Management of Spine Surgery Complications

» Management of Spine Surgery Complications
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Prevention, Recognition, and Management of Spine Surgery Complications

Despite the lengthy title of this news article, it doesn't really begin to tell you about all the information contained within! First, the specific spine surgery in question is anterior lumbar (from the front of the low back).

This type of surgery is done for spinal instability that requires fusion, tumors that have to be removed, and infection that must be cleaned out. Not to mention disk degeneration, trauma, spinal deformity, and other causes of nerve impingement requiring surgery.

Whatever they are called -- complications, problems, or adverse events -- anything that occurs during or after the procedure that has a negative effect on the patient's outcomes (results) is the focus. Any problems from the surgery that require additional treatment (e.g., blood clots, failure of the wound to heal, nerve damage) are also considered complications.

There are many different ways to classify or group complications. If we just look at it from a timeline point-of-view, then there's intraoperative (during surgery) and postoperative (anytime after surgery up to six weeks) complications. But other categories of complications include problems that occurred as a result of the patient position, device-related (implants), or approach (anterior versus posterior incision).

Interbody implants (cages or bone graft placed in between the vertebrae where the disc was removed) can cause problems if they are too small, too tight, too loose, or too narrow. It takes a lot more skill and planning than we might realize for the surgeon to select and put in place the right-sized interbody fusion implants.

The anterior approach is necessary when the risk of spinal cord or nerve root damage is too great using a posterior approach. In the case of tumors or infection, the location of the problem may dictate the use of an anterior incision. But there are a lot of organs, arteries, veins, and deep muscles that can get nicked (cut) by accident during the procedure.

Adverse events linked with the anterior approach tend to be vascular (damage to blood vessels), visceral (injury to abdominal organs including the bowel), and neural structures (traction or cutting of nerve roots or nerve groups).

When removing the disk and replacing it with a metal cage and/or bone graft material, the surgeon must be careful not to over distract the two opposing vertebral bodies. Pulling the two vertebrae too far apart in order to get the disc out and put the cage in is the single most common cause of nerve root injury. Pull or traction on the nerve root causing nerve damage may be temporary but it takes a long time to recover.

Men are at risk for damage to the nerves controlling penis erection and ejaculation. Sometimes a problem called retrograde ejaculation develops. Instead of propelling the semen forward and out the penis, it goes backwards and into the bladder. Not everyone recovers from this problem. In fact, only about one-third regain complete sexual function. Young men should be fully informed about the possibility of this complication with anterior spinal surgery.

Of course, every surgeon does everything possible to avoid procedure, patient, or device-related complications. The use of fluoroscopy, a real-time, three-dimensional) type of X-ray helps guide the surgeon. Even with fluoroscopy, ileus (paralyzed bowel) can develop.

When any type of problem does arise, the next best thing is to manage it well and prevent the need for additional surgery. Management depends on what the problem is. For example, bleeding complications such as uncontrolled bleeding can result in serious complications (e.g., paralysis).

Blood clots can cut off blood supply in the legs or travel to the lungs and cause death. Watching for and recognizing early signs and symptoms is a key to prevention fatal blood clots. Pulses in the feet, skin color, and oxygen levels are measured frequently to assure proper blood circulation.

In summary, any type of surgery comes with its own set of potential complications. Spinal surgeons do everything they can to prevent and avoid such problems right from the start. Patients must be warned what to expect should something go wrong as a result of the surgery itself. Fortunately such adverse events are rare and usually temporary. With quick intervention, the problem can be managed quite well.

Reference: John K. Czerwein, Jr, MD, et al. Complications of Anterior Lumbar Surgery. In Journal of the American Academy of Orthopaedic Surgeons. May 2011. Vol. 19. No. 5. Pp. 251-257.

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