SECTION
Complications
CHAPTER
147
Introduction/State-of-the-Art
Spinal surgery, whether in the cervical, thoracic, or in the lum-
bar spine, has become more common over the years as our
understanding of spinal pathology has increased and surgical
techniques have improved. Despite advances in both the medi-
cal and surgical treatment of patients with spinal pathology,
complications associated with spinal surgery still occur. A com-
plication may be defined as a relevant, unintentional develop-
ment either during or after surgery, which negatively interacts
with the surgical procedure and/or postoperative mobilization
in rehabilitation following surgery. Complications may occur
either intraoperatively, perioperatively, and/or postoperatively.
They can range in severity from minor to major and may require
no treatment or may require intervention ranging from mini-
mal to major depending on the severity of the complication.
The incidence of complications associated with spinal sur-
gery varies tremendously depending on the definition of a
complication and the extent of the surgical procedure. The
incidence of complications associated with deformity surgery,
for example, is quite high and ranges anywhere from 40 to
86%.1,3,8,12 Complications associated with spinal surgery can
occur frequently and may include medical complications, neu-
rologic complications, soft-tissue complications, vascular com-
plications, and other complications such as early and late
wound infections, cerebral spinal fluid leaks, fistulas and
pseudomeningoceles, pseudarthrosis/nonunion, and continu-
ation or development of postoperative spine pain.
Medical complications include pulmonary complications,
cardiac complications, renal complications, gastrointestinal
complications, hematologic complications, and miscellaneous
complications. Of these, urinary tract infections are the most
common medical complication. Fortunately, these are almost
never life threatening. Pulmonary complications including
LWBK836_Ch147_p1581-1583.indd 1581
XIV
Jacob M. Buchowski
pneumonia and pulmonary embolism are among the most fre-
quently seen life-threatening complications associated with spi-
nal surgery. Fortunately, these occur rarely.1
Although neurological complications occur infrequently,
during or after spinal surgery, they may have devastating conse-
quences for both the patient and the surgeon. Neurologic com-
plications can be due to direct injury to the spinal cord or nerve
roots at the surgical site. In addition, neurologic complications
may be due to indirect injury to peripheral nerves during
patient positioning or through prolong compression during
the surgical procedure. Patients at higher risk for a neurologic
deficit include trauma patients, patients in whom revision spine
surgery is being performed, patients with congenital kyphosis,
patients with congenital scoliosis, patients with severe rigid sco-
liosis, those with skeletal dysplasia, those with neurofibromato-
sis, those with a prior infection or radiation to their spine in the
past, those with a preoperative neurologic deficit with poor
intraoperative spinal cord monitoring, those with severe spinal
stenosis, and those with congenital narrowing of the spinal
canal. Great care must be taken when treating these patients.
Patients must be positioned on the operating room table care-
fully in order to avoid iatrogenic compressive injury to periph-
eral nerves. The surgeon should be intermittently aware of
potential neural structures at risk during the exposure, as each
approach to the spine carries its own risk of injury. In addition,
the surgeon should be aware of the potential neurologic risks
associated with the specific procedure being carried out. If an
intraoperative neurologic injury is suspected, the surgeon
should rule out technical errors in neuromonitoring, and
should rule out anesthesia-related factors, assess for hyperten-
sion, increase concentration of oxygen, check for laboratory
abnormalities (i.e., obtain an arterial blood gas, hemoglobin,
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 1582 Section XIV Complications
and a basic metabolic panel), inspect entire spinal instrumenta-
tion, and potentially modify or remove the instrumentation
and any distraction forces applied to the spine, perform a
decompression if neural impingement is suspected, perform a
wake up test if there is no improvement in spinal cord monitor-
ing, and consider removal of instrumentation, use of corticos-
teroids, and emergent radiographic assessment (such as a CT
myelogram or MRI scan) if the wake up examination confirms
the presence of a neurologic deficit.
Soft-tissue complications following spinal surgery include
hematoma and/or seroma formation, skin necrosis, and most
commonly, infection. The incidence of wound complications
following spinal surgery ranges from 0 to 5% and strongly cor-
relates with the use of spinal implants.2,10,14 Prompt diagnosis of
spinal wound complications is essential to limit the sequelae
and keep the wound compromise to a minimal. If a hematoma,
seroma, or abscess is suspected, and the patient has symptoms
such as wound healing problems, wound drainage, or any signs
of infection operative debridement is typically necessary. If
serial dbridements are necessary or the wound cannot be
closed primarily, a vacuum-assisted closure (VAC) device can be
used to bridge the gap to definitive wound closure. On occa-
sion, muscle flap closure may be necessary. In the cervical and
proximal thoracic spine, these closures typically require a tra-
pezius flap, a latissimus dorsi flap, or free tissue transfer. In the
distal thoracic and proximal lumbar spine, paraspinous muscle
flaps, latissimus dorsi flap, reverse latissimus dorsi flap, or free
tissue transfer may be performed. In the distal lumbosacral
spine, a gluteal advancement flap, a superior gluteal artery per-
forator flap, a transpelvic vertical rectus abdominal flap, or free
tissue transfer may be performed. Fortunately, with aggressive
treatment and appropriate soft-tissue coverage, spinal implants
can usually be retained and a successful spinal fusion can be
achieved.
As mentioned above, postoperative wound infections are one
of the most common complications following spinal surgery.
Infections can range from superficial infections to deep infec-
tions, with or without systemic sepsis. Infections can develop
both early and after several years following surgery with involve-
ment with deep implants. Risk factors for development of post-
operative wound infections include patient factors and surgeon
factors. Patient factors include advanced age, increased body
mass index, tobacco use, diabetes, hyperglycemia, malnutrition,
postoperative incontinence, alcohol abuse, previous spinal infec-
tion, and the ASA score. Surgeon factors include the length of
surgery, blood loss, complexity of surgery, increased number of
assistance during the procedure, a posterior approach, tumor
surgery, trauma surgery, inadequate antibiotic prophylaxis, and
the use of corticosteroids.2,9,11,13 If an infection is present, appro-
priate antibiotic coverage should be initiated. Nutritional sup-
port (either enteral or parenteral) should also be initiated.
Aggressive blood sugar control is also necessary. Patients should
be mobilized and a bowel hygiene regiment should begin. In
addition, thorough and aggressive wound debridement may be
necessary. Serial surgical assessment should be performed until
the wound is healed. Early coverage of exposed bone and
implants may be necessary, using muscle flaps, as discussed
above. Implants should be removed if possible. Dead space
should be minimized at the time of surgery. With appropriate
treatment, majority of infections can be resolved.
Another common complication following spinal surgery is
pseudarthrosis. A failure to achieve solid fusion has been a
LWBK836_Ch147_p1581-1583.indd 1582
problem since spinal fusion was first introduced by Hibbs in
1911.4 Patients with pseudarthrosis following surgery will typi-
cally present with pain, increasing deformity, and occasionally
presence of neurologic signs or symptoms. Radiographically,
they may have evidence of rod or screw breakage, progression
of deformity, disc space collapse, hook pull-off or screw pull-
out, halos around the screws, and bony incontinuity. The
patients who are at risk for developing pseudarthrosis are those
who have had a long fusion to the sacrum, those who have had
osteoarthritis of a hip joint, or those in whom a thoracoabdom-
inal approach was used to get down to L5-S1. In addition
patients with thoracolumbar kyphosis, those who are 55 years
of age or older, those who have had a fusion of more than
12 levels, or those who use tobacco/nicotine products. On the
other hand, those who have had complete sacropelvic fixation
with the use of iliac screws, those in whom a paramedian
approach was used to get down to L5-S1 (as opposed to a thora-
coabdominal approach), those with normal sagittal balance
(postoperative SVA less than 5 cm), those with sufficient graft
material, and those who have been confirmed not to use
tobacco/nicotine products or less likely to have pseudarthrosis
following surgery.57 In order to prevent pseudarthrosis or when
revision surgery for pseudarthrosis has to be performed, the
surgeon should make certain that the patient does not smoke
or has ceased smoking and the use of nicotine products. During
surgery, all soft tissues have to be handled in a meticulous fash-
ion. All devitalized tissue should be dbrided prior to wound
closure. In addition, thorough removal of cartilage or soft tis-
sue before placement of bone graft is necessary. An adequate
amount of bone graft has to be placed in order for a fusion to
be successful. On occasion, a circumferential approach may be
necessary. In high-risk patients or those in whom revision sur-
gery is being performed for pseudarthrosis, the use of bone
morphogenetic protein may be considered. As most pseudart-
hrosis tend to occur at the thoracolumbar and lumbar sacral
junctions,57 more attention has to be paid to these areas.
Adequate fixation points using hooks, pedicle screws, or pedi-
cle screws with sacropelvic fixation in long fusions to the sacrum
are often necessary to achieve a solid fusion. The paramedian
approach, rather than the thoroabdominal approach, should
be considered for fusions at L5-S1 in the setting of a long poste-
rior fusion. The surgeon has to carefully consider the location
in the use of domino or transverse connectors, as these can
predispose the patient toward developing pseudarthrosis in
these locations. The rod diameter and rod material have to be
chosen carefully and correspond to the patients body weight,
presence of kyphosis, and whether a long fusion is being per-
formed. When a long fusion is being performed, global sagittal
balance and regional sagittal alignment should be restored to
maximize the chances of achieving a solid arthrodesis. With
careful planning and attention to detail during surgery, major-
ity of pseudarthrosis can be avoided and can be repaired if
necessary.
Another common complication seen following spine sur-
gery is continued pain. Patients are often seen with either
unresolved, incompletely resolved, or recurrent pain following
their surgery. As the number of spine procedures has risen, so
too has the number of patients with continued or recurrent
pain following surgery. The pain can be due to recurrent disc
herniation, recurrent or continued spinal stenosis, or arach-
noiditis/fibrosis, instability/pseudarthrosis, and discitis/infec-
tion. In many cases, the cause of continued pain may not be
8/29/11 9:43:24 PM

known. A systematic approach to diagnosis is essential when
evaluating a patient with continued pain following spine sur-
gery. A careful history focusing on the symptoms prior to previ-
ous surgery, degree of improvement after surgery, length of
pain-free interval, distribution of current symptoms, and sever-
ity of current symptoms is critical. Physical examination,
although important, is typically nonspecific. Radiographic
studies usually consisting of plain radiographs, MRI, and CT
myelogram are essential and often will demonstrate or con-
firm the etiology of the continued pain. Nonoperative treat-
ment is usually tried first. In select cases where the pain does
not improve with nonoperative treatment modalities and the
signs, symptoms, and radiographic findings correlate and
point to a possible surgical solution to the problem, surgical
intervention can often lead to improvement in the patients
symptoms.
As would be expected, there are other numerous complica-
tions that can occur during and after spine surgery. Some of
these include vascular complications, cerebrospinal fluid leaks,
pseudomeningocele development, vascular complications,
development of sagittal imbalance, and so forth. Clearly not all
can be discussed in this chapter, this section, or for that matter,
this textbook. Nevertheless, the common theme in the chapters
contained in this section is that the prevention of potential
complications is the best way to assure an increased likelihood
of success following spine surgery. Avoidance of complications
begins with appropriate patient selection, as even the best-
executed surgery is unlikely to succeed if the surgery is carried
out on a patient who is unlikely to benefit from the procedure.
A well-thought-out and executed surgical plan is also necessary.
Careful attention has to be paid to potential complications
LWBK836_Ch147_p1581-1583.indd 1583
Chapter 147 Introduction/State-of-the-Art 1583
during and after surgery. Should a complication occur, prompt
recognition and appropriate treatment are key to minimizing
the effect of the complication on patient outcome.
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