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Removal of the Deeply Located Intradiscal Broken Knife Blade with Arthroscopic Assistance: A Case Report and Literature review
Journal Pre-proof Removal of the Deeply Located Intradiscal Broken Knife Blade with Arthroscopic Assistance: A Case Report and Literature review Guang Bin Zheng, M.D., Ph. D, Zhangfu Wang, M.M. PII:
S1878-8750(20)30239-4
DOI:
https://doi.org/10.1016/j.wneu.2020.01.221
Reference:
WNEU 14251
To appear in:
World Neurosurgery
Received Date: 9 January 2020 Accepted Date: 28 January 2020
Please cite this article as: Zheng GB, Wang Z, Removal of the Deeply Located Intradiscal Broken Knife Blade with Arthroscopic Assistance: A Case Report and Literature review, World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2020.01.221. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
Removal of the Deeply Located Intradiscal Broken Knife Blade with Arthroscopic Assistance: A Case Report and Literature review
Guang Bin Zheng, M.D., Ph. D., Zhangfu Wang, M.M.*
Department of spine surgery, Taizhou Hospial of Zhejiang Province, Wenzhou Medical University, Linhai , Zhejiang , China. Conflicts of Interest and Source of Funding: Guang Bin Zheng and Zhangfu Wang have nothing to disclose. No benefits in any form have been
or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
*Corresponding author: Zhangfu Wang. Professor of Department of spine Surgery, Taizhou Hospial of Zhejiang Province, Wenzhou Medical University, Linhai , Zhejiang , China. E-mail: [email protected], Tel: +86-1358068527
Zheng
ABSTRACT BACK GROUND: Surgical scalpel broken is rarely reported in posterior lumbar discectomy or fusion surgeries, but when it is happened and even the broken part is deeply located in the disc space, there is no guideline to remove it during the initial surgery. CASE DESCRIPTION: A 56-year-old female with L3-L4 and L4-L5 disc herniation and stenosis underwent two level transforaminal lumbar diskectomy and fusion. The knife blade was broken in the L4-L5 disc space during the annulus resection. Despite of 1.5 hour trial for removal with fluoroscopy, the broken part gradually migrated to the anterior border of the disc space. Eventually, arthroscopy was utilized for retrieval, the blade tip was cleared recognized in the arthroscopic view which improved the accuracy of subsequent operation and it was removed successfully within 30 min. CONCLUSION: Arthroscopic retrieval of broken scalpel deeply locate in the intradiscal space is recommended as an alternative method when conventional effort is unable to remove it, especially the broken blade trends
to
migrate
anteriorly
which
may
provoke
catastrophic
consequences.
KEY WORDS: broken knife blade, arthroscope, lumbar diskectomy.
1
Zheng
INTRUDUCTION Transforaminal lumbar interbody fusion (TLIF) is widely used in treatment of lumbar degenerative diseases
1-3
. During the surgical
procedure, annulus was usually excised by No. 11 knife blade. Although the knife blade broken is an extremely rare complication during the surgery, the retrieval of the broken blade is very challenging if it is deeply located in the disc space or even migrates anteriorly into the retroperitoneal space 4-6. The first literature reported about knife blade broken was published in 20 years ago, the authors recommended second anterior approach to remove the deeply located broken scalpel if the sharp edge was facing at the abdominal visceral and vessels, because inaccurate manipulation may lead to disastrous consequences 7. Transforaminal route was a harmless corridor which may remove the broken part in one-stage without additional another surgery
8, 9
. However, the surgical field may be still
limited for utilize the removing instruments like hemostatic forceps or nucleus pulposus forceps into disc space when the broken scalpel migrates deeply into anterior border. In such situations, it is difficult to retrieve under direct vision even using the microscope. If the blade could not be grasped at the first few times, repeated manipulation may push the broken part anteriorly and even migrate into the retroperitoneal area, which always resulting in a second complicated surgery to avoid 2
Zheng
catastrophic consequences like main vessel injury 4, 6. We presented a case of a successful retrieval of deeply located broken blade by arthroscopic assistance in the initial surgery, which might be a safer and more effective way to remove broken scalpel when migration was once observed.
CASE PRESENTATION A 56-year-old female diagnosed as L3/4
L4/5 disc herniation with
lumbar degenerative stenosis underwent two level TLIF. During the left side L4/5 annulus resection, the knife blade was broken, the broken part was located anteriorly in the disc space and the sharp tip of broken knife was directed to the anterior border in the first lateral view of fluoroscopy (Fig 1a). We tried to remove it with hemostatic forceps or nucleus pulposus forceps under fluoroscopy (Fig 1b). However, the broken blade migrated deeper into the anterior border of the disc space, the posterior edge of broken scalpel was displaced by pushing and made the whole broken blade horizontal shape in the fluoroscopy which increase the retrieval difficulties (Fig 1c). Then, we thought enlarge the disc space may facilitate to the retrieval, the intervertebral disc shaver was used to expand the disc space (Fig 1c). But the broken part was still invisible, in lateral view of fluoroscopy, the broken blade was pushed even deeper just adjacent to the anterior longitudinal ligament. Any of an inappropriate 3
Zheng
manipulation may lead to the broken part migrated toward retroperitoneal space. Despite of 1.5 hour trial, in consideration of the conventional spinal instruments and methods failed to retrieve the broken blade, we performed total laminectomy and applied the arthroscope in the disc space(Fig 1d, e, f). After meticulous hemostasis and debridement, the posterior part of broken blade was identified (Fig 2a), 90°hook was probed beneath the base of the broken part and carefully detached it from the nucleus pulposus tissue around it (Fig 2b, c). After adequate release (Fig 2d), the broken part was successfully grasped and removed by nucleus pulposus forceps (Fig 2e, f). The foreign body removal procedure consumed 2 hours. Then 2 level interbody fusion was performed evenly. The patient was discharged 1 week after surgery and 2-year follow-up showed good recovery.
DISCUSSION Knife blade broken is a rare complication during lumbar diskectomy, there is very limited experience to remove it for most of spine surgeons. Successful and quick retrieval of such flat and sharp fragment becomes very difficult if the broken blade is located deeply in the disc space even if under fluoroscopic or microscopic guidance. In such situations, second surgery of anterolateral approach was suggested for safer removal of the fragment 7. However, the broken blade may migrate to retroperitoneal 4
Zheng
space or even to the aorta or vena cava when the position is changed, which may increase the probability of serious complications like aorta or visceral injury
4, 10
, an unplanned additional surgery also could decrease
patient’s satisfaction. Rahimizadeh etal suggested transforaminal corrider for retrieval of deeply retained broken scalpel in diskectomy 8. Transforaminal approach with pars resection could enlarge the surgical field of the disc space and may be helpful for direct foreign body removal. Microscopic assistance could amplify the surgical field and improve security and successful rate 5. Intraoperative fluoroscopic guidance is essential, repeated AP and lateral views are needed to confirm the location between the broken blade and the retrieval instrument. However, if the knife blade is broken at the first stab of the diskectomy procedure and buried deeply in the disc space, the tip of the broken part could not be seen easily and any of further disc space expanding procedure or the retrieval without assurance may lead to further migration even if under microscope or fluoroscopic guidance. Obviously, in consideration of conservative treatment could provoke many unpredictable detrimental results, retrieving the broken blade with safer and more effective method is required. In this case, we performed total laminectomy, contralateral transforaminal decompression and diskectomy was also applied when we realized the broken blade was located deeply in the disc space and difficult to retrieve in conventional 5
Zheng
way. Then, we utilized the arthroscope in the disc space of ipsilateral side of broken blade to find the broken part. The advantage of arthroscope in this surgery was that the broken scalpel could be identified clearly in amplified view which may reduce repeated clamp and avoid anterior migration. The whole procedure was recorded and we cost only 20 minutes to complete the retrieval since the arthroscope was applied. Fluoroscopic guidance was used to improve the accuracy and safety during the procedure until the broken blade was removal. Deeply retained foreign body removal by arthroscopic assistance has not been reported before. In our case, we retrieved the broken blade under arthroscope safely and effectively. Other than the fluoroscopic guide only, arthroscope could provide the real-time situation between the broken part and retrieving instrument, which increased the successful rate and prevented the anterior migration of the broken scalpel. The reason of the surgical scalpel broken in diskectomy was reported rarely. A knife blade with “narrow junction” was more prone to break than “triangular shaped” knife
7, 8
. But we experienced the triangular shaped knife broken in this
case as well as another reported case 6. A firm and calcified annulus was reported one of the risk factors of knife blade broken 7. A narrowed disc space should be another risk factor. However, in our experience, inadequate resection maneuver should be mostly responsible for the knife blade broken. Twisting or changing the direction of the scalpel edge when 6
Zheng
the blade is located partially in the disc space should be performed cautiously or even prevented. Straight in and out of the knife blade for disc space resection is recommended. For narrowed disc space or calcified annulus, micro-dissector should be used to confirm the disc space instead of knife blade. CONCLUSION Arthroscopic assistance is a safer and more effective way to remove the broken scalpel deeply located in the disc space than fluoroscopic or microscopic guidance. Arthroscope could ensure the broken blade in the surgeon’s view throughout the whole retrieval procedure and increase the successful rate of retrieval in the initial surgery.
REFERENCES 1.
Chen MJ, Niu CC, Hsieh MK, et al. Minimally Invasive Transforaminal Lumbar
Interbody Debridement and Fusion with Percutaneous Pedicle Screw Instrumentation for
Spondylodiscitis.
World
Neurosurg.
2019;128:
e744-e751.
https://doi.org/10.1016/j.wneu.2019.04.249. 2.
Miller LE, Bhattacharyya S, Pracyk J. Minimally Invasive Versus Open
Transforaminal Lumbar Interbody Fusion for Single-Level Degenerative Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg. 2019. https://doi.org/10.1016/j.wneu.2019.08.162. 3.
Yao YC, Lin HH, Chou PH, Wang ST, Chang MC. Differences in the interbody
bone graft area and fusion rate between minimally invasive and traditional open transforaminal lumbar interbody fusion: a retrospective short-term image analysis. European spine journal : official publication of the European Spine Society, the
7
Zheng European Spinal Deformity Society, and the European Section of the Cervical Spine Research
Society.
2019;28(9):
2095-2102.
https://doi.org/10.1007/s00586-019-06002-4. 4.
Limbachia D, Gandhi P. Laparoscopic retrieval of a foreign body (broken surgical
knife) from retroperitoneal space: An interesting case. Gynecol Minim Invasive Ther. 2017;6(4): 193-194. https://doi.org/10.1016/j.gmit.2016.10.003. 5.
Yogesh A, Somnath S, Sanjeev C, Kumar PD. Retrieval of a retained broken
scalpel blade from lumbar intervertebral disc space - a case report. Romanian Neurosurgery. 2017;31(1): 129-132. 6.
Koutserimpas
C,
Ioannidis
A,
Konstantinidis
M,
Athanasopoulos
P,
Antonakopoulos F, Konstantinidis K. Robot-Assisted Removal of a Broken Scalpel Blade
following
Discectomy.
Case
Rep
Surg.
2019;2019:
8609246.
https://doi.org/10.1155/2019/8609246. 7.
Amirjamshidi A, Mehrazin M, Abbassioun K, Ketabtchi E. Retained broken knife
blades within the disc space. Spine. 1994;19(8): 981-984. 8.
Rahimizadeh A, Ghorbani E, Rahimizadeh S. Transforaminal retrieval of
intradiscal retained broken surgical knife blade. Spine. 2013;38(20): E1278-1281. https://doi.org/10.1097/BRS.0b013e31829ef4d7. 9.
Rahimizadeh A, Haddadi K. Is transforaminal retrieval of intradiscal deeply
seated broken surgical knife blade all time pars sparing? A case report. International journal
of
surgery
case
reports.
2016;19:
131-133.
https://doi.org/10.1016/j.ijscr.2015.12.040. 10. De Praetere H, Vanden Eycken C, Meuris B, Herijgers P. Migration of a broken scalpel into the heart after spine surgery. Interactive cardiovascular and thoracic surgery. 2014;18(4): 527-529. https://doi.org/10.1093/icvts/ivt553.
Figure legend Fig. 1. Fluoroscopic views of broken scalpel retrieval procedure.
8
Zheng
Fig. 2. Arthroscopic pictures of broken scalpel retrieval procedure.
9
TLIF：Transforaminal Lumbar Interbody Fusion
S1878-8750(20)30239-4
DOI:
https://doi.org/10.1016/j.wneu.2020.01.221
Reference:
WNEU 14251
To appear in:
World Neurosurgery
Received Date: 9 January 2020 Accepted Date: 28 January 2020
Please cite this article as: Zheng GB, Wang Z, Removal of the Deeply Located Intradiscal Broken Knife Blade with Arthroscopic Assistance: A Case Report and Literature review, World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2020.01.221. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
Removal of the Deeply Located Intradiscal Broken Knife Blade with Arthroscopic Assistance: A Case Report and Literature review
Guang Bin Zheng, M.D., Ph. D., Zhangfu Wang, M.M.*
Department of spine surgery, Taizhou Hospial of Zhejiang Province, Wenzhou Medical University, Linhai , Zhejiang , China. Conflicts of Interest and Source of Funding: Guang Bin Zheng and Zhangfu Wang have nothing to disclose. No benefits in any form have been
or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
*Corresponding author: Zhangfu Wang. Professor of Department of spine Surgery, Taizhou Hospial of Zhejiang Province, Wenzhou Medical University, Linhai , Zhejiang , China. E-mail: [email protected], Tel: +86-1358068527
Zheng
ABSTRACT BACK GROUND: Surgical scalpel broken is rarely reported in posterior lumbar discectomy or fusion surgeries, but when it is happened and even the broken part is deeply located in the disc space, there is no guideline to remove it during the initial surgery. CASE DESCRIPTION: A 56-year-old female with L3-L4 and L4-L5 disc herniation and stenosis underwent two level transforaminal lumbar diskectomy and fusion. The knife blade was broken in the L4-L5 disc space during the annulus resection. Despite of 1.5 hour trial for removal with fluoroscopy, the broken part gradually migrated to the anterior border of the disc space. Eventually, arthroscopy was utilized for retrieval, the blade tip was cleared recognized in the arthroscopic view which improved the accuracy of subsequent operation and it was removed successfully within 30 min. CONCLUSION: Arthroscopic retrieval of broken scalpel deeply locate in the intradiscal space is recommended as an alternative method when conventional effort is unable to remove it, especially the broken blade trends
to
migrate
anteriorly
which
may
provoke
catastrophic
consequences.
KEY WORDS: broken knife blade, arthroscope, lumbar diskectomy.
1
Zheng
INTRUDUCTION Transforaminal lumbar interbody fusion (TLIF) is widely used in treatment of lumbar degenerative diseases
1-3
. During the surgical
procedure, annulus was usually excised by No. 11 knife blade. Although the knife blade broken is an extremely rare complication during the surgery, the retrieval of the broken blade is very challenging if it is deeply located in the disc space or even migrates anteriorly into the retroperitoneal space 4-6. The first literature reported about knife blade broken was published in 20 years ago, the authors recommended second anterior approach to remove the deeply located broken scalpel if the sharp edge was facing at the abdominal visceral and vessels, because inaccurate manipulation may lead to disastrous consequences 7. Transforaminal route was a harmless corridor which may remove the broken part in one-stage without additional another surgery
8, 9
. However, the surgical field may be still
limited for utilize the removing instruments like hemostatic forceps or nucleus pulposus forceps into disc space when the broken scalpel migrates deeply into anterior border. In such situations, it is difficult to retrieve under direct vision even using the microscope. If the blade could not be grasped at the first few times, repeated manipulation may push the broken part anteriorly and even migrate into the retroperitoneal area, which always resulting in a second complicated surgery to avoid 2
Zheng
catastrophic consequences like main vessel injury 4, 6. We presented a case of a successful retrieval of deeply located broken blade by arthroscopic assistance in the initial surgery, which might be a safer and more effective way to remove broken scalpel when migration was once observed.
CASE PRESENTATION A 56-year-old female diagnosed as L3/4
L4/5 disc herniation with
lumbar degenerative stenosis underwent two level TLIF. During the left side L4/5 annulus resection, the knife blade was broken, the broken part was located anteriorly in the disc space and the sharp tip of broken knife was directed to the anterior border in the first lateral view of fluoroscopy (Fig 1a). We tried to remove it with hemostatic forceps or nucleus pulposus forceps under fluoroscopy (Fig 1b). However, the broken blade migrated deeper into the anterior border of the disc space, the posterior edge of broken scalpel was displaced by pushing and made the whole broken blade horizontal shape in the fluoroscopy which increase the retrieval difficulties (Fig 1c). Then, we thought enlarge the disc space may facilitate to the retrieval, the intervertebral disc shaver was used to expand the disc space (Fig 1c). But the broken part was still invisible, in lateral view of fluoroscopy, the broken blade was pushed even deeper just adjacent to the anterior longitudinal ligament. Any of an inappropriate 3
Zheng
manipulation may lead to the broken part migrated toward retroperitoneal space. Despite of 1.5 hour trial, in consideration of the conventional spinal instruments and methods failed to retrieve the broken blade, we performed total laminectomy and applied the arthroscope in the disc space(Fig 1d, e, f). After meticulous hemostasis and debridement, the posterior part of broken blade was identified (Fig 2a), 90°hook was probed beneath the base of the broken part and carefully detached it from the nucleus pulposus tissue around it (Fig 2b, c). After adequate release (Fig 2d), the broken part was successfully grasped and removed by nucleus pulposus forceps (Fig 2e, f). The foreign body removal procedure consumed 2 hours. Then 2 level interbody fusion was performed evenly. The patient was discharged 1 week after surgery and 2-year follow-up showed good recovery.
DISCUSSION Knife blade broken is a rare complication during lumbar diskectomy, there is very limited experience to remove it for most of spine surgeons. Successful and quick retrieval of such flat and sharp fragment becomes very difficult if the broken blade is located deeply in the disc space even if under fluoroscopic or microscopic guidance. In such situations, second surgery of anterolateral approach was suggested for safer removal of the fragment 7. However, the broken blade may migrate to retroperitoneal 4
Zheng
space or even to the aorta or vena cava when the position is changed, which may increase the probability of serious complications like aorta or visceral injury
4, 10
, an unplanned additional surgery also could decrease
patient’s satisfaction. Rahimizadeh etal suggested transforaminal corrider for retrieval of deeply retained broken scalpel in diskectomy 8. Transforaminal approach with pars resection could enlarge the surgical field of the disc space and may be helpful for direct foreign body removal. Microscopic assistance could amplify the surgical field and improve security and successful rate 5. Intraoperative fluoroscopic guidance is essential, repeated AP and lateral views are needed to confirm the location between the broken blade and the retrieval instrument. However, if the knife blade is broken at the first stab of the diskectomy procedure and buried deeply in the disc space, the tip of the broken part could not be seen easily and any of further disc space expanding procedure or the retrieval without assurance may lead to further migration even if under microscope or fluoroscopic guidance. Obviously, in consideration of conservative treatment could provoke many unpredictable detrimental results, retrieving the broken blade with safer and more effective method is required. In this case, we performed total laminectomy, contralateral transforaminal decompression and diskectomy was also applied when we realized the broken blade was located deeply in the disc space and difficult to retrieve in conventional 5
Zheng
way. Then, we utilized the arthroscope in the disc space of ipsilateral side of broken blade to find the broken part. The advantage of arthroscope in this surgery was that the broken scalpel could be identified clearly in amplified view which may reduce repeated clamp and avoid anterior migration. The whole procedure was recorded and we cost only 20 minutes to complete the retrieval since the arthroscope was applied. Fluoroscopic guidance was used to improve the accuracy and safety during the procedure until the broken blade was removal. Deeply retained foreign body removal by arthroscopic assistance has not been reported before. In our case, we retrieved the broken blade under arthroscope safely and effectively. Other than the fluoroscopic guide only, arthroscope could provide the real-time situation between the broken part and retrieving instrument, which increased the successful rate and prevented the anterior migration of the broken scalpel. The reason of the surgical scalpel broken in diskectomy was reported rarely. A knife blade with “narrow junction” was more prone to break than “triangular shaped” knife
7, 8
. But we experienced the triangular shaped knife broken in this
case as well as another reported case 6. A firm and calcified annulus was reported one of the risk factors of knife blade broken 7. A narrowed disc space should be another risk factor. However, in our experience, inadequate resection maneuver should be mostly responsible for the knife blade broken. Twisting or changing the direction of the scalpel edge when 6
Zheng
the blade is located partially in the disc space should be performed cautiously or even prevented. Straight in and out of the knife blade for disc space resection is recommended. For narrowed disc space or calcified annulus, micro-dissector should be used to confirm the disc space instead of knife blade. CONCLUSION Arthroscopic assistance is a safer and more effective way to remove the broken scalpel deeply located in the disc space than fluoroscopic or microscopic guidance. Arthroscope could ensure the broken blade in the surgeon’s view throughout the whole retrieval procedure and increase the successful rate of retrieval in the initial surgery.
REFERENCES 1.
Chen MJ, Niu CC, Hsieh MK, et al. Minimally Invasive Transforaminal Lumbar
Interbody Debridement and Fusion with Percutaneous Pedicle Screw Instrumentation for
Spondylodiscitis.
World
Neurosurg.
2019;128:
e744-e751.
https://doi.org/10.1016/j.wneu.2019.04.249. 2.
Miller LE, Bhattacharyya S, Pracyk J. Minimally Invasive Versus Open
Transforaminal Lumbar Interbody Fusion for Single-Level Degenerative Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg. 2019. https://doi.org/10.1016/j.wneu.2019.08.162. 3.
Yao YC, Lin HH, Chou PH, Wang ST, Chang MC. Differences in the interbody
bone graft area and fusion rate between minimally invasive and traditional open transforaminal lumbar interbody fusion: a retrospective short-term image analysis. European spine journal : official publication of the European Spine Society, the
7
Zheng European Spinal Deformity Society, and the European Section of the Cervical Spine Research
Society.
2019;28(9):
2095-2102.
https://doi.org/10.1007/s00586-019-06002-4. 4.
Limbachia D, Gandhi P. Laparoscopic retrieval of a foreign body (broken surgical
knife) from retroperitoneal space: An interesting case. Gynecol Minim Invasive Ther. 2017;6(4): 193-194. https://doi.org/10.1016/j.gmit.2016.10.003. 5.
Yogesh A, Somnath S, Sanjeev C, Kumar PD. Retrieval of a retained broken
scalpel blade from lumbar intervertebral disc space - a case report. Romanian Neurosurgery. 2017;31(1): 129-132. 6.
Koutserimpas
C,
Ioannidis
A,
Konstantinidis
M,
Athanasopoulos
P,
Antonakopoulos F, Konstantinidis K. Robot-Assisted Removal of a Broken Scalpel Blade
following
Discectomy.
Case
Rep
Surg.
2019;2019:
8609246.
https://doi.org/10.1155/2019/8609246. 7.
Amirjamshidi A, Mehrazin M, Abbassioun K, Ketabtchi E. Retained broken knife
blades within the disc space. Spine. 1994;19(8): 981-984. 8.
Rahimizadeh A, Ghorbani E, Rahimizadeh S. Transforaminal retrieval of
intradiscal retained broken surgical knife blade. Spine. 2013;38(20): E1278-1281. https://doi.org/10.1097/BRS.0b013e31829ef4d7. 9.
Rahimizadeh A, Haddadi K. Is transforaminal retrieval of intradiscal deeply
seated broken surgical knife blade all time pars sparing? A case report. International journal
of
surgery
case
reports.
2016;19:
131-133.
https://doi.org/10.1016/j.ijscr.2015.12.040. 10. De Praetere H, Vanden Eycken C, Meuris B, Herijgers P. Migration of a broken scalpel into the heart after spine surgery. Interactive cardiovascular and thoracic surgery. 2014;18(4): 527-529. https://doi.org/10.1093/icvts/ivt553.
Figure legend Fig. 1. Fluoroscopic views of broken scalpel retrieval procedure.
8
Zheng
Fig. 2. Arthroscopic pictures of broken scalpel retrieval procedure.
9
TLIF：Transforaminal Lumbar Interbody Fusion