Complications of Spinal Surgery

1. Complications of Spinal Surgery Himanshu Sharma Glasgow

3. Oops….

4. ‘FAILED BACK SYNDROME’

5. 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

7. General Mortality Anaesthetic DVT/PE Chest/urinary infections Positioning Local Nerve injury Dural tear Bleeding Infection Pseudarthrosis Instrumentation Complications of Spinal Surgery

8. Wrong Level “3 commonest causes of poor result” • Wrong level • Wrong level • Wrong level [McCullough]

9. Nerve Root Injury • <1% of procedures • Beware wonky anatomy • Beware previous surgery

10. 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%

11. Dural Tear Presentation • Early • Late • Headache, nausea, meningism • Wound leakage

14. Dural Tears - Management • Recognition and exposure • Repair – Suture, patch, fibrin glue, continuous wound suture • Testing • Post-op bed rest, antibiotics

15. Cauda equina syndrome • 1:300 • High index of suspicion Revisiting theatre & recovery • Clinical • MRI

16. BleedingEpidural Bleeding Per-op • Inflammatory mass • Controllable with good vision & bipolar

17. BleedingMajor Vessel Damage

18. BleedingEpidural Haematoma • Severe pain • Varying clinical picture • Documented neuro-obs mandatory

19. Infection

20. Positional • Meralgia paraesthetica • Compartment syndrome • Blindness

21. Recurrent disc -Border enhancement -Positive mass effect Epidural scar -Diffuse enhancement -Negative mass effect MRI

22. Post-discectomy syndrome • Epidural scarring D/D Recurrent disc prolapse

25. Inadequate Decompression

26. Fusion • Pseudarthrosis • Implant failure • Junctional degeneration/deformity [Fusion disease]

27. Back Pain / Instability • Small number of patients have much worse back pain after surgery • Iatrogenic de-stabilisation • Type I • Type II

28. Other ProblemsPseudarthrosis • Pain • Late implant breakage • Incidental • Difficult to diagnose – X-ray, tomograms, isotope bone scan, CT, MRI • Treatment – revision, re-grafting

29. Pedicle Screws

32. Medial Wall

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

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

35. Implant loosening

36. Simple OperationPotential Problems

37. VertebroplastyComplications

39. Complications relatingCervical spine operations

40. ComplicationsSummary • Avoid Pre-op planning

41. ComplicationsSummary • Avoid Pre-op planning

42. ComplicationsSummary • Avoid Pre-op planning Careful surgery

43. ComplicationsSummary • Avoid Pre-op planning Careful surgery • Anticipate

44. ComplicationsSummary • Avoid Pre-op planning Careful surgery • Anticipate • Deal with Appropriate kit