Update: Postoperative hemorrhage after anterior cervical discectomy and fusion

Postoperative hemorrhage after anterior cervical discectomy and fusion


Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain

Surgeons need to be alert for this complication and try their best to prevent it 1) 2) 3) 4), because it is one of the most catastrophic complications of anterior cervical discectomy and fusion(ACDF), which may result in dyspnea, respiratory arrest, and death 5) 6) 7) 8) 9) 10).


see also Anterior cervical discectomy and fusion complications.

The reported incidence of this postoperative complication has varied from 0.2% to 1.9% 11).

Fountas et al. reported that postoperative hematoma occurred in 5.6% patients who underwent ACDF, 2.4% of whom required reoperation 12).

However, Aono et al.reported an incidence of 0.21% 13).

Case reports of life-threatening circumstances and critical patients who required tracheotomy and reoperation have also been published 14) 15) 16).


Neck swelling and progressive respiratory disturbance have become important, as proposed in the guidelines by Palumbo et al 17).

The results of the study of Kogure et al. indicated that indwelling drains are not necessary in patients who undergo one-level anterior cervical fixation surgery, and that observation of the prevertebral space (PVS) on simple cervical spine radiographs is the simplest and most useful method to determine any complications 18).

Basques et al. 19) measured the amount of drainage. Only a few reports have mentioned the drainage status, even in case reports of postoperative hematomas. Furthermore, one report documented the absence of drainage 20).

Bleeding point

In the early postoperative period, when bleeding from the superior thyroid artery was excluded, the point of bleeding during the time of reoperation has been unclear in many cases 21).


Application of Floseal at the end, can significantly reduce the amount of postoperative hemorrhage 22) 23).

1) Yeom JS, Buchowski JM, Shen HX, Liu G, Bunmaprasert T, Riew KD. Effect of fibrin sealant on drain output and duration of hospitalization after multilevel anterior cervical fusion: a retrospective matched pair analysis. Spine (Phila Pa 1976) 2008;33:E543–E547.
2) Cho SK, Yi JS, Park MS, et al. Hemostatic techniques reduce hospital stay following multilevel posterior cervical spine surgery. J Bone Joint Surg Am. 2012;94:1952–1958.
3) Tsutsumimoto T, Shimogata M, Ohta H, Yui M, Yoda I, Misawa H. Tranexamic acid reduces perioperative blood loss in cervical laminoplasty: a prospective randomized study. Spine (Phila Pa 1976) 2011;36:1913–1918.
4) Schubert M, Merk S. Retrospective evaluation of efficiency and safety of an anterior percutaneous approach for cervical discectomy. Asian Spine J. 2014;8:412–420.
5) Sagi HC, Beutler W, Carroll E, Connolly PJ. Airway complications associated with surgery on the anterior cervical spine. Spine (Phila Pa 1976) 2002;27:949–953.
6) , 11) , 17) Palumbo MA, Aidlen JP, Daniels AH, Thakur NA, Caiati J. Airway compromise due to wound hematoma following anterior cervical spine surgery. Open Orthop J. 2012;6:108–113.
7) Dagli M, Er U, Simsek S, Bavbek M. Late results of anterior cervical discectomy and fusion with interbody cages. Asian Spine J. 2013;7:34–38.
8) Pallud J, Belaid H, Aldea S. Successfull management of a life threatening cerebellar haemorrhage following spine surgery: a case report. Asian Spine J. 2009;3:32–34.
9) Song KJ, Choi BY. Current concepts of anterior cervical discectomy and fusion: a review of literature. Asian Spine J. 2014;8:531–539.
10) Buerba RA, Giles E, Webb ML, Fu MC, Gvozdyev B, Grauer JN. Increased risk of complications after anterior cervical discectomy and fusion in the elderly: an analysis of 6253 patients in the American College of Surgeons National Surgical Quality Improvement Program database. Spine (Phila Pa 1976) 2014;39:2062–2069.
12) Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, Lee GP, Robinson JS Jr. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976). 2007 Oct 1;32(21):2310-7. Review. PubMed PMID: 17906571.
13) Aono H, Ohwada T, Hosono N, Tobimatsu H, Ariga K, Fuji T, Iwasaki M. Incidence of postoperative symptomatic epidural hematoma in spinal decompression surgery. J Neurosurg Spine. 2011 Aug;15(2):202-5. doi: 10.3171/2011.3.SPINE10716. Epub 2011 May 6. PubMed PMID: 21529204.
14) , 20) Yu NH, Jahng TA, Kim CH, Chung CK: Life-threatening late hemorrhage due to superior thyroid artery dissection after anterior cervical discectomy and fusion. Spine (Phila Pa 1976) 2010; 35: E739―E742.
15) Skovrlj B, Mascitelli JR, Camins MB, Doshi AH, Qureshi SA: Acute respiratory failure from Surgifoam expansion after anterior cervical surgery: case report. J Neurosurg Spine 2013; 19: 428―430.
16) Dedouit F, Grill S, Guilbeau-Frugier C, Savall F, Rougé D, Telmon N: Retropharyngeal hematoma secondary to cer- vical spine surgery: report of one fatal case. J Forensic Sci 2014; 59: 1427―1431.
18) , 21) Kogure K, Node Y, Tamaki T, Yamazaki M, Takumi I, Morita A. Indwelling Drains Are Not Necessary for Patients Undergoing One-level Anterior Cervical Fixation Surgery. J Nippon Med Sch. 2015;82(3):124-9. doi: 10.1272/jnms.82.124. PubMed PMID: 26156665.
19) Basques BA, Bohl DD, Golinvaux NS, Yacob A, Varthi AG, Grauer JN: Factors predictive of increased surgical drain output after anteriorcervical discectomy and fusion. Spine (Phila Pa 1976) 2014; 39: 728―735.
22) Yeom JS, Buchowski JM, Shen HX, Liu G, Bunmaprasert T, Riew KD. Effect of fibrin sealant on drain output and duration of hospitalization after multilevel anterior cervical fusion: a retrospective matched pair analysis. Spine (Phila Pa 1976). 2008 Jul 15;33(16):E543-7. doi: 10.1097/BRS.0b013e31817c6c9b. PubMed PMID: 18628695.
23) Li QY, Lee O, Han HS, Kim GU, Lee CK, Kang SS, Lee MH, Cho HG, Kim HJ, Yeom JS. Efficacy of a Topical Gelatin-Thrombin Matrix Sealant in Reducing Postoperative Drainage Following Anterior Cervical Discectomy and Fusion. Asian Spine J. 2015 Dec;9(6):909-15. doi: 10.4184/asj.2015.9.6.909. Epub 2015 Dec 8. PubMed PMID: 26713124; PubMed Central PMCID: PMC4686397.

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