Elsevier

The Spine Journal

Volume 19, Issue 4, April 2019, Pages 597-601
The Spine Journal

Clinical Study
Postoperative stroke after anterior cervical discectomy and fusion in patients with carotid artery stenosis: a statewide database analysis

https://doi.org/10.1016/j.spinee.2018.09.011Get rights and content

Abstract

BACKGROUND

Carotid artery injury and stroke secondary to prolonged retraction remains an extremely rare complication in anterior cervical discectomy and fusion (ACDF). However, multiple studies have demonstrated that carotid artery retraction during the surgical approach may alter the normal blood flow, leading to a significant reduction in the cross-sectional area of the vessel. Others have suggested that dislodgment of atherosclerotic plaques following manipulation of the carotid artery can be a potential risk for intracranial embolus and stroke.

PURPOSE

We aimed to evaluate: (1) the incidence of postoperative stroke following ACDF and (2) incidence of other postoperative complications in a cohort of patients who had a diagnosis of carotid artery stenosis (CAS) versus those who did not.

PATIENT SAMPLE

This study utilized the Statewide Planning and Research Cooperative System database from January 1, 2009 to December 31, 2013. All patients who underwent (ACDF) and had a preoperative diagnosis of CAS were identified using the International Classification of Disease, ninth revision codes. Those who had a previous history of stroke were excluded. Patients who had CAS were propensity score matched to patients without history of CAS for demographics and Charlson/Deyo comorbidity scores.

OUTCOME MEASURES

Incidence of postoperative stroke and other complications were compared between the cohorts. The threshold for statistical significance was set at a p<.05. This study received no funding. The authors report no conflict of interests relevant to this study.

RESULTS

There were 34,975 patients who underwent an ACDF in the study time period. After excluding those under the age of 18 and with history of previous stroke, there were 61 patients who had CAS that were compared with a propensity-matched cohort. The CAS cohort had a significantly higher incidence of postoperative stroke during their hospitalization (6.6% vs 0%, p<.042). 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). There were no stroke related deaths.

CONCLUSIONS

Patients with CAS who underwent ACDF had a statistically significant greater incidence of developing a postoperative stroke. To the best of our knowledge, no previous study has evaluated the development of postoperative stroke in patients with CAS undergoing ACDF. Larger, multicenter studies are needed to estimate the true incidence of stroke in this specific patient population. However, our results may illustrate the importance of preoperative optimization, approach-selection, and postoperative stroke surveillance in patients with a history of CAS who undergoes ACDF.

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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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.

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