Unilateral mydriasis: a complication of spine surgery in prone position / Midríase unilateral: uma complicação da cirurgia de coluna em decúbito ventral

Abstract Prone position though is commonly used for better access to surgical site, but may be associated with a variety of complications. Perioperative Visual Disturbances or loss is rare but a devastating complication that is primarily associated with spine surgeries in prone position. In this case we report a 42 year old ASA-II patient who developed anisocoria with left pupillary dilatation following lumbar microdiscectomy in prone position. Following further evaluation of the patient, segmental pupillary palsy of the left pupillary muscles was found to be the possible cause of anisocoria. Anisocoria partially improved but persisted till follow up.

Resumo O posicionamento em decúbito ventral, embora comumente usado para melhorar o acesso ao local cirúrgico, pode estar associado a uma variedade de complicações. Distúrbios ou perda visual no Perioperatório é uma complicação rara, mas devastadora, que está principalmente associada à cirurgia de coluna vertebral em decúbito ventral. Relatamos aqui o caso de um paciente de 42 anos de idade, ASA - II, que desenvolveu anisocoria com dilatação pupilar esquerda após microdiscetomia lombar em decúbito ventral. Após uma avaliação adicional do paciente, observamos que a paralisia segmentar dos músculos pupilares esquerdos seria a possível causa de anisocoria. A anisocoria melhorou parcialmente, mas persistiu até o acompanhamento.

Lesión iatrogénica de la arteria iliaca común izquierda durante discectomía lumbar posterior / Iatrogenic injury to the left common iliac artery for posterior lumbar discectomy

Las lesiones vasculares durante la cirugía de hernia discal son infrecuentes, pero asociadas con una alta mortalidad dependiendo del vaso afectado, requiriendo de una sospecha diagnóstica y manejo temprano que puedan evitar el desenlace mortal. Dependiendo del nivel intervertebral intervenido las lesiones vasculares comprometerán en mayor o menor frecuencia los diferentes grandes vasos, siendo más frecuentes los traumas a la aorta en niveles altos y el compromiso de los vasos arteriales y venosos ilíacos comunes o sus ramificaciones en niveles inferiores, las estadísticas en cuanto a incidencia se creen son subestimadas debido a la infrecuencia con que son reportados estos casos. El objetivo de este artículo es exponer el caso de una lesión traumática intraoperatoria de la arteria ilíaca común izquierda durante un procedimiento de hemilaminectomia y microdisectomia L5 - S1, en la que la temprana sospecha de la lesión y contar con equipo quirúrgico altamente capacitado en la institución permitió realizar un manejo oportuno sin secuelas neurológicas o vasculares para el paciente. Compartimos este caso dado lo infrecuente de sus reportes en la literatura revisada, si tenemos en cuenta la frecuencia con el que neurocirujano o cirujano de columna realiza procedimientos para corrección de hernias discales, sin dimensionar en muchas ocasiones el alto riesgo de morbi-mortalidad derivadas de una complicación quirúrgica, que en nuestro caso de no haber contado con el equipo quirúrgico idóneo (anestesia, cuidados posoperatorios, cirujanos generales y vasculares), no se hubiera obtenido el buen resultado para el paciente.

Vascular injury during surgery herniated disc are rare, but associated with high mortality depending on the affected vessel, requiring a diagnostic suspicion and early management to avoid a fatal deselance. Depending on the level involved surgical, vascular lesions are more commonly involved trauma of the aorta at high levels and commitment of arterial and venous vessels common iliac, less frequently commits its branches at lower levels. Due to the low incidence of reporting of these cases statistics are underestimated. The aim of this article is to present the case of a traumatic injury intraoperative left common iliac artery for a microdiscectomy procedure hemilaminectomy and L5 - S1, where a timely management was conducted through early suspicion of injury and the surgical team highly trained in the institution. There were no neurological or vascular consequences for the patient. We share this case due to the rareness of their reports in the literature reviewed, if we consider the frequency with which neurosurgeon or spine surgeon performs procedures to correct herniated discs, not to mention the high risk of surgical morbidity and mortality. In our case you have not had the ideal surgical equipment (anesthesia, postoperative care, general and vascular surgeons) had not obtained the good result for the patient.

The Clinical Comparison between Open Surgery and Percutaneous Endoscopic Lumbar Discectomy in Extraforaminal Lumbar Disc Herniation

OBJECTIVE: The objective of this study is to evaluate and compare the clinical results between classical open surgery and percutaneous endoscopic lumbar discectomy(PELD) in cases of extraforaminal lumbar disc herniation. METHODS: We obtained the clinical data from 47 patients with extraforaminal lumbar disc herniations who underwent the open paramedian muscle-splitting approach or percutaneous endoscopic lumbar discectomy(PELD) between January 2001 and February 2004. This study consisted of patients with soft disc extraforaminal herniations. The patients were assessed with the visual analogue scale(VAS) and MacNab's criteria before surgery, just before discharge, and postoperative 1 year. RESULTS: There were 25 cases in the open surgery group and 22 cases in the PELD group. The average operating time was 78+/-36.71 min in the PELD group and 110+/-29.68 min in the open surgery group. The mean hospital stay was 2.73+/-2.62 days in the PELD group and 7.68+/-2.59 days in the open surgery group. VAS decreased from 8.34+/-0.66 to 1.29+/-2.27 in the PELD group and from 8.40+/-1.40 to 1.70+/-1.72 in the open surgery group at the one-year follow-up. The success rate of PELD was 86.4%, compared with 80.0% for open surgery. However, there were no statistically significant difference between two groups for success rate and VAS. CONCLUSION: Although the success rates were similar in both groups, PELD is less invasive, faster, and safe procedure than open surgery for extraforaminal disc herniation in selected patients.

Survivor Ship Analysis of Lumbar Microdiscectomy / 대한정형외과학회잡지

PURPOSE: To analyze the post-operative clinical results of lumbar microdiscectomy with respect to time, and to evaluate the causes of fail-ure by survivor ship analysis. MATERIALS AND METHODS: The clinical results of 162 patients were evaluated using MacNab's criteria and the survival rate was analyzed by using Kaplan-Meier survivor ship analysis. Several factors suspected of influencing survival were evaluated. RESULTS: Survival was 93.7% at 12 months after the operation, and showed annual decrements to reach 84.7% at 60 months but did not change thereafter until the final follow up. There were total 18 failed cases and the failure rate after 5 years was 0%. Statistically significant factors influencing the survival rate were, the type and level of disc herniation. The causes of early failure, which occurred within 12 months of surgery, were usually due to residual or recurrent radiating pain, whereas the major cause of late failure, which occurred after 12 months, was usually residual back pain. CONCLUSION: The failure rate was relatively high during the early post-operative period, but this decreased with time. Since long-term survival was relatively high, lumbar microdiscectomy could be considered an effective and satisfactory surgical technique.

A comparison of lumbar microdiscectomy versus standard discectomy.

Forty patients with a diagnosis of simple herniated lumbar disc at L4-5 were reviewed group I comprised 20 patients treated with standard discectomy. Group II comprised 20 patients treated with microdiscectomy. Both groups had similar characteristics regarding age (average=35.9, 35.1 years), sex (M/F=10/10,11/9), side (R/L=11/9,9/11) and time period from beginning of their symptoms to the index operation (average=8.4,9.8 months). In group I, 81 percent of the patients had numbness over the L5 dermatome, while all in group II had the same symptom. In group I, 71.4 percent of the patients had weakness of extensor hallucis longus, while 75 percent had the same symptom in group II. Myelograms were performed on eight patients in group I and on nine patients in group II. Magnetic resonance images were performed on twelve patients in group I and on eleven patients in group II. The data were retrieved from the patients’ records and a comparison made through analyses of the unpaired T test. There was no statistical difference in operative time (average of 83.7 versus 81.6 minutes with p=0.72), or improvement of pain and daily activities at six weeks after the index operations. There were significant differences in length of incision (average 10.6 versus 3.3 cm.), intraoperative blood loss (average=180 versus 48 cc.), length of stay in the hospital after the operation (average=12.3 versus 4.2 days). A complication with a tear of the dura occurred in one patient in group II. One patient in each group developed recurrence of herniated disc at the same level which was resolved by conservative means. Microdiscectomy in selected patients is effective and give comparable results to the standard procedure with the advantages of a smaller incision, less blood loss and shorter length of hospital stay.

The Use of Corticosteroids and Bupivacaine for Pain Management in Lumbar Disc Herniation Patient

The introduction of microdiscectomy in lumbar spine surgery has resulted in a significant decrease in postoperative pain and length of hospital stay. Intraoperative application of long-acting local anesthetic agents and corticosteroids during lumbar discectomy have been used for the management of postoperative pain. However, the efficacy of local anesthetic agents and corticosteroids has not been reported. This study evaluated 30 patients undergoing lumbar microdiscectomy. These patients were divided into three groups. Group I(10 patients) received intramuscular Depomedrol and intravenous Solumedrol at the start of the operation. A gelfoam soaked with Depomedrol was placed over the affected nerve root following discectomy. In addition, bupivacaine was infiltrated into the paraspinal musculature at the skin incision and during closure. Group II(10 patients) received intramuscular bupivacaine and used a saline-soaked gelfoam. Group III(10 patients) acted as a control group without corticosteroids and bupivacaine. Patients in Group I had a statistically significantly shorter hospital stay(8.9 days) compared to the control group(14.9 days). Patients in Group I required less postoperative narcotic analgesia than the other groups. A larger percentage of patients in Group I reported reduction of lower back pain and radicular pain until #POD 3 compared to other groups. These results indicate that the combination of long-acting local anesthetic agents and corticosteroids can reduce postoperative discomfort and hospital stay.