Evaluation and treatment of dural tears in lumbar spine surgery: a review

Incidental durotomy is a frequent complication of lumbar spinal surgery. The number and complexity of spinal procedures is increasing, leading to a greater prevalence of dural tears; therefore, it is imperative that spine surgeons be familiar with safe and effective closure techniques. Occasionally, a tear may not be recognized during the procedure, so that one must recognize the signs and symptoms of a cerebrospinal fluid leak postoperatively. Several newer treatment concepts show promise. The current study represents an extensive review of the recent literature on the prevalence, mechanism, diagnosis, treatment, and outcomes of dural tears. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author's technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid.     

Dural tears in percutaneous endoscopic lumbar discectomy

The objective of the study was to demonstrate the clinical characteristics of dural tears during percutaneous endoscopic lumbar discectomy (PELD) and to discuss how to prevent this unintended complication. The study used data from 816 consecutive patients who underwent PELD between 2003 and 2007. A total of nine patients (1.1%) experienced symptomatic dural tears. The clinical outcomes were evaluated using the visual analogue scale (VAS), the Oswestry disability index (ODI), and modified MacNab criteria. Intractable radicular pain was the most common symptom, while classical manifestations, such as CSF leakage or wound swelling, were rare. In three of the nine cases, the dural tears were detected intraoperatively, while the remaining six cases were not recognized during the procedure. Among the unrecognized patients, two patients were found with nerve root herniation causing profound neurological deficits. All patients were managed by secondary open repair surgeries. The mean follow-up period was 30.8 months. The mean VAS of radicular leg pain improved from 8.3 to 2.6, and that of back pain improved from 4.1 to 2.6. The mean ODI improved from 69.6 to 29.2%. The final outcomes were excellent in one, good in five, fair in one, and poor in two patients. As application of the endoscopic procedure has been broadened to more complex cases, the risk of dural tears may increase. Unrecognized dural tear with nerve root herniation may cause permanent neurological sequelae. Accurate information and proper technical considerations are essential to prevent this unpredictable complication.     

Laparoscopic lumbar spine surgery

The use of transperitoneal endoscopic approaches to the distal segments of the lumbar spine has recently been described. This has been the catalyst for the development of other minimally invasive anterior ¶approaches to the spine. This review looks at the published results so ¶far, and highlights the principles, techniques and complications. The limitations of laparoscopic approaches have meant that surgeons are moving on to endoscopic extraperitoneal and mini-open approaches, but important lessons ¶have been learnt during this short rapid phase of development. The efficacy and safety of minimal access techniques in the spine have been ¶established, and outcome standards set by which future techniques can ¶be judged. The importance of ¶proper training is emphasised.     

经皮穿刺内窥镜下手术治疗腰椎间盘疾患的疗效分析

目的:分析经皮穿刺内窥镜下手术治疗腰椎间盘疾患的效果.总结临床经验.方法:从1998年6月至2007年6月,在我院接受经皮穿刺内窥镜下手术治疗并得到1年以上随访的腰椎间盘疾病患者988例,患者手术时年龄18～84岁,平均48岁.包含性腰椎间盘突出症298例,非包含性腰椎间盘突出症552例,椎间孔外及椎孔间腰椎间盘突出症40例,复发性腰椎间盘突出症42例,椎间隙感染18例,高龄腰椎退变性疾病合并坐骨神经痛38例.病变节段分布:L1/2 5例,L2/3 35例,L3/4 48例,L4/5 582例,L5/S1 218例,43例为多节段.采用MacNab评分对手术疗效进行评估,并对间接性减压术和目标定位椎间盘摘除术治疗包含性(A组)和非包含性(B组)椎间盘突出患者的结果进行统计学分析.结果:术中及术后共发生并发症47例,发生率4.8%,包括局部麻木感29例,硬脊膜微小撕裂1例,手术操作器械折断3例,部分运动神经受损5例.细菌性椎间隙感染5例,非细菌性椎间盘炎4例,所有并发症均得到良好的处理.随访12～84个月,平均58个月.A组患者中间接性减压者MacNab评分满意度为87%,目标定位椎盘摘除术者为93%,两者比较无统计学差异(X2=3.460,P=0.084);B组患者中间接性减压者MacNab评分满意度为53%,目标定位椎盘摘除术者为94%.两者比较有统计学差异(X2=115.757,P<0.001);A、B组比较间接性减压术满意度有统计学差异(X2=37.357,P<0.001),目标定化椎盘摘除术满意度无统计学差异(X2=0.072,P=0.821);椎间孔外及椎孔间型突出者MacNab评分满意度为80%(32/40),复发性腰椎间盘突出症满意度74%(31/42).椎间隙感染满意度72%(13/18),高龄腰椎退变性疾病合并坐骨神经痛满意度71%(27/38).结论:严格选择手术适应证下,应用内窥镜下手术治疗腰椎间盘疾患具有创伤小、术后恢复快.后遗症及并发症少等优点.间接性减压术治疗包含性腰椎间盘突出症的疗效优于非包含性腰椎间盘突出症:目标定位椎盘摘除术治疗包含性及非包含性腰椎间盘突出症均可取得较优良的临床疗效率,且明显优于间接性减压术.内窥镜下手术治疗椎间孔外及椎孔间型腰椎间盘突出症、复发性腰椎间盘突出疗、椎间隙感染和高龄腰椎退化性疾病合并坐骨神经痛也能取得良好的临床效果.     

腰椎椎间孔镜微创手术中的区域定位原则及临床疗效观察

目的应用椎间孔镜技术治疗腰椎间盘突出症(Lumbar Disc Herniation,LDH),探讨区域定位原则的应用价值,评估临床疗效。方法收集应用椎间孔镜技术治疗LDH病例42例,对LDH进行临床分型,根据胡有谷区域定位原则,结合影像学特点,制定椎间盘突出致压部位靶点治疗手术方案。分别于术后6个月及末次随访进行疗效评估,记录视觉模拟疼痛评估VAS量表、腰椎疾患JOA量表、Oswestry功能残障指数及生活质量SF-36评估量表并评定分值,比较不同时点的治疗结果,计算临床治疗优良率及有效率。结果根据影像学特点结合胡有谷区域定位方法,将LDH分为中央型、旁侧型、椎间孔型、椎间孔外型、脱出游离型及特殊型,予以个性化微创手术治疗,平均随访(8.7±4.5)个月,术后6个月随访优良率为83.33%,总有效率为95.23%,末次随访优良率为85.71%,总有效率为92.86%。随访显示VAS、JOA、ODI及SF-36分值均能维持在较满意水平,与术前相比有显著差异(P0.05)。结论区域定位原则具有临床实用意义,根据LDH类型及突出部位选择恰当的手术方式,是腰椎椎间孔镜手术成功的关键。     

脊柱内窥镜技术治疗腰椎间盘突出症的进展

近年来,微创脊柱外科发展迅速,脊柱内窥镜技术在腰椎间盘突出症的手术治疗中具有损伤小、恢复期短、疗效确切、保持脊柱的稳定性等优势,其应用越来越广泛。目前应用于腰椎间盘突出症LDH的脊柱内窥镜技术包括：后路椎间盘镜下腰椎间盘摘除术（MED）、经皮穿刺椎间孔镜下椎间盘摘除术（PELD）及完全内窥镜下腰椎间盘摘除术（FLD）等。正确认识脊柱内窥镜技术,严格适应证和熟练的操作技巧是取得良好疗效的关键。本文将总结各种脊柱内窥镜手术方法在腰椎间盘突出症治疗中应用的现状与进展。     

胸腔镜辅助下胸椎、上腰椎前路手术的体会

目的 探讨胸腔镜技术在胸、腰椎前路手术的适应证、操作要点以及单肺或双肺通气麻醉的选择。方法 对5例结核病人行胸腔镜下结核病灶清除术，其中2例同时行自体髂骨植骨术，1例以自固化磷酸钙人工骨(CPC)植入；对3例爆裂性骨折截瘫及1例L1陈旧性爆裂骨折并马尾综合征病人进行脊髓减压、自体髂骨植骨、钢板螺丝钉内固定术。结果 全部病例都得到随访，术后切口一期愈合，X光、CT检查也都显示病灶清除彻底，脊髓减压充分，复位满意，内固定可靠，位置良好。结论 胸椎、上腰椎结核或骨折，不论是否并发脊髓、马尾神经压迫的病例，均适宜在胸腔镜辅助下进行病灶清除、脊髓减压、脊柱前路内固定术。     

Perioperative care in lumbar spine surgery

Attention to the details of preoperative preparation of the patient, intraoperative technique, and good postoperative care can prevent complications and increase the likelihood of successful elective lumbar spine surgery. Such relevant topics as patient education, smoking and nonsmoking patients, transfusions, and medications are included.     

Short-term outcome in lumbar spine surgery

Summary A prospective survey of the outcome of lumbar surgery was carried out under conditions where all intervention was according to routine procedures. Of a consecutive series of patients 132 cases (92%) could be evaluated. The aim was to investigate possible predictive factors among self-reported data and clinical data readily available under routine circumstances. Follow-up was for six months post-operatively. Surgical findings were: herniated disc (62%), ostechondrosis (21%), other pathology (7%), and negative findings (10%). Unsatisfactory outcome was either relapse, operation before follow-up (9%) or persisting pain (30%). The surgical finding of a disc herniation predicted a significantly better outcome than any other finding. Cases previously operated upon (20%) fared equal with those operated upon for the first time irrespective of surgical findings.Self-reported weighting of preoperative pain and its location showed that predominant sciatica was significantly associated with the finding of a disc herniation, but also with satisfactory outcome irrespective of the operative finding. Factors without predictive value included sex, age, number of prior back surgeries, duration and impact of symptoms, and clinical findings. The social consequences were associated with the duration of low back disease.     

Failed degenerative lumbar spine surgery

Significant back and leg symptoms develop in approximately 10%-15% of patients who have undergone a spinal decompression procedure and approximately 15%-20% of patients who have had a spinal fusion procedure for degenerative disease of the lumbar spine during the ensuing 3-5 year so that they require revision lumbar surgery. The cause for their symptoms has to be diligently looked for, as that is a main predictor of good outcome following revision surgery. Good history taking, including a detailed old chart review, repeat physical evaluation, and input from therapists--physical and psychological, neurologist, and other caregivers--should be sought. These, together with intelligent use of investigations, go a long way in helping establish a cause for failure. Furthermore, developing a revision surgical strategy is also an intellectual exercise in which a simple algorithmic approach may not always work. The process of evaluation and surgical management for failed lumbar degeneration is a science and an art that requires a great deal of understanding and commitment on the part of the surgeon. The temporal trend of improving outcomes is aided in part by emerging technologies, however, one has to be constantly aware of simple factors that influence outcome. The use of published literature and experiences of peers helps one offer appropriate surgical intervention while improving the long-term results of revision surgery of the lumbar spine.     

Minimally invasive endoscopic surgeryof the lumbar spine

The usefulness of endoscopic techniques in orthopaedics as well as in general surgical, gynecologic, urologic, andthoracic procedures is well established. Endoscopic techniques in coronary bypass surgery are being developed. The development of the minimally invasive endoscopic approach to the thoracic and lumbar spine is a technique prompted by the surgeons desire to increase access to the spine while decreasing morbidity. In this article, we address the laparoscopic and retroperitoneal approaches to the lumbar spine. Discussion focuses on indications and applications of the procedures as well as operative setup. Finally, surgical experience is reviewed.     

Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy

Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18–65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12- and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy.     

神经电生理监测在腰椎手术中的应用

随着科学技术的不断发展,神经电生理监测技术的应用越来越受到脊柱外科医生的重视,目前临床上常用的监测技术包括体感诱发电位(SEP)、运动诱发电位(MEP)以及肌电图(EMG),其不仅已作为脊柱外科手术术前、术后神经功能改善状况的重要评估依据和手段,而且已逐渐地应用于颈、胸椎手术术中脊髓功能监测,成为减少神经损伤、提高手术质量不可缺少的重要组成部分.笔者对国内外的相关研究成果及临床应用进展综述如下.     

Influence of unintended dural tears on postoperative outcomes in lumbar surgery patients: a multicenter observational study with propensity scoring

BACKGROUND CONTEXTUnintended dural tears (DTs) are common in spinal surgeries. Some authors have reported that the outcomes in lumbar surgery patients with DTs are equivalent to those in patients without DTs, but this remains uncertain.PURPOSETo assess the effect of unintended DTs on postoperative patient-reported outcomes.STUDY DESIGN/SETTINGA multicenter retrospective observational study.PATIENT SAMPLEWe enrolled patients undergoing lumbar spine surgery at eight hospitals between April 2017 and November 2018.OUTCOME MEASURESWe collected data regarding patients’ backgrounds, operative factors, occurrence of unplanned DTs during surgery, postoperative complications, patient-reported outcomes, such as pain or dysesthesia of the lower back, buttock, leg, or plantar area, EuroQol 5 Dimension (EQ-5D), Oswestry Disability Index (ODI) scores, and postoperative satisfaction.METHODSWe divided the patients into a DT− group (without DTs) and a DT+ group (with DTs). First, multivariate logistic regression analyses were conducted to reveal risk factors for occurrence of DTs. Then, we used propensity score matching to obtain a matched DT− group (mDT− group) and a matched DT+ (mDT+ group). Student's t test was used for comparing continuous variables and Pearson's chi-square test for comparing categorical variables between the two groups.RESULTSWe enrolled 2,146 patients in this study. The number of patients with unintended DTs was 166 (7.7%). Older age, body mass index, ossification of posterior longitudinal ligament / yellow ligament, spinal deformity, and revision surgery were significant risk factors for DTs. We used propensity score matching to compare 163 of the patients with DTs with 163 patients without DTs. No significant difference was found in postoperative pain or dysesthesia of the lower back, buttock, leg, and plantar area between the mDT− and mDT+ groups. When comparing preoperative with postoperative pain and dysesthesia, a statistically significant improvement was found in each group (p<.01 for all variables) except for sensory disorder of the plantar area, where a significant improvement was only observed in dysesthesia of the mDT− group (p<.01). Although some improvements were observed, they were not statistically significant in terms of pain in the mDT− (p=.06) and mDT+ (p=.13) groups and dysesthesia in the mDT+ (p=.13) group. No significant differences were found in postoperative outcomes, such as EQ-5D (p=.44) and ODI (p=.89) scores, and postoperative satisfaction (p=.73) between the two groups.CONCLUSIONSAlthough insufficient improvement of sensory disorder of the plantar area was observed, patients with DTs showed almost equivalent postoperative outcomes compared with patients without DTs.     

经皮脊柱内镜手术的相关问题

<正>随着脊柱手术器械及手术方法的不断发展和创新,脊柱微创手术(minimally invasive spine surgery,MISS)目前已成为脊柱手术的重要手术理念。虽然传统的脊柱融合或非融合手术已广泛应用于治疗椎间盘突出症或椎管狭窄症等退行性病变,但此类传统开放手术存在手术创伤大、术中并发症较多及术后恢复时间较长等缺点。如何保证达到或接近传统开放手术治疗效果,并同时尽可能降低正常软组织的创伤,     

椎间孔镜技术治疗腰椎融合后临近节段病变的临床疗效

[目的]探讨经皮椎间孔镜技术治疗腰椎融合术后相邻节段退变的临床疗效。[方法]回顾性分析2010年8月~2015年8月于本院应用经皮椎间孔镜治疗并获得随访的23例腰椎融合术后相邻节段退变患者的临床资料,采用视觉模拟评分法(visual analogue scale/score,VAS)评估手术疗效,应用日本骨科协会(Japanese Orthopaedic Association Scores,JOA)评分对腰椎功能进行评估,并计算JOA改善率,术后1年改良Mac Nab标准评估临床疗效。[结果]手术时间40~85 min,平均55 min;出血量5~25 ml,平均10 ml;住院时间3~14 d,平均7 d。所有患者随访6~24个月,平均13.5个月。术前VAS评分为(7.13±0.54)分,术后3 d为(2.05±0.34)分,末次随访为(1.41±0.28)分。术前与术后3 d、末次随访比较差异有统计学意义(P<0.01);术前JOA评分为(9.89±0.53)分,出院当天评分为(18.23±2.25)分,末次随访评分为(28.41±2.34)分,术前与出院时、末次随访比较差异有统计学意义(P<0.01)。根据JOA评分标准计算改善率,优18例,良3例,可1例,差1例;术后1年优良率为91.3%。[结论]应用经皮椎间孔镜治疗腰椎融合术后相邻节段退变性疾病疗效确切,具有创伤小、手术时间短、恢复快、术后并发症少等优点。