The Spine Journal 14 (2014) 724–726
Letters to the Editor Symptomatic postoperative spinal epidural hematoma: is evacuation surgery necessary?
To the Editor: A recent article by Amiri et al. [1] suggested that regular alcohol use, multilevel surgery, and revision surgery were identified as risk factors for developing symptomatic postoperative spinal epidural hematoma (SEH). Earlier evacuation surgery performed within 6 hours after the appreciation of maximum neurologic deficit may result in greater neurologic recovery. I agree with the statement of Amiri et al. [1] that drinking greater than 10 units of alcohol a week may be a new risk factor; one in three of our patients with symptomatic postoperative SEH is a heavy drinker. But in our experience, evacuation surgery is not necessary for symptomatic postoperative SEH. Symptomatic postoperative SEHs are very rare and mostly the complications after posterior spinal decompressions [2–4]. It is important to take action rapidly once SEH is detected to achieve the most extensive neurologic recovery [5,6]. However, revision surgery is associated with increased trauma, suffering, and the risk of infection. Therefore, we would like to ask whether these patients could recover without surgeries. So far as we know, it is possible to achieve the goal by negative pressure wound therapy (NPWT). Negative pressure wound therapy is an advanced therapy method for wound management and has been used in multiple surgical fields. Various studies [7,8] have shown that NPWT decreases bacterial levels, promotes removal of excess fluid and debris, enhances formation of granulation tissue, and improves perfusion. It involves a suction tube wrapped in an elastic open-cell foam that is placed into the sutured wound and a fluid-impermeable plastic film for sealing. Negative pressure wound therapy has been used to treat deep subfascial infections after spinal surgery [9]. It also has been successfully applied to postoperative hematomas after high-energy trauma [10], which shows that NPWT can decrease the length of stay and the incidence of infections and wound dehiscence. We have used this technique for evacuating a hematoma, of which the potential mechanisms were mechanical deformation to eliminate dead space and removal of the fluids for decompression. Negative pressure wound therapy was applied with local anesthesia at the bedside. After cleaning the incision and
wrapping with sterile sheets, the surgeon took out two or three stitches, then placed the suction tube wrapped in the sponge deep into the incision 2 or 3 cm under the deep fascia using ultrasound, and finally sealed the device with the fluid-impermeable plastic film and maintained the continuous negative pressure suction at 125 mmHg of pressure (Figure, Top and Bottom). Neurologic deficits were progressed rapidly after several hours. The device was applied for several days (5–7 days) until ultrasound scan revealed no excess hematoma remained. Although our experiences show that NPWT could be safe and effective to evacuate the hematoma, further studies are needed for accurate
Figure. (Top) After taking out two or three stitches, a drainage tube wrapped in a sponge was placed deep into the wound and the device was sealed with a fluid-impermeable plastic film. (Bottom) Schematic of concept.
Letters to the Editor / The Spine Journal 14 (2014) 724–726
evaluation. We believe that NPWT should be a better solution for symptomatic postoperative SEH. References [1] Amiri AR, Fouyas IP, Cro S, et al. Postoperative spinal epidural hematoma (SEH): incidence, risk factors, onset, and management. Spine J 2013;13:134–40. [2] Kou J, Fischgrund J, Biddinger A, et al. Risk factors for spinal epidural hematoma after spinal surgery. Spine 2002;27:1670–3. [3] Glotzbecker MP, Bono CM, Wood KB, et al. Postoperative spinal epidural hematoma: a systematic review. Spine 2010;35:E413–20. [4] Aono H, Ohwada T, Hosono N, et al. Incidence of postoperative symptomatic epidural hematoma in spinal decompression surgery. J Neurosurg Spine 2011;15:202–5. [5] Uribe J, Moza K, Jimenez O, et al. Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125–9. [6] Yi S, Yoon do H, Kim KN, et al. Postoperative spinal epidural hematoma: risk factor and clinical outcome. Yonsei Med J 2006;47:326–32. [7] Tuncel U, Erkorkmaz U, Turan A. Clinical evaluation of gauze-based negative pressure wound therapy in challenging wounds. Int Wound J 2013;10:152–8. [8] Braakenburg A, Obdeijn MC, Feitz R, et al. The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized controlled trial. Plast Reconstr Surg 2006;118:390–7. discussion 398–400. [9] Vicario C, de Juan J, Esclarin A, et al. Treatment of deep wound infections after spinal fusion with a vacuum-assisted device in patients with spinal cord injury. Acta Orthop Belg 2007;73:102–6. [10] Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma 2005;60:1301–6.
Xiaobo Luo, MD Yuanzheng Ma, MD Orthopedic Center The 309th Hospital of Chinese People’s Liberation Army No.17A, Heishanhu Rd, Haidian District Beijing 100091, China FDA device/drug status: Not applicable. Author disclosures: XL: Nothing to disclose. YM: Nothing to disclose. 1529-9430/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved http://dx.doi.org/10.1016/j.spinee.2013.05.044
Evaluating patient, procedure, and provider characteristics as risk factors for postoperative complications
725
variables relating to patients, operative characteristics, hospitals, and surgeons that could contribute to the risk of postoperative complications. Regarding patient characteristics, Schoenfeld et al. [1] do not mention socioeconomic status or employmentdboth of which are known to be important factors in spine surgery. In addition, the authors do not provide any information about insurance status or race, which might be valuable prognostic indicators. For example, using NSQIP data, Scarborough et al. [2] have reported a higher rate of complications after appendectomy among blacks than whites, even after controlling for comorbidities. Regarding procedure characteristics, Schoenfeld et al. [1] do not report the number of spine levels being fused, time of day of the operation, or the need for blood transfusion. Because of a longer operative time and greater anatomic complexity, the risk of complications might be higher after long fusions than one-level procedures. Based on NSQIP data, Kelz et al. [3,4] have demonstrated that the risk of complications after general and vascular surgery may vary depending on the time of day when an operation is performed. Preexisting anemia has recently been identified as a risk factor for early complications of spine surgery [5]; intraoperative blood lossdparticularly if severe enough to necessitate transfusiondmight plausibly be associated with adverse outcomes in the postoperative period. Regarding provider characteristics, it would be useful to know whether the size of the hospital and the number of spinal arthrodesis procedures per year are associated with the risk of complications. Facilities with a large volume of fusions and other spine operations might have a dedicated risk mitigation program in place and thus a lower rate of complications. Similarly, the surgeon’s experience (eg, number of years in practice and number of spinal fusions performed each year) should also be analyzed for a possible association with postoperative complications. The burden of surgical complications is high, in terms of both the human cost and health-care dollars. Schoenfeld et al. [1] have provided important information, but further investigation is warranted. Identifying additional prognostic factors may improve the risk management process and ultimately lead to the prevention or reduction of postoperative complications.
References To the Editor: Using data from the National Surgical Quality Improvement Program (NSQIP), Schoenfeld et al. [1] have identified several risk factors for major and minor complications after spinal arthrodesis. Their large and well-designed retrospective study addresses many patient factors and procedure characteristics, including some that are potentially modifiable. However, the authors have omitted several important
[1] Schoenfeld AJ, Carey PA, Cleveland AW III, et al. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J 2013 Apr 9. [2] Scarborough JE, Bennett KM, Pappas TN. Racial disparities in outcomes after appendectomy for acute appendicitis. Am J Surg 2012;204:11–7. [3] Kelz RR, Tran TT, Hosokawa P, et al. Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study. J Am Coll Surg 2009;209:434–445.e2.
Letters to the Editor Symptomatic postoperative spinal epidural hematoma: is evacuation surgery necessary?
To the Editor: A recent article by Amiri et al. [1] suggested that regular alcohol use, multilevel surgery, and revision surgery were identified as risk factors for developing symptomatic postoperative spinal epidural hematoma (SEH). Earlier evacuation surgery performed within 6 hours after the appreciation of maximum neurologic deficit may result in greater neurologic recovery. I agree with the statement of Amiri et al. [1] that drinking greater than 10 units of alcohol a week may be a new risk factor; one in three of our patients with symptomatic postoperative SEH is a heavy drinker. But in our experience, evacuation surgery is not necessary for symptomatic postoperative SEH. Symptomatic postoperative SEHs are very rare and mostly the complications after posterior spinal decompressions [2–4]. It is important to take action rapidly once SEH is detected to achieve the most extensive neurologic recovery [5,6]. However, revision surgery is associated with increased trauma, suffering, and the risk of infection. Therefore, we would like to ask whether these patients could recover without surgeries. So far as we know, it is possible to achieve the goal by negative pressure wound therapy (NPWT). Negative pressure wound therapy is an advanced therapy method for wound management and has been used in multiple surgical fields. Various studies [7,8] have shown that NPWT decreases bacterial levels, promotes removal of excess fluid and debris, enhances formation of granulation tissue, and improves perfusion. It involves a suction tube wrapped in an elastic open-cell foam that is placed into the sutured wound and a fluid-impermeable plastic film for sealing. Negative pressure wound therapy has been used to treat deep subfascial infections after spinal surgery [9]. It also has been successfully applied to postoperative hematomas after high-energy trauma [10], which shows that NPWT can decrease the length of stay and the incidence of infections and wound dehiscence. We have used this technique for evacuating a hematoma, of which the potential mechanisms were mechanical deformation to eliminate dead space and removal of the fluids for decompression. Negative pressure wound therapy was applied with local anesthesia at the bedside. After cleaning the incision and
wrapping with sterile sheets, the surgeon took out two or three stitches, then placed the suction tube wrapped in the sponge deep into the incision 2 or 3 cm under the deep fascia using ultrasound, and finally sealed the device with the fluid-impermeable plastic film and maintained the continuous negative pressure suction at 125 mmHg of pressure (Figure, Top and Bottom). Neurologic deficits were progressed rapidly after several hours. The device was applied for several days (5–7 days) until ultrasound scan revealed no excess hematoma remained. Although our experiences show that NPWT could be safe and effective to evacuate the hematoma, further studies are needed for accurate
Figure. (Top) After taking out two or three stitches, a drainage tube wrapped in a sponge was placed deep into the wound and the device was sealed with a fluid-impermeable plastic film. (Bottom) Schematic of concept.
Letters to the Editor / The Spine Journal 14 (2014) 724–726
evaluation. We believe that NPWT should be a better solution for symptomatic postoperative SEH. References [1] Amiri AR, Fouyas IP, Cro S, et al. Postoperative spinal epidural hematoma (SEH): incidence, risk factors, onset, and management. Spine J 2013;13:134–40. [2] Kou J, Fischgrund J, Biddinger A, et al. Risk factors for spinal epidural hematoma after spinal surgery. Spine 2002;27:1670–3. [3] Glotzbecker MP, Bono CM, Wood KB, et al. Postoperative spinal epidural hematoma: a systematic review. Spine 2010;35:E413–20. [4] Aono H, Ohwada T, Hosono N, et al. Incidence of postoperative symptomatic epidural hematoma in spinal decompression surgery. J Neurosurg Spine 2011;15:202–5. [5] Uribe J, Moza K, Jimenez O, et al. Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125–9. [6] Yi S, Yoon do H, Kim KN, et al. Postoperative spinal epidural hematoma: risk factor and clinical outcome. Yonsei Med J 2006;47:326–32. [7] Tuncel U, Erkorkmaz U, Turan A. Clinical evaluation of gauze-based negative pressure wound therapy in challenging wounds. Int Wound J 2013;10:152–8. [8] Braakenburg A, Obdeijn MC, Feitz R, et al. The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized controlled trial. Plast Reconstr Surg 2006;118:390–7. discussion 398–400. [9] Vicario C, de Juan J, Esclarin A, et al. Treatment of deep wound infections after spinal fusion with a vacuum-assisted device in patients with spinal cord injury. Acta Orthop Belg 2007;73:102–6. [10] Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma 2005;60:1301–6.
Xiaobo Luo, MD Yuanzheng Ma, MD Orthopedic Center The 309th Hospital of Chinese People’s Liberation Army No.17A, Heishanhu Rd, Haidian District Beijing 100091, China FDA device/drug status: Not applicable. Author disclosures: XL: Nothing to disclose. YM: Nothing to disclose. 1529-9430/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved http://dx.doi.org/10.1016/j.spinee.2013.05.044
Evaluating patient, procedure, and provider characteristics as risk factors for postoperative complications
725
variables relating to patients, operative characteristics, hospitals, and surgeons that could contribute to the risk of postoperative complications. Regarding patient characteristics, Schoenfeld et al. [1] do not mention socioeconomic status or employmentdboth of which are known to be important factors in spine surgery. In addition, the authors do not provide any information about insurance status or race, which might be valuable prognostic indicators. For example, using NSQIP data, Scarborough et al. [2] have reported a higher rate of complications after appendectomy among blacks than whites, even after controlling for comorbidities. Regarding procedure characteristics, Schoenfeld et al. [1] do not report the number of spine levels being fused, time of day of the operation, or the need for blood transfusion. Because of a longer operative time and greater anatomic complexity, the risk of complications might be higher after long fusions than one-level procedures. Based on NSQIP data, Kelz et al. [3,4] have demonstrated that the risk of complications after general and vascular surgery may vary depending on the time of day when an operation is performed. Preexisting anemia has recently been identified as a risk factor for early complications of spine surgery [5]; intraoperative blood lossdparticularly if severe enough to necessitate transfusiondmight plausibly be associated with adverse outcomes in the postoperative period. Regarding provider characteristics, it would be useful to know whether the size of the hospital and the number of spinal arthrodesis procedures per year are associated with the risk of complications. Facilities with a large volume of fusions and other spine operations might have a dedicated risk mitigation program in place and thus a lower rate of complications. Similarly, the surgeon’s experience (eg, number of years in practice and number of spinal fusions performed each year) should also be analyzed for a possible association with postoperative complications. The burden of surgical complications is high, in terms of both the human cost and health-care dollars. Schoenfeld et al. [1] have provided important information, but further investigation is warranted. Identifying additional prognostic factors may improve the risk management process and ultimately lead to the prevention or reduction of postoperative complications.
References To the Editor: Using data from the National Surgical Quality Improvement Program (NSQIP), Schoenfeld et al. [1] have identified several risk factors for major and minor complications after spinal arthrodesis. Their large and well-designed retrospective study addresses many patient factors and procedure characteristics, including some that are potentially modifiable. However, the authors have omitted several important
[1] Schoenfeld AJ, Carey PA, Cleveland AW III, et al. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J 2013 Apr 9. [2] Scarborough JE, Bennett KM, Pappas TN. Racial disparities in outcomes after appendectomy for acute appendicitis. Am J Surg 2012;204:11–7. [3] Kelz RR, Tran TT, Hosokawa P, et al. Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study. J Am Coll Surg 2009;209:434–445.e2.
