General Complications after Spine Surgery by Tariq Elemam Elshafey Awad Assist. Prof. of Neurosurgery & Spine Surgery Suez Canal University Periodic meeting of Egyptian Spine Association – Kasr Eleini LRC 21th April 2016

Clavien- Dindo Classification of Surgical Complications

Classification of complications in spine surgery

Anaesthesia Complications Drugs - hypersensitivity (antibiotic, blood) Complications with blood transfusion Spinal anesthesia in the prone position Controlled Hypotensive Anaesthesia

Controlled Hypotensive Anaesthesia ( more likely in pt with anaemia) Cerebral thrombosis Hemiplegia Acute tubular necrosis Massive hepatic necrosis Myocardial infarction Cardiac arrest Blindness from retinal artery thrombosis or ischemic optic neuropathy

Postoperative Airway Compromise Airway oedema Duration of surgery Amount of blood transfusion Smoking Obesity airway pressure Operations of greater than 4 cervical levels or involving C2

Pulmonary Complications adult respiratory distress syndrome (3%) pneumonitis atelectasis infection Pleural effusion

CNS Complications CVS POVL Symptomatic pneumocephalus associated with lumbar dural tear Postoperative meningitis Guillain-Barré Syndrome.

Post-operative visual loss (POVL) Ophthalmological Complications Post-operative visual loss (POVL) ( more likely in pt with anaemia) rare but devastating complication 1/1100 after prone spinal surgery Causes: Ischemic optic neuropathy (ION) (81%) Central retinal artery occlusion (13%) Unknown diagnosis (6%).

Ophthalmological Complications

Positioning complications and risk factors

Positioning complications and risk factors

THROMBOEMBOLISM IN SPINE SURGERY Deep-vein thrombosis (DVT) pulmonary embolism cardiac arrest cerebral infarction 1. long operating times 2. prolonged bed rest pre- and/or post-op 3. paralyzed limbs 4. alterations in coagulation status A. in patients with spine injury 1. related to the condition itself 2. due to release of thromboplastins during surgery B. increased blood viscosity with concomitant "sludging" 1. from dehydration 2. from volume loss C. use of high-dose glucocorticoids

PROPHYLAXIS AGAINST DVT 1. general measures A. passive ROM B. ambulation as early as possible 2. mechanical techniques (minimal risk of complications): A. pneumatic compression boots (PCBs) or sequential compression devices (SCDs): Do not use if DVTs already present. B. TED Stockings: (TEDS) applies graduated pressure, higher distally. avoid a tourniquet effect at the proximal end C. electrical stimulation of calf muscles D. rotating beds 3. anticoagulation A. full anticoagulation is associated with perioperative complications B. "low-dose" anticoagulation48 (low-dose heparin): 5000 IU SQ q 8 or 12 hrs, starting 2 hrs pre-op or on admission to hospital. Potential for hazardous hemorrhage within brain or spinal canal has limited its use C. LMWH: D. aspirin: 4. combination of PCBs and "mini-dose" heparin starting on the morning of post-op day 1 (no evidence of significant complications)

PROPHYLAXIS AGAINST DVT Risk factor Points Risk Factor score Level of risk DVT incidence (without prophylaxis) Recommendation Overweight and obese (BMI > 25) 1 0-1 Low 2% NO Age 41–60 years 2 Moderate 10%-20% PCB/ TEDs Age 61–75 years 3-4 High risk 20%- 40% Mini dose heparin Confined to bed > 72 h 5+ highest 40%-80% +  Mini dose heparin Malignancy within 5 y   Major surgery (> 45 min) Age > 75 y 3 History of DVT Spinal injury/paraplegia 5

Gastrointestinal Complications Stress ulceration Acute Intestinal Pseudo-Obstruction (Ogilvie's Syndrome) abdominal organ dysfunction possibly because of compromised blood flow (hepatic or pancreatic dysfunction 

Psychological Complications PTSD (20%) Depression (Goals overestimation)

Hardware Complications Diathermy Frame Gardner- Wells Tongs Suction

Conclusions operative time restriction as much as possible Use Controlled hypotensive anaesthesia in selected patients only Thromboembolic prophylaxix is a must in moderate & high risk patients Careful patient positioning (prone complications) Pre-op planning & Careful surgery Anticipate

Thanks