Abstract
Introduction
Despite recent advances in applied instruments and surgical techniques, the incidence of iatrogenic durotomies caused by traditional techniques remains significant. The ultrasonic bone scalpel (UBS) has been shown to improve speed and reduce complications in laminectomies in the cervical and thoracic spine when compared to traditional methods utilizing high-speed burr, punch forceps, or rongeurs. Thus, in this study, we aim to evaluate whether the use of the UBS in the lumbar spine would result in equivalent safety, efficacy, and patient-reported outcomes (PROs) improvement when compared to traditional methods of laminectomy.
Methods
Data from a prospectively collected, single-institution registry was queried between January 1, 2019 and September 1, 2021 for patients with a primary diagnosis of lumbar stenosis who received a laminectomy (with or without fusion) using traditional methods or UBS method. Outcomes included 3-month and 12-month values for all PROs Measurement Information System (PROMIS) subdomains, Numerical Rating Scale (NRS) pain score, Oswestry Disability Index (ODI) percentage, Patient Health Questionnaire 9 (PHQ-9) score, operative complications, reoperations, and readmissions. Covariates selected for matching included age, operation type, and number of levels. A variety of statistical tests were utilized.
Results
As per our findings, 2:1 propensity matching resulted in 64 “traditional group” patients and 32 “UBS group” patients. Post-match analysis found no differences between the traditional and UBS groups for demographic and baseline measures except for race and ethnicity. For the matched sample, no differences were noted in PROs, reoperations, or readmissions. There was a significant difference in rates of durotomies between the traditional and UBS groups (12.5% vs. 0.0%, p=0.049).
Conclusions
Results showed the high-frequency oscillation technology implemented by the UBS helps to decrease the rate of injury to the dura, thus reducing the overall incidence of iatrogenic durotomies. We believe these data provide valuable information to surgeons and patients about the safety and efficacy of the UBS in performing lumbar laminectomies.
Keywords: laminectomy, ultrasonic bone scalpel, durotomy, safety
Introduction
Lumbar laminectomy is a commonly performed procedure to address symptomatic spinal stenosis with either neurogenic claudication or radicular leg pain; it has been shown to have durable improvement on quality of life and physical function1,2). Several traditional methods of performing lumbar laminectomy have been well described, and these include the use of a high-speed burr, Kerrison rongeur, Smith-Petersen and Leksell rongeurs, and osteotome/mallet3-6). Despite recent advances in applied instruments and surgical techniques, the incidence of inadvertent durotomy caused by traditional laminectomy techniques remains significant; in fact, it has been reported in as many as 8% of primary lumbar surgeries and 16% of revision cases7-10). An iatrogenic durotomy may occur during bone removal with rongeurs or, in some cases, with use of a cutting burr8,11). Complications of durotomies stem from either nerve root entrapment or from persistent cerebrospinal fluid leakage, which can lead to pseudomeningocele formation, intracranial hypotension, refractory severe headache, and intracranial hemorrhage12).
Ultrasonic devices are utilized as an assistive tool for osteotomy in various spine surgeries. The ultrasonic bone scalpel (UBS) is a tool that uses high-frequency oscillation to create localized tissue disruption13). By vibrating at high frequency, micromovements of the blade surface preferentially cut through hard surfaces such as bone14). This preferential cutting occurs because the higher natural elasticity of soft tissue structures such as the dura mater allows greater tolerance of vibratory strain15). Subsequently, the UBS can be used to cut through bone with specificity and precision13). This technology has been shown to both improve speed and reduce intraoperative complications in laminectomies for cervical and thoracic spondylotic myelopathy when compared to traditional methods16,17). Operative and postoperative complications can significantly impact patient recovery and have even been shown to significantly impact short-term patient-reported outcomes (PROs)18). Currently, there is a paucity of evidence describing how surgical instrumentation choice (UBS vs. traditional instruments) can affect PROs and complication rates following lumbar laminectomy.
In this present study, we sought to evaluate whether the use of an UBS would result in equivalent safety, efficacy, and PRO improvement when compared to traditional methods of laminectomy. We hypothesize that lumbar laminectomies performed using the UBS will demonstrate equivalent safety, efficacy, and PROs while decreasing rates of durotomies when compared to traditional methods of laminectomy.
Materials and Methods
Data source
This current study was approved by the Institutional Review Board (IRB) of the authors' affiliated institution. Data from a prospectively collected, single-institution registry were queried between January 01, 2019 and September 01, 2021 for all patients with a primary diagnosis of lumbar stenosis who underwent either an isolated laminectomy, laminectomy and fusion, or laminectomy and fusion with an interbody. All revision, infection, and trauma cases were excluded. Patients without adequate 3-month follow-up data were also excluded from this study.
Laminectomy technique
Patients were split into two groups based on the technique used to perform the laminectomy. The first group consisted of patients who underwent laminectomies using traditional methods, including the mechanical burr, Kerrison rongeur, and Smith-Petersen and Leksell rongeurs. Patients in the second group were those who received laminectomy via the UBS with adjunctive use of the Kerrison to aid in lateral recess and foraminal decompression. The specific UBS used in these procedures was the BoneScalpel (Misonix, Inc., Farmingdale, NY), which is an ultrasonic device optimized for bone dissection, sculpting, and removal with utility in orthopedic and neurosurgical procedures19).
Baseline variables and outcome measures
Descriptive variables included age, gender, body mass index (BMI), ethnicity, race, smoking status, number of operated levels, and surgery performed. In addition, baseline values for Patient-Reported Outcomes Measurement Information System (PROMIS) subdomains scores, Numeric Rating Scale (NRS) back and leg pain scores, Oswestry Disability Index (ODI) percentage, and Patient Health Questionnaire 9 (PHQ-9) scores were collected. Outcomes included operative time, estimated intraoperative blood loss, 3-month and 12-month values for PROMIS subdomains, NRS back/leg pain scores, ODI percentage, and PHQ-9 scores. Occurrence of any complications, reoperations, or readmissions within 3 months were also recorded. Complications included deep venous thrombosis, urinary tract infection, surgical site infection, new neurological deficit discovered after surgery, durotomy, nerve root injury, and any other neurological complication.
Statistical analysis
Patients who received a lumbar laminectomy via traditional methods were propensity matched against patients who received a lumbar laminectomy via the UBS in 2:1 fashion using a nearest neighbor algorithm and caliper set to 0.5 of sample standard deviation20). Covariates selected for propensity matching include age, operation type, and number or levels. Descriptive statistics were presented as mean±SD for continuous variables, while categorical variables were presented as frequency and proportion. Comparisons between the two groups were done using Wilcoxon rank-sum test for continuous variables and Pearson's chi-square test for categorical variables. All analyses were performed using R software 3.6.3.
Results
Descriptive statistics
In total, 231 patients have underwent a laminectomy using traditional methods who were propensity matched against 32 patients who received a laminectomy using the BoneScalpel, resulting in 64 patients in the “traditional group” and 32 patients in the “UBS group.” Post-match analysis found no differences between the traditional and UBS groups for age (63.2±11.98 vs. 62.5±13.3, p=0.873), gender (53.1% female vs. 40.6% female, p=0.248), BMI (30.1±5.8 vs. 30.8±4.8, p=0.563), smoking status (p=0.797), number of levels on which a laminectomy was performed (p=0.475), total number of levels operated on with or without a laminectomy (p=0.981), and operation performed (p=0.819) (Table 1). There was a significant difference in race (p=0.041) and ethnicity (p=0.026) between groups.
Table 1.
Demographics of Patients with Traditional Laminectomy vs. Ultrasonic Bone Scalpel.
| Traditional
N=64 |
UBS
N=32 |
P-value | |
|---|---|---|---|
| Age | 63.2±11.98 | 62.5±13.3 | 0.873 |
| Gender | 0.248 | ||
| Female | 34.0 (53.1%) | 13.0 (40.6%) | |
| Male | 30.0 (46.9%) | 19.0 (59.4%) | |
| BMI | 30.1±5.8 | 30.8±4.8 | 0.563 |
| Ethnicity | 0.041 | ||
| Hispanic | 1.0 (1.6%) | 1.0 (3.1%) | |
| Not Hispanic | 61.0 (95.3%) | 26.0 (81.2%) | |
| Prefer not to answer | 2.0 (3.1%) | 5.0 (15.6%) | |
| Race | 0.026 | ||
| Black | 3.0 (4.7%) | 1.0 (3.1%) | |
| Mixed | 1.0 (1.6%) | 0.0 (0.0%) | |
| Native | 1.0 (1.6%) | 0.0 (0.0%) | |
| No response | 1.0 (1.6%) | 5.0 (15.6%) | |
| Others | 0.0 (0.0%) | 1.0 (3.1%) | |
| White | 58.0 (90.6%) | 25.0 (78.1%) | |
| Smoking status | 0.797 | ||
| None | 60.0 (93.8%) | 31.0 (96.9%) | |
| Daily | 2.0 (3.1%) | 1.0 (3.1%) | |
| Occasional | 2.0 (3.1%) | 0.0 (0.0%) | |
| Number of levels which laminectomy was done | 0.475 | ||
| 1 | 38.0 (59.4%) | 16.0 (50.0%) | |
| 2 | 16.0 (25.0%) | 13.0 (40.6%) | |
| 3 | 6.0 (9.4%) | 2.0 (6.2%) | |
| 4 | 4.0 (6.2%) | 1.0 (3.1%) | |
| Total number of levels operated on (with or without laminectomy) | 0.981 | ||
| 1 | 34.0 (53.1%) | 17.0 (53.1%) | |
| 2 | 20.0 (31.2%) | 11.0 (34.4%) | |
| 3 | 6.0 (9.4%) | 3.0 (9.4%) | |
| 4 | 4.0 (6.2%) | 1.0 (3.1%) | |
| Surgery type | 0.819 | ||
| Laminectomy | 14.0 (21.9%) | 7.0 (21.9%) | |
| Laminectomy+fusion | 4.0 (6.2%) | 3.0 (9.4%) | |
| Laminectomy+instrumented fusion with interbody | 46.0 (71.9%) | 22.0 (68.8%) |
x±s represents X±1 SD. N is the number of patients included. Numbers after proportions are frequencies.
Abbreviations- UBS, ultrasonic bone scalpel; BMI, body mass index
Comparison of baseline scores
For the matched sample, no differences were observed in any of the PROMIS domains between the traditional and UBS groups including PROMIS-Physical Function (35.2±5.6 vs. 34.5±4.0, p=0.705), PROMIS-Anxiety (52.0±9.1 vs. 53.2±9.3, p=0.553), PROMIS-Depression (49.6±8.6 vs. 50.4±9.0, p=0.668), PROMIS-Fatigue (53.4±8.7 vs. 55.6±9.1, p=0.182), PROMIS-Sleep Disturbance (52.5±8.1 vs. 53.2±7.8, p=0.839), PROMIS-Social (41.9±8.0 vs. 40.2±7.1, p=0.342), and PROMIS-Pain Interference (65.6±6.4 vs. 66.7±5.0, p=0.418) (Table 2). In addition, no differences were found between the traditional and UBS groups for NRS back pain (6.3±2.3 vs. 6.5±1.8, p=0.654), NRS leg pain (6.4±2.4 vs. 6.8±1.9, p=0.537), %ODI (41.2±16.6 vs. 40.5±13.9, p=0.763) and PHQ-9 scores (6.3±6.1 vs. 5.8±5.1, p=0.861).
Table 2.
Preoperative Scores of Patients with Traditional Laminectomy vs. Ultrasonic Bone Scalpel.
| Traditional
N=64 |
UBS
N=32 |
P-value | |
|---|---|---|---|
| PROMIS scores | |||
| Physical function | 35.2±5.6 | 34.5±4.0 | 0.705 |
| Anxiety | 52.0±9.1 | 53.2±9.3 | 0.553 |
| Depression | 49.6±8.6 | 50.4±9.0 | 0.668 |
| Fatigue | 53.4±8.7 | 55.6±9.1 | 0.182 |
| Sleep disturbance | 52.5±8.1 | 53.2±7.8 | 0.839 |
| Ability to participate in social roles | 41.9±8.0 | 40.2±7.1 | 0.342 |
| Pain interference | 65.6±6.4 | 66.7±5.0 | 0.418 |
| NRS back pain | 6.3±2.3 | 6.5±1.8 | 0.654 |
| NRS leg pain | 6.4±2.4 | 6.8±1.9 | 0.537 |
| ODI percentage | 41.2±16.6 | 40.5±13.9 | 0.763 |
| PHQ-9 score | 6.3±6.1 | 5.8±5.1 | 0.861 |
x±s represents X±1 SD. N is the number of patients included.
Abbreviations- UBS, ultrasonic bone scalpel; PROMIS, Patient-reported Outcomes Measurement Information System; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; PHQ-9, Patient Health Questionnaire-9
Comparison of surgery duration, intraoperative bleeding, outcomes, and complications
For the matched sample, no significant difference was noted between the traditional and UBS groups regarding surgery duration (133.32±75.24. vs. 154.47±61.18, p=0.083) (Table 5). However, post-match analysis did show a significant difference between the traditional and UBS groups as regards estimated intraoperative blood loss (162.06±170.93 vs. 96.88±53.43, p=0.0001), with the UBS group showing significantly less blood loss (Table 5). Additionally, there were no significant differences between the two groups for any patient-reported outcome (PRO) at 3 months (Table 3) or 12 months (Table 4). There was a significant difference in rates of durotomies between the traditional and UBS groups (12.5% vs. 0.0%, p=0.049) (Table 5). All durotomies were treated intraoperatively with the appropriate monofilament sutures, dural patch, or sealant. Reoperation rates for the durotomy cohort was 12.5%. There were no significant differences between the two groups for rates in any other complications as well as reoperation and readmission rates.
Table 5.
Surgery Duration, Intraoperative Bleeding, and Postoperative Complications.
| Traditional, N=64 | UBS, N=32 | P-value | |
|---|---|---|---|
| Surgery duration (minutes) | 133.32±75.24 | 154.47±61.18 | 0.083 |
| Intraoperative bleeding (mL) | 162.06±170.93 | 96.88±53.43 | 0.000 |
| Postoperative complications | |||
| Pneumonia | 0.0 (0.0%) | 0.0 (0.0%) | |
| DVT | 0.0 (0.0%) | 0.0 (0.0%) | |
| UTI | 0.0 (0.0%) | 0.0 (0.0%) | |
| SSI | 1.0 (1.6%) | 1.0 (3.1%) | >0.999 |
| Neurodeficit | 0.0 (0.0%) | 0.0 (0.0%) | |
| Durotomy | 8.0 (12.5%) | 0.0 (0.0%) | 0.049 |
| Root injury | 0.0 (0.0%) | 0.0 (0.0%) | |
| Neurological complication | 0.0 (0.0%) | 1.0 (3.1%) | 0.333 |
| No complication | 56.0 (87.5%) | 31.0 (96.9%) | 0.264 |
| Return to OR | 5.0 (7.8%) | 1.0 (3.1%) | 0.660 |
| Readmission | 10.0 (15.6%) | 2.0 (6.2%) | 0.326 |
x±s represents X±1 SD. Numbers after proportions are frequencies.
Abbreviations- UBS, ultrasonic bone scalpel; DVT, deep vein thrombosis; UTI, urinary tract infection; SSI, surgical site infection; OR, operating room
Table 3.
3-month Outcome of Patients with Traditional Laminectomy vs. Ultrasonic Bone Scalpel.
| Traditional
N=64 |
UBS
N=32 |
P-value | |
|---|---|---|---|
| PROMIS scores | |||
| Physical function | 44.0±6.9 | 45.8±8.4 | 0.558 |
| Anxiety | 47.5±7.8 | 45.2±7.8 | 0.185 |
| Depression | 47.7±9.2 | 46.3±7.1 | 0.632 |
| Fatigue | 48.5±8.7 | 47.0±9.3 | 0.562 |
| Sleep disturbance | 49.6±7.3 | 46.6±8.5 | 0.145 |
| Ability to participate in social roles | 51.2±8.3 | 51.0±9.6 | 0.759 |
| Pain interference | 54.8±8.1 | 53.8±8.7 | 0.584 |
| Please rate your back pain on a scale of 0 to 10 over the past 7 days. | 2.9±2.6 | 2.2±2.3 | 0.332 |
| Please rate your leg pain on a scale of 0 to 10 over the past 7 days. | 2.4±2.9 | 1.7±2.5 | 0.294 |
| Total ODI sum score | 11.1±7.7 | 9.3±8.3 | 0.259 |
| ODI percentage | 22.2±15.4 | 18.6±16.6 | 0.259 |
| PHQ-9 score | 3.1±3.7 | 2.4±3.0 | 0.472 |
x±s represents X±1 SD. N is the number of patients included.
Abbreviations- UBS, ultrasonic bone scalpel; PROMIS, Patient-reported Outcomes Measurement Information System; ODI, Oswestry Disability Index; PHQ-9, Patient Health Questionnaire-9
Table 4.
12-month Outcome of Patients with Traditional Laminectomy vs. Ultrasonic Bone Scalpel.
| Traditional,
N=64 |
UBS,
N=32 |
P-value | |
|---|---|---|---|
| Pain | 3.2±2.3 | 3.5±2.9 | 0.797 |
| Physical function t-score | 45.3±6.7 | 43.1±7.9 | 0.237 |
| Anxiety t-score | 48.4±9.4 | 49.2±10.9 | 0.916 |
| Depression t-score | 48.4±8.9 | 49.5±8.7 | 0.419 |
| Fatigue t-score | 49.0±9.1 | 51.2±12.5 | 0.493 |
| Sleep disturbance t-score | 49.2±8.7 | 51.1±10.9 | 0.431 |
| Ability to participate in social roles t-score | 51.4±8.9 | 49.6±11.1 | 0.705 |
| Pain interference t-score | 53.7±8.8 | 56.2±10.2 | 0.497 |
| Please rate your back pain on a scale of 0 to 10 over the past 7 days. | 2.7±2.6 | 3.2±2.7 | 0.465 |
| Please rate your leg pain on a scale of 0 to 10 over the past 7 days. | 2.5±2.5 | 3.8±3.2 | 0.179 |
| Total ODI sum score | 9.4±6.8 | 10.5±10.7 | 0.843 |
| ODI percentage | 18.8±13.7 | 21.0±21.3 | 0.843 |
| PHQ-9 score | 3.6±5.2 | 5.5±6.9 | 0.204 |
x±s represents X±1 SD. N is the number of patients included.
Abbreviations- UBS, ultrasonic bone scalpel; PROMIS, Patient-reported Outcomes Measurement Information System; ODI, Oswestry Disability Index; PHQ-9: Patient Health Questionnaire-9
Discussion
Laminectomy has been commonly performed on the lumbar spine to treat a variety of spine pathologies; however, the procedure is not without risk. The most common complication resulting from a lumbar laminectomy procedure is an iatrogenic durotomy21). The risk of this iatrogenic durotomy is increased among older patients with advanced spinal pathology. Furthermore, revision cases and other invasive procedures are known to increase the risk of durotomy22). If improperly managed postoperatively, iatrogenic durotomies can increase the risk of developing refractory headache, intracranial hypotension, pseudomeningoceles, or, in rare cases, remote cerebellar hemorrhage12,22-25). The UBS has been utilized in spine surgery with the proposed advantage of decreased operative times, higher volume of bone graft retention, and possibly fewer incidental durotomies14). While previous studies have reported improved operative speed and decreased complications for laminectomies performed by the UBS in the cervical and thoracic regions, the efficacy of the UBS for lumbar laminectomies has remained understudied14,16,17). Thus, in this study, we sought to compare outcomes between patients who received a lumbar laminectomy either through traditional methods or the Misonix BoneScalpel UBS. Our results showed that lumbar laminectomies performed with the UBS resulted in fewer durotomies compared to lumbar laminectomies performed by traditional methods.
In the matched sample, all patient demographics and baseline measurements were similar between groups except for race and ethnicity. This is most likely artifact from the small sample size. While increasing complication rates have been shown to affect short-term PROs, no differences were found in 3-month PROs between the two groups. A potential explanation for this is that while the rate of durotomies was statistically significant between the two groups, overall complication rates were not. This current study may also be underpowered to detect differences in PROs.
The UBS group had a statistically lower rate of durotomies compared to the traditional group. The results suggest that the high-frequency oscillation technology implemented by the UBS helps to decrease the rate of injury to the dura, reducing the incidence of durotomies. This benefit is attributable to a variety of features unique to the UBS. Longitudinal micromovements are produced by the UBS at a frequency of 22.5 kHz13). The recurrent impacts that result from these high-frequency oscillations tend to pulverize noncompliant crystalline structures, such as bone, because such structures do not bend or deviate in position and thus absorb a large portion of the instrument's energy at the point of contact13,17). In contrast, the UBS spares highly compliant and elastic tissues, such as dura, because these tissues move away from the UBS tip upon contact and maintain structural integrity and viability, thereby permitting the safe removal of bone near important soft tissue structures13,15,17,26). Further, the UBS has a narrow cutting blade as opposed to a spinning burr, which mitigates the possibility of soft tissue being captured and causing injury or erratic drill movements13,26). In addition to the lower rate of durotomies, the UBS group has exhibited significantly lower estimated intraoperative blood loss compared to the traditional group. Both findings align with findings from previous literature that have reported reduced intraoperative complication rates when using the UBS16,17).
No differences were detected in reoperation and readmission rates. This could be due to intraoperative recognition and repair of durotomies, eliminating the need for reoperation and readmission. It is also likely our study was underpowered to detect differences in reoperation and readmission rates since both the rate of reoperation and readmission in the UBS group was less than half that of the traditional surgery but did not reach statistical significance.
Limitations
This study should be interpreted considering its inherent limitations. First, this study contained data from a single institution. In addition, patient selection and laminectomy method were at the discretion of the operating surgeons with the potential for bias. Although propensity matching was performed, our study still had a relatively low number of UBS patients, which could mean the study is underpowered to detect differences in multiple outcomes. The heterogeneity of lumbar surgical cases is another limitation. Future studies analyzing these procedures separately could provide valuable information. Lastly, revision laminectomies serve as a future area of study given higher rate of dural tears in this group.
Conclusion
This current study showed that laminectomy procedures performed using the UBS had fewer durotomies when compared to traditional methods. The results also did not show a significant difference in PROs between patients who had a durotomy completed by the UBS compared to the traditional methods. We believe these data could provide valuable information to surgeons and patients about the safety and efficacy of the UBS in performing lumbar laminectomies. Further studies may investigate if the UBS decreases operative time for lumbar laminectomies as compared to traditional laminectomy methods.
Conflicts of Interest: Dr. Zuckerman reports being an unaffiliated neurotrauma consultant for the National Football League. Dr. Stephens reports educational consulting for Medical Device Business Services and a grant from Stryker Spine [R1160501]. The other authors declare that there are no conflicts of interest.
Sources of Funding: None
Author Contributions: All authors were involved in either drafting or revising the submitted manuscript. They all approved the final submission and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Amir Abtahi, Byron Stephens, Julian Lugo-Pico, and Scott Zuckerman were responsible for designing the project and interpreting the data. Alexander O'Brien, W. Hunter Waddell, Robert Elrod, and Justin Vickery were responsible for the acquisition of data. Jeffrey Chen and Hani Chanbour were responsible for the analysis. Anthony Steinle, Wilson Vaughan, and Andrew Croft were responsible for the acquisition and interpretation of data for the submitted work.
Ethical Approval: Institutional Review Board (IRB) approval from Vanderbilt University Medical Center was obtained for this study (IRB #211290).
Informed Consent: Informed consent for publication was obtained from all participants in this study.
References
- 1.Estefan M, Munakomi S, Camino Willhuber GO. Laminectomy. ed. Treasure Island (FL): StatPearls Publishing LLC.; 2022. StatPearls; p. [PubMed] [Google Scholar]
- 2.Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976). 2010;35(14):1329-38. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Djurasovic M, Glassman SD, Carreon LY, et al. Contemporary management of symptomatic lumbar spinal stenosis. Orthop Clin North Am. 2010;41(2):183-91. [DOI] [PubMed] [Google Scholar]
- 4.Gunzburg R, Szpalski M. The conservative surgical treatment of lumbar spinal stenosis in the elderly. Eur Spine J. 2003;12 Suppl 2:S176-80. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Nikouei F, Nabizadeh N, Mirzamohammadi E, et al. Application of Oscillating Saw for Lumbar en Bloc Laminectomy: A Case Series. Arch Bone Jt Surg. 2020;8(3):407-12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ray CD. New techniques for decompression of lumbar spinal stenosis. Neurosurgery. 1982;10(5):587-92. [DOI] [PubMed] [Google Scholar]
- 7.Guerin P, El Fegoun AB, Obeid I, et al. Incidental durotomy during spine surgery: incidence, management and complications. A retrospective review. Injury. 2012;43(4):397-401. [DOI] [PubMed] [Google Scholar]
- 8.Kalevski SK, Peev NA, Haritonov DG. Incidental Dural Tears in lumbar decompressive surgery: Incidence, causes, treatment, results. Asian J Neurosurg. 2010;5(1):54-9. [PMC free article] [PubMed] [Google Scholar]
- 9.Smorgick Y, Baker KC, Herkowitz H, et al. Predisposing factors for dural tear in patients undergoing lumbar spine surgery. J Neurosurg Spine. 2015;22(5):483-6. [DOI] [PubMed] [Google Scholar]
- 10.Turner JA, Ersek M, Herron L, et al. Surgery for lumbar spinal stenosis. Attempted meta-analysis of the literature. Spine (Phila Pa 1976). 1992;17(1):1-8. [DOI] [PubMed] [Google Scholar]
- 11.Papavero L, Engler N, Kothe R. Incidental durotomy in spine surgery: first aid in ten steps. Eur Spine J. 2015;24(9):2077-84. [DOI] [PubMed] [Google Scholar]
- 12.Ishikura H, Ogihara S, Oka H, et al. Risk factors for incidental durotomy during posterior open spine surgery for degenerative diseases in adults: A multicenter observational study. PLoS One. 2017;12(11):e0188038. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Dave BR, Krishnan A, Rai RR, et al. The Effectiveness and Safety of Ultrasonic Bone Scalpel Versus Conventional Method in Cervical Laminectomy: A Retrospective Study of 311 Patients. Global Spine J. 2020;10(6):760-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Sun C, Chen G, Fan T, et al. Ultrasonic bone scalpel for thoracic spinal decompression: case series and technical note. J Orthop Surg Res. 2020;15(1):309. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Lin Q, Lin T, Wang Z, et al. Safety and Effectiveness of Modified Expansive Open-door Laminoplasty Using a Ultrasonic Bone Scalpel Compared With a High-speed Drill. Clin Spine Surg. 2022;35(1):E223-E9. [DOI] [PubMed] [Google Scholar]
- 16.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):4006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Onen MR, Yuvruk E, Akay S, et al. The Reliability of the Ultrasonic Bone Scalpel in Cervical Spondylotic Myelopathy: A Comparative Study of 46 Patients. World Neurosurg. 2015;84(6):1962-7. [DOI] [PubMed] [Google Scholar]
- 18.Chotai S, Parker SL, Sivaganesan A, et al. Effect of complications within 90 days on patient-reported outcomes 3 months and 12 months following elective surgery for lumbar degenerative disease. Neurosurg Focus. 2015;39(6):E8. [DOI] [PubMed] [Google Scholar]
- 19.Bydon M, Xu R, Papademetriou K, et al. Safety of spinal decompression using an ultrasonic bone curette compared with a high-speed drill: outcomes in 337 patients. Journal of Neurosurgery: Spine. 2013;18(6):627-33. [DOI] [PubMed] [Google Scholar]
- 20.Wang Y, Cai H, Li C, et al. Optimal Caliper Width for Propensity Score Matching of Three Treatment Groups: A Monte Carlo Study. PLoS ONE. 2013;8(12):e81045. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Desai A, Ball PA, Bekelis K, et al. SPORT. Neurosurgery. 2015;76(suppl_1):S57-S63. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hassanzadeh H, Bell J, Bhatia M, et al. Incidental Durotomy in Lumbar Spine Surgery; Risk Factors, Complications, and Perioperative Management. J Am Acad Orthop Surg. 2021;29(6):e279-e86. [DOI] [PubMed] [Google Scholar]
- 23.Wolff S, Kheirredine W, Riouallon G. Surgical dural tears: prevalence and updated management protocol based on 1359 lumbar vertebra interventions. Orthop Traumatol Surg Res. 2012;98(8):879-86. [DOI] [PubMed] [Google Scholar]
- 24.Enders F, Ackemann A, Muller S, et al. Risk Factors and Management of Incidental Durotomy in Lumbar Interbody Fusion Surgery. Clin Spine Surg. 2018;31(3):127-31. [DOI] [PubMed] [Google Scholar]
- 25.Floman Y, Millgram MA, Ashkenazi E, et al. Remote Cerebellar Hemorrhage Complicating Unintended Durotomy in Lumbar Spine Surgery. Int J Spine Surg. 2015;9:29. eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Pakzaban P. Ultrasonic Total Uncinectomy: A Novel Technique for Complete Anterior Decompression of Cervical Nerve Roots. Operative Neurosurgery. 2014;10(4):535-41. [DOI] [PubMed] [Google Scholar]