Complications following posterior cervical decompression and fusion: a review of incidence, risk factors, and prevention strategies

Abstract

Posterior cervical decompression and fusion (PCF) is a common surgical technique used to treat various cervical spine pathologies. However, there are various complications associated with PCF that can negatively impact patient outcome. We performed a comprehensive literature review to identify the most common complications following PCF using PubMed, Cochrane Database of Systematic Reviews, and Google Scholar. The overall complication rates of PCF are estimated to range from about 15% to 25% in the current literature. The most common immediate complications include acute blood loss anemia, surgical site infection (SSI), C5 palsy, and incidental durotomy; the most common long-term complications include adjacent segment degeneration, junctional kyphosis, and pseudoarthrosis. Three principal mechanisms are thought to contribute to complications. First, higher number of fusion levels, obesity, and more complex pathologies can increase the invasiveness of the planned procedure, thus increase complications. Second, wound healing and arthrodesis may be impaired due to poor blood flow due to various patient factors such as smoking, diabetes, increased frailty, steroid use, and other medical comorbidities. Finally, increased biomechanical stress on the upper instrumented vertebra (UIV) and lowest instrumented vertebra (LIV) may predispose patient to chronic degeneration and result in adjacent level degeneration and/or junctional problems. Reducing the modifiable risk factors pre-operatively can decrease the overall complication rate. Neurologic deficits may be reduced with adequate intraoperative decompression of neural elements. SSI may be reduced with meticulous wound closure that minimizes dead space, drain placement, and the use of intra-wound antibiotics. Careful design of the fusion construct with consideration in spinal alignment and biomechanics can help to reduce the rate of junctional problems. Spine surgeons should be aware of these complications associated with PCF and the corresponding prevention strategies optimize patient outcomes.

Keywords: Posterior cervical decompression and fusion (PCF); complication; prevention; risk factors.

Conflict of interest statement

Conflicts of Interest: The series “Advanced Techniques in Complex Cervical Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. LAT serves as the unpaid editorial board member of Journal of Spine Surgery from Jan. 2019 to Jan. 2021 and served as the unpaid Guest Editor of the series. Dr Mummaneni is a consultant for DePuy Spine, Globus, and Stryker; has direct stock ownership in Spinicity/ISD; receives clinical/research support from NREF; recieves royalties from DePuy Spine, Thieme Publishers, and Springer Publishers; has a grant from AOSpine; and receives honoraria from Spineart. Dr. Chou is a consultant for Globus and Medtronic. Dr. Tan is a consultant for Stryker and Integrity Implants. The other authors have no conflicts of interest to declare.

2020 Journal of Spine Surgery. All rights reserved.

Figures

Figure 1

Pre-operative (A) MRI and (B) CT demonstrating OPLL and OYL at C6–7 causing circumferential cord compression in a patient with ankylosing spondylitis and fused spine above and below C6–7 level. MRI, magnetic resonance imaging; CT, computed tomography; OPLL, ossification of the posterior longitudinal ligament; OYL, ossification of the yellow ligament.

Figure 2

Post-operative X-rays immediately after surgery, at 2-month follow-up, and after revision surgery. (A) Immediate post-operative X-ray demonstrating C7 corpectomy and C6–T1 anterior fusion with C4 to T2 posterior decompression and instrumentation; (B) 2-month follow-up X-ray showing instrumentation pullout and PJK; (C) post-operative X-ray demonstrating extension of fusion to C2 and correction of PJK. PJK, proximal junctional kyphosis.