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NSAID use, multilevel fusion may increase risk for spinal hematoma

Incidence was 0.2% in study of 15,000 spine procedures.

Issue: Issue 5 2004

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PORTO, Portugal — U.S. investigators recently found that patients undergoing lumbar, thoracic or cervical spine surgery are at increased risk of developing postoperative spinal epidural hematomas if they are older than 60, take anti-inflammatory drugs preoperatively, have multilevel procedures or lose more than one liter of blood during surgery.

Previous studies suggested that using anticoagulation medications increased the risk for developing a postop spinal epidural hematoma, but the findings from a new retrospective study did not support that theory. “Controlled anticoagulation was not a [risk] factor,” said investigator Khaled M. Kebaish, MD.

A hematoma develops when an epidural vein ruptures. Although uncommon, “it can have serious consequences,” Kebaish said. Among them are permanent neurologic injury or deficit leading to paralysis or loss of extremity function.

Kebaish and his co-investigators in the orthopaedic department at Johns Hopkins Hospital in Baltimore included in their investigation all patients undergoing spine surgery at their hospital from 1984 to 2002. From that group they selected all patients who returned to the operating room for any related reason during the first postoperative week and whose diagnosis was hematoma complicating a procedure.

From the 15,000 cases done during the 18-year study period, 32 patients met the criteria for hematoma, and all underwent surgical evaluation. The hematoma incidence was 0.2%.

Patients were matched to 100 control patients who underwent spine surgeries of similar complexity by the same surgeons. Three control patients were included per surgeon. Control procedures had to have been performed within two months of the index procedure.

Significant preop variables

“The significant preoperative variables that we identified specifically were over age 60, NSAID use preoperatively, as well as Rh-positive patients,” he said. Kebaish told Orthopaedics Today that patients who are Rh-negative may have some protective factor. “It’s very hard to look at that single variable since there were very few people who were Rh-negative in the group.”

In addition to the number of levels fused, a hemoglobin level of 10 was identified as a significant intraoperative variable. An INR greater than 2.0 within 48 hours of surgery was deemed a significant postoperative variable.

Keeping these factors in mind, Kebaish said he typically discontinues NSAID use at least 10 days to two weeks prior to surgery and watches all at-risk patients closely.

For more information:

• Kebaish K, Awad J, Donigan J, et al. Analysis of risk factors for the development of post-operative spinal epidural hematoma (POSEH). #A92. Presented at SpineWeek 2004. May 31-June 5, 2004. Porto, Portugal.