SPINE Volume 39, Number 4, pp E246-E252 ©2014, Lippincott Williams & Wilkins

CERVICAL SPINE

Risk Factors for Postoperative Retropharyngeal Hematoma After Anterior Cervical Spine Surgery Kevin R. O’Neill, MD, MS, Brian Neuman, MD, Colleen Peters, MA, and K. Daniel Riew, MD

Study Design. Retrospective review of prospective database. Objective. To investigate risk factors involved in the development of anterior cervical hematomas and determine any impact on patient outcomes. Summary of Background Data. Postoperative (PO) hematomas after anterior cervical spine surgery require urgent recognition and treatment to avoid catastrophic patient morbidity or death. Current studies of PO hematomas are limited. Methods. Cervical spine surgical procedures performed on adults by the senior author at a single academic institution from 1995 to 2012 were evaluated. Demographic data, surgical history, operative data, complications, and neck disability index (NDI) scores were recorded prospectively. Cases complicated by PO hematoma were reviewed, and time until hematoma development and surgical evacuation were determined. Patients who developed a hematoma (HT group) were compared with those that did not (no-HT group) to identify risk factors. NDI outcomes were compared at early (11 mo) time points. Results. There were 2375 anterior cervical spine surgical procedures performed with 17 occurrences (0.7%) of PO hematoma. In 11 patients (65%) the hematoma occurred within 24 hours PO, whereas 6 patients (35%) presented at an average of 6 days postoperatively. All underwent hematoma evacuation, with 2 patients (12%) requiring emergent cricothyroidotomy. Risk factors for hematoma were found to be (1) the presence of diffuse idiopathic skeletal hyperostosis (relative risk = 13.2, 95% confidence interval = 3.2–54.4), (2) presence of ossification of the posterior longitudinal ligament (relative risk = 6.8, 95% confidence interval = 2.3–20.6), (3) therapeutic heparin use (relative risk 148.8, 95% confidence interval = 91.3–242.5), (4) longer operative time, and (5) greater

From the Cervical Spine Service, Washington University, Department of Orthopedics, St. Louis, MO. Acknowledgment date: September 3, 2013. First revision date: October 30, 2013. Acceptance date: November 4, 2013. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, expert testimony, grants/grants pending, royalties, stock/stock options and travel/accommodations/meeting expenses. Address correspondence and reprint requests to K. Daniel Riew, MD, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8233, St. Louis, MO 63110. Email: [email protected]. DOI: 10.1097/BRS.0000000000000139

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number of surgical levels. The occurrence of a PO hematoma was not found to have a significant impact on either early (HT: 30, no-HT: 28; P = 0.86) or late average NDI scores (HT: 28, no-HT 31; P = 0.76). Conclusion. With fast recognition and treatment, no long-term detriment from PO anterior cervical hematoma was found. We identified risk factors to be (1) presence of diffuse idiopathic skeletal hyperostosis, (2) presence of ossification of the posterior longitudinal ligament, (3) therapeutic heparin use, (4) longer operative time, and (5) greater number of surgical levels. Key words: cervical spine surgery, surgical complications, postoperative hematoma, risk factors, patient-reported outcomes, clinical outcomes, postoperative complications, retropharyngeal hematoma, airway compromise. Level of Evidence: 4 Spine 2014;39:E246–E252

A

nterior cervical spine operations are among the most commonly performed procedures by spine surgeons. These operations have generally been found to result in positive patient outcomes1,2 with relatively low associated rates of complications.3–9 The occurrence of a postoperative (PO) hematoma in the retropharyngeal space is an infrequent complication of cervical spine operations, but can quickly result in airway compromise. Therefore, a PO hematoma requires fast recognition and action to prevent catastrophic patient morbidity or death. Because they occur so rarely, little is currently known regarding the risk factors for hematoma development or the outcomes after its successful treatment. Current literature regarding hematomas after anterior cervical surgery is limited. A few case reports have described this complication specifically,8,10–12 and larger studies investigating overall complication rates estimate the incidence of postoperative hematoma to be 0.2% to 2.4%.3,5,7–9,13,14 However, these large studies offer little with regard to specific patient or surgical factors that may have contributed to hematoma formation. Only 1 study evaluated possible risk factors involved, finding neither the number of surgical levels nor the use of a plate to be significant factors.14 Given the potential severe consequences of this complication, it is important to more thoroughly evaluate potential risk factors leading to hematoma development. Therefore, the primary goals of this study were to investigate the incidence of anterior cervical PO hematoma and the risk factors for occurrence. With a better understanding of February 2014

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CERVICAL SPINE the risk factors involved, potential strategies to avoid this lifethreatening complication may then be formulated. In addition, the secondary goal was to investigate the possible effect of hematomas on long-term clinical outcomes and patientreported outcomes. Our hypothesis was that if the hematoma is quickly recognized and evacuated, there would not be a significant impact on outcomes.

Anterior Cervical Hematomas • O’Neill et al

After institutional review board approval (IRB 201304010), an analysis of all anterior cervical spine surgical procedures was performed by the senior author at a single academic institution between August 1995 and December 2012. All patients were at least 18 years old, and no patients were excluded. All surgical cases and any associated complications that occurred during this period were prospectively logged into a database. This was used to identify all patients who underwent an anterior cervical spine operation and had a PO hematoma. For patients who underwent combined approaches (anterior and posterior) during a single operation, each approach was logged separately including the procedure performed and any complications that occurred.

icon, Inc., Cincinnati, OH) was applied along the edges of the longus colli. Surgicel (Ethicon Inc.) was wrapped around the edges of the longus colli, and placed within the wound and along muscle surfaces. A drain was used at the discretion of the senior author and surgeon. A variety of drains were used throughout the study time period, including closed suction drains through separate stab incisions or soft rubber drain tube brought through the surgical incision. All drains were removed on the morning after surgery. Postoperative bracing consisted of soft foam cervical collars for fusions of 1 to 2 levels and hard plastic collars for fusions of 3 or more levels. In some cases, a cricothyroidotomy was required postoperatively. This was performed by initially opening the previous skin incision and platysma layer to allow removal of any obstructive fluid collections or clot (Figure 1A). Next, blunt finger dissection was used to palpate and expose the anterior midline of the trachea. After identifying the thyroid cartilage, cricoid cartilage, and cricothyroid membrane, a blunt hemostat was used to enter the trachea by puncturing through the midline of the membrane (Figure 1B). Spreading the hemostat in longitudinal and transverse directions allowed adequate opening in the membrane to pass an endotracheal tube (Figure 1C).

Patient Data

Surgical Data

Patient data recorded prospectively in a database at the time of surgery included: patient age at the time of surgery, sex, history of diabetes or tobacco use, and the presence of rheumatoid arthritis, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis (DISH), and/or ossification of the posterior longitudinal ligament (OPLL). In addition, surgical diagnoses were classified as trauma, spondylosis, herniated nucleus pulposis, congenital stenosis, cervical deformity, infection, and/or pseudarthrosis by the senior author. Similarly, the preoperative neurological status of patients was categorized as intact, myeloradiculopathy, radiculopathy, myelopathy, quadraparesis, paraparesis, or central cord syndrome. History of previous cervical spine surgery was recorded along with the procedure(s) performed and levels involved. Body mass index (BMI) was determined by medical record review for patients found to have a PO hematoma. In addition, an age- and sexmatched cohort was identified using a 2:1 ratio of patients who did not have a PO hematoma. The BMI for this subgroup without a PO hematoma was then determined by medical record review.

Surgical details including the procedure performed, levels involved, use of instrumentation, type of bone graft product used, use of bone morphogenetic protein, and operative time were recorded. For patients found to have a PO hematoma, the operative blood loss, use and length of use of a drain, length of intubation, length of hospital stay, and the PO time until development of the hematoma and time to surgical evacuation were also determined by medical record review.

MATERIALS AND METHODS

Operative Procedure A standard Smith-Robinson approach was performed in all cases. The senior author uses a left-sided approach unless contraindicated by previous surgery and vocal cord paralysis. At the conclusion of each surgical procedure, meticulous hemostasis was achieved using a combination of electrocautery and hemostatic agents. Beginning in January 2011, bipolar electrocautery was used to coagulate the small artery and vein running ventral to the longus colli and feeding the vertebral body. Then, the bipolar was used to elevate the longus colli. At the conclusion of the case, a commercial hemostatic agent (Floseal; Baxter Healthcare Corporation, Deerfield, IL; or Surgiflo; EthSpine

Clinical Follow-up Outpatient clinical records were stored electronically starting in 2002. Outpatient notes prior to this were not available. Available records were reviewed for patients who had a DT, and any additional complications or reoperations were recorded.

Patient Outcomes Neck disability index (NDI) scores were recorded prospectively in a database starting in June 2005. Outcomes at early (11 mo postoperatively) time periods. Preoperative NDI scores were recorded on an insufficient number of patients to allow meaningful comparisons to be made. Outcomes were therefore compared at 2 PO time periods between patients who developed a hematoma (HT group) and those that did not (no-HT group).

Statistics Comparisons were made between the HT and no-HT groups to identify potential risk factors. The χ2 test was used for nominal variables, and the Mann-Whitney test was used for continuous variables. Relative risk (RR) and 95% confidence intervals (CI) were determined when statistically significant differences (P < 0.05) were found. Comparison was also www.spinejournal.com

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Anterior Cervical Hematomas • O’Neill et al

B

C

Figure 1. A cricothyroidotomy begins by opening the prior incision until midline of the trachea is identified (A). Next, the CC and TC are identified. The pretracheal fascia is opened bluntly between these using a hemostat, allowing identification of the cricothyroid membrane (B). The CT Mem. is pierced in the midline using the hemostat, which is then used to create an opening for subsequent intubation (C). TC indicates thyroid cartilage; CC, cricoid cartilage; CT Mem., cricothyroid membrane; Sup, superior; Inf, inferior.

made between surgical procedures performed before and after implementation of the hemostatic protocol described previously including bipolar coagulation and use of hemostatic agents at the conclusion of the case. All data are presented as mean ± standard deviation unless otherwise noted.

RESULTS There were 2375 anterior cervical spine surgical procedures performed in the study period, with 17 occurrences (0.7%) of PO hematoma (Table 1). There was an additional patient who had PO respiratory distress and underwent exploration, but no fluid collection was encountered, so this case was not counted as a hematoma.

Patients With Hematoma Primary Procedure Anterior cervical corpectomy and fusion and anterior cervical discectomy and fusion were the most common procedures performed. An anterior cervical plate was placed in all cases except patient 9 who underwent excision of osteophytes. A drain was used after the primary operation in 15 cases (88%). Estimated blood loss was 112 ± 49 mL (range, 20–200 mL; median, 100 mL). All patients were extubated in the operating room after the primary operation. Hematoma Diagnosis In 11 patients (65%), the hematoma occurred within 24 hours postoperatively. One of these patients (patient 7) was discharged on the first PO day, and readmitted later that day with respiratory distress. The remaining 6 patients (35%) were discharged after the primary surgery and readmitted with respiratory distress after 6.4 ± 2.9 days. A drain was in E248

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place at the time of hematoma formation in 4 patients (27%), and was removed on the same day prior to hematoma formation 4 patients (27%). Hematoma Evacuation All patients underwent evacuation of the hematoma, with 2 patients (12%) also requiring emergent cricothyroidotomy (patients 1, 2). An active arterial bleeding source of the hematoma was identified in 4 patients (27%), with the unnamed vessels involved in 2 cases (patients 7, 13) and the inferior thyroid artery in the other 2 cases (patients 4, 17). After hematoma evacuation, drains were used in all cases for 2.5 ± 2.6 days (range, 1–10 d; median, 2 d) and 10 patients were kept intubated postoperatively for 1.7±1.1 days (range, 1–4 d; median, 1 d). The remaining 7 patients were extubated after the procedure. The length of hospital stay after evacuation was 4.8 ± 3.9 days (range, 1–15 d; median, 3 d). Other Factors In 2 cases, patients were anticoagulated postoperatively. Patient 9 was started on clopidogrel and heparin on PO day 1 for an acute myocardial infarction, and developed a hematoma on PO day 2. Patient 5 with an aortic valve replacement was resumed on warfarin therapy postoperatively, and developed a hematoma on PO day 6. In addition, patient 2 was taking aspirin daily until 3 days prior to surgery. There were 2 cases of hematoma that developed in proximity to severe coughing episodes (patients 4, 13). A minor fall preceded hematoma development in 1 case (patient 6). Other Complications Outpatient clinical follow-up records were available for all 11 patients who underwent surgery since 2002, and for 2 of February 2014

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Anterior Cervical Hematomas • O’Neill et al

TABLE 1. Patients Who Developed Postoperative Hematomas Requiring Evacuation Procedure

Drain

PO Time to Hematoma (d)

M

C6 ACCF

Yes

1

53

M

C6 ACCF

Yes

0

3

68

M

C4 ACCF

Yes

1

4

53

M

C6 ACCF, C7–T1 ACDF

Yes

1

5

74

M

C3–C4 ACDF

C5 ACCF

Yes

6

6

38

M

C3–C4 ACDF

C5 ACCF, C6–C7 ACDF

Yes

5

7

58

M

C6–C7 ACDF

C5 ACCF

Yes

1

8

45

M

C5 ACCF, C6–C7 ACDF

Yes

3

9

73

M

Osteophyte resection

Yes

1

10

42

M

C5–C6 ACDF

No

0

11

44

M

C6 ACCF

Yes

0

12

56

M

C5–C6 ACDF

Yes

1

13

64

F

C5–C6 ACCF

Yes

9

14

58

F

C2–C3, C3–C4, C4–C5 ACDF, C6 ACCF, C7–T1 ACDF

Yes

1

15

63

F

C3–C4 ACDF, C6–C7 ACDF

Yes

8

16

51

M

C4–C5 ACDA, C5–C6 ACDF, C6–C7 ACDA

Yes

1

17

49

F

C5–C6 ACDF

No

8

Patient

Age (yr)

Sex

1

41

2

Previous Surgery

C5–C6, C6–C7 ACDF

C4–C5, C5-C-6 ACDF

C6–C7 ACDF

ACDF indicates anterior cervical discectomy and fusion; ACCF, anterior cervical corpectomy and fusion; ACDA, anterior cervical discectomy and arthroplasty; PO, postoperative.

the 6 patients who had surgery prior to 2002. Those patients were followed clinically for 2.4 ± 3.0 year (range, 7 mo–9.5 yr; median, 1.0 yr). A dural tear occurred during the primary surgery in patient 3. Persistent drainage was noted at the time of hematoma evacuation, and revision of the dural repair was performed. An infection occurred in patient 17 requiring subsequent debridement. Finally, patient 9 developed a partial left-sided vocal cord paralysis.

Risk Factor Analysis Comparisons between the HT and no-HT groups identified the presence of DISH (RR = 13.2, 95% CI = 3.2–54.4), presence of OPLL (RR = 6.8, 95% CI = 2.3–20.6), therapeutic heparin use (RR = 148.8, 95% CI = 91.3–242.5), longer operative time, and greater number of surgical levels as risk factors for the development of hematoma (Table 2). Male sex (RR = 3.2, 95% CI = 1.1–9.8) and previous anterior cervical surgery (RR = 2.7, 95% CI = 1.0–7.2) were suggestive of possible factors, but did not reach statistical significance. The BMI of the subgroup of no-HT patients, age, and sex matched to that of the HT group, was not statistically different than the HT group (27 ± 3 vs. 29 ± 5; P = 0.5). The incidence of hematoma prior to the use of hemostatic protocol instituted in 2011 (16/2045 cases, 0.8%) was not statistically different Spine

than that after (1/322 cases, 0.3%; P = 0.57). The patient who developed a hematoma after implementation of this protocol was anticoagulated immediately postoperatively for an acute myocardial infarction (patient 9).

Patient Outcomes The occurrence of a postoperative hematoma was not found to have a significant impact on either early (P = 0.86) or late NDI scores (P = 0.76; Table 3). There were no significant differences in the time from surgery of the outcome evaluations at either the early (HT: range = 1–9 mo, median = 8 mo; no-HT: range = 1–10 mo, median = 5 mo; P = 0.055) and late (HT: range = 11 mo–8.4 yr, median = 1 yr; no-HT: range = 11 mo–11.2 yr, median = 2 yr; P = 0.120) time points.

DISCUSSION A postoperative hematoma after anterior cervical spine surgery is a rare but potentially catastrophic complication. Prior studies have not adequately investigated the risk factors that may be involved in the development of hematoma. In the largest single-surgeon series of anterior cervical spine operations, we reviewed 2375 cases and found 17 cases (0.7%) that required evacuation of a hematoma. Significant risk factors for hematoma development were found to be: (1) presence www.spinejournal.com

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Anterior Cervical Hematomas • O’Neill et al

TABLE 2. Comparison Between Patients With

and Without Hematoma

No Hematoma Hematoma (n = 17)

(n = 2375)

P

Male

13 (76)

1188 (50)

0.054

Age (yr)

55 ± 11

51 ± 11

0.219

Diabetes

0 (0)

148 (6)

0.577

Tobacco use

1 (6)

591 (25)

0.127

Spondylosis

15 (88)

2146 (90)

0.397

Disc herniation

6 (35)

1108 (47)

0.489

Deformity

1 (6)

229 (10)

0.912

DISH

2 (12)

22 (1)

0.001

OPLL

4 (24)

99 (4)

0.001

Comorbidities

Diagnosis

Neurological impairment None

0.158 1 (6)

131 (6)

Radiculopathy

10 (59)

1617 (68)

Myeloradiculopathy

6 (35)

360 (15)

Prior Surgery

6 (35)

401 (17)

0.091

1 (6)

271 (11)

0.740

2.5 ± 0.9

2.0 ± 0.8

0.049

ACDF

9 (53)

1775 (75)

0.221

Corpectomy

11 (65)

1064 (45)

0.162

Inst. placement

16 (94)

2165 (91)

0.999

Inst. removal

2 (12)

182 (8)

0.861

2.6 ± 1.3

2.0 ± 1.3

0.020

Autograft

2 (12)

264 (11)

0.762

Allograft (bone bank)

12 (71)

1344 (57)

0.360

Allograft (commercial)

2 (12)

336 (14)

0.946

DBM

10 (59)

1427 (60)

0.867

BMP

6 (35)

969 (41)

0.832

Surgery Anterior/posterior Operative time (hr)

Levels Bone graft

DISH indicates diffuse idiopathic skeletal hyperostosis; OPLL, ossification of the posterior longitudinal ligament; ACDF, anterior cervical discectomy and fusion; DBM, demineralized bone matrix; BMP, bone morphogenetic protein; Inst., instrumentation.

of DISH, (2) presence of OPLL, (3) therapeutic heparin use, (4) longer operative time, and (5) greater number of surgical levels. Furthermore, we found no significant impact on longterm NDI scores when the hematomas were appropriately treated with evacuation. E250

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Airway compromise due to edema seems to be slightly more frequent than that due to hematoma, with reported rates of 1.2% to 6.1%.15–17 Sagi et al16 identified risk factors for edema-related airway compromise, including operative time more than 5 hours, exposure of 3 or more vertebral bodies, exposure of vertebral levels cranial to C4, and blood loss greater than 300 mL. Combined anterior-posterior operations may also be at greater risk.18,19 Similarly, our study found greater levels of exposure and longer operative times did have increased risk of hematoma. However, we did not find anterior-posterior operations to have a higher risk of hematoma and none of the patients developing hematoma had operative times greater than 5 hours or blood loss greater than 300 mL. Furthermore, though an increased risk of airway compromise may exist with the use of bone morphogenetic protein,20 we did not find bone morphogenetic protein to be a risk factor for hematoma development. Although hematoma may lead to airway edema secondarily,21 it is likely that these represent separate etiologies with the same resulting pathology of airway compromise. Therefore, it is perhaps not surprising to find discrepancies in reported risk factors. It has been the senior author’s experience that most patients presenting with airway compromise after surgery have hematomas rather than edema. Therefore, whenever a patient presented with airway issues, the decision was made to reoperate rather than treat the patient with observation, intubation, and steroids. As a result of this approach, the percentage of evacuations that were performed may have been increased. However, in all of these patients, the preoperative symptoms resolved immediately or within hours of the evacuation, confirming that this was due to fluid and not edema. Furthermore, this approach is supported by our data, in which only 1 case (5.6%) was found of a patient who underwent surgical exploration for PO respiratory distress without discovery of a fluid collection. It is interesting to consider the time of presentation of the hematomas in our study. It is common to consider hematoma to be a risk factor primarily within the first several hours postoperatively.11–13,16 However, we found that 35% presented in delayed fashion at an average of 6 days postoperatively. In a case report, Yu et al10 has also described such a delayed presentation of a postoperative hematoma. Therefore, though more common in the acute postoperative period, consideration of a hematoma must be considered for at least 2 to 3 weeks after surgery. Throughout the study period, a variety of drain types were used. The exact type of drain used for each case was unable to be obtained. However, in the senior author’s experience, there was no drain that was preventative of hematoma. In fact, in 27% of cases the drain was in place at the time of hematoma formation. This was also described in a previous case report.11 In addition, in 27% of cases the hematoma formed shortly after drain removal. Although it is possible that the hematoma was forming prior to removal, it should be considered that the drain removal may have aggravated a vessel or muscle bed and contributed to the hematoma forming. Further studies would be necessary to evaluate this question. February 2014

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TABLE 3. NDI Outcome Scores Early Postoperative

Late Postoperative

Group

N

Time (mo)

NDI

N

Time (mo)

NDI

Hematoma

7

6.4 ± 3.0

30.0 ± 23.1

7

27.6 ± 32.9

28.7 ± 23.5

821

4.5 ± 2.5

28.4 ± 19.8

681

31.4 ± 24.8

31.1 ± 21.5

No hematoma

No statistically significant differences (P < 0.05) were noted between times or NDI scores at either time point. NDI indicates neck disability index.

Our study implicates the presence of OPLL or DISH as significant risk factors for hematoma. Significant osteophyte resection commonly necessary in cases of DISH may leave a greater area of exposed cancellous bone, which could contribute to hematoma formation. Alternatively, these enthesopathies are both associated with stiff and ossified paraspinal ligaments, which are perhaps traumatized during or after surgery and may cause additional bleeding. Regardless, while it is perhaps more common to consider hematoma formation to be the result of a vessel injury, it is important to note that this occurred in only 24% of cases. Therefore, strategies to reduce the occurrence of postoperative hematomas must address multiple areas of potential bleeding including vessels, muscle, and exposed cancellous bone. Since 2011, we have been using a standard approach to achieve and maintain hemostasis for each anterior cervical case. As described previously, bipolar electrocautery was used to coagulate small vessels feeding the vertebral body, which are consistently found on the ventral surface of the longus colli. Then, Floseal and Surgicel are placed around the longus colli at the conclusion of the case. Although this protocol was not found to have statistically reduced hematoma formation, it should be noted that the only case that occurred because implementation was a patient who was started on heparin and clopidogrel on PO day 1 for an acute myocardial infarction. Therefore, we think that this approach does reduce PO bleeding and does reduce the risk for hematoma. There were several limitations to our study. First, the retrospective nature of this study may impact overall accuracy. Complications and outcomes were recorded prospectively in a database, but accuracy of the additional data collected on those who had a PO hematoma may have been impacted. Second, we were able to capture NDI scores on only a limited number of patients at both the early and late time points. However, though not ideal, these data are the first available that indicate no long-term sequelae of appropriately treated postoperative cervical hematomas. Finally, there are factors that may contribute to hematoma development that were not accounted for in this analysis, such as coagulation abnormalities, BMI, and use of PO bracing. It is likely that a multicenter prospective study would be required to provide a more exhaustive evaluation of risk factors.

CONCLUSION The occurrence of a postoperative hematoma requires fast recognition and treatment to avoid catastrophic patient morbidity or death. Our study demonstrates that if such timely evacuaSpine

tion is achieved there is no long-term detriment to patient outcomes. Furthermore, we identified risk factors for hematoma development to be (1) presence of DISH, (2) presence of OPLL, (3) therapeutic heparin use, (4) longer operative time, and (5) greater number of surgical levels. Although most hematomas occurred in the acute postoperative period, we found that 35% occurred in a delayed fashion. As a result, we advocate consideration of hematoma as a possible etiology for respiratory distress even beyond the acute postoperative period.

➢ Key Points ‰ The incidence of PO hematoma after anterior cervical surgery was 0.7%. ‰ We identified risk factors to be (1) presence of DISH, (2) presence of OPLL, (3) therapeutic heparin use, (4) longer operative time, and (5) greater number of surgical levels. ‰ When appropriately treated, the occurrence of a PO hematoma was not found to impact patient outcomes.

References

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CERVICAL SPINE 10. Yu NH, Jahng T-A, Kim CH, et al. Life-threatening late hemorrhage due to superior thyroid artery dissection after anterior cervical discectomy and fusion. Spine 2010;35:E739–42. 11. Palumbo MA, Aidlen JP, Daniels AH, et al. Airway compromise due to wound hematoma following anterior cervical spine surgery. Open Orthop J 2012;6:108–13. 12. Sethi R, Tandon MS, Ganjoo P. Neck hematoma causing acute airway and hemodynamic compromise after anterior cervical spine surgery. J Neurosurg Anesthesiol 2008;20:69–70. 13. Lied B, Sundseth J, Helseth E. Immediate (0–6 h), early (6–72 h) and late (>72 h) complications after anterior cervical discectomy with fusion for cervical disc degeneration; discharge six hours after operation is feasible. Acta Neurochir (Wien) 2008;150:111–8; discussion 8. 14. Fountas KN, Kapsalaki EZ, Nikolakakos LG, et al. Anterior cervical discectomy and fusion associated complications. Spine 2007;32:2310–7. 15. Emery SE, Smith MD, Bohlman HH. Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544–51.

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Anterior Cervical Hematomas • O’Neill et al

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February 2014

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Risk factors for postoperative retropharyngeal hematoma after anterior cervical spine surgery.

Retrospective review of prospective database...
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