Dysethesia due to irritation of the dorsal root ganglion following lumbar transforaminal endoscopy: Analysis of frequency and contributing factors

Lewandrowski, Kai‐Uwe; Dowling, Álvaro; Calderaro, André Luiz; Santos, Thiago Soares dos; Bergamaschi, João Paulo Machado; León, Jorge Felipe Ramírez; Yeung, Anthony T.

doi:10.1016/j.clineuro.2020.106073

Cited by 25 publications

(28 citation statements)

References 48 publications

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“…The last three authors of this article have performed the endoscopic transforaminal decompression under local anesthesia using MAC protocols to be able to use patient feedback during surgery while treating the predominant pain generator [ 11 , 22 ]. Their reported dysesthesia rate was lower [ 1 , 8 , 10 ] than reported by other surgeons in another multicenter study with seven participating surgeons and sites [ 53 ]. They reported the incidence of DRG irritation to average 21.5%, ranging from 5% to 41.2% in patients with excellent and good Macnab outcomes [ 53 ].…”

Section: Discussionmentioning

confidence: 98%

“…Their reported dysesthesia rate was lower [ 1 , 8 , 10 ] than reported by other surgeons in another multicenter study with seven participating surgeons and sites [ 53 ]. They reported the incidence of DRG irritation to average 21.5%, ranging from 5% to 41.2% in patients with excellent and good Macnab outcomes [ 53 ]. DRG irritation rates were independent of surgical level but highly dependent on surgeon skill level.…”

Section: Discussionmentioning

confidence: 98%

“…While the course of postoperative DRG irritation following a transforaminal endoscopic discectomy is benign and typically self-limiting with a reduced physical activity program, supportive medical and interventional care measures such as gabapentin, pregabalin, or a transforaminal epidural steroid injection (TESI), the condition can be quite annoying to patients until it resolves typically 2 to 4 weeks postoperatively [ 53 ]. A preoperative education program warning patients of the possibility of burning leg pain developing in the dermatome of the exiting nerve root of the surgical level some 5 to 10 days following the transforaminal endoscopic discectomy after an initial pain-free interval.…”

Section: Discussionmentioning

confidence: 99%

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Feasibility of Using Intraoperative Neuromonitoring in the Prophylaxis of Dysesthesia in Transforaminal Endoscopic Discectomies of the Lumbar Spine

Carvalho

Ramos

Meireles³

et al. 2020

Brain Sciences

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(1) Background: Postoperative nerve root injury with dysesthesia is the most frequent sequela following lumbar endoscopic transforaminal discectomy. At times, it may be accompanied by transient and rarely by permanent motor weakness. The authors hypothesized that direct compression of the exiting nerve root and its dorsal root ganglion (DRG) by manipulating the working cannula or endoscopic instruments may play a role. (2) Objective: To assess whether intraoperative neurophysiological monitoring can help prevent nerve root injury by identifying neurophysiological events during the initial placement of the endoscopic working cannula and the directly visualized video endoscopic procedure. (3) Methods: The authors performed a retrospective chart review of 65 (35 female and 30 male) patients who underwent transforaminal endoscopic decompression for failed non-operative treatment of lumbar disc herniation from 2012 to 2020. The patients’ age ranged from 22 to 86 years, with an average of 51.75 years. Patients in the experimental group (32 patients) had intraoperative neurophysiological monitoring recordings using sensory evoked (SSEP), and transcranial motor evoked potentials (TCEP), those in the control group (32 patients) did not. The SSEP and TCMEP data were analyzed and correlated to the postoperative course, including dysesthesia and clinical outcomes using modified Macnab criteria, Oswestry disability index (ODI), visual analog scale (VAS) for leg and back pain. (4) Results: The surgical levels were L4/L5 in 44.6%, L5/S1 in 23.1%, and L3/L4 in 9.2%. Of the 65 patients, 56.9% (37/65) had surgery on the left, 36.9% (24/65) on the right, and the remaining 6.2% (4/65) underwent bilateral decompression. Postoperative dysesthesia occurred in 2 patients in the experimental and six patients in the control group. In the experimental neuromonitoring group, there was electrodiagnostic evidence of compression of the exiting nerve root’s DRG in 24 (72.7%) of the 32 patients after initial transforaminal placement of the working cannula. A 5% or more decrease and a 50% or more decrease in amplitude of SSEPs and TCEPs recordings of the exiting nerve root were resolved by repositioning the working cannula or by pausing the root manipulation until recovery to baseline, which typically occurred within an average of 1.15 min. In 15 of the 24 patients with such latency and amplitude changes, a foraminoplasty was performed before advancing the endoscopic working cannula via the transforaminal approach into the neuroforamen to avoid an impeding nerve root injury and postoperative dysesthesia. (5) Conclusion: Neuromonitoring enabled the intraoperative diagnosis of DRG compression during the initial transforaminal placement of the endoscopic working cannula. Future studies with more statistical power will have to investigate whether employing neuromonitoring to avoid intraoperative compression of the exiting nerve root is predictive of lower postoperative dysesthesia rates in patients undergoing videoendoscopic transforaminal discectomy.

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Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

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Feasibility of Using Intraoperative Neuromonitoring in the Prophylaxis of Dysesthesia in Transforaminal Endoscopic Discectomies of the Lumbar Spine

Carvalho

Ramos

Meireles³

et al. 2020

Brain Sciences

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“…As a result, the in ammatory mediators of the nucleus pulposus are released and gather around the nerve roots. Different from the open discectomy, PTED is performed under the water boundary during the operation [9,21,22], which may effectively prevent the aggregation of local in ammatory substances thorough continuous irrigation. Furthermore, previous studies demonstrated that in ammatory substances may also be released by the locally damaged tissue around the surgical site [23,24], that may also stimulate the nerve roots and cause reactive pain.…”

Section: Discussionmentioning

confidence: 99%

“…Although it will gradually ease and disappear approximately 2 weeks after it appears [7,8], reactive pain may affect short-term clinical outcomes and postoperative early functional exercise. The true mechanism of this reactive pain is unclear, and recent studies demonstrated that increased release of in ammatory mediators caused by surgical trauma may be one of the possible reasons for this reactive pain [7,8], which was further supported by intraoperative application of the epidural steroid can effectively reduce the postoperative reactive pain since steroid can reduce the surgical local in ammatory substances accumulation [9,10].…”

Section: Introductionmentioning

confidence: 99%

Percutaneous transforaminal endoscopic discectomy ameliorates postoperative reactive pain in patients with lumbar disc herniation

Yang

Wang

2020

Preprint

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Background: Approximately one-third patients with lumbar disc herniation (LDH) showed postoperative reactive pain, and this reactive pain may be related to the postoperative increased release of inflammatory mediators. Percutaneous transforaminal endoscopic discectomy (PTED) can obviously reduce the intraoperative soft tissue trauma. The aim of this study is to investigate the reactive pain in LDH patients undergoing PTED compared with open discectomy. Material and methods: This study retrospectively included 72 patients (PTED vs. open discectomy: 41 vs. 31), and the incidence of reactive pain, as well as both the extent and duration of reactive pain, were evaluated. Furthermore, inflammation related markers in both blood and drainage fluid samples, including white blood cell (WBC) count, C-reactive protein (CRP), creatine kinase (CK), interleukin-6 (IL-6) and IL-1β, were tested before and after operation. Results: Significantly greater number of patients undergoing open discectomy showed reactive pain compared to those undergoing PTED (13/31, 41.9% vs. 7/41, 17.0%; P < 0.05), and the duration of reactive pain is mildly longer in the former (P < 0.05). In both patient groups, the patients with reactive pain showed increased IL-6 and IL-1β in drainage fluid, as well as increased IL-6 in blood samples (P < 0.05), and there is significant correlation between the inflammation markers in drainage fluid and both duration and extent of reactive pain in both patient groups (P < 0.05). Conclusions: Local inflammatory substance accumulation may be potential cause for postoperative reactive pain, and PTED may reduce this inflammatory accumulation at the surgical site and subsequently reduce the risk of reactive pain. Trial registration: This retrospective cohort analysis was retrospectively registered at September 9, 2020.

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Transforaminal Endoscopic Lumbar Discectomy

Lo¹,

Man²,

Lui³

2023

Endoscopy of the Spine

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Dysethesia due to irritation of the dorsal root ganglion following lumbar transforaminal endoscopy: Analysis of frequency and contributing factors

Cited by 25 publications

References 48 publications

Feasibility of Using Intraoperative Neuromonitoring in the Prophylaxis of Dysesthesia in Transforaminal Endoscopic Discectomies of the Lumbar Spine

Feasibility of Using Intraoperative Neuromonitoring in the Prophylaxis of Dysesthesia in Transforaminal Endoscopic Discectomies of the Lumbar Spine

Percutaneous transforaminal endoscopic discectomy ameliorates postoperative reactive pain in patients with lumbar disc herniation

Transforaminal Endoscopic Lumbar Discectomy

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