complications of spinal surgery himanshu sharma glasgow
TRANSCRIPT
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Complications of Spinal Surgery
Himanshu Sharma
Glasgow
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Oops….
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‘FAILED BACK SYNDROME’
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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
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Decompression
Fusion
Instrumentation
In tra d u ra l
Stenosis
Discs
Neuralsurgery
Tumour TraumaInfection
Deformity
LowBackPain
LysisListhesis
The Components of Spinal Surgery
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Complications of Spinal Surgery
General Mortality Anaesthetic
DVT/PE Chest/urinary
infections Positioning
Local Nerve injury Dural tear Bleeding Infection Pseudarthrosis Instrumentation
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Wrong Level
“3 commonest causes of poor result”
• Wrong level
• Wrong level
• Wrong level
[McCullough]
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Nerve Root Injury
• <1% of procedures
• Beware wonky anatomy
• Beware previous surgery
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Dural Tears
Incidence• Rare in non-decompressive surgery• More common in decompressive
surgery• Discectomy 1-4%• Decompression for stenosis5-10%• Revision decompression 11-20%
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Dural Tear
Presentation
• Early
• Late
• Headache, nausea, meningism
• Wound leakage
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Dural Tears - Management
Recognition and exposure Repair – Suture, patch, fibrin glue,
continuous wound suture Testing Post-op bed rest, antibiotics
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Cauda equina syndrome
• 1:300
• High index of suspicion
Revisiting theatre & recovery
• Clinical
• MRI
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BleedingEpidural Bleeding Per-op
• Inflammatory mass
• Controllable with good vision & bipolar
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BleedingMajor Vessel Damage
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BleedingEpidural Haematoma
• Severe pain
• Varying clinical picture
• Documented neuro-obs mandatory
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Infection
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Positional
• Meralgia paraesthetica
• Compartment syndrome
• Blindness
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MRI
• Recurrent disc
-Border enhancement
-Positive mass effect
• Epidural scar
-Diffuse enhancement
-Negative mass effect
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Post-discectomy syndrome
• Epidural scarring
D/D
Recurrent disc prolapse
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Inadequate Decompression
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Fusion
• Pseudarthrosis
• Implant failure
• Junctional degeneration/deformity
[Fusion disease]
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Back Pain / Instability
• Small number of patients have much worse back pain after surgery
• Iatrogenic de-stabilisation
• Type I
• Type II
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Other ProblemsPseudarthrosis
Pain Late implant breakage Incidental Difficult to diagnose – X-ray,
tomograms, isotope bone scan, CT, MRI
Treatment – revision, re-grafting
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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 -
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Medial Wall
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Pedicle Fracture
CausesMalpositionScrew too largeTappingOsteoporosis
ConsequencesReduced holdDural tearNerve root injury
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Pedicle Screw Breakage
Short screws
Small screws
Short insertion
Long fusions
Anterior column insufficiency
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Implant loosening
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Simple OperationPotential Problems
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VertebroplastyComplications
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Complications relatingCervical spine operations
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ComplicationsSummary
• Avoid Pre-op planning
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ComplicationsSummary
• Avoid Pre-op planning
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ComplicationsSummary
• Avoid Pre-op planning
Careful surgery
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ComplicationsSummary
• Avoid Pre-op planning
Careful surgery
• Anticipate
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ComplicationsSummary
• Avoid Pre-op planning
Careful surgery
• Anticipate
• Deal with Appropriate kit
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