Overview and Prevention of Complications During Biportal Endoscopic Cervical Spine Surgery

Article information

J Minim Invasive Spine Surg Tech. 2023;8(Suppl 1):S51-S55

Publication date (electronic) : 2023 July 31

doi : https://doi.org/10.21182/jmisst.2023.00808

Sanghun Park, Jung Hwan Lee, ChungKee Chough

Department of Neurosurgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Corresponding Author: Jung Hwan Lee Department of Neurosurgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10 63(yuksam)-ro, Yeongdeungpo-gu, Seoul 07345, Korea Email: medi98@hanmail.net

Received 2023 May 15; Revised 2023 June 19; Accepted 2023 July 3.

Abstract

INTRODUCTION

Biportal endoscopic spine surgery is rapidly gaining its popularity among spine surgeons all around the world and expanding its application to various spinal pathologies [1]. In the early days, relatively easy and common lumbar decompressive surgery and discectomy were mostly performed, but with the experience of spine surgeons and technical advancements, it is being applied to more challenging and technically demanding cases, such as cervical and thoracic spine diseases [1-3]. However, the safety and efficacy of biportal endoscopic spine surgery in the cervical spine have not yet been fully investigated, and careless attempts by inexperienced and unprepared spine surgeons can cause catastrophic complications. According to our experience, biportal endoscopic cervical spine surgery (BECSS) was not easy at first, even for experienced spine surgeons. It was difficult to determine the exact anatomical orientation and location and achieve complete epidural bleeding control during surgery.

The aim of this study is to evaluate complications of BECSS via available literature reviews and retrospective analysis of our case series. Additionally, the authors aim to identify tips for preventing complications by reviewing literature.

MATERIALS AND METHODS

RESULTS

2. Clinical Data

A total of 227 cases of BECSS were identified in 6 articles. Among them, laminectomy for cord decompression was performed in 19 cases and foraminotomy for nerve root decompression was performed in 208 cases. In 157 cases, discectomy was performed during foraminotomy. In our series, laminectomy for cord decompression was performed in a case, and foraminotomy was performed in the remaining 44 cases. Among the patients who underwent foraminotomy, 21 cases underwent discectomy. The demographic data of the patients are summarized in Table 1.

Table 1.

Demographic data of patients in the included studies

3. Complications

Among 272 cases of BECSS in previous articles and our cases, 16 complications were reported, thus the overall complication rate was 5.9%. The types of complications reported in previous articles and our cases were dura tearing, symptom recurrence, incomplete decompression, postoperative epidural hematoma, and transient paralysis. As a result, reoperation was performed in 3 cases due to incomplete decompression, symptom recurrence and symptomatic postoperative epidural hematoma (Table 2).

Table 2.

Complications of biportal endoscopic cervical spine surgery

DISCUSSION

Currently, when searching the literature, BECSS is performed only with a posterior approach and decompression [3-8]. Similar minimally invasive techniques included the microscopic surgery and the full-endoscopic surgery [6,9,10]. Complications of these surgical techniques are well known via previous articles. Wu et al. [9] reported a complication rate of 0%–18.2% in the full-endoscopic surgery, and reported complication types such as dural tear, transient root palsy, and wound infection. In another article, reported complications included paresthesia, transient motor weakness, palsy, superficial wound infection, postoperative hematoma, and dura tear. And, the complication rate of full-endoscopic surgery was reported to be lower than that of anterior cervical discectomy and fusion [11]. Even in minimally invasive microscopic surgery, a complication rate of 0%–14.3% has been reported, and types of complications were reported as symptom recurrence, paresthesia, and wound infection [10]. Compared with other surgical techniques, the overall complications of BECSS are thought to be similar. Kim et al. [6] directly compared these 3 techniques, and reported that there was no significant difference in frequency or type of complications.

There are several causes of neurological deficit such as hypesthesia, paresthesia or paralysis after the endoscopic spine surgery. It may be a 'normal' postoperative change resulting from revascularization of decompressed nerves [12,13]. However, these symptoms do not last very long. Therefore, reimaging is warranted if these symptoms persist for more than 72 hours [14]. There were some reports that these neurological deficits are related to thermal injury that occurred during surgery [9,15]. To prevent this, care must be taken during coagulation around the nerve [14]. In addition, direct contusion on the nerve during surgery can also cause these neurological deficits, so careful manipulation is always needed [14]. Unlike lumbar spine, there was a very rare case report in which paralysis occurred due to spinal cord injury during endoscopic cervical spine surgery [15]. If excessive force is used in the process of inserting a dilator or tubular retractor, shock can be caused between the lamina. Therefore, when inserting a dilator or tubular retractor, be sure to incise the fascia and perform blunt dissection so as not to apply excessive force [14].

To prevent incomplete decompression during foraminotomy, after sufficient drilling bone, the ligament flavum must be sufficiently removed before disectomy [14]. Similar to other surgical techniques, dura tearing occurs often, but there is no clear way to prevent it [9,16]. In endoscopic spine surgery, dura tearing is usually a small punctate lesion, and it is recommended to use sealants such as fibrin glue [14,16,17]. On the other hand, large dura tearing that causes symptoms requires repairing dura, which usually requires a change into the open surgery [16,17]. However, since there were several technical reports on how to repair dura under the endoscopic environment, it would be necessary to apply it depending on the situation [16-18].

There is a lot of interest in long-term complications such as cervical kyphosis and segmental instability after cervical posterior approach surgery [14,19]. However, nothing has been confirmed about BECSS. Therefore, it is thought that long-term follow-up data will be needed in the future. Maintaining a facet joint of 50% or more, a well-known technique to prevent cervical spine instability, will be important in preventing such complication [14,20].

There are several limitations to this article. Following review only 6 studies were included that met inclusion/exclusion criteria. And, relatively short follow-up time and small cohort size were additionally limited. In order to determine more accurate and specific complications of BECSS and to prevent them, continuously large and prospective research will be needed in the future.

CONCLUSION

Complications of BECSS did not show a significant difference compared to other surgical techniques. In order to prevent these complications as much as possible, extensive education and sharing of knowledge and experience will be required, as in other spinal surgeries. And, a lot of research by all endoscopic spine surgeons will be needed to present good results to patients.

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