Disclosures Complications in Cervical Deformity Surgery Stryker - PDF document

11/4/16 Disclosures Complications in Cervical Deformity Surgery Stryker Spine: royalties Fellowship support: AOSpine, Globus, Nuvasive Bobby K-B Tay, MD . Clinical Professor Department of Orthopaedic Surgery Director of Spine Fellowship University of California at San Francisco Types of Complications Approach Specific Complications 4 Approach specific – Anterior 4 Anterior Approach – Posterior 4 Technique specific – Osteotomy type: neurologic – Preop planning 1

11/4/16 Dysphagia Incidence of Dysphagia After Anterior Cervical Spine Surgery Bazaz, Lee, Yoo. Spine 2002 4 Mechanism – Deinnervation of the pharyngeal or esophageal muscles – Direct muscle trauma – Pharyngeal fibrosis – Edema/hematoma – Prominent hardware/bone graft 4 Symptoms/Studies/Treatment – Trouble eating, heartburn, coughing/choking, regurgitation – Clinical swallow assessment – Videofluoroscopic swallow study 4 249 consecutive patients Recurrent laryngeal injury (1.1%) 4 Presentation: – Hoarseness "Breathy voice” – vocal fatigue – Aspiration – Sensation of lump in throat – Singers (consideration) 2

11/4/16 Infection (1%-2%) 4 Management: – Many recover from stretch injury over 6 month period 4 Temporary – Vocal cord injections/medialization various materials – Voice therapy 4 Permanent – Thyroplasty – Arytenoid adduction – Reinnervation surgery – Teflon injection Pharyngeal Perforation Pharyngeal Perforation Symptoms Rare but well recognized complication 4 0-3.4% in large series 4 Neck and pharyngeal pain 4 Dysphagia 4 At C5 - 6 esophagus lies directly on cervical vertebrae and 4 Odynophagia only covered by fascia dorsally 4 Aspiration 4 Choking 4 Fever 4 Local tenderness 4 Subcutaneous emphysema 3

11/4/16 Pharyngeal perforation 4 May be difficult to diagnose – Xray: – CT – Hypaque swallow – Esophagoscopy Vascular Complications Vertebral artery (0.5%-4.1%) Anterior 4 Smith et al: 10 VA injury (Incidence: 0.5%) 300-4500cc Corpectomy/hemicorpectomy 6/10 neurologic sequelae 4 Daentzer et al. review of literature 0.05-0.95% 8/29 permanent nerologic comp 4/29 mortality Posterior 4 C1-C2 Lateral exposure >1.5cm Transarticular screw (4.1%) 4 Posterior Subaxial Procedure Lateral mass fixation Pedicle screw placement 3.5-5.4% enter at the C7 foramen enters the foramen at C6 (87-89%) 4

11/4/16 Epidural hematoma (0.9%) Dural perforation (0.2%) Complication specific to technique 4 SPO/Ponte 4 Posterior/Anterior/Posterior or Anterior/Posterior/Anterior (“540”) 4 3 column osteotomy 4 Preop planning J Neurosurg Spine 19:141–159, 2013 5

11/4/16 1.5 cm J Neurosurg Spine 19:141–159, 2013 Chin-Brow Vertical Angle J Neurosurg Spine 19:141–159, 2013 J Neurosurg Spine 19:141–159, 2013 6

11/4/16 JSD Tech 25: 2012 J Neurosurg Spine 19:141–159, 2013 7

11/4/16 Loss of correction over time 8

11/4/16 9

11/4/16 High T1 slope 10

11/4/16 Results Study N Technique Correction Complications A-P Abumi, 30.8 deg screw 2 (15%) 13 pts pedicle screws Spine 1999 CSF 1 (8%) Infx 1 (8%) 0.5 deg 7 A-P CSF 13% 38 deg OShaughnessy 16 pts 3 P-A C5 palsy 19% Spine 2008 1 A-P-A QUAD 6% -10 deg 5 P-A-P Prog 6% trach 19% gastros 25% Complications 540 fusion in 7/14 pts Cervical Three Column Osteotomies Osteotomies were performed at 3.9 (3-6) levels anteriorly and 6.6 (3-18) levels posteriorly 4 Durotomy: 2 patients 4 Tracheostomy: 1 pt 4 Subdural hematoma: 1 patient 4 Iliac crest infection: 1 patient 4 Left pneumothorax: 1 patient 4 Transient right C5 palsy: 1 patient 4 Prolonged feeding tube: 2 pts 4 Superficial wound infection: 1 patient 4 Transient recurrent laryngeal nerve palsy: 1 pt 4 Unstable angina: 1 pt 4 average stay in the hospital was 19 days (range 3-55 days) and ICU stay was 6.5 days (range 0-15 days). 4 Days intubated averaged 3.8 days (range 0-15). 11

11/4/16 Thank you! 12