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


 Sohail Bajammal, MBChB, MSc, FRCS(C)
             March 16, 2009
808 pages, $250
808 pages, $250
235 pages, $155
235 pages, $155
104 pages, $55
104 pages, $55
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.
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
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
                  in elective spine surgery
                      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 
                   in elective spine surgery
                       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. 
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
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
    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
Brachial plexus stretch injury
          Brachial plexus stretch injury
• 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
      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
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
  Peripheral nerves compression
• 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
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.
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
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.
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

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.
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.

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.
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

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.
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
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.
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
Approach related complications
  Approach‐related complications
• Timing:
  – Intraoperative
  – Early postoperative (within 1 week)
    Early postoperative (within 1 week)
  – Late postoperative (1‐6 weeks)
Daniels et al. Adverse events associated with anterior cervical spine surgery. J Am Acad Orthop Surg. 2008 
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)




Daniels et al. Adverse events associated with anterior cervical spine surgery. J Am Acad Orthop Surg. 2008 
Dec;16(12):729‐38.
Vascular Injuries
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
           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
Daniels et al. Adverse events associated with anterior cervical spine surgery. J Am Acad Orthop Surg. 2008 
Dec;16(12):729‐38.
Vertebral Artery Injury
                    Vertebral Artery Injury




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
Vertebral Artery Injury
                    Vertebral Artery Injury




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
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
    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.
Exposure of Vertebral Artery
      Exposure of Vertebral Artery
• 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
            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
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
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
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
Recurrent Laryngeal Nerve Injury
 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)
Recurrent Laryngeal Nerve Injury
    Recurrent Laryngeal Nerve Injury
• 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

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
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
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
Recurrent Laryngeal Nerve Injury
 Recurrent Laryngeal Nerve Injury
• 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)
Recurrent Laryngeal Nerve Injury
 Recurrent Laryngeal Nerve Injury
• 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
  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
Superior Laryngeal Nerve Injury
  Superior Laryngeal Nerve Injury
• 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
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
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
Early Postoperative
Acute Airway Compromise
      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
Acute Airway Compromise
         Acute Airway Compromise
• 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
Acute Airway Compromise
        Acute Airway Compromise
•   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
 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. 
Postoperative Wound Hematoma
 Postoperative Wound Hematoma
• 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.
Late Postoperative
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
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
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
 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.
Vascular Injuries of Graft Harvesting
  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
Vascular Injuries of Graft Harvesting
  Vascular Injuries of Graft Harvesting
• 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
  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.
Vascular Injuries of Graft Harvesting
 Vascular Injuries of Graft Harvesting
• 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.
 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.
Safe zone of graft harvesting




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.
Vascular Injuries of Graft Harvesting
 Vascular Injuries 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.
 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.
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
  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.
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
                         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
Sciatic Nerve Injury
           Sciatic Nerve Injury
• 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
  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.
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
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
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




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




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
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
  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.
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.
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




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




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
Case 3 F/U
                                      Case 3 F/U




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
Prevention of violation of 
sacroiliac joint
      l




 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.
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
  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.
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
  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.
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
 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.
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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Thoracolumbar Spine
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Complications In Spine Surgery 2009

  • 1.
  • 2. 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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  • 17. 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.
  • 18. 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.
  • 19. 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. ( )
  • 20. Not covered in this presentation Not covered in this presentation • Long term complications (psuedoarthrosis Long term complications (psuedoarthrosis,  junctional kyphosis, adjacent segment  disease)
  • 21. 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
  • 22. 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.
  • 23. 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
  • 24. 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.
  • 25. Incidence of DVT in elective spine surgery 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.
  • 26. Incidence of DVT  in elective spine surgery 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.
  • 27. 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.
  • 28. 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. 
  • 29. 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. 
  • 30. 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
  • 31. Positioning related complications Positioning‐related complications • Neurological: – Quadriplegia – Peripheral nerve palsies Peripheral nerve palsies • Eye complications • Excessive bleeding
  • 32. Positioning related  Positioning‐related Neurological Complications
  • 33. 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.
  • 34. Brachial plexus stretch injury 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
  • 35. Brachial plexus stretch injury Brachial plexus stretch injury • 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
  • 36. Peripheral nerves compression 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 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
  • 37. Peripheral nerves compression Peripheral nerves compression • 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
  • 38. 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. 
  • 40. 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.
  • 41. 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 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.
  • 42. 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 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.
  • 43. 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 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.
  • 44. 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. 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.
  • 45. 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 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.
  • 46. 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 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.
  • 47. 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
  • 48. Approach related complications Approach‐related complications • Timing: – Intraoperative – Early postoperative (within 1 week) Early postoperative (within 1 week) – Late postoperative (1‐6 weeks)
  • 51. 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
  • 52. 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
  • 53. 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
  • 54. 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) Daniels et al. Adverse events associated with anterior cervical spine surgery. J Am Acad Orthop Surg. 2008  Dec;16(12):729‐38.
  • 56. 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
  • 57. Vertebral Artery Injury 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
  • 58. 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
  • 60. Vertebral Artery Injury Vertebral Artery Injury 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
  • 61. Vertebral Artery Injury Vertebral Artery Injury 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
  • 62. 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
  • 63. Exposure of Vertebral Artery 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.
  • 64. Exposure of Vertebral Artery Exposure of Vertebral Artery • 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.
  • 65. 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
  • 66. 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
  • 68. Neurological Injuries Neurological Injuries • Dural tear Dural tear • Spinal cord injury • Nerve root injury i j • Recurrent & superior laryngeal nerve injury • Sympathetic trunk injury
  • 69. 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
  • 70. 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
  • 71. 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
  • 72. 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 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
  • 73. 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
  • 74. 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.
  • 75. 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
  • 76. 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
  • 77. 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 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
  • 78. Recurrent Laryngeal Nerve Injury 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)
  • 79. Recurrent Laryngeal Nerve Injury Recurrent Laryngeal Nerve Injury • 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 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
  • 80. 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 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
  • 81. Recurrent Laryngeal Nerve Injury Recurrent Laryngeal Nerve Injury • 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)
  • 82. Recurrent Laryngeal Nerve Injury Recurrent Laryngeal Nerve Injury • 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 )
  • 83. Superior Laryngeal Nerve Injury 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
  • 84. Superior Laryngeal Nerve Injury Superior Laryngeal Nerve Injury • 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
  • 85. 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 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
  • 86. 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
  • 87. 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
  • 89. Acute Airway Compromise 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
  • 90. Acute Airway Compromise Acute Airway Compromise • 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
  • 91. Acute Airway Compromise Acute Airway Compromise • 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
  • 92. Postoperative Wound Hematoma 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. 
  • 93. Postoperative Wound Hematoma Postoperative Wound Hematoma • 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.
  • 95. 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
  • 96. 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
  • 97. 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
  • 98. 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
  • 100. 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
  • 101. 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 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.
  • 102. Vascular Injuries of Graft Harvesting 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
  • 103. Vascular Injuries of Graft Harvesting Vascular Injuries of Graft Harvesting • 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 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.
  • 104. Vascular Injuries of Graft Harvesting Vascular Injuries of Graft Harvesting • 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. 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.
  • 106. Vascular Injuries of Graft Harvesting Vascular Injuries 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. 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.
  • 107. 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 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.
  • 108. 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
  • 109. Sciatic Nerve Injury 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
  • 110. Sciatic Nerve Injury Sciatic Nerve Injury • 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
  • 111. 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
  • 112. 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 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.
  • 113. 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 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
  • 114. 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.
  • 115. Case 2 Case 2 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
  • 116. Case 2 Case 2 • Femoral allograft • Tension band cerclage fixation • Crest locking plate & antiglide plate 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
  • 117. 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 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.
  • 119. 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.
  • 120. Case 3 Case 3 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
  • 121. Case 3 postoperative Case 3 postoperative • Allograft • Posterior tension band plate 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
  • 122. Case 3 F/U Case 3 F/U 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
  • 123. Prevention of violation of  sacroiliac joint l 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.
  • 124. 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 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.
  • 125. 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 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.
  • 126. 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 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.
  • 127. 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
  • 128. 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
  • 129. Thank You Next Part 2/2 N t P t 2/2 Thoracolumbar Spine Thoracolumbar Spine