day patient outcomes. Adequate fascial closure and the absence of symptoms may be satisfactory criteria for standard patient discharge regardless of drain output.

Transforaminal lumbar interbody fusion with an expandable interbody device: Two-year clinical and radiographic outcomes

BackgroundThe use of interbody cages as an adjunct to lumbar spinal fusion remains an important technique to enhance segmental stability, promote solid arthrodesis, maintain neuroforaminal decompression, and preserve/improve segmental lordosis. Appropriate segmental lumbar lordosis and sagittal balance is well-known to be critical for long-term patient outcomes. This study sought to evaluate the radiographic and clinical results of TLIF in patients using an articulating, expandable cage. Primary endpoint was clinical and radiographic outcomes, including complications, at 12 and 24 months. MethodsA total of 37 patients underwent open single-level or 2-level TLIF by a single surgeon using an expandable cage with concomitant bilateral pedicle screws and posterolateral arthrodesis. Clinical outcomes included ODI and VAS for back and legs. Radiographic outcomes included pelvic incidence and tilt, lumbar and segmental lordoses, and disc height at the operative level(s). All outcomes were collected at baseline, 2-weeks, 6-weeks, 3-months, 6-months, 12-months, and 24-months postop. ResultsA total of 28 patients were available for analysis. Nine patients failed to follow-up at 24 months. Mean ODI scores showed significant improvement, from pre-to-postoperative at 24 months (55%; p<.0001). VAS for back and legs was significantly lower at 24 months on average by 72 and 79%, respectively (p<.0001 for both). Both segmental and lumbar lordoses significantly improved by 5.3° and 4.2° (p<.0001 and p=.049), respectively. Average disc height improved by 49% or 6.1 mm (p<.001). No device-related complications nor instances of measured subsidence. One patient had a superficial infection, and another had an intraoperatively repaired incidental durotomy. ConclusionsThe use of an expandable cage contributed to improvement in both segmental and lumbar lordosis with no reported complications at 24-month follow-up. All clinical measures significantly improved as well. The expandable cage design represents an effective and safe option to increase cage size and allow significant segmental lordosis correction.

Minimally invasive tubular microdiscectomy for recurrent lumbar disc herniation: step-by-step technical description with safe scar dissection

IntroductionRecurrent lumbar disc herniation (RLDH) is one of the most common reasons for re-operation after primary lumbar disc herniation with an incidence ranging from 5 to 23%. Numerous RLDH studies have been conducted; however, no available studies have provided a specific description of the use of the tubular retractor discectomy technique for RLDH emphasizing safe scar dissection. The objective of this study is to describe a detailed step-by-step technique for RLDH.Material and methodsA surgical technique reporting on our experience from the year 2013–2021 in 9 patients with RLDH at the same level and same side was included in the study. Clinical outcomes were assessed using the visual analog score (VAS) for leg pain before and three months after surgery.ResultsA significant improvement was observed between the preoperative and postoperative VASs [mean (SD): 9.2 (1) vs. 1.5 (1)] for all patients. We did not report any incidental durotomy, neurological deficits or mortality in this study. One patient had superficial wound infection. The study is limited by small population, short follow-up and not reporting stability or spondylolisthesis.ConclusionA modified tubular discectomy technique with safe scar dissection is effective for RLDH treatment. Technically, the only scar needed to be dissected is the scar lateral to the exposed normal dura and the scar extended caudally till the level of the superior end plate of the targeted disc space where the scar can be entered ventrally and the disc fragment retrieved. Adherence to the step-by-step procedure described in our study will help surgeons operate with more confidence and minimize complications of recurrent lumbar disc herniation.

Staged circumferential lumbar fusions have less intraoperative complications and shorter operative time with no difference in 30-, 90-, and 1-year complications: a propensity-matched cohort analysis of 190 patients

Background contextCircumferential lumbar fusions (cLFs) are becoming more common with increasing and more minimally invasive anterior access techniques. Staging allows reassessment of indirect decompression and alignment prior to the posterior approach, and optimization of OR time management. Safety of staging has been well documented in deformity surgery but has yet to be delineated in less extensive, degenerative cLFs. PurposeThe purpose of this study is to compare perioperative complications and outcomes between staged versus single-anesthetic circumferential fusions in the lumbar spine. Study designPropensity-matched comparative observational cohort. Patient samplePatients who underwent cLFs for lumbar degenerative disease. Outcome measuresIn-hospital, 30-day, 90-day, and 1-year complications. MethodsFrom 123 patients undergoing single-anesthetic and 154 patients undergoing staged cLF, 95 patients in each group were propensity-matched based on age, sex, BMI, ASA score, smoking, revision, and number of levels. We compared perioperative, 30-day, 90-day, and 1-year complications between the two cohorts. ResultsMean days between stages was 1.58. Single-anesthetic cLF had longer total surgery time (304 vs 240 minutes, p<.001) but shorter total PACU total time (133 vs 196 minutes, p<.001). However, there was no difference in total anesthesia time (368 vs 374 minutes, p=.661) and total EBL (357 vs 320cc, p=.313). Intraoperative complications were nine incidental durotomies in the single-anesthetic and one iliac vein injury in the staged group (9% vs 1%, p=.018). There was no difference of in-hospital (38 vs 31, p=.291), 30-day (16 vs 23, p=.281), 90-day (10 vs 15, p=.391), 1-year complications (9 vs 12, p=.644), and overall cumulative 1-year complications (54 vs 56, p=.883) between the two cohorts. ConclusionSThere is a decrease in total surgical time and intraoperative complications during staged compared with single-anesthetic cLF with no difference in in-hospital, 30-day, 90-day, and 1-year complications between approaches.

Outcomes of Incidental Durotomy Repair in Thoracolumbar Spine Surgery: An Institutional Experience With Orthopedic Residents.

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.