Spinal Hematoma Research Articles

Incidence and Clinical Features of Postoperative Symptomatic Hematoma after Spine Surgery: A Multicenter Study of 45 Patients.

Introduction Symptomatic postoperative hematoma after spine surgery is a rare but serious complication. The objective of this study was to investigate the incidence and clinical features of symptomatic postoperative hematoma after spine surgery. Methods We retrospectively identified 10,680 patients who underwent spine surgery between 2002 and 2012 in nine hospitals. We reviewed the incidence of postoperative hematoma and its clinical features, including time before onset, main symptoms, and neurological outcomes. Results The overall incidence of symptomatic postoperative hematoma after spine surgery was 0.4% (45/10,680). Postoperative hematoma was more frequent after thoracic spine surgery than after cervical or lumbar surgery. The onset of postoperative hematoma occurred at an average of 2.6 days (range 0-14 days) postoperatively. The chief symptoms caused by postoperative hematoma after spine surgery were tetra/paraplegia in 30 patients, hemiplegia in eight patients, intractable pain in five patients, and airway dysfunction in two patients. Surgical evacuation of the spinal epidural hematoma resulted in improvement of at least one grade in 35 patients, while four patients had complete motor paralysis even after evacuation surgery. Conclusions We report the clinical details of 45 patients with postoperative hematoma after spine surgery. This information could assist surgeons to make a prompt diagnosis and perform early evacuation surgery for postoperative hematoma following spine surgery.

Epidural anesthesia masking pain from spinal epidural hematoma

Spinal epidural hematoma (SEDH) without pain due to epidural anesthesia is a rare but serious complication. We report the successful treatment of a patient with progressive paraparesis after the development of SEDH during the administration of epidural anesthesia. An 84-year-old woman underwent laparoscopy with epidural anesthesia. To prevent deep vein thrombosis, the delivery of low molecular weight heparin was started 16.5 hours after laparoscopy. On the 1st postoperative day she reported painless leg paralysis and on the 2nd day she manifested severe paraplegia and urinary retention. Magnetic resonance imaging revealed an SEDH compressing the spinal cord at the Th12 - L1 and we performed emergent laminectomy. After the laminectomy her symptoms disappeared completely. SEDH is a rare but serious complication related to epidural anesthesia. As its excessive analgesic effect may elicit motor weakness and mask pain, SEDH must be ruled out in patients with paraparesis with continuous epidural anesthesia.

Venous thromboembolism in spine surgery: Review of the current literature and future directions

Venous thromboembolism (VTE) is a serious adverse event that can profoundly affect the neurologic recovery and rehabilitation of spine patients. While routine pharmacologic VTE prophylaxis has been implemented in other orthopaedic surgical subspecialties its use has not been recommended in spinal surgery. Concern regarding post-operative spinal epidural hematoma and its devastating sequelae are a major focus of the discussion surrounding routine VTE prophylaxis in spine surgery. While pharmacologic prophylaxis may be beneficial in high risk patients, further large scale, prospective analyses are necessary to elucidate the role and risks of routine VTE screening and pharmacologic prophylaxis in spine surgery patients.

Catastrophic thoracolumbar spinal massive hematoma triggered by intraspinal anesthesia puncture: A CARE-compliant case report.

Rationale:Intraspinal anesthesia, the most common anesthesia type of orthopedic operation, is regarded as safe and simple. Despite of the rare incidence, puncture related complication of intraspinal anesthesia is catastrophic for spinal cord. Here we present an intradural hematoma case triggered by improper anesthesia puncture. The principal reason of this tragedy was rooted in the neglect of spine deformities diagnosis before anesthesia. To the best of our knowledge, there is no specific case report focusing on the intradural hematoma triggered by improper anesthesia puncture.Patient concerns:Hereby a case of thoracolumbar spinal massive hematoma triggered by intraspinal anesthesia puncture was reported. The presenting complaint of the patient was little neurologic function improvement after surgery at 6-month follow-up.Diagnoses:Emergency MRI demonstrated that massive spindle-like intradural T2-weighted image hypointense signal masses from T12 to S2 badly compressed the dural sac ventrally, and his conus medullaris was at L3/4 intervertebral level with absence of L5 vertebral lamina. Hereby, the diagnoses were congenital spinal bifida, tethered cord syndrome, spine intradural hematoma, and paraplegia.Interventions:Urgent surgical interventions including laminectomy, spinal canal exploration hematoma removal, and pedicle fixation were performed. The patient received both medication (mannitol, mecobalamin, and steroids) and rehabilitation (neuromuscular electric stimulation, hyperbaric oxygen).Outcomes:Postoperation, he had regained only hip and knee flexion at II grade strength. His neurologic function was unchanged until 3 weeks postoperation. Six-month follow-up showed just little neurologic function improvement, and the American Spinal Injury Association grade was C.Lessons:By presenting an intradural hematoma case triggered by improper anesthesia puncture, we shared the treatment experience and discussed the potential mechanism of neurologic compromise. The principal reason for this tragedy is preanesthesia examination deficiency. Necessary radiology examinations must be performed to prevent misdiagnosis for spinal malformation.

Non traumatic spinal epidural haematoma

Spinal epidural haematoma is a rare condition, which may be due to trauma, surgery, epidural catheterisation or disorders of coagulation. We report a case of 60 year old lady who was on warfarin for Atrial fibrillation (AF) presented with history of non-traumatic sudden onset pain in both legs and difficulty in walking. Magnetic resonance imaging (MRI) spine demonstrated epidural haematoma which was treated conservatively. Another dilemma was anticoagulation for AF. We examine the options to manage such case.

Cerebrospinal fluid drainage complications during first stage and completion fenestrated-branched endovascular aortic repair

ObjectiveTo determine the rates and risk factors of complications related to cerebrospinal fluid drainage (CSFD) during first stage and completion fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal and thoracoabdominal aortic aneurysms. MethodsWe reviewed the outcomes of 293 consecutive patients enrolled in a prospective, nonrandomized study to investigate outcomes of F-BEVAR between 2013 and 2018. Patients who received CSFD during first-stage thoracic endovascular aortic repair, index F-BEVAR, or completion of temporary aneurysm sac perfusion procedures were included in the analysis. CSFD complications were graded as severe or moderate if they were life threatening, escalated the level of care, or prolonged the hospital stay. Presence of substantial degenerative lumbar disease (DLD) was identified based on review of preoperative computed tomography. End points included technical difficulties during CSFD placement and CSFD-related complications. ResultsA total of 187 patients (mean age, 73 ± 8 years; 70% male) treated for 20 pararenal and 167 thoracoabdominal aortic aneurysms received CSFD in 240 procedures, including 51 first-stage thoracic endovascular aortic repairs, 184 index F-BEVARs, and 5 completion temporary aneurysm sac perfusion procedures. Nineteen patients (10%) had 22 CSFD-related complications after 21 aortic procedures (9%). Complications were graded as severe to moderate in 17 patients (9%). There were 12 patients (6%) with intracranial hypotension, including three (2%) who had intracranial hemorrhage and nine (5%) with post dural puncture headache requiring blood patches in six. Another six patients (3%) developed spinal hematomas resulting in paraplegia in two (1%) and transient paraparesis in two (1%). One patient had CSF leakage from the puncture site (no intervention required). Four patients had bleeding during attempted drain placement, which required postponement of F-BEVAR. Technical difficulties were experienced in 57 drain insertions (24%), more often in patients with DLD than in those without DLD (35/113 [31%] vs 22/121 [18%]; P = .03). Fluoroscopic guidance was used in 44 drain placements (18%) with a lower rate of technical difficulties compared with the blind approach (9% vs 28%; P = .01). There was a statistically nonsignificant trend toward more complications in patients with technical challenges (14% vs 7%; P = .10). Of 13 study patients who developed spinal cord injuries during aortic procedures, 4 (31%) were attributed to CSFD. ConclusionsAlthough CSFD is widely used to prevent ischemic spinal cord injury during complex aortic repair, the risk of major CSFD-related complications is not negligible and should be carefully weighed against its potential benefits. One-third of spinal cord injuries were caused by CSF drain placement. The use of fluoroscopic guidance may decrease the risk of CSFD-related complications.

Spinal epidural hematoma in a patient on chronic anticoagulation therapy performing self-neck manipulation: a case report

BackgroundSpinal epidural hematoma is a rare condition usually secondary to trauma and coagulopathy. To the best of our knowledge, we present the first case of a patient with an iatrogenic hypercoaguable state performing self-neck manipulation, which resulted in a spinal epidural hematoma and subsequent quadriparesis.Case presentationA 63-year-old man presented to the emergency department with worsening interscapular pain radiating to his neck 1 day after performing self-manipulation of his cervical spine. He was found to be coagulopathic upon admission, secondary to chronic warfarin therapy for the management of atrial fibrillation. Approximately 48 h after the manipulation, the patient became acutely quadriparetic and hypotensive. Urgent magnetic resonance imaging revealed a multilevel spinal epidural hematoma from the lower cervical to thoracic spine.ConclusionsPartial C7, complete T1 and T2, and partial T3 bilateral laminectomy was performed for evacuation of the spinal epidural hematoma. Following a 2-week course of acute inpatient rehabilitation, the patient returned to his baseline functional status. This case highlights the risks of self-manipulation of the neck and potentially other activities that significantly stretch or apply torque to the cervical spine. It also presents a clinical scenario in which practitioners of spinal manipulation therapy should be aware of patients undergoing anticoagulation therapy.

Assessing the effectiveness of an electrical stunning and chilling protocol for the slaughter of Atlantic mackerel (Scomber scombrus).

Inducing unconsciousness in fish using electrical stunning prior to slaughter may improve fish welfare and fillet quality if such practises can be disseminated into wild capture fisheries. The objectives of this study were to: 1) evaluate if an established slaughter protocol consisting of dry electrical stunning (using a coupled AC/DC current at ≈ 110 Vrms) followed by chilling could be used to stun the wild captured species Atlantic mackerel (Scomber scombrus) unconscious within 0.5 s; 2) determine if death could be induced without consciousness recovery by longer duration stunning (5 s) combined with chilling in an ice/water slurry for 6 min; and 3) examine the extent of quality defects arising from the applied slaughter protocol. We determined consciousness by examination of behavioural responses in a standardised vitality assessment. Out of a sample of 10 mackerel, 9 were assumed to be rendered unconscious by the 0.5 s stun, as determined by the presence of tonic and/or clonic muscle cramping consistent with a general epileptic insult. Assumed unconsciousness was maintained throughout chilling treatment in all fish (n = 25) following a full stun of 5 s. All fish were assumed to have died as a result of the protocol. There was no evidence of spinal damage or haematoma quality defects post filleting. These results suggest that the examined protocol is effective at slaughtering mackerel in a manner consistent with good welfare and without inducing quality defects, but further research is required to verify the unconscious condition via electroencephalogram (EEG) and before the procedure can be applied in wild capture fisheries.

Does the drain placement technique affect the amount of postoperative spinal epidural hematoma after microendoscopic decompressive laminotomy for lumbar spinal stenosis?

To prospectively evaluate with magnetic resonance imaging (MRI), the relationship between the distance from the incision of the drain output location and postoperative spinal epidural hematoma (SEH) in patients performed with microendoscopic decompressive laminotomy (MEDL) for lumbar spinal stenosis. Between January 2016 and June 2018, three different kinds of drain placement techniques, according to the drain output location, were performed to a total of 184 patients after MEDL for single-level spinal stenosis. The location of the drain output was within the incision in group 1, 1 cm lateral of the incision in group 2, and 5 cm lateral of the incision in group 3. At 24 h postoperatively, before removal of the drain, MRI examination was carried out in patients. A specific classification was developed by the authors to measure SEH, and the groups were evaluated by comparison. The mean postoperative dural sac cross-sectional area was 1.73 cm2 (standard deviation (SD): 0.711) in group 1, 1.66 cm2 (SD: 0.732) in group 2, and 1.52 cm2 in group 3 (SD: 0.841).The mean cross-sectional area of the postoperative hematoma was 1.45 cm2 (SD: 1.007) in group 1, 1.57 cm2 (SD: 1.053) in group 2, and 2.11 cm2 (SD: 1.024) in group 3. Four grades were defined according to the specific classification. According to this classification, grades C and D postoperative hematomas were determined at a statistically significantly higher rate in group 3 patients (drain output 5 cm lateral from the incision) compared to the other groups (p = 0.000). No significant difference was determined between groups 1 and 2 in respect of hematoma classification. In conclusion, it was determined that better drainage was provided in groups 1 and 2, where the drain output location was in the incision or close to it.

Management of Spinal Emergencies in Patients on Direct Oral Anticoagulants

Spine surgeons increasingly encounter acute spinal pathologies in patients treated with direct oral anticoagulants (DOACs), but only limited data on the management of these patients are currently available. We retrospectively analyzed patients who presented to our department with acute spinal pathology during treatment with DOAC and who required urgent surgical therapy. Patient characteristics and treatment modalities were studied, with specific focus on the management of hemostasis and surgical therapy. Furthermore, we analyzed 19 cases of spinal emergencies during DOAC treatment reported in the literature. A total of 12 patients were identified and included in the present analysis. Patients suffered from acute spinal cord compression caused by spinal tumor manifestation (n= 5), empyema (n= 4), degenerative spinal stenosis (n= 1), hematoma (n= 1), and vertebral body fracture/dislocation (n= 2). All patients underwent emergency surgical treatment. Prohemostatic substances were administered perioperatively in 10 patients (83%) and included administration of prothrombin complex concentrates (83%), tranexamic acid (17%), and transfusion of platelets (8%). A total of 9 patients (75%) showed postoperative improvement of neurologic symptoms, and the in-hospital mortality in this patient cohort was 17%. Emergency spine surgery is feasible and should be considered in patients on treatment with DOAC. The (low) risk of intraoperative bleeding complications has to be weighed against the risk of permanent disability if surgical decompression is delayed. Administration of prothrombin complex concentrates and tranexamic acid may improve the coagulation before surgery, especially in cases of unavailable specific antidotes.

Hematoma espinal epidural espontáneo asociado a tratamiento anticoagulante con acenocumarol: a propósito de un caso. [Spontaneous spinal epidural hematoma in patients treated with acenocumarol: A case study

El hematoma epidural espontáneo es una entidad muy poco frecuente que supone una urgencia neurológica. Su presentación es muy variable, desde un dolor de espalda hasta una tetraplejia, según la gravedad y el nivel de compresión. Se comunica el caso de un paciente cardiópata de 71 años, tratado con acenocumarol, que presentó un hematoma epidural de modo espontáneo. Al inclinarse hacia el suelo, el paciente, que no tenía síntomas, sufrió un dolor brusco cervical seguido de debilidad en los miembros superiores e inferiores. Ante la sospecha clínica de una compresión medular, se decide realizar una resonancia magnética de urgencia, que mostró un hematoma de localización epidural con extensión desde C4 hasta T8. El diagnóstico urgente y el tratamiento de descompresión precoz son fundamentales para reducir al mínimo los daños neurológicos posteriores permanentes. AbstractSpontaneous spinal epidural hematoma is an uncommon condition and a neurological emergency. The clinical presentation of this type of hematoma is very variable, ranging from a backache up to a quadriplegia, according to the severity and the site of compression. Here, we discuss the clinical case of a 71-year-old patient with heart problems, under previous treatment with acenocumarol, that suffered a spontaneous epidural hematoma. The patient, previously asymptomatic, presented, sudden cervical pain when he bent over, followed by weakness in the lower and the upper limbs. Due to the clinical suspicion, an emergency MRI was performed, showing an epidural hematoma extending from C4 to T8. Early diagnosis and decompressive treatment are mandatory to minimize permanent neurological damage.

Erector spinae plane vs. paravertebral blockade for rib fracture analgesia

We would like to commend Adhikary et al. for their continued efforts to show benefit from novel regional techniques for chest trauma 1 and agree that patients with rib fracture(s) have significantly improved pain scores after regional analgesia. We would like to invite the authors to reply to a number of comments that we have about their work. Firstly, the authors make several comments about the technically challenging nature of paravertebral blockade. In our institution, ultrasound-guided thoracic paravertebral blockade is the regional technique of choice in unilateral chest trauma. Data from our experiences reveal an extremely low complication rate, with no significant complications from 314 paravertebral catheters over a 4-year period 1, inserted by consultant and registrar anaesthetists. This is consistent with our experience of thousands of single-shot blocks performed for breast surgery, and with similar experiences in other centres worldwide 2. We recognise that there is, undoubtedly, a learning curve associated with the paravertebral technique, but we believe this is similar in appearance to learning curves for any other new regional anaesthetic technique. Secondly, we note that only 79 patients were administered an erector spinae plane (ESP) block over 19 months. Can we ask whether there were other patients in the authors’ institution that received epidural or paravertebral blockade during this time, and whether comparative analysis has been possible? We are not aware of any published evidence that the ESP block is technically easier, and the results of any such analysis would be useful to know when organising training. Are there novices or non-anaesthetists performing the ESP block at the authors’ institution? Thirdly, the authors question the feasibility of paravertebral blockade in coagulopathy and haemodynamic instability. In our opinion, neither coagulopathy nor anticoagulation is a contra-indication to paravertebral techniques, necessarily. We assess each case individually, in line with the collaborative guideline from on regional anaesthesia techniques in patients with abnormalities of coagulation 3. This guideline classifies paravertebral block as ‘higher risk’ compared with more peripheral or superficial techniques, but provides no quantification of this risk, and does not reference any evidence documenting complications in patients with disorders of coagulation. Furthermore, we can find no case reports of spinal or epidural haematomas following ultrasound-guided paravertebral block performance. The practice of using curled catheters rather than straight in the paravertebral space further reduces the risk of accidental epidural placement. Our experience also reveals no associated haemodynamic instability following paravertebral blockade. Their analysis revealed a statistically significant increase in spirometry values, but such improvement would be expected normally over time, with or without regional anaesthesia. Are the authors confident about ascribing causality between the block and the spirometry improvement, given the 24-h gap between insertion and measurement? In our experience, spirometry improves very soon (within 30 min) after block insertion, and often improves further by the following day. We suggest that paravertebral block overcomes the variability in analgesia observed in the authors’ study, because it places local anaesthetic in close proximity to the target nerves, can be performed by a range of anaesthetist grades, is associated with minimal complications and side-effects, and performance of which is contra-indicated in very few patients. Regardless of the block choice however, we agree with the authors that good analgesia (under the aegis of a comprehensive pain service) remains critical in the successful management of rib fractures.

Complications of Postoperative Epidural Analgesia For Oncologic Surgery: A Review of 18,895 Cases.

The risks of epidural analgesia (EA) differ depending on the population studied. We describe our experience with postoperative EA for oncologic surgery. We searched our Acute Pain Medicine database for cases in which postoperative EA was used between 2003 and 2012. We used word search to identify and catalog cases of neurological changes, magnetic resonance imaging or computed tomography of the spine, electromyography studies, and neurologist or neurosurgeon consultations. Medical records of patients with documented persistent neurological deficits and patients who had spine imaging or neurology consultations were reviewed further. In addition, we cross-checked medical records with billing diagnosis codes for spinal epidural abscess or hematoma. We reviewed 18,895 cases in which postoperative EA was used. Complications included neurological symptoms in 2436 cases (12.9%), epidural insertion site abnormalities in 1062 cases (5.6%), complete epidural catheter migration in 829 cases (4.4%), epidural replacement in 619 cases (3.3%), and inadvertent dura puncture in 322 cases (1.7%). There were 6 cases of persistent deficits of uncertain etiology, 4 deep spinal infections (1:4724), and 2 cases of catheter tip shearing. No spinal epidural hematomas were identified (95% confidence interval, 0-0.0002). Our findings provide a contemporary review of some risks associated with the use of postoperative EA for patients undergoing oncologic surgery. Despite a not-uncommon incidence of neurological changes, serious complications resulting in prolonged sequelae were rare.

Observation of single spinal anesthesia by 25G needle puncture through a lateral crypt for hip surgery in elderly patients.

Background:Lumbar spine hyperosteogeny and ligament calcification are common in the elderly and anesthesia puncture through the conventional approach is difficult in this age group, and repeated puncture can increase the risk of spinal hematoma and nerve injury. This study aimed to observe the feasibility and safety of single spinal anesthesia administered with 25G needle through the lateral crypt for lower-extremity fracture surgery in elderly patients.Methods:The subjects were 60 elderly patients in our hospital (aged 65–80 years; ASA grades I and II) scheduled for lower-extremity fracture surgery (procedure was predicted to last within 2 h) under single spinal anesthesia by different approaches through L3–4. They were randomly divided into 2 groups: in the first group, 25G needle was used in a vertical approach (group C, n=30); in the second, 25G needle was passed through the inner edge of the small joints of L3–4 to the lateral crypt (group L, n=30). After successful completion of the puncture procedure, 2.5 mL of 0.5% hyperbaric ropivacaine was used for spinal anesthesia. We then recorded the puncture times, sensory block level, and adverse reactions (e.g., headache, lumbago, and lower limb pain).Results:No significant differences in onset time, sensory block level and adverse reaction were noted between the 2 groups. The puncture success rate in group L was not significantly higher and the number of attempts per puncture was not significantly less than that in group C (93.3% vs 70%) (P = .063). Nerve-root irritation was more frequent in group L than in group C but with no significant difference (P > .05).Conclusion:Single spinal anesthesia through the lateral crypt approach is safe and effective for lower-extremity fracture surgery in elderly patients. Thus, this approach is a feasible alternative when the conventional approach fails.

A brief review of literature of spontaneous spinal epidural hematoma in the context of an idiopathic spinal epidural hematoma

BackgroundThere is a debate over the origin of bleeding in case of spontaneous spinal epidural hematoma (SSEH). The most widely accepted theory is of venous origin. Since the epidural veins are valveless, there will be increased venous pressure transmitted from intrathoracic and intraabdominal compartments on straining, causing rupture. Another view is that only arterial bleeding can cause rapid compression of spinal cord, since the venous pressure is less than intrathecal pressure. There is a lack of consensus on treatment also. Most of the authors recommend urgent decompressive laminectomy. There is a recent trend towards less invasive options such as partial laminectomy and hemilaminectomy and conservative treatment.Aim, materials, and methodsAim of this study is to review the theories about the origin of bleeding in spontaneous spinal epidural hematoma and the methods of treatment. Literature search was done in PubMed for theories of the origin of spontaneous spinal epidural hematoma and the treatment methods. Descriptive analysis was done.Case presentationA 49-year-old male stoneworker presented with thoracic back pain of acute onset while doing work, followed by weakness of forearm and legs. He had paraplegia with grade 1 power of lower limbs. MRI showed posterior epidural hematoma from C3 to T4. Midline partial laminectomy was done from C5 to T2. Hematoma was evacuated. His power improved over 1 week. Later CT (computed tomography) angiography showed no vascular malformation.ConclusionCervical location and rapid development of weakness point towards arterial origin of spontaneous spinal epidural hematoma. Thoracic location and presence of peroperative venous ooze suggest venous origin. Partial or hemilaminectomy is recommended to reduce postoperative instability. Conservative treatment is preferred in case of coagulopathy.

Hematoma and Abscess After Neuraxial Anesthesia: A Review of 647 Cases

(Br J Anaesth. 2018;120:693–704) Incidences of spinal hematoma or abscess after central neuraxial block (CNB) are estimated to be low, with the former being 1:154,730 and the latter being so rare, it could not even be calculated in a major 2016 study. Because of the rarity, there is no evidence on which to base recommendations for management strategies. However, these adverse events could result in permanent injury for patients, with the incidence of paraplegia or death being 1.8 per 100,000 patients. Therefore, the authors of the present study reviewed all cases reported regarding spinal hematomas or abscesses after CNB, identified potential factors that may predispose patients to these adverse outcomes, and predicted persistent neurological damage.

Reply to the comments on “Spontaneous spinal epidural hematoma mimicking Guillain-Barre Syndrome”

Reply to the comments on “Spontaneous spinal epidural hematoma mimicking Guillain-Barre Syndrome”

Trends in Practice and Safety Measures of Epidural Analgesia: Report of a National Survey

(Acta Anaesthesiol Scand. 2018;62:1466–1472) There is a trend to move away from neuraxial blocks in favor of truncal blocks, peripheral nerve blocks, and local anesthetic wound infiltration in the Netherlands. Furthermore, recent epidural “alert systems” have been introduced, meant to aid in the early detection of spinal hematoma or abscess after neuraxial anesthesia. However, these changes have not been investigated on a national level. The authors of the present study thus quantified trends in the practice of epidural analgesia and assessed the extent to which these epidural alert systems have been introduced in clinical practice.

Risk Factors of Postoperative Spinal Epidural Hematoma After Biportal Endoscopic Spinal Surgery

Although postoperative spinal epidural hematoma is a rare complication, it can cause severe neurologic complications. Studies regarding biportal endoscopic spinal surgery, a type of minimally invasive spinal surgery technique, have been recently reported. The purpose of our study is to report the incidence and risk factors of postoperative hematoma after biportal endoscopic spinal surgery. The subjects included 310 patients that underwent biportal endoscopic spinal surgery from 2015 to 2017. Magnetic resonance imaging (MRI) was performed in all patients before surgery, and also after surgery to identify epidural hematoma. Using electronic medical records, perioperative factors such as age, sex, operation name, operation level, water infusion pump usage, thrombin-containing hemostatic agent, and anticoagulant medication were statistically analyzed in the aspect of postoperative hematoma. The overall occurrence rate of postoperative hematoma was 23.6% (n= 94). A total of 304 levels (76.4%) were without hematoma according to the postoperative MRI among the total 398 levels. Six patients underwent revision surgery of hematoma evacuation. Female sex, old age (>70 years), preoperative anticoagulation medication, and usage of intraoperative water infusion pump were significantly correlated to the occurrence of postoperative hematoma. Although symptomatic postoperative hematoma was extremely rare at 1.9%, radiologic hematoma confirmed by postoperative MRI was higher at 23.6%. The perioperative risk factors of postoperative hematoma after biportal endoscopic spinal surgery include female sex, older age (>70 years), preoperative anticoagulation medication, usage of intraoperative water infusion pump, and surgery requiring more bone work (laminectomy or interbody fusion).

SS08. Cerebrospinal Fluid Drainage Complications During First Stage and Completion Fenestrated-Branched Endovascular Aortic Repair

To determine the rates and risk factors of complications related to cerebrospinal fluid drainage (CSFD) during fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal and thoracoabdominal aortic aneurysms. We reviewed outcomes of 293 consecutive patients enrolled in a prospective, nonrandomized study to investigate outcomes of F-BEVAR between 2013 and 2018. Patients who received CSFD during first-stage thoracic endovascular aortic repair, index F-BEVAR or completion temporary aneurysm sac perfusion procedures were included in the analysis. CSFD complications were graded as severe or moderate if these were life threatening, escalated the level of care or prolonged hospital stay. Presence of degenerative lumbar disease (DLD) was identified based on review of computed tomography scans. End points included technical difficulties during CSFD placement and CSFD-related complications. A total of 187 patients (mean age, 73 ± 8 years; 70% male) treated for 20 pararenal and 167 thoracoabdominal aortic aneurysms received CSFD in 240 procedures, including 51 first-stage thoracic endovascular aortic repairs, 184 index F-BEVARs and 5 completion temporary aneurysm sac perfusion procedures. Nineteen patients (10%) had 22 severe to moderate CSFD-related complications after 21 aortic procedures (9%). There were 12 patients (6%) with intracranial hypotension, including 3 (2%) who had intracranial hemorrhage (Fig 1) and 9 (5%) with severe headache requiring blood patches in 6. Another six patients (3%) developed spinal hematomas (Fig 2) resulting in paraplegia in two (1%) or transient paraparesis in two (1%). Other complications were cerebrospinal fluid leakage in one patient (no intervention) and bleeding during attempted CSFD placement requiring postponement of index F-BEVAR in three. In addition, 20 patients (11%) had blood-tinged drainage or bleeding at the puncture site without any clinical sequela. Technical difficulties were experienced in 57 drain insertions (24%), more often in patients with DLD compared with those without DLD (35/113 [31%] vs 22/121 [18%]; P = .03). Fluoroscopic guidance was used in 44 CSFD placements (18%) with lower rate of technical difficulties compared with blind approach (9% vs 28%; P = .01). There was a statistically nonsignificant trend toward more complications in patients with technical challenges (14% vs 7%; P = .10). Of the 13 patients who developed spinal cord injuries during aortic procedures, 4 (31%) were attributed to CSFD placement. Although CSFD is widely used to prevent ischemic spinal cord injury during complex aortic repair, the risk of major CSFD-related complications is not negligible and should be carefully weighed against its potential benefits. Use of fluoroscopic guidance may reduce the risk of CSFD complications.Fig 2Spinal hematoma.View Large Image Figure ViewerDownload Hi-res image Download (PPT)