Clinical StudyPostoperative stroke after anterior cervical discectomy and fusion in patients with carotid artery stenosis: a statewide database analysis
Introduction
The surgical approach for an anterior cervical discectomy and fusion (ACDF) involves lateral retraction of the sternocleidomastoid muscle and the carotid sheath, as well as medial retraction of the trachea and esophagus, among other structures. Carotid sheath retraction required for the surgical approach may alter carotid arterial flow dynamics. This has been studied and demonstrated to be secondary to a significant reduction in the cross-sectional area in a study of ACDF utilizing duplex ultrasound [1], [2].
Consequences of altered blood flow in the carotid artery could potentially lead to cerebrovascular ischemia. In addition, dislodgment of atherosclerotic plaques following physical manipulation of the carotid artery is a potential risk for intracranial embolus and resulting stroke [2], [3], [4], [5], [6]. Nevertheless, complications related to carotid artery injury and cerebrovascular ischemia are rare [7]. However, these incidents may be severe, resulting in long-term morbidity and even mortality. Theoretically, this may be particularly evident in patients with pre-existing carotid artery stenosis (CAS), where prolonged lateral retraction of the carotid artery may provoke a stroke secondary to direct carotid artery injury, atherosclerotic plaque embolization, or significantly decrease in blood flow in an already stenotic vessel. However, to the best of our knowledge, no study has evaluated the incidence of stroke in patients with carotid artery disease.
Therefore, the purpose of this study was to asses and compare the rates of postoperative stroke following ACDF in a cohort of patients with and without pre-existing CAS. The secondary purpose of this study was to compare and assess other postoperative complications between these two groups.
Section snippets
Database
This study utilized the Statewide Planning and Research Cooperative System (SPARCS) database from January 1, 2009 to December 31, 2013. The SPARCS database is publicly available through the New York State Department of Health's Bureau of Health Informatics and contains patient-level discharge information collected through a collaboration of both industry and government bodies. In total, all patients seen in the state of New York in outpatient, inpatient, emergency department visits, hospital
Incidence of postoperative stroke
The CAS cohort had a significantly higher postoperative incidence of stroke than the group of individuals without CAS (6.6% vs 0%, p<.042) (Table 2a).
Other postoperative complications
The CAS cohort also had higher rates of acute renal failure (27.9% vs 4.9%, p=.01) and sepsis (18% vs 4.9%, p = .023) in comparison to those without CAS. The patients in the CAS cohort also had higher rates of surgical site infection (11.5% vs 6.6%, p = .343), wound dehiscence (3.3% vs 1.6%, p = .559), myocardial infarction (3.3% vs 1.6%, p =
Discussion
Surgical exposure for ACDF involves lateral retraction of the carotid sheath, which may alter carotid arterial flow dynamics. It has been demonstrated that such retraction can lead to significant reduction in the cross-sectional area of the vessel in a study of ACDF utilizing duplex ultrasound [1], [2]. This may lead to reduction of cerebral perfusion and/or dislodgment of atherosclerotic plaques [2], [3], [4], [5], [6], which may theoretically be more likely in an already diseased vessel.
Conclusions
In the present study, we found that patients with CAS who underwent ACDF had a statistically significant greater rate of developing a postoperative stroke in comparison to patients without CAS. It is important to note that the data presented does not offer a "cause and effect" explanation but rather a finding of association. Nevertheless, these patients may benefit from an alternative surgical approach or from medical or surgical optimization of their CAS before undergoing ACDF. Therefore,
Acknowledgments
This study received no funding. The authors have no financial disclosures relevant to this study.
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Cited by (7)
A case report of simultaneous surgery for concurrent symptomatic carotid artery and cervical spinal stenosis
2021, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementCitation Excerpt :The concurrent presentation and potential risks may be underappreciated, especially since cervical stenosis and CAS share risk factors like smoking and older age. Further, asymptomatic CAS patients have a 6.6% risk of developing post-operative stroke when undergoing routine ACDF, likely due to carotid manipulation.[4] This risk may be even higher in symptomatic CAS and raises the question of whether certain patients undergoing anterior cervical approaches should be screened for concurrent cerebrovascular disease, possibly through a questionnaire for verifying stroke-free status (QVSS).[6]
Perioperative Ischemic and Hemorrhagic Stroke in Spine Surgery: A Series of 5 Cases
2021, World NeurosurgeryPredicting In-Hospital Complications After Anterior Cervical Discectomy and Fusion: A Comparison of the Elixhauser and Charlson Comorbidity Indices
2020, World NeurosurgeryCitation Excerpt :A well-recognized challenge to surgeons treating an older patient population is the presence of a relatively greater comorbidity burden compared with younger patients. For all surgical candidates, medical comorbidities are an important consideration because they have been shown to significantly affect the rate of various postoperative complications and also to play a critical role in provider performance assessment, reimbursement, and proposed bundled payment plans.5-14 To better assess surgical patients who may present with any combination of the multitude of possible comorbidities, various scoring measures have been proposed, with 2 specific indexes, the Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index, having attained prominence in orthopedic surgery.15,16
Vascular complications in spine surgery
2019, Seminars in Spine SurgeryCitation Excerpt :The most common approach to the subaxial anterior cervical spine utilizes an anterolateral (Smith-Robinson) interval.6,7 While the incidence of significant vascular injury during anterior cervical approaches is known to be quite rare,8–10 the consequences may be devastating and include blood loss, hematoma, stroke, permanent neurologic sequelae, and death.11,12 Both the carotid and vertebral arteries may be damaged during surgical approach, discectomy, bony resection, or instrumentation.
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Author disclosures: MC: Consulting: Stryker (B), Sage Products (B), DJ Orthopaedics (B), Cymedica (C), Peerwell (C), Reflexion (C). outside the submitted work. TEM: Royalties: Stryker (E); Consulting: Stryker (E), RTI Surgical (B); Speaking and/or Teaching Arrangements: Synthes (D); Trips/Travel: Synthes (D), Stryker (B); Board of Directors: SpineLine (nonfinancial), The Spine Journal (B), NASS, outside the submitted work. JS: Consulting: Stryker (D); Board of Directors: Clinical Spine Surgery, outside the submitted work. MPS: Royalties: Biomet Spine (B); Consulting: Intellirod (A), Stryker Spine (B), Globus (B); Speaking and/or Teaching Arrangements: Stryker (B); Board of Directors: AANS/CNS Section on Disorders of the Spine (Chair Exhibits Committee), Council of State Neurosurgical Societies (Vice Chair); Scientific Advisory Board: Intellirod (B). CBP: DePuy, A Johnson & Johnson CompanyEthicon: Paid presenter or speaker. Other authors: nothing to disclose.