Incidental Durotomy Research Articles

80. Early mobilization after incidental durotomy: a systematic review

<h3>BACKGROUND CONTEXT</h3> The conventional management of incidental dural tears involving a prolonged period of flat bed rest is highly debatable. There is no consensus regarding the need or ideal duration of postoperative bed rest following these dural tears. <h3>PURPOSE</h3> To systematically evaluate the relevant literature regarding the outcomes of mobilization within 24 hours after incidental durotomy with respect to the length of hospital stay, minor complications and reoperation rates. The data were compared to that of later mobilization (after 24 hours). <h3>STUDY DESIGN/SETTING</h3> A systematic review and meta-analysis. <h3>PATIENT SAMPLE</h3> Overall, 533 patients (mean age 61.1 years) had an incidental dural tear and were mobilized within 24 hours. Additionally, 203 patients of mean age 72.8 years (6 studies) were mobilized after 24 hours (24 – 144 hours). <h3>OUTCOME MEASURES</h3> We aimed to measure hospital stay, minor complications and reoperation rates in early mobilized patients after incidental durotomies. <h3>METHODS</h3> A systematic review of the English language literature dating to December 2021, was undertaken using search criteria ([dural tear or durotomy] and [mobilization or bed rest]) and the PRISMA guidelines. Isolated case reports were excluded. <h3>RESULTS</h3> The average hospital stay for early mobilized patients was 3.65 days. Twenty-two out of 533 (4.1%) patients (11 studies) had a major complication that required reoperation while the rate of minor complications was 27 out of 230 (11.7%) (9 studies). Comparing early to late mobilization, there was a significant reduction in the risk of minor complications due to early mobilization (13/102 [12.7%] vs 33/106 [31.1%] RR: 0.47, 95CI: 0.27, 0.80), but no significant difference in major complications (3 studies) (12/106 [11.3%] vs 11/134 [8.2%] RR: 1.55, 95CI: 0.72, 3.35). <h3>CONCLUSIONS</h3> This systematic review compared early and late mobilisers after incidental durotomies, finding that minor complications including headaches, nausea, tinnitus and vomiting were, in fact, significantly reduced with early mobilization. Indeed, early mobilization within 24 hours after incidental dural tears appears to be safe and did not need lead to a significantly higher re-operation rate compared to more prolonged bed rest. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

3. Assessment of in vitro dural repair techniques with a hydrostatic pressure device

<h3>BACKGROUND CONTEXT</h3> Incidental durotomies are a relatively infrequent occurrence during lumbar spine surgery and are generally benign, without significant adverse consequences. Treatment with direct repair, with or without augmentation, is generally very effective and further cerebrospinal fluid (CSF) leak is uncommon. The strength and stability of a dural repair is dependent on several factors, including patient age, quality of dural tissue, the size and location of the durotomy, and the manner in which the repair is performed. There is limited in vitro evidence comparing the strength of different dural repair techniques and the resulting likelihood of recurrent CSF leak. <h3>PURPOSE</h3> To compare the strength and stability of various dural repair techniques in an in vitro human cadaveric durotomy model. <h3>STUDY DESIGN/SETTING</h3> An in vitro testing device was created to apply controlled, hydrostatic pressure to evaluate the integrity of a surgically-created durotomy. <h3>PATIENT SAMPLE</h3> Sixteen human cadaveric specimens. <h3>OUTCOME MEASURES</h3> The hydrostatic pressure required to cause a leak at the site of the dural repair. <h3>METHODS</h3> Complete human cadavers were placed in the prone position and the dura in the thoracic and lumbar spines was exposed through a midline incision and subsequent laminectomies. The dura was clamped 8 cm proximal and distal to the level of the durotomy and clamped with reliable, water-tight plastic rings. A 16-gauge plastic catheter was introduced into the lateral aspect of the dura and sutured in a water-tight fashion to serve as the source for instilling saline into the dura. The catheter was attached to a hydrostatic pressure measuring column to assess the intradural pressure. Linear durotomies of either 1 cm or 6 cm in length were made with a 15 blade in both the thoracic and lumbar spines of each cadaver. A dural repair was performed with either a 6-0 prolene or 2-0 silk suture. Repair technique were either multiple, simple interrupted sutures or a simple running repair with knots at the respective margins of the durotomy. An analysis of variant analysis (ANOVA) was employed to assess differences in leak rates with respect to applied hydrostatic pressure. <h3>RESULTS</h3> Eight repair groups (thoracic vs lumbar / 6-0 prolene vs 2-0 silk / running vs multiple interrupted) were studied for each of the 1 cm and 6 cm durotomies. There were no significant differences noted in the frequency or extent of spinal fluid leak at different hydrostatic pressures with respect to either suture type employed or suture technique performed. There was a slight difference in the mean applied hydrostatic pressure applied to create a fluid leak in the 6 cm durotomy (16 cm H2O) compared to the 1 cm durotomy (12 cm H2O) but this did not reach statistical significance. <h3>CONCLUSIONS</h3> In this in vitro study of the integrity of the repair of experimentally created durotomies, no significant difference was noted with respect to different suture type or technique of repair. Larger durotomies had a slight, not significant trend for recurrent leak at lower applied hydrostatic pressures. In general, expansion of the repaired dura with controlled delivery of intrathecal fluid, simulating an in vivo, intraoperative Valsalva maneuver, did not reveal significant differences in varying repair types. While this in vitro study does not directly replicate an in vivo scenario, the results do reinforce the necessity of a meticulous water tight suture repair to adequately treat incidental durotomies and thus avoid the troublesome consequences of a recurrent CSF leak. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P118. Anterior versus lateral lumbar fusion: a comparison of 2-year outcomes in the treatment of degenerative spinal disorders

<h3>BACKGROUND CONTEXT</h3> Extreme lateral interbody fusion (XLIF) and anterior lumbar interbody fusion (ALIF) have both been progressively utilized by spinal surgeons, offering advantages of reduced tissue trauma, blood loss and improvements in postoperative patient reported outcomes. Although the literature has reported a higher proportion of neurological complications in XLIF, the anterior approach has been associated with a larger overall complication proportion, including a greater number of vascular and visceral complications. However, there is a paucity of reports comparing the two approaches over the long-term. Therefore, the purpose of this study was to assess and compare the overall revision rates, perioperative complications and functional clinical outcomes with minimum 2-year followup in both ALIF and XLIF. <h3>PURPOSE</h3> To compare ALIF versus XLIF in the treatment of degenerative spinal disorders with minimum 2-year followup. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort comparative study. <h3>PATIENT SAMPLE</h3> A total of 293 patients from 2013-2018 with a minimum follow-up of 2 years. One hundred and seventy-eight patients underwent ALIF and 115 patients underwent XLIF. <h3>OUTCOME MEASURES</h3> (1) Revision rate and average time to revision; (2) Perioperative complications; (3) Functional outcome scores including Oswestry Disability Index (ODI) and Visual Analog Scale for back (VAS-b). <h3>METHODS</h3> A retrospective review was performed to identify all patients between 2013-2018 who underwent ALIF or XLIF for degenerative lumbar spinal disorders with a minimum followup of 2 years. Demographic data was recorded and compared between both cohorts. Revision rates and time to revision in each group were compared. Perioperative complications were recorded. Functional outcomes were assessed with ODI and VAS back measurements at followup visits. Standard binomial and categorical comparative analyses were performed. <h3>RESULTS</h3> A total of 293 patients were included, 178 in the ALIF cohort and 115 in the XLIF cohort. Mean followup for the XLIF and ALIF groups were 46.3 and 42.2 months, respectively. The overall revision rate was 7.8% for the XLIF group and 7.9% for the ALIF group (p= 0.990). The average time to revision was 270.1 ± 133.0 days and 301.1 ± 140.7 days for the ALIF and XLIF groups, respectively (p= 0.058). The most common reason for revision in each cohort was persistent radiculopathy in the ALIF group (57.1%) and symptomatic adjacent segment disease in the XLIF group (44.4%). Three patients (1.7%) in the ALIF group required intraoperative repair of the common iliac vein due to incidental transection perioperatively whereas one patient (0.9%) underwent repair of the dura due to incidental durotomy in the XLIF cohort (p= 0.557). There were 46 males and 69 females in the XLIF cohort compared to 89 males and 89 females in the ALIF cohort (p= 0.094). Both cohorts experienced significant improvements in their functional outcomes scores compared to their preoperative values. VAS scores decreased by a mean of 5.6 in the XLIF group and a mean of 2.5 in the ALIF group, a significant difference (p= <0.001). <h3>CONCLUSIONS</h3> Our 2-year results show revision and overall complication rates did not differ significantly between XLIF and ALIF after 2-year followup. However, the ALIF group had a larger number of complications which were all related to vascular injury. Regarding patient reported outcomes, the XLIF cohort had significantly greater VAS-b score improvement compared to the ALIF cohort. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

176. The long-term outcomes of patients with early surgical site infections following instrumented lumbar fusions

176. The long-term outcomes of patients with early surgical site infections following instrumented lumbar fusions

Dural Repair Simulation Model

Incidental durotomy is a potential complication encountered in pediatric spine surgery. Direct dural repair is technically challenging and thus is often performed by the senior surgeon. The dural repair simulation represents a low-cost but high-fidelity method of teaching and practicing dural repair for trainees and junior surgeons.

Incidental Dural Tears in Lumbar Decompressive Surgery: Incidence, Causes, Treatment, Results

Durotomy (Incidental dural tears or ID) is a very rarely occurring disorder when decompressive surgery (spinal surgery) of the patients takes place. This disorder has severe effects on patients. During different surgeries of the spinal cord, the chances of this durotomy vary greatly. Objective: The main objective of this research work is to evaluate the main reasons for the incidence of this durotomy disease. During different surgeries of the spinal cord surgeries (decompressive and compressive) within the different regions, many factors play their role in the initiation of this durotomy disease. It is the target of this work to find the initiation factors of the disease so that effective methods of treatment can also find out. Methods: It was a retrospective study with a statistical approach. This study was conducted in Neurosurgery unit, Mardan medical complex / Bacha khan medical college, Mardan for the Duration of one year August 2020 to July 2021. To proceed with this study, 30 patients were selected with posterolateral and posterior compressive and decompressive surgeries within the different regions of the spinal cord. The patients were randomly selected from December 2020 to December 2021. Results: The incidence of this durotomy disease was investigated within all groups and the probability of this disease was only 12.65%. The occurrence of this disease also depends upon the type of surgery. Patients suffering from spinal trauma, stenosis of the spinal, different tumors, and vertebral disc herniation had exaggerating role in the incidence of durotomy in patients having some spinal surgery. Conclusion: The durotomy disease should be considered a serious issue with a number of other complications. For the treatment of this disease, prevention is the best method and to know about the complications is important because all of the factors involved in the incidence of durotomy should be considered while performing any kind of surgery

NATIONWIDE SURVEY ON INCIDENTAL DURAL TEARS DURING ENDOSCOPIC SPINE SURGERY IN JAPAN

Purpose: The Japanese Orthopedic Association has conducted a nationwide survey on the status of endoscopic spine surgery in Japan every year since 2006. This study aimed to analyze incidental dural tear. Method:We sent questionnaires to all spine surgery hospitals in Japan and received responses from an average of 1296 hospitals (974–1746) each year. The average response rate for the questionnaire was 63.7% (45.2–85.8). Results:The average number of facilities performing endoscopic spine surgery was 314 (222–415). The percentage of facilities performing endoscopic procures was 24.3% (20.3–27.3%). Incidental dural tear accounted for 65.4% (3113/4758) of all complications, which was significantly higher than nerve root injuries, cauda equina injuries (4.6%), and hematomas (10.0%). The number of accidents resulting in harm to patients was 154 (3.6%) for incidental dural tear which was significantly less than that for hematoma (75.5%) and for nerve root cauda equina injury (49.5%). Conclusion:As the number of endoscopic procedures increased, the number of complications increased year by year. However, the rate of complications has remained constant, with incidental durotomy tending to be the most common endoscopic lumbar laminectomy for lumbar spinal canal stenosis.

Incidence and risk factors for incidental durotomy in spine surgery for lumbar stenosis and herniated disc.

Incidental durotomy (ID) is one of the most common complications in degenerative surgery. Due to the negative consequences of ID, knowledge about incidence and risk factors is warranted. A total of 1,139 surgical procedures for lumbar spinal stenosis (LS) and lumbar herniated disc (LDH) were included from the spine surgery database: DaneSpine. Uni- and multivariate analyses were performed for the assessment of possible risk factors. ID occurred in 10.4% of the surgical procedures. A multivariate regression analysis revealed an increased relative risk of ID by 2% per year of age, 58% by revision surgery, and 55% by decompression on multiple levels. In our single-centre cohort study, one in ten patients experiences an ID. Increasing age, revision surgery and decompression of multiple levels are risk factors of ID in degenerative surgery of the lumbar spine.

CORR Insights®: Can We Geographically Validate a Natural Language Processing Algorithm for Automated Detection of Incidental Durotomy Across Three Independent Cohorts From Two Continents?

1Associate Professor, Division of Orthopaedic Surgery, University of Ottawa, Ottawa, ON, Canada E. K. Wai ✉, The Ottawa Hospital, Civic Campus, Room J1-141, 1053 Carling Avenue, Ottawa, ON, K1H 8L6, Canada, Email: [email protected] This CORR Insights® is a commentary on the article “Can We Geographically Validate a Natural Language Processing Algorithm for Automated Detection of Incidental Durotomy Across Three Independent Cohorts From Two Continents?” by Karhade and colleagues available at: DOI: 10.1097/CORR.0000000000002200. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Can Cervical and Lumbar Epidural Blood Patches Help Avoid Revision Surgery for Symptomatic Postoperative Dural Tears?

Incidental durotomies resulting in symptomatic postoperative cerebrospinal fluid (CSF) leaks can be treated with bedrest, subarachnoid lumbar drain, and surgical re-exploration. Another option is an epidural blood patch, which forms a clot over the dural tear in a minimally invasive manner. Our objective was to describe our center's outcomes and complications following epidural blood patches for symptomatic postoperative durotomies. Patients undergoing spine surgeries at one institution from 2012-2020 were included. Patient charts were reviewed for demographic information, surgical data, rate of dural tear, type of repair, and use of blood patches postoperatively. A total of 1392 patients (726 male, 666 female, average age: 56.3 ± 15.4 years), including 436 cervical and 956 posterior thoracolumbar/lumbar spine surgeries were screened. There were 6 (1.4%) cervical, 64 (6.7%) lumbar, and a total of 70 (5.0%) patients with incidental dural tears/blebs. Of these patients, we identified 2 cervical and 8 lumbar spine patients with persistent CSF leaks who received epidural blood patches postoperatively. Nine of 10 (90%) had resolution of symptoms. One lumbar patient failed both an initial blood patch and subsequent surgical re-exploration, but had successful relief after a second blood patch. The incidence of dural tears/blebs was 1.4% in cervical, 6.7% in lumbar, and 5.0% in all spine surgeries. Of the 10 patients with symptomatic CSF leaks, 9 were successfully treated with blood patches. Targeted epidural blood patch is effective in treating symptomatic CSF leaks and minimizes the morbidity of surgical re-exploration.

Minimally invasive versus open lumbar spinal fusion: a matched study investigating patient-reported and surgical outcomes.

With the expanding indications for and increasing popularity of minimally invasive surgery (MIS) for lumbar spinal fusion, large-scale outcomes analysis to compare MIS approaches with open procedures is warranted. The authors queried the Quality Outcomes Database for patients who underwent elective lumbar fusion for degenerative spine disease. They performed optimal matching, at a 1:2 ratio between patients who underwent MIS and those who underwent open lumbar fusion, to create two highly homogeneous groups in terms of 33 baseline variables (including demographic characteristics, comorbidities, symptoms, patient-reported scores, indications, and operative details). The outcomes of interest were overall satisfaction, decrease in Oswestry Disability Index (ODI), and back and leg pain, as well as hospital length of stay (LOS), operative time, reoperations, and incidental durotomy rate. Satisfaction was defined as a score of 1 or 2 on the North American Spine Society scale. Minimal clinically important difference (MCID) in ODI was defined as ≥ 30% decrease from baseline. Outcomes were assessed at the 3- and 12-month follow-up evaluations. After the groups were matched, the MIS and open groups consisted of 1483 and 2966 patients, respectively. Patients who underwent MIS fusion had higher odds of satisfaction at 3 months (OR 1.4, p = 0.004); no difference was demonstrated at 12 months (OR 1.04, p = 0.67). Lumbar stenosis, single-level fusion, higher American Society of Anesthesiologists Physical Status Classification System grade, and absence of spondylolisthesis were most prominently associated with higher odds of satisfaction with MIS compared with open surgery. Patients in the MIS group had slightly lower ODI scores at 3 months (mean difference 1.61, p = 0.006; MCID OR 1.14, p = 0.0495) and 12 months (mean difference 2.35, p < 0.001; MCID OR 1.29, p < 0.001). MIS was also associated with a greater decrease in leg and back pain at both follow-up time points. The two groups did not differ in operative time and incidental durotomy rate; however, LOS was shorter for the MIS group. Revision surgery at 12 months was less likely for patients who underwent MIS (4.1% vs 5.6%, p = 0.032). In patients who underwent lumbar fusion for degenerative spinal disease, MIS was associated with higher odds of satisfaction at 3 months postoperatively. No difference was demonstrated at the 12-month follow-up. MIS maintained a small, yet consistent, superiority in decreasing ODI and back and leg pain, and MIS was associated with a lower reoperation rate.

Can We Geographically Validate a Natural Language Processing Algorithm for Automated Detection of Incidental Durotomy Across Three Independent Cohorts From Two Continents?

Incidental durotomy is an intraoperative complication in spine surgery that can lead to postoperative complications, increased length of stay, and higher healthcare costs. Natural language processing (NLP) is an artificial intelligence method that assists in understanding free-text notes that may be useful in the automated surveillance of adverse events in orthopaedic surgery. A previously developed NLP algorithm is highly accurate in the detection of incidental durotomy on internal validation and external validation in an independent cohort from the same country. External validation in a cohort with linguistic differences is required to assess the transportability of the developed algorithm, referred to geographical validation. Ideally, the performance of a prediction model, the NLP algorithm, is constant across geographic regions to ensure reproducibility and model validity. Can we geographically validate an NLP algorithm for the automated detection of incidental durotomy across three independent cohorts from two continents? Patients 18 years or older undergoing a primary procedure of (thoraco)lumbar spine surgery were included. In Massachusetts, between January 2000 and June 2018, 1000 patients were included from two academic and three community medical centers. In Maryland, between July 2016 and November 2018, 1279 patients were included from one academic center, and in Australia, between January 2010 and December 2019, 944 patients were included from one academic center. The authors retrospectively studied the free-text operative notes of included patients for the primary outcome that was defined as intraoperative durotomy. Incidental durotomy occurred in 9% (93 of 1000), 8% (108 of 1279), and 6% (58 of 944) of the patients, respectively, in the Massachusetts, Maryland, and Australia cohorts. No missing reports were observed. Three datasets (Massachusetts, Australian, and combined Massachusetts and Australian) were divided into training and holdout test sets in an 80:20 ratio. An extreme gradient boosting (an efficient and flexible tree-based algorithm) NLP algorithm was individually trained on each training set, and the performance of the three NLP algorithms (respectively American, Australian, and combined) was assessed by discrimination via area under the receiver operating characteristic curves (AUC-ROC; this measures the model's ability to distinguish patients who obtained the outcomes from those who did not), calibration metrics (which plot the predicted and the observed probabilities) and Brier score (a composite of discrimination and calibration). In addition, the sensitivity (true positives, recall), specificity (true negatives), positive predictive value (also known as precision), negative predictive value, F1-score (composite of precision and recall), positive likelihood ratio, and negative likelihood ratio were calculated. The combined NLP algorithm (the combined Massachusetts and Australian data) achieved excellent performance on independent testing data from Australia (AUC-ROC 0.97 [95% confidence interval 0.87 to 0.99]), Massachusetts (AUC-ROC 0.99 [95% CI 0.80 to 0.99]) and Maryland (AUC-ROC 0.95 [95% CI 0.93 to 0.97]). The NLP developed based on the Massachusetts cohort had excellent performance in the Maryland cohort (AUC-ROC 0.97 [95% CI 0.95 to 0.99]) but worse performance in the Australian cohort (AUC-ROC 0.74 [95% CI 0.70 to 0.77]). We demonstrated the clinical utility and reproducibility of an NLP algorithm with combined datasets retaining excellent performance in individual countries relative to algorithms developed in the same country alone for detection of incidental durotomy. Further multi-institutional, international collaborations can facilitate the creation of universal NLP algorithms that improve the quality and safety of orthopaedic surgery globally. The combined NLP algorithm has been incorporated into a freely accessible web application that can be found at https://sorg-apps.shinyapps.io/nlp_incidental_durotomy/ . Clinicians and researchers can use the tool to help incorporate the model in evaluating spine registries or quality and safety departments to automate detection of incidental durotomy and optimize prevention efforts. Level III, diagnostic study.

Surgical management of lumbar spinal stenosis in patients over 80: is there an increased risk?

Management of lumbar spinal stenosis (LSS) represents the first cause of spinal surgery for the elderly and will increase with the aging population. Although the surgery improves quality of life, the procedure involves anaesthetic and operative risks. The aim of this study was to assess whether the postoperative complication rate was higher for elderly patients and to find confounding factors. We conducted a retrospective study including all LSS surgeries between 2012 and 2020 at the University Hospital of Caen. We compared two populations opposing patients aged over 80 with others. The primary endpoint was the occurrence of a severe complication (SC). Minor complications were the secondary endpoint. Comorbidities, history of lumbar spine surgery and surgical characteristics were recorded. Nine hundred ninety-six patients undergoing surgery for degenerative LSS were identified. Patients over 80 were significantly affected by additional comorbidities: hypertension, heart diseases, higher age-adjusted comorbidity Charlson score, ASA score and use of anticoagulants. Knee-chest position was preferred for younger patients. Older patients underwent a more extensive decompression and had more incidental durotomies. Of the patients, 5.2% presented SC. Age over 80 did not appear to be a significant risk factor for SC, but minor complications increased. Multivariate analysis showed that heart diseases, history of laminectomy, AA-CCI and accidental durotomies were independent risk factors for SC. Surgical management for lumbar spinal stenosis is not associated to a higher rate of severe complications for patients over 80years of age. However, preoperative risk factors should be investigated to warn the elderly patients that the complication risk is increased although an optimal preparation is the way to avoid them.

805 Initial Results of Precision Treatment of Postoperative Cerebrospinal Fluid Leak with Ultrasound-Guided Epidural Blood Patch

INTRODUCTION: Incidental durotomy, a known complication of spinal surgery, can lead to persistent cerebrospinal fluid (CSF) leak and pseudomeningocele if unrecognized or incompletely repaired. METHODS: A retrospective review was performed to determine demographic, procedural, and outcome characteristics for patients who underwent US-EBP for symptomatic postoperative pseudomeningocele. RESULTS: Overall, 48 patients who underwent 49 unique episodes of care were included. The average age and BMI were 60.5±12.6 years and 27.8±4.50 kg/m2, respectively. The most frequent index operation was laminectomy (24.5%) and 36.7% of surgeries were revision operations. Durotomy was intended or recognized in 73.4% of cases, and the median time from surgery to symptom development was 7 (IQR 4-16) days. A total of 61 US-EBPs were performed, with 51.0% of patients experiencing resolution of their symptoms after the first US-EBP. An additional 20.4% were successful with multiple US-EBP attempts. Complications occurred in 14.3% of cases and the median clinical follow-up was 4.3 (IQR 2.4-14.5) months. CONCLUSIONS: This manuscript represents the largest series in the literature describing US-EBP for the treatment of postoperative pseudomeningocele.

115 Minimally Invasive Versus Open Lumbar Spinal Fusion: A Matched Study Investigating Patient-Reported and Surgical Outcomes

INTRODUCTION: With the expanding indications for and increasing popularity of minimally invasive spine surgery (MIS) for lumbar spinal fusion, large-scale analysis of patient outcomes after MIS approaches compared to traditional open procedures is warranted. METHODS: Patients undergoing MIS and open lumbar fusion were matched at a 1:2 ratio on 33 baseline variables to create two highly homogeneous groups. Primary endpoints of interest were overall satisfaction and a decrease in Oswestry Disability Index (ODI) at 3 months postoperatively. Satisfaction was defined as score 1-2 in the North American Spine Association index; minimal clinically important disease (MCID) for ODI was defined as = 30% decrease from baseline. Secondary endpoints were satisfaction and decrease in ODI at 12 months, length of stay (LOS), operative time, and incidental durotomy rate. RESULTS: The MIS and open groups consisted of 1,483 and 2,966 patients, respectively. MIS fusion patients had a higher odds of satisfaction compared to open surgery at 3 months (OR = 1.4, p = 0.004), while maintaining non-inferior odds of satisfaction at 12 months (OR = 1.04, p = 0.67). Lumbar stenosis, single-level fusion, predominant back pain, higher ASA grade, and absence of spondylolisthesis were associated with higher odds of satisfaction with MIS compared to open surgery. Patients in the MIS group had slightly lower ODI scores at 3 months (mean difference=1.61, p = 0.006; MCID OR = 1.14, p = 0.0495), and 12 months (mean difference=2.35, p &lt; 0.001; MCID OR = 1.29, p &lt; 0.001). The groups did not differ in terms of operative time and incidental durotomy rate; however, LOS was shorter for the MIS group. CONCLUSION: These results demonstrate that MIS fusion is associated with higher odds of satisfaction and, possibly, a greater decrease in ODI than open fusion at 3 months postoperatively while maintaining a greater ODI improvement and performing non-inferiorly to open in regards to satisfaction at 12 months.

Comparison of Primary Versus Revision Lumbar Discectomy Using a Biportal Endoscopic Technique.

Retrospective study. To compare the clinical outcomes of the biportal endoscopic technique for primary lumbar discectomy (BE-LD) and revision lumbar discectomy (BE-RLD). Eighty-one consecutive patients who underwent BE-LD or BE-RLD, and could be followed up for at least 12months were divided into two groups: Group A (BE-LD; n = 59) and Group B (BE-RLD; n = 22). Clinical outcomes included the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab's criteria. Perioperative results included operation time (OT), length of hospital stay (LOS), amount of surgical drain, and kinetics of serum creatine phosphokinase (CPK) and C-reactive protein (CRP). Clinical and perioperative outcomes were assessed preoperatively and postoperatively at 2days and at 3, 6, and 12months. Postoperative complications were noted. Both groups showed significant improvement in pain (VAS) and disability (ODI) compared to baseline values at postoperative day 2, which lasted until the final follow-up. There were no significant differences in the improvement of the VAS and ODI scores between the groups. According to the modified MacNab's criteria, 88.1 and 90.9% of the patients were excellent or good in groups A and B, respectively. OT, LOS, amount of surgical drain, and kinetics in serum CRP and CPK levels were comparable. Complications in Group A included incidental durotomy (n = 2), epidural hematoma (n = 1), and local recurrence (n = 1) and in Group B incidental durotomy (n = 1) and epidural hematoma (n = 1). BE-RLD showed favorable clinical outcomes, less postoperative pain, and early laboratory recovery equivalent to BE-LD.

Quantitative lateral flow immunoassay for rapid detection and monitoring of cerebrospinal fluid leakage following incidental durotomy

Cerebrospinal fluid (CSF) leakage due to incidental durotomy is an inherent complication of spine surgery. With appropriate treatment, complications of CSF leakage, such as headache and even meningitis, can be reduced. CSF leakage could be detected on the basis of correlated clinical symptoms; diagnosis should be based on these symptoms and appropriate imaging studies. However, the diagnosis of CSF leakage remains a challenge, especially if incidental durotomy is unrecognized during surgery; even if incidental durotomy is detected and repaired intraoperatively, the severity of the leakage and quality of the primary dural repair are difficult to evaluate postoperatively. Rapid, inexpensive, and safe methods of detecting CSF-containing samples are currently lacking; hence, the development of a point-of-care test (POCT) method to improve diagnostic efficiency is necessary. We developed a high-sensitivity lateral flow immunoassay with a stacking pad (sLFIA) for quantitative detection of β-trace protein (BTP), a specific CSF marker. The BTP concentration in 39 clinical samples was calculated using a calibration equation for test-line intensity and evaluated by a standard laboratory method. To avoid the hook effect, we diluted each sample prior to testing. The correlation coefficient between the enzyme-linked immunosorbent assay and our BTP sLFIA method was 0.991 A 75-fold sample dilution was applied owing to the hook effect point, identified as 175 ng mL−1. We established an optimal sample-specific cutoff point at a value of 4.0 μg mL−1 for CSF leakage in subfascial drainage samples following spinal posterior decompression. The sensitivity and specificity of the BTP sLFIA method were 90% and 97%, respectively, according to a receiver operating characteristic curve analysis. In addition, clinical samples from patients who underwent primary dural repair intraoperatively were tested, and CSF leakage was successfully diagnosed using our method. Finally, the quantitation of BTP in samples collected daily provided an accurate assessment of the severity of the residual leakage. Our results demonstrate that the BTP sLFIA method possesses the potential to serve as a POCT method for screening and monitoring postoperative CSF leakage.

Anterior cervical pseudomeningocele causing syncope after spinal surgery: A case report.

Introduction and importancePseudomeningocele formation from incidental durotomy is a known risk in spine surgery. We present a case of incidental durotomy leading to anterior neck pseudomeningocele, compressing the carotid body (CB) resulting in syncopal episodes. To our knowledge, this is the first case report implicating syncopal episodes to CB compression via a pseudomeningocele.Case presentationA mid sixty-year-old patient with history of obesity, hypertension, and diabetes presented with gait impairment and hand weakness. Ossification of posterior longitudinal ligament (OPLL) was diagnosed with computed tomography imaging (CT) and magnetic resonance imaging (MRI). Elective surgery was completed with an anterior and posterior approach for decompression and fusion. Hospital course (San Jose, CA, USA) was complicated by respiratory depression and incomplete tetraplegia. On post-operative day (POD) six, CT revealed anterolateral soft tissue neck swelling; subsequent CT and MRI showed fluid collection expansion, with associated syncopal episodes on POD thirty-nine. Despite interventional radiology drainage, the fluid collection and symptoms returned five days later. The patient ultimately underwent durotomy revision and repair with muscle patch.Clinical discussionThis case highlights the challenges in managing anterior cervical dural tears resulting in pseudomeningocele. Risk factors include anterior cervical corpectomy and decompression, as well as an underlying diagnosis of OPLL. Untreated dural tears may develop into pseudomeningoceles which can contribute to life-threatening outcomes.ConclusionThis case report presents the serious consequences of incidental durotomy, the unique post-surgical complication of syncope due to compression of the CB from a pseudomeningocele, and the challenges of managing a persistent pseudomeningocele.

Role of microendoscopic discectomy for the treatment of recurrent lumbar disc herniation: A retrospective review

Background: Recurrent herniation following lumbar disc excision has been reported in 5–11% of patients. There are very few studies on role and outcomes of minimally invasive techniques for the treatment of recurrent disc herniation.Study Design: A retrospective analytical study of 22 patients with recurrent lumbar disc herniation treated with minimally invasive techniques.Objectives: To analyze the role and scope of minimally invasive surgical techniques and consequent outcome in various cases of recurrent lumbar disc herniation.Method: Total 22 patients with recurrent lumbar disc herniations who underwent operations in the form of microendoscopic discectomy (MED) were studied for a period of 1 year. These cases of recurrent lumbar disc herniation with the perioperative data and clinical outcomes (according to modified Macnab criteria) upto 1 year follow up were compared with the previously published data.Results: Overall, the clinical outcomes were significantly excellent or good during and at 1 year follow-up. No case had to be converted to open procedure. Complications occurred in three cases including one incidental durotomy and two patients had recurrent disc herniation. No other significant morbidity including wound infection, neural injury or residual instability occurred till last follow-up. Operative duration, blood loss, complication rate and overall outcomes were statistically comparable to the previously published data.Conclusions: This study suggests that outcomes of minimally invasive techniques for treating recurrent lumbar disc herniation are equivalent to or even superior in some cases in which conventional open surgery was considered. The operative time, blood loss and complications of patients treated with revision MED were comparable to the previously published data. The procedure appears to be a safe and effective alternative with significant improvement in pain, disability, and faster return to work in case of recurrent lumbar disc herniation.

Early mobilization after incidental durotomy: A systematic review

Early mobilization after incidental durotomy: A systematic review