1. General Complications after Spine Surgeryby
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

2. Clavien- Dindo Classification of Surgical Complications

3. Classification of complications in spine surgery

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

5. 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

6. 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

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

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

9. 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%).

10. Ophthalmological Complications

11. Positioning complications and risk factors

12. Positioning complications and risk factors

13. 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

14. 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)

15. 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

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

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

18. Hardware Complications
Diathermy
Frame
Gardner- Wells Tongs
Suction

19. 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

20. Thanks