What are the potential complications of endoscopic percutaneous dissectomy?

Complications of Endoscopic Percutaneous Discectomy

The most significant complications of endoscopic percutaneous discectomy include nerve root injury, dural tears, incomplete removal of herniated discs, epidural hematoma, and infection, with overall complication rates ranging from 2-5% depending on the specific technique used. 1

Common Complications

Neurological Complications

• Nerve root injury occurs in approximately 1.2% of cases, which can result in new or worsened neurological deficits 1
• Exiting nerve root irritation affects about 2.0% of patients, causing leg paresthetic pain that typically resolves within 6-12 weeks with medication 2
• Nerve root-induced hyperalgesia or burning-like nerve root pain occurs in approximately 2.3% of cases 1
• Dural tears occur in about 0.9% of procedures, which may lead to cerebrospinal fluid leakage 1

Hemorrhagic Complications

• Post-surgical epidural hematoma requiring surgical evacuation occurs in approximately 1.0% of cases 2
• Retroperitoneal hematoma is a rare but potentially serious complication 1
• Radicular artery injury with massive bleeding has been reported, sometimes requiring conversion to open surgery 1

Technical and Procedural Complications

• Incomplete removal of herniated discs occurs in approximately 1.4% of cases 1
• Recurrence of disc herniation is reported in about 2.8% of patients 1
• Passage of working channel through the spinal canal into the disc space has been reported as a unique complication 1
• Surgical instruments becoming caught on anatomical structures (e.g., super-elastic nerve hook caught by exiting nerve root) 1

Rare Complications

• Intraoperative seizures have been reported during the procedure 1
• Neck pain during surgery has been reported in approximately 2.0% of patients 2
• Transient hoarseness of voice can occur, particularly with cervical procedures 3
• Coughing episodes in the supine position have been reported after cervical procedures 3

Risk Factors for Complications

Patient-Related Factors

• Previous spinal surgery at the same level increases complication risk 1
• Anatomical variations may increase the risk of nerve injury 1
• Patients with significant comorbidities may have higher risk of complications 1

Procedure-Related Factors

• Surgeon experience significantly impacts complication rates, with a steep learning curve for this technique 1, 4
• The transforaminal approach may have different complication profiles compared to interlaminar approaches 1
• Initial landing point being too far from the target increases risk of complications 4

Prevention Strategies

Technical Considerations

• Initial landing should be as close to the target as possible to minimize tissue trauma 4
• Complete herniotomy after thorough release of annular anchorage is key to successful outcomes 4
• The definitive endpoint of the procedure should be free mobilization of neural tissues, not direct exposure 4
• Use of local anesthesia allows for patient feedback during the procedure, potentially reducing nerve injury risk 5

Perioperative Management

• Careful patient selection is crucial to minimize complications 1
• Thorough preoperative imaging to identify anatomical variations 1
• Patients on antiplatelet or anticoagulant therapy require special consideration regarding medication management 6
• For high-risk endoscopic procedures, anticoagulants should be resumed up to 48 hours after the procedure, depending on the perceived bleeding and thrombotic risks 7

Management of Complications

Neurological Complications

• Conservative management with medications for nerve root irritation and paresthetic pain 2
• Surgical intervention may be required for significant dural tears 1

Hemorrhagic Complications

• Surgical evacuation for symptomatic epidural hematoma 2
• Conversion to open surgery may be necessary for uncontrolled bleeding 1

Recurrence and Incomplete Removal

• Revision surgery may be required for recurrent disc herniation or incomplete removal of disc material 1
• The technique for revision surgery should be carefully selected based on the specific situation 1

Outcomes After Complications

Most patients with complications from percutaneous endoscopic discectomy have good recovery by 3 months postoperatively with appropriate medical intervention and physical therapy 1. The overall success rate of the procedure remains high despite these potential complications, with significant improvement in pain scores and functional outcomes in the majority of patients 5.