Postoperative spine complications

[Imaging Evaluation of Early and Long-Term Complications Associated with the Postoperative Spine]

As the number of spinal surgeries being performed expands, the number of medical imaging procedures such as radiography, CT, and MRI is also increasing, and the importance of their interpretation is becoming more significant. Herein, we present the radiological findings of a variety of complications that can occur after spinal surgery and discuss how effectively and accurately they can be diagnosed through imaging. In particular, this study details the characteristic imaging findings specific to the early and long-term postoperative periods. Early complications of spinal surgery include improper placement of surgical instruments (instrument malpositioning), seromas, hematomas, pseudomeningoceles, and infections in the region surrounding the surgical site. Conversely, long-term complications may include osteolysis around surgical instruments, failure of fusion, adjacent segment disease, and the formation of epidural fibrosis or scar tissue. A precise understanding of the imaging assessments related to complications arising after spinal surgery is crucial to ensure timely and accurate diagnosis, which is necessary to achieve effective treatment.

Complications Have Not Improved With Newer Generation Robots

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to see whether upgrades in newer generation robots improve safety and clinical outcomes following spine surgery.

METHODS

All patients undergoing robotic-assisted spine surgery with the Mazor X Stealth EditionTM (Medtronic, Minneapolis, MN) from 2019 to 2022 at a combined orthopedic and neurosurgical spine service were retrospectively reviewed. Robot related complications were recorded.

RESULTS

264 consecutive patients (54.1% female; age at time of surgery 63.5 ± 15.3 years) operated on by 14 surgeons were analyzed. The average number of instrumented levels with robotics was 4.2 ± 2.7, while the average number of instrumented screws with robotics was 8.3 ± 5.3. There was a nearly 50/50 split between an open and minimally invasive approach. Six patients (2.2%) had robot related complications. Three patients had temporary nerve root injuries from misplaced screws that required reoperation, one patient had a permanent motor deficit from the tap damaging the L1 and L2 nerve roots, one patient had a durotomy from a misplaced screw that required laminectomy and intra-operative repair, and one patient had a temporary sensory L5 nerve root injury from a drill. Half of these complications (3/6) were due to a reference frame error. In total, four patients (1.5%) required reoperation to fix 10 misplaced screws.

CONCLUSION

Despite newer generation robots, robot related complications are not decreasing. As half the robot related complications result from reference frame errors, this is an opportunity for improvement.

A C-Arm-Free Minimally Invasive Technique for Spinal Surgery: Cervical and Thoracic Spine

Background and Objectives: C-arm-free MIS techniques can offer significantly reduced rates of postoperative complications such as inadequate decompression, blood loss, and instrumentation misplacement. Another advantageous long-term aspect is the notably diminished exposure to radiation, which is known to cause malignant changes. This study emphasizes that, in some cases of spinal conditions that require a procedural intervention, C-arm-free MIS techniques hold stronger indications than open surgeries guided by image intensifiers. Materials and Methods: This study includes a retrospective analysis and review of various cervical and thoracic spinal procedures, performed in our hospital, applying C-arm-free techniques. The course of this study explains the basic steps of the procedures and demonstrates postoperative and intraoperative results. For anterior cervical surgery, we performed OPLL resection, while for posterior cervical surgery, we performed posterior fossa decompression for Chiari malformation, minimally invasive cervical pedicle screw fixation (MICEPS), and modified Goel technique with C1 lateral mass screw for atlantoaxial subluxation. Regarding the thoracic spine, we performed anterior correction for Lenke type 5 scoliosis and transdiscal screw fixation for diffuse idiopathic skeletal hyperostosis fractures. Results: C-arm-free techniques are safe procedures that provide precise and high-quality postoperative results by offering sufficient spine alignment and adequate decompression depending on the case. Navigation can offer significant assistance in the absence of normal anatomical landmarks, yet the surgeon should always appraise the quality of the information received from the software. Conclusions: Navigated C-arm-free techniques are safe and precise procedures implemented in the treatment of surgically demanding conditions. They can significantly increase accuracy while decreasing operative time. They represent the advancement in the field of spine surgery and are hailed as the future of the same.

Robotic and navigated pedicle screws are safer and more accurate than fluoroscopic freehand screws: a systematic review and meta-analysis

BACKGROUND CONTEXT

Navigated and robotic pedicle screw placement systems have been developed to improve the accuracy of screw placement. However, the literature comparing the safety and accuracy of robotic and navigated screw placement with fluoroscopic freehand screw placement in thoracolumbar spine surgery has been limited.

PURPOSE

To perform a systematic review and meta-analysis of randomized control trials that compared the accuracy and safety profiles of robotic and navigated pedicle screws with fluoroscopic freehand pedicle screws.

STUDY DESIGN/SETTING

Systematic review and meta-analysis PATIENT SAMPLE: Only randomized controlled trials comparing robotic-assisted or navigated pedicle screws placement with freehand pedicle screw placement in the thoracolumbar spine were included.

OUTCOME MEASURES

Odds ratio (OR) estimates for screw accuracy according to the Gertzbein-Robbins scale and relative risk (RR) for various surgical complications.

METHODS

We systematically searched PubMed and EMBASE for English-language studies from inception through April 7, 2022, including references of eligible articles. The search was conducted according to PRISMA guidelines. Two reviewers conducted a full abstraction of all data, and one reviewer verified accuracy. Information was extracted on study design, quality, bias, participants, and risk estimates. Data and estimates were pooled using the Mantel-Haenszel method for random-effects meta-analysis.

RESULTS

A total of 14 papers encompassing 12 randomized controlled trials were identified (n=892 patients, 4,046 screws). The pooled analysis demonstrated that robotic and navigated pedicle screw placement techniques were associated with higher odds of screw accuracy (OR 2.66, 95% CI 1.24-5.72, p=.01). Robotic and navigated screw placement was associated with a lower risk of facet joint violations (RR 0.09, 95% CI 0.02-0.38, p<.01) and major complications (RR 0.31, 95% CI 0.11-0.84, p=.02). There were no observed differences between groups in nerve root injury (RR 0.50, 95% CI 0.11-2.30, p=.37), or return to operating room for screw revision (RR 0.28, 95% CI 0.07-1.13, p=.07).

CONCLUSIONS

These estimates suggest that robotic and navigated screw placement techniques are associated with higher odds of screw accuracy and superior safety profile compared with fluoroscopic freehand techniques. Additional randomized controlled trials will be needed to further validate these findings.

Anterior cervical discectomy and fusion, open-door laminoplasty, or laminectomy with fusion: Which is the better treatment for four-level cervical spondylotic myelopathy?

Four-level cervical spondylotic myelopathy (CSM) is a common disease affecting a large number of people, with the optimal surgical strategy remaining controversial. This study compared the clinical outcomes, radiological parameters, and postoperative complications of primarily performed surgical procedures such as anterior cervical discectomy and fusion (ACDF), open-door laminoplasty (LAMP), and laminectomy with fusion (LF) in treating four-level CSM. A total of 116 patients who received ACDF (38 cases), LAMP (45 cases), and LF (33 cases) were followed up for a minimum of 24 months were enrolled in this study and retrospectively analyzed. Clinical outcomes were evaluated using the Japanese Orthopedic Association (JOA) scoring system, the Neck Disability Index (NDI), and the Visual Analogue Scale (VAS). Changes in the curvature of the cervical spine were determined using the cervical curvature index (CCI) and the C2-C7 Cobb angle. Cervical mobility was evaluated using the C2-C7 range of motion (ROM) and active cervical ROM (aROM). Complications were recorded and compared among the three groups. All patients achieved significant improvement in JOA, NDI, and VAS scores at the final follow-up (P < 0.05), whereas no remarkable difference was found among the groups (P > 0.05). In addition, both C2-7 ROM and aROM were significantly reduced in the three groups and LAMP showed the least reduction relatively. As for complications, LAMP showed the lowest overall incidence of postoperative complications, and patients in the ACDF group were more susceptible to dysphagia, pseudoarthrosis than LAMP and LF. Considering improvements in clinical symptoms and neurological function, no remarkable difference was found among the groups. Nevertheless, LAMP had advantages over the other two surgical procedures in terms of preserving cervical mobility and reducing postoperative complications.

Wrong-Level Spine Surgery: Introduction of a Protocol for Avoidance of This Complication

Wrong-level spine surgery, in which an operation is performed at a vertebral level different from the intended one, is a rare but serious complication with wide-ranging medical and legal effects. Although many protocols have been developed to prevent such a serious unfavorable event, the problem has not yet been eliminated. Research into the effectiveness of strategies to prevent wrong-level spine surgery is lacking. Herein, we describe a case of 44-year-old woman presented with neck pain and bilateral upper extremity weakness and numbness. Magnetic resonance imaging showed C5/6 and C6/7 disc herniations with spinal cord compression. The patient underwent anterior cervical discectomy and fusion; however, at the conclusion of the surgery, intraoperative radiographs showed that it was accomplished at C4/5 and C5/6-one level above the intended level. On the basis of this case and similar ones, a new protocol was developed that included implementation of a Spine Level Safety Checklist to document the reference point, the landmark, and the level of exposure that is marked on the intraoperative radiograph. Since implementation of this protocol, the incidence of wrong-level spine surgery at the senior author's institution has decreased from 4/7000 to 0/11,200. Adoption of this protocol by other centers is thus recommended to reduce the incidence of such complication.

Development of Acute Inflammatory Demyelinating Polyneuropathy 11 Days after Spinal Surgery: A Case Report and Literature Review

Guillain–Barré syndrome (GBS) usually has a good prognosis; however, patients may develop sequelae without prompt treatment. We herein describe an 81-year-old woman who developed acute-onset excruciating thigh pain and weakness in her lower extremities after spinal surgery. We diagnosed acute inflammatory demyelinating polyradiculoneuropathy by a nerve conduction study, which showed findings of demyelination without cerebrospinal fluid analysis because of a spinal prosthesis. Although anti-GM1 and anti-GalNAc-GD1a antibodies were positive, the patient was clinically diagnosed with acute inflammatory demyelinating polyradiculoneuropathy (a subtype of GBS), not acute motor axonal neuropathy. She recovered well with immunoglobulin therapy. A literature review of 18 cases revealed that unexplained weakness, areflexia, and numbness of the extremities after spinal surgery, a shorter time from spinal surgery to symptom onset to general GBS, abnormal nerve conduction study results, normal spinal imaging findings, and the development of atypical symptoms such as cranial and autonomic nerve syndrome and respiratory failure are useful for diagnosing GBS when cerebrospinal fluid examination cannot be performed after spinal surgery.

Severe lumbar spinal stenosis combined with Guillain-Barré syndrome: A case report

BACKGROUND

Guillain-Barré syndrome (GBS) is a rare disorder that typically presents with ascending weakness, pain, paraesthesias, and numbness, which mimic the findings in lumbar spinal stenosis. Here, we report a case of severe lumbar spinal stenosis combined with GBS.

CASE SUMMARY

A 70-year-old man with a history of lumbar spinal stenosis presented to our emergency department with severe lower back pain and lower extremity numbness. Magnetic resonance imaging confirmed the diagnosis of severe lumbar spinal stenosis. However, his symptoms did not improve postoperatively and he developed dysphagia and upper extremity numbness. An electromyogram was performed. Based on his symptoms, physical examination, and electromyogram, he was diagnosed with GBS. After 5 d of intravenous immunoglobulin (0.4 g/kg/d for 5 d) therapy, he gained 4/5 of strength in his upper and lower extremities and denied paraesthesias. He had regained 5/5 of strength in his extremities when he was discharged and had no symptoms during follow-up.

CONCLUSION

GBS should be considered in the differential diagnosis of spinal disorder, even though magnetic resonance imaging shows severe lumbar spinal stenosis. This case highlights the importance of a careful diagnosis when a patient has a history of a disease and comes to the hospital with the same or similar symptoms.

Effect of change in preoperative depression/anxiety on patient outcomes following lumbar spine surgery

OBJECTIVE

The purpose of this study was to investigate the association between positive change in depression or anxiety within three months post-operation and clinically meaningful changes in long-term clinical outcomes after lumbar spine surgery.

METHODS

This study included adults with preoperative diagnosis of depression or anxiety who underwent lumbar spine surgery in the Quality Outcomes Database (QOD) from 2012 to 2018 with either a 12- or 24-month follow-up. Positive change in depression and anxiety was assessed three months after surgery. Clinical outcomes measured included Numeric Rating Scale (NRS) score for back pain (BP) and leg pain (LP), Oswestry Disability Index score (ODI) for disability, EuroQol Visual Analog Scale score (EQ-VAS) for health-related quality of life (HRQOL), and North American Spine Surgery (NASS) index score for patient satiaction measured at 12- and 24 months after surgery.

RESULTS

Of the 9,656 and 1,393 patients who were included in the 12- and 24-month cohort, respectively, 7,277 patients (75.4 %) and 1,089 (78.2 %) experienced a positive change in depression or anxiety within three months after surgery. At both 12- and 24-month follow-up, patients who had positive change in depression or anxiety were more likely to achieve minimal clinically important changes in NRS-BP/LP, ODI, EQ-VAS, and NASS (all p < 0.01) compared to those who did not experience improvement in depression or anxiety.

CONCLUSION

Depression and anxiety are important comorbidities to consider in patients undergoing lumbar spine surgery. Positive change in depression and anxiety are associated with improvements in pain, disability, satisfaction, and overall functioning.

Postoperative Guillain-Barré Syndrome, a Neurologic Complication that Must Not Be Overlooked: A Literature Review

BACKGROUND

Guillain-Barré syndrome (GBS) is an uncommon, yet life-threatening postoperative neuropathic complication that is easily neglected, and hence, timely treatment is not provided in the clinics. This review aims to summarize the clinical features of postoperative GBS, and thus, improve the understanding of postoperative GBS.

METHODS

We reviewed the literature on postoperative GBS and assessed the demographic information, clinical manifestation, operation, time of onset of postoperative GBS, and prognosis.

RESULTS

A total of 33 cases of postoperative GBS were included in this study. The average age of patients with postoperative GBS was 46.9 years, and there was a peak in occurrence of GBS between ages 50 and 70 years. Men seemed more likely to have postoperative GBS than did women, with a ratio of 2.67:1. Progressive muscular weakness, present in 31 of the cases, was the most common presentation. Patients with spinal surgery were at further increased risk for GBS, and 84.8% of the patients with GBS had a good prognosis after prompt treatment.

CONCLUSIONS

Surgery is probably a potential risk factor for the occurrence of GBS. Early diagnosis and prompt treatment are imperative to reduce mortality.

Neural Mobilization in a 54-Year-Old Woman With Postoperative Spinal Adhesive Arachnoiditis

OBJECTIVE

This case report describes the clinical features, complications, imaging characteristics, and management of postoperative spinal adhesive arachnoiditis.

CLINICAL FEATURES

A 54-year-old woman presented with right posterior thigh and leg pain after a lumbar spine fusion surgery to correct a degenerative spondylolisthesis of L3/4. Her pain was sharp and shooting and worsened with knee extension. A lumbar computed tomography myelogram demonstrated clumping and adhesion of the nerve rootlets in the cauda equina at the surgical fusion levels. Findings were consistent with spinal arachnoiditis.

INTERVENTION AND OUTCOME

The patient was treated with 2 sets of neural mobilization of the sciatic nerve with 15 repetitions each. Treatment was provided 2× per week for 3 weeks. The patient used the neural mobilization exercises at home and performed to tolerance. The patient's Oswestry Questionnaire was reduced significantly by 19% with decreased pain intensity of 2 points on the verbal analogue scale.

CONCLUSION

Neural mobilization was used successfully in the management of a patient with postoperative spinal arachnoiditis.

Anterior cervical discectomy and fusion: review and update for radiologists

OBJECTIVES

The goals of this article are to describe the various types of interbody grafts and anterior cervical plating systems, techniques for optimizing evaluation of cervical spine metallic implants on CT and MR imaging, expected appearance and complications of ACDF on postoperative imaging and imaging assessment of fusion. Optimization for optimizing metal induced artifacts.

CONCLUSION

Currently, ACDF is the most commonly performed surgical procedure for degenerative cervical spine disease. Interbody fusion is performed with bone grafts or interbody spacers, and may be supplemented with anterior cervical plating. Compressive pathologies at the vertebral body level may be addressed by simultaneous corpectomy. Postoperatively, imaging plays an integral role in routine screening of asymptomatic individuals, fusion assessment and evaluation of complications.

Guillain-Barré Syndrome After Elective Spinal Surgery

Guillain-Barré syndrome is a rare autoimmune condition characterized by ascending motor weakness of the extremities that can ascend to the diaphragm, causing substantial morbidity and mortality. This case report describes a 57-year-old man who exhibited characteristics of Guillain-Barré syndrome 9 days after undergoing lumbar fusion at L3-S1. The diagnosis was based on the patient's ascending motor weakness and areflexia and was confirmed with electromyography. The patient progressed to respiratory failure, requiring mechanical ventilation. He regained motor function and ambulation within 6 months. Although the syndrome typically manifests initially as ascending paralysis, this patient's initial symptom was new-onset atrial fibrillation, a sign of autonomic dysfunction. Because it can cause paralysis and respiratory failure, Guillain-Barré syndrome should be included in the differential diagnosis whenever motor weakness is observed after lumbar surgery. The timing of symptoms, imaging results, and the development of atypical symptoms can help distinguish this rare possibility from other postoperative spinal complications.

Neuroimaging of the Postoperative Spine

Operative treatments of the spine are becoming increasingly more common for the availability of a wide range of surgical and minimally invasive procedures. MR imaging allows for excellent evaluation of both normal and abnormal findings in the postoperative spine. This article provides the basic tools to evaluate complications after different operative procedures and offers an overview on the main topics a radiologist may encounter during his or her professional carrier.

Imaging of post-surgical treatment and of related complications in spinal trauma

Spinal trauma is a devastating event with a high morbidity and mortality. The rationale of imaging is to diagnose the traumatic abnormalities and characterize the type of injury, to estimate the severity of the lesions, to evaluate the potential spinal instability. In case of spinal instability, the goals of operative treatment are decompression of the spinal cord canal and stabilization of the disrupted vertebral column. Particularly, diagnostic imaging, mainly by CT and MR, has a main role in the post-treatment evaluation. The neuroradiological evaluation of the postoperative spine requires a general knowledge of the surgical approach to each spinal region and of the normal temporal evolution of expected postoperative changes. The neuroradiologist should evaluate the devices implanted, their related complications and promptly alert the surgeon of acute complications, mainly vascular and infective. During the follow-up, it is mandatory to know and search chronic complications as pseudomeningocele, accelerated degenerative disease, arachnoiditis, peridural fibrosis. Knowledge of specific complications relating to each surgical approach will assist the neuroradiologist in interpretation of postoperative images.

Decompressive Laminectomy Complicated by Postoperative Mycoplasma hominis Epidural Abscess and Meningitis in a Young Woman: A Case Report

CASE

A twenty-eight-year-old woman underwent decompressive laminectomy and placement of an interlaminar stabilizer due to L4/L5 disc herniation. Thirteen days later she developed a fever unresponsive to meropenem and vancomycin, along with signs of meningitis. A Mycoplasma hominis epidural abscess was identified. She had no preoperative risk factors for extragenital M. hominis infection, but had had a urinary catheter inserted intraoperatively.

CONCLUSION

M. hominis postoperative surgical site infection is a rarely identified complication of spinal surgery. Seeding from the genitourinary tract is the most likely source.

Imaging of lumbar spinal surgery complications

Abstract

Lumbar spine surgery for spinal stenosis is a frequently performed procedure and was the fastest growing type of surgery in the US from 1980 to 2000. With increasing surgical invasiveness, postoperative complications also tend to be higher. Cross-sectional imaging techniques (CT and MRI) are more sensitive than radiographs and play an increasingly important role in evaluation of patients with lumbar spine surgery. Their use in patients with metallic implants is somewhat limited by artefacts, which can obscure pathology and decrease accuracy and reader confidence. Metal artefact reduction techniques have been developed, which can significantly improve image quality and enable early detection of postoperative complications. Complications can occur throughout postoperative course. Early complications include hardware displacement, incidental durotomy, postoperative collections—most commonly seroma, and less likely haematoma and/or infection. Incidental durotomy with CSF leak causing intracranial hypotension has characteristic MR brain findings and diagnosis of occult leak sites have been improved with use of dynamic CT myelography. Haematomas, even when compressing the thecal sac, are usually asymptomatic. Early infection, with nonspecific MR findings, can be diagnosed accurately using dual radiotracer studies. Delayed complications include loosening, hardware failure, symptomatic new or recurrent disc herniation, peri-/epidural fibrosis, arachnoiditis, and radiculitis.

Teaching Points

• CT and MRI play an increasingly important role in evaluation of patients with lumbar spine surgery

• Complications can occur throughout the postoperative course and early detection is critical

• Artefact reduction techniques can improve image quality for early and improved detection of complications

A Rare Complication of Spine Surgery: Guillain-Barré Syndrome

OBJECTIVE

Since little has been reported about Guillain-Barré syndrome (GBS) after spine surgery, we sought to determine some of the clinical features and the management of the condition.

METHODS

A total of 4 cases of GBS after spine surgery were included. The medical charts of the patients were reviewed to obtain demographic and clinical details. All the patients underwent neurologic and electrophysiologic examinations and were followed up after surgery.

RESULTS

The onset of symptoms about GBS was 2-7 days after the operation. Neurologic evaluation showed weaknesses of upper and lower extremities and repeal of tendon reflexes. The patients exhibited typical clinical symptoms and signs of GBS and electromyographic findings. Lumbar puncture was performed in 2 cases, and cerebrospinal fluid examination showed albuminocytological dissociation. All the 4 patients were diagnosed as GBS on the basis of typical clinical, laboratory, and electrophysiologic findings. Intravenous immunoglobulin was instituted. At follow-up, one patient needed ventilator support; one patient could transfer from bed to chair; one walked with assistive devices; and the remaining patient had residual minor neurologic deficits.

CONCLUSIONS

These cases warn surgeons to be alert to the association of GBS and spine surgery. On the basis of our experience, we recommend consideration of this rare diagnosis in patients with paralysis after spine surgery.