Complications of Spinal Surgery

The following page provides a guide as to the risks associated with spinal surgery and with surgery in general.

Not all individuals will be at risk of all of the complications detailed below and this page should be seen as an informative list of potential complications of surgery. It is not an exhaustive list of potential complications.

Although there is a small but definite risk to all surgery, many of the complications are uncommon. If you have any questions or feel anxious about any aspect of possible surgery, Sherief Elsayed will be pleased to talk it through with you.

Most Serious Complications, Specific to Spinal Surgery:

Nerve or Spinal Cord damage

• Due to an intra-operative event – vascular insult, technical error

• Due to a post-operative haematoma (blood collection)

This is the most serious complication in Spinal Surgery but it is thankfully one of the least common. The worst possible consequence of injury to the spinal cord is permanent paralysis and loss of bladder, bowel and erectile function.

Most Common Complications, Specific to Spinal Surgery:

Dural Tear

• The spinal cord and nerve roots ('nervelets' that leave the spinal cord before joining to form major nerves) are covered in a layer known as the dura.

• Akin to an onion skin, especially in the elderly patient with long-term compression, the dura can be thinned and prone to tear. A tear means a repair of the dura is required, increasing the length of the surgery, but it is important to repair it in order to prevent a leak of cerebrospinal fluid (CSF – the fluid that bathes the brain and spinal cord).

• Invariably the tear settles and no long-term complications are encountered. Occasionally further surgery is required if a dural tear causes a persistent leak or other problems (stroke – rare).

Other Complications of Spinal Surgery:
Anterior Cervical Surgery (neck surgery, from the front)

Damage to the nerves which supply the vocal cords

• Hoarseness of voice, usually temporary, occasionally permanent

• Alteration in the pitch of voice (not usually noticed unless a professional singer)
  

Damage to vascular structures (carotid artery, jugular veins, thyroid artery and veins), which could lead to massive haemorrhage, stroke and loss of life

Damage to the trachea

Damage to the oesophagus, which may necessitate a prolonged period of being 'nil by mouth' or further surgery

Difficulty with swallowing

Failure of metalwork, for example: disc replacement that subsequently fuses, instrument migration

Failure to relieve symptoms, particularly in patients with excessively long duration of suffering

Fusion issues – a failure to fuse or 'pseudoarthrosis', which may lead to persistent / recurrent pain

...plus other complications listed

Posterior Cervical Surgery (neck surgery, from the back)

Damage to the vertebral arteries that could lead to a stroke or loss of life

Damage to the spinal cord or nerve roots

Dural tear

Failure of instrumentation

Failure of fusion

Failure to relieve symptoms

…plus other complications listed

Anterior Thoracic Surgery

Pneumothorax (collapsed lung)

Damage to the spinal cord

Damage to large vessels which could lead to massive haemorrhage and loss of life

Damage to the lungs / heart / diaphragm / intestines

Damage to the kidneys

…plus other complications listed

Anterior Lumbar Surgery

Damage to the kidneys / ureter

Damage to the bowel

Damage to large vessels which could lead to massive haemorrhage and loss of life

Damage to the pre-sacral plexus

Leading to retrograde ejaculation in men

Inability to control bladder during orgasm in females

Incisional hernia

…plus other complications listed

Posterior Thoracic / Lumbar Surgery

Damage to the spinal cord or nerve roots

Dural tear

…plus other complications listed

Complications Applicable to most Forms of Spinal Surgery

Infection

All surgery carries a risk of infection. Measures undertaken to reduce intra-operative infection in the modern operating theatre include:

• Pre-admission swabs

• Exclusion of unnecessary personnel from the operating theatre

• The use of 'clean-air' theatres

• Intravenous antibiotics prior to surgery, with further doses dependent on the surgical procedure / length of operation

• Antiseptic skin preparation

• Antimicrobial skin drapes

• Surgical team face masks

• Double-gloving by the surgeon, his assistant and the scrub nurse with glove changes as required

• Appropriate covering of equipment in the theatre suite with sterile covers (e.g.: X-ray machines)

What You can do to Minimise your Risk of Infection:

Ensure a healthy diet prior to your surgery – unless you are clearly malnourished there is not usually a need for supplementation beyond a healthy diet that includes fruit and vegetables

Ensure your diabetes is well-controlled (if applicable)

Stop smoking

Avoid excessive alcohol

Inform all relevant healthcare professionals of medication you are taking that may have an 'immunosuppressive' or 'anticoagulant' (blood-thinning) effect

Thankfully most infections which occur in spinal surgery are 'superficial', or involve only the wound.  These infections usually settle without invasive treatment.

'Deep' infection, particularly where metalwork has been inserted into the spine, may be much more problematic to eradicate.  Patients can expect repeated visits to the operating theatre for 'debridement' and 'wash-outs', prolonged intravenous antibiotic therapy, and in the worst case scenario, removal of the metalwork.  This is why numerous measures are undertaken in the operating suite to minimise the risk of infection, but unfortunately the risk can never be completely eliminated.

Post-operative Haematoma

A post-operative haematoma typically occurs within hours of surgery, and should be rapidly picked up by nursing staff, who will be regularly checking the movements of your arms or legs. A postoperative haematoma that causes compression of the spinal cord or nerve roots, leading to weakness, altered sensation or bladder and bowel dysfunction requires urgent surgical evacuation.

Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

A Deep Vein Thrombosis (DVT) is an abnormal clot which forms in one of the deep veins of the leg or thigh (occasionally elsewhere). It is typically caused by immobility and there are numerous risk factors. Preventing a DVT is an important step that your healthcare professional should aim for. Preventing a DVT is an important step that your healthcare professional should aim for. 

Developing a DVT is not typically in itself life-threatening, but should a piece of that 'clot' break off from the leg and migrate into the vessels supplying the lung (Pulmonary Embolism or PE), it does then have the potential to be a life-threatening condition.

Developing a DVT also places you at risk of further DVTs in the future, with other complications also occasionally encountered.

In order to minimise the risk of a DVT, Sherief Elsayed ensures his patients have pneumatic intermittent compression devices applied to both lower legs during surgery, which help to reduce the risk of developing a DVT.  In addition, you are typically encouraged to mobilise as soon as possible following surgery and to ensure you remain well-hydrated.  Finally, you are typically started on a 'blood-thinning agent' from the day after surgery, which again reduces the risk of a DVT developing.

You should inform Sherief Elsayed if you have a hereditary condition that predisposes you to abnormal coagulation.

Post-operative Instability / Kyphosis

With modern surgical techniques the risk of postoperative instability and kyphosis (secondary deformities caused by surgery), have significantly reduced.  Some cases will require further surgery, in the form a stabilisation or fusion in order to prevent further deformity or progression of instability while some cases will require no treatment.

Damage to the Spinal Cord or Nerve Roots

As described above, damage to the spinal cord is potentially the most catastrophic complication of Spinal Surgery, which can potentially result in paralysis of one or all limbs and a complete loss of control of bladder, bowel and erectile function.  Fortunately, it is not a common complication.

There are various causes of spinal cord injury during surgery but it is rarely down to the direct accidental actions of the surgeon.  Rather, it is the compromised spinal cord itself that can react in an abnormal way when the surgeon is attempting to rectifying the reason for compression of the spine, i.e.: a tumour, infection, fracture or degenerative changes.  An injured cord is further thought not to be able to regulate its blood flow as a normal spinal cord may be able to. 

Furthermore, any anaesthetic complications, such as a large drop in blood pressure due to anaesthetic agents or a failure to keep up with surgical blood loss, can result in injury to the spinal cord.  Occasionally, the formation of a haematoma following surgery can compress the spinal cord with the potential to cause injury, hence the use of drains in some circumstances.

The spinal cord itself typically ends at the level of the L1 vertebra. Below this the last few nerve roots continue as the 'Cauda Equina', the Latin meaning for 'horse's tail', with nerves supplying the lower limbs, bladder and bowel. As such, surgery below the level of L1 is not likely to cause damage to the spinal cord itself, but either the Cauda Equina as a whole or a solitary nerve root. The spectrum of damage to the spinal cord, Cauda Equina or nerve roots is vast and it may take many months (or longer) for all the damage to be completely repaired.

Damage to a nerve root supplying one of the lower limbs may result in partial weakness, permanent numbness, a sensation of pins and needles, persistent pain, worsening of pain and the development of different types of pain, for example: a 'burning' neuropathic pain where the initial pain was a sharp shooting pain.

It is frequently the case that a patient will complain to their surgeon of a sensation of numbness following a discectomy to relieve the pressure of a prolapsed disc on a compromised nerve root, for example. This is not necessarily due to a surgical nerve injury, but rather the fact that the pain experienced prior to the surgery far outweighed the sensation of numbness, only for the numbness to be noted when the painful stimulus is removed by surgery.  Although there are cases where the numbness never fully recovers, it normally improves noticeably over the following months.

Dural Tear

A dural tear is one of the commoner complications of Spinal Surgery, as described above.  Management varies from surgeon to surgeon: whether or not to repair, types of closure, the use of drains, post-operative immobilisation, the use of antibiotics and more. In the case of a dural tear occurring, Sherief Elsayed will make an intra-operative decision about how best to manage your tear.  It will usually involve repair of the tear, a water-tight closure and the use of a drain.

Failure to Resolve Symptoms (non-emergency surgery)

It is paramount to Sherief Elsayed, and of course to you as the patient, that any surgical procedure has a good chance of success.  It is for this reason that various pre-operative investigations may need to be carried out in order to try and identify the causes of pain in your spine. This way, they can be targeted effectively with surgery if non-operative measures have failed. Despite best efforts, patients can continue to experience symptoms, be it ongoing back pain, ongoing nerve related pain or other symptoms.

The causes may include an inaccurate diagnosis, poor surgical technique, or 'abnormal programming' of the pain pathways to the brain (typically in those suffering with pain for prolonged periods of time).  The latter group of patients will frequently require (and should positively engage in) treatment modalities in addition to surgery.

Recurrence

There are incidences of recurrence of symptoms following surgery, varying as to the underlying problem and the procedure undertaken.

For example, a prolapsed disc removed by surgery may prolapse again in the future.  Spinal stenosis that has been decompressed may recur at the same level or adjacent levels in the future. You can ask Sherief Elsayed about the risks of recurrence for your condition (if data is available).

Adjacent Level Degeneration

Fusion of one (or more) spinal segments can lead to a phenomenon known as adjacent level degeneration.  This has been proven by research, though degeneration on various scans does not necessarily equate with the degeneration felt by the patient. If you feel adjacent level degeneration applies to you, Sherief Elsayed will be able to provide you with more details and advice.

Need for Further Surgery

As with all parts of the body, there is occasionally a need for further, unexpected surgery.  This may be due to, amongst other issues, postoperative haematoma, infection, failure of metalwork (particularly in osteoporotic bone), failure of fusion, recurrence or failure to resolve symptoms.  Further surgery may be immediate or many years down the line.

Risks due to Co-morbidities

Additional health problems may have a role in how you do during the operation and in your post-operative rehabilitation.

For example, patients with underlying chest disease are liable to peri-operative chest infections, whilst those with underlying heart disease are at higher risk of myocardial infarctions or 'heart attacks'.

Elderly patients who have a change of environment in hospital, combined with new medications, accidental omissions of regular medications at home, anaesthetic agents, postoperative infections and so on may find themselves to be in a state of confusion.  This is usually self-limiting depending on the cause, but if you or your relatives feel that you are becoming progressively confused you should inform the nursing staff promptly.

If you are a patient with multiple co-morbidities or if your fitness for surgery is questionable, Sherief Elsayed will arrange for an anaesthetic opinion / opinion from other specialists as required.

Post-operative Nausea and Vomiting

Advances in anaesthesia have reduced the sensation of nausea and vomiting following the administration of various anaesthetic agents and painkillers. Sherief Elsayed's patients are regularly prescribed with medication to prevent or treat such symptoms. Nevertheless, some patients will experience nausea and vomiting, though in most cases this quickly passes and can eased with various medications.

Constipation

Medications, particularly some of the stronger painkillers, can cause constipation. Patients are usually started on laxatives to prevent or reduce this if such painkillers are used, though if you feel you are particularly prone to this please mention it at your consultation with Sherief Elsayed.