Complications of Spinal Surgery

Later complications of spinal surgical procedures include skin breakdown, wound infection, spinal instability (after wide lumbar decompressive procedures not accompanied by fusion), hardware failure, pseudarthrosis, epidural fibrosis, and more rarely, arachnoiditis. (122,127)

The most common complications after spinal surgery with corresponding nursing interventions are listed in Table 2.

Table 2:
Physiolgic Variables Associated with Complications of Spinal Surgery
Early: Post-Operative Hospitalization Phase

Complication: Atelectasis/Pneumonia
Cause: Decreased inspiratory volume and reduced lung expansion from 'splinting'; (decreased respiratory effort related to pain) with inadequate mobilization of secretions.
Risk Factors: History of smoking, inadequate pain relief, immobility, and previous respiratory history (asthma, COPD), thoracic or anterior lumbar surgery. (102,128)
Symptoms: Low grade fever.
Exam Findings: Decreased lung sounds, adventitious lung sounds.
Diagnostic Tests: Chest x-ray.

Complication: Deep Vein Thrombosis
Cause: Venous stasis, injury to blood vessels, hypercoagulability. (88,129, 130, 131)
Risk Factors: General anesthesia, anterior lumbar spinal surgery, immobility, paralysis.
Symptoms: Pain, swelling.
Exam Findings: Pain with passive stretch, warmth, erythema, distal edema. Diagnostic Tests: Color flow Dupplex Doppler Imaging, venogram.

Complication: Dysphagia and Hoarseness
Causes: Injury to the superior or recurrent laryngeal nerves from retraction or dissection intra-operatively, intra-operative retraction of esophagus, pressure from post-operative hematoma, swelling. (13,29,132) The most commonly injured nerve in the upper cervical spine is the superior laryngeal nerve. In the lower cervical spine, the recurrent laryngeal nerve is the most commonly injured.
Risk Factors: Anterior upper cervical surgical approaches, prolonged retraction.
Symptoms: Coughing after oral intake, difficulty swallowing, feeling like a 'lump in the throat', aspiration, voice fatigue (from injury to superior laryngeal nerve), significant edema (from hematoma), hoarseness, vocal cord paralysis (from injury to recurrent laryngeal nerve). (29,125,132)
Diagnostic Tests: Bedside swallow evaluation by a speech therapist, videoscopic swallow evaluation, chest radiograph to detect aspiration pneumonia. CT or MRI if hematoma suspected. (125)

Complication: Hemorrhage
Cause: Altered coagulation studies, inadequate hemostasis intra-operatively or vessels previously in spasm relax.
Risk Factors: Pre-operative use of NSAIDs or anticoagulants, prolonged intra-operative time with large fluid volume replacement and blood product administration.
Symptoms: Increased sanguineous wound drainage, hypotension, lightheadedness, tachycardia, swelling about the incision, increased pain, deteriorating neurologic status (could indicate cauda equina syndrome). (122,127)
Diagnostic Tests: CBC (for hemoglobin, platelet count), CT scan if deep bleeding is suspected (epidural hematoma).

Complication: Ileus
Cause: Slowed peristalsis/decreased GI motility from activation of inhibitory reflexes, release of inflammatory mediators, opioid use. (133-135)
Risk Factors: NPO status, anesthetic use, opioid use, anterior lumbar spinal surgery, decreased mobility. (88,122)
Symptoms: Abdominal pain, bloating, cessation of bowel movements, absence of flatus, nausea, vomiting.
Exam Findings: Decreased, absent (or high-pitched) bowel sounds, distended, firm, tender abdomen, tympany to percussion.
Diagnostic Tests: Abdominal flat plate x-ray.

Complication: Spinal Fluid Leak
Causes: Sharp spicule of bone present in close proximity to the dura post-operatively, dural tear at the time of surgery.
Risk Factors: Decompressive laminectomy, advanced spondolytic changes, severe stenosis, revision surgery, use of pedicle screws. (122,127)
Symptoms: Headache, nausea, vomiting (often postural), clear drainage from the surgical wound, localized swelling. (127)
Diagnostic Tests: Myelography, MRI, cisternogram. CSF analysis if meningitis also suspected.

Complication: Upper Airway Obstruction
Causes: Swelling after cervical spine surgery, laryngospasm, hematoma, dislodged cervical bone graft, CSF extravasation. (125)
Risk Factors: Anterior cervical surgery, combined anterior-posterior cervical surgery, multiple level cervical surgery. (125)
Symptoms: Dyspnea, apnea, stridor, hypoxia.
Diagnostic Tests: Arterial blood gases, x-ray to evaluate soft tissue swelling, CT scan to identify hematoma.

Late: Post Discharge Phase

Complication: Arachnoiditis
Cause: Inflammation of pia and arachnoid membrane.
Risk Factors: Unclear, but may be related to bleeding, trauma, post-operative infection, previous myelography procedures with oil-based agents, and genetics. (136)
Symptoms: May be pain-free, but severe cases will present with burning back and leg pain. Urinary frequency, urgency or incontinence. Sensory alteration below the affected level. (136)
Diagnostic Tests: MRI, contrast-enhanced CT, or myelography to identify clumping or non-visualization of nerve roots. (127) The use of MRI and CT reflects a trend toward non-invasive means of diagnosing arachnoiditis. (136)

Complication: Epidural Fibrosis
Cause: Post-operative healing process produces excessive scar that can adhere to nerves.
Risk Factors: Surgery.
Symptoms: May be totally asymptomatic, may develop radicular pain, often several months post-operatively after an initial resolution of pre-operative symptoms.
Diagnostic Tests: MRI with gadolinium enhancement to differentiate recurrent disc herniation from epidural fibrosis. (127)

Complication: Non-Union
Cause: Failure of sufficient osteoblastic activity to form new 'bridging' bone across fusion site.
Risk Factors: Tobacco use (nicotine) (137-141), multiple level fusions, high grade spondylolisthesis, previously failed fusion, inadequate post-operative immobilization (142), and possibly post-operative use of some NSAIDs (143,144).
Symptoms: Persistent pain and disability.
Diagnostic Tests: Radiographs (including flexion-extension and oblique views) demonstrating bridging bone or progression of deformity and instrumentation failure (broken screws or rods), CT, tomograms.

Variable: May Occur Acutely or Late

Complication: Infection
Cause: Alteration in skin integrity from surgical wound with introduction of organisms in susceptible host or hematogenous spread of organisms from a remote site (e.g., urinary or GI source). (88)
Risk Factors: Surgical wound, prolonged intra-operative retraction time, diabetes, poor nutritional status (116,117,145-147), chronic urinary tract infections, immunocompromised state.
Symptoms: Fever, increased pain, erythema and swelling about the surgical wound, drainage (serous or purulent), spasm.
Diagnostic Tests: CBC (WBC count and differential), sedimentation rate, and if discitis or deep infection suspected, bone scan, MRI, CT-guided biopsy for cultures.