Incidence, Management, and Cost of Complications After Transforaminal Endoscopic Decompression Surgery for Lumbar Foraminal and Lateral Recess Stenosis: A Value Proposition for Outpatient Ambulatory Surgery

Kai-Uwe Lewandrowski
International Journal of Spine Surgery 2019, 13 (1): 53-67

Objective: The objective of this study is to analyze incidence, estimate cost savings, and evaluate best management practices of complications resulting from outpatient transforaminal endoscopic decompression surgery for lumbar foraminal and lateral recess stenosis performed in an ambulatory surgery center.

Background: Endoscopic spinal surgery is gaining popularity for the treatment of lumbar disc herniations. Recent advances in surgical techniques allow for endoscopically assisted bony decompression for neurogenic claudication symptoms due to spinal stenosis. Postoperative complications from dural tears, recurrent disc herniations, nerve root injuries, foot drop, and facet and pedicle fractures, and postoperative sequelae such as dysesthetic leg pain and infiltration of the surgical access and spinal canal with irrigation fluid causing spinal headaches and painful wound swelling, as well as failure to cure, have been reported.

Methods: A retrospective study of 1839 consecutive patients with an average mean follow up of 33 months (range: 24 to 85 months) that underwent transforaminal endoscopic decompression surgery at 2076 levels between 2006 and 2015 was conducted to analyze incidence, and estimate the cost savings of postoperative adverse events following endoscopic foraminotomy and microdiscectomy. Complications were stratified using Dindo's 7-category grading system, distinguishing them from procedure-inherent sequelae as well as failure to cure. Only patients with unilateral radiculopathy due to either herniated disc or lateral recess stenosis were included in this study. Preoperatively, disc migration was graded by direction and distance from the disc space according to Lee's radiologic 4-zone classification. The type of disc herniation was classified either as contained or extruded. Contained herniations were further subclassified as disc protrusions versus disc bulges. In addition, the preoperative disc height was recorded. Bony spinal foraminal stenosis and lateral recess stenosis were graded on preoperative magnetic resonance imaging and computed tomography scans into mild, moderate, and severe by dividing the lumbar neuroforamen into 3 zones: (1) entry zone, (2) midzone, and (3) exit zone. Surgical outcomes were classified according to the Macnab criteria. In addition, reduction in the visual analog scale (VAS) scores were assessed.

Results: According to the Macnab criteria, excellent and good results were obtained in 82.2% of patients with extruded disc fragment (331/1839). In this group, the mean VAS score decreased from 5.9 ± 2.5 preoperatively to 2.4 ± 1.8 at final follow-up ( P  < .01). Patients with contained disc herniations (648/1839) had excellent and good results 72.7% of the time. In this group, the mean VAS score decreased from 7.2 ± 1.6 preoperatively to 3.1 ± 1.5 at final follow-up ( P  < .01). In the spinal stenosis group (860/1839), 75% of patients had excellent to good results. Postoperative grade I complications (any deviation from normal postoperative course treated with observation) occurred in 2 patients who immediately developed foot drop postoperatively on the surgical side (0.11%) and in another 2 patients (0.11%) with incidental durotomy. Grade II complications (any deviation with pharmacological interventions) occurred in 11 patients due to chronic obstructive pulmonary disease exacerbation, and in another 2 patients due to infections as the latter were successfully treated with antibiotics. Grade IIIb complications (any deviation requiring surgical, endoscopic, or radiological intervention under general anesthesia) occurred in 9 patients with reherniations of extruded discs within the first 3 postoperative months (recurrence rate 2.7%). Reherniations were associated with preserved disc height of > 6 mm ( P  < .02). Grade IV (organ failure), and grade V (death) complications did not occur. Procedure-inherent sequelae from adverse operative side effects were noted in 8 patients with spinal headaches (0.44%), and in 69 patients (3.75%), who had extravasations of irrigation fluid into the subcutaneous tissues causing wound swelling. Another 229 patients developed postoperative dysesthetic leg pain due to irritation of the dorsal root ganglion (12.45%), which was associated with severe foraminal stenosis ( P  < .01) and improved with supportive care in all cases. Failure to cure occurred in 39 patients (2.12%) with bony stenosis in the central canal, and lateral recess involving the entry zone of the neuroforamen and in 41 patients (2.23%) with contained disc herniations.

Conclusions: Complications after outpatient transforaminal endoscopic decompression surgery with respect to reherniation, wound infections, durotomy, and nerve root injury are approximately 1 magnitude lower than equivalent reported complication rates with microdiscectomy while delivering comparable clinical outcomes and lower readmission rates to an emergency room or hospital. Postoperative sequelae are typically self-limiting and successfully managed with supportive care measures. Significant cost savings are realized due to a considerably lower rate of decompensated postoperative medical problems.

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