Complications of anterior cervical spine surgery: a systematic review of the literature
Review Article on Advanced Techniques in Complex Cervical Spine Surgery

Complications of anterior cervical spine surgery: a systematic review of the literature

Timothy J. Yee, Kevin Swong, Paul Park

Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA

Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: TJ Yee, K Swong; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Prof. Paul Park, MD. Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA. Email: ppark@umich.edu.

Abstract: The anterior approach to the cervical spine is commonly utilized for a variety of degenerative, traumatic, neoplastic, and infectious indications. While many potential complications overlap with those of the posterior approach, the distinct anatomy of the anterior neck also presents a unique set of hazards. We performed a systematic review of the literature to assess the etiology, presentation, natural history, and management of these complications. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a PubMed search was conducted to evaluate clinical studies and case reports of patients who suffered a complication of anterior cervical spine surgery. The search specifically included articles concerning adult human subjects, written in the English language, and published from 1989 to 2019. The PubMed search yielded 240 articles meeting our criteria. The overall rates of complications were as follows: dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%. Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications involving vascular, aerodigestive, neural, and osseous structures.

Keywords: Anterior cervical; discectomy; corpectomy; fusion; complications

Submitted Dec 03, 2019. Accepted for publication Jan 15, 2020.

doi: 10.21037/jss.2020.01.14

Introduction

The anterior approach to the cervical spine was first described in the 1950s by Cloward, Robinson, and Smith (1,2), and it has since become a widely utilized technique for central and foraminal decompression. As overall morbidity rates for anterior cervical spine surgery have been historically low, and in some studies lower than those for posterior approaches (3), surgeons have been examining the safety and efficacy of performing it on an outpatient basis (4-6). However, given the complex regional vascular, neural, and aerodigestive anatomy, the anterior approach presents a broad and unique set of potential complications. Furthermore, several of these complications, such as esophageal perforation or vertebral artery pseudoaneurysm, can be fatal if not rapidly recognized.

The current literature of complications associated with the anterior approach to the cervical spine is largely comprised of retrospective studies and case reports. Extant systematic reviews regarding these complications (7-14) comprise individual complications or subsets of patient populations. The most recent review of complications was a focused variant and not systematic (15). In this systematic review, we aim to provide comprehensive qualitative description of the rates, etiologies, management strategies, and outcomes of surgical complications following anterior cervical spine surgery in adults.

Methods

A PubMed search was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for articles containing the terms “anterior cervical” AND (“spine” OR “spinal”) AND “complication.” Studies were limited to those involving adult human subjects, written in the English language, and published over the past 30 years (January 1989 through June 2019). Case reports, retrospective studies, and prospective studies were included. Secondary studies (e.g., existing systematic reviews and meta-analyses), abstracts, letters to the editor, cadaveric studies, studies involving single stage combined anterior and posterior approaches, and studies of non-surgical populations were excluded. Two authors first screened all titles and abstracts and then jointly assessed that the following criteria were consistently applied: the patients underwent anterior-only cervical spine surgery and the patients suffered a surgical complication that was not present preoperatively. The authors then performed a full-text review of the remaining studies. The last search was performed on October 6, 2019.

Data regarding timing, etiology, management, and outcomes of complications were abstracted where available. When reporting pooled incidences in the presence of overlapping patient populations across studies, only the more recent study was included. Presented “n” values reflect the sum of all patients at risk, i.e., the denominator. Comparative analysis was limited given the large number of case reports and heterogeneous patient populations. Qualitative analysis was performed and therefore advanced statistical methodology was not needed for this review.

Results

The initial PubMed search yielded 411 records without duplicates. A title and abstract review excluded 92 records, resulting in 319 full-text articles to be assessed for eligibility. After excluding 79 full-text articles, 240 studies remained for inclusion in the systematic review. A flowchart of this process is illustrated in Figure 1. A summary of pooled complication rates and ranges is displayed in Table 1.

Figure 1 PRISMA flow diagram.
Table 1
Table 1 Summary of complication rates and ranges across all prospective and retrospective studies
Full table

Dysphagia

We identified 1 case report (16), 2 case series (17,18), 10 prospective cohort studies (19-28), and 53 retrospective cohort studies; the retrospective group comprised 2 studies from 1989 to 1999 (29,30), 13 from 2000 to 2009 (31-43), 13 from 2010 to 2014 (44-56), and 25 from 2015 to 2019 (57-81). The case report discussed one patient who presented 8 months after C6–7 ACDF with dysphagia and was found to have a hypopharyngeal diverticulum thought secondary to a spontaneous adhesion of the hypopharynx to the interbody graft. While there was no evidence of perforation, the diverticulum was excised and repaired with fascia lata graft. The dysphagia resolved over 18 months. Across all studies (n=737,041), the rate of postoperative dysphagia at any time point was 5.3%. Among prospective studies (n=1,968), overall rates of postoperative dysphagia ranged from 1.4% to 60.0% with a pooled incidence of 11.5%. Among prospective studies reporting chronic dysphagia (lasting greater than 3 months) (22,23,25,27,28) (n=577), this rate ranged from 0% to 18.0% with an overall rate of chronic dysphagia of 10.1%. Among retrospective studies (n=735,073), overall rates of postoperative dysphagia ranged from 0.21% to 87.5% with a pooled incidence of 5.2%. Among retrospective studies reporting rates of chronic dysphagia (lasting greater than 3 months) (n=2,122) (30-32,34-36,38,41,45,55,57,60-62,74), incidence ranged from 0% to 21.7% with a pooled incidence of 0.8%.

The presence of dysphagia was found to be a predictor for patient re-admission and increased length of stay post-operatively (18). Use of BMP was associated with increased rates of postoperative dysphagia in four retrospective studies (41,42,51,54) (n=332,077) and one prospective study (26) (n=224). The two retrospective studies (52,81) (n=341) that did not find increased rates of dysphagia in the BMP group both reported more severe rates of dysphagia when present in the BMP group compared to the allograft group. De la Garza-Ramos and colleagues (62) in retrospective study of 97 patients found a significantly increased risk of dysphagia in patients undergoing 4- vs. 3-level ACDF (30.8% vs. 12.7%). Another retrospective study of 1,015 patients undergoing ACDF at a single institution (34) found an increased risk of dysphagia in 3-level versus 1- or 2-level ACDF. Lee and colleagues prospectively studied 348 patients undergoing anterior cervical surgery and found that female sex, revision surgery, and greater than two-level operations were associated with greater rates of postoperative dysphagia. A case series of 67 patients with dysphagia after anterior cervical surgery at a single institution (17) found that 70% of the cases were involved more than two levels. Three retrospective studies comparing ACDF to anterior corpectomy (45,57,66) (n=236) found no difference in the rates of postoperative dysphagia. The other two retrospective studies including such a comparison did not identify whether differences were significant (46,47).

A prospective randomized control study (27) found no change in the rate of postoperative dysphagia at 6 weeks, 3 months, or 6 months postoperatively with limiting and monitoring the endotracheal tube cuff pressure to 15 mmHg. The use of local intraoperative steroids was found to reduce the rate of dysphagia at 90 days in patients undergoing ACDF of 3 or more levels, but not in patients undergoing 1- or 2-level ACDF in one retrospective review of the PearlDiver Patient Records Database (80). Local steroids also were shown to reduce Bazaz-Yoo scores at both 6 weeks and 3 months postoperatively in patients undergoing multilevel ACDF in a retrospective case-control study (59). Lower postoperative dysphagia scores in patients who were randomized to preoperative tracheal traction exercises before multilevel ACDF, but this association was not seen for single-level ACDF (28).

Esophageal perforation

We identified 11 retrospective cohort studies (34,56,65,70,71,82-87) that reported rates of esophageal perforation and 31 case reports or case series, this latter group comprising 3 studies from 1989 to 1999 (88-90), 13 from 2000 to 2009 (91-103), and 15 from 2010 to 2019 (104-118). There were no prospective studies. Incidence among the retrospective cohort studies ranged from 0% (71,83,85) to 0.46% (82) with a pooled incidence of 0.2% (n=12,842). Timing of presentation varied widely, ranging from intraoperative discovery (34) to delayed discovery 20 years postoperatively (110). When not discovered intraoperatively, the most common presentation is with dysphagia or odynophagia (82,89,91,93,95,96,98,100,101,103-109,112-114,118), but others include sepsis (109), wound drainage (82,86,102), meningitis (105), quadriparesis secondary to epidural abscess (110), recurrent pneumonia (92,99,103,114), hemoptysis (90), and expectoration of hardware (108).

Management nearly exclusively involves initiation of broad-spectrum antibiotics; exploration; debridement; removal of hardware; primary repair of the esophageal defect; and nutrition via nasogastric tubes, gastrostomy tubes, or jejunostomy tubes (86-88,90-93,96-104,106,107,110-115,117). When primary repair was reinforced, the majority of studies reported use of pedicled muscular flaps (sternocleidomastoid, pectoralis, or strap muscle), though one case series described the successful use of free omental flaps (94) after failure of initial repair. Addition of posterior instrumented fusion (98,112) or placement of an external fixation system (101,115) has been reported for situations in which anterior fusion was not yet achieved. Few exceptions to aggressive surgical management were found. A case report by Shah and colleagues on a patient presenting one week after ACDF described spontaneous esophageal healing after two rounds of debridement but without hardware removal or attempted primary repair (109), another case report of a patient presenting 3.5 years postoperatively after expectorating the anterior construct was not found to have any esophageal defects requiring repair (108), and another case report described successful conservative management with antibiotics and nasogastric tube feeds for 10 days after fistula discovery (95). In a case series of 14 patients with esophageal perforations, Perrone and colleagues reported 2 patients with minimal leaks managed conservatively and who ultimately fully recovered (115).

Culture results are inconsistently reported but are most commonly polymicrobial. The most frequently isolated organisms are Staphylococcus and Streptococcus (91,102,106,107), though Pseudomonas (98,115), Klebsiella (115), Candida (98,106), Acinetobacter (115), and Lactobacillus (105) have also been found. The single case report of meningitis directly associated with esophageal perforation occurred secondary to an esophago-meningeal fistula; Lactobacillus rhamnosus meningitis lead to rapid neurological deterioration and death after a 20-day ICU stay, during which time the surgical intervention was deemed futile (105). Mortality in the literature directly related to the esophageal perforation ranged from 0% (87,114) to 33% (34). Barring death, ultimate resumption of oral intake ranged from 60% (116) to 100% (87,115).

Recurrent laryngeal nerve palsy

We identified 3 case reports (119-121), 6 prospective studies (19,20,24,122-124), and 34 retrospective cohort studies; the retrospective group comprised 7 studies from 1989 to 1999 (29,30,84,125-128), 8 from 2000 to 2009 (18,31,34,37,40,41,129,130), and 19 from 2010 to 2019 (44-49,55-57,62,63,66,73,76,78,85,131-133). Recurrent laryngeal nerve (RLN) palsy was defined as postoperative hoarseness, dysphonia, or vocal cord paralysis. Across retrospective and prospective studies, the pooled incidence of RLN palsy was 1.3%. Among retrospective studies, incidence of RLN palsy ranged from 0.1% to 60.9%, with a pooled incidence of 1.2% (n=26,464). Among prospective studies, incidence of RLN palsy ranged from 0.8% to 5.9%, with a pooled incidence of 2.2% (n=884). Within the studies that reported ultimate outcome of postoperative RLN palsy (n=4,591) (29-31,34,37,41,49,63,84,85,122,126-130), 83.4% of patients experienced partial or complete recovery. The use of a zero-profile cage versus a cage with a separate plating system did not affect the rate of RLN palsy in one prospective study of 104 patients (123) and one retrospective study of 56 patients (31). A retrospective cohort study of 900 patients did find significantly higher rates of RLN palsy in two-level ACDF versus single-level ACDF (129), though two subsequent retrospective studies (n=1,112) (34,62) did not find an association of this complication with the number of operative levels. None of four retrospective studies (n=656) (45-47,66) found a difference in the rates of RLN palsy between multilevel ACDF and corpectomy. The use of recombinant human bone morphogenic protein did not appear to affect rates of RLN palsy in two retrospective studies (41,76). Apfelbaum and colleagues found high rates of RLN palsy in their subset of patients undergoing ACDF for pseudarthrosis (20%) and those undergoing ACDF after any previous anterior neck surgery (10%) (129). Similarly, a subsequent retrospective study of 525 patients who underwent zero profile ACDF did find that RLN palsy was more common in secondary procedures (8%) than primary procedures (2%), a difference that remained significant after multivariate analysis (78).

Infection

We identified 6 case reports (105,134-138), 5 prospective studies (19,20,122-124), and 46 retrospective studies; the retrospective group comprised 4 studies from 1989 to 1999 (29,30,84,125), 4 from 2000 to 2009 (34,35,139,140), 11 from 2010 to 2014 (3,44,46-48,51,53,56,141-143), 10 from 2015 to 2016 (58,62,72,80,133,144-148), and 17 from 2017 to 2019 (66,70,71,78,81,85,131,149-158). Case reports comprised the following: one patient who presented 2 weeks and again 5 months after 3-level ACDF with deep neck space infections growing microaerophilic Streptococci with an odontogenic source (134); one patient who presented 6 weeks after two-level ACDF with osteodiscitis and epidural abscess growing Serratia marcescens (136); one patient who presented 9 months after 2-level corpectomy with a large prevertebral abscess (no culture results) (135); one patient who presented 2 years after 1-level ACDF with a prevertebral abscess growing Streptococcus intermedius (137); one patient who presented 4 years after 1-level ACDF with retropharyngeal abscess growing Streptococcus anginosus, Streptococcus intermedius, Veilonella parcula, and Petptostreptococcus anaerobius (138); and one patient who presented 6 years after 3-level ACDF with meningitis secondary to a esophago-dural fistula growing Lactobaccilius rhamnosus (105). Five of these 6 patients fully recovered after debridement and antibiotic therapy. The case of Lactobacillus meningitis was deemed surgically futile, and the patient died 20 days after presentation despite maximal medical therapy. Across prospective and retrospective studies, the pooled incidence of any infectious complication was 1.2%. Among prospective studies, the incidence of any infectious complication ranged from 0% to 5.0% with a pooled incidence of 1.0% (n=396). Among retrospective studies, the incidence of any infectious complication ranged from 0% to 16.7% with a pooled incidence of 1.2% (n=965,867). Among the studies that specified multiple types of infectious complication (30,44,70,142,143,145,147,154,155,159), bacteremia or sepsis comprised 47.6% of infectious complications. One retrospective analysis of the Medicare database comprising 119,254 patients who underwent anterior cervical fusion found significantly higher rates of postoperative infection in those with rheumatoid arthritis versus those without (157). Preoperative hypoalbuminemia (148), obesity (141), use of BMP (51,81), or use of intraoperative local steroids (80) were not associated with infectious complications. One single-institution retrospective study did not find any difference in infectious complications between 3- and 4-level ACDF (62). Across four retrospective studies, no difference in the rates of infection were found between discectomy and corpectomy cohorts (46,47,57,144).

Adjacent segment disease

We identified 2 prospective studies (20,160) and 12 retrospective studies (35,39,43,47,62,79,132,161-165) that reported rates of adjacent segment disease. Overall, the rate of ASD, inclusive of radiographic cases, symptomatic cases, and those requiring reoperation, was 8.1%. Among prospective studies, rates of ASD ranged from 2.6% to 3.3% with a pooled incidence of 2.9% (n=243). Among retrospective studies, rates of ASD ranged from 0.9% to 52.2% with a pooled incidence of 8.6% (n=2,699). Among studies reporting rates of secondary surgery (20,35,39,43,62,79,132,160,161,163-165), rates of reoperation for ASD ranged from 0% to 12.4% with a pooled incidence of 4.5% (n=2600). Two retrospective studies reported mean times to reoperation of ASD of 32 months (163) and 3.1 years (39). Pre-existing radiographic degeneration of the adjacent level was associated with shortened time to ASD at that level (30 vs. 42 months) in one retrospective study of 1,345 patients (163). Three retrospective studies (43,79,161) found no association between ASD and use of stand-alone cages versus cages with anterior plates (n=404). Rates of ASD were found to be significantly higher in shorter segment fusions in two retrospective studies (163,164) (n=1,447), and non-significant trends toward this association were found in two other retrospective studies (62,162) (n=259).

Pseudarthrosis

We identified 1 case report (166), 1 case series (167), 6 prospective studies (19,20,24,26,160,168), and 31 retrospective studies; the retrospective group comprised 4 studies from 1989 to 1999 (30,125,169,170), 13 from 2000 to 2009 (35,39,41,43,139,161,171-177), and 14 from 2010 to 2019 (52,53,62,74,79,85,123,146,156,159,162,164,165,178). The case report discussed two patients, one 18 months postoperative and one 4 months postoperative from anterior corpectomy, who presented with neck pain after minor trauma and were found to have plate fracture in the setting of known pseudarthrosis. Both patients underwent revision and ultimately achieved complete fusion. The case series included 19 consecutive patients who underwent revision surgery for pseudarthrosis after ACDF. The most common symptom was intractable neck pain with radiculopathy (17 of 19 patients. Mean time to revision for pseudarthrosis was 20 months, and all patients ultimately achieved solid fusion (167). Across all studies, the rate of pseudarthrosis (radiographic, symptomatic, and those requiring revision) at last follow-up was 2.0%. Among prospective studies, the rate of pseudarthrosis ranged from 0.7% to 55.0% with a pooled incidence of 7.0% (n=1,578). Among retrospective studies, the rate of pseudarthrosis ranged from 0% to 23.7% with a pooled incidence of 1.7% (n=32,996). Among studies reporting rates of pseudarthrosis requiring reoperation (20,35,39,41,43,62,74,79,85,139,156,160-162,165,168,171-177), the incidence was 3.0% (n=3,276). Five retrospective studies (79,123,169,170,172,173) (n=379) found no association between use of anterior plating and rates of pseudarthrosis, though one retrospective study of 60 patients did find higher rates of pseudarthrosis in a non-plated ACDF cohort (25%) versus the plated group (0%) (171). Use of BMP was associated with lower rates of pseudarthrosis compared to allograft in two retrospective studies (26,52) (n=860). A retrospective study of 52 patients found no difference in the rate of pseudarthrosis between single level corpectomy and ACDF (173). Two retrospective studies found higher rates of pseudarthrosis with increasing numbers of operated levels (85,164) (n=191), but two other retrospective studies found no such association (62,177) (n=233). One of the retrospective studies that reported higher rates of pseudarthrosis in multilevel ACDF than single-level ACDF noted that no cases warranted reoperation and that that 72.4% of patients with pseudarthrosis at 1 year postoperatively ultimately fused by 2 years (85). A retrospective study of 160 patients who underwent corpectomy found smoking to be an independent risk factor for pseudarthrosis (159) but not in three other retrospective studies (52,170,171) (n=290).

Graft and hardware failure

We identified 11 case reports (179-189), 3 prospective studies (22,24,25), and 42 retrospective cohort studies; the retrospective group comprised 6 studies from 1989 to 1999 (29,30,125,127,128,169),15 from 2000 to 2009 (18,31,32,34,39,43,83,139,140,161,175,176,190-192), and 21 from 2010 to 2019 (3,44-47,56,65,66,74,79,81,149,152,154,156,159,165,193-196). Graft or hardware failure was defined as screw breakage or pullout, screw loosening, plate fracture, graft migration, graft subsidence, or graft fracture. Pseudarthrosis is discussed in a separate section. The case reports discussed graft expectoration 1 day (n=1) (188) and 5 years (n=1) (181) after ACDF, hardware migration into the distal gastrointestinal tract 5 weeks (n=1) (183), 5 months (n=1) (189), and 16 months (n=1) (184) after ACDF, fibular strut allograft fracture 10 months (n=1) and 17 months (n=1) after anterior corpectomy (182), fatigue fracture of the polyurethane sheath 8 years after arthroplasty (n=1) (187), screw loosening and erosion into the pharyngeal mucosa 17 years after ACDF (n=1) (185), retrolisthesis with new myelomalacia at an instrumented level 6 months after corpectomy (n=1) (179), and fracture through an instrumented level 5 years (n=1) (180) and 2 years (n=1) (186) after ACDF. Across prospective and retrospective studies (n=303,714), the overall rate of graft or hardware failure was 2.1%. Among prospective studies (n=565), the rate of graft or hardware failure ranged from 1.2% to 25.0% with a pooled incidence of 3.0%. Among retrospective studies (n=303,149), the rate of graft or hardware failure ranged from 0% to 50.0% with a pooled incidence of 2.1%. Among studies reporting rates of reoperation (22,24,31,34,79,83,127,128,140,169,175,191-194) (n=2,469), the incidence of hardware failure leading to surgical revision ranged from 0% to 100% with a pooled incidence of 22.7%.

Interbody graft fracture was associated with loss of graft height, plate migration, and loss of sagittal alignment in a prospective study of 40 patients undergoing ACDF at a single institution (25). Kaiser and colleagues (161) performed a retrospective study of 233 patients who underwent ACDF with plate stabilization and compared them to 289 historical controls without plating; a significantly higher graft complication rate was seen in the non-plated group. However, in two other retrospective studies (31,169) (n=99), no association was found between graft complication and use of plating. Incidence for graft failure was found to be significantly higher in corpectomy versus multilevel ACDF in two retrospective studies (45,66) (n=190). Two retrospectives studies by Liu and colleagues (46,47) (n=466) did not report measures of statistical significance, but rates of graft or hardware failure were higher in the corpectomy groups than multilevel discectomy groups and the hybrid discectomy-corpectomy groups. In a retrospective study of 120 patients undergoing multilevel ACDF, hybrid discectomy-corpectomy, or corpectomy for multilevel stenosis, the only case of hardware failure occurred in the corpectomy group; however, the difference did not reach statistical significance.

Cerebrospinal fluid leak

We identified 6 case reports (197-202), 2 prospective studies (24,123), and 30 retrospective studies; the retrospective group comprised 1 study from 1989 to 1999 (84), 4 from 2000 to 2009 (24,34,140,203), and 25 from 2010 to 2019 (44-47,49,56,66,70,77-79,123,131-133,146,149,150,159,193,204-208). The case reports discussed the following: 1 patient who suffered quadriparesis immediately postoperative from C5-6 ACDF due to expansion of hydrogel used to repair an intraoperative CSF leak and underwent successful primary repair (197), 4 patients who presented with delayed dysphagia or neck swelling after anterior cervical fusion and underwent successful exploration and repair (198,199,201), one patient who presented 24 hours after C4-5 ACDF with progressive dysphagia and was successfully managed with three lumbar punctures without wound exploration (200), and one patient who experienced wound drainage on postoperative day 1 from C5-7 ACDF and was successfully treated with a cervical epidural blood patch (202). Across prospective and retrospective studies (n=32,229), the rate of CSF leak was 0.5%. Among prospective studies, rates of CSF leak ranged from 0.2% to 1.0% with a pooled incidence of 0.3% (n=592). Among retrospective studies, rates of CSF leak ranged from 0.03% to 7.7% with a pooled incidence of 0.5% (n=31,637). Though the study by Hannallah and colleagues of 1,600 patients undergoing anterior cervical spine surgery found a greater than 3-fold relative risk of CSF leak in corpectomy versus ACDF (203), this association was not found in five moderately sized retrospective studies (45-47,66,193) (n=776). Hannallah and colleagues also found an increased risk of CSF leak in revision versus initial operations (RR 2.75), and in cases of ossification of the posterior longitudinal ligament (RR 13.74). Use of lumbar drains was highly variable, ranging from 0% to 100% (34,140,204).

Hematoma

We identified 5 case reports (209-213), 3 prospective studies (20,122,123), and 37 retrospective studies discussing postoperative cervical wound or epidural hematoma; the retrospective group comprised 2 studies from 1989 to 1999 (30,84), 7 from 2000 to 2009 (18,34,35,39,42,140,214), 11 from 2010 to 2014 (3,44,45,47,51,54,56,159,193,215,216), and 17 from 2015 to 2019 (58,63,66,70,71,73,77,78,146,149,150,156,165,217-220). We separately identified 1 case report (221) and 1 prospective study (222) discussing iliac donor graft site hematoma. The case reports comprised a case of cervical wound hematoma 6 weeks after 1-level ACDF associated with instrumentation settling resulting in neck pain, dysphagia, and shortness of breath (209) (n=1), one case of cervical wound hematoma resulting in neck swelling and dyspnea 16 days after 2-level ACDF secondary to superior thyroid artery hemorrhage requiring hematoma evacuation and endovascular coil embolization (213), and three cases of large ventral epidural hematomas resulting in tetraparesis immediately postoperatively from single level ACDF, single level corpectomy, and 4-level ACDF (210-212) (n=3). All four patients in the case reports underwent evacuation of the hematoma and ultimately recovered. The overall rate of postoperative cervical hematoma across all studies (n=865,340) was 1.0%. Among prospective studies (n=288), the incidence of postoperative cervical hematoma ranged from 0% to 0.7% with a pooled incidence of 0.3%. Among retrospective studies (n=865,052), the incidence of postoperative cervical hematoma ranged from 0% to 12.5% with a pooled incidence of 1.0%. Among studies reporting rates of reoperation for cervical hematoma (18,34,35,165,214,215) (n=1,594), frequency of postoperative hematoma leading to surgical intervention ranged from 0% to 100% with a pooled frequency of 46.1%.

Intentionally kept separate from the above pooled figures of cervical hematomas was the single prospective study of 61 patients undergoing single-level ACDF randomizing patients to non-plated tantalum interbody implant and to autologous iliac bone grafting with plating that reported a 6.1% rate of donor site hematoma requiring evacuation (222). The case report (221) discussed 1 patient who presented 1 month postoperatively from ACDF with a painful left inguinal mass and was found to have a hematoma associated with a pseudoaneurysm of the deep circumflex iliac artery. This was managed with open evacuation of the hematoma and coil embolization of the pseudoaneurysm.

A retrospective study of 37,261 patients in the NSQIP database who underwent ACDF found that a cervical hematoma requiring reoperation significantly increased the risk of re-intubation, ventilator dependence, deep wound infection, and pneumonia (217). This study also identified multilevel ACDF, preoperative INR greater than 1.2, BMI less than 24 kg/m2, and ASA class 3 or greater as independent predictors of postoperative hematoma. Use of BMP was significantly associated with increased risk of hematoma or seroma in a retrospective study of the MarketScan Database and two retrospective studies of the Nationwide Inpatient Sample (42,51,54) (n=332,031). De la Garza Ramos and colleagues reported increased rates of postoperative hematoma in patients with either ESRD or CKD compared to those without kidney disease in a retrospective study of 164,097 patients in the Nationwide Inpatient Sample Database (220). Two retrospective studies (45,66) (n=190) found no difference in the rate of postoperative hematoma between multilevel ACDF and corpectomy for central stenosis. Fountas and colleagues (34) found no association between the number of levels instrumented in ACDF and rate of postoperative hematoma in a retrospective study of 1,105 patients.

Horner syndrome

We identified 1 case report (223), 2 prospective studies (19,20), and 6 retrospective cohort studies (18,30,34,56,84,156) that discussed postoperative Horner syndrome. The case report discussed a patient who was found to have ipsilateral Horner syndrome and contralateral Harlequin syndrome immediately postoperatively from left-sided C6–7 ACDF. An urgent cerebrocervical CT did not demonstrate any hematoma or construct complication, but it did show the surgical drain lying on the ventral surface of the longus colli muscle. Symptoms resolved within hours of drain removal, suggesting local mass effect of the drain on the sympathetic chain was the culprit. Across all studies, the rate of Horner syndrome was 0.4%. Across prospective studies (n=193), the incidence of Horner syndrome ranged from 0.1% to 2.5% with a pooled incidence of 1.0%. Across retrospective studies (n=4,663), the incidence of Horner syndrome ranged from 0.3% to 1.3% with a pooled incidence of 0.3%. The single case of Horner syndrome reported in the retrospective cohort study of 1,105 patients undergoing ACDF at a single institution by Fountas and colleagues (34) resolved completely within 6 weeks.

C5 palsy

We identified 19 retrospective studies (39,40,45-47,57,62,142,144,150,159,196,206,224-229) that discussed postoperative C5 palsy. Across all of the studies (n=5,134) incidence ranged from 0.1% to 7.7% with a pooled incidence of 3.0%. The mean time to recognition of C5 palsy after ACDF or anterior corpectomy in one single institution retrospective study of 176 patients (225) was 1.7 days. Five retrospective studies (45-47,57,144) (n=652) comparing ACDF and anterior corpectomy all found non-significant trends toward higher rates of C5 palsy in the corpectomy groups. One retrospective study of 97 patients undergoing ACDF (62) found no significant difference in rates of postoperative C5 palsy between patients undergoing 4-level or 3-level ACDF. Another retrospective study of 196 patients undergoing ACDF at a single institution by Wagner and colleagues (229) found no significant association between the number of levels operated and the rate of C5 palsy. This study also reported that 6 of the 10 patients with postoperative C5 palsy completely recovered, 2 of the 10 recovered partially, and 2 of the 10 did not recover to any degree by last follow-up (mean 7 months). Eskander and colleagues (225) found that preoperative rotation of the spinal cord was an independent predictor of C5 palsy after ACDF or anterior corpectomy. Those patients who suffered C5 palsy had a mean rotation of 10.3 degrees, and those without this complication had a mean rotation of 2.1 degrees.

Vertebral artery injury

We identified 7 case reports or case series (230-236) and 4 retrospective cohort studies (62,78,140,237) that discussed vertebral artery injury. Across all studies (n=3,884), the incidence of vertebral artery injury ranged from 0.2% to 2.2% with a pooled incidence of 0.4%. One retrospective cohort study of 97 patients undergoing 4- and 3-level ACDF (62) reported a significantly higher risk of vertebral artery injury in 4-level ACDF compared to 3-level ACDF. Among the 16 patients across all studies for whom the clinical history was available, injury was noted intraoperatively in 15 cases (140,230-234,236,237), delayed rupture of a pseudoaneurysm was reported in two cases (234,235), an aberrantly medial vertebral artery was implicated in 3 cases (230,232,233), excessive lateral drilling was implicated in 1 case (234), primary repair without sequelae was achieved in 6 cases (236,237), and arterial ligation without sequelae was achieved in 3 cases (140,236,237). All 3 patients with postoperative neurologic deficit, which were all secondary to PICA territory infarction had undergone endovascular management or intraoperative hemostatic packing (233,235,237). There was 1 intraoperative death due to hypovolemic shock after vertebral artery injury (237).

New or worsened neurologic deficit

We identified 4 case reports (238-241), 1 prospective study (160), and 15 retrospective studies (29,32,34,44,56,72,77,81,83,84,127,133,141,146,206) that discussed new or worsening neurological deficit postoperatively. Across all studies, the overall incidence of new or worsening neurological deficit was 0.5%. The prospective study of 90 patients undergoing ACDF with zero profile cages reported an incidence of 1.1%. Among retrospective studies (n=137,654), the incidence ranged from 0% to 25.7% with a pooled incidence of 0.5%. Among the 10 patients in 6 studies that provided individual clinical history (34,127,238,239,241), 2 patients developed worsened myelopathy due to buckling of the ligamentum flavum and subsequently underwent posterior decompression, 1 patient with OPLL suffered postoperative hemiplegia secondary to spinal cord herniation into a corpectomy defect and subsequently underwent posterior decompression and fusion, 1 patient suffered postoperative hemiplegia secondary to polymethylmethacrylate extrusion into the spinal canal and underwent further anterior decompression with partial recovery, 2 patients suffered worsening myelopathy due to intraoperative cord contusion but recovered with conservative management, 1 patient developed transient Brown Sequard syndrome after dislodging a chip of fibular autograft requiring reoperation for retrieval, 2 patients suffered transient radiculopathy managed conservatively, and 1 patient suffered permanent quadriparesis thought due to intraoperative hypotension. One retrospective study of the California State Inpatient Database (141) found that morbidly obese individuals had a significantly increased odds (OR 3.7) of any postoperative neurological complication compared to those of normal BMI.

Infrequently reported complications

We identified 17 studies for which only case reports existed or fewer than 3 cohort studies existed. Three case reports related to the airway discussed 1 patient with facial cyanosis and hypoxia after multilevel corpectomy requiring reintubation secondary to an overly tight-fitting cervical collar (242), 1 patient with angioedema and tracheal edema in PACU after anterior osteophytectomy requiring tracheostomy (243), and 1 patient with arytenoid dislocation likely secondary to endotracheal intubation for corpectomy resulting in postoperative hoarseness (244). One case series discussed 3 patients with osteoporosis who suffered fractures of the anterior iliac crest at the donor graft site (245). Two case reports related to cervical arthroplasty hardware discussed 1 patient with incidentally discovered, unintended bony fusion across the operated level (246) and another patient with persistent postoperative neck pain likely secondary to excessively augmented segmental mobility (247). Two retrospective studies reported rates of unintended level surgery in ACDF of 0.36% (78) and 2.8% (133). The latter study by Stienen and colleagues did specify that all cases of unintended level surgery were only related to the exposure and that only the intended disc was removed and level fused. Two case reports related to lymphatic injury discussed 1 patient who underwent right-sided ACDF without noted intraoperative thoracic duct injury yet suffered bilateral chylothorax requiring bilateral thoracostomy tube placement (248) and 1 patient who underwent left-sided ACDF and suffered intraoperative thoracic duct injury due to an aberrantly cephalad course of the duct requiring intraoperative ligation with no further sequelae (249). One case report related to cranial nerve injury discussed one patient with permanent hypoglossal nerve palsy thought secondary to intraoperative traction injury during C3 and C4 corpectomy (250). Four case reports related to vascular complications discussed 1 patient with internal jugular vein thrombosis thought secondary to retraction resulting in neck swelling 5 days after single-level ACDF managed successfully with anticoagulation (251), 1 patient with immediate ipsilateral hemothorax of unclear cause after single-level ACDF resulting in dyspnea and tracheal deviation managed with tracheostomy and thoracostomy (252), 1 patient with an unruptured inferior thyroid artery pseudoaneurysm thought secondary to electrocautery resulting in tracheal deviation and neck pain 9 days after single-level ACDF managed successfully with endovascular embolization (253), and 1 patient who suffered a massive brainstem infarct of unclear cause and death after routine single-level ACDF (254).

Discussion

We sought to describe the incidences, etiologies, management strategies, and outcomes of anterior approaches to the cervical spine. Dysphagia is one of the most common postoperative complications, with an incidence of nearly 90% in one identified retrospective study. Fortunately, rates of dysphagia lasting for greater than 3 months appears to be low with a pooled estimate of less than 1%. The most consistent risk factors for postoperative dysphagia were the use of BMP and greater numbers of operated levels. Inconsistent benefit was seen for preoperative tracheal traction exercises and intraoperative local steroid use to decreased rates of dysphagia. Esophageal perforation is an exceedingly rare (pooled incidence of 0.19%) but often life-threatening complication (mortality up to 33%) with delayed presentations including sepsis, aspiration pneumonia, epidural abscess, and meningitis. Cultures are largely polymicrobial, and management is nearly exclusively aggressive with broad-spectrum antibiotics, debridement, hardware removal, esophageal repair, and nutritional bypass. Patients surviving this complication appear to have favorable chances of resuming oral intake, ranging from 60% to 100%.

Recurrent laryngeal nerve palsy manifested by hoarseness or vocal cord hypomobility visualized on laryngoscopy was found to occur at a rate of 1.3% across all studies, and patients experienced rates of partial or complete recovery of greater than 80%. Isolated retrospective studies found higher rates of nerve palsy after revision cases, presumably secondary to the difficulty of navigating disrupted fascial planes and adhesions. Associations with greater operated levels were inconsistent, and no studies found a difference in rates of palsy between multilevel ACDF and corpectomy. Rates of infectious complications were low with an incidence of 0.9% across all studies. While potentially skewed by reporting bias, the finding that nearly half of all infectious complications were bacteremia or sepsis may suggest that the rare infection that occurs postoperatively is often serious and systemic. The only significant association found was in patients with rheumatoid arthritis, a finding that may rationalized by the immunosuppressive effect of several disease modifying anti-rheumatic regimens.

Adjacent segment disease proved to be a heterogeneous entity given inconsistent reporting of radiographic cases, symptomatic cases, or those requiring reoperation. When restricted to only cases requiring reoperation, the pooled incidence was low at 4.5%. The two studies that reported mean times to reoperation provided a similar figure of approximately 3 years. A potentially counterintuitive but largely consistent finding was the lower rate of adjacent segment disease in longer constructs. Though there is creation of a longer lever arm with a longer construct, these also may tend to include the adjacent discs that are at risk of degeneration into the fusion. Further study is necessary to determine the clinical value of prophylactically including radiographically degenerated but asymptomatic adjacent levels, though this strategy has not been proven successful in lumbar spine literature (255).

Rates of pseudarthrosis varied widely given reporting of asymptomatic radiographic graft subsidence to symptomatic neck pain or radiculopathy leading to revision surgery. Nevertheless, the pooled rate remained low at 2.0% at last follow-up. We found significantly lower rates of pseudarthrosis in plated ACDF cohorts, BMP cohorts, and cohorts of fewer operated levels. Smoking was not consistently found to be associated with pseudarthrosis. An encouraging finding in one retrospective study is the high rate of ultimate fusion in patients found to have pseudarthrosis at 1 year postoperatively, though this will need to be verified in prospective studies. Graft and hardware failure proved to be yet another heterogeneous entity with presentations ranging from radiographic screw loosening to graft expectoration or fracture leading to spinal cord injury. The overall incidence was low across all studies at 2.1% with an estimated reoperation rate of 22.7%. Corpectomy compared to ACDF was significantly associated with higher risk of hardware failure in one study with similar non-significant trends in the remainder of the retrospective studies examining the association, suggesting an issue of statistical power.

Cerebrospinal fluid leak was found to be a rare complication with an overall incidence of 0.5%. Significant associations were found with corpectomy versus ACDF, revision versus initial operations, and in patients with ossification of the posterior longitudinal ligament. When discovered in delayed fashion, management was variable, ranging from reoperation to less invasive strategies such as serial lumbar punctures or cervical epidural blood patch. Cervical wound hematoma was found to occur at a rate of 1% with a relatively high frequency leading to reoperation at 46.1%. This is unsurprising given the risks for rapid airway compromise or neurologic deficit in the setting of epidural hematoma. Though retrospective, analyses of large national databases found significant associations of postoperative hematoma with multilevel ACDF, supranormal INR, underweight status, ASA class greater than 3, and impaired kidney function.

As the sympathetic chain lies ventral to the longus colli muscles, they can be damaged at various stages of anterior cervical spine surgery, particularly during exposure of the vertebral bodies (256). The lone case report demonstrated that the sympathetic chain is vulnerable even after dissection is complete; the mass effect of a surgical drain may be sufficient to result in Horner syndrome and Harlequin syndrome. The rates of postoperative Horner syndrome are low in the literature with a pooled rate of 0.4% with some data to suggest recovery can occur even if an immediately reversible cause is not identified. The rate of postoperative C5 palsy across all studies was 3.0%. No association was found with number of operative levels in ACDF, but five retrospective studies reported higher non-significant trends on this complication in corpectomy versus ACDF. Given the low incidence of this complication, this may reflect lack of statistical power. The retrospective study reporting the association of the complication with higher degrees of spinal cord rotation does fit our current paradigm of C5 palsy as a stretch-induced ischemic phenomenon (257).

Vertebral artery injury was reported by few studies and is likely rare with an overall incidence of 0.4%. The case reports and case series illustrated the variable outcomes from no sequelae to PICA territory infarction to intraoperative death. As the vertebral artery is typically within 5 mm of the tip of the uncinate process (258), injury can occur during the decompression with a drill or rongeur as in one of the included case reports. However, aberrant medial location of the vertebral artery can place it at risk even if traditional landmarks are observed, emphasizing the need to scrutinize preoperative imaging.

A multitude of mechanisms have been reported for new or worsened neurologic deficit after anterior cervical surgery, which had a low overall incidence of 0.5%. Severity ranged from transient radiculopathy to permanent quadriparesis, and unsurprisingly, all reported cases with evidence of residual neural compression underwent reoperation. While one study reported higher rates of neurological decline among the morbidly obese compared to normal weight individuals, it remains to be demonstrated whether other approaches to the cervical spine provide a more favorable risk profile in this population if conservative management is not a viable option.

Our review was limited by retrospective data collection and risk of reporting bias, particularly given the preponderance of case reports for several classes of complications.

Conclusions

Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications—some life-threatening—involving vascular, aerodigestive, neural, and osseous structures.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Lee A. Tan and Ilyas S. Aleem) for the series “Advanced Techniques in Complex Cervical Spine Surgery” published in Journal of Spine Surgery. The article was sent for external peer review organized by the Guest Editors and the editorial office.

Conflicts of Interest: The series “Advanced Techniques in Complex Cervical Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. Dr. Park is a consultant for and receives royalties from Globus, is a consultant for NuVasive, and receives grants from Depuy and the International Spine Study Group. These relationships pose no conflict of interest with the research reported. Drs. Yee and Swong have no disclosures or conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Yee TJ, Swong K, Park P. Complications of anterior cervical spine surgery: a systematic review of the literature. J Spine Surg 2020;6(1):302-322. doi: 10.21037/jss.2020.01.14

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