Published online Jun 18, 2026. doi: 10.5312/wjo.v17.i6.119695
Revised: February 25, 2026
Accepted: April 15, 2026
Published online: June 18, 2026
Processing time: 134 Days and 4.8 Hours
Hidden blood loss (HBL) is an important problem that is often overlooked in spinal surgery. Although single-channel dual-media spinal endoscopy (DME) has become a minimally invasive technique for the treatment of lumbar spinal ste
To investigate the characteristics and related risk factors of HBL during intra
We retrospectively analyzed 146 patients who underwent DME surgery. Patient demographics, operative data, and blood loss parameters were collected. HBL was calculated using Nadler’s formula and changes in hematocrit. Pearson or Spearman correlation analysis was used to identify risk factors associated with HBL. Independent risk factors were calculated by multivariate linear regression.
Patient blood volume was 4.037 ± 0.702 L. Total blood loss was 352.704 ± 176.852 mL. Visible blood loss was 43.620 ± 19.301 mL. HBL was 309.088 ± 175.924 mL. Multiple linear regression analysis identified operating time (P < 0.001) and fibrinogen levels (P < 0.001) as independent risk factors for HBL.
Although DME is minimally invasive, HBL remains significant and is influenced by operating time and hematological parameters, underscoring the importance of risk factor identification for perioperative management.
Core Tip: This retrospective study of 146 patients explored hidden blood loss (HBL) during dual-media spinal endoscopy (DME) for lumbar spinal stenosis. HBL was calculated using Nadler’s formula and hematocrit (Hct) changes, and risk factors were analyzed by correlation and regression methods. HBL accounted for the majority of total blood loss (TBL) in DME. Operating time, TBL, preoperative Hct and hemoglobin were independent risk factors for HBL. Activated partial thromboplastin time and fibrinogen were also correlated with HBL. Clarifying these factors aids perioperative blood management.
- Citation: Ye PH, Zhang H, Wu X, Zeng Y, Su SH. Hidden blood loss in dual media spinal endoscopy surgery: Analysis of perioperative risk factors. World J Orthop 2026; 17(6): 119695
- URL: https://www.wjgnet.com/2218-5836/full/v17/i6/119695.htm
- DOI: https://dx.doi.org/10.5312/wjo.v17.i6.119695
Hidden blood loss (HBL), a significant yet often overlooked problem in spinal surgery, is frequently underestimated due to the lack of readily available and concise evaluation methods[1,2]. HBL was initially described in 2000 by Sehat et al[2] in the context of total hip and knee replacements, and its relevance has gained increasing recognition in orthopedic procedures. Studies have established a link between HBL and increased blood loss, perioperative complications, and exacerbation of postoperative hemoglobin drop. If not properly managed, HBL can lead to delayed wound healing, increased risk of infection, and prolonged postoperative rehabilitation. Although HBL has been shown to account for a substantial proportion of total blood loss (TBL) in open and minimally invasive spinal surgery, its clinical characteristics and the factors influencing it in the specific context of spinal procedures remain poorly understood[3]. Therefore, accurate assessment of HBL and its influencing factors are crucial to ensure perioperative safety in spinal surgery, especially for vulnerable populations such as older patients with anemia.
With the development of minimally invasive technology, spinal endoscopy is increasingly used in the treatment of lumbar spinal stenosis, and lumbar disc endoscopy and transforaminal endoscopy have gradually replaced some traditional open surgery procedures[4,5]. Minimally invasive surgery is favored due to its advantages such as less bleeding, small incision, mild local pain and short hospital stay[6]. Dual-media spinal endoscopy (DME) is a surgical method invented by our team. The operation control and supervision system is the subject of a computer software copyright certificate (8084840), and the relevant device has been authorized with a utility model patent (CN 217793269 U). This procedure has been widely used in clinical practice. Our team has published related surgical methods in national journals; however, there are no reports nationally or internationally on DME research in relation to HBL. DME not only has the above-mentioned minimally invasive advantages, but also has the characteristics of a clear surgical field, no lens fogging, large instrument operating space, high decompression efficiency, ease of use and low risk of nerve injury.
Previous studies have shown that minimally invasive surgery, such as unilateral biportal endoscopy and minimally invasive transforaminal lumbar interbody fusion, causes significantly less trauma than traditional open surgery, with a low amount of intraoperative bleeding. However, many patients still suffer from postoperative anemia; thus, HBL is an issue that cannot be ignored. Currently, there is limited knowledge regarding HBL during spinal surgery, and DME is a new spinal surgical method. Exploring HBL during spinal surgery is of clinical importance.
Data were obtained from patients hospitalized in the Department of Orthopedics, Jinhua People’s Hospital, Jinhua, Zhejiang Province, China, from January 2022 to December 2024 (Clinical trial No. 202141). Diagnostic criteria: (1) Typical clinical symptoms of lumbar spinal stenosis, such as intermittent claudication; (2) Imaging manifestations consistent with single-segment lumbar spinal stenosis (Figure 1A and B); and (3) Clinical manifestations and imaging diagnosis must be consistent. Inclusion criteria: Patients with a disease course > 6 months, who had undergone ≥ 3 months of formal conservative treatment, but whose symptoms had not improved significantly. Exclusion criteria: (1) Discitis or other infections; (2) Obvious ossification and calcification of the yellow ligament; (3) Severe ossification of the posterior longitudinal ligament and vertebral osteophyte hyperplasia; (4) Spondylolisthesis and instability; (5) Severe lumbar central spinal stenosis; (6) Serious important organ diseases; and (7) Symptoms relieved by conservative treatment.
All procedures were performed by the same senior surgical team using a standardized operative protocol throughout 2022-2024. Anesthesia management, irrigation pressure parameters, and perioperative medication regimens remained consistent across patients during the study period.
Routine epidural anesthesia was adopted, and the patient was placed in the prone position with hip and knee flexion. Kirschner wire positioning and C-arm confirmation were performed. An incision was made approximately 2 cm from the midline of the spinous process of the appropriate segment. The intervertebral disc plane was the surface incision point. When the target point for decompression was reached, the channel tube was gradually inserted (Figure 1C), and a dual-medium spinal endoscope was installed (Figure 1D). The 3-L bag was connected, and the affected intervertebral disc was confirmed using the C-arm. Under water medium, the plasma radiofrequency vaporization system and radiofrequency plasma surgical electrode were used to ablate and clean the soft tissue outside the lamina (Figure 1E). The power system was used as the main method for bone decompression (Figure 1F). The lamina rongeurs and bone knives assisted in removing the bone tissue, including the lower edge of the upper lamina and the upper and lower articular processes on the inner side. The head and tail sides and the lateral yellow ligament were exposed. To reduce the complications of the water medium and water pressure damage to the cauda equina and nerve roots, the air medium was switched to decompress the yellow ligament and intervertebral disc as needed. The yellow ligament was removed, the walking nerve root and part of the cauda equina dural sac were gradually exposed. Radiofrequency plasma surgical electrodes were used for hemostasis; the nerve root was explored, protected and separated; the intervertebral disc tissue was removed (Figure 1G); the nerve root was completely decompressed (Figure 1H); and the wound surface was flushed and sutured layer by layer. During the operation, the injection of normal saline could be stopped and replaced with air medium, or the air medium could be replaced with water medium according to the needs of the surgeon and the operation. Postoperative crystalloid infusion was standardized at 1.5-2.0 L/day unless clinically indicated otherwise, to minimize variability related to perioperative hemodilution.
Patient demographics and operative data were collected, including age, sex, body mass index (BMI), weight, height, presence of hypertension (blood pressure ≥ 140/90 mmHg), diabetes mellitus [fasting blood glucose ≥ 7.0 mmol/L or glycated hemoglobin (≥ 6.5%)], surgical time, American Society of Anesthesiologists physical status classification, and volume of postoperative drainage. Blood-loss-related parameters were also collected: Patient blood volume (PBV) (using Nadler’s formula), intraoperative blood loss (estimated by the anesthesiologist), preoperative hematocrit (Hct), preoperative Hb, postoperative Hct (measured within 3 days after surgery), postoperative Hb (measured within 3 days after surgery), prothrombin time, activated partial thromboplastin time (APTT), fibrinogen (FIB) level and platelet (PLT) count. Postoperative blood-related indicators were measured on postoperative day 2.
HBL was the difference between TBL and visible blood loss (VBL) plus blood transfusion. As none of the patients received blood transfusion, the formula was simplified to HBL (mL) = TBL - VBL[7]. Firstly, PBV was calculated using height and weight, with the formula PBV (L) = k1 × height3 + weight × k2 + k3. As there are differences between men and women, the k value is different. For men, k1 = 0.3669, k2 = 0.03219 and k3 = 0.6041; for women, k1 = 0.3561, k2 = 0.03308 and k3 = 0.1833[8]. Secondly, TBL was calculated using preoperative Hct (Hctpre), postoperative Hct (Hctpost), PBV and average Hct (Hctave), with the formula Hctave = (Hctpre + Hctpost)/2. TBL was calculated based on TBL (mL) = PBV × (Hctpre - Hctpost)/Hctave × 1000[9]. VBL was the surgical bleeding volume plus postoperative drainage volume.
Statistical analysis was performed using IBM SPSS Statistics 29.0.2.0 software. Continuous variables are expressed as mean ± SD or median and interquartile range depending on the distribution of data, and categorical variables are expressed as n (%). Student’s t test or Mann-Whitney U test was used to compare continuous variables. Pearson or Spearman correlation analysis was used to identify risk factors associated with HBL. Independent risk factors were calculated by multivariate linear regression. Prior to multivariate regression analysis, candidate variables were evaluated for potential mathematical dependency with HBL. Parameters directly involved in HBL calculation were excluded from the final model to prevent artificial collinearity. Multicollinearity among retained predictors was assessed using variance inflation factor (VIF), with < 5 considered acceptable. Statistical significance was set at P < 0.05. The statistical methods used in this study were reviewed by Jun-Jian Ye of Southern Medical University.
A total of 146 patients who underwent single-channel dual-media endoscopic spinal surgery were included in this study. Table 1 summarizes all demographic and baseline characteristics. The study included 81 women and 65 men, ranging in age from 23 years to 89 years. Their mean BMI was 24.401 ± 3.416 kg/m2. The mean operating time was 1.453 ± 0.507 hours. PBV was 4.037 ± 0.702 L, TBL was 352.704 ± 176.852 mL, VBL was 43.620 ± 19.301 mL, and HBL was 309.088 ± 175.924 mL. The preoperative Hb and Hct levels were 137.310 ± 15.655 g/L and 40.910% ± 4.280%, respectively. Postoperative Hb and Hct were 125.040 ± 14.725 g/L and 37.440% ± 4.134%, respectively. Hb loss was 12.320 ± 6.529 g/L and Hct loss was 3.469% ± 1.792%. Postoperative Hct and Hb were significantly lower than those before the operation (P < 0.001, P < 0.001) (Table 2). Pearson or Spearman correlation analysis showed that the following parameters were significant: Operating time (P < 0.001), TBL (P < 0.001), preoperative Hb (P < 0.001), preoperative Hct (P = 0.002), Hb loss (P < 0.001), Hct loss (P < 0.001), APTT (P = 0.004), and FIB (P < 0.001) (Table 3). To avoid mathematical dependency and potential collinearity with HBL calculation, variables directly involved in the computation of HBL (TBL, Hb loss, and Hct loss) were excluded from the final multivariate model. Multicollinearity diagnostics confirmed acceptable VIF values for all retained predictors (range: 1.050-1.305). In the adjusted multiple linear regression analysis, operating time (β = 0.406, P < 0.001) and FIB level (β = -0.488, P < 0.001) were identified as independent predictors of HBL. In contrast, APTT (P = 0.127) and preoperative Hb (P = 0.284) did not remain significant after adjustment (Table 4).
| Parameters | Statistics |
| Total patients (n) | 146 |
| Gender (n) | |
| Female | 81 |
| Male | 65 |
| Age (year) | 59.410 ± 13.931 |
| BMI (kg/m2) | 24.401 ± 3.416 |
| Hypertension (n) | |
| No | 99 |
| Yes | 47 |
| Diabetes mellitus (n) | |
| No | 124 |
| Yes | 22 |
| Fusion level (n) | |
| L3/L4 | 35 |
| L4/L5 | 58 |
| L5/S1 | 53 |
| ASA (n) | |
| 1 | 41 |
| 2 | 51 |
| 3 | 50 |
| 4 | 4 |
| Operating time (hours) | 1.456 ± 0.507 |
| PBV (L) | 4.037 ± 0.702 |
| TBL (mL) | 352.704 ± 176.852 |
| VBL (mL) | 43.620 ± 19.301 |
| HBL (mL) | 309.088 ± 175.924 |
| Hbpre (g/L) | 137.310 ± 15.655 |
| Hctpre (%) | 40.910 ± 4.280 |
| Hbpost (g/L) | 125.040 ± 14.725 |
| Hctpost (%) | 37.440 ± 4.134 |
| Hb loss (g/L) | 12.320 ± 6.529 |
| Hct loss (%) | 3.469 ± 1.792 |
| PT (second) | 11.451 ± 1.389 |
| APTT (second) | 30.787 ± 17.115 |
| Platelets (109/L) | 211.706 ± 61.040 |
| FIB (g/L) | 3.065 ± 0.715 |
| Parameters | Sig | P value |
| Gender | -0.139 | 0.094 |
| Age | -0.112 | 0.176 |
| BMI | 0.041 | 0.627 |
| Hypertension | -0.065 | 0.414 |
| Diabetes mellitus | -0.052 | 0.536 |
| Fusion level | ||
| L3/L4 | -0.015 | 0.860 |
| L4/L5 | 0.065 | 0.438 |
| L5/S1 | -0.052 | 0.529 |
| ASA | -0.095 | 0.256 |
| Operating time | 0.654 | < 0.001b |
| PBV | 0.101 | 0.225 |
| TBL | 0.994 | < 0.001b |
| VBL | -0.007 | 0.936 |
| Hbpre | 0.261 | < 0.001b |
| Hctpre | 0.259 | 0.002a |
| Hbpost | -0.112 | 0.179 |
| Hctpost | -0.145 | 0.082 |
| Hb loss | 0.882 | < 0.001b |
| Hct loss | 0.952 | < 0.001b |
| PT | -0.056 | 0.500 |
| APTT | -0.236 | 0.004a |
| Platelets | 0.070 | 0.403 |
| FIB | -0.696 | < 0.001b |
Single-channel DME is an advanced minimally invasive technique that significantly reduces VBL and HBL. One of its key advantages over traditional open surgery is its ability to minimize soft tissue damage. In conventional procedures, large muscle dissection disrupts vascular networks, leading to increased blood loss and prolonged recovery. In contrast, this technique only requires a small incision, preserving muscles, ligaments, and fascia, which not only reduces blood loss but also decreases postoperative pain and recovery time.
Compared to transforaminal endoscopic surgery, which often uses long-term water-based irrigation that can induce tissue edema and increase fluid exudation, the dual-medium approach alternates between water and air. This switch effectively limits tissue immersion, reducing the risk of HBL from fluid exudation. Additionally, the small, controlled operating channel acts as a physical barrier, preventing blood from spreading to surrounding tissues, further minimizing hidden bleeding. It should be emphasized that the proposed advantage of the dual-medium air-water switching mechanism remains hypothesis-generating. As no conventional endoscopic control cohort was included, superiority claims cannot be established based on the present data.
The technique also reduces operating time, which directly decreases the chance of blood loss. Prolonged exposure of tissues increases bleeding risk, but the efficient decompression strategies of the single-channel dual-medium system shorten surgery duration while maintaining effective decompression. The powered grinding head used for bone operations removes bone tissue more evenly than traditional instruments do, lowering the risk of bleeding from rough bone surfaces. Overall, this approach enhances patient safety by effectively controlling both VBL and HBL throughout the procedure.
Although DME is minimally invasive and VBL is limited, HBL accounts for the majority of TBL. This finding helps explain postoperative Hb decline despite minimal intraoperative bleeding. While most patients in this study developed only mild anemia without transfusion requirement, HBL may still be clinically relevant in individuals with limited hematological reserve, such as older patients or those with pre-existing anemia. Therefore, quantification of HBL contributes to more accurate perioperative blood management, improved risk stratification, and optimization of recovery strategies in minimally invasive spinal surgery.
The calculation of HBL was based on early postoperative Hct changes, which may be influenced by perioperative fluid administration, hemodilution, and physiological fluid redistribution within the first 48-72 hours. These factors could introduce estimation bias independent of actual red blood cell loss. Although fluid management remained consistent in our cohort, minor interindividual variation cannot be excluded. In addition, because most patients developed only mild postoperative anemia without clinical symptoms, repeated hematological measurements at multiple time points were not routinely performed in order to minimize unnecessary blood sampling. Therefore, the calculated HBL should be interpreted as an estimation rather than an absolute value.
Previous studies have shown that TBL was significantly correlated with HBL in univariate analysis[10], which may be because TBL is calculated based on the change in total Hct. In the present study, patients with high TBL also had higher HBL, similar to that seen in previous studies[10].
The present study revealed that preoperative Hb/Hct was significantly correlated with HBL in univariate analysis. Lower preoperative Hb/Hct levels make patients more sensitive to blood loss, which means that even a small amount of HBL may lead to more obvious physiological disorders and clinical symptoms. HBL exacerbates anemia that exists before surgery, further reducing the patient's blood volume and oxygen-carrying capacity, thus forming a vicious circle. This interaction emphasizes the importance of preoperative evaluation and optimization of the patient's blood status, as well as the necessity for close monitoring and timely intervention during surgery. In addition, the changes in Hb and Hct before and after surgery were also significantly correlated with HBL, which is consistent with previous studies of other surgical procedures[11,12], suggesting that HBL has a greater impact on postoperative anemia. Therefore, the detection of Hb, Hct and other indicators before and after surgery is significant for assessing the patient’s condition.
APTT is an important indicator for evaluating the intrinsic coagulation pathway. The results of this study are consistent with other studies[13], indicating that significantly prolonged APTT during surgery is associated with an increased risk of HBL, which may be related to many mechanisms. Firstly, prolonged APTT may directly reflect a decline in the patient’s coagulation function, making it difficult for hemostasis to proceed effectively, thereby leading to HBL. Secondly, some pathological conditions that lead to prolonged APTT (such as disseminated intravascular coagulation) may increase the risk of microvascular bleeding, thereby exacerbating HBL[14,15]. In addition, the dilution of coagulation factors that may be caused by large amounts of intraoperative infusion may also exacerbate prolonged APTT and HBL[16]. The surgery itself is a complex dynamic process that can alter APTT. In some cases, surgical stress may lead to activation of the coagulation system and transient shortening of APTT[17]. In other cases, tissue damage and vascular rupture caused by surgery may lead to consumption of coagulation factors and prolong APTT[18-20].
Although TBL, perioperative Hb/Hct changes and APTT were significantly correlated with HBL in univariate analysis, they were not independent predictors. This suggests that these variables likely only reflect mathematical or physiological coupling. Operating time was identified as an independent predictor of HBL in multivariate linear regression analysis, leading to an increase in HBL. Therefore, surgeons should carefully evaluate the surgical plan before surgery and fully estimate potential risks to avoid prolonged surgery due to intraoperative accidents. In addition, prolonged time in the prone position affects intra-abdominal pressure, thereby increasing epidural venous bleeding; therefore, during surgery, care should be taken to keep the abdomen suspended to reduce the impact of intra-abdominal pressure on venous return. Thus, doctors should enhance their surgical skills and proficiency, effectively control the operating time, reduce bleeding and reduce the possibility of HBL.
In this study, FIB level in patients was also identified as an independent predictor of HBL in multivariate linear regression analysis. FIB is an inflammatory protein that is converted into fibrin by thrombin and directly participates in the adhesion and activation of PLT[21,22]. Zhou et al[3] also found a negative correlation between FIB level and HBL in a retrospective study of risk factors for HBL in 137 patients. Our study confirmed this association; however, it should be noted that not all studies have reached consistent conclusions, as some have shown that FIB level is a positive factor affecting HBL[23,24]. In some studies, patients underwent posterior lumbar fusion and had drains placed after surgery[25]. The amount of postoperative drainage requires to be subtracted when calculating HBL; thus, accurate measurement of drainage volume is crucial. In these studies, some patients had elevated FIB levels and a hypercoagulable state, which may have led to blood clots in the dead space[26]. In this case, the amount of postoperative drainage was reduced, leading to an underestimation of the actual blood loss, which increased the HBL. Nevertheless, we still need stratified analysis or model adjustments to further strengthen the causal explanation. Prospective studies are needed to further validate these findings.
As this study was conducted at a single center and involved a specific patented DME system, the generalizability of our findings should be interpreted with caution. Surgical workflow, irrigation parameters, instrumentation, and perioperative management protocols may vary across institutions, potentially influencing perioperative blood loss patterns. In addition, patient characteristics such as baseline Hb level, comorbidity burden, and case complexity may differ in other clinical settings.
Notably, our center was among the earliest institutions nationwide to implement and refine the DME technique, and many other centers adopted this approach following structured training and technical exchange programs. This unified technical origin may reduce variability in surgical workflow and procedural principles across institutions to some extent. Nevertheless, multicenter prospective studies involving broader surgical indications and heterogeneous patient populations remain necessary to validate the external applicability of these findings.
Although DME surgery is a minimally invasive technique with limited VBL, HBL remains clinically relevant. In this cohort, operating time and FIB level were independently associated with HBL. Prolonged surgical duration and reduced FIB were linked to increased HBL. These findings underscore the importance of surgical efficiency and appropriate perioperative coagulation management while preserving the inherent advantages of DME.
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