Classification and management of early complications in open lumbar microdiscectomy

Abstract

IntroductionThough open lumbar disc surgery is still the most frequent and the most important intervention in spine, in the last two decades more papers about other procedures such as percutaneous intradiscal therapy or instrumented fusion have been published. One reason may be that there have been no significant developments concerning this operation in the last years. Another factor may be that industry has little interest in open disc surgery because there is nothing to inject or to implant. Once you have the microscope and instruments you are equipped for a life time.Only a few publications consider the complications and side effects of open disc surgery; these topics are mainly to be found in books by experienced spine surgeons [11,13]. The last multicenter studies of any great value in this field took place many years ago [14,15,20]. Studies about complications in lumbar spine surgery are very important, because poor patient selection and intraoperative complications mostly end up in failed back surgery syndrome.Open lumbar disc surgery is known not to be life threatening, but is nevertheless risky. In our European Spine Society questionnaire [8] to evaluate a risk and value score for different diagnostic and therapeutic procedures in spine, open discectomy had the highest effectivity rate but a negative overall risk value score because of complications and poor results. Our studies in the past years considered different factors that influenced the outcome of open lumbar disc surgery with reference to the predictors for failed back surgery syndrome [4,8].Abstract Complications and side effects in any kind of surgery, especially in spine surgery, should be evaluated to prevent those problems in the future. Since retrospective studies are of minor value and randomized controlled studies for complications are impossible to perform because of ethical and legal reasons, so-called "expert opinion" has to take their place in evidence-based medicine. On the basis of an analysis of the results of three spine centers together with the opinions of experienced spine surgeons, the authors have drawn up a classification of complications in open lumbar disc surgery and recommendations on how to manage common complications such as excessive bleeding, dural opening, nerve root lesions and recurrent disc herniation. The man-agement of intraoperative complications should have the same training in microdiscectomy instructional courses as the operation itself.

The Posterior Epidural Ligaments: A Cadaveric and Histological Investigation in the Lumbar Region

“…The variable histological presentations of the ligaments were outlined (Figures 4 and 5). The histological union of the dura mater and ligamentum flavum makes the intraoperative identification of separate tissue structures difficult, and care should be taken during surgery [11, 12]. …”

“…The authors support the previous literature [10, 11] that recommends that two-step flavotomies, using semisharp dissectors, during a posterior approach to the lumbar spine should be standard surgical practice. Furthermore, with knowledge of the features of the posterior epidural ligaments, it is recommended that in cases where movement of the dura is visualized, areas of adherent ligamentum flavum should be left in situ [12]. …”

Discectomia endoscópica transforaminal lombar: Resultados clínicos e complicações

“…12 Mesmo assim, a microdiscectomia apresenta algumas desvantagens em comum com a cirurgia aberta, como retração da musculatura paravertebral, dor pós-operatória, ressecção óssea, além dos risco de complicações em longo prazo (recorrência, fibrose epidural, instabilidade vertebral), as quais são desafios para um cirurgião experiente. 13 Os resultados da microdiscectomia lombar nos prolapsos discais recorrentes não são bons quando comparados com os dos casos primários. 14 Diante dessas limitações, a discectomia endoscópica percutânea por via transforaminal é uma alternativa usada para tratar herniações de disco lombares.…”

Aggressive discectomy for single level lumbar disk herniation

“…3 There are many different options for lumbar herniated disk surgery, but open lumbar disc surgery using minimally invasive technique is still the most frequent and important intervention of spine even with the development of many surgical techniques. 4 Among the different options one is aggressive discectomy, which means removal of the offending herniated disc as well as curettage of the normal disc 5 and other is limited discectomy which means removal of the offending disc fragment alone with or without minimum invasion of the disc space 6, 7 but the overall unsatisfactory rate after discectomy is 3 to 20%. [8][9][10][11][12] Its recurrence (at the same level regardless of ipsilateral or contralateral herniation) following disc excision is reported to be 5 to 11%.…”