Complications of Spinal Surgery Himanshu Sharma Glasgow

Oops….

‘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

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 [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 stenosis 5-10% 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

Bleeding Epidural Bleeding Per-op Inflammatory mass Controllable with good vision & bipolar

Bleeding Major Vessel Damage

Bleeding Epidural 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 Problems Pseudarthrosis Pain Late implant breakage Incidental Difficult to diagnose – X-ray, tomograms, isotope bone scan, CT, MRI Treatment – revision, re-grafting

Pedicle Screws

Medial Wall

Pedicle Fracture Causes Malposition Screw too large Tapping Osteoporosis Consequences Reduced hold Dural tear Nerve root injury

Pedicle Screw Breakage Short screws Small screws Short insertion Long fusions Anterior column insufficiency

Implant loosening

Simple Operation Potential Problems

Vertebroplasty Complications

Complications relating Cervical spine operations

Complications Summary Avoid Pre-op planning

Complications Summary Avoid Pre-op planning

Complications Summary Avoid Pre-op planning Careful surgery

Complications Summary Avoid Pre-op planning Careful surgery Anticipate

Complications Summary Avoid Pre-op planning Careful surgery Anticipate Deal with Appropriate kit