Ultrasonic bone scalpel for thoracic spinal decompression: case series and technical note

Chuiguo Sun, Guanghui Chen, Tianqi Fan, Weishi Li, Zhaoqing Guo, Qiang Qi, Yan Zeng, Woquan Zhong, Zhongqiang Chen, Chuiguo Sun, Guanghui Chen, Tianqi Fan, Weishi Li, Zhaoqing Guo, Qiang Qi, Yan Zeng, Woquan Zhong, Zhongqiang Chen

Abstract

Background: Thoracic spinal stenosis (TSS) is a rare but intractable disease that fails to respond to conservative treatment. Thoracic spinal decompression, which is traditionally performed using high-speed drills and Kerrison rongeurs, is a time-consuming and technically challenging task. Unfavorable outcomes and high incidence of complications are the major concerns. The development and adaptation of ultrasonic bone scalpel (UBS) have promoted its application in various spinal operations, but its application and standard operating procedure in thoracic decompression have not been fully clarified. Therefore, the purpose of this study is to describe our experience and technique note of using UBS and come up with a standard surgical procedure for thoracic spinal decompression.

Methods: A consecutive of 28 patients with TSS who underwent posterior thoracic spinal decompression surgery with UBS between December 2014 and May 2015 was enrolled in this study. The demographic data, perioperative complications, operation time, estimated blood loss, and pre- and postoperative neurological statuses were recorded and analyzed. Neurological status was evaluated with a modified Japanese Orthopaedic Association (JOA) scale, and the neurological recovery rate was calculated using the Hirabayashi's Method.

Results: Thoracic spinal decompression surgery was successfully carried out in all cases via a single posterior approach. The average age at surgery was 49.7 ± 8.5 years. The mean operative time of single-segment laminectomy was 3.0 ± 1.4 min, and the blood loss was 108.3 ± 47.3 ml. In circumferential decompression, the average blood loss was 513.8 ± 217.0 ml. Two cases of instrument-related nerve root injury occurred during operation and were cured by conservative treatment. Six patients experienced cerebrospinal fluid (CSF) leakage postoperatively, but no related complications were observed. The mean follow-up period was 39.7 ± 8.9 months, the average JOA score increased from 4.7 before surgery to 10.1 postoperatively, and the average recovery rate was 85.8%.

Conclusions: The UBS is an optimal instrument for thoracic spinal decompression, and its application enables surgeons to decompress the thoracic spinal cord safely and effectively. This standard operating procedure is expected to help achieve favorable outcomes and can be used to treat various pathologies leading to TSS.

Keywords: Complication; High-speed drill; Laminectomy; Thoracic spinal stenosis; Ultrasonic bone scalpel.

Conflict of interest statement

Not applicable

Figures

Fig. 1
Fig. 1
a Ultrasonic osteotomy system XD860A. b Handpiece equipped with a straight tip. c Angled tip (left) and straight tip (right)
Fig. 2
Fig. 2
Schematic diagrams of thoracic spinal circumferential decompression with UBS. a Expose the lamina and transverse processes of diseased segments. b Cut through the lamina and ossified ligament flava along the middle line of bilateral facet joints. c Separate the adhesion of ossified ligaments and the dura mater and remove the lamina and OLF integrally. d Resect bilateral facet joints and expose the nerve root and intervertebral disk. e Remove partial intervertebral disk, create an interconnected passage at the ventral side of OPLL, and thinning, and remove the ossified lesions. UBS, ultrasonic bone scalpel; OLF, ossification of the ligamentum flavum; OPLL, ossification of posterior longitudinal ligament
Fig. 3
Fig. 3
The intraoperative images of a standard operating procedure for circumferential decompression with UBS. a Expose the lamina and transverse processes. b Pry and amputate the lamina. c Separate the adhesion of the ossified ligament and the dura mater. d En bloc resection of the lamina and ossified ligamentum flavum. e Resect the facet joints. f Cut the base of OPLL with a specific designed angled tip. g Complete decompression. h The resected OPLL mass. i Pressurized fixation with screw-rod system
Fig. 4
Fig. 4
Illustrative case presentation (case 18). a–c Preoperative X-ray, sagittal MRI, and CT images reveal multiple segment OPLL and isolated OLF in the thoracic spine. d Axial CT image indicates decompression segment OPLL. e Axial CT image shows complete resection of OPLL. f–g Postoperative X-ray and CT images show OPLL resection and stable internal fixation. OPLL, ossification of posterior longitudinal ligament; OLF, ossification of the ligamentum flavum

References

    1. Gao R, Wen Y, Yang L, et al. Clinical features and surgical outcomes of patients with thoracic myelopathy caused by multilevel ossification of the ligamentum flavum. Spine J. 2013;13:1032–1038.
    1. Hou X, Sun C, Liu X, et al. Clinical features of thoracic spinal stenosis-associated myelopathy: a retrospective analysis of 427 cases. Clin Spine Surg. 2016;29(2):86–89.
    1. Jia LS, X-s C, S-y Z, et al. En Bloc Resection of lamina and ossified ligamentum flavum in the treatment of thoracic Ossification of the ligamentum flavum. Neurosurgery. 2010;66:1181–1186.
    1. Kim CH, Renaldo N, Chung CK, et al. Use of an ultrasonic osteotome for direct removal of beak-type ossification of posterior longitudinal ligament in the thoracic spine. J Korean Neurosurg Soc. 2015;58:571–577.
    1. Liu XW, Li TF, Shi L, et al. Application of piezosurgery in en bloc laminectomy for the treatment of multilevel thoracic ossification of ligamentum flavum. World Neurosurg. 2019;126:541–546.
    1. Kato S, Murakami H, Demura S, et al. Novel surgical technique for ossification of posterior longitudinal ligament in the thoracic spine. J Neurosurg Spine. 2012;17:525–529.
    1. Kim CH, Chung CK, Choi Y, et al. The efficacy of ultrasonic bone scalpel for unilateral cervical open-door laminoplasty: a randomized controlled trial. neurosurgery. 2019; undefined:undefined.
    1. Nakagawa H, Kim S-D, Mizuno J, et al. Technical advantages of an ultrasonic bone curette in spinal surgery. J Neurosurg Spine. 2005;2:431–435.
    1. Paolo C, Cavallo LM, Isabella E, et al. Bone removal with a new ultrasonic bone curette during endoscopic endonasal approach to the sellar-suprasellar area: technical note. Neurosurgery. 2010;66:E118.
    1. Hirabayashi K, Miyakawa J, Satomi K, et al. Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine. 1981;6(4):354–364.
    1. Sawamura Y, Fukushima T, Terasaka S, et al. Development of a handpiece and probes for a microsurgical ultrasonic aspirator: instrumentation and application. Neurosurgery. 1999;45:1192–1198.
    1. Onishi E, Yasuda T, Yamamoto H, Iwaki K, Ota S. Outcomes of surgical treatment for thoracic myelopathy: a single-institutional study of 73 patients. Spine (Phila Pa 1976) 2016;41(22):E1356–E1363.
    1. Shiro I, Kei A, Kazuhiro T, et al. Perioperative complications after surgery for thoracic ossification of posterior longitudinal ligament: a nationwide multicenter prospective study. Spine. 2018;43:E1389–E1E97.
    1. Masashi Y, Makondo M, Yoshikazu I, et al. Clinical results of surgery for thoracic myelopathy caused by ossification of the posterior longitudinal ligament: operative indication of posterior decompression with instrumented fusion. Spine. 2006;31(13):1452–1460.
    1. Xin-Zhi S, Zhong-Qiang C, Qiang Q, et al. Diagnosis and treatment of ossification of the ligamentum flavum associated with dural ossification: clinical article. J Neurosurg Spine. 2011;15(4):386–392.
    1. Parker Scott L, Kretzer Ryan M, Recinos Pablo F, et al. Ultrasonic BoneScalpel for osteoplastic laminoplasty in the resection of intradural spinal pathology: case series and technical note. Neurosurgery. 2013;73:ons61–ons66.
    1. Lu X-D, Yi-Bo Z, Xiao-Feng Z, et al. Efficacy and safety analysis of ultrasonic bone curette in the treatment of thoracic spinal stenosis. Orthop Surg. 2019;11:1180–1186.
    1. Satoshi K, Hideki M, Satoru D, et al. Indication for anterior spinal cord decompression via a posterolateral approach for the treatment of ossification of the posterior longitudinal ligament in the thoracic spine: a prospective cohort study. Eur Spine J. 2020;29:113–121.
    1. Norio K, Katsuro T, Hideki M, et al. Circumspinal decompression with dekyphosis stabilization for thoracic myelopathy due to ossification of the posterior longitudinal ligament. Spine. 2008;33(1):39–46.
    1. Tomita K, Kawahara N, Baba H, Kikuchi Y, Nishimura H. Circumspinal decompression for thoracic myelopathy due to combined ossification of the posterior longitudinal ligament and ligamentum flavum. Spine. 1990;15(11):1114–1120.
    1. Tsuzuki N, Hirabayashi S, Abe R, Saiki K. Staged spinal cord decompression through posterior approach for thoracic myelopathy caused by ossification of posterior longitudinal ligament. Spine. 2001;26(14):1623–1630.
    1. Osman Nebiyu S, Cheung Zoe B, Hussain Awais K, et al. Outcomes and complications following laminectomy alone for thoracic myelopathy due to ossified ligamentum flavum: a systematic review and meta-analysis. Spine. 2018;43:E842–E848.
    1. Xu N, Yu M, Xiaoguang L, et al. A systematic review of complications in thoracic spine surgery for ossification of the posterior longitudinal ligament. Eur Spine J. 2017;26:1803–1809.
    1. Mcmahon P, Dididze M, Levi AD. Incidental durotomy after spinal surgery: a prospective study in an academic institution - Presented at the 2012 Joint Spine Section Meeting. Clinical article. J Neurosurg Spine. 2012;17(1):30–36.
    1. Chen Y, Chang Z, Yu X, et al. Use of ultrasonic device in cervical and thoracic laminectomy: a retrospective comparative study and technical note. Sci Rep. 2018;8(1).
    1. KatoSatoshi MH, Satoru D, et al. Gradual spinal cord decompression through migration of floated plaques after anterior decompression via a posterolateral approach for OPLL in the thoracic spine. J Neurosurg Spine. 2015;23:479–483.
    1. Yu S, Wu D, Fengning L, et al. Surgical results and prognostic factors for thoracic myelopathy caused by ossification of ligamentum flavum: posterior surgery by laminectomy. Acta Neurochir. 2013;155:1169–1177.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir