Background and etiology:

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  Incidence rates approach 20 to 30% of patients undergoing spinal procedures.

  
  
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  Risk factors include the following:

  
  
  
  
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    Patient factors: female gender, history of motion sickness or postoperative nausea and vomiting (PONV), nonsmokers, younger age.

    
    
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    Surgical factors: extended duration of anesthesia.

    
    
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    Pharmacologic factors: postoperative opioids.

Management:

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  Prevention:

  
  
  
  
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    Avoid general anesthesia and volatile anesthetics if possible.

    
    
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    Limit opioid use.

    
    
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    Promote adequate hydration.

  
  
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  Treatment:

  
  
  
  
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    Antiemetics.

    
    
    
    
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      5-HT3 receptor antagonists, neurokinin 1 (Nk-1) receptor antagonists, corticosteroids, butyrophenones, antihistamines, anticholinergics, phenothiazines.

      
      
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      Use of dopamine and serotonin antagonist medication is associated with QT prolongation; monitoring of echocardiogram (ECG) for QT interval and presence of arrhythmias is recommended.

Background and etiology:

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  Incidence rate approaching 71% following cervical procedures; most common in the first postoperative week.

  
  
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  Risk factors include the following:

  
  
  
  
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    Patient factors: female gender, older age.

    
    
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    Surgical factors: multilevel procedures, revision procedures, procedures involving lower cervical levels (C4–C6).

  
  
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  Etiology is multifactorial and may involve manipulation of esophageal tissue during surgery, hardware displacement, esophageal perforation, retropharyngeal abscesses, or neural injury.

Presentation:

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  Reflexive coughing.

  
  
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  Difficulty swallowing food or drink with leakage.

  
  
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  Risk for aspiration and possible pneumonia.

Clinical evaluation:

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  Bedside swallowing test.

  
  
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  Speech/language pathology consultation.

Radiographic evaluation:

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  Cervical radiographs: to evaluate for structural etiologies.

  
  
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  Videofluoroscopic/modified barium swallow study: allows for evaluation of the pharynx and esophagus:

  
  
  
  
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    Soft-tissue swelling with displacement of the esophagus is the most common finding.

    
    
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    Can additionally evaluate for hardware failure.

Management:

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  Prevention:

  
  
  
  
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    Avoidance of prolonged operative time.

    
    
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    Intermittent relaxation of self-retaining retractors and partial deflation of the endotracheal cuff once retractors are in place.

    
    
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    Instrumentation modifications (anchored spacer, smaller cervical plates).

  
  
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  Treatment:

  
  
  
  
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    Nothing by mouth (NPO) or restricted dietary status:

    
    
    
    
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      Consider nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube placement if severe dysfunction with aspiration risk and nutritional deficits is present.

    
    
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    Behavioral modifications: postural changes, swallowing maneuvers.

Background and etiology:

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  Incidence rate of 3.5% after elective spinal procedures (most common after anterior lumbar and lateral retroperitoneal procedures).

  
  
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  Risk factors include the following:

  
  
  
  
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    Patient factors: older age, male gender, previous opioid use, history of gastroesophageal reflux disease (GERD), history of abdominal surgery.

    
    
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    Surgical factors: anterior or lateral surgical approaches.

  
  
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  Etiology involves failure of peristalsis due to a pathologic response by the gastrointestinal (GI) tract to surgical manipulation and tissue trauma:

  
  
  
  
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    Underlying sepsis and electrolyte abnormalities (hypokalemia, hyponatremia, and hypomagnesemia) may worsen ileus.

Presentation:

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  Pain, nausea, vomiting, abdominal distention, inability to pass flatus or stool.

Radiographic evaluation:

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  Abdominal radiographs:

  
  
  
  
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    Identify possible bowel distention or transition points indicative of mechanical obstruction.

  
  
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  Computed tomography (CT) scan:

  
  
  
  
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    Evaluate for mechanical obstruction or bowel injury.

Management:

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  Prevention:

  
  
  
  
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    Limit bowel manipulation.

    
    
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    Minimize narcotic consumption.

  
  
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  Treatment:

  
  
  
  
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    Place patient NPO for bowel rest.

    
    
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    Administer intravenous (IV) fluids for electrolyte correction.

    
    
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    Laxatives and slow diet advancement as tolerated.

    
    
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    For patients with vomiting and distention, a nasogastric tube may provide symptomatic relief; however, there is no conclusive evidence that nasogastric tubes facilitate resolution of ileus.

Background and etiology:

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  Incidence approaching 6.1% of patients undergoing cervical spine surgery.

  
  
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  Risk factors include the following:

  
  
  
  
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    Patient factors: morbid obesity, obstructive sleep apnea, history of pulmonary disease, low preoperative hematocrit, high serum creatinine.

    
    
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    Surgical factors: exposures involving more than three vertebral bodies, blood loss greater than 300 mL, exposures of C2–C4, operative time greater than 5 hours, anteroposterior approach.

  
  
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  Etiologies include laryngopharynx and prevertebral soft-tissue edema, hematoma, cerebrospinal fluid (CSF) leaks, or hardware dislodgement.

  
  
  
  
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    Presentation after 12 hours postoperatively is associated with airway edema.

    
    
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    Delayed presentation after 72 hours postoperatively is associated with hematoma, CSF leaks, hardware failure.

Presentation:

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  Dyspnea, dysphonia.

  
  
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  Can progress to stridor, cyanosis.

  
  
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  Increased risk of aspiration.

Clinical evaluation:

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  Arterial blood gases demonstrate hypercarbia and hypoxia.

Radiographic evaluation:

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  Plain radiographs and CT scan:

  
  
  
  
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    Lateral views often demonstrate prevertebral soft-tissue swelling.

Management:

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  Prevention:

  
  
  
  
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    In high-risk patients, consider delayed extubation with postoperative intensive care unit (ICU) admission.

  
  
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  Treatment:

  
  
  
  
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    Emergent intubation is required if there is evidence of airway compromise.

Background and etiology:

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  Incidence ranges from 0.45 to 1.05% depending on surgical location.

  
  
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  Risk factors include the following:

  
  
  
  
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    Cervical procedures: Older age, chronic obstructive pulmonary disease (COPD), increased operative time, dependent functional status.

    
    
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    Lumbar procedures: COPD, diabetes, increased number of operative levels, steroid use.

  
  
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  Etiology is multifactorial:

  
  
  
  
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    Endotracheal intubation can lead to mini-aspirations.

    
    
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    Postoperative atelectasis reduces air movement.

    
    
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    Postoperative dysphagia poses an additional aspiration risk.

Presentation:

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  Fever, dyspnea, productive cough often presenting postoperative day 3 (POD3) or later.

  
  
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  Associated with higher rates of sepsis, mortality, and readmission.

Clinical evaluation:

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  White blood cells (WBCs).

  
  
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  Sputum culture.

Radiographic evaluation:

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  Chest radiography: pattern of infiltrate can help determine etiology:

  
  
  
  
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    Lobar infiltrates are associated with bacterial sources.

    
    
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    Diffuse, interstitial infiltrates are associated with viral sources.

    
    
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    Infiltrates in dependent areas are associated with aspiration:

    
    
    
    
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      If patients are upright: inferior lung segments.

      
      
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      If patients are supine: posterior lung segments.

  
  
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  CT scan: allows for detailed evaluation:

  
  
  
  
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    Detection of complications such as pleural effusions or abscess formation.

Management:

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  Prevention:

  
  
  
  
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    Elevation of head of bed to 30 degrees and sitting up for all meals to prevent aspiration.

    
    
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    Oral hygiene.

    
    
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    Pulmonary rehabilitation with incentive spirometry to prevent atelectasis.

    
    
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    Adequate analgesia.

    
    
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    Supervised ambulation.

  
  
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  Treatment:

  
  
  
  
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    Antibiotics.

    
    
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    Pulmonary rehabilitation.

Background and etiology:

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  Incidence ranges from 1 to 2% after spinal procedures.

  
  
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  Risk factors include the following:

  
  
  
  
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    Patient factors: older age (>65 years), atrial fibrillation, hypertension, prior MI, current anticoagulation requirement.

    
    
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    Abnormal lab values: low albumin, creatinine greater than 1 mg/dL.

    
    
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    Surgical factors: traumatic indication, two-level fusion, intraoperative transfusion requirement, length of stay greater than 7 days.

  
  
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  Etiology:

  
  
  
  
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    Associated with decreased coronary perfusion secondary to operative blood loss.

    
    
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    Hypotension and hemodynamic instability are also more frequent in the prone position due to decreases in blood pressure and cardiac function.

Presentation:

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  Crushing chest pain with radiation to the shoulder, arm, and jaw.

  
  
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  Dyspnea, diaphoresis.

Clinical evaluation:

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  ECG changes differ by type and location of MI:

  
  
  
  
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    Non-ST–segment elevation MI (NSTEMI): ST-segment flattening, T-wave flattening or inversion.

    
    
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    ST-segment elevation MI (STEMI): ST elevation in ischemic areas, ST depression in reciprocal areas, Q-wave formation.

    
    
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    Troponin and creatine kinase-MB (CK-MB) levels:

    
    
    
    
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      Elevated in both STEMI and NSTEMI.

  
  
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  Radiographic evaluation:

  
  
  
  
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    ECG can be used to detect wall motion abnormalities:

    
    
    
    
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      Do not delay treatment for radiographic examinations if there is significant clinical suspicion for MI.

  
  
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  Management:

  
  
  
  
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    All patients receive morphine for pain control, supplemental oxygen, nitrates, aspirin, beta-blockers, and statins.

    
    
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    STEMI: emergent percutaneous revascularization or fibrinolytic therapy.

    
    
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    NSTEMI: anticoagulation, possible escalation to revascularization therapy based on cardiac catheterization findings.