Seizure After Percutaneous Endoscopic Surgery—Incidence, Risk Factors, Prevention, and Management

doi:10.1016/j.wneu.2020.03.121

World Neurosurgery

Volume 138, June 2020, Pages 411-417

https://doi.org/10.1016/j.wneu.2020.03.121 Get rights and content

Background

Percutaneous endoscopic surgery is a popular surgery to treat lumbar spinal disorders. However, seizure after percutaneous endoscopic surgery is an unpredictable complication. The only prodromal sign for seizure currently known is neck pain. We reviewed the incidence of, and risk factors for, seizure during percutaneous endoscopic surgery and present the cases of 3 patients with seizure and our management.

Case Description

From October 2006 to March 2019, 3 of 816 patients (0.34%) with thoracic lumbar disorders who had undergone percutaneous endoscopic surgery experienced a seizure episode. The cases of those 3 patients were carefully reviewed. Studies of the risk factors for seizure after spinal procedures reported before June 13, 2019 were identified through a PubMed search. We found that infusion fluid containing cefazolin, the infusion rate, a prolonged operative time, the occurrence of a dural tear, and sevoflurane anesthesia might be associated with seizure, both described in the reported data and found in our experience. Three patients who experienced a seizure episode had had general anesthesia with sevoflurane, and the surgical approach used was interlaminar for a herniated disc in L5-S1. We noted a “red flag sign,” namely an uncontrollable hypertension episode combined with a decreasing pulse rate, in all 3 patients who had experienced a seizure, which was not observed in the other patients. All 3 patients had received antihypertensive medication (labetalol) ≥3 times without response.

Conclusion

Seizure after percutaneous endoscopic surgery is rare, but lethal. Although its cause remains unknown, all risk factors for seizure should be checked and corrected immediately when a red flag sign, uncontrolled hypertension, appears.

Introduction

Percutaneous endoscopic surgery has been a popular method to treat lumbar disc herniation. Various surgical techniques have been recommended for more indications.1, 2, 3, 4, 5, 6, 7 However, this procedure is relatively challenging. Complications such as inadequate decompression, nerve root injury, vessel injury, and dural tear have been reported.⁸^,⁹ Seizure after percutaneous endoscopic surgery is a relatively rare and unexpected complication. Choi et al.¹⁰ suggested that increased intracranial pressure (ICP) might induce seizure during surgery. In the present report, we have provided our observations and experiences regarding the signs and management of this major complication.

Section snippets

Methods

From October 2006 to March 2019, the cases of 816 patients with thoracic lumbar disorders who had undergone percutaneous endoscopic surgery in our hospital were retrospectively analyzed. Surgery had been performed by 3 doctors for various diagnoses, including a herniated intervertebral disc (HIVD; n = 691; 84.68%), stenosis (n = 41; 5.02%), and infectious spondylodiscitis (n = 84; 10.29%). The overall complication rate was 2.57%. We reviewed the medical records for the following complications:

Results

Of the 816 patients, 3 (0.34%) experienced a seizure attack after percutaneous endoscopic surgery. The incidence rate was 0.86% in the GA group using the interlaminar approach and 0% in the LA group using the transforaminal approach (P = 0.156). The characteristics of the 3 patients with seizure are presented in Table 2. Of the 3 patients, 2 had experienced a convulsion episode during reversal of the residual muscle relaxant effect. The third patient had started convulsing after extubation at

Discussion

Seizure is an electrical disturbance in the brain, commonly caused by electrolyte imbalances, hypoxia, brain tumor, stroke, traumatic brain injury, or central nervous system infection. It can also occur after brain surgery; however, it is rare as a complication after spinal surgery.¹¹^,¹² To the best of our knowledge, only cases of seizure after percutaneous endoscopic discectomy have been reported.¹⁰^,13, 14, 15, 16, 17, 18 Although the incidence of this complication is rare, seizure is

Conclusion

Percutaneous endoscopic surgery has been proved to be an effective, safe, and minimally invasive surgery technique. However, the rare complication of seizure can occur. Although the definite cause of seizure remains uncertain, we found that recurring uncontrolled hypertension could be a red flag sign for a seizure attack during surgery. When recurring uncontrolled hypertension occurs, all risk factors for seizure should be checked and corrected immediately. Reducing the infusion pressure,

CRediT authorship contribution statement

Chia-Yu Lin: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft. Chien-Chun Chang: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft. Chun Tseng: Data curation. Yen-Jen Chen: Formal analysis. Chun-Hao Tsai: Writing - review & editing. Yuan-Shun Lo: Formal analysis. Pang-Hsuan Hsiao: Formal analysis. Hsi-Kai Tsou: Writing - review & editing. Chih-Sheng Lin: Formal analysis. Hsien-Te Chen: Conceptualization, Methodology,

Acknowledgments

English Language editing was supplied by Wallace Academic Editing Company.

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Neurological complications during full-endoscopic spine surgery (FESS) might be attributed to intracranial pressure (ICP) increase due to continuous saline infusion (CSI). Understanding CSI and ICP correlation might modify irrigation pump usage. This study aimed to evaluate invasive ICP during interlaminar FESS; correlate ICP with irrigation pump parameters (IPPs); evaluate ICP during saline outflow occlusion, commonly used to control bleeding and improve the surgeon's view; and, after durotomy, simulate accidental dural tear.
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Clinical Features and Management of Seizure After Percutaneous Endoscopic Spine Surgery: A Retrospective Case Series Analysis
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Citation Excerpt :
Seizure after PESS is considered unpredictable and fatal.7 It has been sporadically reported in the literature, including hypotheses and discussions of its risk factors, pathogenesis, clinical features, and preventive measures.5-12 However, the management and follow-up of seizure after PESS have been less explored in these reports.
To describe the perioperative clinical features, management, and outcomes of patients with seizure after percutaneous endoscopic spine surgery (PESS).
Patients who experienced seizure after PESS in a tertiary orthopedic hospital between January 2016 and June 2022 were retrospectively recruited, and patient charts were reviewed.
Twenty-nine patients were recruited, and the incidence of seizure after PESS was 0.52%. The operation time was 110.0 minutes (interquartile range [IQR], 82.5–235.0 minutes) and the irrigation speed was 109.0 mL/minute (IQR, 86.5–145.5 mL/minute). Definitive dural tears were reported in 15 patients (51.7%). In addition to agitation and myotonia, significant increased respiratory rate (29.9 ± 6.5 breaths/minute), tachycardia (112.1 ± 20.6 beats/minute), and hypertension (systolic, 189.5 ± 21.9 mm Hg; diastolic, 98.3 ± 10.6 mm Hg) were observed. Arterial blood gas analysis showed hypocapnia, metabolic acidosis, and hyperlactatemia. All patients received analgesia and sedation as well as hyperosmolar therapy. The estimated duration of seizure was 3.0 hours (IQR, 2.5–4.0 hours) and the postoperative length of hospital stay was 3.0 (IQR, 3.0–5.5) days. The Japanese Orthopaedic Association score and visual analog scale score improved markedly within 6 months after surgery.
Despite the low incidence and short duration, seizure after PESS should be considered a critical and urgent syndrome. Management strategies for seizure mainly involve intensive care, securing the airway, analgesia and sedation, hyperosmolar therapy, and negative fluid balance. No significant adverse effects of seizure on clinical outcomes were observed during 6 months of follow-up.
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In this study, the anesthesiologists stated that patients with epilepsy would receive more monitoring in the recovery area compared to patients without epilepsy. During this period triggers of seizures like pain, noise, lightening would be minimized [44,45]. Additionally, opioid analgesics with epileptogenic or neurotoxic properties would be avoided [24].
This qualitative exploratory study was conducted to explore how anesthesiologists in Palestine provide perioperative care for patients with epilepsy and how they account for the unique challenges relevant to epilepsy while planning perioperative care for patients with epilepsy.
This study was conducted in an explorative qualitative design. Purposive and snowball sampling approaches were used to recruit the study participants. Qualitative semi-structured in-depth interviews were conducted with anesthesiologists (n = 10) and a neurologist (n = 1). The qualitative data collected in this study were thematically analyzed using the interpretive description methodology to generate themes, subthemes, and patterns.
Three major themes emerged from the collected qualitative data with a total of 18 subthemes. The 3 themes were: 1) considerations/challenges while assessing patients, 2) anesthetic considerations, and 3) recovery considerations. Lack of epilepsy-specific assessment and anesthesia protocols, underuse of neurology referral services, and lack of neuromonitoring were identified.
Findings of this study highlighted the need to develop specific anesthesia protocols for patients with epilepsy. Anesthesiologists and planners of perioperative care should improve collection of patient information and assessment methods, ensure control over seizures, reduce triggers of seizures, and improve patient monitoring approaches. Findings of this study might be used to inform anesthesiologists and decision makers in professional groups, patient advocacy groups, and healthcare authorities to benchmark and improve anesthesia care and services offered to patients with epilepsy. More studies are still needed to quantitatively assess the quality of anesthesia care and services provided to patients with epilepsy.
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View all citing articles on Scopus

: Conflict of interest statement: The present study was supported by China Medical University Hospital (grant CMUH CRS-108-034).

: Chia-Yu Lin and Chien-Chun Chang contributed equally to the present study.

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Case ReportSeizure After Percutaneous Endoscopic Surgery—Incidence, Risk Factors, Prevention, and Management

Background

Case Description

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

CRediT authorship contribution statement

Acknowledgments

World Neurosurg

World Neurosurg

Clin Neurol Neurosurg

Br J Anaesth

Br J Anaesth

Endoscopic discectomy of L5-S1 disc herniation via an interlaminar approach: prospective controlled study under local and general anesthesia

Surg Neurol Int

A modified approach of percutaneous endoscopic lumbar discectomy (PELD) for far lateral disc herniation at L5-S1 with foot drop

Korean J Pain

New strategy for minimally invasive endoscopic surgery to treat infectious spondylodiscitis in the thoracolumbar spine

Pain Physician

Percutaneous endoscopic debridement and drainage with four different approach methods for the treatment of spinal infection

Pain Physician

Percutaneous endoscopic lumbar discectomy for highly migrated lumbar disc herniation

Pain Physician

Learning curve of percutaneous endoscopic lumbar discectomy based on the period (early vs. late) and technique (in-and-out vs. in-and-out-and-in): a retrospective comparative study

J Korean Neurosurg Soc

Complications of lumbar disc herniation following full-endoscopic interlaminar lumbar discectomy: a large, single-center, retrospective study

Pain Physician

Risk of developing seizure after percutaneous endoscopic lumbar discectomy

J Spinal Disord Tech

Seizure and delayed emergence from anesthesia resulting from remote cerebellar hemorrhage after lumbar spine surgery—a case report

Korean J Anesthesiol

Possible causes of seizure after spine surgery

J Pediatr Neurosci

Case Report
Seizure After Percutaneous Endoscopic Surgery—Incidence, Risk Factors, Prevention, and Management