CHAPTER
148
Neurological Complications
INTRODUCTION
Neurological injury during spine surgery may have devastating
consequences for both patient and surgeon. An awareness of
the potential causes of neurological complications may help to
anticipate and potentially prevent their occurrence. Overall,
neurological injuries during spine surgery are rare. Direct
injury to the spinal cord or nerve roots may occur at the surgi-
cal site. Indirect injury to peripheral nerves may occur during
patient positioning through prolonged compression during
the course of surgery. The risk of neurological injury depends
on the surgical procedure performed, the amount of manipu-
lation of the spinal cord or nerve roots, the use of spinal instru-
mentation, and the degree of preoperative spinal deformity
and stability.
The spinal cord is more sensitive to manipulation than indi-
vidual nerve roots. The pathophysiology of spinal cord injury is
complex and involves the physiological processes of inflamma-
tion, edema, hemorrhage, and ischemia. Compressive injury to
the spinal cord, for example, due to trauma, tumor, or malposi-
tioned spinal instrumentation, is a common inciting event of
neurological injury with the extent of damage dependent on
the duration of compression. Prevention, identification, and
treatment of neurological injury are essential to limiting the
sequlae of spinal cord injury. This chapter focuses on the neu-
rological complications that may occur during the preopera-
tive, intraoperative, and postoperative phases of spine surgery.
PREOPERATIVE NEUROLOGICAL
COMPLICATIONS
Patients who present with complaints involving the spine,
whether in the outpatient, inpatient, or emergency room set-
ting, require a prompt evaluation and examination. Patients
with a spinal cord injury or impending neurological injury may
require urgent spinal cord decompression and stabilization.
The onset, duration, severity, and progression of neurological
symptoms need to be determined. Medical comorbidities (e.g.,
cardiopulmonary disease, renal or hepatic dysfunction, coagu-
lopathy, osteoporosis, and inflammatory arthropathy) that may
influence the surgical timing, surgical planning, or surgical
outcomes are essential to identify and it is important to discuss
their influence on the potential treatment outcome with the
patient. Early recognition and prompt management of spinal
cord injuries is crucial to improving patient outcome. Spinal
1584
LWBK836_Ch148_p1584-1590.indd 1584
Lukas P. Zebala
Jacob M. Buchowski
column stability needs to be assessed with the use of plain
radiographs, computed tomography (CT) scans or magnetic
resonance imaging (MRI). Unstable spine injuries should be
stabilized with traction or bracing to prevent further injury and
potentially provide decompression through realignment of the
spinal canal. Spine surgical emergencies, such as incomplete
spinal cord injury, progressive neurological deficit, or cauda
equina syndrome, need to be diagnosed promptly. In general,
the force of the initial injury and time of spinal cord compres-
sion may determine the extent and reversibility of the neuro-
logical deficit. A delay in the diagnosis or a protracted surgical
intervention of a spinal cord injury may lead to unnecessary
complications that may have been prevented in the preopera-
tive time period. The establishment of regional spinal cord
injury referral centers has helped reduce the proportion of
complete spinal cord injuries through efficient management of
these patients.
Injury to the spinal cord can be classified as a complete or
incomplete injury. In a complete spinal cord injury, there is
absence of motor or sensory function below the level of injury
without sacral sparing (S4 to S5). An incomplete spinal cord
injury has preservation of some motor or sensory function below
the spinal cord injury level. Patients may have some function for
several segments below the injury site (zone of partial preserva-
tion), have partial preservation of function on one side (lateral
preservation), or have some recovery of function days to weeks
after injury. Sacral sparing is evidence of the physiological conti-
nuity of spinal cord long tract fibers and helps to distinguish
between complete and incomplete spinal cord injury.
Spontaneous neurological recovery is decreased when sacral
sparring is absent. The neurological level of injury is the most
caudal spinal level at which the motor and sensory levels are
normal. The American Spinal Injury Association (ASIA) has
defined an impairment scale to grade the level of neurological
loss (Table 148.1). Neurological recovery after incomplete spi-
nal cord injury may be guided by this classification. Most patients
with Grade A or B spinal cord injury will show no recovery, but
some patients may show some nonfunctional improvement.
Patients with Grade C or D injury are expected to improve at
least one motor grade. Traumatic injury to the spinal cord may
be accompanied by spinal shock, which is defined as the tran-
sient loss of motor, sensory, and reflex function below the level
of the injury and may persist for up to 72 hours. Spinal shock
resolution is signified by the return of the bulbocavernous reflex
or anal wink (sacral spinal reflexes). The end of spinal shock
allows for classification of the spinal cord injury.
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 Chapter 148 Neurological Complications 1585

TABLE 148.1 ASIA Impairment Scale

A Complete No motor or sensory function is preserved in the sacral segments (S4 to S5)
B Incomplete Sensory but no motor function is preserved below the level of injury and includes S4
to S5
C Incomplete Motor function is preserved below the injury level; more than half of preserved
muscles have grade 3 function
D Incomplete Motor function is preserved below the injury level; more than half of preserved
muscles have higher than grade 3 function
E Normal Normal motor and sensory function

Source : Data are taken from the American Spinal Injury Association (ASIA). Standards for neurological
and functional classification of spinal cord injury---revised 1992, Chicago: American Spinal Injury
Association, 1992.

Incomplete spinal cord injuries can also be classified into offers the greatest chance for neurological function preserva-
several different types whose symptoms are predicated by the tion and recovery.
anatomic area of injury within the spinal cord. Central cord
syndrome, the most common type, is often seen in elderly
patients with cervical spondylosis who sustain a hyperextension INTRAOPERATIVE NEUROLOGICAL
injury of the cervical spine. Central cord syndrome is associated COMPLICATIONS
with greater motor and sensory deficits in the upper extremi-
ties than the lower extremities. Neurological recovery after cen- POSITIONING
tral cord syndrome is fair with elderly patients having a much
poorer recovery rate than younger patients. The relatively com- From the time a patient enters the operating suite, the spine
mon anterior cord syndrome is characterized by damage to the surgeon should be aware of potential pitfalls that may increase
anterior two-thirds of the spinal cord by anterior spinal artery the patients risk of a neurological injury. Patients at high risk
injury or by flexion-compression spine fracture. It is associated of developing an intraoperative neurological injury should
with a loss of motor function below the level of injury with vari- be identified through preoperative screening and planning
able changes in sensitivity to pain, light touch, and temperature (Table 148.2). For high-risk patients, appropriate intraopera-
while deep pressure and proprioception are preserved. The tive precautions should be taken. Patients at risk of neurologi-
functional recovery after anterior cord syndrome is poor. cal injury with intubation (e.g., cervical spondylosis with spinal
BrownSquard syndrome occurs with damage to one-half of canal stenosis, congenitally narrow spinal canal, ankylosing
the spinal cord often due to a penetrating trauma and is char- spondylitis, rheumatoid arthritis, or other inflammatory
acterized by an ipsilateral motor weakness and proprioception arthropathy causing potential cervical spine instability) may
loss and contralateral loss of pain, temperature, and light touch require fiber optic intubation to avoid cervical spine hyperex-
sensation. BrownSquard syndrome is an uncommon injury tension.
pattern, but it has the best prognosis for functional recovery. Patient positioning is critical to avoid iatrogenic injury that
Posterior cord syndrome is extremely rare and described as a may compromise surgical outcomes. For surgical operations in
loss of vibrational sensation and proprioception. Other incom- the prone position, avoidance of excessive shoulder abduction
plete spinal cord injuries include conus medullaris syndrome and hyperextension (90/90 shoulderelbow position ideal) is
and cauda equina syndrome. Conus medullaris syndrome is important to minimize the risk of brachial plexus injury. Bony
associated with injury to the sacral cord and lumbar nerve roots prominences need adequate padding to prevent excessive
causing are flexic bladder, bowel, and lower limb function with
occasional preservation of sacral reflexes. Cauda equina syn-
Patients at Higher Risk for
drome is caused by injury to the lumbosacral nerve roots lead-
ing to bowel and bladder dysfunction, saddle anesthesia, and TABLE 148.2 Intraoperative Neurological
bilateral lower extremity pain and weakness. The role of ste- Deficit
roids in the acute management of incomplete spinal cord injury Trauma patients
remains controversial. Several factors to consider before initiat- Revision spine cases
ing methylprednisolone include timing of injury, penetrating Congenital kyphosis
versus blunt trauma, and medical comorbidities that may make Congenital scoliosis
the use of steroids harmful. Severe, rigid scoliosis
Surgical timing of decompression with or without stabiliza- Skeletal dysplasia
tion also remains controversial and often patient specific. Early Neurofibromatosis
surgical intervention is indicated for spinal cord compression Postinfection
with a progressive neurological deficit. Treatment of nonpro- Postradiation
Preoperative neurological deficit with poor intraoperative
gressive neurological injury has been advocated on an acute,
neuromonitoring
urgent, or delayed time basis, often after the patient is medi- Severe spinal stenosis
cally stabile for surgery. However, spine decompression and sta- Congenital narrowing of spinal canal
bilization in a timely fashion with a medically stable patient

LWBK836_Ch148_p1584-1590.indd 1585 8/26/11 2:19:49 PM

 1586 Section XIV Complications
pressure on peripheral nerves with special attention to the
ulnar nerve that is the most frequently injured peripheral
nerve due to patient malpositioning. Other areas at risk of
compressive neuropathy include the anterior superior iliac
spine (lateral femoral cutaneous nerve) and the knees (per-
oneal nerve). In the prone position, avoidance of spine hyper-
extension is important as this may place the spinal cord, nerve
roots, or anterior vascular structures on tension potentially
causing ischemic damage or stretch injury. Similar precautions
need to be taken for spine surgery in the anterior or lateral
positions.
SURGICAL APPROACH
The surgical approaches for spine surgery have inherent dan-
gers of neurological injury. Anterior cervical spine dissection
may proceed through a transoral, anterior retropharyngeal, lat-
eral retropharyngeal, or a retrosternomastoid approach. The
transoral approach is a less frequently utilized anterior cervical
approach, useful when access to the upper cervical spine would
be difficult with either a SmithRobinson or posterior approach.
The transoral approach is a relatively safe approach, but dural
tears, cerebrospinal fluid (CSF) leaks, and cranial nerve injury
may occur. The anterior retropharyngeal approach is an exten-
sion of the SmithRobinson approach that allows access to the
upper cervical spine. The facial, glossopharyngeal, vagus, and
hypoglossal nerves may be at risk with this approach. Iatrogenic
injury to the superior laryngeal nerve, as it crosses the surgical
field at C3 to C4, may cause postoperative dysphasia and dys-
phonia. The spinal accessory and lesser occipital nerves may be
injured during the retrosternocleidomastoid approach. The
common SmithRobinson approach offers excellent exposure
of the anterior cervical spine from C3 to T1. Recurrent laryn-
geal nerve injury by laceration or excessive retraction resulting
in transient or permanent dysphonia has been reported.4 This
risk may be minimized with a left-side approach as the left
recurrent laryngeal nerve follows a more direct course within
the tracheoesophageal groove that serves as protection. The
right recurrent laryngeal nerve takes a variable course, often
across the surgical field, outside of the tracheoesophageal
groove increasing the risk of iatrogenic injury. Injury of the
sensory branch of the superior laryngeal nerve, commonly
founded between C2 and C3, may result in voice changes or
decreased aspiration protection. Horners syndrome may occur
with sympathetic chain injury by dissection lateral to the longus
colli muscles, misplacement of retractors, or inadvertent injury
by electrocauterization. Risk of neurological injury during
anterior cervical spine surgery may be increased with increased
levels of surgery and revision surgery that require larger surgi-
cal exposures. Posterior cervical spine surgery is relatively safe
and effective in addressing different pathologies including
trauma, tumor, infection, radiculopathy, and myelopathy.
Abnormal or injured posterior bony anatomy may increase the
risk of inadvertent spinal canal penetration and spinal cord
injury.
Anterior surgical approaches to the thoracolumbar (thora-
coabdominal, transthoracic-transdiaphragmatic, transpleural-
retroperitoneal) and lumbar spine (anterior retroperitoneal,
transperitoneal) are relatively safe with reported neurological
injury less than 1%.14 During transthoracic dissection, inter-
costal neurovascular structures should be carefully dissected
and protected. Segmental spinal artery injury within the
LWBK836_Ch148_p1584-1590.indd 1586
thoracic critical zone (T4 to T9) or injury to the artery of
Adamkiewicz may cause spinal cord ischemia and delayed
paraparesis or paralysis. Temporary clamping of segmental ves-
sels and transcranial motor-evoked potential (tcMEP) moni-
toring may help identify critical segmental vessels that must be
preserved to prevent neurological injury. Within the lumbar
spine, anterior surgical approaches may place the lumbar
nerve plexus at risk. The genitofemoral nerve (L1 to L2)
pierces the psoas muscle from posterior to anterior at L3 to L4
and descends on the abdominal surface of the psoas muscle.
This nerve is at risk with psoas muscle splitting at L3 or L4.
The lumbar sympathetic chain may be injured with psoas mus-
cle dissection. Lumbar sympathetic nerves ramify and form the
superior (presacral) hypogastric plexus, commonly located at
L4 to L5. The superior hypogastric fibers are located within
the retroperitoneal space and are anterior to the L5 vertebral
body within the prevertebral space. Retrograde ejaculation
after superior hypogastric plexus injury during lumbar spine
surgery has been reported with an incidence of between 1%
and 20%.30 In addition, anterior lumbar spine surgery may be
complicated by injury of the L5 nerve root as it courses over
the sacrum.
Neurological injury during posterior or posterolateral tho-
racic or lumbar spine surgery is rare. Preoperative identifica-
tion of spinal bony anomalies with posterior element deficiency
may help avoid spinal cord or nerve root injury through inad-
vertent spinal canal penetration. Careful lamina resection may
prevent inadvertent canal penetration, dural tears, or nerve
root injury. Nerve roots should be protected during exposure
of the transverse process. Lumbar nerve roots pass ventral to
the transverse process of the next lower lumbar level and are
protected by intertransverse muscles. Maintenance of dissec-
tion dorsal to these muscles minimizes the risk of iatrogenic
lumbar nerve root injury.
OPERATIVE PROCEDURE
AND INSTRUMENTATION
The risk of neurological injury also depends on the surgical
procedure, surgical indication, and spinal instrumentation and
fusion. Anterior cervical decompression with discectomy, cor-
pectomy or both for radiculopathy, myelopathy, or myelora-
diculopathy is relatively safe.13 The incidence of nerve root or
spinal cord injury during anterior cervical decompression has
been reported at approximately 1% to 2%.13 Multilevel corpec-
tomy with a long structural graft for fusion increases the risk of
neurological injury. Ischemic injury of the cervical spinal cord
may occur with overcorrection of cervical lordosis by large
anterior structural grafts that places anterior vascular structures
on stretch. The use of anterior cervical plates has become more
common to help provide construct stability, decrease the risk of
graft extrusion, and help maintain cervical alignment. Graft or
cage extrusion posteriorly into the spinal canal is a potential
complication of anterior cervical spine fusion that may lead to
compression of the cervical cord. Graft kick out risk is larger
with longer fusions as the construct lever arm increases. Older
anterior cervical plating systems that relied on bicortical screw
purchase had a potential risk of damaging the thecal sac or
spinal cord. Newer plating systems incorporate unicortical
screws with locking mechanisms that have eliminated this
potential complication if screw length is measured correctly.
Stress is shared between structural grafts and newer dynamic
8/26/11 2:19:49 PM

anterior cervical plates that may help graft fusion and decrease
the risk of plate breakage and graft extrusion. Dural tear and
spinal cord or nerve root injury are potentially reduced with en
bloc laminectomy techniques compared to piecemeal removal
of lamina. Nerve root palsy has been reported more frequently
after posterior cervical decompressions, but may occur with
anterior decompression.25 The etiology of postoperative cervi-
cal nerve root palsy is unclear. It may occur due to direct nerve
root injury, thermal injury from burring or as a stretch injury of
the nerve root due to increased spinal canal volume after
decompression, and restoration of cervical lordosis. The inci-
dence of nerve palsy after cervical decompression has been
reported between 3% and 13% and is characterized by slow,
progressive recovery.25 C5 palsy is most common and is theo-
rized to occur due to the short length of the C5 nerve root,
maximal lordosis at the C5 level, and extent of spinal cord pos-
terior shifting at C5 is greater that at other levels.25 Postlamine-
ctomy kyphosis may result in neurological deficits by persistent
spinal cord compression through the kyphotic apex or by insta-
bility at the kyphotic level. Ossification of the posterior longitu-
dinal ligament (OPLL) often requires multilevel anterior and/
or posterior decompression with greater neurological injury
risk. Dural deficiency or adherence may be encountered at
time of surgery potentiating the risk of a neurological injury.
Recent studies have reported postoperative neurological dete-
rioration of 7% to 9% after anterior or posterior OPLL decom-
pression.19
Neurological injury with instrumentation and implant mal-
position occurs slightly more with posterior than anterior cervi-
cal surgery.15 Safe insertion of cervical lateral mass and pedicle
screws may be accomplished with knowledge of cervical spine
anatomical features and correct insertion techniques.1--3
Improper screw insertion may injure nerve roots by screw lac-
eration or compression. Direct spinal cord injury is less fre-
quent, but may occur with improper insertion technique and
medial canal penetration. The risk of neurological injury with
cervical pedicle screw placement is higher between C3 and C6
due to variable pedicle morphology and close proximity of neu-
rological structures compared to C2 or C7.1--3 The thoracic
spine is stiffer than cervical or lumbar segments due to rib artic-
ulation in the thoracic cavity. In addition, the spinal canal area
is smaller than within the cervical or lumbar segments and the
thoracic spinal cord and nerve roots are in closer proximity to
thoracic pedicles. Posterior thoracic spine surgery often
requires direct manipulation of the spinal cord to access ante-
rior structures. The risk of spinal cord injury from direct
manipulation needs to be weighted against the morbidity of a
thoracotomy and is dictated by the surgical problem and patient
health. However, thoracic nerve roots may occasionally be sacri-
ficed with less functional loss than with nerve root loss in the
cervical or lumbar spine.
Overall, the risk of neurological injury with lumbar decom-
pression is low and variable based on the type of decompres-
sion (i.e., direct open, endoscopic, and minimally invasive).
Revision lumbar decompression has increased risk of spinal
cord, nerve root, or thecal sack injury as anatomical structures
may be obscured by or scarred within postoperative granula-
tion tissue.
Lumbar interbody fusions offer increased spinal fusion area,
increased spine stiffness, stability, and maintenance of disc
height.16 Lumbar interbody fusion has an inherent risk of
neurological injury predicated by the surgical approach and
LWBK836_Ch148_p1584-1590.indd 1587
Chapter 148 Neurological Complications 1587
insertion technique. The original posterior lumbar interbody
fusion (PLIF) techniques had initial good fusion rates, but high
associated neurological deficits from graft extrusion without
instrumentation. Newer PLIF techniques have had less reported
transient and permanent neurological deficits.20 However, lum-
bar nerve root injury, cauda equina injury, dural tear, and post-
operative epidural fibrosis may occur with excessive neural
retraction during PLIF.20 The transforaminal lumbar interbody
fusion (TLIF) is an alternative to PLIF that reduces some of the
spinal canal trauma from PLIF with good early outcomes and
low neurological injury.24 By accessing the intervertebral space
through a unilateral neuroforamen, there is less manipulation
of the neural elements, avoidance of excessive soft-tissue dissec-
tion and potentially less epidural scaring, and preservation of
ligamentous structures and spinal stability. Anterior lumbar
interbody fusion offers the most direct and complete exposure
of the intervertebral disc space, offers a large surface area for
interbody fusion that potentially matches the entire vertebral
end-plate, and spares the posterior spinal soft tissue. ALIF com-
plications are associated with the necessary anterior (retroperi-
toneal or transperitoneal) surgical approach. Lumbar disc
arthroplasty, which offers a potential for maintaining some
lumbar spine motion, may be a safe and effective alternative to
lumbar interbody fusion; however, only early clinical outcomes
are available.31 Minimally invasive techniques for lumbar inter-
body fusion are being utilized more commonly and require
detailed knowledge of spinal anatomy and good surgical tech-
nique to prevent neurological injury; however, early results
appear similar to open technqiues.12
Spinal deformity surgery has many potential surgical com-
plications that occur more frequently in adults than adoles-
cents. The risk of neurological injury during spinal deformity
surgery is less than 1% to 5%.5--7 Surgical complications, includ-
ing neurological injury, may be higher in cases with congenital
anomaly, skeletal dysplasia, inflammatory arthropathy, postin-
fection, postirradiation, or posttraumatic deformity. Adolescent
idiopathic scoliosis surgery has relatively low risk of permanent
neurological deficits, but may be complicated with large, rigid
curves with rotational deformity. Surgical correction may be
obtained with anterior, posterior, or combined spine surgery
dictated by patient and curve factors and desired amount of
correction.5 Combined anterior and posterior surgery, rigid
curves, and hyperkyphosis increase the risk of intraoperative
neurological deficits.6 Spinal osteotomy for deformity correc-
tion has an inherent risk of neurological injury influenced by
the type, level, and number of osteotomies.5,7,9 Lumbar osteot-
omy is preferentially performed below the level of the conus
medullaris to eliminate the risk of direct injury to the spinal
cord. Wide decompression, central canal enlargement, and
debris removal are important to prevent postoperative cauda
equina syndrome or radiculopathy with closure of the osteot-
omy site.7 Prior laminectomy or fusion may create scar tissue
adherence to the dural sac that needs debridement to prevent
compression of nerve roots with osteotomy closure, but osteot-
omy through a prior fusion mass or laminectomy may be per-
formed safely.7 SmithPetersen osteotomy and pedicle subtrac-
tion osteotomy may both be complicated by neurological
deficits, often transient in nature.10 Recently, Buchowski et al9
reported an 11% incidence of neurological deficit after pedicle
subtraction osteotomy attributed to a combination of sublux-
ation, residual dorsal impingement, and dural buckling. Visual
field defects and vision loss from ischemic optic neuropathy,
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 1588 Section XIV Complications
retinal artery occlusion, or cerebral ischemia may occur with
prolonged prone position, large blood loss, and periods of
intraoperative hypotension that may occur during difficult
adult spinal deformity surgery.26 Spinal cord ischemia and
delayed postoperative paraplegia have been reported after
adult spinal deformity and attributed to atherosclerosis, post-
operative hypovolemia, and spinal artery compression after
coronal and sagittal plane correction.29
The risk of neurological injury with pedicle screw insertion
in the thoracic and lumbar spine is influenced by anatomical
differences between the thoracic and lumbar spine. The upper
and midthoracic regions of the spine have smaller pedicle
dimension, smaller spinal canal area, and closer proximity of
the spinal cord to the medial pedicle wall than the lumbar
spine. A thicker medial pedicle wall and a 0 to 4 mm safe zone
medial to the medial pedicle wall composed of epidural and
subarachnoid space may help protect against neurological
injury with incorrect pedicle screw insertion.21 Recent studies
have reported the safe use of pedicle screws for various indica-
tions within the lumbar and thoracic spine with a low incidence
of permanent neurological deficits.8,22,27 Pedicle screw instru-
mentation has been shown to be anatomically feasible and rela-
tively safe for treatment of adolescent idiopathic scoliosis
despite concerns of variable pedicle morphology and rota-
tion.8,22,27 The spinal cord shifts toward the concave side at the
scoliotic curve apex and may be at risk with a medial pedicle
wall breach.22,28 Intraspinal instrumentation such as sublaminar
wires or laminar hooks may cause direct injury to the spinal
cord or dura during insertion or by indirect spinal cord com-
pression by their space occupying nature or epidural hema-
toma formation.
NEUROMONITORING
Intraoperative assessment and spinal cord monitoring are
important aspects of spine surgery and will be discussed briefly
in this chapter. Please see the corresponding chapter on neu-
romonitoring for a full discussion of this topic. The Stagnara
wake-up test was the first widely used intraoperative monitor-
ing test and remains a sensitive diagnostic test.23 It remains the
gold standard in detection of gross motor deficits, but it does
not offer direct information on the spinal cord sensory tracts,
nerve root function, or peripheral nerves. The wake-up test
does not allow continuous neurological monitoring or offer
insight into the potential cause of a neurological injury. It is
limited by the need for interruption of the surgery to arouse
the patient, patient compliance with verbal commands, and
potential for patient recall of the intraoperative exercise.
Spinal cord monitoring has evolved considerably since the
inception of the wake-up test. The purpose of intraoperative
neurophysiological monitoring is to provide information about
neural function before the development of irreversible neuro-
logical injury and to allow time for intervention to diminish or
prevent postoperative neurological deficits. Modern intraoper-
ative neurophysiologic monitoring uses a combination of
modalities to evaluate the global function of the nervous system
during a surgical procedure. Somatosensory-evoked potentials
(SSEP) were the first to be developed and are used widely in
cervical, thoracic, and lumbar spine surgery.11 SSEPs provide
direct data (signal amplitude and latency) on the posterior col-
umn ascending sensory tracts and offer indirect information
on the function of ventral motor tracts. SSEPs offer no data on
LWBK836_Ch148_p1584-1590.indd 1588
individual nerve roots. A significant intraoperative signal
change occurs if signal latency changes more than 10% or
amplitude decreases more than 50% from baseline values.23 A
signal amplitude change is more relevant as spinal cord injury
without amplitude change is unlikely. Inaccurate SSEP data
may occur with the use of halogenated anesthetic agents,
nitrous oxide, hypothermia, hypotension, and extraneous elec-
trical stimulation. SSEPs may be unreliable in patients with
severe myelopathy, spinal cord tumors, obesity, or peripheral
neuropathy.
Motor function can be assessed by tcMEPs.11 MEPs may be
elicited directly from the spinal cord (D- and I-waves) or from
muscle (compound muscle action potentials (CMAPs).11 Motor
tract monitoring is easier with CMAPs that use skin electrodes
or submuscular needles to record specific muscle action. A
10% change in signal latency or 80% change in signal ampli-
tude of CMAPs are significant changes.23 tcMEP uses an electri-
cal pulse to stimulate a part of the premotor and motor cortex
with the resulting stimulus impulse traveling through brain
into the corticospinal tracts stimulating motor neurons and
ultimately innervating a peripheral muscle. tcMEPs directly
evaluate the function of the corticospinal motor tracts, nerve
roots, peripheral nerves, and nerve plexuses. tcMEPs have been
reported to be sensitive to impending spinal cord injury due to
insufficient spinal cord perfusion.
Electromyography (EMG) allows analysis of individual nerve
roots.11 Spontaneous (free running) mechanically elicited EMG
is useful during the dynamic phase of surgery (implant place-
ment, nerve root manipulation) and can be used to map a
nerve root. Stimulus-evoked (triggered) EMG is useful during
the static phase of surgery to test individual pedicle screws for
potential medial cortical breach and impingement on the spi-
nal cord or nerve root. A cortical breach creates an area of low
resistance to electrical current flow allowing the stimulus cur-
rent to take the path of least resistance through the breach into
the nerve root. This allows the nerve root to depolarize at a
much lower current (<7 mA) compared to an intact pedicle (10
to 12 mA) and contract its innervated peripheral muscle.
Pedicle stimulation has been extensively applied to the cervical,
thoracic, and lumbar spine regions.11 Chronic compression of
a nerve root elevates its threshold for eliciting an action poten-
tial and may cause false negative EMG results despite ongoing
injury of that nerve root.18
Overall, a significant intraoperative neurophysiological alert
occurs if SSEP amplitude decreases by 50%, or tcMEP ampli-
tude decreases by 75% from baseline. tcMEP amplitude loss in
the presence of a stable SSEP is not uncommon, but SSEP
amplitude loss in the presence of a stable tcMEP occurs rarely.
Isolated latency changes are most likely unrelated to a surgical
insult. If a significant intraoperative neurophysiological
alert does occur, the spine surgeon should have a systematic
approach to assess for potential causes of neurological injury
(Table 148.3).
POSTOPERATIVE NEUROLOGICAL
COMPLICATIONS
There are numerous potential causes of neurological compro-
mise in the postoperative period. Specific causes of a neuro-
logical deficit may present in an immediate or delayed fashion,
which may help elicit the cause of the deficit and guide
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 Chapter 148 Neurological Complications 1589

Systematic Approach to Assess for Potential Causes

TABLE 148.3
of Neurological Injury
1. Rule out technical error (check neuromonitoring leads)
2. Rule out anesthesia related factors (no inhalational agents, no muscle relaxants or paralytic agents)
3. Assess hypotension (increase blood pressure/MAP >90 mmHg)
4. Increase concentration of inspired oxygen
5. Assess ABG, hemoglobin, metabolic abnormalities
6. Inspect entire spinal instrumentation (modify or remove instrumentation, distraction forces, irrigate
wound with warm saline, perform decompression/laminectomy)
7. Perform wake-up test if still no improvement
8. If no improvement, consider removal of instrumentation, use of corticosteroids, and emergent
radiographic assessment (CT myelogram, MRI)
ABG, arterial blood gas; MAP, mean arterial pressure.

treatment. Neurological deficits recognized in the immediate
postoperative period often require prompt surgical explora-
tion for decompression and potential removal of instrumenta-
tion. Also, progressive neurological deficits often require
urgent surgical intervention to stop the progression of the neu-
rological injury. Delayed or nonprogressive neurological inju-
ries may be evaluated with MRI or CT myelograms to help
pinpoint a specific cause for the neurological injury that needs
to be addressed at surgery. The majority of neurological deficits
recognized postoperatively are transient with resolution of
symptoms.
Epidural hematoma leading to neurological compromise
may present acutely or in a delayed fashion. Potential causes
include inadequate hemostasis, unrecognized vascular injury
with spine instrumentation, or poor postoperative wound drain-
age. MRI will show the extent of the epidural hematoma.
Surgical decompression is often needed and guided by the
degree and progression of the neurological deficit. Retained
osteophytes, bone fragments, or nucleated disc may occur with
inadequate spine decompression and lead to acute or delayed
postoperative neurological deficits. These may occur from
inadequate surgical exposure and poor visualization during
minimally invasive surgery. Persistent neurological symptoms
from wrong level surgery may occur with limited exposure sur-
gery or microsurgical techniques if the surgical level is not con-
firmed. Spinal instability after excessive bone resection may
cause instability and delayed neurological compromise. Despite
decompression, radiculopathy may persist if unrecognized
extraforaminal disc herniation is present. Epidural scarring
and fibrosis may develop with excessive nerve root manipula-
tion and epidural bleeding leading to delayed neurological
symptoms or a battered-root syndrome. Revision surgery may
also lead to epidural scarring due to the compromised surgical
site. Recurrent disc herniations may occur days to years after
spine decompression leading to neurological symptoms.
Delayed neurological deficits may occur with spinal instrumen-
tation malposition or injury during insertion as previously
described. Postoperative radiographs or advanced imaging
such as CT scans may help evaluate if instrumentation error is
the cause of a postoperative neurological deficit. Spinal instru-
mentation and fusion increase the stresses at levels above or
below the fusion.17 This adjacent level degeneration may lead
to subluxation, instability, and disc herniation leading to new
neurological symptoms. Furthermore, spine fracture at the
upper instrumented vertebra may occur due to increased
stresses potentially causing neurological injury through bone
fragment retropulsion or increased spine instability. Dural tears
may occur during spine instrumentation, decompression, or
fusion. Unrecognized or inadequately repaired dural tears may
lead to the formation a pseudomeningocele and entrapment of
the spinal cord or nerve roots. Ischemic injury of the spinal
cord and delayed neurological deficits may occur with anterior
vascular injury by direct injury with spinal instrumentation or
stretch after deformity correction. Radiculitis or radiculopathy
may occur with the use of anterior interbody fusion (ALIF,
TLIF, PLIF) and may present as an acute or delayed neurologi-
cal injury. Nerve root injury or irritation may occur during
placement by direct nerve root manipulation, by overstretching
the nerve, or by cage migration and nerve root impingement.
Structural bone graft misplacement, collapse, or extrusion may
occur, leading to a postoperative neurological injury in an acute
or delayed fashion. Postoperative spinal infections may cause
delayed neurological deficits through vertebral body collapse,
instability, bleeding, or epidural abscess formation that com-
press the spinal cord or nerve roots.
REFERENCES
1. Abumi K, Kaneda K. Pedicle screw fixation for nontraumatic lesions of the cervical spine.
Spine 1997;22(16):1853--1863.
2. Abumi K, Shono Y, Ito M, Taneichi H, Kotani Y, Kaneda K. Complications of pedicle screw
fixation in reconstructive surgery of the cervical spine. Spine 2000;25(8):962--969.
3. Abumi K, Takada T, Shono Y, Kaneda K, Fujiya M. Posterior occipitocervical reconstruction
using cervical pedicle screws and plate-rod systems. Spine 1999;24(14):1425--1434.
4. Apfelbaum RI, Kriskovich MD, Haller JR. On the incidence, cause, and prevention of
recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine
2000;25(22):2906--2912.
5. Bradford DS, Tay BK, Hu SS. Adult scoliosis: surgical indications, operative management,
complications, and outcomes. Spine 1999;24(24):2617--2629.
6. Bridwell KH, Lenke LG, Baldus C, Blanke K. Major intraoperative neurologic deficits in
pediatric and adult spinal deformity patients. Incidence and etiology at one institution.
Spine 1998;23(3):324--331.
7. Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K. Pedicle subtraction osteotomy for
the treatment of fixed sagittal imbalance. J Bone Joint Surg Am 2003;85(3):454--463.
8. Brown CA, Lenke LG, Bridwell KH, Geideman WM, Hasan SA, Blanke K. Complications of
pediatric thoracolumbar and lumbar pedicle screws. Spine 1998;23(14):1566--1571.
9. Buchowski JM, Bridwell KH, Lenke LG, et al. Neurologic complications of lumbar pedicle
subtraction osteotomy: a 10-year assessment. Spine 2007;32(20):2245--2252.
10. Cho KJ, Bridwell KH, Lenke LG, Berra A, Baldus C. Comparison of Smith-Petersen versus
pedicle subtraction osteotomy for the correction of fixed sagittal imbalance. Spine
2005;30(18):2030--2037.
11. Devlin VJ, Schwartz DM. Intraoperative neurophysiologic monitoring during spinal sur-
gery. J Am Acad Orthop Surg 2007;15(9):549--560.
12. Eck JC, Hodges S, Humphreys SC. Minimally invasive lumbar spinal fusion. J Am Acad
Orthop Surg 2007;15(6):321--329.

LWBK836_Ch148_p1584-1590.indd 1589 8/26/11 2:19:49 PM

 1590 Section XIV Complications
13. Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthr-
odesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-
up. J Bone Joint Surg Am 1998;80(7):941--951.
14. Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L. The surgical and medical peri-
operative complications of anterior spinal fusion surgery in the thoracic and lumbar spine
in adults. A review of 1223 procedures. Spine 1995;20(14):1592--1599.
15. Graham JJ. Complications of cervical spine surgery. A five-year report on a survey of the
membership of the Cervical Spine Research Society by the Morbidity and Mortality Com-
mittee. Spine 1989;14(10):1046--1050.
16. Groth AT, Kuklo TR, Klemme WR, Polly DW, Schroeder TM. Comparison of sagittal con-
tour and posterior disc height following interbody fusion: threaded cylindrical cages versus
structural allograft versus vertical cages. J Spinal Disord Tech 2005;18(4):332--336.
17. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myel-
opathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone
Joint Surg Am 1999;81(4):519--528.
18. Holland NR, Lukaczyk TA, Riley LH III, Kostuik JP. Higher electrical stimulus intensities
are required to activate chronically compressed nerve roots. Implications for intraopera-
tive electromyographic pedicle screw testing. Spine 1998;23(2):224--227.
19. Iwasaki M, Okuda S, Miyauchi A, et al. Surgical strategy for cervical myelopathy due to
ossification of the posterior longitudinal ligament: Part 2: Advantages of anterior decom-
pression and fusion over laminoplasty. Spine 2007;32(6):654--660.
20. Kim KT, Lee SH, Lee YH, Bae SC, Suk KS. Clinical outcomes of 3 fusion methods through
the posterior approach in the lumbar spine. Spine 2006;31(12):1351--1357; discussion 8.
21. Kothe R, OHolleran JD, Liu W, Panjabi MM. Internal architecture of the thoracic pedicle.
An anatomic study. Spine 1996;21(3):264--270.
LWBK836_Ch148_p1584-1590.indd 1590
22. OBrien MF, Lenke LG, Mardjetko S, et al. Pedicle morphology in thoracic adolescent
idiopathic scoliosis: is pedicle fixation an anatomically viable technique? Spine
2000;25(18):2285--2293.
23. Owen JH. The application of intraoperative monitoring during surgery for spinal defor-
mity. Spine 1999;24(24):2649--2662.
24. Potter BK, Freedman BA, Verwiebe EG, Hall JM, Polly DW Jr, Kuklo TR. Transforaminal
lumbar interbody fusion: clinical and radiographic results and complications in 100 con-
secutive patients. J Spinal Disord Tech 2005;18(4):337--346.
25. Sakaura H, Hosono N, Mukai Y, Ishii T, Yoshikawa H. C5 palsy after decompression surgery
for cervical myelopathy: review of the literature. Spine 2003;28(21):2447--2451.
26. Stambough JL, Dolan D, Werner R, Godfrey E. Ophthalmologic complications associ-
ated with prone positioning in spine surgery. J Am Acad Orthop Surg 2007;15(3):
156--165.
27. Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER. Thoracic pedicle screw fixation in spinal
deformities: are they really safe? Spine 2001;26(18):2049--2057.
28. Suk SI, Lee CK, Kim WJ, Chung YJ, Park YB. Segmental pedicle screw fixation in the treat-
ment of thoracic idiopathic scoliosis. Spine 1995;20(12):1399--1405.
29. Taylor BA, Webb PJ, Hetreed M, Mulukutla RD, Farrell J. Delayed postoperative paraplegia
with hypotension in adult revision scoliosis surgery. Spine 1994;19(4):470--474.
30. Tiusanen H, Seitsalo S, Osterman K, Soini J. Retrograde ejaculation after anterior inter-
body lumbar fusion. Eur Spine J 1995;4(6):339--342.
31. Zigler J, Delamarter R, Spivak JM, et al. Results of the prospective, randomized, multi-
center Food and Drug Administration investigational device exemption study of the
ProDisc-L total disc replacement versus circumferential fusion for the treatment of 1-level
degenerative disc disease. Spine 2007;32(11):1155--1162.
8/26/11 2:19:49 PM