Complications following posterior cervical decompression and fusion: a review of incidence, risk factors, and prevention strategies
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Abstract: Posterior cervical decompression and fusion (PCF) is a common surgical technique used to treat various cervical spine pathologies. However, there are various complications associated with PCF that can negatively impact patient outcome. We performed a comprehensive literature review to identify the most common complications following PCF using PubMed, Cochrane Database of Systematic Reviews, and Google Scholar. The overall complication rates of PCF are estimated to range from about 15% to 25% in the current literature. The most common immediate complications include acute blood loss anemia, surgical site infection (SSI), C5 palsy, and incidental durotomy; the most common long-term complications include adjacent segment degeneration, junctional kyphosis, and pseudoarthrosis. Three principal mechanisms are thought to contribute to complications. First, higher number of fusion levels, obesity, and more complex pathologies can increase the invasiveness of the planned procedure, thus increase complications. Second, wound healing and arthrodesis may be impaired due to poor blood flow due to various patient factors such as smoking, diabetes, increased frailty, steroid use, and other medical comorbidities. Finally, increased biomechanical stress on the upper instrumented vertebra (UIV) and lowest instrumented vertebra (LIV) may predispose patient to chronic degeneration and result in adjacent level degeneration and/or junctional problems. Reducing the modifiable risk factors pre-operatively can decrease the overall complication rate. Neurologic deficits may be reduced with adequate intraoperative decompression of neural elements. SSI may be reduced with meticulous wound closure that minimizes dead space, drain placement, and the use of intra-wound antibiotics. Careful design of the fusion construct with consideration in spinal alignment and biomechanics can help to reduce the rate of junctional problems. Spine surgeons should be aware of these complications associated with PCF and the corresponding prevention strategies optimize patient outcomes.Keywords:
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Objective. To analyze the efficacy of the method for selecting the distal level of fusion in treatment of thoracic hyperkyphosis in Scheuermann’s disease. Material and Methods. Treatment results in 36 patients operated on in the Department of Children and Adolescent Spine Pathology during 2007-2010 were analyzed. Patients were divided into two groups: in Group 1 (n = 29) a lower instrumented vertebra corresponded to the sagittal stable one, and in Group 2 (n = 7) this vertebra located proximally. Results. The mean preoperative magnitude of kyphosis was 79.3° ± 11.6°, postoperative - 40.6° ± 11.9° (correction 49.9 %), and loss of correction was 4.9° ± 7.0°. Sagittal balance changed from -0.3 ± 3.2 cm before surgery to -1.7 ± 2.1 cm. Distal junctional kyphosis developed in 1 case (4 %) in Group 1, and in 5 cases (71 %) in Group 2. Conclusion. Distal level of instrumentation ending at the first lordotic vertebra is not justified and causes violation of sagittal balance and development of distal junctional kyphosis. Including sagittal stable vertebra in fusion prevents the development of distal junctional kyphosis. Hir. Pozvonoc. 2012;(2):24-29.
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In Brief Study Design. Retrospective case review at a single center. Objective. To analyze the incidence and risk factors associated with proximal junctional kyphosis (PJK) and distal junctional kyphosis (DJK) in patients undergoing instrumented spinal fusion for Scheuermann kyphosis. Summary of Background Data. Previously reported risk factors for junctional kyphosis include improper end vertebrae selection, curve correction greater than 50%, or excessive junctional soft tissue dissection. Methods. Clinical and radiographic data on 67 patients (mean age 37) from a single center treated with instrumented fusion for Scheuermann kyphosis were reviewed. All patients had complete radiographic data with a minimum 5-year follow-up (mean: 73 months). Abnormal PJK was defined by a proximal junctional angle greater than 10° and at least 10° greater than the corresponding preoperative measurement. DJK was similarly defined between the caudal endplate of the lower instrumented vertebra to the caudal endplate that was 1 vertebra below. Results. The incidence of PJK as defined above was seen in 20 patients (30%). The development of PJK was associated with failure to incorporate the proximal end vertebra (15 patients), disruption of junctional ligamentum flavum (3 patients), or combination of both (2 patients). The most common cause of inappropriate end vertebra selection was poor visualization of the upper thoracic vertebra. DJK occurred in 8 patients (12%) and 7 of them had fusion short of including the first lordotic disc. Conclusion. The incidence of PJK can be minimized by the appropriate selection of the upper end vertebra to be fused and avoiding disruption of the junctional ligamentum flavum. The development of DJK can be minimized by incorporation of the first lordotic disc into the fusion construct. An analysis of 67 surgically treated patients with Scheuermann kyphosis (mean follow-up: 73 months) revealed proximal junctional kyphosis in 30% and related either to too short a fusion, or disruption of the posterior ligament complex. Distal junctional kyphosis was seen in 12% and was related to failure in incorporating the first lordotic disc.
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Objective. To analyze the efficacy of the method for selecting the distal level of fusion in treatment of thoracic hyperkyphosis in patients with Scheuermann’s disease. Material and Methods. Over the period of 2007–2010 years 36 patients were operated in the Department of Children and Adolescent Spine Pathology. Patients were divided into two groups: in Group I (n = 29) a lower instrumented vertebra (LIV) corresponded to the sagittal stable one and in Group II (n = 7) this vertebra located proximally. Results. The mean preoperative magnitude of kyphosis was 79.3° ± 11.6°, postoperative – 40.6° ± 11.9° (correction 49.9 %), loss of correction was 4.9° ± 7.0°. Sagittal balance changed from -0.3 ± 3.2 cm before surgery to -1.7 ± 2.1 cm. Distal junctional kyphosis (DJK) developed in 1 case (4 %) in Group I, and in 5 cases (71 %) in Group II. Conclusion. Distal level of instrumentation ending at the first lordotic vertebra is not justified and causes violation of sagittal balance and development of distal junctional kyphosis. The inclusion of a sagittal stable vertebra in fusion prevents the development of distal junctional kyphosis.
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Six of 14 patients surgically treated for Scheuermann's disease developed a short segmental kyphosis adjacent to the fusion. In four patients, the original fusion had incorporated the end vertebrae of the curves. However, there was mild wedging of the end vertebra, which led to a loss of correction occurring at the junction between fused and unfused segments. These losses averaged 13° (range, 6–29°) at follow-up, ranging from 1 to 5.5 years (average, 2.8 years). The resultant short segmental kyphosis ranged in magnitude from 15° to 34° (average, 23°). The kyphosis occurred distally in five patients and proximally in one patient. The risk of developing a short segmental kyphosis may be minimized if the fusion and instrumentation extend beyond all wedged vertebrae to the first "square" vertebra. This will necessitate fusing into the upper lumbar spine for many patients.
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Objective. To analyze the efficacy of the method for selecting the distal level of fusion in treatment of thoracic hyperkyphosis in Scheuermann's disease. Material and Methods. Treatment results in 36 patients operated on in the Department of Children and Adolescent Spine Pathology during 2007-2010 were analyzed. Patients were divided into two groups: in Group 1 (n = 29) a lower instrumented vertebra corresponded to the sagittal stable one, and in Group 2 (n = 7) this vertebra located proximally. Results. The mean preoperative magnitude of kyphosis was 79.3° ± 11.6°, postoperative 40.6° ± 11.9° (correction 49.9 %), and loss of correction was 4.9° ± 7.0°. Sagittal balance changed from -0.3 ± 3.2 cm before surgery to -1.7 ± 2.1 cm. Distal junctional kyphosis developed in 1 case (4 %) in Group 1, and in 5 cases (71 %) in Group 2. Conclusion. Distal level of instrumentation ending at the first lordotic vertebra is not justified and causes violation of sagittal balance and development of distal junctional kyphosis. Including sagittal stable vertebra in fusion prevents the development of distal junctional kyphosis.
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To investigate the feasibility and clinical significance of posterior vertebra column resection and reconstruction in the treatment of severe kyphosis.We retrospectively analyzed the clinical data of 12 patients with severe kyphosis who received posterior vertebra column resection and reconstruction from January 2003 to July 2007.The mean operation time was 5.0 h (4.0 - 7.8 h) and the evaluated blood loss during operation was 1 800 ml (800-3,000 ml). No neurologic complications or post-operative infections were noted. The patients became ambulatory 8 days after operation. Before operation, 5 patients were found to have neurological deficit, including Frankel grade A in 1 patient and D in 4 patients. After operation, the grades were all recovered to Frankel E. After operation, the Cobb angle of the kyphosis was corrected to 38 degrees, with an average correction rate of 63%.Posterior vertebra column resection and reconstruction may be a safe and effective technique for the treatment of severe kyphosis. It can fully decompress the neurological structures, correct the kyphosis deformity, and achieve early weight-bearing. It is especially useful to avoid neurological injury.
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To analyze the efficacy of the method for selecting the distal level of fusion in treatment of thoracic hyperkyphosis in patients with Scheuermann's disease.The fusion area needs to include all the kyphotic deformity in Scheuermann patients; however, precise levels of the distal fixation have not been determined yet.Retrospective cohort review.Thirty-six patients were operated in the Department of Children and Adolescent Spine Pathology between 2007 and 2010. These patients were divided into two groups: in group I (n = 29) a lower instrumented vertebra corresponded to the sagittal stable one and in group II (n = 7) - this vertebra located proximally.The mean preoperative kyphosis was 79.3° ± 11.6°, the postoperative - 40.6° ± 11.9° (correction of 49.9%), loss of correction was 4.9° ± 7.0°. Sagittal balance changed from -0.3 ± 3.2 cm before surgery to -1.7 ± 2.1 cm after surgery. Distal junctional kyphosis developed in 1 case (4%) in Group I, and in 5 cases (71%) in Group II.A distal level of instrumentation ending at the first lordotic vertebra is not justified and causes violation of sagittal balance and development of distal junctional kyphosis. The inclusion of a sagittal stable vertebra in fusion prevents the development of this undesirable situation.
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