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Journal of Peking University (Health Sciences) ›› 2024, Vol. 56 ›› Issue (6): 1058-1064. doi: 10.19723/j.issn.1671-167X.2024.06.018

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Incidence and risk factors of postoperative epidural hematoma following anterior cervical spine surgery

Yang TIAN1, Yongzheng HAN1, Jiao LI1, Mingya WANG1, Yinyin QU1, Jingchao FANG2, Hui JIN3, Min LI1, Jun WANG1, Mao XU1, Shenglin WANG4, Xiangyang GUO1,*()   

  1. 1. Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
    2. Department of Radiology, Peking University Third Hospital, Beijing 100191, China
    3. Department of Anesthesiology, The First Affiliated Hospital of Hainan Medical College, Haikou 570102, China
    4. Department of Orthopaedics, Peking University Third Hospital, Beijing 100191, China
  • Received:2024-06-11 Online:2024-12-18 Published:2024-12-18
  • Contact: Xiangyang GUO E-mail:puthmzk@163.com
  • Supported by:
    Capital's Funds for Health Improvement and Research(2024-2-40912)

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Abstract:

Objective: To investigate the incidence and potential risk factors associated with postoperative spinal epidural hematoma (SEH) following anterior cervical spine surgery (ACSS). Methods: A retrospective analysis was conducted on the clinical data of patients who underwent ACSS for cervical spondylosis at Peking University Third Hospital between March 2013 and February 2022. Patients who developed postoperative SEH were categorized as the SEH group, while those in the cohort without SEH were randomly selected as the non-SEH group by individually matching with the same operator, same gender, same surgery year, and similar age (±5 years) at a ratio of 4 ∶ 1. The general condition, preoperative comorbidities, anticoagulant or antiplatelet therapy, preoperative coagulation and platelet counts, American society of Anesthesiologists physical status classification, cervical spondylosis classification, preoperative modified Japanese Orthopaedic Society score and cervical disability index score, surgical modality, surgical segment levels, ossification of the posterior longitudinal ligament among the surgical level, surgery duration, estimated blood loss, postoperative drainage volume, preoperative mean arterial pressure, mean arterial pressure during postoperative awakening periods, hospital stay and hospitalization cost were compared between the two groups. A bivariate Logistic regression model was applied to screen out the independent risk factors and calculate the odds ratios of indicators associated with SEH. Receiver operating characteristic curve and area under the curve (AUC) were used to describe the discrimination ability of the indicators. Results: A total of 85 patients were enrolled in the study, including 17 patients in the SEH group and 68 patients in the non-SEH group. Seventeen patients with SEH underwent hematoma evacuation, and all of them were successfully treated and discharged from the hospital. Corpectomy (OR=7.247; 95%CI: 1.962-26.766; P=0.003) and the highest mean arterial pressure during awakening (OR=1.056; 95%CI: 1.002-1.113; P=0.043) were independent risk factors for SEH. The AUC values were 0.713 (95%CI: 0.578-0.848) and 0.665 (95%CI: 0.51-0.82) respectively. The patients with SEH had longer hospital stays (P < 0.001) and greater hospitalization costs (P=0.035). Conclusion: Corpectomy and elevated maximum mean arterial pressure during awakening are independent risk factors for the development of postoperative SEH following ACSS. High-risk patients should be closely monitored during the perioperative period.

Key words: Anterior cervical spine surgery, Spinal epidural hematoma, Risk factors

CLC Number: 

  • R681.55

Table 1

Characteristics of SEH group"

Case number Symptom Symptom onset time Diagnostic method Time from symptom onset to evacuation Outcome
1 Quadriplegia 2 h Clinical examination 0.5 h Resolved
2 Quadriplegia 1 h MRI 2.5 h Resolved
3 Quadriplegia 1 h Clinical examination 1 h Resolved
4 Numbness 7 d MRI 6 d Resolved
5 Significant pain in left hand 1 h CT 0.5 h Resolved
6 Numbness 2 h MRI 8 h Resolved
7 Quadriplegia 3 h Clinical examination 2 h Resolved with residual neurologic deficits (mild motor weakness)
8 Quadriplegia 12 h Clinical examination 1 h Resolved
9 Sensory disorder and weakness in right upper limb 5 d MRI and CT 2 d Unresolved
10 Quadriplegia 3 h MRI and CT 2.5 h Resolved
11 Quadriplegia 4 h Clinical examination 0.5 h Resolved with residual neurologic deficits (mild motor weakness)
12 Paraplegia 2 h Clinical examination 2.5 h Resolved with residual neurologic deficits (mild motor weakness)
13 Quadriplegia 2 h Clinical examination 1 h Resolved
14 Weakness in left upper limb 20 h MRI 8 h Resolved with residual neurologic deficits (mild motor weakness)
15 Paraplegia 3 h Clinical examination 1 h Resolved
16 Paraplegia 1 h Clinical examination 2 h Resolved with residual neurologic deficits (mild motor weakness)
17 Paraplegia 0.5 h Clinical examination 0.5 h Resolved

Table 2

Comparison of demographic characteristics between SEH group and non-SEH group"

Characteristic SEH group (n=17) Non-SEH group (n=68) χ2/Z/t P value
Gender, n (%) χ2=0.000 >0.999
  Male 13 (76.5) 52(76.5)
  Female 4 (23.5) 16(23.5)
Age/years, $\bar x \pm s$ 53±10 53±9 t=0.116 0.908
Hypertension, n (%) 4 (23.5) 21(30.9) χ2=0.089 0.766
Body mass index/(kg/m2), $\bar x \pm s$ 26.2±3.2 24.9±3.8 t=-1.239 0.219
Smoking history, n (%) 7 (41.2) 21(30.9) χ2=0.652 0.419
Anticoagulant or antiplatelet therapy, n (%) 1 (5.9) 6(8.8) χ2=0.000 >0.999
ASA classification, n (%) >0.999#
  Ⅰ-Ⅱ 17 (100.0) 65 (95.6)
  ≥Ⅲ 0 (0) 3 (4.4)
Preoperative blood index
  Prothrombin time/s, $\bar x \pm s$ 10.9±0.9 10.9±0.7 t=0.039 0.969
  International normalized ratio, $\bar x \pm s$ 1.02±0.79 1.02±0.06 t=0.176 0.860
  Fibrinogen/(g/L)，$\bar x \pm s$ 3.11±0.63 2.91±0.53 t=-1.329 0.187
  Activated partial thromboplastin time/s, $\bar x \pm s$ 33.2±4.1 31.7±3.1 t=-1.615 0.109
  Thrombin time/s, $\bar x \pm s$ 14.0±1.2 14.0±0.9 t=-0.098 0.921
  Platelet counts/(×109/L), M (IQR) 255 (58) 220 (67) Z=1.719 0.086

Table 3

Comparison of disease, surgery, and anesthesia related factors between SEH group and non-SEH group"

Characteristic SEH group (n=17) Non-SEH group (n=68) χ2/Z/t P value
Classification of cervical spondylosis, n (%) χ2=5.379 0.146
  Cervical spondylotic myelopathy 14 (82.4) 39 (57.4)
  Cervical spondylotic radiculopathy 0 (0) 14 (20.6)
  Mixed cervical spondylosis 3 (17.6) 13 (19.1)
  Other types 0 (0) 2 (2.9)
m-JOA score, M (IQR) 13.5 (3.9) 14.5 (3.5) Z=-1.292 0.196
Neck disability index score, M (IQR) 10.5 (15.8) 10.0 (17.3) Z=-0.049 0.961
Surgical segments, M (IQR) 2 (0.5) 2 (1.0) Z=1.305 0.192
OPLL among the surgical level, n (%) 9 (52.9) 22 (32.4) χ2=2.488 0.115
Corpectomy, n (%) 13 (76.5) 23 (33.8) χ2=8.460 0.004
Surgery duration/min, M (IQR) 95 (40) 86 (52) Z=0.868 0.385
Estimated blood loss/mL, M (IQR) 60 (95) 20 (35) Z=2.889 0.004
Drain volume/mL, M (IQR) 18 (50) 30 (35) Z=-1.063 0.288
Preoperative MAP/mmHg, ±s 97±9 95±10 t=-0.848 0.399
Maximum MAP during awakening/mmHg, M (IQR) 116 (18) 103 (21) Z=2.101 0.036
Length of stay/d, M (IQR) 7 (4) 4 (2) Z=3.536 < 0.001
Cost/yuan, M (IQR) 69 949 (28 116) 60 007 (21 208) Z=2.104 0.035

Table 4

Bivariate Logistic regression (Back-Wald) analysis of the risk factors for SEH"

Variable B SE P value OR 95%CI
Corpectomy 1.981 0.667 0.003 7.247 1.962-26.766
Maximum MAP during awakening 0.054 0.027 0.043 1.056 1.002-1.113
Constant -8.335 3.057 0.006 0

Table 5

Predictive values of risk factors for predicting SEH"

Variable AUC SE P value 95%CI
Corpectomy 0.713 0.069 0.007 0.578-0.848
Maximum MAP during awakening 0.665 0.079 0.036 0.510-0.820
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