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Abstract

Abstract


Symptomatic spinal epidural haematoma (SSEH) is a rare but serious postoperative complication. This study aimed to assess the prevalence, causes and treatment of SSEH after adult spinal deformity (ASD) surgery. The patients admitted from August 2012 till August 2016 were retrospectively reviewed using case notes. During these four years, 102 patients were admitted with adult spinal deformity, out of which 3 (2.9%) developed post-operative SSEH. The duration between surgery to onset of SSEH was 10-13 hours (average 11.7 hours) post-operatively. Three patients were treated by haematoma evacuation at 8.5-14 hour (average 11.4 hours) after the symptoms appeared. One patient had improved by 2 Frankel grades, and two patients had improved by1 Frankel grade at the last followup. The results concluded that post-operative SSEH occurred in 2.9% of ASD patients who underwent corrective spinal procedures. Improvement in neurological deficits can be achieved by early haematoma evacuation.

Keywords: symptomatic spinal epidural haematoma; postoperative complication; adult spinal deformity; treatment

 

DOI: https://doi.org/10.47391/JPMA.951

 

Introduction

 

Different degrees of epidural haematoma can be identified by computed tomography (CT) scans and magnetic resonance imaging (MRI).The prevalence of asymptomatic epidural haematoma has been reported in the literature as 33-100%.1-3 Most post-operative epidural haematomas are clinically asymptomatic and do not require surgical intervention. However, symptomatic spinal epidural haematoma (SSEH) following spine surgery is a serious post-operative complication which can result in fatal neurological deficits, including bowel and bladder incontinence, saddle anaesthesia, sciatica and motor weakness of the extremities and reduced sexual performance. The prevalence rate is 0.1-1.0% for SSEH, which requires immediate surgical evacuation of the haematoma.4-9 Risk factors, such as multilevel procedures, substantial blood loss and advanced age, have been identified for the development of SSEH after spine surgery.1,7,10 Usually, these risk factors are associated with adult spinal deformity (ASD). However, the prevalence, risk factors and proper management of SSEH in ASD patients undergoing corrective spinal procedures is unknown. Thus far, only a few cases of SSEH after adult spinal deformity surgery have been reported.11 The aim of this study was to assess the prevalence, causes and outcomes of SSEH after ASD surgery.

 

Case Series

 

A retrospective search for post-operative SSEH was conducted on patients presenting with adult spinal deformity in Fuzhou Second Hospital affiliated to Xiamen University, China, from August 2012 till August 2016. Adults with spinal deformity who underwent corrective spinal procedures for scoliosis, kyphosis, or kyphoscoliosis at this institution were included. The preoperative diagnosis included degenerative scoliosis in 58 cases, post-traumatic scoliosis in 24 cases, ankylosing spondylitis kyphotic deformity in 5 cases, idiopathic scoliosis in 11 cases, congenital scoliosis in 3 cases and neuromuscular scoliosis in l case. Those with infective spondylitis, epidural abscess and spinal trauma were excluded. The diagnosis of SSEH was made on the basis of the development of neurological deficits and was confirmed by CT scans, MRI assessment or a surgical finding. Once an SSEH had been identified on CT or MRI, the patient was treated with emergent haematoma evacuation. Meanwhile, intravenous Methylprednisolone, 30 mg/kg over 15-30 minutes, was started, followed by maintenance infusion of 5.4 mg/(kg/hr) for another 23 hours, even after haematoma evacuation. Study data and medical records, including patients’ demographics, neurological examination, intraoperative variables, symptoms of the post-operative epidural haematoma, duration to onset, duration from onset to evacuation, recovery rate (Frankel grade), and neurological outcomes, as well as plain radiographs, MRI and CT, of patients who developed SSEH after ASD surgery, were collected. For this study, we only used information from patients’ records.

 

Results

 

In total, 102 patients were included in the study, and 3 (2.9%) patients were identified with post-operative SSEH, of which two were males and one female. The average age of the patients was 56.3±9.3 years (range 50 to 67). Their original diagnoses, for which the first operation was performed, were degenerative scoliosis, post-traumatic kyphoscoliosis and idiopathic spinal scoliosis. The operation sites were all located in the lumbar spine. Preoperative prothrombin times and blood platelet counts were all within normal limits. (Table 1).





None of the patients had symptoms in the immediate postoperative period, and the duration to onset of symptoms was 10-13 hours (average 11.7±1.5 hours). All patients showed motor weakness and sensory loss in the lower extremities. One patient experienced severe radicular pain, and one patient had incisional pain. To reduce incision bleeding after surgery, haemostatic agents (Hemocoagulase, 1 ku/dose, intramuscular injections at 1 and 2 hours after surgery) were administered in two patients (patients 1 and 3). The total volumes of wound drainage were 800 ml, 470 ml and 615 ml (average19.3±3.5 months) when symptoms appeared, respectively. After that, the drainage decreased sharply. The drainage volumes were 20 ml, 50 ml and 180 ml (average 83.3±85.0 ml) from onset to evacuation. Meanwhile, progressive deterioration of neurological functions was observed. The Frankel grades of the three patients were C, B and C, respectively, with manual muscle test (MMT) scores