COMPLICATIONS IN CERVICAL AND LUMBAR SPINAL SURGERY

Daniel A Capen MD Downey Orthopedic Group

Complications in Spinal Surgery

Positioning Complications

Approach Complications

Procedure Complications

Post-surgical Complications

Complications in Cervical Spine Surgery

Nassr et al Journal of Neurosurgical Spine 2010

Analysis of 25 Studies- 8.9% Overall Rate

No Difference if Prospective or Retrospective

Rates Increased in >60 Age

Increased for Diagnosis of Spondylosis with Myelopathy

Positioning Complications

Brachial Plexopathy from Shoulder Taping

Ulnar Nerve Injury

Occular Compression Blindness in Posterior Surgery

Knee and Ankle Compression

Malpositioning to Create Kyphosis or Hyperlordosis

Anterior Approach Related Complications

Dysphagia

Dysphonia

Horners Syndrome Injury to Chassaignac’s Ganglion

Carotid Injury

Excessive Lumbar Tissue Trauma

All Related to Retraction and Anterior Spine Dissection

Procedure Related Complications

Vertebral Artery Injury Nassr- 0.3% Anterior

Neurologic Injury 0.3-0.4%

Poor Cage or Graft Placement

End-Plate Violation

Incomplete Decompression

Lordosis Loss

Insufficient Fixation From Malpositioned Screws or Cages

Post Surgical Complications

Dysphagia- Bazaz Spine 2002

>50% of 249 Patients Had Moderate or Severe in the 1st Month

12.5% at 12 Months

Risk Factors Number of Levels, Length of Surgery, Female Patients

Indication for Hardware Explantation if Severe

Post Surgical Complications in Lumbar Surgery DVT—5-7% incidence Compression

Stockings, Early Ambulation

Cage Migration ,Screw Cut Out-Immediate repositioning

Infection rates 2-13% Low In Alif, Higher in Posterior Approaches

Incisional Vancomycin Powder in ALL Posterior Instrumented Fusions

Rates Reduced to <1%

Post Surgical Complications

Dysphonia

Recurrent Laryngeal Nerve Injury

Kahraman et al Euro-Spine 2007- 235 Cases

Incidence 1.27 % 3 males

All Surgery at C6/7

Improvement with Time

Post Surgical Complications

Retro-Pharyngeal Hematoma

Palumbo et al 2012 Open Ortho Journal

0.2 to 1.9%

Tachypnea, Desaturation Throat Swelling

Life Threatening--- Immediate Evacuation

Surgical Drain for All Anterior Cases-24hrs

Posterior Cervical Complications

Graham et al Spine 1996 1.8% Radiculopathy with Lateral Mass Fixation <15mm Screws

Facet Fracture or Violation 6% Rate

Pedicle Penetration 6.8%

Overall Neurologic Injury Rate >2%

Post Surgical Infection in Cervical Surgery

Rates 0.4 to 4.5% Vacarro et al 2003

Posterior Approach Greater-Muscle Trauma and Blood Loss

Staph Strep Klebsiella

If Anterior Infection Need to R/O Esophageal Perforation

Age, Smoking, Immune Compromise-Increase Infection Risk

Avoidance of Complications

SSEP and MEP Monitoring

Careful Pre Surgical Positioning

Real Time Imaging for Fixation

Frequent Relaxation of Retraction

Avoid Bi-cortical Screws Anterior or Posterior

Hemostasis, Irrigation and Drainage

Vancomycin In Lumbar PSF and all MRSA Cases

THANK YOU

Cerebral Aneurysms

Incidence

Diagnosis

Treatment Options

Daniel A Capen MD

Cerebral Aneursyms

Cerebral Aneurysms

Associated with Hernia, Peripheral Aneurysm

1 in 50 in US Population

1% of population at autopsy

At or Near Circle of Willis

At Arterial Junctions

Types of Aneurysms

Saccular—”Berry” Most Frequent

Fusiform –Usually do Not Rupture

Charco-Bouchard –Usually <15mm –Hypertension- Usually Slow Bleed

Giant Aneurysm > 2.5 cm Always Risk for Sudden Death or Hemorrhagic Stroke

Types of Aneurysms

Aneurysm Risk Factors

Marfan Syndrome

Polycystic kidney Disease

Neurofibromatosis

Hereditary Telangectasia

Ehlers – Danlos Type II and IV

CAUSES of Aneurysm

Genetic Tendency

Weakness of Connective Tissue

High Blood Pressure

Mycosis, Infection, Trauma

Drug Abuse—Cocaine, Amphetamines

SIGNS AND SYMPTOMS

Headache

Nausea- Vomiting

Confusion

Visual Disturbance

Focal Facial Numbness

Meningismus

Focal Neural Defecit

Sudden Coma

Diagnosis

CAT SCAN with Angiography

MRI for post- aneurysm Bleed

Screen For Any Of Risk Patients

Angiography

Treatment Options

Observation if Diagnosed But No Symptoms

Endovascular Embolization or Coil

Craniotomy For Clipping

Cerebral Aneurysms

Treatment Options

Results With Rupture

40% Mortality Rate

15% Die Before Reaching Hospital

Female > Male For Rupture

Once Aneurysm Ruptures >60% Have Permanent Neurologic Deficits

Multiple Aneurysms

Cerebral Aneurysms

Diagnosis

Types Of Aneurysms

Multiple Aneurysms