Perioperative complications associated with spine surgery in patients with established spinal cord injury

Abstract

Background context

Only a small percentage of patients with spinal cord injury (SCI) require consideration for reconstructive surgery after their initial injury. For those who do, perioperative complications can be frequent and significant. There has been very little published literature examining treatment of these patients and essentially nothing to guide the surgeon in perioperative decision making and management.

Purpose

To identify some of the common challenges associated with surgery in this patient population and review the literature to highlight the perioperative concerns in patients with chronic SCI.

Study design

Review article.

Methods

A primary PubMed literature search was performed and reviewed for patients with chronic SCI with emphasis on the complications and difficulties encountered during surgical treatment of patients with chronic SCI.

Results

For those who do proceed with surgery in this patient population, preoperative nutrition, bone density, and skin should be evaluated and optimized. Preoperative inferior vena cava filters should be considered. The integrity of the reconstruction will be extensively challenged. In addition, augmented fixation and bracing should be contemplated.

Conclusions

Patients with chronic SCI who require spinal reconstruction provide many unique challenges. Indications for surgery must be strong as perioperative complications can be frequent and long-term outcomes unpredictable. Close monitoring for postoperative complications is essential.

Introduction

Currently, the best estimates predict about 12,000 new cases of spinal cord injury (SCI) every year [1]. About 40% are complete injuries, with the majority being thoracolumbar spine injuries resulting in paraplegia [1]. Most patients are under 35 years of age, with approximately 80% being male [2], and many benefit from surgical stabilization for their traumatic injury. Relative to patients without SCI, they have both common and unique concerns associated with their perioperative course, and these are well understood and anticipated. In the subacute and chronic phases of SCI, operative indications are much different, and the nature of the challenges and complications changes. These patients are much different. They can have established problems with neuropathic pain, malnutrition, ulcers, spasticity and contractures, depression, recurrent infections, atrophy, osteoporosis, and neurogenic bowel and bladder issues. Unfortunately, there are no known data on the frequency of spinal reconstruction in the patient population with chronic SCI, and similarly, an extensive search of the English literature revealed no data other than case reports for complications associated with these surgeries. For certain, the incidence of surgery is low, but just as certain, the technical challenges for successful reconstruction are significant in this distinctive patient population. Other than infection, the primary reasons for spinal reconstructive surgery in the patient with chronic SCI include pseudarthrosis, Charcot spine, and neuromuscular deformity. The purpose of this report is to highlight many common challenges associated with surgical care, review the literature to highlight the perioperative concerns, and provide some guidance for management of patients with chronic SCI.