|
Year |
2005 |
|---|---|
|
Question Number |
53. |
|
Category |
Spine |
Question
A patient who underwent an anterior C5-C6 corpectomy and fusion 1 day ago now reports difficulty breathing. Examination reveals a tense mass beneath the incision. What is the next most appropriate step in management?
1- MRI
2- CT myelogram
3- Compressive dressing
4- Emergent return to the operating room
5- Needle aspiration of the mass
Figures
Answer (click for answer)
PREFERRED RESPONSE: 4
Historically, laminectomy had been regarded as the standard posterior procedure for the treatment of multilevel cervical myelopathy (MCM). Laminectomy, however, fell into relative disfavor because of well-known sequelae, such as segmental instability, kyphosis, perineural adhesions, and late neurologic deterioration.
Limitations of the laminectomy procedure prompted the development of alternative surgical strategies. Although numerous procedures have been proposed, multilevel corpectomy with fusion and laminoplasty have become the most widely adopted surgical methods for treating MCM involving three or more motion segments. Complications of multiple level corpectomy include progression of myelopathy, nonunion, persistent dysphagia, persistent dysphonia, and subjacent motion segment ankylosis, and hematoma or angioedema.
The sited article from JBJS discusses 7 cases of this complication which requires emergent intubation and decompression in the OR. Here is the abstract : We reviewed the cases of seven patients who had had obstruction of the upper airway immediately after an anterior procedure on the cervical spine and had required reintubation. All patients had had moderate or severe myelopathy preoperatively (average, 3.6 on the Nurick scale), and all had had a multilevel anterior cervical corpectomy for decompression followed by arthrodesis. The early compromise of the upper airway was believed to be due to edema rather than to the formation of a hematoma. Five patients had no sequelae, but two died of complications related to the obstruction. Risk factors common to these patients included moderate or severe myelopathy and multilevel corpectomy. Six patients had a history of heavy smoking and one, of asthma. We believe that extra caution should be used in the postoperative management of the airways when multilevel corpectomy is performed in patients who have these pre-existing conditions.
Reference: RECOMMENDED READINGS: Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multilevel corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551. Roy SP: Acute postoperative neck hematoma. Am J Emerg Med 1999;17:308-309.