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Research ArticleEndoscopic Minimally Invasive Surgery

Durotomy- and Irrigation-Related Serious Adverse Events During Spinal Endoscopy: Illustrative Case Series and International Surgeon Survey

Roth A.A. Vargas, Vincent Hagel, Zhang Xifeng, Huilin Yang, Jorge Felipe Ramírez León, Morgan Lorio, Albert E. Telfeian, Paul Houle, Raymond Gardocki, Álvaro Dowling, Paulo Sérgio Teixeira de Carvalho, Anthony Yeung, Martin Knight, Stefan Hellinger and Kai-Uwe Lewandrowski
International Journal of Spine Surgery June 2023, 17 (3) 387-398; DOI: https://doi.org/10.14444/8454
Roth A.A. Vargas
1 Neurosurgeon, Department of Neurosurgery, Foundation Hospital Centro Médico Campinas, Campinas, SP, Brazil
MD
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Vincent Hagel
2 Asklepios Hospital Lindau, Spine Center, Lindau, Germany
MD
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Zhang Xifeng
3 Department of Orthopedics, First Medical Center, PLA General Hospital, Beijing, China
MD
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Huilin Yang
4 The First Affiliated Hospital of Soochow University, Suzhou, China
MD, PhD
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Jorge Felipe Ramírez León
5 Minimally Invasive Spine Center, Bogotá, DC, Colombia
6 Reina Sofía Clinic, Bogotá, DC, Colombia
7 Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá, DC, Colombia
MD
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Morgan Lorio
8 Advanced Orthopedics, Altamonte Springs, FL, USA
MD
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Albert E. Telfeian
9 Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
MD, PhD
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Paul Houle
10 Boston University School of Medicine, Cape Cod Healthcare, Hyannis, MA, USA
MD
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Raymond Gardocki
11 Vanderblit Orthopaedics, Nashville, TN, USA
MD
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Álvaro Dowling
12 Department of Orthopaedic Surgery, USP, Ribeirão Preto, Brazil
MD
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Paulo Sérgio Teixeira de Carvalho
13 Pain and Spine Minimally Invasive Surgery Service at Gaffre e Guinle University Hospital, Rio de Janeiro, Brazil
MD, PhD
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Anthony Yeung
14 Desert Institute for Spine Care, Phoenix, AZ, USA
MD
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Martin Knight
15 The Weymouth Hospital, Weymouth, London
MD
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Stefan Hellinger
16 Department of Orthopedic Surgery, Arabella Klinik, Munich, Germany
MD
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Kai-Uwe Lewandrowski
17 Departmemt of Orthopaedics, Fundación Universitaria Sanitas, Bogotá, DC, Colombia
MD
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  • For correspondence: business@tucsonspine.com
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  • Figure 1
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    Figure 1

    Shown are examples of postoperative scans and videoendoscopic views of patients with incidental durotomy and neurological complications following gravity-irrigated interlaminar full-endoscopic spinal endoscopy. The left column shows a postoperative sagittal and an axial magnetic resonance imaging of the cervical spine of a 52-y-old female patient demonstrating hemorrhage spreading anteriorly and laterally distant from the posterior decompression site. The head computed tomography (CT) revealed massive blood in the subarachnoid space and the basal cisterns, the III, IV, and lateral ventricles, and ventricular dilatation consistent with hydrocephalus and arterial subarachnoid Fisher grade IV hemorrhage. However, the CT angiography of the head via femoral catheterization did not reveal any bleeding from possible vascular malformation such as an aneurysm or angioma or any source suggesting that the blood traveled with the irrigation fluid rostrally and intracranially. The center column shows head CT images of ar male patient who underwent lumbar L4-L5 interlaminar gravity-irrigated full-endoscopic decompression surgery with an incidental lumbar durotomy. This patient developed intraoperative seizures, cardiac arrhythmia, and hypotension. His head CT showed intracranial air entrapment. Both illustrated patients were medically stabilized and discharged from the hospital 10 and 3 days postoperatively, respectively. Images in the right column show an exemplary incidental lumbar durotomy that was recognized in the second patient. Consistent with the observed pressure gradients, injury to an epidural vein typically may not cause much bleeding compared with bleeding from an injured arterial vessel.

  • Figure 2
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    Figure 2

    The hydrostatic pressure of a static fluid column varies with the height of the liquid column (h), the viscosity or density (d) of the fluid, and the force of gravity (g). It does not depend on area (A) or the shape of the liquid column. For the intraoperative hydrostatic pressure measurements during full-endoscopic lumbar spinal surgery, 2 L bags of physiological saline were hung 2.30 m above the patient and 3.50 m above the floor, considering the height of the operating table of 1.20 m. The fluid bags were connected with flexible tubing via a 2-way connector to the endoscope (Panoview Plus 25°, length 165 mm, working channel Ø 4.1 mm Richard-Wolf Vertebris). The Baxter transducer assembly was registered at the height of the physiological saline bags at 3.50 m. An irrigation pump was not used to ensure that the hydrostatic pressure column remained constant throughout the intraoperative epidural hydrostatic pressure measurements.

  • Figure 3
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    Figure 3

    The difference in the hydrostatic pressure measurement between the measurement on the back of the patient (103 mm Hg) and the average epidural pressure measured of 24.5 mm Hg is due to the occurrence of a Venturi effect, which is illustrated in the top panel as a reduction in fluid pressure that results when a fluid flows through a constricted section (or choke) of a pipe (top panel). In a typical gravity-assisted tubing set-up for spinal endoscopy, this occurs as the fluid runs from the back through the tubing system into the narrow irrigation channel of the spinal endoscope and then into the epidural space and from there runs out through the larger working channel of the endoscope (Ø 4.1 mm). Considering the choked flow in an open system gravity-assisted irrigation setup during spinal endoscopy, various diameter changes occur as the fluid runs through it, and the fluid velocity approaches the local speed of sound. When a liquid system is in a state of choked flow, a further decrease in the downstream pressure environment will not increase velocity unless the fluid is compressed. Our measurements revealed an average drop of 78.5 mm Hg from the initial hydrostatic pressure of 103 mm Hg at the patient level before entering the spinal endoscope down to 24,5 mm Hg in the epidural space. The average epidural hydrostatic pressure of 24.5 mm Hg was higher than the reported intradural cerebrospinal fluid (CSF) or intravenous pressures (bottom panel).

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    Figure 4

    Seven hundred sixty-six spine surgeons accessed the online survey. Forty-four submitted a valid survey recording in English at the completion rate 43.1% (A—top panel). Two hundred submitted a valid survey recording at a completion rate of 44.0% (B—bottom panel).

Tables

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    Table 1

    Hydrostatic epidural pressure measurements in patients who underwent routine L4-L5 and L5-S1 interlaminar full-endoscopic discectomy.

    PatientGenderAge, yWeight, kgMeasured Hydrostatic Pressure, mm Hg
    1M548226.5
    2M627120.0
    3F4613122.5
    4M659226.0
    5M728623.0
    6F586129.0
    7F516520.0
    8F469028.0
    9M397823.5
    10M408921.0
    11M367029.0
    12M526225.5
    • Abbreviations: F, female; M, male.

    • View popup
    Table 2

    Training, experience, and practice setting of responding spine surgeons.

    Question n %Cumulative %
    What is your postgraduate training background?
     Missing response10.4.4
     Not applicable20.81.2
     Neurosurgeon166.67.8
     Orthopedic surgeon21186.594.3
     Pain management145.7100.0
     Total244100.0
    What percentage of your practice is endoscopic spine surgery?
     0%31.21.2
     1%–5%2610.711.9
     5%–20%6125.970.5
     21%–40%5924.236.1
     41%–60%239.445.5
     61%–80%3413.984.4
     81%–100%3815.6100.0
     Total244100.0
    What is your practice setting?
     Employed by large physician group52.02.0
     Hospital employed18776.678.7
     Private practice3012.391.0
     Private practice with academic appointment124.995.9
     University employed104.1100.0
     Total244100.0
    • View popup
    Table 3

    Demographic data of responding spine surgeons.

    Question n %Cumulative %
    Years performing spinal endoscopy   
     031.21.2
     1–45020.521.7
     55321.843.5
     6239.452.9
     7208.261.1
     82510.271.3
     993.775.0
     10–32 y60.025.0100.0
     Total244100.0 
    Country   
     Missing response62.52.5
     Angola10.42.9
     Brazil197.810.7
     Canada10.411.1
     Chile20.811.9
     China19178.390.2
     Colombia31.291.4
     Croatia10.491.8
     Ecuador10.492.2
     Germany52.094.3
     Mexico62.596.7
     South Korea10.497.1
     Thailand31.298.4
     United Kingdom10.498.8
     United States31.2100.0
     Total244100.0 
    • View popup
    Table 4

    Adverse events and complications related to irrigation during lumbar spinal endoscopy reported by responding spine surgeons.

    Adverse Events or Complications n %Cumulative %
    None17270.570.5
    Headaches and seizures
     Headache114.575
     Headache and seizure20.875.8
     Headache and seizure, and abdominal pain10.476.2
     Headache and seizure, nerve root injury10.476.6
     Headache, neck pain31.277.8
    Neck pain and seizures
     Neck pain12582.8
     Neck pain and seizure10.483.2
     Neck pain and seizure, soft tissue edema10.483.6
     Neck pain and stiffness10.484
     Neck pain, delirium10.484.4
    Nerve damage and neurological deficit
     Nerve root injury31.285.6
     Nerve root injury, infection10.486
     Nerve root injury, seizure10.486.4
     Dural edema10.486.8
     Numbness in lower extremities20.887.6
     Durotomy5289.6
     Cauda equina syndrome10.490
    Autonomic dysreflexia with hypertension
     Autonomic dysreflexia with hypertension177.297.2
     Durotomy, headache, and autonomic dysreflexia with hypertension10.497.6
     Paralysis, autonomic dysreflexia with hypertension10.498
    Other adverse events
     Prolonged wakeup from general anesthesia10.498.4
     Prolonged postoperative recovery due to hypovolemia170.498.8
     Soft tissue edema20.899.6
     Epidural hematoma10.4100
     Missing response10.4100.4
     Total244100.0
    • a The cumulative total exceeds 100 due to rounding.

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International Journal of Spine Surgery
Vol. 17, Issue 3
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Durotomy- and Irrigation-Related Serious Adverse Events During Spinal Endoscopy: Illustrative Case Series and International Surgeon Survey
Roth A.A. Vargas, Vincent Hagel, Zhang Xifeng, Huilin Yang, Jorge Felipe Ramírez León, Morgan Lorio, Albert E. Telfeian, Paul Houle, Raymond Gardocki, Álvaro Dowling, Paulo Sérgio Teixeira de Carvalho, Anthony Yeung, Martin Knight, Stefan Hellinger, Kai-Uwe Lewandrowski
International Journal of Spine Surgery Jun 2023, 17 (3) 387-398; DOI: 10.14444/8454

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Durotomy- and Irrigation-Related Serious Adverse Events During Spinal Endoscopy: Illustrative Case Series and International Surgeon Survey
Roth A.A. Vargas, Vincent Hagel, Zhang Xifeng, Huilin Yang, Jorge Felipe Ramírez León, Morgan Lorio, Albert E. Telfeian, Paul Houle, Raymond Gardocki, Álvaro Dowling, Paulo Sérgio Teixeira de Carvalho, Anthony Yeung, Martin Knight, Stefan Hellinger, Kai-Uwe Lewandrowski
International Journal of Spine Surgery Jun 2023, 17 (3) 387-398; DOI: 10.14444/8454
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  • adverse events and complications

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