24 Surgical Complications Surgery is inherently associated with risk. Surgeries involving the spine and spinal cord are subject to various severe complications, and thus warrant additional intervention. An understanding of these complications, along with appropriate prevention and treatment strategies, is essential to patient safety. Therefore, it is important to recognize the etiology, presentation, and management strategies for common surgical complications including postoperative fever, surgical site infection, durotomy, and spinal epidural hematoma (Table 24.1). • Background: – Body temperature greater than 38.6°C (101.5°F). – Incidence rate of 14 to 91%. • Etiology: – Immediate onset: ∘ Majority are noninfectious (>50% of cases). – Acute, subacute, and delayed onset: ∘ Strongly consider infectious etiology. • Risk factors: – Immunosuppression, prolonged operative time, nosocomial infections. – Urinary catheterization, respiratory ventilation. • Presentation: – Diaphoresis, chills, headache. • Background: – Postoperative infection localized to surgical site; occurs within 30 days. – Incidence following spine surgery is 1 to 12%. – Surgical site infection (SSI) types and associated tissues (Fig. 24.1). • Etiology: – Routes of infection: ∘ Direct Inoculation of skin flora. ∘ Wound contamination. – SSI pathogens association: ∘ Gram (+): Staphylococcus. aureus (50% of SSIs), S. epidermidis, and Streptococcus. ∘ Gram (–): Pseudomonas. aeruginosa, Escherichia coli, and Proteus. • Risk factors: – Preoperative: diabetes, smoking history, body mass index (BMI), corticosteroid use, age. – Intraoperative: sterile technique, invasiveness, operative duration. – SSI risk by procedure: trauma > diskitis > tumor resection > minimally invasive. – SSI risk by location: thoracic (2.1%) > lumbar (1.6%) > cervical (0.8%) vertebrae. • Presentation: – Clinical symptoms: ∘ Back pain, wound drainage, erythema, palpable fluctuance. ∘ Fever, fatigue (deep SSI [DSSI] > SSSI). • Clinical evaluation: – Laboratory tests: ∘ Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) elevation (high sensitivity 94–100%). ∘ White blood cell (WBC) elevation (poor sensitivity 44–58%). ∘ Bacterial cultures: ▪ Positive in 51 and 78% of SSSI and DSSI cases, respectively. ▪ Intraoperative and deep cultures preferred. • Radiographic evaluation: – Magnetic resonance imaging (MRI) at 3 to 5 days postoperatively (sensitivity 93%): ∘ T2: edema appears as hyperintense signal. ∘ Decreased height of vertebral disk/body seen with late stage infection. – Radionucleotide imaging: increased uptake of 67Ga at sites of infection. – X-ray: decreased intervertebral height discernable 4 to 6 weeks postoperatively. – Computed tomography (CT): bony destruction, soft-tissue abscesses. • Treatment: – Antibiotics, wound care: ∘ Start antibiotics with broad coverage and narrow upon determination of causative organism. – If conservative treatment fails or symptoms progress: debridement, removal of hardware. • Background: – Incidental tear of dura mater. – Severity determines need for corrective surgery (1–17% of tears). – Cerebrospinal fluid (CSF) leak may create fistulas and pseudomeningoceles. • Etiology: – Direct injury from instrumentation or injection (Fig. 24.2). – Failed dural repair (i.e., tumor/cyst resection, shunt placement). • Risk factors: – Preoperative: diabetes, smoking, age, BMI, radiation, or steroid therapy. – Intraoperative: procedure invasiveness, revision surgery. – Risk by primary diagnosis: spinal trauma (20%) > degenerative stenosis (11.2%) > tumors (10.5%) > lumbar disk herniations (8%). – Risk by surgery location: thoracic (2.2%) > lumbar (2.1%) > cervical (1%) spine. • Cutaneous CSF fistula: – Etiology: ∘ Residual opening permits leak (Fig. 24.3). ∘ CSF drains along surgical tract. ∘ Infection can occur (meningitis).
24.1 Introduction
24.2 Postoperative Fever
24.3 Surgical Site Infections
24.4 Durotomy
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