Romanian Neurosurgery | Volume XXXI | Number 1 | 2017 | January - March Article Retrieval of a retained broken scalpel blade from lumbar intervertebral disc space - a case report Yogesh Agrawal, Somnath Sharma, Sanjeev Chopra, Devendra Kumar Purohit INDIA DOI: 10.1515/romneu-2017-0020 Romanian Neurosurgery (2017) XXXI 1: 129 – 132 | 129             DOI: 10.1515/romneu-2017-0020 Retrieval of a retained broken scalpel blade from lumbar intervertebral disc space - a case report Yogesh Agrawal, Somnath Sharma, Sanjeev Chopra, Devendra Kumar Purohit Department of Neurosurgery, Sawai Man Singh Medical College and Hospital Jaipur, Rajasthan, INDIA Abstract: Lumbar diskectomy is a common procedure in neurosurgery, besides the common complications broken scalpel blade during disc removal is a rare event. Usually retrieval of such sharp retained fragments in same sitting is difficult and to prevent further complications another session is warranted [1]. We report a case of broken scalpel blade during L1-L2 lumbar intervertebral disc removal and successful surgical retrieval of that tip of knife with the help of operative microscope under fluoroscopic guidance during same sitting before any hazardous complications develop. Key words: broken scalpel, fluoroscopy, retrieval Introduction Lumbar diskectomy is being done in increasing frequency worldwide, one such risk associated with this procedure is breaking of the surgical knife blade during disc removal. The complications caused by iatrogenic foreign bodies are well known, but cases are rarely published because of the medico legal implications [2], early identification and removal of a foreign body can prevent hazardous and detrimental complications [3]. However in a few cases, surgeon's attempts might be successful but Most of the broken blades could not be retrieved during the initial surgery because it is lost in disc space and attempt to remove cause further descent of fragment so procedure is terminated [1], this retained foreign body in the disc space may remain clinically silent [4] or migration of such foreign body during ambulation might have lead to hazardous complications [3] and removal of such sharp fragment to prevent further complications, another session is warranted usually [1], Literature regarding this issue is scarce, and there are no unique guidelines to address these complications. We are reporting a case in which scalpel blade broken during lumber intervertebral disc removal and successful surgical retrieval of that tip of knife blade done in same sitting with the help of microscope under fluoroscopic guidance before any hazardous complication develop. 130 | Agrawal et al - Retrieval of a retained broken scalpel blade             Case summury A 29 year male presented with complain of back pain for last 6 month and sudden weakness in bilateral lower limb with urinary and fecal incontinence for last 10 days. imaging confirm significant compression of thecal sac and B/L neural foraminas at L1/L2 vertebra level due to intervertebral disc herniation (Figure 1) hence L1 laminectomy and L1/L2 disc removal was planned, While removing the intervertebral disc the tip of no. 15 scalpel blade (Figure 4) snapped off and was jammed in the disc space, attempts to retrieve the tip resulted in a further descend of the knife into the disc space, fluoroscopy revealed that knife was still in the disc space (Figures 2, 3). Owing to the risk of migration further attempt of blind removal was stopped and by using microscope under fluoroscopic guidance we catch the tip and exteriorized successfully before any hazardous complication develop. Figure 1 – Saggital T2w MRI of dorso-lumbar region showing L1/L2 inter-vertebral disc protrudion with thecal sac compression Romanian Neurosurgery (2017) XXXI 1: 129 – 132 | 131             Discussion Among common complications that occur during intervertebral disc removal, retained foreign body like broken scalpel blade are rare, very few cases are reported in literature. First case series of four cases on Retained foreign body (broken knife) within the disc space and migration towards abdominal cavity and viscera was published by Amirjamshidi et al in 1994. The no 15 knife blade with narrow junction is more prone to break during cutting of firm and calcified annulus and posterior longitudinal ligament. The broken fragment may be seen within disc space and can be removed in same setting. However attempts to remove it, can cause further descent of fragment in deep disc space and fluoroscopy and better illumination is required for removal of such fragment ,if such facility in operative room is not available, surgeon should close the wound and refer the patient to center where these facilities are available. In that cases patient should be informed and kept under close observations. Retrieval of a broken knife blade buried in the intervertebral disc space can be a challenge and even impossible to achieve despite hours of attempts hence second surgery is recommended in most of case [1]. 132 | Agrawal et al - Retrieval of a retained broken scalpel blade             Migration these foreign bodies during intra-operative surgical manipulation or ambulation in postoperative period could led to serious complications and the clinical manifestation of these foreign body depends upon their locations and vicinity to the vital structures, anterior migration of the knife could cause gut and retroperitoneal viscera injury or vascular complications like injury to large vessels ,on the other hand posterior migration into the spinal canal could cause injury to spinal cord and neurological deficit [1, 3, 5]. Complications due to broken scalpels and migration into the blood circulation or heart has been described by Herbert De Praetere at al (5). A broken sharp scalpel left in an intervertebral space and slipped to pelvic cavity during an operation of intervertebral disc also reported by LE wang at al [6] In our case we need to respond the question whether the object should be retrieve or not ?, conservative treatment is an option in asymptomatic foreign bodies without associated risks, particularly if they are small, smooth, rounded, blunt and minimal contaminated and embedded in and paraspinal muscles. Patients in whom the blade is within a collapsing disc space or is pointing towards the vertebral body secondary intervention can be postponed [1]. Intervention is necessary if symptomatic, irrespective of their location or asymptomatic patients with sharp foreign body with associated risk factors and possible complications [5]. Owing to the risk of hazardous complications, removal was the only option in our case and blind procedure was not appropriate due to the nature of the object. Therefore successful localization under fluoroscopic guidance and removal of tip of knife was done with the help of operative microscopic in our patient in same sitting. Conclusion Because of the potential hazards of migration and late serious complications, removal of sharp retained fragment in same or another session is recommended and we have to be cautious while using 15 no surgical knife in narrow disc space. Correspondence Dr. Yogesh Agrawal MBBS, MS, 3rd year Mch resident Address: Department of neurosurgery, Sawai Man Singh medical college and hospital Jaipur, Rajasthan, India Phone: 08955560199 E-mail: agrawaly_2k@yahoo.co.in References 1. Amirjamshidi A, Mehrazin M, Abbassioun K, Ketabtchi E. Retained broken knife blades within the disc space. Spine 1994;19:981-4. 2. Karcnik TJ, Nazarian LN, Rao VM, Gibbons GE Jr. Foreign body granuloma simulating solid neoplasm on MR. Clin Imaging 1997;21:269-72 3. Alexander PH Chan, KM sieh,SM Leung ,KY Cheung, KY Fung- Extacorporeal foley catheter spring device mimicking an intervertebral foreign body in transforaminal lumbar interbody fusion surgery.Hongkong Med j vol no. 5,oct 2009 4. Okten AI, Adam M, Gezercan Y. Textiloma: a case of foreign body mimicking a spinal mass. Eur Spine J 2006;15 Suppl 5:626S-629S. 5. Migration of a broken scalpel into the heart after spine surgery Herbert De Praetere, Caroline Vanden Eycken, Bart Meuris, and Paul Herijgers Interact Cardiovasc Thorac Surg. 2014Apr;18(4): 527–529 6. A broken sharp scalpel left in an intervertebral space and slipped to pelvic cavity during an operation of intervertebral disc displacement H Li, W Wang, A He - Hunan yi ke da xue xue bao Hunan yike, 1997 - europepmc.org