16. Complications of BESS/UBE and their management
@ProfFishchenkoBiportal endoscopic spine surgery (BESS/UBE) may be accompanied by intraoperative and postoperative complications. Their analysis is needed for risk assessment, procedural planning, and timely treatment.
Complication rates
Rates depend on the spinal region, type of operation, patient characteristics, surgeon experience, definitions of complications, and duration of follow-up. Techniques should be compared using similar procedures and comparable patient groups. We assess asymptomatic postoperative MRI findings, clinically significant complications, and events requiring reoperation separately.
Dural injury
Accidental dural injury may cause cerebrospinal fluid leakage and headache and increase the risk of infection. Contributing factors include complex anatomy, calcified herniations, inadequate visualization, and operator experience.
In our practice, we close defects up to and including 5 mm with TachoSil; we suture defects larger than 5 mm with absorbable VICRYL 4-0 (RB-1 Plus needle, 17 mm, 1/2 circle). We also consider the shape and location of the defect and involvement of neural structures.
Infectious complications
Infection may be superficial or deep, including discitis or an epidural abscess. Fever, increasing pain, and neurological disturbances may occur. Contributing factors include microbial contamination of the surgical wound, including breaches of asepsis.
The strategy is determined by the location, depth, and severity of infection. We prescribe antibiotics when indicated, considering the likely pathogens, and subsequently adjust them according to microbiological results. We separately assess the need for drainage or surgical debridement of the focus and decompression of neural structures. A new or progressive neurological deficit or signs of sepsis require emergency assessment and treatment without waiting for culture results.
Epidural hematoma
Irrigation may mask bleeding during surgery. Clinical signs of a compressive hematoma include increasing pain, weakness, and other new neurological deficits. An asymptomatic MRI finding is not equivalent to a symptomatic hematoma. Signs of neural compression require emergency assessment and a decision on hematoma evacuation; waiting for spontaneous resorption is unacceptable in this situation.
Recurrent disc herniation
Recurrence means a new herniation at the operated level. A retained fragment must be distinguished from true recurrence. Further disc degeneration and the condition of the operated segment are relevant.
When indicated, we perform repeat decompression or, in selected cases, BELIF/UBE-LIF interbody fusion. Recurrent herniation and recurrence of pain are different outcomes. The rate of postoperative reherniation is not directly compared with the return of symptoms after nonsurgical treatment. Comparisons between operations require identical definitions and comparable follow-up periods.
Neural injury
Direct instrument contact, excessive retraction, and complex anatomical conditions may injure a nerve root or the spinal cord. Paresthesias, weakness, or sensory disturbances may occur; the prognosis depends on injury severity.
In our practice, when neural structures are injured intraoperatively, we include high-dose corticosteroids in treatment, taking contraindications and risks into account. Corticosteroid administration must not delay emergency assessment and relief of compression when present. We select rehabilitation according to the neurological deficit and patient condition.
Other complications
Deep vein thrombosis is associated, among other factors, with prolonged immobilization and individual risk factors.
Pseudomeningocele is a collection of cerebrospinal fluid in paravertebral tissues following a dural defect.
Risk factors
Risk depends on surgeon experience and training, anatomical complexity, calcification, stenosis severity, and procedure duration. The duration of training depends on the surgeon’s prior preparation and type of intervention.
Comparison with other methods
A pooled analysis of two randomized studies of single-level lumbar procedures for herniation or stenosis found no statistically significant difference in the overall adverse event rate between BESS and conventional microsurgery. Wound dehiscence was less frequent in the BESS group.
When comparing with uniportal endoscopy, the specific approach and operation matter. In a lumbar discectomy study, the learning curve for the uniportal transforaminal method was longer and more difficult than for BESS; the result also depends on prior experience and training.
Practical conclusion
Understanding anatomy, appropriate training, control of visualization and irrigation, meticulous hemostasis, and timely recognition of complications form the basis of BESS/UBE safety. A new neurological deficit requires emergency assessment.
References
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