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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 47-49

Pitfalls of ultrasonic bone scalpel: A case-based discussion


Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission04-May-2021
Date of Decision10-Jun-2021
Date of Acceptance10-Jun-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Dr. Amit Kumar Salaria
Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_5_21

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  Abstract 


The role of ultrasonic bone scalpel (UBS) in the field of spine surgery is well known. There are numerous studies in the literature advocating its use where bone cutting in the form of laminectomy, laminotomy, foraminotomy, or vertebral body resection is required. Its principal advantage is the relative sparing of the soft tissues. The literature mentioning the complications and technical difficulties of UBS use is scarce and scanty. We report a unique complication encountered during its use and discuss some of the technical difficulties which need to be addressed with the aim and intent to caution the surgeons regarding its proper use. While performing laminectomy we encountered a unique complication of breakage of the blade of UBS. Although well-known for greater accuracy, reduced bleeding, reduced operative time, and en bloc removal of the bone as compared to traditional bone cutting devices even then it has to be used with great caution, and there is a learning curve of the technique which needs to be mastered.

Keywords: Bone scalpel, caution, failure, laminectomy, laminotomy


How to cite this article:
Kumar V, Salaria AK, Daggar A, Neradi D, Dhatt SS. Pitfalls of ultrasonic bone scalpel: A case-based discussion. J Orthop Dis Traumatol 2021;4:47-9

How to cite this URL:
Kumar V, Salaria AK, Daggar A, Neradi D, Dhatt SS. Pitfalls of ultrasonic bone scalpel: A case-based discussion. J Orthop Dis Traumatol [serial online] 2021 [cited 2021 Dec 6];4:47-9. Available from: https://www.jodt.org/text.asp?2021/4/2/47/324599




  Introduction Top


Ultrasonic bone scalpel (UBS) is a novel device introduced in the recent years for cutting the bone. Its usefulness in spine surgery is well established. It selectively cuts the bone with minimal impact on the soft tissues, thereby minimizing chances of dural injuries compared to other traditional devices such as osteotomes, Kerrison Roungers, and high-speed burrs. Its use is supported in numerous studies mentioned in the literature.[1],[2] Although a wonderful technique to reduce the duration of surgery and minimize the blood loss its not hundred percent full proof.[3] There is relative scarcity of literature mentioning the complications and technical difficulties during its use. We hereby present the first reported case of a complication of UBS during its use with an aim and intent to caution the surgeons to understand that its use has a learning curve and proper technique must be followed to avoid any inadvertent complications.


  Description Top


We hereby present a case of 50-year-old male diagnosed with compressive cervical myelopathy planned for posterior decompression and lateral mass screw fixation. After all the necessary investigations and anesthesia clearance, the patient was taken up for surgery under general anesthesia. A posterior approach to the cervical spine was used. After erasing the paraspinal muscles, laminectomy was planned for C4-C6 vertebrae with the help of UBS. While performing the laminectomy we encountered a unique complication of breakage of the blade of UBS (Misonix) [Figure 1] and [Table 2]. The broken scalpel was retrieved with the help of a needle nose pliers and the laminectomy was completed through standard laminectomy techniques with the help of osteotomes and Kerrison rongeurs. The patient outcome was not affected by the broken scalpel. A thorough search of the literature was done, but we could not find out any similar reported complication intraoperatively.
Figure 1: Image showing the broken tip of the ultrasonic bone scalpel

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Figure 2: Image showing the intraoperative broken tip along with the handle of the ultrasonic bone scalpel

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  Discussion Top


UBS is one of the revolutionary equipments used in the field of spine surgery in the recent past.[1],[2] It is a unique surgical device that offers a controlled osteotomy that slices the hard bone while the soft tissues remain largely unaffected. The major benefits of using this modern instrument are the sparing of soft tissue, controlled cutting, reduced bleeding, and thereby better surgical outcome. There are several studies in the literature propagating its use in various surgeries such as thoracoplasties, osteotomies, vertebral column resections,[4] laminectomies and laminoplasty,[4],[5],[6],[7],[8],[9] corpectomies,[10],[11] foraminotomy,[12] laminotomy, facectomy, and scoliosis surgeries. It is one of the precise and finest instruments available for bone cutting which can be of great value while working near the vicinity of the spinal cord, dura, and nerve roots. Although not 100 percent safe, it can significantly minimize the risk of ripping the soft tissues as compared to osteotomes, Kerrisons, and the high-speed rotating burrs. It also has a distinct advantage of minimizing the thermal damage due to its attached irrigation component. Various studies have proven its efficiency in decreasing the operating time, increased fusion rates, and decreasing the blood loss.[13],[14] Although its a relatively easy technique to master on a very basic training is required initially.

Bone scalpel assembly consists of a handpiece mounted with a disposable cutting tip which is connected to an ultrasonic generator/irrigation console. The ultrasonic tip oscillates to and fro with a frequency of 22,500 per second for very small distances.[15] The cutting tip is further composed of two parts blade and the shaver tip. Blade acts like an ultrasonic osteotome and the shaver tip acts like a nonrotating burr which has got selectivity for the bone. It works on the principle of high energy transfer to a small surface area at the point of contact resulting in its destruction while the soft-tissue structures (dura, ligamentum flavum, nerve roots etc.,) due to their high resilience can vibrate, bend, deform, or move away. Hence, the energy transfer is significantly reduced to these tissues and hence spared. This relative specificity of the bone scalpel is directly proportional to the rigidity of the tissues, i.e. rigid tissues will be cut and soft tissues will be spared by bending, deforming, moving away, or vibrating upon contact with the blade. However, this selectivity is not hundred percent, if adequate time and too much pressure are given even soft tissues can also be cut. For the safe and effective use, the development of tactile “feel” of penetrating the inner cortex should be mastered. Immediately after penetration, the blade should be withdrawn and no pressure should be applied. There are few case reports and studies published in literature of incidental durotomies if this technique is not mastered.[3],[16]

The bone-cutting technique of ultrasound bone scalpel blade also needs a thorough understanding. It works more efficiently when the axial pressure is applied rather than side-to-side movements. Three-step technique has been described for cutting the bone with the help of UBS.

  1. Scoring the outer cortex of the bone with lateral movement and minimal axial pressure
  2. Liberal lateral sweeps and axial pressure through the midportion of the bone
  3. Short lateral sweeps with cyclical controlled forward and backward movements for penetration of the inner cortex. Controlled axial pressure with tactile feedback is the key here as one cannot see the underlying soft tissues.


We believe that the cause of breakage of ultrasonic scalpel blade in our case was due to mismatch between the lateral sweeps and the axial pressure. This is another very important point which needs to be stressed for its efficient and safe use.

There are several other pitfalls which need to be avoided. There should be no plunging or lingering over the dura as it can potentially cause neural injury. If there is any suspicion of dura being adherent to the bone (in cases of ossified posterior longitudinal ligament, epidural fibrosis) this device should be used with great caution as there is limited dural resilience and decreased ability to move away. Adherent Dura must be dissected from undersurface of the bone by MacDonald's dissector. This is possible only by cutting bone slices adjacent to the region of adherence rather than directly using the UBS.

Hence, advanced planning of bone cuts and familiarizing oneself with the tactile feel and the amount of axial pressure required, palpating with bone scalpel off and using the UBS in conjugation with traditional bone cutting devices such as Kerrison rongeurs and the use of MacDonald's dissector to sway away the soft tissues can greatly enhance the safety and efficacy of this revolutionary device in the field of spine surgery.

In the present scenario, there are the following technical issues which need to be addressed:

  1. Whether the ultrasonic scalpel speed can be adjusted depending on the amount of resistance which is encountered in cutting different bone qualities
  2. What is the ideal fluid for irrigation and what should be its rate
  3. What kind or thickness of scalpel to be used for dealing with different bone densities
  4. How much axial pressure is to be applied
  5. Of what material the scalpel should be made
  6. What should be the shape of the scalpel for every procedure?



  Conclusion Top


Although gaining popularity very rapidly; caution must be exercised for the safe and efficient use of UBS. The surgeons must master the proper technique of its use and understand that it has got a learning curve although short. Thorough knowledge and understanding of its basic mechanism of action are of paramount importance. In the present scenario, there are several scopes of improvement to make this revolutionary equipment full proof.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nakase H, Matsuda R, Shin Y, Park YS, Sakaki T. The use of ultrasonic bone curettes in spinal surgery. Acta Neuro Chir Wien 148:207-13.  Back to cited text no. 1
    
2.
Nakagawa H, Kim SD, Mizuno J, Ohara Y, Ito K. Technical advantages of an ultrasonic bone curette in spinal surgery. J Neurosurg Spine 2005;2:431-5.  Back to cited text no. 2
    
3.
Kim K, Isu T, Matsumoto R, Isobe M, Kogure K. Surgical pitfalls of an ultrasonic bone curette (SONOPET) in spinal surgery. Neurosurgery 2006;59:S390-3.  Back to cited text no. 3
    
4.
Al-Mahfoudh R, Mitchell PS, Wilby M, Crooks D, Barrett C, Pillay R, et al. Management of giant calcified thoracic disks and description of the trench vertebrectomy technique. Global Spine J 2016;6:584-91.  Back to cited text no. 4
    
5.
Hamburger C. T-laminoplasty--a surgical approach for cervical spondylotic myelopathy. Technical note. Acta Neuro chir Wien 1995;132:131-3.  Back to cited text no. 5
    
6.
Herman JM, Sonntag VK. Cervical corpectomy and plate fixation for postlaminectomy kyphosis. J Neurosurg 1994;80:963-70.  Back to cited text no. 6
    
7.
Hirabayashi K, Watanabe K, Wakano K, Suzuki N, Satomi K, Ishii Y. Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine (Phila Pa 1976) 1983;8:693-9.  Back to cited text no. 7
    
8.
Ito K, Ishizaka S, Sasaki T, Miyahara T, Horiuchi T, Sakai K, et al. Safe and minimally invasive laminoplastic laminotomy using an ultrasonic bone curette for spinal surgery: Technical note. Surg Neurol 2009;72:470-5.  Back to cited text no. 8
    
9.
Park AE, Heller JG. Cervical laminoplasty: Use of a novel titanium plate to maintain canal expansion–Surgical technique. J Spinal Disord Tech 2004;17:265-71.  Back to cited text no. 9
    
10.
Shousha M, El-Saghir H, Boehm H. Corpectomy of the fifth lumbar vertebra, a challenging procedure. J Spinal Disord Tech 2014;27:347-51.  Back to cited text no. 10
    
11.
Hu SS. Blood loss in adult spinal surgery. Eur Spine J 2004;13:S3-5.  Back to cited text no. 11
    
12.
Morimoto D, Isu T, Kim K, Sugawara A, Matsumoto R, Isobe M. Microsurgical medial fenestration with an ultrasonic bone curette for lumbar foraminal stenosis. J Nippon Med Sch 2012;79:327-34.  Back to cited text no. 12
    
13.
Chen HT, Hsu CC, Lu ML, Chen SH, Chen JM, Wu RW. Effects of combined use of ultrasonic bone scalpel and hemostatic matrix on perioperative blood loss and surgical duration in degenerative thoracolumbar spine surgery. BioMed Res Int 2019;2019:6286258.  Back to cited text no. 13
    
14.
Hu X, Ohnmeiss DD, Lieberman IH. Use of an ultrasonic osteotome device in spine surgery: Experience from the first 128 patients. Eur Spine J 2013;22:2845-9.  Back to cited text no. 14
    
15.
Vercellotti T. Technological characteristics and clinical indications of piezoelectric bone surgery. Minerva Stomatol 2004;53:207-14.  Back to cited text no. 15
    
16.
Cornips EM, Janssen ML, Beuls EA. Thoracic disc herniation and acute myelopathy: Clinical presentation, neuroimaging findings, surgical considerations, and outcome. J Neurosurg Spine 2011;14:520-8.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]



 

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