Complications in Spine Surgery
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Transcript of Complications in Spine Surgery
Complications Complications in in
Spine SurgerySpine Surgery
G.S. SapkasG.S. Sapkas
1st Orthopaedic Department 1st Orthopaedic Department University Hospital “ATTIKON”University Hospital “ATTIKON”
Medical SchoolMedical SchoolAthens UniversityAthens University
Pre-existing conditions associated with increased Pre-existing conditions associated with increased operative risk or difficulties operative risk or difficulties
I.I. Deformities Deformities • scoliosis,scoliosis,• spondylolysis spondylolysis • spondylisthesisspondylisthesis
I.I. Infections Infections II.II. TumorsTumorsIII.III. OsteoporosisOsteoporosisIV.IV. Pre existing instabilitiesPre existing instabilitiesV.V. Previous Previous
• discectomydiscectomy• laminectomylaminectomy• lumbar fusion lumbar fusion • operated spinal deformity operated spinal deformity
I.I. Inadequate investigationInadequate investigation• Clinical Clinical • Radiological Radiological
Adult degenerative scoliosisAdult degenerative scoliosis& stenosis – neurologic deficit& stenosis – neurologic deficit
DiabetesDiabetes MalignancyMalignancy Tobacco use Tobacco use Obesity Obesity Cardiovascular problemsCardiovascular problems Age ≥ 70 yrsAge ≥ 70 yrs
Pre-operative medical conditions and Pre-operative medical conditions and risk factors are reported to be:risk factors are reported to be:
Cont-ed
Steroid use Steroid use ImmunosuppressionImmunosuppression Myelodysplasia Myelodysplasia Post - radiationPost - radiation
Pre-operative medical conditions and Pre-operative medical conditions and risk factors are reported to be:risk factors are reported to be:
Weinstein MA et al J. Spin. Disord. 2000Weinstein MA et al J. Spin. Disord. 2000O.K.U. A.A.O.S. Spine 2 2002O.K.U. A.A.O.S. Spine 2 2002
Length of pre-operative hospitalization Length of pre-operative hospitalization Revision surgery Revision surgery Duration of surgery Duration of surgery Number of fused segmentsNumber of fused segments Bone graft or methylmethacrylateBone graft or methylmethacrylate Blood loss and transfusionBlood loss and transfusion
Weinstein MA et al J. Spin. Disord. 2000Weinstein MA et al J. Spin. Disord. 2000O.K.U. A.A.O.S. Spine 2 2002O.K.U. A.A.O.S. Spine 2 2002
Pre- and intra-operative riskPre- and intra-operative risk factors are reported to be:factors are reported to be:
Intra-operative causes of complications Intra-operative causes of complications
Hemorrhage Hemorrhage
Facets’ – pedicles’ Facets’ – pedicles’ destructiondestruction
Screws misplacementScrews misplacement
Battered nerve rootsBattered nerve roots
Graft’s quality and quantityGraft’s quality and quantity
Inadequate decompressionInadequate decompression
Facet’s destructionFacet’s destruction
Instability Instability
Pedicle screw Pedicle screw misplacement misplacement
Aorta
Nerve root traction Nerve root traction
The use of instrumentationThe use of instrumentation The type of implantsThe type of implants
SteelSteel TitaniumTitanium Cross linksCross links
Weinstein MA et al J. Spin. Disord. 2000Weinstein MA et al J. Spin. Disord. 2000O.K.U. A.A.O.S. Spine 2 2002O.K.U. A.A.O.S. Spine 2 2002
Intra-Post-operative riskIntra-Post-operative risk factors are reported to be:factors are reported to be:
Early post-operative causes of complicationsEarly post-operative causes of complications (0 – 3 wks) (0 – 3 wks)
HaematomaHaematoma
InfectionInfection
Implants’ failureImplants’ failure
Posteriorly Posteriorly displaced displaced
interbody spacer interbody spacer
1st p. op.
3 yrs p.op
Post radiation Wound dehiscence
Late post-operative causes of complicationsLate post-operative causes of complications(a. 3wks – 3mts)(a. 3wks – 3mts)
Implants’ failureImplants’ failureScrews Screws
loosening loosening
Broken Broken
Dislodged Dislodged
Rods Rods BrokenBroken
Destabilization Destabilization
InfectionInfection
Osteoporosis Osteoporosis
Late Heamatoma Late Heamatoma
Late infectionLate infection
Late infectionLate infection
Osteoporotic Osteoporotic vertebravertebra
Late post-operative causes of complicationsLate post-operative causes of complications(b. > 3mts)(b. > 3mts)
Implants failureImplants failureDestabilizationDestabilization
at the level(s) of the operationat the level(s) of the operationat the level above -//-at the level above -//-at the level below -//-at the level below -//-
Pseudarthrosis Pseudarthrosis Recurrence of stenosis Recurrence of stenosis Late infectionLate infection
Post laminectomy - Facetectomy Post laminectomy - Facetectomy Instability Instability
Screw looseningScrew loosening
Broken rodsBroken rods
Flat back syndromeFlat back syndrome
Extension Flexion
Failure of Adjacent Failure of Adjacent Vertebral SegmentsVertebral Segments
Failure of the cranial Failure of the cranial adjacent segment can adjacent segment can occur occur
acutely as a result of acutely as a result of vertebral body fracture vertebral body fracture
or or as a long term as a long term
complication complication caused by degeneration caused by degeneration of the adjacent motion of the adjacent motion segment.segment.
Tissue reactionsTissue reactionstoto
Spinal implantsSpinal implantsFactors of corrosion Factors of corrosion
1) 1) Combination of different metallic materialsCombination of different metallic materials2) 2) Surfaces’ composition and irregularitySurfaces’ composition and irregularity 3) 3) Micro-movements between the parts of the Micro-movements between the parts of the
spinal instrumentation spinal instrumentation 4) 4) Ions of ClIons of Cl-- from the plasma and from the plasma and
intercellular areaintercellular area5) 5) pHpH6) 6) Different concentration of ODifferent concentration of O22 ions ions
in free and covered metallic areasin free and covered metallic areas
Metal corrosionMetal corrosion galvanic corrosion
different metals
fretting corrosion same metals in micro-movement
crevice corrosion metals in different electrolytic fluids
Galvanic corrosion different metals
Accelerated Accelerated decay due to neighboring of dissimilar metallic decay due to neighboring of dissimilar metallic implants in a corrosiveimplants in a corrosiveelectrolitic invironmentelectrolitic invironmentElectrochemical dissimilarity Electrochemical dissimilarity
It is possible to take placeIt is possible to take placeeven between the same typeeven between the same typeof materials in different end-plate of materials in different end-plate surfacessurfaces
It is common in articulated spinal implantsIt is common in articulated spinal implants
Fretting corrosionFretting corrosion same metals in micro-movement
Ionic debrisIonic debris is additive is additive to the influences to the influences of of particulate debrisparticulate debris and and can have a significant impact on can have a significant impact on local cytotoxicity.local cytotoxicity.
In vitro studies have In vitro studies have shown that these metal shown that these metal particles can be particles can be phagocytizedphagocytized intracellularlyintracellularly leading leading to release of to release of inflammatory cytokinesinflammatory cytokines
Betts F. et al, Clin Orth., 1992Lee JM et al, J.B.J.S. 1992
This inflammatory This inflammatory cascade may lead in cascade may lead in turn to: turn to:
resoption of bone resoption of bone and and
cellular deathcellular death
Hallab NJ, Cunnigham B et al, Spine 2003
The potential The potential for for bonebone resorptionresorption is particularly distressing is particularly distressing in spinal surgery because in spinal surgery because much of the operation’s much of the operation’s success depends on success depends on obtaining obtaining a spinal fusion.a spinal fusion.
The toxic effects The toxic effects of these metal particles of these metal particles also are of great concern also are of great concern because because the the neural elementsneural elements are are widely exposed during widely exposed during spinal decompressions.spinal decompressions.
Although instrumentation is Although instrumentation is
typically left in place in the typically left in place in the
early post-operative period, early post-operative period,
all other foreign bodies suchall other foreign bodies such
as :as :
Bone waxBone wax
Absorbable gelatin spongeAbsorbable gelatin sponge
Must be removedMust be removed
Other Complications Other Complications associated with:associated with:
Anterior Anterior thoracic thoracic spinal spinal
surgerysurgery
Adamkiewicz arteryAdamkiewicz artery
American Journal of Neuroradiology 27:1573-1575, August 2006© 2006 American Society of Neuroradiology
MR Angiography of the Adamkiewicz Artery and Anterior Radiculomedullary Vein: Postmortem Validation
R.J. Nijenhuisa,b, M.J. Jacobsb, J.M.A. van Engelshovena and W.H. Backesa
SUMMARY: Spinal cord arteries and veins are difficult to visualize and distinguish by MR angiographic techniques because of their small sizes, similar spatial course, and close vascular anatomy. Contrast-enhanced MR angiography was demonstrated to dynamically resolve the Adamkiewicz artery from the anterior radiculomedullary vein in the thoracolumbar spinal cord. The location of the Adamkiewicz artery and the anterior radiculomedullary vein could be validated in the postmortem specimen of a thoracoabdominal aortic aneurysm patient.
Posterior Posterior spinal spinal
surgerysurgery
Lumbar stenosisLumbar stenosis
Rupture of Rupture of the meningesthe meninges
Sacral fractureSacral fracture
Meninges ruptureMeninges rupture
CSF leakage
CSF leakage
CSF leakage
Air embolism
Air embolism
Duraseal Duraseal
Cement leakageCement leakageSpinal canalSpinal canalNerve root Nerve root compressioncompression
Vertebroplasty
Spinal canal
Aorta
Treatment optionsTreatment options
Personal Personal communication with communication with
the patient and the patient and relatives in case of relatives in case of
complications complications
Screw reinforcementScrew reinforcementwithwith
methylmethacrylatemethylmethacrylate
Osteoporotic vertebra
Treatment of Treatment of post – operative infectionpost – operative infection
Early and decisive treatment Early and decisive treatment should be initiated on diagnosisshould be initiated on diagnosis
As medical management is As medical management is likely to fail, aggressive surgical likely to fail, aggressive surgical intervention typically is intervention typically is suggested for post-operative suggested for post-operative infectionsinfections
O.K.U. A.A.O.S. Spine 2 2002
Hardware removal Hardware removal
is appropriate:is appropriate: if the instrumentation has if the instrumentation has failed failed
in refractory infections in refractory infections
in cases of late in cases of late hematogenous infection hematogenous infection occurring after a fusion has occurring after a fusion has healed healed
Post laminectomy instabilityPost laminectomy instabilityFlat backFlat back
3636oo stabilizationstabilization
Above Above spondylodesia spondylodesia
instabilityinstabilityExtension of Extension of
spondylodesiaspondylodesia
University Hospital “ATTIKON”