Frequency, recognition, and management of postoperative hematomas following anterior cervical spine surgery: A review
- Clinical Professor of Neurological Surgery, School of Medicine, State University of NY at Stony Brook, New York, United States.
DOI:10.25259/SNI_669_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Nancy Epstein. Frequency, recognition, and management of postoperative hematomas following anterior cervical spine surgery: A review. 21-Oct-2020;11:356
How to cite this URL: Nancy Epstein. Frequency, recognition, and management of postoperative hematomas following anterior cervical spine surgery: A review. 21-Oct-2020;11:356. Available from: https://surgicalneurologyint.com/surgicalint-articles/10339/
Background: We reviewed the frequency, recognition, and management of postoperative hematomas (HT) (i.e. retropharyngeal [RFH], wound [WH], and/or spinal epidural hematomas [SEH]) following anterior cervical discectomy/fusion (ACDF), anterior corpectomy fusion (ACF), and/or anterior cervical spine surgery (ACSS).
Methods: Postoperative cervical hematomas following ACDF, ACF, and ACSS ranged from 0.4% to 1.2% in a series of 11 studies involving a total of 44, 030 patients. These included; 4 single case reports, 2 small case series (6 and 30 cases), 4 larger series (758–2375 for a total of 6729 patients), an a large NSQUIP (National Surgical Quality Improvement Program ) Database involving 37,261 ACDF patients.
Results: Risk factors contributing to postoperative cervical hematomas included; DISH (diffuse idiopathic skeletal hyperostosis), ossification of the posterior longitudinal ligament (OPLL), therpeutic heparin levels, longer operative times, multilevel surgery, ASA Scores of +/= 3, (American Society of Anesthesiologists), prone surgery, operative times > 4 hours, smoking, higher/lower body mass index (BMI), anemia, age >65, > medical comorbidities, and male gender. Notably, the use of drains did not prevent HT, and did not increase the infection, or reoperation rates.
Conclusion: In our review of 11 studies focused on anterior cervical surgery, the incidence of postoperative hematomas ranged from 0.4 to 1.2%. Early recognition of these postoperative hemorrhages, and appropriate management (surgical/non-surgical) are critical to optimize recovery, and limit morbidity, and mortality.
Keywords: Anterior diskectomy/fusion, Out-patient surgery, Postoperative wound hematoma, Retropharyngeal hematoma, Risk factors, Selection criteria, Symptomatic epidural hematoma
Postoperative retropharyngeal (RFH), wound (WH), and/or spinal epidural hemorrhages (SEH) following anterior cervical discectomy/fusion (ACDF), anterior corpectomy fusion (ACF), and/ or anterior cervical spine surgery (ACSS) occur in from 0.4%- 1.2% of cases.[
Risk factors contributing to postoperative cervical hematomas included; the presence of DISH (diffuse idiopathic skeletal hyperostosis), OPLL (ossification of the posterior longitudinal ligament), therapeutic heparin levels, longer operative times, multiple surgical levels, ASA Scores of +/= 3, (American Society of Anesthesiologists), prone surgery, operative times (e.g. >4 h), increased intraoperative blood loss, more medical comorbidities, age over 65, smoking, higher/lower body mass index (BMI), wider exposures, intraoperative hypotension, anemia, and male gender.[
Four case reports focused on the incidence of postoperative hematomas following anterior cervical surgery [
Hematomas following cervical spine surgery were evaluated in 2 case series respectively involving 6, and 30 patients [
We looked at 4 larger series of patients (2011–2018) ranging in number from 785 to 2375. We identified 54 postoperative hematomas out of the total of 6729 patients undergoing anterior cervical surgery [
RISK OF HEMATOMAS IN NSQUIP (NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM) DATABASE INVOLVING 37,261 ACDF
In Bovonratwet et al. series (2019) involving 37,261 ACDF obtained from the NSQUIP database, 0.4% (148 cases) of patients required reoperations for postoperative hematomas [
In 6 studies, the interval between surgery, and the surgical removal of postoperative hematomas ranged from 2.5 hours to 6 days [
3 PATIENTS FROM 2 STUDIES REQUIRING EMERGENT POSTOPERATIVE CRICOTHYROIDOTOMY FOR ACUTE HT FOLLOWING ANTERIOR CERVICAL SURGERY
Three 3 patients from two studies required emergent postoperative cricothyroidotomies [
ONE MORTALITY DUE TO ACUTE POSTOPERATIVE HEMATOMA OUT OF 11 SERIES (44,030 PATIENTS) UNDERGOING ANTERIOR CERVICAL SURGERY
Out the 11 series involving a total of 44,030 patients undergoing anterior cervical surgery, there was just one reported death attributed to a combined RPH/WH/SEH [
Postoperative hemorrhages, including retropharyngeal hematomas (RPH), wound hematomas (WH), and spinal epidural hematomas (SEH) occurred in from 0.4 to 1.2% of cases following anterior cervical spinal surgical procedures performed in 11 studies (e.g. ACDF, ACF, and ACSS).[
Patient’s consent not required as patients identity is not disclosed or compromised.
There are no conflicts of interest.
Postoperative hematomas following anterior cervical spine surgery are important clinical entities. They require urgent decompression for restoration and preservation of neurologic and systemic function, maintenance of cord perfusion, and correction of underlying metabolic disturbances. Medical comorbidities predisposing to bleeding diatheses (including thrombocytopenia, platelet dysfunction, anticoagulation use, liver disease and renal insufficiency) are taken into account pre-operatively. Intraoperatively, metabolic acidosis from hemodynamic instability is corrected, facilitating intraoperative hemostatic control. Traumatic extubation may increase Valsalva Maneuvers, thus acutely increasing systemtic blood pressure, resulting in an immediate postoperative clot. Alternative early postoperative manifestations of hematomas may be subtle, and include restlessness from hypercarbia prior to development of dyspnea and associated with periextubation episodes of Valsalva maneuvers.
Montreal Neurological Institute & Hospital, McGill University; Quebec, Canada
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