The Incidence Of An Epidural Hematoma Following Cervical Spine Surgery

Transcription

1 The Incidence Of An Epidural Hematoma Following Cervical Spine Surgery Gregory D. Schroeder, MD, Alan S. Hilibrand MD, Paul Arnold, MD, David Fish, MD, Jeffrey C. Wang, MD, Jeffrey L. Gum, MD, Zachary A. Smith, MD, Wellington K. Hsu, MD, Ziya L. Gokaslan MD, Robert Isaacs, MD, Adam Kanter, MD, Thomas E. Mroz, MD, Ahmad Nassr, MD, Rick Sasso, MD, Michael G. Fehlings MD PhD, Zorica Buser, PhD, Mohamad Bydon, MD, Elizabeth L. Lord, MD, Emily C. Nguyen, MD, Daniel Riew, MD. Please see the program for a complete list of all authors disclosures

2 Background Cervical spine surgery for multiple pathologies has been associated with significant improvements in health related quality of life outcomes. However, there are significant risks associated with undergoing cervical spine surgery. Rare complications such as a symptomatic epidural hematoma may lead to significant morbidity such as permanent neurologic deficits. The purpose of this study is to determine the incidence and circumstances surrounding the development of a symptomatic postoperative epidural hematoma in the cervical spine.

3 Methods The study is a large retrospective multi-center case-series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network. Centers included in this network are selected for their excellence in spine care, clinical research infrastructure, and experience. Medical records for 17,625 patients who received cervical spine surgery between January 1, 2005 to December 31, 2011 were reviewed and the incidence of an epidural hematoma following cervical spine surgery was identified

4 A total of 16,582 cervical spine surgeries occurred between January 1, 2005 and December 31, 2011 at 19 different institutions, and 15 patients developed a postoperative epidural hematoma, Incidence of 0.090%. Substantial variation between institutions was noted, with 11 sites reporting no epidural hematomas, and one site reporting an incidence of 0.76% All patients initially presented with a neurologic deficit. Nine patients had complete resolution of the neurologic deficit Two of the three patients (66%) who had a delay in the diagnosis of the epidural hematoma had residual neurologic deficits compared to only four of the twelve patients (33%) who had no delay in the diagnosis or treatment (p = 0.53).

5 Patient demographics and operative details Average Age / Number of Men 8 (53.3%) Average Height (cm) / Average Weight (kg) / Diagnosis Myelopathy 10 (66.7%) Radiculopathy 4 (26.7%) Degenerative Disc Disease 2 (13.3%) Instability 1 (6.7%) Fracture 1 (6.7%) Other 4 (26.7%) Smoking Status Number of Current Smokers 6 (42.9%) Number of Former Smokers 2 (14.9%) Number of Non-Smokers 6 (42.9%) Operative Details Number of Anterior Procedures 5 (33.3%) Number of Posterior Procedure 10 (66.6%) Operative Time (minutes) / Estimated Blood Loss (ml) / Level involved C2 2 (13.3%) C3 11 (73.3%) C4 12 (80.0%) C5 13 (86.7%) C6 13 (86.7%) C7 10 (66.7%) T1 2 (13.3%) T2 2 (13.3%)

6 The %me of symptom onset, if there was a delay in diagnosis and if there were residual neurologic symptoms for each of the fi9een cases Case Number Surgery Days from surgery to ini%al symptoms New postopera%ve symptoms Delay between ini%al change in neurologic symptoms and diagnosis Length of Delay Reason for delay between presenta%on of ini%al symptoms and diagnosis Outcome 1 C4 - C7 Posterior Decompression with a C4- T1 fusion 5 Days Muscle weakness and pain No None Not Applicable Resolved 2 C4 - C5 ACDF 2 Days Muscle weakness and pain No None Not Applicable Resolved 3 C3 - T1 Posterior Decompression and Fusion 2 Days 4 C6 - C7 ACDF Unclear Muscle Weakness No None Not Applicable residual neurologic deficits (Significant motor weakness ASIA C) Significant numbness Unclear Unclear Not Applicable Resolved 5 C6 - C7 ACDF 6 hours Significant pain No None Not Applicable Resolved

7 The %me of symptom onset, if there was a delay in diagnosis and if there were residual neurologic symptoms for each of the fi9een cases Case Number Surgery Days from surgery to ini%al symptoms New postopera%ve symptoms Delay between ini%al change in neurologic symptoms and diagnosis Length of Delay Reason for delay between presenta%on of ini%al symptoms and diagnosis Outcome 6 C5 - T1 ACDF 10 hours Significant pain No None Not Applicable Resolved 7 C3 - C4 Posterior Decompression and Fusion 2 Days Muscle weakness and pain No None Not Applicable residual neurologic deficits (Mild motor weakness- - Asia E) 8 C4 - T3 Posterior Decompression and Fusion 28 Days Significant pain No None Not Applicable Resolved 9 C5 - T1 ACDF Unclear Muscle Weakness Unclear Unclear Not Applicable residual neurologic deficits 10 C4 - T1 Posterior Decompression and Fusion 1 hour Numbness and Muscle Weakness No None Not Applicable Resolved

8 Case Number The %me of symptom onset, if there was a delay in diagnosis and if there were residual neurologic symptoms for each of the fi9een cases Days from Delay between ini%al surgery to change in neurologic Reason for delay between ini%al New postopera%ve symptoms and Length of presenta%on of ini%al symptoms Surgery symptoms symptoms diagnosis Delay and diagnosis Outcome C4 - T3 Posterior Decompression and Muscle weakness, Fusion 2 Days numbness and pain No None Not Applicable Resolved C4 - C7 Posterior Decompression with a C4- T1 fusion C4 - T1 Posterior Decompression and Fusion C5 - C7 laminoplasty with parval C4 and T1 laminectomies 1 Day 3 Days 1 Day Muscle weakness, numbness and pain No None Not Applicable Muscle Weakness and numbness Yes 1 day AwaiVng results of MRI and CT residual neurologic deficits (Significant numbness and motor weakness ASIA C) residual neurologic deficits (persistent numbness and weakness unspecified) Muscle weakness, numbness and pain Yes 7 days Delay in obtaining MRI Resolved 15 C4 - C7 laminoplasty 14 Days Muscle Weakness and numbness Yes 13 days PaVent had significant numbness and radicular pain postoperavvely, and a hematoma was not though to be the cause. PaVent eventually underwent EMG/NCS & MRI to make the diagnosis residual neurologic deficits (Persistent numbness and mild weakness; Asia D)

9 Patients who were diagnosed with a symptomatic postoperative epidural hematoma had no significant improvement in health-related quality of life (HRQOL) metrics between the preoperative evaluation and the final followup evaluation The health related quality of life metrics for patients who developed a postoperative epidural hematoma. NDI MJOA NURICK PHY-SF-36 MENT-sf-36 Baseline score (Not available for all patients) / / / / / Score at final follow up (Not available for all patients) / / / / / Number of patients with both preoperative and follow-up outcomes reported Average Difference / / / / P Value 0.4 NA NDI = Neck Disability Index; MJOA = Modified Japanese Orthopedic Association; PHY-SF-36 = Physical Component of the Short Form (36) Health Survey; MENT-sf-36 = Mental Component of the Short Form (36) Health Survey

10 Conclusion This is the largest series to date to analyze the incidence of an epidural hematoma following cervical spine surgery, and this study suggest that an epidural hematoma occurs in approximately 1 out of 1,000 cervical spine surgeries. Prompt diagnosis and treatment may improve the chance of making a complete neurologic recovery, but patients who develop this complication do not show improvements in the HRQOL measurements