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 Table of Contents  
SYMPOSIUM - MINIMALLY INVASIVE SPINE SURGERY
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 34-40

Complications and limitations of tubular retractor system in minimally invasive spine surgery: A review


1 Department of Spine Surgery, Ahmedabad, Gujarat, India
2 Chirayu Hospital, Ahmedabad, Gujarat, India

Date of Submission01-May-2019
Date of Decision13-Aug-2019
Date of Acceptance03-Jan-2020
Date of Web Publication05-Feb-2020

Correspondence Address:
Dr. Amit C Jhala
Dr. Amit C. Jhala, Chirayu Hospital, Chirayu Complex, Near NID, Narayan Nagar Road, Paldi, Ahmedabad 380007, Gujarat.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/isj.isj_33_19

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  Abstract 

The aim of a minimally invasive spine surgery is to decrease the collateral damage to the surrounding soft tissue, while performing the same task as that of a conventional open spine surgery. With widening of applications of the tubular retractor system, complications are prone to occur while performing surgery using tubular retractors. The aim of this review was to assess the spectrum of complications that are associated with tubular access spine surgery. A systematic review in English language literature on PubMed for clinical outcomes or complications in minimally invasive spine surgery using tubular retractors was carried out. A total of 11 articles were filtered from 2010 to 2018. Articles that were excluded were those with focus on open spine surgery, surgeries without using tubular retractors, Destandau technique, and endoscopic spine surgeries. The studies were divided into discectomy, decompressions, and fusions. Overall complications that were observed in the review were incidental durotomy, neurodeficits, infection, instability, reherniation, implant malposition, pulmonary embolism, hematoma, and urinary retention. The manifold advantages that are offered by the tubular retractor system include decreased iatrogenic tissue damage, decreased probability of surgical wound infections, decreased chances of instability, and rapid ambulation of the patients, providing an impetus to the number of day care procedures being performed for spine conditions. The complication profile in this review is comparable to the open spine surgeries except the risk of higher radiation hazard in minimally invasive transforaminal lumbar interbody fusion surgery but more high-quality randomized studies are required.

Keywords: Complications, minimally invasive, spine surgery, tubular retractor


How to cite this article:
Jhala AC, Gajjar SC. Complications and limitations of tubular retractor system in minimally invasive spine surgery: A review. Indian Spine J 2020;3:34-40

How to cite this URL:
Jhala AC, Gajjar SC. Complications and limitations of tubular retractor system in minimally invasive spine surgery: A review. Indian Spine J [serial online] 2020 [cited 2020 Apr 7];3:34-40. Available from: http://www.isjonline.com/text.asp?2020/3/1/34/277809




  Introduction Top


Last two decades have seen extensive development in minimally invasive spine surgery (MISS). The basic tenet on which MISS is developed is to decrease the collateral damage to spinal muscles during the approach compared to conventional open posterior approach. The basic workhorse for MISS is the tubular retractor. Muscle splitting serial tube dilators and retractors were designed to minimize disruption of the paraspinal musculature and provide direct and focal access to the diseased anatomy.[1] Tubular retractor system has revolutionized and proved to be a paradigm shift in the field of spine surgery because of the variety of advantages it provides, obviating the need for a comparatively morbid open posterior approach. This system has the advantage of viewing the surgical images directly under the microscope.[2] Though the primary indication for which the tubular retractor system was developed is lumbar disc herniation, gradually with increased expertise, the spectrum has widened to treat a plethora of spine conditions. With certain modifications, the indications have widened to carry out multilevel interbody fusions using multiple ports and augmented by percutaneous screws and rods as well as minimally invasive anterior approaches. Targeted approach to the focal neurological compression with minimal bony and paraspinal muscle injury is the striking advantage of this system as it preserves the stability, which is provided by the envelope of paraspinal muscles. It provides a distinct advantage in patients who are obese as it reduces the surgical morbidity by reducing the cone of exposure to the size of tubular port.[3],[4],[5]

In the recent studies, most authors have shown that the clinical results obtained after MISS are comparable to that of open surgeries with an added advantage of lesser blood loss, shorter operative time, lesser postoperative pain, early return to normal activities, and early discharge.[6] In this study, we have reviewed various studies that deal with the complications, which are associated with the tubular retractors.


  Materials and Methods Top


We performed a literature search on PubMed for clinical outcomes or complications in MISS using tubular retractor system. Keywords included minimally invasive, tubular retractor, and spine surgery. Initial search yielded 103 articles, which were in English language and were filtered further to include articles from 2010 to 2018. Tubular retractor technique was in evolution phase before 2010, and hence, we excluded articles before 2010. Only those articles in which complications were mentioned in some detail were considered. Articles that were excluded were those with focus on open spine surgery, surgeries without using tubular retractors, Destandau technique, and transforaminal endoscopic spine surgeries. All the remaining articles are enumerated in [Table 1].
Table 1: Literature review for complications in MISS

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  Results Top


A total of 11 articles were obtained on the basis of our inclusion and exclusion criteria, which dealt with the tubular retractor system and also describing the complications that were encountered during their use. They were a mix of prospective and retrospective studies comparing open surgery to MISS using the tubular retractor.

Lumbar discectomy

Yoon et al.[8] conducted a prospective study to evaluate the clinical results of tubular discectomy. There were two cases (5.7%) of minor complications of the total 35 patients operated. One (2.8%) was an incidental durotomy and 1 (2.8%) was of recurrence, and both of them were treated conservatively.[8]

Lumbar decompression

Nomura and Yoshida[9] conducted a prospective study of 70 patients who were operated by microendoscopic decompression using tubular retractors. None of the patients encountered infection, any dural tears, or nerve injuries. However, two patients (2.9%) were detected to be having fracture of the base of spinous process, both of which were incidental findings detected postoperatively on computed tomography scan. Both the patients were asymptomatic. The fractures took the form of longitudinal fissures at the base of the spinous process, presumed to be caused while the tubular retractor was advanced to the midline.[9]

Ha et al.[16] conducted a case–control study in which 85 elderly patients (age > 66 years) operated by minimally invasive unilateral laminectomy for bilateral decompression for spinal stenosis by a single surgeon at a single institute were followed up for 1 year. There were 15 complications (17%); 7 patients (8%) had incidental durotomies, 4 patients (5%) had transient motor weakness, one patient had a permanent motor weakness, one patient had a wound dehiscence, and two patients (1.3%) had postoperative neuropathic pain.[16]

Minimally invasive spine fusions

Lee et al.[7] compared the results of open versus MIS transforaminal lumbar interbody fusion (TLIF) in a prospective observational comparative study with 72 patients in each group. All the patients were operated by a single spine surgeon and the instrumentation used was of a single manufacturer. Among the complications that were encountered, one patient (1.3%) in the MIS group had a screw malposition which required revision, and one patient in each group (1.3%) had postoperative pneumonia, requiring intravenous antibiotics. One patient (1.3%) in the MIS group had incidental durotomy, which was promptly repaired intraoperatively. One patient (1.3%) in the open group had postoperative anemia and wound abscess requiring debridement.[7]

Wong et al.[11] conducted a retrospective study on 513 patients of MIS TLIF operated by four surgeons over 10 years. There were 81 multilevel fusions and 432 single-level fusions. A total of 130 cases were revision surgeries and 381 were primary cases. The most common complication was durotomy (5.1%) followed by instrumentation failure (2.1%) and postoperative urinary retention (1.4%). Seven patients (1.4%) had deep vein thromboembolism or pulmonary embolism, with one pulmonary embolism resulting into cardiopulmonary arrest and death. Eleven patients had instrumentation failure, of which five patients had cage migrations and two of them required revision surgeries. Six patients had intraoperative fracture of the K wire used for the insertion of the screws. There were seven patients (1.4%) of perioperative medical infections and one patient of surgical wound infection. There were 8 (6.2%) patients with incidental durotomy in revision surgeries, and 18 (4.7%) patients who were operated for the first time had incidental durotomy. There were four cases (0.8%) of neurological deficits, of which two patients recovered completely, whereas two patients had partial recovery. There were four cases (0.8%) of wound hematoma but none of them caused any neurological deficits.[11]

Park et al.[12] conducted a retrospective study on 124 patients (141 segments) who underwent MIS TLIF to evaluate the incidence of perioperative complications during the learning curve of the surgeon. There were three cases (2.1%) of transient postoperative neuralgia, two patients (1.4%) with screw misplacement, two patients (1.4%) with cage migrations, one patient (0.7%) with incidental durotomy, and one patient (0.7%) with grafted bone extrusion. Additional surgeries were required in seven patients (6%), including four for instrumentation failure, one for graft extrusion, and two for infected cage removal.[12]

Wang et al.[15] conducted a retrospective study to evaluate the results of MIS TLIF with unilateral fixation. A total of 58 patients with single-level segment were operated by transforaminal fusion using iliac crest bone graft and unilateral fixation. There were two cases of skin flap necrosis (3.45%) which resolved with dressing, and eight cases of bone graft site pain (13.8%), which resolved with the use of 3 months of nonsteroidal anti-inflammatory drugs.[15]

Cervical decompression

Branch et al.[13] conducted a retrospective study on 463 patients who underwent cervical foraminotomy using tubular retractor over 14 years by a single surgeon. There were four incidental durotomies (0.8%) which required repair, and one case of surgical wound infection (0.2%) which required incision and drainage. There was one case of meningitis (0.2%), the exact cause of which could not be identified but the patient required hospital admission and intravenous antibiotics, following which the patient recovered. There was one case of unilateral vertebral artery occlusion, which was thought to be due to compression by the endotracheal tube, which got corrected after making the patient supine and reinserting the tube. There were two cases of unilateral biceps weakness post surgery (0.4%), both of which recovered within 2 months of starting steroids.[13]

Combined

Ross[6] conducted a retrospective study of complications associated with tubular retractors in surgeries of cervical, thoracic, and lumbar spine. A total of 1231 patients were operated by a single surgeon, of which 929 were lumbar surgeries. No infection or neurological deficit was encountered. One patient (0.1%) had an epidural hematoma, which required evacuation. There were 32 incidental durotomies (3.2%), but none of the patients had cerebrospinal fluid (CSF) leakage or complaints of postoperative headache.[6]

Ee et al.[10] carried out a retrospective study on surgical site infections (SSI) of 2299 patients operated for lumbar surgery by open and MIS techniques. Twenty-seven patients of the total (1.6% of open and 0.5% of MIS) had SSI, and these patients were compared with a matched cohort of 162 patients in a nested case–control study. The most common organism isolated from 12 patients (0.5%) was Staphylococcus aureus, and 13 patients required revision surgery for SSI (0.5%). They concluded that open surgery had five times increased probability of SSI as compared to MIS surgery with diabetes and obesity working as independent risk factors.[10]

Kulkarni et al.[14] conducted a retrospective study of prospectively collected data of all the tubular surgeries performed at a single center from January 2007 to January 2015. Of the total 1043 surgeries, 763 were non-instrumented and 280 were instrumented. There were three cases of surgical deep wound infections, and all of them occurred in instrumented cases. All of them required debridement and intravenous antibiotics and were then resolved.[14]


  Discussion Top


There has been accumulating data, which supports MISS, but the recent reviews suggest that there is a need for more level 1 and level 2 studies to prove the advantage of MISS over conventional open spine surgeries.[6] Open spine surgery is associated with morbidity due to extensive exposure, which has the potential to lead to a recognized entity known as “Failed back syndrome.”[17] It is documented by mysosomal enzyme studies that after conventional open spine surgery exposure, paraspinal muscle atrophy is observed, which is due to muscle denervation and pressure-induced muscle ischemia.[18] The tubular retractors used in MISS do not erase the insertions of muscles from the midline spinous processes but cause splitting of the paraspinal muscles, maintaining the posterior spinal tension band. However, it is not warranted that MIS with tubular retractors should be replacing the traditional open spine surgery on the basis of these theoretical advantages. These theoretical advantages should be potentiated with evidence-backed randomized control trials with sufficient period of follow-up, which prove the benefits of MISS over open surgery clinically.

In this review, we have attempted to elaborate all the complications, which are associated with tubular retractor systems. This study was limited by the quality of the studies to review the complications of tubular retractors used in discectomy, decompression, and fusion surgeries. There is a learning curve, which is associated with MIS techniques. With increasing experience, the operative time decreases significantly over time to become comparable with open surgery. Also the blood loss is considerably less than that of open surgeries.[19] Even in fusion surgeries, MIS TLIF which requires specialized instrumentation, and has a learning curve, has shown superior clinical outcomes and shorter operative times with experience and lesser blood loss offsetting the higher operative costs associated with this surgery.[7]

Microtubular discectomy

Open microsurgical decompression for lumbar spinal stenosis and disc herniations are among the most successful and satisfying operations in spinal surgery.[20],[21],[22] Not long after the introduction of lumbar microdiscectomy in 1970, the surgeons were further interested to develop newer techniques to minimize the tissue damage caused by open spine exposure. In 1993, Mayer and Brock[23] mentioned the use of percutaneous endoscope to access the lumbar disc. In 1997, microendoscopic discectomy (MED) system was introduced, which allowed the surgeons to excise the herniated disc fragment under the vision of endoscope via minimally invasive technique.[24] METRx system was the first commercially available product to be used for MIS surgery. Before the advent of this system, a kind of speculum or polyethylene tube was used as a tubular retractor system.[25],[26] Subsequently, in 1999, microendoscopic tubular approach was used by Foley et al.,[24] in which they used a tubular retractor combined with an endoscope to perform laminotomy, medial facetectomy, foraminotomy, and discectomy.[24] Over a period, MED and open discectomy have been found to be equally effective in the treatment of lumbar disc herniations.[27],[28],[29] What started with excision of lumbar disc herniations gradually, along with increased expertise of the surgeons, the indications of tubular retractors extended to the decompression for lumbar stenosis and fusions with instrumentation.

The most common complication encountered in microtubular discectomy in the studies that we reviewed was incidental durotomy. Incidence of durotomy appears to be decreased in tubular retractor–based studies as compared to those reported in open surgical series.[30] Apart from decreased incidence, the reduction of the dead space for the formation of a pseudomeningocele for the accumulation of CSF, and no easy route for the outflow of the CSF, the consequences of the durotomy are also reduced in tubular-based surgery, which can help in decreasing the hospital stay.

Surgical site infection is a catastrophic complication that can worsen the clinical outcome of the surgery performed.[30],[31] Open discectomy, which involves larger incisions, wider soft tissue dissections, and nonuniform tension on the soft tissue by the retractors, reports the rates of surgical site infection from 0.7% to 16%.[32],[33],[34] This incidence is higher compared to incidence of tubular discectomy reviewed in this study.[10],[14] Multiple reasons can be hypothesized for decreased SSI in MIS. Reduction of the dead space with the avoidance of postoperative hematoma or seroma, minimum exposure of the wound to the skin and the surgeon’s hand, decreased use of monopolar coagulation, and uniform tension over the retracted muscles by the tube lead to decreased devitalization of the tissue, and hence decreased postoperative infections.

Though postoperative neurological deficit was not found in the articles reviewed by authors, in a meta-analysis by Shriver et al.,[35] the rate of new or worsening of postoperative neurological deficit occurring after MED was 3%, whereas direct nerve injury occurred at the rate of 0.9%. Other postoperative complications such as instability, paralytic ileus, urinary retention, and postoperative anemia were almost nonexistent in the studies reviewed by us for tubular discectomy.

Microtubular decompression

After the success of tubular retractors in discectomy, there were attempts to use them in cases of lumbar spinal stenosis. Roh et al.[36] showed the feasibility of microendoscopic decompression by foraminotomy in foraminal stenosis in a cadaveric study. Guiot et al.[37] showed the results of four techniques: unilateral tubular approaches for bilateral decompression, bilateral tubular approaches for bilateral decompression, unilateral open laminectomy for bilateral decompression, and bilateral open laminectomy for bilateral decompression. The results of all the studies showed excellent visualization and radiographic evidence of the decompressed neural elements. Even though all the four techniques had similar clinical outcomes, there is a substantial preservation of the native anatomical structures with unilateral tubular approaches for bilateral decompression. Since then, this technique has gradually come into vogue in the treatment of lumbar canal stenosis.

The incidence of complications such as durotomy in open spine surgery for lumbar spinal stenosis can be as high as 18%.[38] The incidence of durotomy for lumbar spinal stenosis operated by tubular discectomy in the studies reviewed by us was 2%–3%. One of the major complications of laminectomy is long-term instability, which has been proven in cadaveric studies that there is progression of spondylolisthesis if more than 50% of the facet joint is sacrificed at any one level.[39] The follow-up period of the studies included in our review was not sufficient enough for the evaluation of the postoperative instability, but there were two incidences of fracture of the base of spinous process in a study by Nomura and Yoshida,[9] though they are unlikely to cause any instability in the long course. Theoretically, the maintenance of the posterior tension band due to use of tubular retractors will decrease the chances of long-term spinal instability.

Of the other notable complications, there were four cases of transient neurological weakness (0.3%) and one case of permanent neurological weakness (0.06%). Comparing the results with open spine surgery from a large database of Scoliosis Research Society, the rate of neurological deficit in non-instrumented spine surgery was 0.52%.

In a study by Branch et al.[13] on posterior cervical foraminotomy of 463 patients, the complication rate was found to be 2.2%. There were four cases of durotomies (0.8%), two cases of transient neurological weakness (0.4%), one wound infection (0.2%), one meningitis (0.2%), and one case of unilateral vertebral occlusion (0.2%). The most common location of durotomy was the axilla of the nerve root when an attempt was made to free the root from adhesions.

Minimally invasive transforaminal lumbar interbody fusion

The conventional TLIF is a well-established approach, and the literature supports its efficacy, safety, and rate of perioperative complications.[40],[41],[42] TLIF provides for a 360° spinal fusion using dorsal approach and has been reported to have higher arthrodesis rate as compared to posterior onlay techniques.[43],[44] The deleterious effects of extensive soft tissue retraction and iatrogenic paraspinal muscles fibrosis have also been well-documented.[45],[46] These undesired side effects of fusion surgery occur with so much frequency that a term called “fusion disease” has been coined for such complications. The rationale for MIS TLIF procedure has evolved from MED, which was developed for microdiscectomy, but customized instruments and larger tubular dilators have made the procedure of MIS TLIF technically feasible with the placement of the percutaneous transpedicular screws through the same incisions as for cage insertions.[47]

The retrospective study by Wong et al.[11] with 513 cases performed over 10 years was with the largest number of cases. There were 27 cases with durotomy (1.8%) in total, making it the most common complication. A review of open TLIF procedures documents the incidence of durotomy in the range of 0%–20% with an average of 4.6%.[11],[40],[41],[42] In MIS TLIF durotomy was most common at one of the three steps: bony decompression, resection of the flavum, and discectomy. The incidence of durotomy was more with multilevel surgery than with single-level surgery and more with revision surgery than with primary surgery.

There were four cases of neurodeficits (0.3%) that occurred in a study by Wong et al.,[11] and all of them occurred during the insertion of cage as documented by the loss of signals of neuromonitoring during cage insertion. The incidence of neurological deficits in MIS TLIFs documented in literature was 0.7%–9.5%, which was comparable.[48],[49] The complication rate related to instrumentation failure in MIS TLIF in literature varied from 0%–12.3%, and the rate of interbody graft migration varied from 3.9% to 5.8%.[7],[11],[48],[49] There were seven cases of cage migration (0.5%), one case of bone graft migration (0.07%), three cases of screw malposition (0.2%), and six cases of K wire fracture (0.4%). Instrumentation failure was the most common cause of resurgery in studies after MIS TLIF.

Other significant complications, which were noted in the studies were paralytic ileus, pulmonary embolism, deep venous thrombosis, and urinary retention, but none of these were related to the tubular retractors used in MIS TLIF.

Limitations of minimally invasive spine surgery

Minimally invasive procedures are advantageous for the patients with lumbar degenerative disorders but they also entail significant fluoroscopy, which is disadvantageous for the entire surgical team due to intraoperative radiation. Funao et al.[50] conducted a prospective study, which involved measuring the radiation over the surgeon’s body by placing the dosimeter at five different places. They concluded that the radiation levels did not exceed significantly and were comparable to open TLIF in single-level TLIF, but there was considerable increase in the radiation exposure while performing multilevel MIS TLIF. Also the need for radiation was significantly increased in patients with obesity. Wang et al.,[51] in their study, showed that the mean radiation exposure in revision MIS TLIF was significantly higher than that in revision open TLIF surgery. Dusad et al.,[52] in their study, concluded that the radiation exposure was significantly increased in the non-navigation MIS TLIF, and thus navigation-based MIS TLIF may aid in reducing the radiation hazards to the surgeon. Also, MIS TLIF also required a steep learning curve, which was reflected in revision surgeries if performed during the initial learning phase of the surgeon.[51]

This review conducted by the authors has some limitations. The studies included in this review were class II and III in nature. This means there may be a lot of bias in the studies. There were very few articles, which directly dealt with the complication profiles in tubular retractor systems. Hence only the articles which mention complications were scrutinized. This would reduce the number of articles in the review. This review was a comprehensive review for all the procedures carried out by tubular retractors, such as discectomy, decompression, and fusion. The diameter of the tubes and the types of tube whether expandable or non-expandable used by each author were never mentioned in the studies. Hence, there is a need for high-quality class I studies for evaluating the complications in tubular retractor surgery.


  Conclusion Top


Tubular retractors have come a long way from being an innovative approach for the traditional extensive open spine surgeries to addressing focal spine conditions to gradually becoming the mainstay of degenerative spine conditions. The manifold advantages that are offered by the tubular retractor system in the form of decreased iatrogenic tissue damage, decreased probability of surgical wound infections, decreased chances of instability, and rapid ambulation of the patients provide an impetus to the number of day care procedures being performed for spine conditions. The complication profile in this review is comparable to the open spine surgeries except the risk of higher radiation hazard in minimally invasive TLIF surgery, but more high-quality randomized studies are required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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