24 Surgical Complications

10.1055/b-0039-166433

24 Surgical Complications

Ikechukwu Achebe, Ankur S. Narain, Fady Y. Hijji, Philip K. Louie, Daniel D. Bohl, and Kern Singh

24.1 Introduction

Surgery is inherently associated with risk. Surgeries involving the spine and spinal cord are subject to various severe complications, and thus warrant additional intervention. An understanding of these complications, along with appropriate prevention and treatment strategies, is essential to patient safety. Therefore, it is important to recognize the etiology, presentation, and management strategies for common surgical complications including postoperative fever, surgical site infection, durotomy, and spinal epidural hematoma (Table 24.1).

**Table 24.1** Common etiologies of postoperative fever
Etiology	Approximate day of onset	Clinical evaluation	Imaging	Primary treatment
Surgical trauma and tissue manipulation	POD 0	–	–	Self-limited
Atelectasis	POD 1–2	Incentive spirometry	CXR	Oxygen therapy Pulmonary rehabilitation
Pneumonia	POD 3	WBC, sputum culture	CXR	Antibiotics Pulmonary therapy
UTI	POD 2–3	Urinalysis, urine culture	–	Antibiotics Catheter removal or replacement
DVT/PE	POD 3–7	D-dimer	CT angiogram, duplex ultrasonography	Anticoagulation
Wound infection or bacteremia	POD 3–7	WBC, ESR, CRP, blood culture, wound culture	MRI	Antibiotics Wound care Debridement and removal of hardware
Implant infection	Delayed (weeks to months)	ESR, CRP, WBC, wound culture	MRI	Antibiotics Debridement Hardware removal
Abbreviations: CRP, C-reactive protein; CT, computed tomography; CXR, chest X-ray; DVT, deep vein thrombosis; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; PE, pulmonary embolism; POD, postoperative day; UTI, urinary tract infection; WBC, white blood cell.

24.2 Postoperative Fever

Background:
- Body temperature greater than 38.6°C (101.5°F).
- Incidence rate of 14 to 91%.
Etiology:
- Immediate onset:
  - Majority are noninfectious (>50% of cases).
- Acute, subacute, and delayed onset:
  - Strongly consider infectious etiology.
Risk factors:
- Immunosuppression, prolonged operative time, nosocomial infections.
- Urinary catheterization, respiratory ventilation.
Presentation:
- Diaphoresis, chills, headache.

24.3 Surgical Site Infections

Background:
- Postoperative infection localized to surgical site; occurs within 30 days.
- Incidence following spine surgery is 1 to 12%.
- Surgical site infection (SSI) types and associated tissues (Fig. 24.1).
Etiology:
- Routes of infection:
  - Direct Inoculation of skin flora.
  - Wound contamination.
- SSI pathogens association:
  - Gram (+): Staphylococcus. aureus (50% of SSIs), S. epidermidis, and Streptococcus.
  - Gram (–): Pseudomonas. aeruginosa, Escherichia coli, and Proteus.
Risk factors:
- Preoperative: diabetes, smoking history, body mass index (BMI), corticosteroid use, age.
- Intraoperative: sterile technique, invasiveness, operative duration.
- SSI risk by procedure: trauma > diskitis > tumor resection > minimally invasive.
- SSI risk by location: thoracic (2.1%) > lumbar (1.6%) > cervical (0.8%) vertebrae.
Presentation:
- Clinical symptoms:
  - Back pain, wound drainage, erythema, palpable fluctuance.
  - Fever, fatigue (deep SSI [DSSI] > SSSI).
Clinical evaluation:
- Laboratory tests:
  - Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) elevation (high sensitivity 94–100%).
  - White blood cell (WBC) elevation (poor sensitivity 44–58%).
  - Bacterial cultures:
    - Positive in 51 and 78% of SSSI and DSSI cases, respectively.
    - Intraoperative and deep cultures preferred.
Radiographic evaluation:
- Magnetic resonance imaging (MRI) at 3 to 5 days postoperatively (sensitivity 93%):
  - T2: edema appears as hyperintense signal.
  - Decreased height of vertebral disk/body seen with late stage infection.
- Radionucleotide imaging: increased uptake of 67Ga at sites of infection.
- X-ray: decreased intervertebral height discernable 4 to 6 weeks postoperatively.
- Computed tomography (CT): bony destruction, soft-tissue abscesses.
Treatment:
- Antibiotics, wound care:
  - Start antibiotics with broad coverage and narrow upon determination of causative organism.
- If conservative treatment fails or symptoms progress: debridement, removal of hardware.