Pitfalls in Cervical Spine Surgery (eBook)

Copyright Page 4
Foreword 5
Foreword 7
Preface 8
Contents 10
Contributors 12
Part I: General Complications 15
Chapter 1 16
Complication Related to Medical Conditions 16
1.1 Introduction 16
1.2 Comorbidities Increasing the Risk of Major Perioperative Complications 16
1.3 Comorbidities Specifi cally Increasing the Risk of Perioperative Cardiac Events 17
1.4 Comorbidities Increasing the Risk of Postoperative Infections and Their Management 18
1.5 Comorbidities Complicating Spinal Fusion 20
1.6 Comorbidities Associated with Poor Neurologic Recovery After Surgery 21
References 22
Chapter 2 25
Hematologic Issues in Cervical Spine Surgery 25
2.1 Changes in Blood Cell Count Parameters 25
2.1.1 Anemia 25
2.1.1.1 Approach to the Anemic Patient 25
2.1.1.2 Anemia’s Decalogue for the Surgeon 27
2.1.2 Polycythemia 27
2.1.2.1 Polycythemia and Cervical Spinal Surgery 28
2.1.2.2 Tips for the Orthopedic Surgeon in the Presence of a PV 28
2.1.3 Reduction in the White Blood Cell Count 28
2.1.3.1 Absolute Neutropenia 28
2.1.3.2 Absolute Lymphocytopenia 29
2.1.4 Increase in White Blood Cell Count 29
2.1.4.1 Absolute Neutrophilia 29
2.1.4.2 Absolute Lymphocytosis 29
2.1.4.3 Absolute Eosinophilia and Absolute Monocytosis 29
2.1.5 Changes in Platelet Count 29
2.1.5.1 Abnormal Increase in Platelet Count 29
2.1.5.2 Abnormal Decrease in Platelet Count 30
2.1.6 How a Cervical Spine Surgeon should Manage Patients with Changes in Blood Cell Count 30
2.2 Patients with Monoclonal Gammopathy 31
2.2.1 Monoclonal Gammopathy of Undetermined Significance (MGUS) 31
2.2.2 Multiple Myeloma 32
2.3 Preoperative Evaluation of the Hemorrhagic Risk 32
2.3.1 Abnormal Hemostatic and Coagulation Parameters 32
2.3.1.1 Qualitative Platelets Defects (Thrombocytopathies) 33
2.3.1.2 Coagulopathies 34
2.3.1.3 The laboratory Interface 35
2.4 Preoperative Evaluation of the Thromboembolic Risk 35
2.5 Thromboprophylaxis in Cervical Spine Surgery 36
References 38
Chapter 3 40
Complications in Surgical Management of Cervical Spinal Metastases 40
3.1 Spinal Metastases: Introduction 40
3.1.1 Epidemiology 40
3.1.2 Anatomical Localization and Pathophysiology 40
3.1.3 Presentation 41
3.1.4 Management: Past and Present 42
3.1.5 Surgical Indications and Approaches 43
3.2 Surgery-Related Prognosis in Bone Metastatic Patients 43
3.2.1 Surgery-Related Complications 44
3.2.1.1 Surgical Complications 44
3.2.1.2 Hardware-Related Complications 45
3.2.1.3 Medical Complications 46
3.2.1.4 Complications Rates of Spinal Surgery and Minimally Invasive Spinal Surgery 46
3.2.2 Presurgical Quantifi cation of Risk and Patient Selection 48
3.2.2.1 Classifi cations: Prediction of Life Expectancy and Optimal Treatment Selection 49
References 53
Chapter 4 55
Systematic Approach to the Patient to Minimize Errors of Diagnosis and Surgical Indications 55
4.1 Introduction 55
4.2 Approach to the Patient with NeckPain: History 56
4.3 Physical Examination 58
4.4 Laboratory Studies 60
4.5 Imaging 60
4.6 Neurophysiology (Electrodiagnostic Studies) 62
4.6.1 Electromyography 62
4.6.2 Evoked Potentials 63
4.6.2.1 Somatosensory-Evoked Potentials 63
4.6.2.2 Motor-Evoked Potentials 63
4.7 General Considerations and Conclusions 63
References 65
Part II: Peri-operative complications 67
Chapter 5 68
Considerations and Anesthesiologic Complications in Spinal Surgery 68
5.1 Preoperative Consideration 68
5.1.1 Age 68
5.1.2 General Health Conditions 68
5.1.3 Functional State 68
5.1.4 Nutrition Conditions 69
5.1.5 Psychological State 69
5.1.6 Cardiologic Problems 69
5.1.7 Lung Disease 70
5.1.8 Liver Disease 70
5.1.9 Kidney Disease 70
5.2 Perioperative Considerations 70
5.2.1 Airways Management 70
5.2.1.1 Direct Laryngoscopy 71
5.2.1.2 Trachlight ® 71
5.2.1.3 Airtraq ® 71
5.2.1.4 Glidescope ® 72
5.2.1.5 LMA-Classic™ 73
5.2.1.6 LMA-Fastrach™ 73
5.2.1.7 LMA-Proseal™ 73
5.2.1.9 Cobra PLA 74
5.2.2 Pulmonary Ventilation in Vertebral Surgery 74
5.2.3 Mechanic Breathing and Patient’s Positioning Effects 75
5.2.4 Controlled Hypotension 75
5.2.5 Perioperative Monitoring 75
5.2.5.1 Breathing Monitoring (Primus/Zeus Drager ® ) 75
5.2.5.2 Hemodynamic Monitoring 75
5.2.5.3 Fluid Balance 75
5.2.5.4 Body Temperature Monitoring 76
References 76
Chapter 6 78
General Complications Related to Patient Positioning 78
6.1 Introduction 78
6.2 Posterior Approach: Precautions and Recommendation 78
6.3 Anterior Approach: Precautions and Recommendation 81
6.4 Circumferential Approach: Precautions and Recommendation 83
References 85
Part III: Complications of Surgical Approaches 87
Chapter 7 88
Complications Related to Anterior Approaches 88
7.1 Transoral Approach 88
7.1.1 Surgical Technique 89
7.1.2 Complications 91
7.1.2.1 Intraoperative Complications 92
Soft Tissue Injury 92
Neural Injury 93
Osseous Injury 93
7.1.2.2 Postoperative Complications 93
Soft Tissues Injury 93
Neural Injury 94
Osseous Injury 94
Postoperative Infection 94
7.2 Transmandibular Approach 94
7.2.1 Complications 94
7.3 Submandibular Approach 95
7.3.1 Complications 95
References 96
Chapter 8 98
Complications Related to Anterolateral Approaches 98
8.1 High and Low Presternocleidomastoid Approaches (Retropharyngeal and Precarotid) 98
8.1.1 Surgical Technique 98
8.1.1.1 Low Anterolateral Approach 98
8.1.1.2 High Anterolateral Approach 101
8.1.2 Intraoperative Complications 102
8.1.2.1 Vascular Injuries 102
Carotid Artery 102
Vertebral Artery 104
Jugular Vein 105
Thyroid Vessels 105
8.1.2.2 Soft Tissue and Visceral Injury 106
Esophagus and Pharynx 106
Salivary Duct 106
The Thyroid Gland 107
The Thoracic Duct 107
8.1.2.3 Neurological Injury 108
Facial Nerve (Seventh Cranial Nerve) and Hypoglossal Nerve (Twelfth Cranial Nerve) 108
Laryngeal Nerves 108
Cervical Sympathetic Chain 109
Spinal Cord and to the Nerve Roots 109
8.1.3 Postoperative Complications 109
8.2 Presternocleidomastoid Approach (Retropharyngeal and Retrocarotid) 109
8.2.1 Technique 110
8.2.2 Complications 110
8.2.2.1 Vascular Injury 110
8.2.2.2 Neurological Injury 111
8.2.2.3 Visceral Injury 111
8.2.3 Advantages 111
8.3 Retrosternocleidomastoid Approach 111
References 113
Chapter 9 116
Complications Related to Posterior Approach 116
9.1 Introduction 116
9.2 Pitfalls 118
9.2.1 Bad Positioning 118
9.2.2 Neurological Injury 118
9.2.3 Cerebrospinal Fluid Leaks 120
9.2.4 Postoperative C5 Palsy 120
9.2.5 Vascular Injuries 121
References 123
Part IV: Complications related to osteo-articular diseases 126
Chapter 10 127
Degenerative Disk Disease 127
10.1 Introduction 127
10.2 Anterior Surgical Techiques 127
10.2.1 Anterior Discectomy/Corpectomy and Fusion 127
10.2.1.1 Vascular Lesions 132
Common Carotid Artery Lesions 132
Vertebral Artery Lesion 133
Jugular Vein Lesion 134
10.2.1.2 Soft Tissue Lesions 134
10.2.1.3 Spinal and Dural Lesions 135
10.2.2 Anterior Decompression with Multiple Subtotal Corpectomies 136
10.2.2.1 Complications 137
10.2.3 Anterior Instrumentation 139
10.2.3.1 Plates and Screws 142
10.2.3.2 Anterior Cervical Cages 144
10.3 Posterior Surgical Techniques 146
10.3.1 Laminectomy and Fusion 146
10.3.1.1 Dural Tears and Neural Lesions 148
10.3.1.2 Bleeding from Venous Plexus 148
10.3.1.3 Lateral Mass Removal 148
10.3.1.4 General Complications 149
10.3.2 Laminoplasty 150
10.3.2.1 Complications Related to the Laminae or Hinge 150
10.3.2.2 Selective Paralysis of the C5 Root 151
10.3.2.3 Wrong Patient Selection 151
10.3.3 Posterior Instrumentation at the Lower Cervical Spine 151
10.3.3.1 Wiring Techniques and Laminar Hooks 152
10.3.3.2 Screw-Based Systems 153
Lateral Mass Screw Fixation 153
10.3.3.3 Pedicle Screw Fixation 155
10.3.3.4 Bone Graft Mobilization 155
10.4 Cervical Spine Arthroplasty 155
10.4.1 Implants 155
10.4.2 Clinical Results 156
10.4.2.1 Bryan Cervical disk 156
10.4.2.2 Prestige 156
10.4.2.3 Prodisc-C 157
10.4.3 Complications and Revision Surgery 157
10.5 Pitfalls Related to Minimally Invasive Cervical Spine Surgery 160
10.5.1 Anterior Approaches 161
10.5.2 Posterior Approaches 162
10.5.2.1 Surgical Technique 162
10.5.2.2 Complications 163
References 164
Chapter 11 170
Cervical Spine Bone Tumor Surgery 170
11.1 General Considerations in Cervical Spine Tumor Surgery 170
11.1.1 Indications 171
11.2 Complications 172
11.2.1 Vascular Complications 173
11.2.1.1 Vertebral Artery Lesions 173
11.2.2 Lesions of the Deep Structures of the Neck 174
11.2.3 Neurological Complications 174
11.2.3.1 Myeloradicular Lesions and Liquoral Fistulas 174
11.2.3.2 Intradural and Extradural Hematoma 175
11.2.4 Extracanalar Neurological Lesions 176
11.2.5 Reconstruction Failures 176
11.2.5.1 General Complications 177
References 178
Chapter 12 180
Cervical Spine Traumas 180
12.1 Introduction 180
12.2 Classifi cation and Surgical Indications 184
12.2.1 Upper Cervical Spine Injuries 184
12.2.2 Lower Cervical Spine Injuries 190
12.2.2.1 Compression Flexion 191
12.2.2.2 Vertical Compression 191
12.2.2.3 Distractive Flexion Injuries 192
12.2.2.4 Compressive Extensions 192
12.2.2.5 Distractive Extension 192
12.2.2.6 Lateral Compression 192
12.2.2.7 Complications 192
References 195
Chapter 13 197
Infections of the Cervical Spine 197
13.1 Introduction 197
13.2 Iatrogenic Infections 198
13.2.1 Intrinsic Risk Factors 198
13.2.2 Extrinsic Risk Factors 199
13.2.3 Classifi cation 201
13.2.4 Diagnosis 201
13.2.4.1 Laboratory Findings 201
13.2.4.2 Imaging 202
13.2.5 Management 202
13.2.5.1 Wound Infections 202
13.2.5.2 Discitis 203
13.2.5.3 Vertebral Osteomyelitis 203
References 205
Chapter 14 206
Pitfalls Related to Infl ammatory Disorders 206
14.1 General Considerations 206
14.2 Pitfalls Related to Patients with Rheumatoid Arthritis 206
14.2.1 Considerations for Fixation and Fusion 208
14.2.2 Anterior Approaches 208
14.2.3 Complications of Occipito-Cervical Decompression and Fusion Procedures 210
14.2.3.1 Complications to Meninges, Spinal Cord, and Nerve Roots 212
14.2.3.2 Vascular Lesions 213
14.2.3.3 Mobilization of Instrumentation 213
14.2.4 Posterior Fixation at C1–C7 in Patients with RA 213
14.3 Pitfalls Related to Patients with Ankylosing Spondylitis 214
14.3.1 Treatment of Cervical Flexion Deformity in AS 214
14.3.1.1 Surgical Technique of Cervical Extension Osteotomy 215
14.3.1.2 Complications of Cervical Extension Osteotomy 216
14.3.2 Cervical Spine Fractures in AS 217
14.3.2.1 Complications of Surgery for Cervical Spine Fractures in AS 218
References 218
Part V: Complications related to neural diseases 222
Chapter 15 223
Spinal Cord Neoplasms 223
15.1 Primary and Metastatic Intradural Cervical Spine Tumors 223
15.2 Intradural Intramedullary Neoplasms 223
15.2.1 Astrocytomas 224
15.2.2 Ependymomas 224
15.2.3 Hemangioblastomas 225
15.2.4 Intramedullary Spinal Cord Metastases 225
15.3 Intradural Extramedullary Neoplasms 225
15.3.1 Meningiomas 226
15.3.2 Nerve Sheath Tumors 226
15.4 Surgical Technique and Complication Avoidance 226
References 229
Chapter 16 231
Syringomyelia 231
16.1 Syringomyelia and the Chiari Malformations 231
16.2 Pathogenesis and Development Theories 231
16.3 Symptomatology 232
16.4 Diagnosis and Evaluation 232
16.5 Surgical Treatment and Complications Avoidance 232
16.5.1 Primary Syringomyelia: Decompression of Subarachnoid Space 233
16.5.2 Shunting Procedures for Syringomyelia 233
16.5.3 Syringomyelia and Chiari Malformation: Posterior Fossa Decompression 234
References 237
Part VI: Miscellanea 238
Chapter 17 239
Complications Related to Graft 239
17.1 Introduction 240
17.2 Autograft 240
17.3 Allografts 241
17.3.1 Studies Comparing Allografts vs. Autografts 241
17.4 Bone Graft Substitutes 244
17.4.1 Ceramics 244
17.4.2 Demineralized Bone Matrices 244
17.4.3 Osteoinductive Growth Factors 245
17.5 Donor Site Complications 245
17.5.1 The Iliac Crest 245
17.5.1.1 Donor Site Pain 246
17.5.1.2 Nerve Injury 246
17.5.1.3 Vascular Injury 251
17.5.1.4 Fractures of the Ilium 251
17.5.1.5 Violation of the Sacroiliac Joint 251
17.5.1.6 Hernia 261
17.5.1.7 Hematoma 261
17.5.1.8 Gait Disturbance 266
17.5.1.9 Infections 266
17.5.1.10 Other Complications 266
17.5.1.11 Cosmetic Deformity 266
17.5.1.12 Tumor Transplantation 266
17.6 Bicortical Cylindrical Graft as Required by the Cloward Instrumentation 268
17.6.1 Errors 268
17.7 Tricortical Rectangular Graft for Smith–Robinson-Type Vertebral Fusion 268
17.7.1 Errors 269
17.8 Tricortical Graft for Multiple Subtotal Vertebrectomies and Reconstruction 269
17.8.1 Errors 269
17.9 Fibula 270
17.9.1 Fibular Donor Site Complications 270
17.10 Tibia 270
17.11 Recipient Site Complications 270
17.12 Cervical Nonunion 271
17.13 Failure of Long Strut Graft for Multilevel Cervical Corpectomy 273
17.13.1 Prevention of Failure 275
17.14 The Future 276
References 277
Chapter 18 282
Pitfalls Related to Inadequate or Incomplete Surgical Technique and Errors of Level 282
18.1 Incomplete or Inadequate Surgical Technique 282
18.2 Errors of Level 284
18.2.1 To Prevent the More Common Errors of Level: Revision of the Literature and General Considerations 285
References 289
Chapter 19 290
Complications Due to Inadequate Cervical Spinal Immobilization 290
19.1 Introduction 290
19.2 Complications of Cervical Spinal Orthoses 292
19.3 Halo Vest Immobilization 293
19.3.1 Complications of the Halo Immobilization 295
References 297
Index 299