Thursday, November 30, 2023
This activity is intended for neurologists, pain medicine specialists, physiatrists, and physicians who care for patients before and after cervical spine surgery.
Because of the high incidence of cervical radiculopathy, the frequency of cervical spine surgeries in the United States (US) has increased substantially over the past 2 decades to more than 1.3 million inpatient surgeries performed between 2002 and 2009. Cervical spine surgery is associated with relatively low morbidity and mortality rates, but perioperative complications can lead to substantial patient suffering. Physicians involved in the perioperative care of patients undergoing cervical spine surgery, particularly specialists such as neurologists who refer patients for surgical consultation and provide care after surgery, will benefit from reviewing common surgical complications and strategies for recognizing those complications in clinical practice.
Upon completion of this activity, participants will be able to:
Med-IQ requires any person in a position to control the content of an educational activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as those in any amount occurring within the past 12 months, including those of a spouse/life partner, that could create a conflict of interest (COI). Individuals who refuse to disclose will not be permitted to contribute to this CME activity in any way. Med-IQ has policies in place that will identify and resolve COIs prior to this educational activity. Med-IQ also requires faculty to disclose discussions of investigational products or unlabeled/unapproved uses of drugs or devices regulated by the US Food and Drug Administration.
The content of this activity has been peer reviewed and has been approved for compliance. The faculty and contributors have indicated the following financial relationships, which have been resolved through an established COI resolution process, and have stated that these reported relationships will not have any impact on their ability to give an unbiased presentation.
This activity was developed by Med-IQ in collaboration with Duke University Health System Department of Clinical Education and Professional Development.
Med-IQ is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Med-IQ designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nurse practitioners, physician assistants, and other healthcare professionals who successfully complete the activity will receive a Statement of Participation indicating the maximum credits available.
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]
There are no fees for participating in or receiving credit for this online educational activity. For information on applicability
and acceptance of continuing education credit for this activity, please consult your professional licensing board.
This activity is designed to be completed within the time designated on the title page; physicians should claim only those
credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the
activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 100% on the post-test.
Follow these steps to earn CME/CE credit*:
You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it.
Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print
out the tally as well as the certificates from the CME/CE Tracker.
*The credit that you receive is based on your user profile.
CME Released: 1/12/2018
Valid for credit through: 1/12/2019, 11:59 PM EST
processing....
This 15-minute activity features a brief video introduction by faculty expert Dr. Gottfried in which he relates anterior and posterior surgical approaches for patients with cervical radiculopathy, the effects of these surgeries on neck tissue, and the surgical complications that patients may experience. The text that follows continues on to explore these topics in greater detail.
Cervical radiculopathy, in which a compressed nerve triggers pain, numbness, or weakness in the neck and surrounding areas, is a very common condition, with an annual incidence of 107 in 100,000 for men and 64 in 100,000 for women.[1,2] Cervical spondylitic myelopathy (CSM), a degenerative disease responsible for the highest proportion of spinal cord compression and dysfunction, is estimated to have an incidence of 4.1 per 100,000 of nontraumatic spinal cord injuries.[3]
Initial treatment of both conditions is typically conservative, but the frequency of cervical spine surgeries in the United States (US) has increased substantially over the past 2 decades; more than 1.3 million inpatient surgeries were performed between 2002 and 2009.[1,4-7] Surgery may be offered to patients with moderate progressive CSM on presentation but is otherwise reserved for refractory or progressive degeneration.[1,4,5] When surgery is indicated, the tissues that are affected, and, therefore, the ensuing complications, depend on whether an anterior, posterior, or combined approach was taken.[1,5] The anterior approach is the most common; according to 2002 to 2009 data; just over 80% of patients received anterior procedures.[7]
Cervical spine surgery is associated with nontrivial morbidity but low mortality rates. Morbidity rates have been estimated to range from 9% to 20%, with similar rates of success between the anterior and posterior approaches.[8,9] Post-procedure mortality rates are low: 2.9 per 1,000 for anterior surgical cervical fusion and 13.8 per 1000 for posterior cervical fusion.[7]
Because these surgeries are becoming more common, it is important that physicians responsible for post-surgical patient management understand the short- and long-term effects of the procedures. To that end, this publication describes the most common complications associated with cervical spine surgery that may lead to substantial patient disability, with the goal of providing insights on the post-surgical challenges that patients might encounter and the symptoms that might present in the healthcare setting.
Complications or undesirable postoperative outcomes of cervical spine surgery primarily result from injury or swelling of the soft tissues and structures affected by manipulation or retraction during surgery.[1] The most common anterior procedure, anterior cervical discectomy and fusion (ACDF), decompresses nerves by removing bone spurs and/or the injured disc and then fusing the cervical spine with a bone graft and adding a plate and screws for stabilization. Cervical disc arthroplasty, also known as artificial disc replacement, is another anterior approach in which the degenerated disc is removed and replaced with a mechanical joint implant. For more serious compression or multisegment spinal compression, cervical corpectomy may be performed and involves removing a vertebral body or bodies in addition to the intervening disc and replacing it with cages packed with bone, plates, and screws.[1]
Approximately 20% of cervical spine surgeries are performed using a posterior approach.[6,7] Common procedures, each of which manipulates the lamina to decompress the spinal canal, include laminoforaminotomy, laminoplasty, or laminectomy with or without surgical fusion:
Some of the most common post-surgical and delayed complications of such procedures include vocal changes, hoarseness, sore throat, hematoma, and respiratory failure or difficulty breathing. Issues that typically present after a longer period of time include complications related to loss of structural spinal integrity, such as graft extrusion and spinal fusion nonunion (pseudoarthrosis), and adjacent segment degeneration.[1,8,11,12] Of note, nerve root or spinal cord injuries are more common for posterior surgeries than for anterior surgeries; the incidence of such complications is approximately 0.18% to 5%.[13,14]
Bleeding complications following cervical spine surgery are rare (0% to 1.8%, depending on procedure type) but potentially serious and include blood vessel damage and hematoma formation.[10,11,15] Patients have a higher risk of bleeding when anterior surgical approaches are used. Most bleeding events occur in the first 24 hours after surgery, although cases may present 1 week or more postoperatively.[16] Patients who use over-the-counter anticoagulant medications have an elevated risk of this complication and should be monitored.
Hematomas, which can be life-threatening, typically occur within hours of surgery but have also been reported days after surgery. An analysis of ACDF outcomes at a single institution found that 0.1% of patients developed hematomas, and a meta-analysis of 14 studies of various approaches and surgical procedures for cervical spine surgery found that epidural hematoma occurred in approximately 1% of patients.[11,17] Patients experiencing hematoma may present with complaints of neck swelling, difficulty swallowing, or difficulty breathing.[17] In such situations, emergency surgery should be performed to evacuate the hematoma immediately.[17]
Poor wound healing leading to infection is another infrequent but potentially serious complication. A recent meta-analysis of 107 studies found a 2.8% overall infection rate following cervical compression surgery, but a subset of 25 studies also showed a wide range of infection rates across anterior and posterior surgeries (0.4% to 54.6%).[11] Patients whose surgeries lasted more than 3 hours were shown to have an increased risk of infection, as were patients undergoing fusion procedures.[10,13] A multicenter study compared patients who received laminoplasty or laminectomy with fusion and found that, compared with laminoplasty, the fusion procedure was associated with higher rates of serious (1.2% vs 0.0%) and superficial (3.0% vs 2.0%) infection.[10] Key symptoms of postoperative infection include pain, wound drainage, and localized erythema. Patients with more serious infections may have chills, fever, night sweats, or compromised respiratory function.[13] Importantly, deep-space infections require surgical washout and, if recurrent, may require hardware and bone graft removal; this is especially true with posterior surgeries.[13]
Acute graft or implant extrusion is a serious potential surgical complication.[8,17] Extrusion may be total or partial and occurs when the implant material moves in an anterior or posterior direction following surgery. A high proportion of patients with this complication will require revision surgery to prevent esophageal penetration and subsequent infection.[8,13] Other risks of untreated extrusion include spinal compression and fracture.[8,17] Patients with poor bone quality or who have undergone corpectomy have a higher risk of this complication.[8,13] Table 1 summarizes the incidence and key signs and symptoms of graft extrusion.
Table 1. Incidence and Key Signs and Symptoms of Postoperative Graft Extrusion
| Complication Type | Incidence | Signs and Symptoms |
|---|---|---|
| Graft extrusion | 0.0% to 0.88% | Intractable neck pain Persistent neurologic symptoms New neurologic deficits |
Data derived from Smith GA, et al.[8] and Nanda A, et al.[17]
The exact cause of nerve palsy is difficult to ascertain, but nerve injury, retraction, ischemia, or reperfusion of tissues during surgery are possible complications.[13] Nerve palsies more commonly experienced after cervical surgery include the recurrent and superior laryngeal nerve and the C5 nerve root.[13]
Recurrent laryngeal nerve injury or palsy occurs in 0.07% to 16.7% of patients.[11,13,17] Patients can present with hoarseness or vocal cord paralysis.[13,17] Most occurrences resolve within several weeks of surgery, but paralysis can be permanent.[13] Of note, referral to an otolaryngologist can help patients manage lingering symptoms.
C5 palsy affects the deltoid and sometimes the bicep muscles and includes muscle weakness, pain, or paralysis in one or both arms.[13] These symptoms may be caused by spinal cord decompression with some remaining tethering on the nerve roots.[11,18] In a systematic review of 25 studies, the overall incidence of this complication was nearly 6%; patients who received laminectomies had the highest risk (pooled incidence of 11.3%), and the incidence following laminoplasty ranged from 3.1% to 4.5%, depending on procedure type.[18] Cases typically present within a few days of surgery, sometimes even immediately after surgery, and risk factors include excessive spinal cord drift or preexisting intervertebral stenosis or ligament ossification. Most patients recover within 1 week to several months or years using conservative treatments, such as physical therapy and rest.[18] Table 2 summarizes the incidence and key signs and symptoms of C5 palsy.
Table 2. Incidence and Key Signs and Symptoms of Postoperative Palsy
| Complication Type | Incidence | Signs and Symptoms |
|---|---|---|
| Recurrent laryngeal nerve injury or palsy | 0.07% to 16.7% | Hoarseness Vocal cord paralysis Dysphagia |
| C5 palsy | 5.9% | Muscle weakness Brachialgia Upper limb numbness |
Data derived from Nanda A, et al.[17] and Gu Y, et al.[18]
Pseudarthrosis, or joint nonunion, accounts for up to 56% of revision surgeries and is a leading cause of pain for patients who have undergone fusion surgery.[19] Based on a recent retrospective review, pseudarthrosis was a delayed complication in up to 20% of patients who received a 1-level fusion and in up to 60% of those who received a multilevel fusion.[20] A meta-analysis of pseudarthrosis rates in patients who underwent ACDF found a much lower overall rate of 2.6%.[21]
Documented patient risk factors for pseudoarthrosis include smoking, younger age, chronic steroid use, obesity, diabetes, and/or metabolic syndrome.[19] As part of a differential diagnosis, it is important to rule out infection, implant failure, adjacent segment disease, and postoperative pain syndromes.[19,20] Symptoms of incomplete fusion may resolve on their own, or patients may require revision surgery.[20] Table 3 summarizes the incidence and key signs and symptoms of pseudoarthrosis.
Table 3. Incidence and Key Signs and Symptoms of Postoperative Pseudoarthrosis
| Complication Type | Incidence | Signs and Symptoms |
|---|---|---|
| Pseudoarthrosis | 3.7% for 1-level 3.1% for ≤ 24-month follow-up 2.3% for > 24-month follow-up |
Recurrent or persistent mechanical neck pain, exacerbated by motion and radiating to the arm Radiculopathy or myelopathy Approximately 30% of cases are initially asymptomatic |
Data derived from Leven D, et al.[19] and Shriver M, et al.[21]
With adjacent segment degeneration, spinal motion segments proximal to the surgical site undergo disc degeneration and/or osteophyte formation, most likely resulting from a combination of the redistribution of forces causing increased stress at levels adjacent to the fusion, as well as the natural progression of degenerative spine disease.[12,22] Rates of adjacent segment degeneration after anterior and posterior surgeries may be as high as 15% and 9%, respectively.[13] Clinical symptoms include radiculopathy or myelopathy, and approximately two-thirds of patients will require reoperation to achieve symptom relief.[12] A key risk factor for this complication is preexisting radiographic evidence of degeneration.[12] Table 4 summarizes the incidence and key signs and symptoms of adjacent segment degeneration.
Table 4. Incidence and Key Signs and Symptoms of Adjacent Segment Degeneration
| Complication Type | Incidence | Signs and Symptoms |
|---|---|---|
| Adjacent segment degeneration | 2.4% at 1 year 13.6% at 5 years 25.6% at 10 years |
Radiculopathy or myelopathy Radiographic degeneration at segments adjacent to surgical levels |
Data derived from Kaye D, Hilibrand AS[12] and Hilibrand AS, et al.[22]
As previously noted, the majority of cervical spine surgeries are performed using an anterior approach.[6,7] The most common complication of this surgical approach is dysphagia.[23]
Many patients experience some hoarseness and/or dysphagia immediately after surgery; some have persistent symptoms.[1] This complication may be caused by laryngeal nerve injury, transient pharyngeal weakness, and/or postoperative edema.[24] Although reported rates vary, a prospective longitudinal study found that 50% of patients who underwent anterior cervical spine surgery reported some degree of dysphagia at 1 month.[24,25] Importantly, though, prevalence decreased over time: by 2 months postprocedure, 11.2% of patients reported moderate or severe dysphagia, and by 6 months postprocedure, only 4.8% of cases were ongoing.[24-26] Men and the elderly, as well as patients with 3- or more level fusions, bone morphogenetic protein (BMP) use, or preoperative comorbidities, are more likely to experience dysphagia in the immediate postoperative period.[25] In the long-term, however, persistent dysphagia is associated with smoking, female sex, multiple-level or revision procedures, and the use of intraoperative BMP.[23,24] Other research has associated higher risk with long surgery duration, plate failure or loose screws, and older patient age (> 60 years).[23,24]
In general, most patients with postoperative dysphagia should improve to some extent within 3 months.[24] It is important, therefore, to identify and address prolonged dysphagia, as this condition increases the risk of weight loss, dehydration, aspiration/aspiration pneumonia, and chronic lung disease.[23] Prolonged dysphagia also has social consequences, such as embarrassment when eating.[23] Prompt identification of dysphagia or other related oral or vocal symptoms is important, and patients should be referred to a speech therapist and otolaryngologist for symptom management. Table 5 summarizes the incidence and key signs and symptoms of dysphagia.
Table 5. Incidence and Key Signs and Symptoms of Postoperative Dysphagia
| Complication Type | Incidence | Signs and Symptoms |
|---|---|---|
| Dysphagia | Moderate to severe dysphagia:
|
Reflexive coughing or wet/gurgly voice during/after swallowing Needing extra time or effort to chew or swallow Food/liquid gets stuck in or leaks from mouth |
Data derived from Anderson K, Arnold P.[23]; Leonard RL, Belafsky P.[24] ; Singh K, et al.[25]; Bazaz R, et al.[26]
Durotomy and cerebrospinal fluid (CSF) leakage is a common problem in spinal surgeries.[27] Risk factors include older age, ligament ossification, and scarring from previous surgeries.[13] Presentation is often asymptomatic, but when symptoms do appear, they are typically neurologic in nature (eg, headache, nausea, vertigo, or tinnitus).[13] Persistent leakage can lead to CSF fistulas, brain abscesses, meningitis, hemorrhage/hematoma, or pseudomeningoceles.[13,27] Typically, CSF leakage is treated by directly suturing, patching, and placing fibrin glue at the dural tear.[13,27] Table 6 summarizes the incidence and key signs and symptoms of durotomy and CSF leakage.
Table 6. Incidence and Key Signs and Symptoms of Durotomy and CSF Leakage
| Complication Type | Incidence | Signs and Symptoms |
|---|---|---|
| Durotomy/CSF leak | All procedure types: 0.54% ACDF: 1.3% Laminectomy: 0.3% to 13% |
Typically asymptomatic Postural headache, nausea, vomiting, and/or dizziness Photophobia, tinnitus, vertigo |
Data derived from Baird E, et al.;[6] Cheung J, Luk K.;[13] Nanda A, et al.[17]
Cervical spine surgery is an effective and safe procedure to address persistent radiculopathy and associated pain, but patients and their physicians should be aware of potential complications that may arise postoperatively. Understanding the potential complications can help set realistic surgical expectations and promote the early detection and management of complications.
