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MBBS, DNB ORTHOPAEDIC SURGERY MNAMS FMISS & FMISSAB
( SPINE SURGERY)
A Prospective Study of the Accidental Durotomies in
Microendoscopic Lumbar Spine Decompression
Surgeries. Incidence, Surgical Outcomes, Postoperative
Patient Mobilization Protocol.
Abhijith Shetty1, Manikant Anand1, Praveen Goparaju1, Vishal Kundnani1, Ameya Rangnekar1, Nikhil Dewnany2, Saijyoth Raut1, Amit Chugh1
Objective: To study the incidence, risk factors, surgical outcomes of accidental durotomies (ADT)
in patients of microendoscopic lumbar decompression surgeries (MLDS) and the postoperative
patient mobilization protocol.
Methods: A total of 550 patients who underwent MLDS from January 2012 to march 2020 under single surgeon and single institute were included in the study and incidence of ADT risk factors like age, BMI, smoking status, diabetes mellitus, surgeon’s experience were studied for the
same and early mobilization protocol for all the patients was followed.
Results: Age >60 years (p=0.0062), bilateral decompression with unilateral approach, surgeons experience in the first 3 years over next 5 years (p=0.037) were the statistically significant risk factors for increased incidence of ADT. Most of the ADT were small which did not require primary repair and managed with sealants like gelfoam and fibrin glue. Postoperative recovery in JOA and ODI scores in both ADT and non ADT cohorts were same.
Conclusion: MISS has low incidence of ADT and age >60 years and surgical technique of bilateral decompression with unilateral approach and surgeons expertise are the significant risk factors. MISS also has less risk of CSF leak symptoms and pseudomeningocele formation because
of limited dead space formation in the soft tissue which helps in early postoperative mobilization and reduces the duration of hospital stay.
Key Words: Accidental durotomy, Microendoscopic disectomy, Gelfoam, Cerebrospinal fluid
leak, Surgeons experience
Awake Microtubular Spinal Decompression: A Step Towards Better Peri Operative Patient Safety, and Satisfaction
Goparaju VNR Praveen , Amit Chugh , Ameya Rangnekar , Vishal Kundnani , Mani Kant Anand , Abhijith Shetty
Introduction: Microtubular decompression (MTD) being a short-duration surgery, with many advantages has gained popularity and can
be done either in general anaesthesia (GA) or awake techniques like spinal anaesthesia (SA). The authors ventured to assess perioperative
parameters, quantify peri-operative complications as the primary aim and determine patient satisfaction as the secondary aim of the study.
Materials and Methods: It was a retrospective study performed over a period of ten years (2009–2019) and included 625 patients. The
patients included were aged greater than 18 years, American Society of Anaesthesiologists (ASA) score 1, 2, or 3. Patients with ASA 4 or 5,
spinal instability, infection, or revision surgeries were excluded.
Results: There is no significant difference in the complication rates. The clinical outcome in the form of VAS and ODI score showed
significant differences both in SA and GA groups at final follow-up. The total anaesthetic, surgical times, the mean arterial pressure (MAP),
and the heart rate (HR) perioperatively were longer in the GA group (P < 0.05). The perioperative blood pressures are lower in the SA group.
The dissatisfaction rate is about 3.5%, of which the patients and a total of 88.5% of patients would like to opt for SA for future surgeries.
Conclusion: This study represents the ten-year experience with MTD operated either with SA or GA. Awake spinal surgery is promising
and has the glaring benefits of better peri-operative hemodynamic stability, and faster recovery with reduced surgical and anaesthetic
duration. Dissatisfaction rates can be decreased by better explanation and the patient’s decision.
Keywords: Awake spine surgery, Microtubular decompression, Hemodynamic parameters, Complications, Patient satisfaction.
Efficiency of Spinal Anaesthesia Versus General Anaesthesia for Single Level Lumbar Micro-Discectomy Prospective Analysis of 50 Patients: An Observational Study
Ashutosh.C. Tripathi, Chaitanya Chikhale, Ganesh N. Pundkar, Rajendra.W. Baitule, Yogesh Rathod, Sanjeev Jaiswal.
Background: In most of the institutes Lumbar Microdiscectomy surgery is done under general anaesthesia . However it is not Uncommon to
do these surgeries under spinal anaesthesia
Aims and objectives: To compare the analgesic effectiveness in postoperative pain, cost effectiveness and complications of spinal
anaesthesia and general anaesthesia who underwent single level lumbar microdiscectomy under general anaesthesia vs who were
administered spinal anaesthesia for the same
Materials and methods: A prospective observational study was conducted on patients undergoing lumbar micro-discectomy in the
department of orthopaedics of a tertiary care hospital in Maharashtra, India. The study duration was two years (January 2020 to December
2020). The patients older than 18 years who were not responding to 6 weeks of conservative therapy, epidural steroid injection,
physiotherapy, and having low back pain with radiculopathy with claudication with or without neurological deficit were included in the
study. We included 25 cases each in the spinal anaesthesia (SA) and general anaesthesia (GA) group. Outcome variables like peri-operative
complications (blood loss, urinary retention, PONV), surgery length, length of stay (LOS), time from entering OT to incision, time from
bandaging to exit time, and time of stay in the recovery room were studied among both the groups. Chi-square or fishers exact test to test the
difference between proportions and student t-test to test between the means were statistical tests used.
Results:The VAS score reduction immediately post operative among GA group was 79% and SA group was 75% and this difference was not
significant. (p>0.05)The time from post anaesthesia care unit from operation theatre (GA Vs. SA; 60.44 minutes Vs. 20.45 minutes) , time of
surgery (time to enter in OT to incision) (GA Vs. SA; 30.22 minutes Vs. 15.55 minutes), time from bandaging to exit from OT (GA Vs. SA;
16.34 minutes Vs. 6.12 minutes) and average hospital stay (GA Vs. SA; 3.05 days Vs. 1.61 days) were significantly higher among GA group
when compared to SA group. (p<0.05) The average cost of procedure among GA group was 26500 INR and among SA group was 18500
INR. (p<0.05)
Conclusions:In terms of VAS pain score reduction, SA was comparable with GA. Our study showed that SA was superior to GA in terms of
time consumption, cost, and hospital stay while maintaining better perioperative hemodynamic stability without increasing adverse side
effects.
Keywords:Lumbar micro-discectomy, Spinal anaesthesia, General anaesthesia, Cost effectiveness
Awake spinal fusion: a retrospective analysis of minimal invasive single
level transforaminal lumbar interbody fusion done under spinal anaesthesia in 150 cases
Ameya Rangnekar, Mani K. Anand*, Praveen Goparaju, Amit Chugh,
Abhijith Shetty, Saijyot Raut, Vishal Kundnan
Background: Spinal anaesthesia carries the advantage of having rapid onset, lesser blood loss, early recovery and
hospital stay as compared to general anaesthesia. The present study evaluated outcomes of awake spinal fusion i.e.,
minimal invasive single level transforaminal lumbar interbody fusion (MIS-TLIF) under spinal anaesthesia. Current
study is a retrospective analysis of prospectively collected data carried to assess patient related outcome benefits for a
single level transforaminal lumbar interbody fusion done under spinal anaesthesia.
Methods: Patients who fit deemed criteria not responding to 6 weeks of conservative treatment to lumbar
degenerative pathologies underwent MIS-TLIF. The demographic data, visual analogue pain scale (VAS), Oswestry
disability index (ODI), blood loss, time from entering operation theatre to time of incision, time of bandaging to exit
from operation theatre, time of stay in post anaesthesia care unit (PACU), duration of surgery, nausea/vomiting,
urinary retention, requirement of analgesics, duration of stay in hospital, peri-operative complications, fusion rate and
satisfaction score were compiled and assessed.
Results: 150 patients were operated with MISTLIF under spinal anaesthesia. VAS and ODI score improved
significantly at final follow up (p<0.05). The mean duration of surgery was 148±18.24 minutes and blood loss were
109.64±110.45 ml. The average time from entering OT to incision and bandaging to exit was respectively 27.32±8.44
and 6.43±3.28 minutes. Mean PACU time was 36.74±6.32 minutes while duration of stay averaged 1.58±0.67 days.
Post operative analgesia requirement was in 10.6% patients and radiographic fusion was observed in 96.6% patients.
90.6% patients were fully satisfied with spinal anaesthesia.
Conclusions: Awake spinal fusion should be considered as a novel surgical approach with newer minimal invasive
surgical techniques and regional anaesthesia to improve patient satisfaction and overall surgical outcome.
Keywords: Spinal anaesthesia, Spinal fusion, TLIF, ODI, VAS, MIS TLIF
Efficiency of Spinal Anesthesia versus General Anesthesia for Minimal Invasive Single Level Transforaminal Lumbar Interbody Fusion: A Retrospective Analysis of 178 Patients
Ameya Rangnekar, Goparaju VNR Praveen, Amit Chugh, Saijyot Raut, Vishal Kundnani
Objective: To evaluate the efficacy of spinal anesthesia in patients undergoing minimal invasive
single level transforaminal lumbar interbody fusion (MIS TLIF) surgery and to compare the results with that of general anesthesia.
Method: 178 patients were included in the study, 86 were in general anesthesia and 92 were in
spinal anesthesia. Patients aged between 20 to 70 years who had undergone MIS TLIF not responding to 6 weeks of conservative treatment were included. The routine steps of anesthesia
for both general and spinal anesthesia were adhered. The visual analogue scale, blood loss, duration of surgery, time from entering operation theatre to time of incision, time of bandaging to
exit from operation theatre, time of stay in Post Anesthesia Care Unit (PACU), nausea/vomiting,
urinary retention, duration of stay in hospital, peri-operative complications were compiled and
assessed. Appropriate statistical analysis was applied.
Results: The mean time for entering the operation theatre to the incision; mean time from bandaging to the exit; mean PACU time and the mean hospital stay were significantly lower in the
spinal anesthesia group (p<0.05). The other parameters are comparable except, urinary retention which was significantly higher in spinal anesthesia group (p<0.05).
Conclusion: Spinal anesthesia offers efficient operating room functioning with decreasing
overall operation theatre time. It is very efficient alternative technique to general anesthesia
which can be considered for elective lumbar surgeries with a lower late of adverse events especially at lower lumbar levels.
Key Words: Spinal anesthesia, General anesthesia, Lumbar surgery, Visual analog scale, Minimal
invasive single level transforaminal lumbar interbody fusion
Safety, efficacy, surgical, and radiological outcomes of short segment occipital plate and C2 transarticular screw construct for occipito‑cervical instability
Objective: Our study aims to assess the safety, efficacy, clinicoradiological, functional, neurological outcomes, and complications of posterior
occipitocervical fixation using an occipital plate and C1‑2 transarticular screw (TAS) construct.
Study Design: This was a retrospective analysis of prospectively collected data.
Methods: Data of 27 patients who underwent occipital plate and C1‑2 TAS construct at a single institute from 2010 to 2015 were collected
and analyzed. Demographics, clinical parameters (Visual Analog Score, Oswestry Disability Index, and modified JOA score), radiological
parameters – mean atlantodens interval, posterior occipitocervical angle, occipitocervical‑2 angle, surgical parameters (operative time, blood
loss, hospital stay, and fusion), and complications were evaluated.
Results: The mean age of the patients was 54.074 ± 16.52 years (18–81 years), the mean operative time was 116.29 ± 12.23 min, and the
mean blood loss was 196.29 ± 38.94 ml. The mean hospital stay was 5.22 ± 1.28 days. The mean ± standard deviation follow‑up duration was
62.52 ± 2.27 months. There was a significant improvement in clinical parameters and radiological parameters postoperatively. One patient with
implant failure, one patient with pseudoarthrosis, one with neurological deterioration, two wound complications, and two dural tears were noted.
Conclusion: Posterior occipitocervical reconstruction with O‑C1‑2 TAS construct provided excellent clinical outcomes, radiological outcomes, optimal
correction of malalignment in the occipitocervical region, and with biomechanically sound fixation. Extending the instrumentation into the subaxial
spine will lead to a decrease in the range of motion, increased surgical time, blood loss, more extensive muscle damage, and also increase the costs.
Keywords: Occipital plate C1-2 Transarticular screw construct, occipitocervical instability, short segment construct
Peri-operative Management and the Role of Minimally
Invasive Spine Surgery in a Case of Hemophilia B
VNR Praveen Goparaju, Amit Chugh, Ameya Rangnekar, Vishal Kundnani
Hemophilia A and B are rare X-chromosome-linked recessive bleeding disorders caused by mutations in the genes causing abnormalities of blood clotting factors VIII and IX, respectively.
Surgery in these patients will require additional planning and interaction among the surgeon,
anesthetist, and a hematologist because they inevitably result in bleeding, excessive blood loss,
and other life-threatening complications. The authors present a case 62-year-old male with
haemophilia B and progressive neurological claudication. On plain radiographs and MRI the patient had grade 1 spondylolisthesis with lumbar canal stenosis at L4-L5 with a VAS score of 8
and ODI score of 45 and was operated with MIS-TLIF with 22 mm diameter tubular retractor
(METRx, Medtronics) and an operating microscope. Pre-operatively, the hematologist opinion
was taken and the patient was optimised by maintaining the plasma factor peak level activity
according to the WFH guidelines. The patient had uneventful peri-operative period. The total
hospital stay is 16 days and a VAS score of 3 and ODI score of 12 after one-year follow-up and
without any notable complications. Minimally invasive surgical techniques are a better option
in hemophilia patients as these techniques provide the surgeon with an excellent magnification
of the operative field, which enables the use of a smaller incision, better hemostasis, and facilitates less traumatic procedures.
Key Words: Hemophilia B, Factor IX, Minimally invasive surgery, spinal fusion, Spine, Surgical
blood loss