Complications of Spinal
Surgery
Himanshu Sharma
Glasgow
Oops….
‘FAILED BACK SYNDROME’
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
The Components of Spinal Surgery
Neural
surgery
Decompression
Instrumentation
Intradural
Fusion
Deformity
Discs
Stenosis
Tumour Trauma
Infection
Lysis
Listhesis
Low
Back
Pain
Complications of Spinal Surgery
General
 Mortality
 Anaesthetic
DVT/PE
 Chest/urinary
infections
 Positioning
Local
 Nerve injury
 Dural tear
 Bleeding
 Infection
 Pseudarthrosis
 Instrumentation
Wrong Level
“3 commonest causes of poor result”
• Wrong level
• Wrong level
• Wrong level
[McCullough]
Nerve Root Injury
• <1% of procedures
• Beware wonky anatomy
• Beware previous surgery
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%
Dural Tear
Presentation
• Early
• Late
• Headache, nausea, meningism
• Wound leakage
Dural Tears - Management
 Recognition and exposure
 Repair – Suture, patch, fibrin glue,
continuous wound suture
 Testing
 Post-op bed rest, antibiotics
Cauda equina syndrome
• 1:300
• High index of suspicion
Revisiting theatre & recovery
• Clinical
• MRI
Bleeding
Epidural Bleeding Per-op
• Inflammatory mass
• Controllable with good vision & bipolar
Bleeding
Major Vessel Damage
Bleeding
Epidural Haematoma
• Severe pain
• Varying clinical picture
• Documented neuro-obs mandatory
Infection
Positional
• Meralgia paraesthetica
• Compartment syndrome
• Blindness
MRI
• Recurrent disc
-Border enhancement
-Positive mass effect
• Epidural scar
-Diffuse enhancement
-Negative mass effect
Post-discectomy syndrome
• Epidural scarring
D/D
Recurrent disc prolapse
Inadequate Decompression
Fusion
• Pseudarthrosis
• Implant failure
• Junctional degeneration/deformity
[Fusion disease]
Back Pain / Instability
• Small number of patients have much
worse back pain after surgery
• Iatrogenic de-stabilisation
• Type I
• Type II
Other Problems
Pseudarthrosis




Pain
Late implant breakage
Incidental
Difficult to diagnose – X-ray,
tomograms, isotope bone scan, CT,
MRI
 Treatment – revision, re-grafting
Pedicle Screws
Degenerative Spondylolisthesis
Intraoperative
events
Pedicle
fracture
Screw
breakout
Loss of
purchase
Implant
breakage
Nerve root
injury
Spinal cord
injury
Vascular
injury
Vertebral
body
penetration
Dural tear
by screw
Dural tear
not by
screw
Other
Pedicle
Screw
Fixation
Fracture
NonInstrumented
Pedicle
Screw
Fixation
Fracture
(2177)
(456)
(586)
(221)
1.2
-
0.2
-
1
-
0.7
-
1.7
-
0.2
-
0.2
-
0.7
-
0.4
-
0.2
-
0.1
-
0.2
-
0.1
-
0.2
-
0.3
-
0.7
-
0.1
-
0
-
7.3
-
11.3
-
1.3
-
0.9
-
Medial Wall
Pedicle Fracture
Causes
Malposition
Screw too large
Tapping
Osteoporosis
Consequences
Reduced hold
Dural tear
Nerve root injury
Pedicle Screw Breakage
Short screws
Small screws
Short insertion
Long fusions
Anterior column
insufficiency
Implant loosening
Simple Operation
Potential Problems
Vertebroplasty
Complications
Complications relating
Cervical spine operations
Complications
Summary
• Avoid
Pre-op planning
Complications
Summary
• Avoid
Pre-op planning
Complications
Summary
• Avoid
Pre-op planning
Careful surgery
Complications
Summary
• Avoid
• Anticipate
Pre-op planning
Careful surgery
Complications
Summary
• Avoid
Pre-op planning
Careful surgery
• Anticipate
• Deal with
Appropriate kit