Complications Associated with Posterior Approaches in Minimally Invasive Spine Decompression

Posterior approaches for decompression in minimally invasive spine surgery are increasingly used for a wide range of pathology. Surgeons and patients must understand these risks in order to identify, manage, and ideally prevent complications. Technical intraoperative complications, recurrences and reoperations, infections, and medical complications associated with the surgery are considered for common posterior minimally invasive decompression procedures of the cervical and lumbar spine. Methods of possibly avoiding these complications are also discussed. This article then aggregates the relevant data to allow concise understanding of the complications associated with these procedures.

Key points

  • •

    Complications associated with posterior approaches for minimally invasive decompressions may be categorized as related to the intraoperative approach and decompression, need for reoperation, infections, or perioperative medical concerns.

  • •

    The incidence and nature of these complications are presented.

  • •

    Complications may be prevented with careful surgical technique.

Introduction

Minimally invasive approaches for spinal decompression are increasingly used for a wide range of degenerative pathology. These techniques have been developed to allow equivalent or improved outcomes compared with their open counterparts, with decreased iatrogenic disruption of the normal anatomy. Minimally invasive spine surgeries have been associated with less morbidity and quicker return to work compared with traditional open techniques, with a similar to possibly decreased overall risk of complications. All surgical procedures carry risk of complications, however, and the complication profile varies by procedure and approach.

Common minimally invasive posterior spine procedures include the foraminotomy, diskectomy, and laminectomy. These posterior decompressive procedures may be used in the cervical, thoracic, or lumbar spine. Cervical and thoracic approaches are used to address radiculopathy and/or myelopathy, with surgical indications and goals similar to traditional open laminectomies, diskectomies, and foraminotomies. In the lumbar spine, these same procedures are similarly used for decompression in the treatment of lumbar radiculopathy or neurogenic claudication.

Although these approaches are largely successful, it is important for surgeons and patients to understand the potential complications associated with these procedures. The learning curve for minimally invasive techniques is more significant than the open surgical correlates, and perspective on the anatomy encountered during a minimally invasive approach may be less familiar to surgeons. These factors may contribute to either intraoperative complications or to disease recurrence requiring reoperation. Understanding the risk of infection and medical complications associated with surgery is critical for managing patients in the postoperative period. This article presents relevant data regarding these classes of complications associated with posterior minimally invasive decompressions. A case example helps demonstrate important considerations for complication avoidance ( Figs. 1–7 ).

Fig. 1
Case example. The patient is a 23-year-old man presenting with signs and symptoms consistent with a left S1 radiculopathy. MRI of the lumbar spine demonstrates a left herniated disk at L5-S1, shown on ( A ) parasagittal and ( B ) axial images. After failing conservative management, he is taken for elective left L5-S1 minimally invasive microdiskectomy.
Fig. 2
Localization. ( A ) The L5-S1 interspace is appropriately identified on this localizing fluoroscopy image. The surgeon must be comfortable with fluoroscopic interpretation to ensure that the Kirschner wire, if used, is not inadvertently placed in the central canal, neural foramen, or lateral to the facet and transverse process. ( B ) Anterior-posterior fluoroscopy may help define midline prior to making incision, which is approximately 15-mm lateral from midline on the side of dominant pathology, as marked by an overlaid instrument. Careful interpretation of localizing images, with comparison to preoperative imaging and reconfirmation as needed, helps avoid operating on the incorrect side or level.
Fig. 3
Dilation. Sequential tubular dilators are placed over the appropriate disk space, and a working channel is secured.
Fig. 4
Initial intraoperative approach. ( A ) After insertion of the tubular retractor and remaining soft tissue removal, the base of the spinous process and inferior laminar edge are identified. ( B ) After exposure, unilateral or bilateral decompressions may be achieved via ipsilateral laminotomy, here started with a Kerrison rongeur. Preoperative imaging may alert the surgeon to aberrant local anatomy, such as a hypertrophied facet joint, that could potentially confuse this approach.
Fig. 5
Laminotomy. ( A ) The laminotomy is completed using a combination of Kerrison rongeurs and a high-speed drill. Care is taken to avoid facet joint violation, and the ligament is maintained until the bony removal is completed. ( B ) Fluoroscopic confirmation of the extent of exposure helps reassure the surgeon that access is obtained to all relevant pathology.
Fig. 6
Diskectomy. Disckectomy is accomplished using a combination of rongeurs and blunt instruments in standard fashion. Note the retraction of the traversing nerve root, which allows access to the disk space while protecting the nerve root and dura.
Fig. 7
Inspection. In addition to visual and tactile inspection of the nerve root, fluoroscopy may also help confirm adequate decompression prior to hemostasis, irrigation, and wound closure.

A literature review of recent high-quality studies demonstrating complications for posterior minimally invasive spinal decompression was performed. These studies were individually reviewed for further understanding of the nature and incidence of complications. The data were further aggregated across complication classes according to spinal region ( Table 1 ). Studies were included if they were designed to capture the relevant complications and sufficient data were provided to allow result aggregation. Cumulative data are shown for the cervical and lumbar regions; none of the included studies provided data regarding complications of procedures in the thoracic spine. The reported results were also compiled according to complication class ( Tables 2–5 ).

Table 1
Aggregated data regarding complications of posterior minimally invasive decompressions
Complication Rate
Cervical region
Intraoperative 6.6% (26/391)
Reoperation 1.3% (5/391)
Infectious 0.5% (2/391)
Medical 0.3% (1/391)
Lumbar region
Intraoperative 4.4% (368/8417)
Reoperation 3.5% (96/2755)
Infectious 1.4% (34/2464)
Medical 1.6% (34/2082)
Table 2
Intraoperative complications related to approach or decompression with posterior minimally invasive decompressive surgery
Author, Year n Intraoperative Complications Rate
Adamson 2001 a 100 2 Dural tears (2%) 2 Activity-related paresthesias/pain (2%) 2 Intermittent paresthesias/numbness (2%) 6/100 (6%)
Asgarzadie & Khoo, 2007 b 48 5 Dural tears (10.4%) 5/48 (10.4%)
Casal-Moro et al, 2011 b 120 5 Dural tear (3 required open surgery for sutures) (4.2%) 4 Periradicular fibrosis (3.3%) 3 Progression of diskopathy (2.5%) 3 L5 paresis (2.5%) 1 L4 paresis (0.8%) 1 Pituitary rongeur rupture (removed by open surgery) (0.8%) 1 Root puncture with microknife (0.8%) 1 Early recurrent herniation (0.8%) 1 Hernia relapse (0.8%) 1 Hernia relapse associated with periradicular fibrosis (0.8%) 21/120 (17.5%)
Castro-Menendez et al, 2009 b 50 5 Dural tears (10%) 1 Epidural hematoma causing cauda equina syndrome (2%) 6/50 (12%)
Chang et al, 2009 b 26 2 Irreparable dural tears converted to open diskectomy (7.7%) 1 Pseudomeningocele (3.8%) 3/26 (11.5%)
Garg et al, 2011 b 55 5 Dural tears (9.1%) 2 Transient S1 neuralgia (3.6%) 1 Recurrence (1.8%) 8/55 (14.5%)
Ikuta et al, 2007 b 114 12 Transient neurologic symptoms (10.5%) 6 Dural tears (5.3%) 3 Inferior facet fracture (2.6%) 21/114 (18.4%)
Jagannathan et al, 2009 a 162 9 Kyphosis (5.6%) 4 Dural tears (2.5%) 2 Nerve root injury (1.2%) 1 Hematoma (0.6%) 16/162 (9.9%)
Jhala & Mistry, 2010 b 100 7 Dural tears (7%) 5 Inadvertent removal of facet joint (5%) 4 Recurrence of herniation (3 required reoperation) (4%) 1 Nerve root damage (required conversion to open) (1%) 17/100 (17%)
Khoo & Fessler, 2002 b 25 4 Dural tears (16%) 4/25 (16%)
Lawton et al, 2012 a 38 1 CSF leak 1/38 (2.6%)
Martin-Laez et al, 2012 b 37 2 Dural tears (5.4%) 1 Radiculopathy (2.7%) 3/37 (8.1%)
Matsumoto et al, 2010 b 5609 Lumbar diskectomy (4336) 126/5609 (2.2%)
55 Dural tears (1.3%)
2 Cauda equina injury (0.05%)
4 Root injury (0.1%)
2 Hematoma (0.05%)
2 Wrong level (0.05%)
1 Wrong side (0.02%)
5 Facet fracture (0.1%)
Lumbar laminectomy/fenestration (1273)
43 Dural tears (3.4%)
1 Cauda equina injury (0.08%)
4 Hematoma (0.3%)
4 Wrong level (0.3%)
2 Facet fracture (0.2%)
1 Decubitus (0.08%)
Matsumoto et al, 2013 b 344 37 Recurrent disk herniation (22 treated with revision surgery) 37/344 (10.8%)
Pao et al, 2009 b 53 5 Dural tears (9.4%) 4 Transient neuralgia (7.5%) 2 Wrong-level operations (3.8%) 1 Instability (1.9%) 12/53 (22.6%)
Perez-Cruet et al, 2002 b 150 8 Dural tears (5.3%) 1 Pseudomeningocele (0.7%) 9/150 (6%)
Podichetty et al, 2006 b 220 17 Dural tears (7.7%) 10 Hematoma or delayed wound healing (4.5%) 7 Radicular or chronic pain unchanged from preoperative level (3.2%) 1 Foot drop (0.5%) 35/220 (15.9%)
Rahman et al, 2008 b 38 2 dural tears (5.3%) 1 Synovial cyst (2.6%) 3/38 (7.9%)
Ranjan & Lath, 2006 b 107 3 Dural tears (2.8%) 3/107 (2.8%)
Righesso et al, 2007 b 21 1 Seroma (4.8%) 1 Dural tear (4.8%) 2/21 (9.5%)
Ruetten et al, 2008 a 91 3 Transient dermatome-related hypesthesia (3.3%) 3/91 (3.3%)
Shih et al, 2011 b 23 1 Dural tear (4.3%) 1/23 (4.3%)
Teli et al, 2010 b 70 8 Recurrence of herniation (11.4%) 6 Dural tears (8.6%) 2 Root injury (2.9%) 2 Worsening deficit (2.9%) 18/70 (25.7%)
Wang et al, 2012 b 151 5 Dural tears (3.3%) 5/151 (3.3%)
Wu et al, 2006 b 873 14 Dural tears (1.6%) 3 Acute hematomas of the sacrospinalis (0.3%) 17/873 (1.9%)
Xu et al, 2010 b 32 2 Dural tears (6.3%) 2/32 (6.3%)
Zhou et al, 2009 b 151 5 Recurrence of herniation (3.3%) 5 Dural tears (3.3%) 10/151 (6.6%)

a Denotes cervical spinal region described in studies.

b Denotes lumbar spinal region described in studies.

Table 3
Reoperation rates of posterior minimally invasive decompressions
Author, Year n Reoperation Rates and Associated Complications Rate
Casal-Moro et al, 2011 b 120 4 Periradicular fibrosis (3.3%) 3 Progression of diskopathy (2.5%) 1 Hernia relapse (0.8%) 1 Hernia relapse associated with periradicular fibrosis (0.8%) 9/120 (7.5%)
Castro-Menendez et al, 2009 b 50 3 Clinical relapse and/or epidural fibrosis (6%) 2 Secondary lumbar instability requiring fusion (4%) 1 Epidural hematoma (2%) 6/50 (12%)
Chang et al, 2009 b 26 2 Irreparable dural tears (7.7%) 1 Reoperation for pseudomeningocele (3.8%) 3/26 (11.5%)
Garg et al, 2011 b 55 1 Recurrent disk herniation 1/55 (1.8%)
Ikuta et al, 2007 b 114 1 Cauda equina herniation (0.9%) 1/114 (0.9%)
Jagannathan et al, 2009 a 162 1 Postoperative hematoma (0.6%) 1 Deep wound infection (0.6%) 2/162 (1.2%)
Jhala & Mistry, 2010 b 100 3 Recurrent disk herniation (3%) 1 Nerve root damage (1%) 1 Débridement and interbody fusion for diskitis (1%) 5/100 (5%)
Matsumoto et al, 2013 b 344 22 Recurrent disk herniation 22/344 (6.4%)
Matsumoto et al, 2010 b 5609 Lumbar diskectomy (4336) 6/5609 (0.1%)
4 Open conversion (0.1%)
Lumbar laminectomy/fenestration (1273)
2 Open conversion (0.2%)
Perez-Cruet et al, 2002 b 150 4 Recurrent disk herniation 4/150 (2.7%)
Podichetty et al, 2006 b 220 2 Facet fractures requiring later surgery (0.9%) 1 Required instrumented fusion (0.5%) 3/220 (1.4%)
Rahman et al, 2008 b 38 1 Dural tear (resulted in conversion to open) 1/38 (2.6%)
Ranjan & Lath, 2006 b 107 2 Recurrent disk herniation 2/107 (1.9%)
Righesso et al, 2007 b 21 1 Recurrent disk herniation 1/21 (4.8%)
Ruetten et al, 2008 a 91 3 Reoperations for recurrence 3/91 (3.3%)
Teli et al, 2010 b 70 8 Recurrent disk herniation 8/70 (11.4%)
Wang et al, 2012 b 151 5 Revisions (open diskectomies) 5/151 (3.3%)
Wu et al, 2006 b 873 10 Segmental instability or displacement (1.1%) 6 Recurrent herniations (0.7%) 2 Herniations at different level (0.2%) 2 Lumbar stenosis involving several segments after MED procedures (0.2%) 20/873 (2.3%)
Zhou et al, 2009 b 151 5 Revisions due to recurrence of herniation 5/151 (3.3%)

a Denotes cervical spinal region described in studies.

b Denotes lumbar spinal region described in studies.

Table 4
Infectious complications of posterior minimally invasive decompressions
Author, Year n Infectious Complications Rate
Adamson 2001 a 100 1 Superficial wound infection 1/100 (1%)
Casal-Moro et al, 2011 b 120 1 Diskitis 1/120 (0.8%)
Castro-Menendez et al, 2009 b 50 2 Superficial wound infections 2/50 (4%)
Chang et al, 2009 b 26 2 Superficial wound infections 2/26 (7.7%)
Jagannathan et al, 2009 a 162 1 Deep wound infection 1/162 (0.6%)
Jhala & Mistry, 2010 b 100 4 Diskitis 4/100 (4%)
Perez-Cruet et al, 2002 b 150 1 Superficial wound infection 1/150 (0.7%)
Podichetty et al, 2006 b 220 3 Superficial wound infection (1.4%) 1 Diskitis (0.5%) 1 Epidural abscess (0.5%) 5/220 (2.3%)
Rahman et al, 2008 b 38 1 Superficial wound infection 1/38 (2.6%)
Ranjan & Lath, 2006 b 107 1 Superficial wound infection (0.8%) 1 Diskitis (0.8%) 2/107 (1.9%)
Teli et al, 2010 b 70 1 Spondylodiskitis 1/70 (1.4%)
Wang et al, 2012 b 151 3 Spinal spondylodiskitis 3/151 (2%)
Wu et al, 2006 b 873 5 Diskitis (0.6%) 4 Superficial wound infection (0.5%) 9/873 (1%)
Zhou et al, 2009 b 151 3 Vertebral/disk infection 3/151 (2%)

a Denotes cervical spinal region described in studies.

b Denotes lumbar spinal region described in studies.

Table 5
Medical complications of posterior procedures
Author, Year n Medical Complications Rate
Casal-Moro et al, 2011 b 120 1 DVT 1/120 (0.8%)
Garg et al, 2011 b 55 4 Temporary urinary retention 4/55 (7.3%)
Jagannathan et al, 2009 a 162 1 MI 1/162 (0.6%)
Khoo & Fessler, 2002 b 25 5 Medical complications (unspecified) 5/25 (20%)
Podichetty et al, 2006 b 220 6 Urinary retention (2.7%) 1 Prolonged nausea (0.5%) 1 Atelectasis (0.5%) 1 MI (0.5%) 1 Pneumonia (0.5%) 1 CHF exacerbation (0.5%) 1 Pneumonia and cerebrovascular accident (0.5%) 12/220 (5.4%)
Shih et al, 2011 b 23 3 Urinary retention 3/23 (13%)
Wu et al, 2006 b 873 7 Acute urinary retention (0.8%) 2 Acute gastritis (0.2%) 9/873 (1.0%)

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Oct 12, 2017 | Posted by in NEUROSURGERY | Comments Off on Complications Associated with Posterior Approaches in Minimally Invasive Spine Decompression

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