Analysis of the risk factors for the development of post-operative spinal epidural hematoma

Johns Hopkins University, Baltimore, Maryland, United States
The Bone & Joint Journal (Impact Factor: 3.31). 09/2005; 87(9):1248-52. DOI: 10.1302/0301-620X.87B9.16518
Source: PubMed


In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma.

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    • "Previous reports identified multilevel procedures, excessive blood loss, and preoperative coagulopathy as risk factors for PSEH [2] [3]. In an analysis of 14,932 spinal surgeries, Awad et al. reported that risk factors for PSEH were age over 60 years, preoperative administration of nonsteroidal antiinflammatory drugs, Rh-positive blood type, multiple operative levels, a hemoglobin level of <10 g/dL, intraoperative blood loss >1 L, and an international normalized ratio >2.0 within the first 48 hours [2]. However, they also concluded that well-controlled anticoagulation did not increase the risk of PSEH. "
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    ABSTRACT: A 71-year-old man underwent cervical laminectomy and developed two symptomatic epidural hematomas during the acute postoperative period. On both occasions, drain obstruction was the predominant cause. Congenital Protein S deficiency was diagnosed postoperatively. Protein S is a vitamin K-dependent natural anticoagulant and is essential for inhibiting thrombosis in microcirculation. We assume that Protein S deficiency followed by perioperative bed-rest and surgical invasiveness led to severe hypercoagulability and subsequent drain obstruction. The present findings suggest that both bleeding disorders and hypercoagulability are risk factors for postoperative symptomatic epidural hematoma.
    Full-text · Article · Aug 2015
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    • "Reports of primary surgical procedure for the majority of these studies involved at least two or more fused levels (n = 5) but also included single level lumbar laminectomy (n = 1), as well as intradural tumor removal (n = 1) [16] [17] [18]. Two additional papers were included in the analysis of the use of a drain versus no drain that did not have wound healing as the primary outcome [5] [11]. These were large retrospective reviews highlighting the incidence of epidural hematoma requiring surgical evacuation. "
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    ABSTRACT: The purpose of this study was to systematically search, critically appraise and summarize published randomized control trials (RCT) and non-RCT examining the effect of drains and dressings on wound healing rates and complications in posterior spine surgery. The use of post-operative drains and the type of post-operative dressing is at the discretion of the treating surgeon with no available clinical guidelines. Drains will theoretically decrease incidence of post-operative hematoma and therefore, potentially decrease the risk of neurologic compromise when the neural elements have been exposed. Occlusive dressings have more recently been advocated, potentially maintaining a sterile barrier for longer time periods post-operatively. A systematic review of databases from 1969-2013 was undertaken. All papers examining drains in spine surgery and dressings in primary healing of surgical wounds were included. Revman (version 5.2; The Nordic Cochrane Centre, The Cochrane Collaboration, Oxford, UK) was used to test for overall treatment effect, clinical heterogeneity and risk of bias. Of the papers identified, 1348 examined post-operative drains in spine surgery and 979 wound dressings for primary wound healing of all surgical wounds. Seven studies were included for analysis for post-operative drains and 10 studies were analyzed for primary wound healing. The use of a post-operative drain did not influence healing rates and had no effect secondarily on infection (odds ratio [OR] 1.33; 95% confidence interval [CI] 0.76-2.30). We were not able to establish whether surgical drains prevent hematomas causing neurologic compromise. There was a slight advantage to using occlusive dressings versus non-occlusive dressings in wound healing (OR 2.09; 95% CI 1.44-3.02). Incisional vacuum dressings as both an occlusive barrier and superficial drainage system have shown promise for wounds at risk of dehiscence. There is a relatively high risk of bias in the methodology of many of the studies reviewed. We recommend favoring of occlusive dressings based on heterogeneous and potentially biased evidence. Drain use does not affect wound healing based on similar evidence. Incisional vacuum dressings have shown promise in managing potentially vulnerable wounds. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Mar 2015 · Journal of Clinical Neuroscience
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    • "Spinal epidural hematoma is a well-known complication of spinal surgery in humans that is often asymptomatic . Studies have shown magnetic resonance imaging and computed tomography to have identified asymptomatic SEH in 33% to 100% of patients following lumbar disc or decompression surgery [16] [17] [18] [19]. In contrast, clinically significant hematomas resulting in neurologic deficits are rare (0.1%–0.2%) [19]. "
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    ABSTRACT: Objective: Piezoelectric surgery is a novel technology that allows for the osteotomy of mineralized tissue with less risk of damaging underlying soft tissue structures. This selective cutting increases the safety of osteotomies performed in close vicinity to delicate structures such as dura mater, blood vessels, and neural tissue. This study aimed to develop and describe the technique of piezoelectric surgery for dorsal laminectomy and to assess its clinical safety in normal sheep. Methods: A piezoelectric, dorsal laminectomy technique was developed using ovine cadavers. Following technique development, six live sheep underwent a piezoelectric (n = 6) two-level dorsal laminectomy at L2-L3 and L4-L5 (PiezoL2-3,4-5), and another 30 live sheep underwent a three-level laminectomy at L1, L3, and L5 (PiezoL1,3,5) for a total of 102 laminectomy sites. Surgery time and postoperative complications were recorded. Results: Dorsal laminectomy was safely and accurately performed in 35/36 study sheep using a Piezoelectric surgical instrument. No dural tears were noted in any animal. Non-ambulatory paraparesis in one study sheep (PiezoL1,3,5) led to euthanasia at 48 hr and only mild epidural hematoma was noted on necropsy. No other major postoperative complications were observed in any of the animals. Subjectively, PiezoL was easy to perform and with a rapid learning curve. Mean surgery time was 105 min (range: 75-165 min; median: 97.5) for PiezoL2-3,4-5 and 93 minutes (range 55-100 min; median: 67.5) for PiezoL1,3,5. Conclusions: Based on our study, PiezoL is considered a safe and viable technique for performing ovine dorsal laminectomy in the preclinical research setting.
    Full-text · Article · Dec 2014 · Journal of Investigative Surgery
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