Key ArticlesBaron EM, Albert TJ 2006 Medical complications of surgical treatment of adult spinal deformity and how to avoid them.. Spine 31:S106–18 Recent extensive review of complicati
Trang 1weight patients are at higher risk [22, 105] Causal treatment is reduction of the correction This is usually not required The symptoms will ameliorate within weeks and with intravenous hyperalimentation In rare cases, duodenojejuno-stomy will be required.
Urogenital Complications Urinary Tract Infection
Check for bladder residual
urine
The most frequent urogenital complication is a simple urinary tract infection (UTI), which can occur in up to 9 % of patients [5] Ascending infection with pyelonephritis or sepsis is rare These complications can be minimized when perioperative catheterization is used only when absolutely indicated On the other hand, incomplete bladder emptying also increases the risk of infection Ultrasonography is very helpful in estimating the residual urine amount, which should be less than 100 cc.
Postoperative Anuresis
Check perianal sensation
in postoperative anuresis
In the immediate postoperative period, patients often have difficulty in urinat-ing The most frequent cause is the inability to empty the bladder in a lying posi-tion However, anal tone and sensation must be controlled to rule out a cauda equina syndrome Early mobilization solves this problem If this is not possible, catheterization is necessary to avoid bladder overdistension.
Urinary Bladder Dysfunction
After anterior surgery, a bladder dysfunction can result from an injury to the parasympathetic presacral nerves especially at the level of L5/S1 This complica-tion can perhaps be reduced by a retroperitoneal approach, where the sympa-thetic and parasympasympa-thetic fibers located close to the peritoneum in the bifurca-tion of the vessels are left intact [34].
Retrograde Ejaculation
Initial reports have perhaps underestimated the problem A survey of 20 sur-geons in 1984 reported 0.42% retrograde ejaculation and 0.44% impotence
fol-lowing anterior lumbar spine fusion [37] The more thoroughly studies were undertaken, the higher (2 – 4 %) was the reported incidence [8, 11, 99] It seems that the problem is mainly approach related, with the incidence being much higher in transperitoneal than in retroperitoneal approaches to the lumbar spine. This complication is most
likely more common
than reported
Recently, in anterior lumbar interbody fusion the rate was 2 % in retroperitoneal and 13 % in transperitoneal cases [99] A lesion of the hypogastric plexus must be avoided during approaches to the lumbar spine The plexus is located in front of the vessel bifurcation, close to the peritoneum In transperitoneal approaches, the plexus is split directly under the peritoneum Retroperitoneal approaches allow for preparation behind the vessels, so the plexus can be preserved The restrictive use of bipolar cauterization may reduce the risk.
Trang 2Frequency of complications. Complication rates of
spinal procedures are dependent on the type of
surgery, spinal pathology, the experience of the
sur-geon and confounding factors such as age and
co-morbidities The most frequent complications of
cervical surgery are infection (1.6%) and Horner’s
syndrome (1.1%) as well as neurologic
deteriora-tion (3.3 %) in cervical myelopathy In anterior spinal
surgery, death and paraplegia are encountered in
0.3 – 0.4 % and 0.2 – 0.4 %, respectively The overall
complication rate for posterolateral fusion is about
6% and is dependent on the age of the patient
Im-plant related neurological compromise and
post-operative wound infection are among the most
frequent complications.
Preventive measures. The best treatment for
com-plications is their avoidance Important measures to
prevent complications are the screening for risk
fac-tors such as past history of thromboembolic
com-plications, previous postsurgical infections,
previ-ous surgery, malnutrition, cardiovascular disease,
COPD, smoking, and medications (e.g., NSAIDs).
Detailed preoperative planning including potential
salvage strategies is mandatory to minimize the risk
of complications A profound knowledge of the
sur-gical anatomy is indispensable Correct patient
po-sitioning reduces blood loss Neuromonitoring is a
must in cases in which deformity correction is
at-tempted.
Approach-related complications The superior
and recurrent laryngeal nerve and the cervical
ar-teries are at risk when performing an anteromedial
cervical approach Lung lacerations and injuries to
the thoracic vessels may occur when a thoracotomy
is done Pulmonary artery lesions are very
chal-lenging to repair even for very experienced thoracic
surgeons Postoperative pneumothorax and
he-matothorax can be avoided by proper drainage A
chylothorax can become a life-threatening
prob-lem and requires temporary parenteral nutrition A
thoraco-lumbar approach may jeopardize the liver
and spleen Venous and arterial injuries may occur
with abdominal approaches and require adequate
repair and aftertreatment Bowel and urethral inju-ries are rare but must not be overlooked.
Procedure-related complications Excessive epi-dural bleeding is a frequently encountered
prob-lem during posterior decompressive surgery and
can be reduced with correct patient positioning.
Nerve root injuries subsequent to posterior Instru-mentation can be minimized with proper training
and experience Unintended durotomy is not
infre-quent in cases with severe spinal canal stenosis,
and direct repair is recommended whenever pos-sible Distraction during deformity correction is
prone to neurological compromise and must be avoided Hypotensive surgery should be avoided
when correcting severe spinal deformity Reduc-tion of high-grade spondylolisthesis jeopardizes
the L5 nerve root and complete reduction should therefore be avoided.
Postoperative complications. Postoperative moni-toring must include blood loss, neurological and
vascular status Continuous postoperative bleed-ing is a frequent problem particularly after
posteri-or revision surgery and spinal osteotomies This problem can be minimized with proper intraopera-tive hemostasis and timely blood and factor
substi-tution Persistent wound drainage is indicative of infection or malnutrition A hypoliquorrhea syn-drome only occurs with tiny leaks not discovered
intraoperatively and which most often need to be
repaired Postoperative vascular complications are
rare but may be detrimental if overlooked, particu-larly large vessel injuries with continuous bleeding
or arterial thrombosis Pulmonary complications
can be minimized with proper preoperative
respira-tory treatment The duration of postoperative bowel atonia can be reduced by avoiding extensive
opioid treatment and alternatively using
postoper-ative peridural anesthesia Urinary tract infections
are not infrequent and routine catherization for short surgeries should be avoided The rate of retro-grade ejaculation (2–13%) is more frequent than as-sumed and can be reduced by avoidance of cauter-ization of the pre-discal vessels.
Trang 3Key Articles
Baron EM, Albert TJ ( 2006) Medical complications of surgical treatment of adult spinal deformity and how to avoid them Spine 31:S106–18
Recent extensive review of complications in adult spinal surgery
Bungard TJ, Kale-Pradhan PB ( 1999) Prokinetic agents for the treatment of postopera-tive ileus in adults: a review of the literature Pharmacotherapy 19:416–423
A good description of how to treat postoperative bowel atonia The different pharmaceu-tical options are discussed
Coe JD, Arlet V, Donaldson W, Berven S, Hanson DS, Mudiyam R, Perra JH, Shaffrey CI ( 2006) Complications in spinal fusion for adolescent idiopathic scoliosis in the new mil-lennium A report of the Scoliosis Research Society Morbidity and Mortality Commit-tee Spine 31:345–9
Review of complications in 6 334 patients undergoing surgery for adolescent idiopathic scoliosis
Flinn WR, Sandager GP, Silva MB Jr, Benjamin ME, Cerullo LJ, Taylor M ( 1996) Prospec-tive surveillance for perioperaProspec-tive venous thrombosis Experience in 2643 patients Arch Surg 131:472–480
An excellent study of all aspects of thrombosis and pulmonary embolism in spine sur-gery The article demonstrates the relatively low risk of venous thrombosis in comparison
to orthopedic procedures like arthroplasty of large joints
Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L ( 1995) The surgical and medi-cal complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults A review of 1223 procedures Spine 20:1592–1599
This article is a good overview of the incidence of complications of anterior deformity surgery The overall estimation of the risk is perhaps too optimistic Therefore the article
by Leung and Grevitt (2005) cited below is recommended in addition to achieve a more balanced view
Fritzell P, Hagg O, Nordwall A; Swedish Lumbar Spine Study Group ( 2003) Complica-tions in lumbar fusion surgery for chronic low back pain: comparison of three surgical techniques used in a prospective randomized study A report from the Swedish Lumbar Spine Study Group Eur Spine J 12:178–189
An overview of all aspects of complications in lumbar fusion, showing a high increase of complications with instrumentation and further with 360° fusion In the further course, several articles were published by the same authors, showing fewer complications like pseudoarthrosis in the midterm with instrumented 360° fusion
Inamasu J, Guiot BH ( 2005) Iatrogenic vertebral artery injury Acta Neurol Scand 112:349–357
This article describes all iatrogenic causes of vertebral artery lesions, including percuta-neous puncture, treatment options and outcome
Jansson KA, Nemeth G, Granath F, Blomqvist P ( 2004) Surgery for herniation of a lum-bar disc in Sweden between 1987 and 1999 An analysis of 27576 operations J Bone Joint Surg Br 86:841–847
This is the best casuistry on complications of surgery for disc herniation A remarkable mortality of 0.5 % was found in the first 30 days after surgery, which was clearly associ-ated with increased age
Kraemer R, Wild A, Haak H, Herdmann J, Krauspe R, Kraemer J ( 2003) Classification and management of early complications in open lumbar microdiscectomy Eur Spine J 12:239–246
This review article gives a good overview of complications after lumbar microdiscectomy, with recommendations on treatment
Lapp MA, Bridwell KH, Lenke LG, Baldus C, Blanke K, Iffrig TM ( 2001) Prospective ran-domization of parenteral hyperalimentation for long fusions with spinal deformity: its effect on complications and recovery from postoperative malnutrition Spine 26:809–817
This paper emphasizes the importance of sufficient alimentation in avoiding periopera-tive spinal complications
Trang 4Key Articles
Leung YL, Grevitt M, Henderson L, Smith J ( 2005) Cord monitoring changes and
seg-mental vessel ligation in the “at risk” cord during anterior spinal deformity surgery.
Spine 30:1870–1874
A valuable article for identification of patients at risk of paraplegia
Timberlake GA, Kerstein MD ( 1995) Venous injury: to repair or ligate, the dilemma
revisited Am Surg 61:139–145
An article on 322 venous lesions, treatment options and the sequelae
Oderich GS, Panneton JM, Hofer J, Bower TC, Cherry KJ Jr, Sullivan T, Noel AA, Kalra M,
Gloviczki P ( 2004) Iatrogenic operative injuries of abdominal and pelvic veins: a
poten-tially lethal complication J Vasc Surg 39:931–936
This article reports a high mortality rate after venous lesions and should be read in
con-junction with the article by Timberlake et al
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Trang 9Outcome Assessment
in Spinal Surgery
Mathias Haefeli, Norbert Boos
Core Messages
✔ The evaluation of treatment modalities for
spi-nal disorders by self-administered
question-naires has entered into clinical practice
✔ Functional and psychosocial aspects often
exhibit a closer correlation with fair or poor
outcome after spinal surgery than
organ-spe-cific symptoms and morphological alterations
and must therefore be evaluated in outcome
research
✔ The main subjects addressed by outcome tools
are pain, disability, health-related quality of life
and work status
✔ For more thorough investigations, psychosocial aspects, work-related parameters and fear avoidance behavior should additionally be assessed
✔ There are several standardized and validated questionnaires available
✔ Current research is trying to facilitate data assessment by developing short but reliable instruments
General Concepts of Outcome Assessment
The evaluation of treatment modalities in spinal orders by self-administered
assessment tools has become standard in most institutions In many fields of
medicine and particularly in spinal surgery, it has become evident that treatment
outcome is influenced by a large variety of non-morphological factors [100]
Psy-chosocial aspects and work-related factors often exhibit a higher predictive value
than pathomorphological and surgical aspects [47] Therefore, it has become
apparent that a meaningful outcome assessment should consider most of these
confounding variables, which, however, is not always possible to achieve in a
busy clinical practice The minimal data set that should be collected consists of:
) pain
) disability
) quality of life
) work status
Several criteria should be considered when data assessment is performed by
self-rating questionnaires:
) comparability
) validity
) availability
) scale characteristics
When a comparison between treatment groups is chosen in a study, the criteria
of comparability of a questionnaire must be defined If the results are to be
Trang 10com-pared with a control group out of the literature, an identical questionnaire must
be used.
Validity [2] is the degree to which an instrument measures what it is intended
to measure It is the most important quality of a questionnaire and there are
dif-ferent types of validity A questionnaire ideally should fulfill:
) content validity, i.e the extent to which the instruments include the domain
of the target phenomenon
) criterion validity, i.e extent of agreement when comparing with a “gold
standard”
) construct validity, i.e extent to which the instrument corresponds to
theo-retical concepts of the target phenomenon Most of the questionnaires are developed for the English language If these tools are used in non-English speaking countries, these versions should ideally be translated and validated first for the used language (availability) Several rules
should be considered in this process of cross-cultural adaptation [13] According
to this, such a process should start with at least two forward translations into the target language In a second step a synthesis of the two translations should be done before performing at least two back translations in the next step After a consolidation of all versions of the instruments resulting from the first three
Table 1 Outcome tools in spinal surgery
(validated versions only)
French [38]
German [156]
Greek [24]
Portuguese [115]
Spanish [88]
Swedish [82]
Turkish [90]
ODI English [50]
Finnish [63]
French [157]
German [11, 101, 102] Greek [24]
NASS-Q English [39]
German [123]
Italian [119]
FAQH German [86]
NDI English [145]
French [157]
Swedish [3]
NPDI English [154]
French [157]
Turkish [20]
Quality of life WHOQOL-100/-Bref www.who.int
SF-36/-12/-8 www.sf36.com EQ-5D www.euroqol.org SRS-22/-30 English: www.srs.org
Spanish [10]
Fear avoidance behavior FABQ English [149]
German [121, 138]
Core item tools Low back pain English [41]
German [99]
Neck pain English [155]