Complications In Spine Surgery 2009

Complications in Spine Surgery
Prevention and Treatment
Prevention and Treatment
1/2

Sohail Bajammal, MBChB, MSc, FRCS(C)
March 16, 2009

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Words of Wisdom
Words of Wisdom
• “A busy surgeon will have complications throughout his
or her career, no matter how meticulously and
carefully he or she performs surgery.”

• “A surgeon who has no complications is a surgeon who
either does not operate or is not truthful.”

• “How a surgeon deals with complications that arise
intraoperatively or postoperatively is one of the key
p y p p y y
components that separates a great surgeon from one
who is average.”

Herkowitz HN. Foreword. In An HS, Jenis LG (ed): Complications of Spine Surgery: Treatment and
Prevention. Lippincott Williams & Wilkins. 2006.

Maxims Concerning Complications
Maxims Concerning Complications
1. There is no such thing as a simple spine operation.
2. It is easier to stay out of trouble than to get out of trouble.
3. p g p
The time expended in avoiding complications will be more than
compensated by the time saved in not having to treat them.
4. The patient’s well‐being is paramount. A spine surgeon should
never hesitate to request consultation, or assistance, during
never hesitate to request consultation or assistance during
surgery.
5. Surgeons should always operate with the meticulousness that
they would wish for if they were the patient. It is a salutary
th ld i h f if th th ti t It i l t
exercise for surgeons to think of their own feelings and reactions if
they had to undergo the procedures being carried out.

Benzel EC. Preface. In Benzel EC (ed): Spine Surgery: Techniques, Complication Avoidance, and Management.
2nd Edition. Elsevier. 2005.

Definition
• No agreed upon definition
No agreed upon definition
Benzel EC. Preface. In Benzel EC (ed): Spine Surgery: Techniques, Complication Avoidance, and Management.
2nd Edition. Elsevier. 2005.

• Episodes that may affect patient outcome or
y q ,
that may require intervention, further
diagnostic tests, or monitoring.
Daniels et al. Adverse events associated with anterior cervical spine surgery. J Am Acad Orthop Surg. 2008
Dec;16(12):729‐38.
( )

Not covered in this presentation
Not covered in this presentation
• Long term complications (psuedoarthrosis
Long term complications (psuedoarthrosis,
junctional kyphosis, adjacent segment
disease)

DVT & PE

General Positioning

Others: pain,
cardiovascular,
Complications in
Complications in GI, nutrition
Spine Surgery Surgical
approach‐
related

Procedure‐ Implants‐
specific related

Bone graft‐
related

Causes of Complications
Causes of Complications
• Planning:
– Poor patient selection
Poor patient selection
– Incorrect diagnosis
– Ill‐chosen approach

• Procedure:
– Overaggressive handling of soft tissue
Overaggressive handling of soft tissue
– Hardware failure
– Inadequate operation (e.g., incomplete
decompression)
d )
– Injury to normal anatomic structures

Zileli M, Naderi S, Benzel EC. Chapter 19: Preoperative and Surgical Planning for Avoiding Complications. In
Benzel EC (ed): Spine Surgery: Techniques, Complication Avoidance, and Management. 2nd Edition. Elsevier.
2005.

Incidence of DVT
in elective spine surgery
l
• I 1966 P th
In 1966, Prothero et al reported on two series, each
t l t d t i h
of 500 lumbar and lumbosacral fusion patients,
compared one decade apart.
compared one decade apart

• Initial incidence of VTE in spine patients was 4.2%
and had decreased to 2.2% at the second evaluation.

• The method of surveillance and the use or non‐use
The method of surveillance and the use or non use
of prophylaxis were not noted.

Prothero SR, Parkes JC, Stinchfield FE: Complications after low‐back fusion in 1000 patients:Acomparison of
two series one decade apart.1966. Clin Orthop Relat Res 1994;306:5‐11.

Incidence of DVT
l
• The only studies evaluating spine surgery cohorts
without the use of mechanical or pharmacologic
prophylaxis have come from eastern Asia.
prophylaxis have come from eastern Asia

• Using contrast venography, one study reported a
15.5% incidence of DVT, although only 0.9% of
occurrences were proximal to or inclusive of the
popliteal vein. No patients were clinically
lit l i N ti t li i ll
symptomatic.

Oda T, Fuji T, Kato Y, Fujita S, Kanemitsu N: Deep venous thrombosis after posterior spinal surgery. Spine
2000;25:2962‐2967.

Incidence of DVT
l
• A retrospective study of 1,954 patients undergoing
elective spine surgery in the cervical, thoracic, and
l h l h d
lumbar spine
• C
Compression stockings were used in conjunction with
i t ki di j ti ith
pharmacologic prophylaxis consisting of LMWH initiated
within 24 hours after surgery.
– 00 % i k f
0.05% risk of VTE and a 0% risk of PE
d 0% i k f
– 0.4% incidence of spinal epidural hematoma:
• A progressive postoperative neurologic deficit was present in
77% of patients
77% f ti t
• Only 60% of the patients who developed a progressive
deficit were discharged with a normal neurologic
examination, even after prompt surgical decompression
examination even after prompt surgical decompression
Gerlach R, Raabe A, Beck J,Woszczyk A, Seifert V: Postoperative nadroparin administration for prophylaxis of
thromboembolic events is not associated with an increased risk of hemorrhage after spinal surgery. Eur Spine J
2004;13:9‐13.

Incidence of DVT
in traumatic fracture/dislocation
f /d l
• Duplex ultrasound to screen 120 patients with severe head
Duplex ultrasound to screen 120 patients with severe head
and spinal trauma, including 11 patients with spinal
fractures.
• Patients were randomized to receive either intermittent
pneumatic compression or intermittent pneumatic
compression and LMWH (enoxaparin, 40 mg/day). The
LMWH was initiated approximately 24 hours after
admission.
• Overall there was a 5 8% incidence of DVT and a 5%
Overall, there was a 5.8% incidence of DVT and a 5%
incidence of PE.
• There was no difference between treatment groups.
There was no difference between treatment groups.

Incidence of DVT
in spinal cord injury
l d
• When prophylaxis is not used, VTE in the
patient with spinal cord injury is common,
with a minimum incidence of 80% (Brach et al,
J Trauma 1977; Geerts et al, NEJM 1994)

Heck CA, Brown CR, Richardson WJ. Venous thromboembolism in spine surgery. J Am Acad Orthop Surg.
2008 Nov;16(11):656‐64.

DVT Prophylaxis
DVT Prophylaxis

Heck CA, Brown CR, Richardson WJ. Venous thromboembolism in spine surgery. J Am Acad Orthop Surg.
2008 Nov;16(11):656‐64.

Positioning related complications
Positioning‐related complications
• Neurological:
– Quadriplegia
– Peripheral nerve palsies
Peripheral nerve palsies
• Eye complications
• Excessive bleeding

Positioning related
Positioning‐related
Neurological Complications

Quadriplegia
• Extreme rotation, extension, of flexion of the
, ,
head  cervical spinal cord damage

• Older patients with server cervical spondylosis
are high risk

• Prevention:
– Awake positioning: neutral or near‐neutral
p g
– Awake intubation
– Neuromonitoring
Zileli M, Naderi S, Benzel EC. Chapter 19: Preoperative and Surgical Planning for Avoiding Complications. In
Benzel EC (ed): Spine Surgery: Techniques, Complication Avoidance, and Management. 2nd Edition. Elsevier.
2005.

Brachial plexus stretch injury
• Mechanism:
– Prone: if the arms abducted >90°
– Supine: if the shoulders are aggressively taped down
Supine: if the shoulders are aggressively taped down
– Lateral decubitus: if you forgot to put an axillary roll
under the dependent side

• Presentations:
– shoulder or supraclavicular fossa pain, mixed motor
and sensory deficits

• Prognosis:
Prognosis:
– Majority, sponataneous improvement within 3‐6
months

• P
Prevention:
ti
– Prone: abduction of arms < 90°
– Supine: gently tape the shoulders
– Lateral: axillary roll under the dependent side
Rao RD, David KS. Chapter 1: Anterior Cervical Surgery. In Rao RD (ed): Complications in Orthopaedics: Spine
Surgery. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006

Peripheral nerves compression
• Ulnar nerve:
U a e e:
– Most commonly compressed around the elbow
– Prevented by a pad under the slightly extended elbow
– Injuries occasionally occur despite padding
– Symptoms appear 1‐4 days postop, resolve in weeks

• Radial nerve:
– C b i j d if th
Can be injured if the arm hangs at the edge of the
h t th d f th
table.
– Prevented by padding under the arm
Prevented by padding under the arm

• Common peroneal nerve:
Common peroneal nerve:
– Results in foot drop
– May occur in supine prone or lateral position
May occur in supine, prone or lateral position
– Compression around the fibular head

Lateral femoral cutaneous nerve injury
Lateral femoral cutaneous nerve injury
• Incidence: 20% (of 105 patients supine & prone
Incidence: 20% (of 105 patients, supine & prone,
cervical & lumbar)

• Mechanisms:
– Compression of ASIS in the prone position
– During bone graft harvesting at the anterior iliac crest
– At the retroperitoneum by hematoma or traction

• Consequences: meralgia paresthetica
Mirovsky Y. Neuwirth M. Injuries to the lateral femoral cutaneous nerve during spine surgery. Spine.
25(10):1266‐9, 2000 May 15.

Eye Complications
Eye Complications

Eye Complications
Eye Complications
• Position:
– Supine, lateral & prone.
– Prone position: 10 fold increased complications
Prone position: 10 fold increased complications

• Incidence:
– SRS survey: 1% of eye complications
– Perioperative blindness: 0.05‐1%

Stambough JL. Dolan D. Werner R. Godfrey E. Ophthalmologic complications associated with prone positioning
in spine surgery. Journal of the American Academy of Orthopaedic Surgeons. 15(3):156‐65, 2007 Mar.

Eye Complications
Eye Complications
• Classification:
– Corneal injury (ophthalmic)
– Ischemic optic neuropathy (ION)
– Retinal vessel occlusion
R ti l l l i
– Cortical blindness (non‐ophthalmic)

• Mechanisms:
– Alterations in blood flow to the eyeball or optic nerve,
either by decreased perfusion or embolism
ith b d d f i b li
– Direct pressure on the periorbital area or the globe
itself: less common

Corneal Abrasion
Corneal Abrasion
• Corneal abrasion is the most common surgical and
general anesthesia–related eye complication.

• Direct result of lagophthalmos “incomplete closure of
Direct result of lagophthalmos incomplete closure of
the eye”.

• Management:
– Most cases are self‐limiting
– Ophthalmologist consult
Ophthalmologist consult
– Topical eye antibiotics
– AVOID topical eye anesthetics: delay corneal epithelization
and promote keratitis
and promote keratitis

Ischemic Optic Neuropathy (ION)
Ischemic Optic Neuropathy (ION)
• Posterior ION is the most commonly reported
y p
visual loss secondary to prone positioning in
spine surgery

• Almost always irreversible visual loss

• Risk factors:
kf
– Blood loss >4L
– Hypotensive event or relative hypotension over an
Hypotensive event or relative hypotension over an
extended period
– Long surgery


Central Retinal Artery Occlusion (CRAO)
Central Retinal Artery Occlusion (CRAO)
• Second most common cause of postoperative
Second most common cause of postoperative
blindness with general anesthesia and prone
positioning

• Almost always irreversible visual loss
Almost always irreversible visual loss

• Direct or indirect pressure on the eye
Direct or indirect pressure on the eye
increases intraocular pressure.


Cortical Blindness
Cortical Blindness
• Occipital lobe stroke usually bilateral
Occipital lobe stroke, usually bilateral
blindness

• Partial to near complete recovery is expected

• Risk factors:
– Hypoxia
– Blood loss & hypotension


Prevention of Eye Complications
Prevention of Eye Complications
1. A slight reverse Trendelenburg (head up)
position: decrease facial edema and periorbital
ii d f i l d d i bi l
swelling
2. Avoid direct pressure on the eyes
3. Tape the eyes
p y
4. Maintenance of blood pressure
5. Catching up with bleeding
g g gp
6. Staging long procedure

Approach related complications
Approach‐related complications
• Timing:
– Intraoperative
– Early postoperative (within 1 week)
Early postoperative (within 1 week)
– Late postoperative (1‐6 weeks)

Dec;16(12):729‐38.

Intraoperative
Cervical Spine
Cervical Spine

Esophageal Injury
Esophageal Injury
• 0.2‐0.4 %
0.2 0.4 %

• Etiology:
– Inappropriate retractor placement: excessive force
during retraction or sharp retractor teeth
during retraction or sharp retractor teeth
– Intraoperative trauma by a high‐speed drill or
sharp instrument
– Late erosion, rare: loosening and migration of the
implant

Esophageal Injury
Esophageal Injury
• Presentation:
ese tat o :
– Intraoperative detection
– Delayed presentation: subcutaneous emphysema,
dysphagia, odynophagia, neck swelling, fever, early
wound infection, abscess

• Prevention:
– retractor teeth under the longus coli muscles
retractor teeth under the longus coli muscles
– esophagus should be directly protected by hand‐held
retractors during use of the high‐speed burr

Esophageal Injury
Esophageal Injury
• Intraoperative detection:
Intraoperative detection:
– 30cc of Indigo carmine dye through NGT
– Modification of above with Foley catheter proximal
Modification of above with Foley catheter proximal
and distal (Taylor et al, J Spine Disord Tech 2006)
– Intraoperative throacic or general surgeon
consultation  primary repair
– Pedicled muscle flap (e.g., sternocleidomastoid) to
protect the repair
h i
– If still in doubt, feeding tube and investigate
postoperatively.
postoperatively

Esophageal Injury
Esophageal Injury
• Consequences:
– If missed, mortality 20% if treated within 24 hours
– Mortality 50% if treatment delayed > 24 hours
Mortality 50% if treatment delayed > 24 hours
(Orlando et al, Spine 2003)

Dec;16(12):729‐38.

Vascular Injuries
Vascular Injuries
• Carotid sheath:
– Carotid artery or internal jugular vein injury, rare
– From sharp retractor teeth or during dissection
– Artery: primary repair
Artery: primary repair
– Vein: primary repair or ligation

• Thyroid vessels:
Thyroid vessels:
– Bleeding from superior (above C4) and inferior (below C6)
thyroid arteries can be controlled easily
– However keep in mind close proximity of:
However, keep in mind close proximity of:
• Superior laryngeal nerve with superior thyroid artery
• Recurrent laryngeal nerve with inferior thyroid artery

• Vertebral artery

Vertebral Artery Injury
• Incidence:
– 0.3% (of 1976 patients) anterior approach

• Anatomy:
– The mean distance from the uncovertebral joint to the
transverse foramen: 5.5 mm in the subaxial vertebrae

• Anomalies:
– Curylo et al: a 2.7% incidence of unilateral artery
displacement, with transverse foramen enlargement as far
medial as the mid‐vertebral body level.
y

Mechanisms of Vertebral Artery Injury
• Anterior spine:
1. Excessively wide corpectomy (limit to 15‐17mm)
2. Loss of the vertebral midline orientation, leading to an off‐
center or oblique corpectomy
3. Unrecognized vertebral artery tortuosity or other anomalies,
e.g., a vertebral artery located anterior to the transverse
e g a vertebral artery located anterior to the transverse
process
4. Using a burr to decompress the nerve root at the
uncovertebral region can bind dense fibrous bands within
g
transverse foramen
5. Excessive dissection beneath the longus colli (when the artery
is unprotected) between the transverse foramena
6. Soft lateral bone resulting from infection or tumor

• Posterior spine:
1.
1 C1‐C2 transarticular scew
C1 C2 t ti l
2. Lateral mass screws: too medial
3. Over dissection lateral to the lateral masses

Management of Vertebral Artery Injury
Management of Vertebral Artery Injury
• Notify anesthesia
Notify anesthesia
• Ask for blood
• Ask for help (vascular surgeon)
kf h l ( l )
• 4 options:
– Direct tamponade: temporary
– Direct repair
– Proximal and distal ligation
– Endovascular stent or coagulation
g

Exposure of Vertebral Artery
• When technically feasible, repair of the
When technically feasible, repair of the
vertebral artery injury is the preferred
approach.

• Once active bleeding is controlled, the artery
Once active bleeding is controlled, the artery
should be exposed at the level of the
transverse process directly over the transverse
foramen, to determine whether it should be
ligated or repaired.

• After the longus coli muscle is elevated, a small curet is
used to free the soft tissues adherent to the undersurface
of the costal process, which can then be readily removed
with a 2‐mm Kerrison rongeur. This often results in a minor
amount of venous oozing, which is controllable by injecting
t f i hi h i t ll bl b i j ti
a hemostatic agent into the transverse foramen.

• A right angle clamp is then placed under the artery to
facilitate the passage of vessel loops cephalad and caudad
to the site of injury. Lifting up on the two vessel loops
occludes the artery at the site of injury, allowing ligation or
l d th t t th it f i j ll i li ti
repair, depending on the severity of the laceration.

Consequences of Vertebral Artery
Injury
• The predicted incidence of brainstem
infraction in the presence of normal
contralateral vessel is:
t l t l li
– 3.1% when the left vertebral artery is ligated
– 1 8% h th i ht
1.8% when the right vertebral artery is ligated
t b l t i li t d

• L t
Late consequences: fistula, late‐onset
fi t l l t t
hemorrhage, pseudoaneurysms, thrombosis,
emboli

Prevention of Vertebral Artery Injuries
Prevention of Vertebral Artery Injuries
• Preoperative:
– Review the position of vertebral artery in preop imaging
– If in doubt, MR angio or conventional angio

• Intraoperative:
– Anterior approach:
• Orient yourself to midline: paired longus colli uncovertebral joints &
Orient yourself to midline: paired longus colli, uncovertebral joints &
contour of vertebral body
• For revision or deformity cases, floroscopy
– Posterior approach:
pp
• Limit dissection to 15mm from midline over C1 arch
• Use documented trajectory of lateral mass screws
• Do not dissect beyond the lateral border of lateral masses
y

Neurological Injuries
Neurological Injuries
• Dural tear
Dural tear
• Spinal cord injury
• Nerve root injury
i j
• Recurrent & superior laryngeal nerve injury
• Sympathetic trunk injury

Dural Tear
Dural Tear
• Incidence:
c de ce:
– 3.7% anterior approach

• Risk factors for dural tear:
– Revision surgery
– OPLL

• Consequences:
– Persistent leak  fistula formation & airway
compromise

Dural Tear
Dural Tear
• Management:
– Watertight closure, if feasible
– Fibrin glue
Fibrin glue
– Lumbar drain
– U i ht
Upright position postoperatively
iti t ti l

Spinal Cord Injury
Spinal Cord Injury
• Incidence:
– Anterior: 0.2‐0.9 %

• Risk factors:
– myelopathy
– cervical kyphosis
– spinal cord atrophy
p p y
– spinal instability
– fractures through long fused spinal segments
g g p g

Mechanism of Spinal Cord Injury
Mechanism of Spinal Cord Injury
• Problems related to positioning and/or intubation
p g /
• Direct mechanical injury: surgical instruments,
penetration of posterior cortex with drill or screws
• Uncontrolled intraoperative distraction (esp, trauma
patient with torn soft tissue)
• Inserting the graft too far (AP diameter of graft should
Inserting the graft too far (AP diameter of graft should
be ≤13mm)
• Removal of osteophytes at the posterior vertebral body
p y p y
margin
• Epidural hematoma

Prevention of Spinal Cord Injury
Prevention of Spinal Cord Injury
• Maintenance of systolic blood pressure >80mm Hg

• Avoidance of excessive extension or distraction
(
(consider pre‐intubation positioning and neurological
p p g g
examination)

• Neuromonitoring: transcranial electric motor‐evoked
Neuromonitoring: transcranial electric motor evoked
potential (tceMEP) monitoring and somatosensory‐
evoked potential (SSEP)
• Proper instrument handling: bracing, two hands
technique, do not pass instruments over the wound

Spinal Cord Injury
Spinal Cord Injury
• In a retrospective study of patients
In a retrospective study of patients
undergoing cervical spine surgery, the
sensitivity and specificity for detecting
sensitivity and specificity for detecting
evolving motor tract injury:
– with tceMEP was 100%
with tceMEP was 100%
– compared with a 25% sensitivity and 100%
specificity with SSEP
specificity with SSEP

Hilibrand AS, Schwartz DM, Sethuraman V, Vaccaro AR, Albert TJ: Comparison of transcranial electric motor
and somatosensory evoked potential monitoring during cervical spine surgery. J Bone Joint Surg Am 2004;86:
1248‐1253.

What to do if there was an alert?
What to do if there was an alert?

Devlin VJ, Schwartz DM. Intraoperative Neurophysiologic Monitoring During Spinal Surgery. J Am Acad
Orthop Surg 2007;15:549‐560

Management of Spinal Cord Injury
Management of Spinal Cord Injury
• If no neuromonitoring used usually detected
If no neuromonitoring used, usually detected
in recovery room:
– Urgent X ray: R/O dislodgement of graft or
Urgent X‐ray: R/O dislodgement of graft or
hardware
– Urgent MRI (± CT): R/O epidural hematoma and
Urgent MRI (± CT): R/O epidural hematoma and
hardware malposition
– If no structural problems, treatment is largely
If no structural problems, treatment is largely
expectant

C5 Radiculopathy post Cervical
Decompression
• Mechanism:
ec a s :
– C5 roots are shorter than other cervical nerve roots
– C5 is usually at the midpoint of the decompressed
segment and subject to the greatest stretch with
shifting of the spinal cord
– Restoration of the cervical lordosis shifts the spinal
Restoration of the cervical lordosis shifts the spinal
cord posteriorly and increase the stretch on C5 roots
– Deltoid has unisegmental innervation which makes C5
palsy more clinically obvious

• Prognosis: self‐limiting take months to recover
Prognosis: self limiting, take months to recover

Recurrent Laryngeal Nerve Injury
• Recurrent laryngeal nerve:
Recurrent laryngeal nerve:
– Motor innervation of the intrinsic laryngeal muscles
(
(except cricothyroid) and sensory input below glottis
p y ) y p g
– Right side: passes beneath right subclavian artery,
then ascends obliquely towards the
tracheoesophageal groove
– Left side: passes beneath the arch of aorta, lies in the
groove throughout most of its ascent
groove throughout most of its ascent
– Non‐recurrent inferior laryngeal nerve occurs in 1% of
patients (mainly on the right side)
patients (mainly on the right side)

• Incidence: 5‐16%
• Risk factors:
– direct surgical trauma
g
– stretching
– postoperative edema
– attempted control of inferior thyroid bleeding,
attempted control of inferior thyroid bleeding
– revision surgery
– surgery at C6‐T1 region

• Clinical presentation: hoarseness, aspiration, persistent
cough, dysphagia


Management of Recurrent Laryngeal
Nerve Injury
• Spontaneous recovery is expected in most
Spontaneous recovery is expected in most
patients, but can take up to 1 year.
• If h
If hoarseness persisted >6 weeks, laryngoscopic
i d 6 k l i
evaluation of the vocal cords and laryngeal
muscles is indicated
• In patients with significant aspiration, vocal cord
medialization (injecting absorbable gelatin
(injecting absorbable gelatin
sponge into the injured vocal cord)
– Provides 4‐6 weeks of medialization

• Prevention:
e e to :
– Respect the relation of superior thyroid artery (with
superior laryngeal nerve) and inferior thyroid artery
(with recurrent laryngeal nerve)
( ith tl l )

– Historically, left‐sided is safer. Currently, no difference.
Right‐handed surgeons use right‐handed approach.

– Monitoring endotracheal tube cuff pressure and
g p
deflating the endotracheal tube cuff after placement
of the retractor: reduced the rate of injury from 6.4%
to 1.7% (Apfelbaum et al, Spine
to 1 7% (Apfelbaum et al Spine 2000)

• For revision anterior cervical cases:
For revision anterior cervical cases:
– Get laryngoscopic examination
– If both recurrent laryngeal nerves are intact  go
If both recurrent laryngeal nerves are intact  go
to the contralateral side (to avoid scar from
previous surgery)
previous surgery)
– If one of the recurrent laryngeal nerve is injured
 go to the ipsilateral side (side of injured nerve)
g p ( j )

Superior Laryngeal Nerve Injury
• Anatomy of superior laryngeal nerve:
Anatomy of superior laryngeal nerve:
– Arises from the inferior ganglion of the vagus
nerve as it exits the skull
nerve as it exits the skull
– Descends just medial to the carotid artery
– At the level of hyoid bone it bifurcates into:
At the level of hyoid bone, it bifurcates into:
• A small external laryngeal branch: motor to cricothyroid
• A larger internal laryngeal branch: sensory laryngeal
a ge te a a y gea b a c se so y a y gea
mucosa above the glottis

• Clinical Presentations:
Clinical Presentations:
– Injury to sensory branch (internal laryngeal):
• Post‐swallowing cough chocking sensation and
Post‐swallowing cough, chocking sensation and
aspiration because of loss of sensation above the vocal
cords and loss of reflexive closure of vocal cords to
prevent aspiration
i i
– Injury to motor branch (external laryngeal):
• U il t l i j
Unilateral injury: subtle change in the pitch of voice.
btl h i th it h f i
Unnoticed, except for singers.
j y y
• Bilateral injury: voice hoarseness and tires easily

Sympathetic Trunk Injury
Sympathetic Trunk Injury
• Anatomy:
–AAnterior to longus colli &
i l lli & posterior to internal carotid
i i l id
– Superior (C2‐3) and middle cervical ganglion and
stellate ganglion (C7)

• Horner’s Syndrome:
– I id
Incidence: 0.2‐4%
0 2 4%
– More in revision surgery
– Result from injury to the chain cephalad to the inferior
Result from injury to the chain cephalad to the inferior
half of stellate ganglion or from postganglionic injury
– Prevention: dissection beneath longus colli and
avoiding excessive retraction of the muscle
avoiding excessive retraction of the muscle

Thoracic Duct Injury
Thoracic Duct Injury
• Anatomy:
y
– Enters the base of the neck on the left of the
esophagus
– Crossing the subclavian artery at T1 and enters left
Crossing the subclavian artery at T1 and enters left
subclavian vein

• At risk in left‐sided anterior approaches to lower
cervical and cervicothoracic junction

• Consequences: chylomediastinum or a chylous
p
pleural effusion

Management of Thoracic Duct Injury
Management of Thoracic Duct Injury
• If detected intraoperatively, double ligation of the thoracic
duct
• Non‐surgical management (if detected postoperatively):
– Reduction of the chyle flow:
• Eliminating enteral feeds
• Very low fat TPN
– D i
Drainage of pleural cavity
f l l it
– Nutritional support
– Prevention of sepsis: risk of bacterial and fungal sepsis and 50%
mortality

• If non‐surgical treatment failed  vascular clip and fibrin
glue through thoracotomy or thoracoscopy
glue through thoracotomy or thoracoscopy

Acute Airway Compromise
• Incidence of reintubation following anterior
Incidence of reintubation following anterior
cervical spine surgery: 1.7‐2.8%

• Risk factors:
– hematoma formation
– CSF leakage
– hardware or bone graft displacement,
– laryngeal or prevertebral soft‐tissue swelling

• Suk et al
– peak swelling POD 2 & 3
– swelling at the C2‐C4 levels was more clinically significant than it was
below C5.

• Other risk factors for airway compromise caused by prevertebral
swelling include:
– obesity
– obstructive sleep apnea
– surgical time >5 hours
– revision surgery
g y
– history of asthma
– exposure of three or more disk levels
– transfusion of more than four units of blood

• Consider keep intubated for high risk patients
Consider keep intubated for high risk patients
• Assess weaning parameters
• Elevation of the head of the bed
l i f h h d f h b d
• Diuresis
• Inhaled or IV steroids for soft tissue edema

Postoperative Wound Hematoma
• Incidence: 0.2‐1.9%

• Mechanism:
– due to venous bleeding or from an unrecognized or
inadequately controlled arterial source.
– can occur despite placement of a postoperative drain
p p p p
and adequate hemostasis at the time of wound
closure due to:
• Increased blood pressure
p
• coughing
• vomiting
• coagulopathy
• the use of an anticoagulant.

• Consequences:
– Can cause life‐threatening airway compromise
– Persistent wound drainage and infection
g

• Patients with life threatening airway
Patients with life threatening airway
compromise and apparent swelling at the site
g
of incision are candidates for urgent wound
incision and drainage at the bedside or in the
operating room.

Dysphagia
• Incidence: 28‐57%

• Multifactorial:
– esophageal denervation
esophageal denervation
– postoperative soft‐tissue swelling
– scar tissue formation
– cervical immobilization
i li bili ti
– cervical hyperextension resulting from improper halo or
collar positioning
– prominence of anterior instrumentation
– hematoma formation
– injury to specific nerves involved in swallowing: the
j y p g
pharyngeal plexus, hypoglossal nerves, superior and
recurrent laryngeal nerves

Dysphagia
• Improves with time
– 1‐month: 54%
– 2‐month: 33.6%
– 6‐month: 18.6%
– 12‐month: 15.2%
– 24‐month: 13.6%

• Sever dysphagia:
– Radiologic work‐up: R/O graft dislodgement, abscess, or
hematoma
– Speech Language Pathologist Consult
– Modified Barium Swallow: sitting position, small amount of
liquid

Wound Infection
Wound Infection
• Incidence:
Incidence:
– 0.2‐1.6% anterior spine

• Relatively rare in the anterior spine except
after esophageal injury or
ft h li j
immunocompromised patients

• Management: I & D, IV antibiotics

Ebraheim NA. Elgafy H. Xu R. Bone‐graft harvesting from iliac and fibular donor sites: techniques and
complications. Journal of the American Academy of Orthopaedic Surgeons. 9(3):210‐8, 2001 May‐Jun.

Iliac graft donor site complications
Iliac graft donor site complications
• Donor Site Pain
• Neurovascular injury
• Avulsion fractures of the ASIS
• Instability of the sacroiliac joint
• Hematoma
• Infection
• Herniation of abdominal contents
• Gait disturbance
G i di b
• Cosmetic deformity
• Ureteral injury
Ureteral injury

Donor Site Pain
Donor Site Pain
• Persistent pain at least 3 months after surgery
Persistent pain at least 3 months after surgery

• Incidence: 2.8‐25% (Summers et al, JBJS(B)
1989)

• M h i
Mechanism: unclear
l
– Muscular or periosteal secondary to the stripping
of the abductors from the ilium
of the abductors from the ilium
– May be related to injury of the superior cluneal
nerves

Vascular Injuries of Graft Harvesting
• Posteriorly: superior gluteal artery
Posteriorly: superior gluteal artery
– Branch of internal iliac, exit the sciatic notch

• Anteriorly: fourth lumbar artery, iliolumbar
artery and deep circumflex iliac artery
t dd i fl ili t
– Extensive anastomoses in the pelvis overlying the
iliacus muscle
ili l

• Rare but serious complication
a e but se ous co p cat o

• Case reports

• Mechanism of injuring the superior gluteal
vessels:
vessels:
– Harvesting iliac bone too close to the greater sciatic
notch
– Improper placement of the Taylor retractor in the
greater sciatic notch

• Management:
a age e t:
– Ask for help (anesthesia, vascular surgeon): brisk
bleeding, upto 1.5 Litre
– Exploration and ligation of the artery laceration if
possible
– Usually the artery retracts into the retroperitoneum
Usually, the artery retracts into the retroperitoneum.
Options:
• Partial osteoectomy of the ilium to improve exposure.
• Pack, close and endovascular embolization.
• Close and flip the patient. Transperitoneal or retroperitoneal
approach.

Safe zone of graft harvesting


• Prevention:
– Stay in zone 1 (safe zone)
– The caudal limit should be the inferior margin of
g
the roughened area anterior to the PSIS on the
outer table to keep from injuring the superior
gluteal artery.
gluteal artery
– With the patient lying prone on the operating
table, the gouge or osteotome should be directed
table the gouge or osteotome should be directed
perpendicular to the operating table so as to avoid
the greater sciatic notch.

Nerve Injuries of Graft Harvesting
Nerve Injuries of Graft Harvesting
• Nerves at risk:
Nerves at risk:
– Posteriorly: superior cluneal nerves, sciatic,
superior gluteal nerve
superior gluteal nerve
– Anteriorly: lateral femoral cutaneous, ilioinguinal,
iliohypogastric, femoral
iliohypogastric, femoral

• Prevention:
– Posteriorly: stay within 6cm lateral to PSIS
– Anteriorly: start incision 3cm posterior to ASIS
Anteriorly: start incision 3cm posterior to ASIS

Superior Cluneal Nerve
Superior Cluneal Nerve
• L1‐L3, cutaneous branches, supply large area of
, , pp y g
skin over the gluteal area
• Pierce the lumbodorsal fascia over the crest 8cm
Pierce the lumbodorsal fascia over the crest 8cm
lateral to PSIS.
• P
Presentation: pain and numbness over the
t ti i d b th
buttock
• Prevention: stay within 6cm of PSIS
• Treatment: injection, excision
Treatment: injection, excision

Sciatic Nerve Injury
• L4‐S3, enters the gluteal area through sciatic notch
, g g

• Lies distal to a line drawn from PSIS perpendicular to
the floor with patient prone

• Ri k f i j i th
Risks of injuring the nerve:
– Cobb elevator or osteotome can violate the sciatic notch
– Taylor retractor used for muscle retraction: sharp tip is
Taylor retractor used for muscle retraction: sharp tip is
usually malleted into the outer table above the sciatic
notch  might slip and cause sciatic nerve injury

Shamie AN, Wang JC. Chapter 6: Anterior and Posterior Bone Graft Harvest for Spine Surgery. In Rao RD (ed):
Complications in Orthopaedics: Spine Surgery. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006

• Presentation:
– May mimic a nerve root injury rather than a
complete sciatic nerve injury because the
complete sciatic nerve injury because the
lumbosacral plexus does not condense for few
centimeters after they exit the notch

• Prevention:
– Stay above the perpendicular line of the PSIS
– Careful with instruments near the sciatic notch
Careful with instruments near the sciatic notch

Lateral Femoral Cutaneous Nerve
Lateral Femoral Cutaneous Nerve
• Cutaneous branch of lumbar plexus
Cutaneous branch of lumbar plexus
– Sensation of anterolateral aspect of thigh

• Usually, it exits under the inguinal ligament and
the sartorius muscle (both originate from ASIS)

• In 10% of patients, it courses over the crest
lateral to ASIS within a 2‐cm margin
lateral to ASIS ithin a 2 cm margin

• Meralgia paresthetica, usually self‐limited
Meralgia paresthetica, usually self limited

Fractures of the Ilium
Fractures of the Ilium
• Avulsion fracture of ASIS.

• Mechanism:
– Stress riser created if the graft is taken too close to
the ASIS (within 3cm).
– Avulsion results from the action of the sartorius and
Avulsion results from the action of the sartorius and
tensor fascia lata muscles.

• Treatment:
– Small piece: non‐operative
– Large piece: ORIF
Large piece: ORIF

Case 1
Case 1
• 62yr female
62yr female
• 2 level ACDF
• 3cm posterior to ASIS
3 i SS
• No immediate
complication
• 2 mo later: severe left
anterior groin pain &
numbness

Case 2
Case 2
• 68yr female
68yr female
• Single level ACDF
• 6 k
6wk postop, rising from a crossed legged
ii f dl d
position when she heard a pop in the anterior
hip and felt immediate pain radiating to
hi df l i di i di i
anterior thigh. Weakness of knee extension.

Case 2
Case 2


Case 2
Case 2
• Femoral allograft
• Tension band cerclage fixation
• Crest locking plate & antiglide plate


Violation of Sacroiliac Joint
Violation of Sacroiliac Joint
• Not uncommon.

• Rare (6 case reports) of pelvic instability: damage
to posterior sacroiliac ligaments

• W k
Work up:
– Difficult to pinpoint: pre‐existing spinal pain, graft‐site
p
pain or sacroiliac pain.
p
– Diagnostic injection: floroscopy‐guided
– CT

Case 3
Case 3
• 78yr female
78yr female
• Bilateral posterior iliac crest bone harvest
• Multilevel fusion of thoracolumbar spine
l il l f i f h l b i
• Steroid‐dependent RA & osteoporosis
• 10 days postoperatively, severe pain when
g
transferring her from bed to wheelchair.

Case 3
Case 3


Case 3 postoperative
Case 3 postoperative
• Allograft
• Posterior tension band plate


Case 3 F/U
Case 3 F/U


Prevention of violation of
sacroiliac joint
l


Hernia
• If the defect is large and the adjacent muscles are
g j
not carefully repaired  Herniation of abdominal
contents through an iliac bone‐graft donor site
• Treatment options:
– Soft tissue repair
– Mesh
– Re‐contouring of iliac crest (Bosworth technique,
JBJS(A) 1955)
( ) )

• Prevention: good soft tissue closure

Hematoma after Graft Harvesting
Hematoma after Graft Harvesting
• Incidence: 10% (Fowler et al, Am J Orthop 1995)

• Increase the risk of infection

• Mechanism:
– Bleeding from the exposed cancellous bone
– Injury to the vessels adjacent to the anterior ilium, such as the deep
circumflex iliac, or iliolumbar

• Prevention:
– Strictly subperiosteal dissection
– Obtaining hemostasis before closure:
Obtaining hemostasis before closure:
• Gelfoam: thrombin‐soaked or epinephrine‐soaked
• Bone wax: discouraged by some authors, may cause local reaction and impair
healing
– ± suction drain
i d i

Infection after Graft Harvesting
Infection after Graft Harvesting
• Incidence: 1%
Incidence: 1%

• Prevention:
– Perioperative antibiotic administration
– Use of separate instruments to avoid
contamination from other potentially infected
sites
– M ti l
Meticulous hemostasis
h t i
– Use of newer techniques utilizing trephines to
avoid muscle stripping
avoid muscle stripping

Rationale for Separate Incision for the
Posterior Iliac Crest Graft
l f
• Cross contamination from an infected primary
Cross contamination from an infected primary
wound is less likely if the bone graft is harvested
through a separate incision.

• Cross contamination of the primary spine wound
may not occur if the donor site becomes infected.
may not occur if the donor site becomes infected

• Focusing on the details of the harvesting
Focusing on the details of the harvesting
technique is easier if the bone graft is harvested
through a separate incision.
Stambough JL Guest Perspective on Chapter 6: Anterior and Posterior Bone Graft Harvest for Spine Surgery. In
Rao RD (ed): Complications in Orthopaedics: Spine Surgery. Rosemont, IL, American Academy of Orthopaedic
Surgeons, 2006

Gait Disturbance
Gait Disturbance
• Occur with both anterior and posterior iliac crest
Occur with both anterior and posterior iliac crest
harvesting
– Anterior: weak abductors  abductor lurch
Anterior: weak abductors  abductor lurch
– Posterior: weak gluteus maximus  difficulty in
climbing stairs or getting up from seated

• Prevention:
– Create a thick fascial sleeve at the time of exposure
– Meticulous and complete fascial repair

Thank You

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Complications In Spine Surgery 2009

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