Complications of Spinal Surgery

Himanshu Sharma

Glasgow

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‘FAILED BACK SYNDROME’

Type I-Improper case selection

Type II-Incorrect diagnosis

Type III-Incorrect indication

Type IV-Incorrect level

Type V-Incorrect surgery

Type VI-Iatrogenic

Type VII-Idiosyncratic

Decompression

Fusion

Instrumentation

In tra d u ra l

Stenosis

Discs

Neuralsurgery

Tumour TraumaInfection

Deformity

LowBackPain

LysisListhesis

The Components of Spinal Surgery

Complications of Spinal Surgery

General Mortality Anaesthetic

DVT/PE Chest/urinary

infections Positioning

Local Nerve injury Dural tear Bleeding Infection Pseudarthrosis Instrumentation

Wrong Level

“3 commonest causes of poor result”

• Wrong level

• Wrong level

• Wrong level

[McCullough]

Nerve Root Injury

• <1% of procedures

• Beware wonky anatomy

• Beware previous surgery

Dural Tears

Incidence• Rare in non-decompressive surgery• More common in decompressive

surgery• Discectomy 1-4%• Decompression for stenosis5-10%• Revision decompression 11-20%

Dural Tear

Presentation

• Early

• Late

• Headache, nausea, meningism

• Wound leakage

Dural Tears - Management

Recognition and exposure Repair – Suture, patch, fibrin glue,

continuous wound suture Testing Post-op bed rest, antibiotics

Cauda equina syndrome

• 1:300

• High index of suspicion

Revisiting theatre & recovery

• Clinical

• MRI

BleedingEpidural Bleeding Per-op

• Inflammatory mass

• Controllable with good vision & bipolar

BleedingMajor Vessel Damage

BleedingEpidural Haematoma

• Severe pain

• Varying clinical picture

• Documented neuro-obs mandatory

Infection

Positional

• Meralgia paraesthetica

• Compartment syndrome

• Blindness

MRI

• Recurrent disc

-Border enhancement

-Positive mass effect

• Epidural scar

-Diffuse enhancement

-Negative mass effect

Post-discectomy syndrome

• Epidural scarring

D/D

Recurrent disc prolapse

Inadequate Decompression

Fusion

• Pseudarthrosis

• Implant failure

• Junctional degeneration/deformity

[Fusion disease]

Back Pain / Instability

• Small number of patients have much worse back pain after surgery

• Iatrogenic de-stabilisation

• Type I

• Type II

Other ProblemsPseudarthrosis

Pain Late implant breakage Incidental Difficult to diagnose – X-ray,

tomograms, isotope bone scan, CT, MRI

Treatment – revision, re-grafting

Pedicle ScrewsDegenerative Spondylolisthesis Fracture

Pedicle Screw

Fixation

Non-Instrumented

Pedicle Screw

FixationFracture

Intra-operative events

(2177) (456) (586) (221)

Pedicle fracture

1.2 - 0.2 -

Screw breakout

1 - 0.7 -

Loss of purchase

1.7 - 0.2 -

Implant breakage

0.2 - 0.7 -

Nerve root injury

0.4 - 0.2 -

Spinal cord injury

0.1 - 0.2 -

Vascular injury

0.1 - 0.2 -

Vertebral body penetration

0.3 - 0.7 -

Dural tear by screw

0.1 - 0 -

Dural tear not by screw

7.3 - 11.3 -

Other 1.3 - 0.9 -

Medial Wall

Pedicle Fracture

CausesMalpositionScrew too largeTappingOsteoporosis

ConsequencesReduced holdDural tearNerve root injury

Pedicle Screw Breakage

Short screws

Small screws

Short insertion

Long fusions

Anterior column insufficiency

Implant loosening

Simple OperationPotential Problems

VertebroplastyComplications

Complications relatingCervical spine operations

ComplicationsSummary

• Avoid Pre-op planning

ComplicationsSummary

• Avoid Pre-op planning

ComplicationsSummary

• Avoid Pre-op planning

Careful surgery

ComplicationsSummary

• Avoid Pre-op planning

Careful surgery

• Anticipate

ComplicationsSummary

• Avoid Pre-op planning

Careful surgery

• Anticipate

• Deal with Appropriate kit