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”