Comparison of Symptomatic Cerebral Spinal Fluid Leak Between Patients Undergoing Minimally Invasive versus Open Lumbar Foraminotomy, Discectomy, or Laminectomy

Wong, Ashley; Shih, Patrick; Smith, Timothy R.; Slimack, Nicholas P.; Dahdaleh, Nader S.; Aoun, Salah G.; Ahmadieh, Tarek Y. El; Smith, Zachary A.; Scheer, Justin K.; Koski, Tyler R.; Liu, John C.; Fessler, Richard G.

doi:10.1016/j.wneu.2013.11.012

Cited by 70 publications

(46 citation statements)

References 26 publications

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“…Some hypothesize that the smaller incision length and decreased soft-tissue dissection result in lower postoperative pain. 4,6,[8][9][10]14,20,22,33,35 Improved pain control would minimize the sedating side effects associated with narcotics that may prolong the patient's recovery period. In addition, the increased rate of postoperative CSF leakage and lumbar drain placement in open cases increases the hospitalization time.…”

Section: Discussionmentioning

confidence: 99%

Comparison of open and minimally invasive surgery for intradural-extramedullary spine tumors

Wong

Lall

Dahdaleh

et al. 2015

FOC

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OBJECT Patients with symptomatic intradural-extramedullary (ID-EM) tumors may be successfully treated with resection of the lesion and decompression of associated neural structures. Studies of patients undergoing open resection of these tumors have reported high rates of gross-total resection (GTR) with minimal long-term neurological deficit. Case reports and small case series have suggested that these patients may be successfully treated with minimally invasive surgery (MIS). These studies have been limited by small patient populations. Moreover, there are no studies directly comparing perioperative outcomes between patients treated with open resection and MIS. The objective of this study was to compare perioperative outcomes in patients with ID-EM tumors treated using open resection or MIS. METHODS A retrospective review was performed using data collected from 45 consecutive patients treated by open resection or MIS for ID-EM spine tumors. These patients were treated over a 9-year period between April 2003 and October 2012 at Northwestern University and the University of Chicago. Statistical analysis was performed to compare perioperative outcomes between the two groups. RESULTS Of the 45 patients in the study, 27 were treated with the MIS approach and 18 were treated with the open approach. Operative time was similar between the two groups: 256.3 minutes in the MIS group versus 241.1 minutes in the open group (p = 0.55). Estimated blood loss was significantly lower in the MIS group (133.7 ml) compared with the open group (558.8 ml) (p < 0.01). A GTR was achieved in 94.4% of the open cases and 92.6% of the MIS cases (p = 0.81). The mean hospital stay was significantly shorter in the MIS group (3.9 days) compared with the open group (6.1 days) (p < 0.01). There was no significant difference between the complication rates (p = 0.32) and reoperation rates (p = 0.33) between the two groups. Multivariate analysis demonstrated an increased rate of complications in cervical spine tumors (OR 15, p = 0.05). CONCLUSIONS Thoracolumbar ID-EM tumors may be safely and effectively treated with either the open approach or an MIS approach, with an equivalent rate of GTR, perioperative complication rate, and operative time. Patients treated with an MIS approach may benefit from a decrease in operative blood loss and shorter hospital stays.

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Section: Discussionmentioning

confidence: 99%

Comparison of open and minimally invasive surgery for intradural-extramedullary spine tumors

Wong

Lall

Dahdaleh

et al. 2015

FOC

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“…A study by Wong et al was performed in an institution where 37% of all decompressions over a 5-year period (320 of 863) were MISS procedures. 44 This high volume of MISS procedures speaks to the technical proficiency of the surgeons contributing to this series, which in part could explain the lower durotomy rate. Furthermore, the standard selection markers for minimally invasive procedures favor choosing patients who have a relatively lower risk for durotomies, i.e., younger, undergoing nonrevision surgery, less degenerative spondylosis, and lower BMI.…”

Section: Cohort-matched Open Surgery Versus Miss Approachesmentioning

confidence: 96%

“…3 Wong and colleagues, who evaluated 863 patients undergoing 1-or 2-level decompression in a retrospective matched-cohort study, noted a significantly higher durotomy rate in the open surgery group versus the MISS group (9% vs 4.7%, p = 0.01). 44 To date, only 1 other cohort-matched study revealed a higher rate of durotomy in the open surgery category. 32 In addition to the retrospective design, one major confounder in the Wong et al study was the significantly higher percentage of revision surgery patients in the open surgery cohort (21.7% vs 16.0%, p = 0.05).…”

Section: Cohort-matched Open Surgery Versus Miss Approachesmentioning

confidence: 97%

Unintended durotomy in lumbar degenerative spinal surgery: a 10-year systematic review of the literature

Ghobrial

Theofanis

Darden

et al. 2015

FOC

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OBJECT Unintended durotomy is a common occurrence during lumbar spinal surgery, particularly in surgery for degenerative spinal conditions, with the reported incidence rate ranging from 0.3% to 35%. The authors performed a systematic literature review on unintended lumbar spine durotomy, specifically aiming to identify the incidence of durotomy during spinal surgery for lumbar degenerative conditions. In addition, the authors analyzed the incidence of durotomy when minimally invasive surgical approaches were used as compared with that following a traditional midline open approach. METHODS A MEDLINE search using the term “lumbar durotomy” (under the 2015 medical subject heading [MeSH] “cerebrospinal fluid leak”) was conducted on May 13, 2015, for English-language medical literature published in the period from January 1, 2005, to May 13, 2015. The resulting papers were categorized into 3 groups: 1) those that evaluated unintended durotomy rates during open-approach lumbar spinal surgery, 2) those that evaluated unintended durotomy rates during minimally invasive spine surgery (MISS), and 3) those that evaluated durotomy rates in comparable cohorts undergoing MISS versus open-approach lumbar procedures for similar lumbar pathology. RESULTS The MEDLINE search yielded 116 results. A review of titles produced 22 potentially relevant studies that described open surgical procedures. After a thorough review of individual papers, 19 studies (comprising 15,965 patients) pertaining to durotomy rates during open-approach lumbar surgery were included for analysis. Using the Oxford Centre for Evidence-Based Medicine (CEBM) ranking criteria, there were 7 Level 3 prospective studies and 12 Level 4 retrospective studies. In addition, the authors also included 6 studies (with a total of 1334 patients) that detailed rates of durotomy during minimally invasive surgery for lumbar degenerative disease. In the MISS analysis, there were 2 prospective and 4 retrospective studies. Finally, the authors included 5 studies (with a total of 1364 patients) that directly compared durotomy rates during open-approach versus minimally invasive procedures. Studies of open-approach surgery for lumbar degenerative disease reported a total of 1031 durotomies across all procedures, for an overall durotomy rate of 8.11% (range 2%–20%). Prospectively designed studies reported a higher rate of durotomy than retrospective studies (9.57% vs 4.32%, p = 0.05). Selected MISS studies reported a total of 93 durotomies for a combined durotomy rate of 6.78%. In studies of matched cohorts comparing open-approach surgery with MISS, the durotomy rates were 7.20% (34 durotomies) and 7.02% (68), respectively, which were not significantly different. CONCLUSIONS Spinal surgery for lumbar degenerative disease carries a significant rate of unintended durotomy, regardless of the surgical approach selected by the surgeon. Interpretation of unintended durotomy rates for lumbar surgery is limited by a lack of prospective and cohort-matched controlled studies.

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“…Thence, utilizing special equipments while performing MEDL and retaining ligamentum flavum till finishing the bony work are advantageous in reducing risk of the above complication as recommended by Pao and Stadler. 45 Wong et al, 53 concluded a statistically significant higher rate of CSF leaks in open laminectomy compared to MEDL with increased likelihood of reoperation. Medial facetectomy occasionally occurred accidentally due to too much bony work; however no iatrogenic spinal instability was noticed in this study.…”

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confidence: 99%

Microendoscopic bilateral Decompression via Unilateral Approach in Single and Multiple Level Lumbar Canal Stenosis: A Series of 583 Cases

Kabil

Ebrahim

2017

Egyptian Spine Journal

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Background Data: Traditionally, lumbar canal stenosis (LCS) has been treated with conventional laminectomy involving wide resection of posterior supporting structures of the lumbar spine such as the supraspinous and inter-spinous ligamentum complex, the spinous process as well as wide areas of the lamina. In addition, this required a large incision of the skin and underlying musculoligamentous complex (posterior tension band). Purpose: The current study focuses on the clinical outcome and utility of minimally invasive microendoscopic decompression from a unilateral approach in surgical management of patients with single and multiple level lumbar canal stenosis. The objective is to describe the indications, significance and applications of endoscopic spine surgery in patients with single and multiple level LCS. Additionally, to highlight important anatomical perspectives of the technique and share surgical experience and results. Study Design: A retrospective clinical case study. Patients and Methods: From May 2008 to January 2016, 583 consecutive patients were treated for LCS and included in this study. Patients' main complaint was bilateral neurogenic claudication in addition to back pain and sciatic neuralgia. Single level decompression was performed in 468 (80%) patients and multiple level decompressions in 115 (20%) patients. Magnetic resonance imaging (MRI), computed tomography (CT) scan and plain X-rays were performed for all patients to confirm evidence of central stenosis and then repeated postoperatively. All patients were followed up for at least 3 months and their data collected. Clinical and functional outcomes were assessed using Visual Analogue Scale (VAS) and the Japanese Orthopedic Association Score (JOA) score for lumbar disease. Results: Compared to preoperative complaint, there was an improvement of back pain in 77.9% of patients and in radiating leg pain in 86.3%. With regards to functional outcomes, median preoperative JOA score was 14.93 ± 0.48 and improved postoperatively to 27.17 ± 1.45 (p < 0.001). The mean operating time per level was 78 minutes, and the mean intraoperative blood loss per level was 18 ml. Complications mainly included dural tears in 27 (4.6%) patients, transient postoperative dysesthesia in 46/583 (7.9%) patients and excess bony work in the form of unintended medial facetectomy in 38/583 (6.5%) patients and fracture of the spinous process in 3 (0.5%) patients.

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Comparison of Symptomatic Cerebral Spinal Fluid Leak Between Patients Undergoing Minimally Invasive versus Open Lumbar Foraminotomy, Discectomy, or Laminectomy

Cited by 70 publications

References 26 publications

Comparison of open and minimally invasive surgery for intradural-extramedullary spine tumors

Comparison of open and minimally invasive surgery for intradural-extramedullary spine tumors

Unintended durotomy in lumbar degenerative spinal surgery: a 10-year systematic review of the literature

Microendoscopic bilateral Decompression via Unilateral Approach in Single and Multiple Level Lumbar Canal Stenosis: A Series of 583 Cases

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