Anterior Approach Burn s Space Esophagus

Transcription

1 Cervical Complications Complications after Cervical Spine Surgery Dr. Rock Patel University of Michigan, Ann Arbor APPROACH RELATED Anterior Posterior PROCEDURE RELATED ACDF Disc Arthroplasty Laminectomy/Fusion Foraminotomy Laminaplasty Anterior Cervical Surgery (Uncinate Process) Anterior Approach Burn s Space Esophagus Sympathetic Trunk Hyoid Thyroid Cartilage Cricoid Cartilage

2 Cricothyroid m Voice fatigue Hoarseness More commonly Non recurrent Intraoperative Esophageal Injury Vertebral Artery Injury Dural Tear Spinal Cord Injury Peripheral Nerve Injury Postoperative Airway Compromise Dysphagia Dysphonia Wound Infection Causes Retractor Placement Direct Injury with Instrument Hardwear Complications Esophageal Injury Esophageal Injury Horners Rare Injuries.2.4% (Orlando et al, Spine 2003) Ideally Recognized Intraoperatively (Indigo Carmine, Direct Visualization, Endoscopy) Can lead to mediastinal infection Late Signs: Fever, Dysphagia, Swelling, TTP Radiographys: Air Edema Mortality 20% w/i 24 hr 50% delayed Horners Ptosis, Miosis, Anhydrosis

3 Low Rate.3% (Burke et al., Spine 2005) Causes Include Loss of Orientation Aberent VA Anatomy 2.7% (Curylo et al, Spine 2000) Avoidable Study pre op s Proper technique What to do? Acute control Primary repair Graft Stent Vertebral Artery 3.7% Incidence (Emery et al. JBJS 1998) Occurs in revision cases and OPLL Position patient upright and consider lumbar drain Caution! Watch the airway! Dural Tears Rare <1% Patients with Myelopathy and Cervical Kyphosis are predisposed MEPs SSEPs (Hilibrand, JBJS 2004) MAP>80 Steroids? Spinal Cord Injury <1% incidence Tracheal Injury Use proper planes and keep retractor blades beneath longus coli Tracheal Injury Airway Compromise Rates of Reintubation ( %) Causes for Airway Compromise Hematoma CSF Hardware Soft Tissue Swelling BMP Obesity Surgical Time >5 hours More than 3 Levels Exposed (Epstein J Neurosurg 2001, Sagi Spine 2002)

4 Dysphagia Dysphagia The Most Common 5 50% CSRS study group: 3 mos 6 mos 2 yrs Risk Factors Multilevel surgery Female Pre op dysphagia Use of plates (1.6x) Cranial levels Advanced Age Plate malposition Swallowing Pharyngeal Plexus (C2 C5) Hypoglossal Nerve (Above C3) Superior Laryngeal Nerve (C3 4) Recurrent Laryngeal Nerve (C5 T1) Recurrent laryngeal nerve injury (1 7%) Dysphonia LEFT or RIGHT side: Does it matter? Be facile with both sides Deflate/Inflate ET cuff: RLN palsy dropped from 6.8 to 2.0% Apfelbaum/Kiscovich 2000 NO! 2 30% Upto 2.5% Persistent Dysphonia Causes SLN injury RLN injury Direct Cord Trauma (Intubation) Laryngeal Edema Other Complications Wound Infection.2 1.6% Anterior Cervical Fusion Graft Related complications - Corpectomy(7-20%) Pseudoarthrosis (11-40%) Esophageal Injury Permanent speech and swallowing issues Vertebral Artery Injury Airway Obstruction Adjacent Segment Disease Prolonged Immoblization-3 months Death

5 Graft Dislodgement Riew et al., pts treated with cervical corpectomy/plate fixation 1-Complete Graft Extrusion 1-Plate dislodgement despite Ant/Post 3-Pseudarthrosis (2 requires PSF) 1 Severe airway compromise and Death Pseudoarthosis Metaanalysis of Fusion Rates Fraser and Hartl,, JNS, articles, 2682 patients 1 Level Surgery ACD 84.9% ACDF 92.1% ACDFP 97.1% 3 Level surgery 2 Level surgery 3 level ACDF 65.0% 3 level ACDFP 82.5% 2 level COR 89.8% 2 level CORP 96.2% 2 level ACDF 79.9% 2 level ACDFP 94.6% 1 level COR 95.9% 1 level CORP 92.9% Adjacent Segment Degeneration BMP in the Cervical Spine Rihn et al., 2009 ASD occurs in 3% of patients per year Expected to increase to 25% of patients in the first 10 years of the index procedure Recommend considering motion-sparing technology Hilibrand et al., patients treated with Anterior arthrodesis Symptomatic ASD- 2.9%/year 25.6% of pts developed ASD within 10 years Off label use in the cervical spine Reports of soft tissue swelling leading to airway compromise 23 27% rate of swelling severe enough to cause clinical concern and/or extended hospital stay (Smucker, Spine 2006) (Shields, Spine 2006) Posterior Cervical Surgery Approach Related Complications: Neck Pain/Wound Healing Procedural Complications Laminectomy Laminectomy and Fusion Foraminotomy/Disc Laminectomy complications Post laminectomy kyphosis Violate facet joints Progressive kyphosis Recurrent symptoms Post laminectomy membrane?? Recurrent stenosis Recurrent symptoms?

6 C5 Palsy after laminectomy & posterior cervical fixation Chen et al. (2007) J Spinal Disord Tech.: Class III 49 pts. with OPLL Compared pre op & post op X ray, CT & MRI b/w pts. with & without C5 root palsies Post op C5 root palsies occurred in 9 pts. 6 to 64 hrs post operatively Pts. tended to have increased cervical lordosis & severe OPLL No significant positive correlation w/an increase in T2 weighted hyperintense foci on magnetic resonance studies Mean distance from lateral mass to spinal nerve C3 6: mm C7: 8.5 mm Nerve Anatomy Safe Zone for Lateral Mass Screws Superior Lateral Quadrant avoids both the exiting nerve root as well as the vertebral artery Occasionally will lay medial in path of C2 screw Carefully study preoperative films prior to instrumenting Vertebral Artery Lamino foraminotomy Iatrogenic instability Resection of of less than 50 % facet should be protective (based on biomechanical in vitro study) Zdeblick et al, JBJS 74: 22 27, 1992

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