Vertebral artery injury
- Numbers
- Lee 2019: Surgery-specific incidence of vertebral artery injury
- 1.35% in cases involving C1-2 posterior fixation
- 0.20% in cases involving C3-6 posterior fixation.
- Vertebral artery location
- Farthest from the midline at the lowest level C6/7
- Closest to the midline at the higher level C3/4
- Oh 2019: higher risk of injury above C5/6
- Aetiology of injury
- Lee 2019:
- Screw-in (31%)
- High-speed drilling (23%)
- Consequence of injury
- Lee 2019: 23% involved cerebellar or stem infarction.
- The infarction had no substantial correlation with injury grade or dominancy.
- Preventing
- Use a Doppler
- Get CTA → Look at the scan
- Managing
- Plug the hole with mashed up muscle and then Surgicel
- Within v2 segment plug it above and below the vertebral artery injury
Dysphagia
- Increased risk in major Reconstruction eg: corpectomies.
- Clinical features
- Common
- Patients experience mild symptoms such as soreness and slight discomfort when swallowing.
- These symptoms usually settle early: Initial 24–48 hours:
- Rarer
- Pain
- Significant dysphagia even when trying to swallow saliva
- Patient may repeatedly try to clear frothy saliva, and there may be a visible, swollen, and fluctuating area.
- Investigate with
- Barium swallow ? oesophageal injury
- Treatment options:
- Analgesics and anti-inflammatory drugs.
- Topical use of steroids for treatment is a debatable topic.
- Technique: a left-sided Smith–Robinson surgical approach. Interbody fusion was carried out using a polyetheretherketone (PEEK) spacer, local bone graft, 0.35 cc (0.5 mg) of BMP-2 per level, and plate fixation. A 1 × 3 cm collagen sponge was saturated by the nurse with either saline (1 cc) or depomedrol (40 mg/1 cc) based on the randomization protocol described above. Before closure, the sponge was placed ventral to the plate. A 10-French silicone drain was placed into the retroesophageal space in all patients.
- Li 2022:
- Local steroid group had less patients with dysphagia, lower swallowing VAS scores and less severe of prevertebral soft-tissue edema on the fourth day after surgery.
- No significant difference in non-fusion rate between the two groups was observed.
Oesophageal injury
- Investigation
- Confirming diagnosis: A perforation is confirmed with a Methylene blue test at the operative wound site.
- Assessing size and location:
- Contrast oesophagography is used to determine the size and site of the issue.
- Endoscopy
- Computer Tomography (CT) scans and Endoscopy examinations are also used.
- Methylene blue test given orally seen at wound site
- Conservative Treatment
- When to use it:
- Small contained defect (less than 1 cm),
- no or minimal mediastinal/pleural contamination
- No signs of septicemia.
- Treatment actions:
- Stop all oral feeding.
- Initiate hypercaloric feeding via a Ryles tube, but never through the neck.
- Administer broad-spectrum intravenous sensitive antibiotics.
- Perform liberal wound drainage.
- Maintain close observation of the patient.
- Recovery timeline:
- Secretion decreases significantly in 3-4 days.
- Semi-solid food can be introduced after 1 week.
- Liquid food can be introduced after 2 weeks.
- Surgical Treatment
- Primary Repair:
- The re-exploration should ideally be performed by the first surgeon, as they have knowledge of the previous soft tissue plane and procedure.
- Alternatively, a G.I. surgeon who routinely performs oesophageal reconstruction can do it.
- If a prominent implant is causing the injury, it must be removed.
- The injured oesophagus is then repaired or reconstructed.
- Primary Repair with Flap Reinforcement:
- This technique uses various flaps to reinforce the repair, including:
- Sternocleidomastoid
- Longus coli
- Pectoralis Major
- Sternohyoid
- Sternothyroid
- Jejunum
- Omentum
- Pleural
- Platysma
CSF leak
- Problems of CSF leak:
- Swelling & Dysphagia
- CSF Fistula
- Meningitis
- Pseudoarthrosis
- Acidic CSF disrupts healing cascade.
- Implant failure
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