Dural Tears During Lumbar Spinal Endoscopy: Surgeon Skill, Training, Incidence, Risk Factors, and Management.

BACKGROUND: Incidental dural tears during lumbar endoscopy can be challenging to manage. There is limited literature on their appropriate management, risk factors, and the clinical consequences of this typically uncommon complication. MATERIALS AND METHODS: To improve the statistical power of studying durotomy with lumbar endoscopy, we performed a retrospective survey study among endoscopic spine surgeons by email and chat groups on social media networks, including WhatsApp and WeChat. Descriptive and correlative statistics were done on the surgeons' recorded responses to multiple-choice questions. Surgeons were asked about their clinical experience with spinal endoscopy, training background, the types of lumbar endoscopic decompression they perform by approach, the decompression instruments they use, and incidental durotomy incidence with routine lumbar endoscopy. RESULTS: There were 689 dural tears in 64 470 lumbar endoscopies, resulting in an incidental durotomy incidence of 1.07%. Seventy percent of the durotomies were reported by 20.4% of the surgeons. Eliminating these 19 outlier surgeons yielded an adjusted durotomy rate of 0.32. Endoscopic stenosis decompression (54.8%; P < .0001), rather than endoscopic discectomy (44.1%; 41/93), was significantly more associated with durotomy. Medium-sized dural tears (1-10 mm) were the most common (52.2%; 48/93). Small pinhole durotomies (less than 1 mm) were the second most common type (46.7%; 43/93). Rootlet herniations were seen by 46.2% (43/93) of responding surgeons. The posterior dural sac injury during the interlaminar approach (57%; 53/93) occurred more frequently than traversing nerve-root injuries (31.2%) or anterior dural sac (23.7%; 22/93). Exiting nerve-root injuries (10.8%;10/93) were less common. Over half of surgeons did not attempt any repair or closure (52.2%; 47/90). Forty percent (36/90) used sealants. Only 7.8% (7/90) of surgeons attempted an endoscopic repair or sutures (11.1%; 10/90). DuralSeal was the most commonly used brand of commercially available sealant used (42.7%; 35/82). However, other sealants such as Tisseal (15.9%; 13/82), Evicel (2.4%2/82), and additional no-brand sealants (38; 32/82) were also used. Nearly half of the patients (48.3%; 43/89) were treated with 24-48 hours of bed rest. The majority of participating surgeons (64%; 57/89) reported that the long-term outcome was unaffected. Only 18% of surgeons reported having seen the development of a postoperative cerebrospinal fluid (CSF)-fistula (18%;16/89). However, the absolute incidence of CSF fistula was only 0.025% (16/64 470). Severe radiculopathy with dysesthesia; sensory loss; and motor weakness in association with an incidental durotomy were reported by 12.4% (11/89), 3.4% (3/89), and 2.2% (2/89) of surgeons, respectively. CONCLUSIONS: The incidence of dural tears with lumbar endoscopy is about 1%. The incidence of durotomy is higher with the use of power drills and the interlaminar approach. Stenosis decompression that typically requires the more aggressive use of these power instruments has a slightly higher incidence of dural tears than does endoscopic decompression for a herniated disc. Most dural tears are small and can be successfully managed with mechanical compression with Gelfoam and sealants. Two-thirds of patients with incidental dural tears had an entirely uneventful postoperative course. The remaining one-third of patients may develop a persistent CSF leak, radiculopathy with dysesthesia, sensory loss, or motor function loss. Patients should be educated preoperatively and reassured. LEVEL OF EVIDENCE: 3.

Indication and Contraindication of Endoscopic Transforaminal Lumbar Decompression.

BACKGROUND: The indications and contraindications to the endoscopic transforaminal approach for lumbar spinal stenosis are not well defined. METHODS: We performed a Kaplan-Meier durability survival analysis of patients with the following types of spinal stenosis: type I, central canal; type II, lateral recess; type III, foraminal; and type IV, extraforaminal. The 304 patients comprised 140 men and 164 women, with an average age of 51.68 ± 15.78 years. The average follow-up was 45.3 years (range, 18-90 years). The primary clinical outcome measures were the Oswestry Disability Index, visual analog scale, and the modified Macnab criteria. RESULTS: Of 304 study patients, 70 had type I (23.0%) stenosis, 42 type II (13.7%), 151 type III (49.7%), and 41 type IV (13.5%). Excellent outcomes were obtained in 114 patients (37.5%), good in 152 (50.0%), fair in 33 (10.9%), and poor in 5 (1.6%). Kaplan-Meier durability analysis of the clinical treatment benefit with the endoscopic transforaminal decompression surgery showed statistically significance differences (P < 0.0001) on log-rank (Mantel-Cox) χ2 testing between the estimated median (50% percentile) survival times of type I (28 months), type II (53 months), type III (32 months), and type IV (66 months). CONCLUSIONS: We recommend stratifying patients based on the underlying compressive disease and the skill level of the endoscopic spine surgeon to decide preoperatively whether more difficult central or complex foraminal stenotic lesions should be considered for alternative endoscopic approaches.

[High-risk clusters and temporal trends in congenital syphilis infection in Brazil]. / Aglomerados de alto risco e tendência temporal da sífilis congênita no Brasil.

OBJECTIVE: To determine the occurrence of high-risk clusters for congenital syphilis (CS) in Brazil and describe the temporal trends in the CS infection in the country, comparing children whose mothers received vs. those whose mothers did not receive prenatal care. METHOD: This ecological study used data from the National Disease Notification System (Sistema de Informação de Agravos de Notificação, SINAN) and the Live Birth Information System (Sistema de Informações sobre Nascidos Vivos, SINASC). For cluster analysis, the Kulldorff scan statistic was applied to the population at risk. Statistical significance was determined by the log-likelihood ratio based on Poisson discrete distribution. To analyze the temporal trends of disease detection rates, Prais-Winsten regression was used. The analysis was performed with SatScan 9.4 and Stata 14.0 software. RESULTS: Clusters with detection rates of 41.3, 44.4 and 188.1 CS cases/10 000 live births were identified in 2001, 2009 and 2017 respectively. In 2001, the rates were 8 times higher in the clusters than in the remaining country; in 2009, the rates were 3.3 times higher; and in 2017, 2.5 times higher. An increasing trend in CS infection was detected in all regions and federation units. The rates were 8.53 times higher in the children of mothers without prenatal care (243.3 cases/1 000 live births vs. 28.3 cases/1 000 live births in the children of mothers with prenatal care). CONCLUSIONS: The identification of municipality clusters at high risk for CS and of increasing trends in CS infection across the country, even in the presence of prenatal care, suggests the need for improvement of public health actions to fight this disease.

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

BACKGROUND: New onset of acute dysethetic leg pain due to irritation of the dorsal root ganglion (DRG) following uneventful recovery from an expertly executed lumbar transforaminal endoscopic decompression is a common problem. Its incidence and relation to any risk factors that could be mitigated preoperatively are not well understood. METHODS: We performed a multicenter frequency analysis of DRG irritation dysesthesia in 451 patients who underwent lumbar transforaminal endoscopic decompression for herniated disc and foraminal stenosis. The 451 patients consisted of 250 men and 201 women with an average age of 55.77 ± 15.6 years. The average follow-up of 47.16 months. The primary clinical outcome measures were the modified Macnab criteria. Chi-square testing was employed to analyze statistically significant associations between increased dysesthesia rates, preoperative diagnosis, the surgical level(s), and surgeon technique. RESULTS: At final follow-up, Excellent (183/451; 40.6 %) and Good (195/451; 43.2 %) Macnab outcomes were observed in the majority of patients (378/451; 83.8 %). The majority of study patients (354; 78.5 %) had an entirely uneventful postoperative recovery without any DRG irritation, but 21.5 % of patients were treated for it in the immediate postoperative recovery period with supportive care measures including activity modification, transforaminal epidural steroid injections, non-steroidal anti-inflammatories, gabapentin, or pregabalin. There was no statistically significant difference in dysesthesia rates between lumbar levels from L1 to S1, or between single (DRG rate 21.8 %) or two-level (DRG rate 20.2 %) endoscopic decompression (p = 0.742). A statistically significantly higher incidence of postoperative dysesthesia was observed in patients who underwent decompression for foraminal stenosis (38/103; 27 %), and recurrent herniated disc (7/10; 41.2 %; p = 0.039). There were also statistically significant variations in dysesthesia rates between the seven participating clinical study sites ranging from 11.6%-33% (p = 0.002). Unrelenting postoperative dysesthetic leg pain due to DRG irritation was statistically associated with less favorable long-term clinical outcomes with DRG rates as high as 45 % in patients with a Fair and 61.3 % in patients with Poor Macnab outcomes (p < 0.0001). CONCLUSIONS: Postoperative dysesthesia following transforaminal endoscopic decompression should be expected in one-fifth of patients. There was no predilection for any lumbar level. Foraminal stenosis and recurrent herniated disc surgery are risk factors for higher dysesthesia rates. There was a statistically significant variation of dysesthesia rates between participating centers suggesting that the surgeon skill level is of significance. Severe postoperative dysesthesia may be a predictor of Fair of Poor long-term Macnab outcomes.

Outcomes with transforaminal endoscopic versus percutaneous laser decompression for contained lumbar herniated disc: a survival analysis of treatment benefit.

BACKGROUND: Contained lumbar disc herniations frequently cause back- and leg pain. Clinical outcomes with surgical treatment may be affected by the size and location of the disc herniation. The surgical directly visualized transforaminal endoscopic decompression has gained acceptance and popularity, while the simplified percutaneous laser disc decompression has fallen out of favor in spite of its initial success as a minimally invasive intervention. In an attempt to better understand the durability of both procedures, the authors performed a comparative analysis of clinical outcomes in patients with contained lumbar disc herniations. METHODS: The study population was comprised 248 patients consisting of 162 patients in the endoscopy group (group 1) and 86 patients in the laser group (group 2). Primary outcome measures were Macnab criteria. Herniations were classified as large or small. Additional parameters of advanced degeneration of the lumbar motion segment including posterior disc- and lateral recess height of <3 mm were recorded. IBM SPSS 25.0 was used for Kaplan-Meier survival analysis and cross-tabulation of these variables with statistical testing for significant associations. RESULTS: The mean follow-up was 43.5 months. The serial time recorded for Kaplan-Meier analysis ranged from 1.5 to 84 months. The mean age was 53.37 years (standard deviation =14.65 years). The majority of patients had Excellent and Good Macnab outcomes (212/248; 85.5%) regardless of treatment. Fair and Poor results were achieved in another 36 patients (14.5%). There was a higher percentage of Excellent Macnab outcomes in the endoscopy group (94/162; 58.0%) than in the laser group (38/86; 44.2%) at a statistical significant level (P<0.0001). There was a statistically significantly higher percentage of Excellent and Good Macnab outcomes with endoscopic decompression of small paracentral herniations (97.1%; P<0.0001). Percutaneous laser decompression of large central disc herniations was not statistically better than endoscopic surgical decompression (P=0.125). Endoscopic bony and soft tissue decompression was also better than laser at alleviating symptoms in patients with reduced posterior disc- and lateral recess height with 96.7% in patients with reduced disc height of <3 mm and 94% in patients with reduced lateral recess height of <3 mm (P=0.001). Kaplan-Meier (K-M) Survival time showed longer median survival of the treatment benefit for patients who underwent visualized endoscopic surgical decompression (66.0 months) compared to median K-M survival time for percutaneous laser decompression of 17 months (P<0.0001). CONCLUSIONS: Transforaminal endoscopic decompression for symptomatic herniated disc is an effective and durable surgical treatment to alleviate sciatica-type and back symptoms in the vast majority of patients with good long-term survival of pain relief for up to six years. Interventional percutaneous non-visualized laser decompression for the same condition may provide favorable outcomes in the short-term with soft protrusions. However, the treatment effect deteriorates much faster with a median survival of 17 months.