In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma

Introduction: Spontaneous spinal epidural haematoma is an uncommon clinical problem which may lead to severe and permanent neurological deficit. The treatment options for spinal cord compression by extradural haematoma in the anticoagulated patient are limited. The majority of cases reported have been treated surgically. 1. Operative intervention carries a potential risk of extending the haematoma with further deterioration of the neurological deficit. Methods: A case of paraplegia following spontaneous epidural haemorrhage is reported with a review of the prognostic factors that determine likely improvement in neurological function post-surgery. Case report: A 59-year old man was referred to the regional Spinal Trauma Centre with a 34-hour history of severe lower back pain of sudden onset and 14 hour history of neurological deficit in both legs and urinary overflow incontinence. He had undergone aortic valve replacement two years previously, with subsequent anticoagulation with Warfarin. Examination showed complete paraplegia below L3 with grade 1 power on hip flexion only. On catheterisation, the residual volume of urine was 1200mls. The INR was 3.5. An MRI of the spine showed epidural haematoma that extended from the level of T11 to L5. The patient was treated non-operatively. On discharge at 10 weeks he had normal sensation to L3 and grade 5-power on left knee extension and grade 4-power on the right. There was no motor recovery distal to this. He had a hypotonic neurological bladder with sufficient resting tone in the sphincter to prevent incontinence. Discussion: Although associated with a definite mortality, surgical decompression of the spinal cord and evacuation of the haematoma improves neurological outcome and is the treatment of choice. 1. The decision to treat non-operatively should be based on the duration and severity of the neurological deficit. A literature review identifies neurological deficit greater than 12 hours and severe neurological deficit on presentation are poor prognostic indicators. 2. The prognosis for neurological recovery in this case was poor. In a patient with severe coexisting medical problems these factors can assist when making the decision to operate on an individual patient with spinal epidural haematoma

Aims. Our aim was to perform a systematic review of the literature to assess the incidence of post-operative epidural haematomas and wound infections after one-, or two-level, non-complex, lumbar surgery for degenerative disease in patients with, or without post-operative wound drainage. Patients and Methods. Studies were identified from PubMed and EMBASE, up to and including 27 August 2015, for papers describing one- or two-level lumbar discectomy and/or laminectomy for degenerative disease in adults which reported any form of subcutaneous or subfascial drainage. Results. Eight papers describing 1333 patients were included. Clinically relevant post-operative epidural haematomas occurred in two (0.15%), and wound infections in ten (0.75%) patients. Epidural haematomas occurred in two (0.47%) patients who had wound drainage (n = 423) and in none of those without wound drainage (n = 910). Wound infections occurred in two (0.47%) patients with wound drainage and in eight (0.88%) patients without wound drainage. Conclusion. These data suggest that the routine use of a wound drain in non-complex lumbar surgery does not prevent post-operative epidural haematomas and that the absence of a drain does not lead to a significant change in the incidence of wound infection. Cite this article: Bone Joint J 2016;98-B:984–9

Aims. To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis. Patients and Methods. A total of 2181 adults underwent 2366 elective spinal procedures between January 2007 and January 2012. All patients wore anti-embolic stockings, mobilised early and were kept adequately hydrated. In addition, 29% (689) of these were given low molecular weight heparin (LMWH) while in hospital. SSI surveillance was undertaken using the Centers for Disease Control and Prevention criteria. Results. In patients who only received mechanical prophylaxis, the incidence of VTE was 0.59% and that of SSI 2.1%. In patients who were additionally given LMWH, the incidence of VTE was 0% and that of SSI 0.7%. The unadjusted p-value was 0.04 for VTE and 0.01 for SSI. There were no cases of epidural haematoma or 90-day mortality in either group. When adjusted for case-mix, LMWH remained a significant factor (p = 0.006) for VTE, but not for SSI. Conclusion. A peri-operative protocol involving mechanical anti-embolism stockings, adequate hydration, and early post-operative mobilisation is effective in significantly reducing the incidence of VTE. The addition of LMWH is safe in patients at higher risk of developing VTE. Cite this article: Bone Joint J 2017;99-B:1204–9

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status. Cite this article: Bone Joint J 2015;97-B:527–31

The purpose of this study is to call attention to the diagnosis of spinal cyst caused by lumbar disc herniation. Reviewing a total of 11 cases of lumbar spinal cyst that have been encountered in our spinal practice, we propose our views concerning the pathology of this lesion. The clinical findings of lumbar spinal cyst are identical to those in acute disc herniation such as low back pain and radiculopathy. The characteristics of imaging study are as follows; The magnetic resonance imaging (MRI) demonstrates a relatively large, rounded mass postero-laterally to the vertebral body. These lesions are isointense relative to the intervertebral disc on T1-weighted images and homogeneously hyperintense on T2. A gadolinium -DTPA-enhanced MRI shows a rim-enhancing lesion. A discogram reveals leakage of the contrast medium into the mass. The operative findings demonstrated encapsulated soft tissue masses which contained bloody fluid and small fragments of herniated disc tissue. The pathologic examinations revealed fibrous tissue with hemosiderin deposit in cyst wall and degenerative disc materials with inflammatory cell infiltration. This type of lumbar spinal cyst has been recognized as spinal epidural hematoma in recent years. Wiltse suggested that epidural hematoma may result from tearing of fragile epidural veins due to acute disc disruption. However, MRI characteristics of hematoma are not identical with those with lumbar spinal cyst. It is more likely that the lesions showing the pattern of changes are herniated disc tissue accompanied by hemorrhage and inflammation. If hernial tissue is covered with some membranous susbtance, formation of cystic lesions is understandable. Hence, we hypothesize that lesions, in which lysis liquefaction and absorption of the herniated disc tissue associated with inflammatory response have progressed, and the herniated disc tissue has completely disappeared, may be filled solely with bloody fluid, showing an appearance like cysts

The evaluation of results following posterior decompression and fusion for the management of cervical spondylotic myelopathy. Between July 2006 and May 2008, 68 patients with cervical myelopathy underwent posterior decompression with laminectomies and pedicle screw fixation of the cervical spine. All patients were selected based on the presence of multi-level degenerative disease and the correction of cervical lordosis on the pre-operative dynamic radiographs. Patient demographics, co-morbidities and post-operative complications were recorded and analysed. Functional outcome was assessed by using the Japanese Orthopaedic Association (JOA) score. There were 37 male and 31 female patients with an average age 67.4 years. The average follow up period was 18 months. The mean pre-operative JOA score was 8.7, whereas the mean post-operative score was 12.1 on the latest follow-up visit. 9 patients had unsatisfactory clinical results and consequently underwent anterior procedures with significant improvement. Complications included 1 epidural haematoma, 2 superficial infections and 4 cases of myofascial pain. In three cases there was mild dysfunction of the C5 nerve root which resolved spontaneously with conservative measures. In the present series of patients posterior decompression with laminectomies is an effective method for the management of cervical spondylotic myelopathy

Purpose of the study: Surgical strategy for the treatment of pyogenic spondylodiscitis remains a controversial issue, mainly because of the low incidence. This retrospective review was undertaken to clarify current practices. Material and methods: Nineteen patients (11 male, 6 female)with pyogenic spondylodiscitis underwent surgery from 2003 to 208. Mean age at surgery was 62.7 years (41–100). The localisation was cervical (n=6), thoracic (n=8) and lumbar (n=3). Motor deficit was present preoperatively in 13 patients. There were no cases of complete paralysis. The indication for surgery was aggravation of the neurological deficit in 14 patients and kyphosic deformity in three. The release was achieved via an anterior access for the cervical cases and via a posterior access for the thoracic and lumbar cases. The circumferential procedure achieved complete bilateral arthrectomy. In all cases the instrumented fusion was followed by postoperative immobilisation for three months. Antibiotics were also given for three months. Functional and radiographic outcome were assessed at last follow-up. Results: Mean follow-up was months (12–26 months). There were no clinical or biological signs of recurrent infection despite implantation of osteosynthesis material. Irrespective of the delay to treatment, the 13 patients with a preoperative deficit presented signs of recovery. Eight of them recovered completely and the five others had a motor deficit rated at 4/5. Radiographically, there were no fusion failures at last follow-up. Two patients had revision surgery: one for recurrent tetraparesia due to a postoperative epidural haematoma, the other to achieve impaction of the graft in the vertebral body. Discussion: – This series emphasises the clinical impact of surgical treatment of pyogenic spondylodiscitis. Surgery enables a certain degree of neurological recover achieved by wide decompression. It enables bone fusion despite instrumentation in this complex septic situation

The lumbar or sacral root compression is frequently associated with degenerative spinal diseases. It may be caused by the hypertrophic facets, hypertrophic ligamentum flavum, or protruding disc. Canal stenosis, epidural hematoma, the cyst of pseudo-joint from degenerative or lytic-type spondylolisthesis, or tumors are less common. We present one unusual case with the severe progressive symptom of bilateral S2-4 root compression. The 80-year-old active male suffered the intermittent claudication for 4 months and got the worse symptom including bilateral painful buttocks in recent one month. The bilateral radiation pain cannot be changed at any position and taking a rest. Plain x-ray showed the degenerative spondylolisthesis over L4-5 level. The magnetic resonance imaging showed the cyst-like mass indented the dura posteriorly. During the operation, one huge psudo-joint capsule created from the interspinous ligament compressed the dorsal side of the cauda equina. We performed the posterior decompression and removal of the pseudo-joint capsule and ligamentum flavum with posterolateral fusion. The patient was completely resolved from all the symptoms after surgery. Therefore we present the unusual case and discuss the differentiation from synovial or ganglion cysts of the spine

Over 5 years we gave 84 patients epidural cortisone (80 mg depomedrol and local anaesthesia) for back and/or leg pain due to degenerative disease of the spine. The mean age of the 35 men and 49 women was 65.2 years (37 to 86). All patients had back pain and 77% had neurogenic leg pain. Spinal radiographs demonstrated degenerative changes, including intervertebral disc space narrowing and/or facet joint arthritis, in 84%. MRI, performed in 80 patients (95%), confirmed degenerative disease of the lumbar spine and demonstrated neural compression in 78 of the 80 (97%). Five patients received a second epidural injection and one a third. Complete resolution of back and/or leg pain occurred in 32 patients (38%), and 34 (40%) had relief for between 1 and 12 months. There was no change in the symptoms of 18 patients (21%). Surgery was undertaken in 17 patients (20%), with seven undergoing spinal decompression alone and 10 decompression and a fusion. After surgery, four of the seven patients who did not have a fusion still had back pain. All 10 of the patients who underwent decompression and fusion had a good outcome. One patient developed an epidural haematoma following the epidural injection. Epidural steroid injection had a favourable outcome in 78% of our patients, with a low incidence of complications. Patients who failed to respond to the epidural injection did poorly with spinal decompression alone

The purpose of this study was the investigation and treatment of all the complications that may occur from the epidural postoperative analgesia in patients who have undergone major orthopaedic surgery. From October 1999 to April 2002, 200 patients ASA I- III, aged 45–90 (average 72) were studied. They all received postoperative epidural analgesia and were given a mixture of local anaesthetic and Opioid analgesic, more specifically Ropivacaine 2% 10 ml/h and Morphine 0, 1 ug/h via the epidural catheter by means of a stable infusion pump. The analgesic effect covers the patients for the first 2–3 postoperative days and permits earlier and pain free mobilization and physiotherapy. The analgesic result of this method was completely satisfactory with a mean of VAS 96. The most frequent side-effects were nausea and vomiting. Pruritus, mild hypotension, hypaesthesia and motor blockage were documented as well but in a very small percentage. No case of respiratory depression or medical toxicity was mentioned, neither epidural haematoma nor infection due to the placement of epidural catheter. The complications during the recovery phase were treated easily by discontinuation of the infusion or by symptomatic therapy. Epidural analgesia with a steady infusion pump is a secure method of analgesia. However it is of great importance that the patient is informed about the epidural anaesthesia and postoperative analgesia, in a such a way as to attain his/ her consent, participation and collaboration for the best therapeutic result

This is a study to investigate the diagnostic and prognostic value of MRI in spinal cord injury. We performed this prospective study on sixty two patients of acute spinal trauma. We evaluated the epidemiology of spinal trauma & various traumatic findings by MRI. MRI findings were correlated with clinical findings at admission & discharge according to ASIA impairment scale. Four types of MR signal patterns were seen in association with spinal cord injury-cord edema / non haemmorhagic cord contusion (CC), severe cord compression (SCC), cord hemorrhage (CH) and epidural heamatoma (EH). Isolated lesion of cord contusion was found in 40%. All other MR signal patterns were found to be in combination. In cord contusion we further subdivided the group into contusion of size < 3 cm and contusion of size > 3 cm to evaluate any significance of length of cord contusion. In cord heammorhage involving >1cm of the cord, focus was said to be sizable. On bivariate analysis, there was a definitive correlation of cord contusion (CC) involving <3cm & > 3cm of cord with sensory outcome. In >3cm, chances of improvement was 5.75 times lesser than in patients with CC involving <3cm of cord (odds ratio = 5.75 (95% CI: 0.95, 36), Fisher's exact p = 0.0427 (p<.05). In severe cord compression (SCC) the risk of poor outcome was more (odds ratio 4.3 and p=0.149) however was not statistically significant. It was noted that the patients in which epidural hematoma (EH) was present, no improvement was seen, however, by statistical analysis it was not a risk factor and was not related with the outcome (odds ratio – 0.5 and p = 0.22). Presence of cord oedema / non haemorrhagic contusion was not associated with poor outcome (odds ratio 0.25 and p=0.178). On multiple logistic regression / multivariate analysis for estimating prognosis, sizable focus of haemorrhage was most consistently associated with poor outcome (odds ratio −6.73 and p= 0.32) however it was not statistically significant. The risk of retaining a complete cord injury at the time of follow up for patients who initially had significant haemorrhage in cord was more than 6 fold with patients without initial haemorrhage (odds ratio 6.97 and p= .0047). Besides being helpful in diagnosis, MRI findings may serve as a prognostic indicator for clinical, neurological and functional outcome in acute spinal trauma patients

We evaluated the safety and efficacy of a multimodal approach for prophylaxis of thromboembolism after THA, which includes preoperative autologous blood donation; hypotensive epidural anesthesia; intravenous administration of heparin during surgery, before femoral preparation when the thrombogenesis is maximally activated; expeditious surgery, minimizing femoral vein occlusion and blood loss; pneumatic compression; and early mobilization after surgery. 1946 consecutive, non-selected patients (2016 THAs) who received multimodal thromboembolic prophylaxis were followed prospectively for 3 months. Only patients with history of thrombocytopenia (platelet count < 100.000) or adverse reaction to heparin were excluded. The average age was 65 years (14 to 93), ASA classification was 1 in 14%, 2 in 48%, 3 in 37% and 4 in 1% of patients. There was a history of DVT in 86 patients and PE in 35. After surgery, the patients also received pharmacologic prophylaxis for 6 weeks (aspirin 83%; warfarin 17%). The incidence of asymptomatic DVT assessed by ultrasound in the first 198 consecutive patients was 7.1% (14 of 198). The incidence of clinical DVT in the subsequent 1748 patients was 1.8% (32 of 1748). Symptomatic PE occurred in 0.56% (11 of 1946), none of them fatal. The rate of PE in patients receiving aspirin was 0.49% (8 of 1615) and warfarin 0.9% (3 of 331). There was 1 PE among 95 patients with a prior history of PE or DVT (1%). One morbidly obese patient died of a cardiac arrhythmia confirmed by autopsy. There was only one major bleeding complication: one patient with a history of coagulopathy developed hematuria requiring a bladder flush and five units of blood, with an uneventful recovery. No patients developed epidural hematoma following administration of intraoperative heparin. A multimodal approach to prevent thromboembolic disease, showed results that compare favorably with the literature, and with our historic control of 2592 THRs without intraoperative heparin (PE rate of 1%; 0.04% fatal). This multimodal approach appears safe and efficacious as thromboembolic prophylaxis. Our low rate of PE does not support routine anticoagulation prophylaxis with drugs with a significant risk of bleeding

A 14 year-old-female, underwent a T3-L3 instrumented posterior spinal fusion for a double major curve. Surgery under controlled hypotensive anesthesia was uneventful, with normal somatosensory and motor potentials. After instrumentation, patient underwent a normal wake-up test. The preoperative haemoglobin and haematocrit was 15.1g/dl with 41%, respectively. Estimated blood loss was 400cc and postoperative haemoglobin and haematocrit were 9.7g/dl and 31% respectively. Clinical examination was normal immediately postoperatively, on the first postoperative day and the beginning of the second postoperative day. At the end of POD 2, the patient started to feel both lower extremities “heavy” and sensitive to touch. She developed generalized proximal lower extremity weakness and was unable to stand. She was also unable to void after catheter removal. At this stage, her hemoglobin had dropped from 10 g/dl on POD 1 to 7.3 g/dl. Her haemoglobin fell to 6.2 g/dl the next day with a haematocrit of 18%. No significant bleeding was noticed, and other than lightheadedness, no haemodynamic changes were noted. Transfusion was performed correcting the haemoglobin to 9.3 g/dl and haematocrit to 27%. Compressive etiology was ruled out by post-operative myelogram-CT. Patient was discharged on POD 13 and was neurologically intact at three month follow-up. Discussion: Delayed neurological deficits have been reported, and are associated most frequently with epidural haematomas. Postoperative hypotension as the etiological factor has been reported only in an adult patient. As cord compression was ruled-out the only event we can correlate with the beginning of the neurological deficit is the unexplained acute drop in haemoglobin levels on the second day, possibly impairing normal cord oxygenation. If this is not the case, we would have to accept false negative results for the three standard methods currently available for spinal cord monitoring during surgery. In this case, the normal postoperative neurological exams, performed during the first 48 hours after surgery, and the subjective symptoms the patient experienced associated with the beginning of motor deficit, leads us to conclude that the injury happened on the second day in relation to the postoperative anaemia. Although we believe children tolerate low levels of haemoglobin, transfusion policies might have to be reconsidered as the cord may be transiently at risk for ischemic events after deformity correction

Aims

The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption.

Introduction and Objectives: This is a retrospective study on the treatment of lumbar degenerative disk disease (LDDD) using intervertebral arthroplasty. The lack of uniformity in the treatment of LDDD, persistence of pain even with solid fusion, and the possibility of changes over the fusion site have encouraged us to seek other solutions for this condition. Total intervertebral arthroplasty has been proposed as a possible alternative for selected cases of LDDD. Materials and Methods: Between November 1999 and July 2002, 16 patients with LDDD were treated surgically using third-generation total intervertebral arthroplasty (Link SB Charité III) with a chromium-cobalt alloy and ultra-high molecular weight (UHMW) poly-ethylene. Average follow-up time was 14 months (6-36 months), and average age was 42 years (35–52). There were 11 females and 5 males. All patients underwent radi-olographic studies, CT scan, MRI, and discography (minimum 2 levels). Indications included LDDD of one to three segments, absence of root tension signs, absence of complete disc collapse, and iconography including concordant discography. LDDD was primary in 11 cases and post-discectomy in 5 cases. Surgery was indicated when at least 6 months of conservative treatment failed to yield results. Blood loss and length of hospital stay were compared to a similar group that underwent posterolateral arthrodesis. Pain, function, and degree of disability were evaluated before and after surgery using GEER (1999) instruments for the evaluation of degenerative lumbar pathology. Increase in height of the posterior intervertebral space and segmentary lordosis were also measured. Results: Preoperative VAS: 7.8; postoperative VAS: 2.3. Disability index (Oswestry) was 41.3% preoperative and 10.8% postoperative. Average increase in height of posterior intervertebral space was 2.4mm, and mean segmental lordosis was 19.5°, which remained constant through the end of the follow-up period. Average hospital stay was 4.8 days (3–15) compared with 7.5 (5–18) for a group of patients who underwent suspended arthrodesis of L4–L5 with a much smaller quantity of blood loss. No infections were found. Complications: One patient developed an epidural haematoma, which was treated conservatively. Another developed a postoperative retroperitoneal haematoma, which was also treated conservatively. In neither case was there an adverse effect on the outcome of the procedure. One patient showed malpositioning of the prosthetic components on follow-up radiographs, with poor clinical progression at one year postoperative. The patient was treated with posterolateral fusion and right L5 foraminotomy. No infections were seen. Discussion and Conclusions: Treatment of LDDD with intervertrebral arthroplasty was shown to be effective in the short term, if strict guidelines are followed. Aggressive surgical management is highly inferior to conventional arthrodesis. A longer follow-up period is needed to confirm the validity of this treatment. Technical error in malpositioning of the components in one case caused a poor result

The December 2022 Spine Roundup³⁶⁰ looks at: Deep venous thrombosis prophylaxis protocol on a Level 1 trauma centre patient database; Non-specific spondylodiscitis: a new perspective for surgical treatment; Disc degeneration could be recovered after chemonucleolysis; Three-level anterior cervical discectomy and fusion versus corpectomy- anterior cervical discectomy and fusion “hybrid” procedures: how does the alignment look?; Rivaroxaban or enoxaparin for venous thromboembolism prophylaxis; Surgical site infection: when do we have to remove the implants?; Determination of a neurologic safe zone for bicortical S1 pedicle placement; Do you need to operate on unstable spine fractures in the elderly: outcomes and mortality; Degeneration to deformity: when does the patient need both?

Aims

Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure.

Aims

Whether to perform hybrid surgery (HS) in contrast to anterior cervical discectomy and fusion (ACDF) when treating patients with multilevel cervical disc degeneration remains a controversial subject. To resolve this we have undertaken a meta-analysis comparing the outcomes from HS with ACDF in this condition.