INTRODUCTION
Over recent decades, the surgeries for spinal disorders have grown exponentially. Overall reported occurrence of complications in spine surgery is 16.4%. Preventive measures are effective in reducing the complications in spinal surgeries. This report narrates four cases’ scenarios where authors miserably met with major complications in their corresponding cases.
CASE SCENARIO 1
A 63-year-old woman came with complaints of low backache and bilateral lower limb radicular symptoms.
Evaluation and imaging
She was admitted and underwent detailed preoperative blood tests and radiological investigations. The blood tests were within normal limits. Radiological scans revealed multiple-level lumbar canal stenosis with adult spinal deformity [Figure 1].
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Figure 1: (A) X-ray of the whole spine: standing AP and lateral view showing left lumbar degenerative curve. (B) Dynamic lateral view X-ray showing signs of instability with Modic endplate changes at L2-3 and L3-4 level. (C) MRI LS spine showing lumbar canal stenosis with PIVD and signal changes at endplates. (D) Postoperative X-ray showing spinal fixation and deformity correction from D12-S1 levels
Management
After explaining the condition and taking consent for the surgical procedure, she underwent surgical management by posterior spinal instrumentation, decompression, deformity correction, and fusion from T12-S1. The patient withstood the procedure well and post-operatively she was mobilized with support and was subjected to rehabilitation. The surgical wounds healed without any incidence.
Follow-up and complication
She was comfortably performing her daily routine activities with ease and was pain-free during her follow-up visits. After 5 months of surgery, the patient came to the emergency department with severe excruciating pain over the back, associated with bilateral lower limb radicular pains and weakness. There was no history of trauma or injury. The patient underwent thorough clinical assessment and radiological investigations which revealed a compression fracture of the uppermost instrumented vertebrae, that is, T12 segment.
Revision surgery
The surgical procedure and its complications were explained and she underwent revision surgery in the form of implant removal at the fractured vertebra segment supported with vertebroplasty and extension of the construct by instrumenting T10 and T11 vertebrae [Figure 2]. The patient was gradually mobilized and regained her motor function, which was supplemented with anabolic agents to optimize bone healing.
Figure 2: (A and B) MRI LS spine showing signal changes and fluid collection in the upper instrumented vertebrae on T1WI and T2WI. (C) X-ray showing evidence of vertebral body collapse at the D12 level. (D) Postop X-ray showing extension of the construct to D10, D11 segment with the removal of D12 screws and prophylactic vertebroplasty of the D12 body
DISCUSSION
Prevention and treatment of proximal junctional pathologies associated with adult spine deformity surgery are some of the most intriguing problems faced by surgeons. There are very limited studies on the etiological factors for the incidence of proximal junctional fracture (PJFr) following adult spine deformity surgery. The risk of proximal deformity pathology rates is also greater when surgery is extended to the pelvis and/or sacrum. Kebaish et al. stated that prophylactic vertebroplasty at the upper instrumented vertebrae (UIV) and its supra-adjacent vertebrae reduces the incidence of proximal junctional fractures after long posterior spinal instrumentation in his axial-loaded cadaver model.[1] Kurra et al.[2] concluded that higher preoperative global sagittal imbalance with lower computer tomography bone mineral density values at the UIV and/or at adjacent vertebrae may amplify proximal junctional fracture incidence. Therefore, the use of proximal junctional hooks may supplement the pathogenesis. Matsumura et al.[3] concluded that transverse process hooks can be used as an alternative to pedicle screws to prevent vertebral collapse due to higher mechanical load. Safaee et al.[4] stated that ligament augmentation is a novel technique to strengthen the UIV segment for the prevention of proximal junctional kyphosis and PJF in adult spinal deformity correction surgery. Spina Nicholas et al. noted that the rate of acute proximal junctional failure was higher when the UIV was T10 vs. T11, T12, or L1, with a fracture of the UIV or UIV+1 segment.
We used prophylactic vertebroplasty after implant removal at the fractured vertebrae along with the extension of a construct cranially as a novel method for increasing the mechanical strength at the proximal junction of long spinal fusion constructs. Additional studies on this phenomenon are warranted to elucidate the pathogenesis of this complication.
CASE SCENARIO 2
Minimally invasive TLIF—Technique
There are three broad components to the procedure of minimally invasive transforaminal lumbar interbody fusion (TLIF) (MIS-TLIF), namely:
- (A) Decompression and instrumented fusion through a tubular retractor
- (B) Insertion of guide wires to aid percutaneous screw insertion, and
- (C) Segmental stabilization with percutaneous pedicle screw-rod system
Surgeons generally perform the above steps in the order of technique (1) A → B → C or technique, (2) B → A → C. The current authors changed the technique from former (1) to latter (2) amid their practice over the past 12 years.
Technique 1 starts with Step (A) and involves parking the tubular retractor at a strategic location using tubular dilators exposing the lamina and facet-joint complex. This is followed by microscopic decompression of the canal, the extent, and dimensions of which may vary based on the etiology. This step is followed by disc-space clearance, preparation of the endplates, impaction of sentinel bone graft, and insertion of a press-fit cage. Following step (A), guide wires are inserted percutaneously under the guidance of the image intensifier into the four pedicles of the segment being fused. This step can also be performed using navigation and robotics. However, the image intensifier is the most widely used device and provides images in two dimensions—AP (anteroposterior) and lateral, leaving behind the third dimension (axial) for the surgeon to mentally conceptualize while inserting the guide wire. An 11 gauge Jamshidi needle is initially probed and inserted into the pedicle through which the guide wire is advanced into the vertebral body, all under image guidance. This is followed by step (C), that is, confirmation of the precise location of the guide wires being followed by insertion of screws into the pedicles by rail-roading over guide wires using image guidance. Rods are seated bilaterally on the tulips of the pedicle screw heads using one of a variety of minimal access techniques (Sextant, Pivot, and reduction-screw mechanisms) to achieve immediate stabilization.
Complication of technique 1
The authors successfully employed technique 1 for over close to six years. A multiplicity of reasons influenced the team to shift gears to technique 2. One predominant reason relates to an unfortunate intra-operative event with technique 1. Following step (A), the spinal canal is wide open especially on the side of laminectomy and facetectomy, potentially exposing the dural sac and its components to any incidental injury secondary to the play of any surgical instrument or implant. This incident caused a dural tear and substantial intra-operative CSF leak while inserting the Jamshidi needle [Figure 3].
Figure 3: Depiction of the mishap of incidental dural tear while inserting the Jamshidi needle
This catastrophe could have been prevented if the lamina was intact thus shielding the neural structures. Hence the authors deemed it safe to make a radical shift in the order of steps from technique 1 to technique 2.
Technique 2 entails the insertion of guidewires in the presence of intact posterior elements as the first step (step B). The guidewires are then anchored to the drapes on the sides [Figure 4A and B].
Figure 4: (A) Guidewires inserted at all four pedicles of the involved segment and anchored to the drapes. (B) Fluoroscopic image (AP view) after advancing all four guidewires at bilateral pedicles of the involved segment
Special care is taken to continuously monitor the position of the tips of the guide wires from advancing anteriorly or retracting posteriorly from the vertebral body on the image intensifier throughout the operation. The next step involves decompression and fusion through tubular retractors (A), followed by stabilization with a pedicle screw-rod system (C).
MIS-TLIF is a novel surgical technique developed to reduce the incidence of approach-related morbidities associated with the conventional TLIF procedure.[5] As with any technically demanding surgery, a steep learning curve has been described for this technique.[6] Subjective variability is noted in the sequence of steps performed to performing decompression and inserting the guidewires at the pedicles. Insertion of the guidewires at the pedicle with intact posterior neural structures ensures effective shielding of the dura from incidental injury during the placement of the Jamshidi needles.
The authors have made a radical shift in the sequence of steps after the mishap described in this case report, and have deemed it to be a safer approach to place the guidewires at the pedicles followed by performing microscopic decompression.
CASE SCENARIO 3
A 37-year-old male patient came with complaints of neck pain and left upper limb radicular pain for 3–4 months. He was treated initially with oral medications and was subjected to physiotherapy exercises, where the pain was relieved for a few days. Subsequently, the patient came with a recurrence of the same pain with an increase in severity affecting activities of daily living.
On clinical examination, Spurling’s sign was positive with intact power and mild hypoesthesia around the C7 dermatome without any evidence of myelopathy features.
Imaging
Radiological investigations were performed including MRI and dynamic X-rays of the C-spine which revealed C6-7 left paracentral disc herniation.
Management
After explaining the condition and procedure required to the patient, a full endoscopic posterior cervical laminoforaminotomy with discectomy was planned.
Complication
The cannula docking was done under C-arm guidance and the position was checked under C arm. Once the setting was done, the surgery was started without reconfirming the cannula position. Initial muscle was removed to expose the “V” of the interlaminar space but even after removing more muscles’ fibers than usual the V was not seen or palpated. The lateral view in C arm was checked and it was seen that the cannula was placed anterior to the facet joint level. Cannula was again repositioned and the procedure was performed without any further problems. During surgery, bleeding/oozing was more as compared to the usual. Discectomy was completed and decompression of the nerve root was confirmed. Once the patient was turned supine for extubation severe swelling of the neck and left side of face was seen [Figure 5]. There was difficulty in extubation (oxygen saturation was less than normal) so the patient shifted to intensive care unit and kept on ventilator till next morning. Ultrasound of the neck in the intensive care unit showed fluid extravasation in the inter and intramuscular planes [Figure 6]. The swelling decreased after 48 hours following which he was extubated and mobilized [Figure 7]. Postoperatively patient had tingling and numbness in the left hand for a few days which gradually subsided in following 3 weeks. Patient developed mild symptoms of Horners’ syndrome which recovered completely within one month. Postoperative oral steroids were given and patient became asymptomatic after 6 weeks.
Figure 5: Swelling of neck noticed at end of the procedure
Figure 6: Ultrasound of neck showing fluid extravasation in intermuscular planes
Figure 7: Resolution of neck swelling after 48 h
Discussion
Cervical spondylotic radiculopathy is a common spinal condition with potentially disabling nerve root compression. Majority of the cases are treated conservatively unless surgical intervention is needed for persistence or recurrence of symptoms, neurological deficits, or severe pain affecting activities of daily living. Anterior cervical discectomy and fusion is the current gold standard for surgical management of cervical radiculopathy. But complications like access related damage to oesophagus and common carotid vessels, adjacent segment degeneration, implant failure and pseudarthrosis are sometimes possible. Posterior cervical laminoforaminotomy, performed by minimally invasive approach or endoscopically, is a viable alternative to ACDF which is more safe, less expensive and also more physiological.[7,8,9]
In our case, the patient was intubated for the duration of the procedure and when the patient was re-positioned to supine after the procedure, we noticed swelling of the neck and left side of the face. This probably occurred due to dislocation of the working channel lateral to facet joint—while the surgeon was trying to stand on a footstep and arranging foot pedals-causing extravasation of fluid in the posterior triangle of the neck. Ultrasound revealed evidence of fluid leakage intramuscularly and through the fascial planes. The patient was kept intubated and monitored in intensive care unit for the next few hours until extubation was safe. The patient was extubated after 12 h of surgery and mobilized immediately; however, initially the patient complained of paresthesia of the left upper limb which gradually subsided. The swelling was reduced completely in 2–3 days and was discharged with post-operative instructions and medications.
Vier et al.[10] demonstrated a similar incident with extravasation of fluid in shoulder arthroscopic surgery with established risk factors such as lateral decubitus position, prolonged operative time, and performing a subacromial decompression, which was modifiable and are important preoperative and intraoperative considerations for the treating surgeons.
Fluid extravasation not only affects the local soft tissues but may have systemic complications such as an electrolyte imbalance. Ichai et al.[11] showed that there is a systemic absorption of glycine irrigation fluid during shoulder arthroscopy and suggested that the risk of systemic absorption can be avoided with lower pump pressures and lower volume of irrigation fluid during the surgical procedure. Total operative time is directly proportional to the volume of irrigation fluid used and subsequent weight gain by the patient, presumably from absorption of the irrigation fluid. Adequate visualization of the surgical field during the endoscopic procedure is a necessity, but the surgeon should have an understanding of the risks of elevated pump pressures and the liberal use of lavage cycles.[12,13]
CASE SCENARIO 4
A 67-year-old woman presented with chronic back pain without any neurodeficit. She was suffering from chronic kidney disease for last ten years and was on regular dialysis for past five years.
Imaging
X-ray showed non-union of L1 fracture.
Management
In view of failed conservative treatment by routine medications (oral calcium, vitamin D and bisphosphonates), vertebroplasty was offered.
Complication
She underwent vertebroplasty under local anesthesia after routine painting and draping. Both pedicles were probed with Jamshidi needle. The cement was injected after it reached to the toothpaste consistency. But as we injected the cement it spread all around the vertebra in lateral, posterior and anterior compartments. Fortunately, cement did not leak into the canal. It was indeed the most frightening scene per operative [Figure 8]. She walked out of operation theater.
Figure 8: Post-operative radiograph of vertebroplasty of L1 with spillage of cement around the vertebral compartments
In follow-up she was treated with routine medical management for osteoporosis and continued to remain functional till she lived and died due to renal failure in 2015. A few other examples of failed vertebroplasty cases have been depicted in Figures 9-12. The complications of vertebroplasty are mentioned in Table 1.
Figure 9: Representative case of cement embolization
Figure 10: Representative case of fracture of cement
Figure 11: Representative case of thermal necrosis
Figure 12: Representative case of Koch’s Infection, cement injected, and reoperated
Table 1: Complications of vertebroplasty
Discussion
In the initial day, the literature was in favor of this procedure, however and over a period contradictory findings were reported. Inadequate cementing leads to re-fracture and excessive injection leads to cement leakage.[14] One study reported the re-fracture rate of up to 63%.[15] Necessity of repeat vertebroplasty for unrelieved pain has also been reported.[16] Progressive kyphosis has been reported after vertebroplasty in osteoporotic vertebral compression fractures.[17] Leakage of cement into the adjacent disc is found to increase the risk of having a new fracture of the adjacent vertebral body.[18] Along with cement leakage, osteoporosis is also a risk factor for new symptomatic vertebral compression fracture in patients who have undergone percutaneous vertebroplasty or kyphoplasty.[19] High- to moderate-quality evidence indicated that vertebroplasty offered no clinical benefits compared with the sham procedure and did not recommend vertebroplasty to treat acute or subacute osteoporotic vertebral fractures.[20,21] Medical management of osteoporosis was superior to vertebroplasty in alleviating back pain and improving physical ability and health-related quality of life, with no requirements for hospitalization.[22] The overall unfavorable risk–benefit ratio of vertebroplasty should be convincing doctors and patients to stop the use of this procedure. At the very least, clinicians should fully inform their patients about the evidence including the likelihood of improving without vertebroplasty.[20]
Having learnt and still learning about the Duets (osteoporosis and sarcopenia), the practice scenario has to be changed. Patient education (drama, booklets, posters, TV interviews, and webinars), early active management need to be practiced and it may change the major practice scenario.
Vertebroplasty is to be taken with lots of care and caution and has to be planned after failed conservative treatment. Osteoporosis is lifetime medical disease; second fracture is on the way if not treated properly. Teriparatide, Denosumab and bisphosphonates with oral calcium and vitamin D are the pillars of medical management but each drug has its own usage schedule, and must be followed. Original molecule teriparatide was found to be effective in uncomplicated (neuro normal) patients with fragility fracture. Injection of teriparatide may be needed only after 6 weeks of well-executed conservative treatment in an uncomplicated case. Complications of vertebroplasty are enumerated in Table 1. A summary of the four cases is provided in Table 2 for the benefit of our readers.
Table 2: Summary of case scenarios
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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