With the continuous improvement of scientific understanding of lumbar disc herniation and lumbar spinal stenosis and the continuous improvement of surgical techniques, endoscopic technology is recognized by most spine surgeons and patients because it is minimally invasive and less likely to cause iatrogenic lumbar instability. With the widespread development of unilateral dual-channel spinal endoscopic technology, many common complications have occurred, such as residual nucleus pulposus, nerve root injury, dural tear (cerebrospinal fluid leakage), surgical instrument breakage, intraspinal hematoma, and surgery. Site infection, etc. A very small number of patients develop uncommon complications, such as spinal cord hypertension syndrome, with clinical symptoms such as neck pain, irritability, fast heart rate, high blood pressure, epilepsy and even disturbance of consciousness. There is currently no clear explanation for the cause of spinal cord hypertension syndrome, which is mainly related to epidural high perfusion pressure, spinal venous anatomy, and surgical methods[4].
There is a gap between the spinal cord and the spinal canal, called the epidural space, which is filled by loose epidural fat and the epidural venous plexus. It is precisely because of the existence of the epidural space that during spinal endoscopic surgery, when the ligamentum flavum is broken through, the normal saline suspended high during the operation can enter the epidural space, causing the epidural pressure to increase and compress the spinal cord and the spinal cord. The intravertebral venous plexus within this physiological space. The increased epidural pressure first directly compresses the dura mater and then is transmitted to the brain, causing an increase in intracranial pressure. In order to ensure the intracranial blood supply, the body raises the body's blood pressure to meet the intracranial blood supply. If the operator further increases the perfusion pressure, a vicious cycle will occur in which the epidural pressure and intracranial pressure continue to increase.[5] The compression of the spinal cord will gradually increase, and the clinical manifestations will gradually develop from neck pain to epileptic seizures. When external pressure causes changes in the hemodynamics of the spinal venous plexus, spinal venous return is difficult or even reverse flow occurs, leading to spinal cord ischemia, hypoxia, edema, and even spinal cord nerve cell necrosis, limb sensory and movement disorders[6]. With the continuous advancement of medical equipment, the field of view of spinal endoscopic surgery has been greatly improved. However, due to factors such as anatomical structure and narrow space, the field of view that can be observed during the operation is still relatively limited. Small breaks in the dura mater sometimes occur during the operation. Hard to spot. The author believes that the cause of spinal cord hypertension-like syndrome may be the reverse infusion of high-pressure saline through the breach, resulting in a rapid increase in intradural pressure, which in turn compresses the spinal cord[7].
Spinal cord hypertension-like syndrome is a rare and serious complication of minimally invasive spinal surgery. It is very necessary to take corresponding measures to actively prevent it. By searching relevant literature and studying the experience and lessons of this case, we have summarized the following treatment and preventive measures: The treatment of spinal cord hypertension-like syndrome mainly focuses on symptomatic treatment and life support treatment. Timely detection and timely treatment are required to avoid further development of the disease[8]. When patients experience head and neck pain, soreness and swelling, it is recommended to adjust the surgical position, keep the head high and feet low, lower the height of the irrigation fluid, or stop the perfusion for more than 5 minutes[9]. Most patients can relieve themselves on their own. When the patient experiences neck discomfort that is not relieved after reducing the lavage fluid, adjusting the surgical position, and pausing the surgery for 5 minutes, the surgery should be completed as soon as possible while increasing the symptomatic treatment with analgesic and sedative drugs.When a patient develops neck discomfort accompanied by dyspnea and limb sensorimotor dysfunction, it is recommended to stop the operation immediately and provide necessary life support such as oxygen inhalation and sedation as appropriate. For patients with severe convulsions and disturbance of consciousness, the operation should be stopped immediately for rescue, and if necessary, they should be transferred to the intensive care unit for treatment. Preventing the occurrence of spinal cord hypertension syndrome is mainly to reduce the pressure on the dura mater and avoid damage to the dura mater. First, try to shorten the operation time (lavage time) as much as possible. When the perfusion pressure is constant, the longer the irrigation time, the greater the amount of fluid in the epidural space, and the easier it is to cause a decrease in dural compliance. When performing operations outside the working channel, the lavage fluid should be closed as much as possible to reduce unnecessary fluid from entering the epidural space. On the premise of improving surgical efficiency, the intervertebral disc nucleus pulposus in the spinal canal is carefully processed to avoid reverse perfusion of lavage fluid into the dura mater due to dural tear. On the premise of meeting the needs of endoscopic visual operation, the basic perfusion speed should be reduced as much as possible. The faster the perfusion speed, the more fluid will enter the epidural space, and the corresponding epidural pressure will be greater. Use radiofrequency blades rationally to stop bleeding and deal with bleeding points in a timely manner. Areas with a greater risk of epidural hemorrhage can be placed in the second half of the operation. Severely degenerated intervertebral discs should be treated first, bleeding points should be stopped in a timely manner, and the method of increasing lavage pressure for compression and hemostasis should be avoided. The transforaminal approach is preferred to perform surgical operations to reduce direct compression and stimulation to the back of the spinal cord. If an interlaminar approach is required, surgical treatment under local anesthesia should be performed as much as possible.Prefer lavage fluid with a suitable temperature and avoid using lavage fluid with too low temperature. Low temperature stimulation may cause spasm of blood vessels and is not conducive to spinal blood reflux. Pay attention to body positioning during the operation, keep the head high and the bottom of the foot, and avoid the head down and foot high position[10]. Pay close attention to the patient's intraoperative symptoms, promptly detect prodromal symptoms such as neck pain, soreness, and swelling, and deal with them promptly to avoid progression of the disease.
Spinal cord hypertension syndrome is a rare systemic complication in percutaneous transforaminal surgery, and its specific pathophysiological mechanisms have not been studied in more depth at home or abroad. Active prevention before surgery, careful operation during surgery, early detection and timely and appropriate treatment after the occurrence of discomfort symptoms can avoid or quickly recover the discomfort symptoms caused by spinal cord hypertension syndrome. Physicians should pay attention to the rare and serious complication of spinal cord hypertension syndrome during UBE surgery, actively prevent it before surgery, perform meticulous operations during surgery, and manage anesthesia carefully. They should detect and detect early symptoms after the occurrence of discomfort and handle them promptly and appropriately to ensure that patients Perioperative safety.