Vol 2 | Issue 1 | January-April 2025 | page: 28-30 | Arvind Vatkar, Sachin Kale, Sushant Srivastava, Dushyant Vashist, Akhil Gailot, Nikhil Hiwrale

Authors: Arvind Vatkar [1], Sachin Kale [1], Sushant Srivastava [2], Dushyant Vashist [1], Akhil Gailot [1], Nikhil Hiwrale [1]

[1] Department of Orthopaedics, Dr. D Y Patil Hosital, Nerul, Navi Mumbai, India.
[2] Department of Orthopaedics, Mata Gujri Memorial Medical College and Lions Seva Kendra Hospital Kishanganj Bihar, India.

Address of Correspondence
Dr. Arvind Vatkar,
Department of Orthopaedics, Dr. D Y Patil Hosital, Nerul, Navi Mumbai, India.
Email: vatkararvind@gmail.com

Abstract

Transforaminal lumbar interbody fusion (TLIF) is a standard surgical treatment for degenerative lumbar spine disorders such as severe stenosis and spondylolisthesis.1 While the surgery is typically safe, intraoperative problems such as instrument breakage sometimes arise, providing new challenges for the surgical team.2 This case report discusses how to treat a broken disc forceps during a TLIF operation at the L4-5 level in a patient with significant right-sided stenosis and foot drop.
Keywords: Disc forceps, discectomy , lumbar surgery, broken , transforaminal lumbar interbody fusion.

Introduction
Transforaminal lumbar interbody fusion (TLIF) is a standard surgical treatment for degenerative lumbar spine disorders such as severe stenosis and spondylolisthesis [1]. While the surgery is typically safe, intraoperative problems such as instrument breakage sometimes arise, providing new challenges for the surgical team [2]. This case report discusses how to treat a broken disc forceps during a TLIF operation at the L4-5 level in a patient with significant right-sided stenosis and foot drop.

Case Presentation:
A 41-year-old male presented with severe right-sided radiculopathy, neurogenic claudication, and foot drop for 5 days. Preoperative MRI imaging revealed right sdied- severe foraminal and central canal stenosis at the L4-5 level and L5S1 right-sided huge disc with degenerative disc disease. Neurological examination demonstrated motor weakness in the right L4 and L5 nerve with an MRC grade power of 3/5. As the patient had sudden weakness with severe radicular pain, the patient was scheduled for a TLIF at the L4- 5 level with L5s1 decompression and discectomy.

Intraoperative Course
The procedure was performed under general anesthesia with the patient in the prone position. A standard midline incision and a right-sided TLIF approach were undertaken. An osteotome was used to break the Pars interarticularis and inferior articular process of L4 of L45 proper facet joint. After exposing the disc, 15 a blade was used to cut the disc’s annulus. During discectomy, while using disc forceps to remove the degenerated disc material, the jaw of the disc forceps broke, and a part of the broken jaw of the disc forceps (Pitutary rounger) became lodged deep within the intervertebral disc space.

Management of the Broken Instrument:
1. Initial Assessment:
The surgeon visualised and identified the broken piece, as shown in Figure 1. Later, under fluoroscopy, it was confirmed to be located deep within the disc space, away from the neural elements, as seen in Figure 2. A cautious and systematic approach was adopted to avoid further complications, such as nerve root injury or dural tear.

2. Sequential Disc Removal:
The exposure to the intervertebral disc was improved by removing more bone and ligamentum flavum from the right side. Instead of using disc preparation shavers or aggressive instrumentation, the superficial disc material was carefully and sequentially removed using disc forceps and curettes. This allowed the fragment of the broken disc forceps to ascend gradually near the annulus.

3. Retrieval of the Broken Piece:
Once the fragment was adequately visualised, it was gently grasped with a fine-tipped disc forceps and removed intact. Care was taken to avoid excessive manipulation or force, which could have led to further instrument breakage. Lastly, the broken fragment was matched to the disc forcep, and an x-ray was taken to confirm that no other broken instrument fragment is left behind as shown in figure 3. The total time required to retrieve the fractured instrument fragment was about 30 minutes.

4. Completion of the Procedure:
After successfully retrieving the broken forceps, the discectomy and endplate preparation were completed. The interbody cage was packed with autologous bone graft and positioned under fluoroscopic guidance. Posterolateral fusion was performed with pedicle screw fixation.
Also, standard laminectomy and left-sided discectomy of the L5S1 level was done with the fragment shown in figure 4.

Postoperative Course:
The patient was monitored closely for neurological deficits or signs of infection. Postoperative imaging confirmed the proper placement of the interbody cage and instrumentation. The patient was mobilised the next day with a walker and discharged in 2 days at home.

Discussion:
The breakage of surgical instruments during spinal procedures, including discectomy, is a recognised but infrequently reported complication. As highlighted in the literature, there is a lack of clear guidance on managing such events, making each case unique and requiring individualised strategies [3].
In some instances, retrieving a broken instrument from the intervertebral space is challenging. Repeated manipulation might push the fractured part of the instrument anteriorly if the shattered fragment cannot be gripped on the first try, allowing it to migrate into the retroperitoneal area. According to reports, this can necessitate a second operation to avoid disastrous outcomes like significant vessel damage [4].
Menger et al. gave a step-wise algorithm technique for extracting a fractured disc rongeur, starting with fluoroscopic localisation to detect its location. If the fragment is visible, it is retrieved by direct visualisation; otherwise, exposure is enhanced using magnetic retrieval, blunt instrumentation, or endplate drilling. If the fragment remains undetected but produces radiographic alterations, blind removal under fluoroscopic guidance is tried, followed by formal TLIF if needed. An anterior approach is employed to see and remove the device as a final option [5].
Using a magnetic probe, as described in other reports, represents an innovative and potentially valuable tool for retrieving metallic fragments from the intervertebral space [2]. While this technique was not utilised in the present case, it underscores the importance of having a variety of retrieval options available, particularly for metallic fragments from instruments such as burr tips, drill bits, guiding pins, or dissectors. The success of such methods highlights the need for further research and standardisation of protocols for managing instrument breakage in spine surgery.

Key takeaways from this case include:
– Careful handling of surgical instruments to prevent breakage is paramount. Regular audits of the health of surgical instruments are essential.
– The value of fluoroscopic guidance in locating and retrieving broken fragments.
– Slow and patient removal of the disc fragments to make the broken instrument fragment ascend is essential. Aggressive removal of disc fragments and disc shavers can cause the fractured instrument fragment to sink deep in the disc space near the anterior longitudinal ligament, making removal more difficult.

Conclusion:
This case underscores the potential for unexpected complications during spinal surgery and the importance of a calm, methodical approach to managing them. The broken disc forceps fragment was successfully retrieved by prioritising patient safety and employing a stepwise strategy without compromising the procedure’s outcome. The patient’s clinical improvement postoperatively demonstrates the effectiveness of this approach.

References

1. de Kunder SL, van Kuijk SMJ, Rijkers K, Caelers IJMH, van Hemert WLW, de Bie RA, et al. Transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis: a systematic review and meta-analysis. Spine J [Internet]. 2017 Nov;17(11):1712–21. Available from: http://dx.doi.org/10.1016/j.spinee.2017.06.018
2. Alberto Navarro-Aceves L, Alberto Navarro-Orozco L, Miguel Rosales-Olivarez L, Garcia Ramos CL, Estevez IO, Zárate-Kalfópulos B. Successful retrieval of a broken pituitary rongeur tip from the lumbar intervertebral disc space using a magnetic probe: illustrative case. J Neurosurg Case Lessons [Internet]. 2024 Dec 2;8(23). Available from: http://dx.doi.org/10.3171/CASE24377
3. Karcnik TJ, Nazarian LN, Rao VM, Gibbons GE Jr. Foreign body granuloma simulating solid neoplasm on MR. Clin Imaging [Internet]. 1997 Jul-Aug;21(4):269–72. Available from: http://dx.doi.org/10.1016/s0899-7071(96)00025-3
4. Zheng GB, Wang Z. Removal of the Deeply Located Intradiskal Broken Knife Blade with Arthroscopic Assistance: Case Report and Literature Review. World Neurosurg [Internet]. 2020 May;137:272–5. Available from: http://dx.doi.org/10.1016/j.wneu.2020.01.221
5. Menger RP, Lazzari Z, Nanda A. Stepwise Retrieval of a Broken Pituitary Disc Rongeur. Cureus [Internet]. 2020 Jun 11;12(6):e8561. Available from: http://dx.doi.org/10.7759/cureus.8561

How to Cite this article: Vatkar A, Kale S, Srivastava S, Vashist D, Gailot A, Hiwrale N. Management of a Broken Disc Forceps during Lumbar Surgery. Journal of Orthopaedic Complications | January-April 2025;2(1):28-30.

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