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Abstract

Lumbar spinal stenosis (LSS) is a common and debilitating pathology globally. Conservative and surgical treatment options exist for patients. Recently, minimally invasive lumbar decompression (MILD) has been described as a less invasive technique for the treatment of early spinal stenosis ≥2.5mm ligamentum thickening or in patients at high risk for general anesthesia. Often, MILD is performed by interventional pain providers and shows low complication rates. We describe a 76-year-old woman who presented to the emergency department immediately after undergoing a MILD procedure at an outside surgery center with lower back/sacral pain resulting from an acute epidural hematoma extending from T12-L3. Early recognition and surgical evacuation resulted in a good outcome with no complications. Our goal is to increase awareness of this rare complication and encourage multidisciplinary approaches to managing LSS between spine surgeons and pain providers.

Introduction

Chronic low back pain is typically defined as pain concentrated in the lumbosacral region of the spine that lasts longer than three months [1]. There is a high likelihood that >60% of people will experience debilitating low back pain during their lifetime, with an increased prevalence in populations of advanced age, low socioeconomic status, and those with more comorbidities [2,3]. Among the spectrum of causes for lower back pain, lumbar spine stenosis (LSS) occurs with an incidence of up to 38% globally [4]. The North American Spine Society has formally defined LSS as "a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal" [5].

This spinal canal narrowing can result from osteoarthritis, degenerative disk disease, ligamentum hypertrophy, and generalized joint degeneration [6-9]. The evidence suggests that for many patients, a multimodal approach to treatment is the most suitable, including conservative and surgical options, ranging from analgesic pain medications to lumbar fusion surgeries [10,11].

First described in 2005, the Minimally Invasive Lumbar Decompression (MILD) procedure has become one of the mainstay treatments when ligamentum flavum hypertrophy is present (Vertos Medical, Aliso Viejo, CA, USA) [12]. The procedure is carried out under sedation and through percutaneous access for patients with symptomatic LSS and ligamentous hypertrophy ≥2.5mm. Contraindications include patients with grade II spondylolisthesis. Debulking of hypertrophic ligamentum flavum and the corresponding interlaminar bone is the primary goal. This localized removal of the canal-narrowing pathology allows spinal cord decompression at the intended target [13].

Prospective studies, case reports, and extensive review articles have assessed the safety and efficacy of the procedure [12-15]. In a recent review, Jain et al. detailed that two level-one randomized control trials, five prospective studies, two meta-analyses, four retrospective studies, and three case series had been published justifying the safety profile of the MILD procedure. Of these studies, only Staats et al. reported a 1.3% device- or procedure-related adverse event among its 143 patients treated with the MILD procedure, while none noted major complications such as dural tear, cerebrospinal fluid leak, or wound-healing complications. They also showed a significantly low likelihood of reoperation, 5.6% [5,16].

We report a case of a rare epidural hematoma forming after a MILD procedure and the multidisciplinary approach to diagnosis and treatment.

Case Presentation

A 76-year-old female patient with a past medical history of osteoarthritis and coronary artery disease presented to the emergency department after having undergone a left L2/L3 MILD procedure under monitored anesthesia care that same day for degenerative spondylosis and moderate-to-severe LSS. She denied antiplatelet use or a history of bleeding disorder. Upon discharge following the procedure, she had worsening lumbar and left buttock/hip pain worsened with movement, left leg radiculopathy, lower extremity weakness, and progressive bilateral numbness of her...(More)

For more info please read, Lumbar Epidural Hematoma as a Rare Complication From Minimally Invasive Lumbar Decompression, by Cureus