Postoperative retroperitoneal hematoma following transforaminal percutaneous endoscopic lumbar discectomy

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The purpose of this study was to demonstrate the clinical characteristics of postoperative retroperitoneal hematoma (RPH) following transforaminal percutaneous endoscopic lumbar discectomy (PELD) and to discuss how to prevent the complication of unintended hemorrhage.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The medical records of 412 consecutive patients treated with transforaminal PELD between January 2005 and May 2007 were reviewed. A total of 4 patients (0.97%) experienced symptomatic postoperative RPH. The clinical outcomes were evaluated using the visual analog scale and the Oswestry Disability Index.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The common symptom in all patients with a hematoma was inguinal pain. The mean hematoma volume was 527.9 ml (range 53.3–1274.1 ml). Two patients with massive diffuse-type RPHs compressing the intraabdominal structures required open hematoma evacuation performed by general surgeons, and the other 2 patients with small, localized RPHs of &lt; 100 ml were treated conservatively. The mean follow-up period was 21.3 months (range 13–29 months). The mean visual analog scale score for radicular leg pain improved from 7.6 to 1.8 and that for back pain improved from 4.3 to 2. The mean Oswestry Disability Index improved from 58.8 to 9.1%. The preoperative symptoms improved after the second treatment without significant neurological sequelae in all patients.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Although transforaminal PELD is a minimally invasive and safe procedure, the possibility of RPH should be kept in mind. Adequate technical and anatomical considerations are important to avoid this unusual hemorrhagic complication, especially in the patient with underlying medical problems or previous operative scarring. A high index of suspicion and early detection is also important to avoid the progression of the hematoma.</jats:p></jats:sec>

3D Reconstructions of Spinal Segmental Arteries Using CT Angiography: Applications in Minimally Invasive Spinal Procedures

“…Reports of arterial injury and hematoma after minimally invasive operations are a cause for concern. 3,4,6 Our results also show a significantly higher frequency of segmental arteries with uncommon pathways at L2 through L4, a region in which percutaneous transforaminal endoscopic diskectomy is frequently attempted. This finding supports the routine practice at our institution of performing spinal CT angiography and reviewing the anatomic structure of segmental arteries before minimally invasive operations and anterior approaches.…”

“…3,4,6 With the patient under regional anesthesia, one can monitor nerve root injury as patients complain of radiating pain or tingling. 7 Segmental artery injury may not be monitored, however, and symptoms develop only after surgery.…”

“…Occasionally, segmental artery injury may result in a retroperitoneal hematoma requiring invasive treatment such as endovascular embolization or surgical ligation. 3,4 In this study, we tested the feasibility of using 3D spinal CT angiography to determine the positions of spinal segmental arteries before percutaneous lumbar endoscopic diskectomy or extrapedicular vertebroplasty. Such presurgical evaluation may help avoid arterial injury.…”

“…[3][4][5][6][7] The percutaneous lumbar transforaminal endoscopic approach and the extrapedicular approach in vertebroplasty or kyphoplasty may directly cause such injury. Occasionally, segmental artery injury may result in a retroperitoneal hematoma requiring invasive treatment such as endovascular embolization or surgical ligation.…”

Surgery Related Complications in Percutaneous Endoscopic Lumbar Discectomy under Local Anesthesia

“…There are two types of the post-operative hematoma : epidural and retroperitoneal hematoma (13). Ahn et al (13) performed transforaminal PED for 412 cases, and experienced 4 (0.97%) cases of symptomatic retroperitoneal hematoma.…”