Is spinal surgery considered a high-risk procedure?

Spinal Surgery is Considered High Risk

Yes, spinal surgery is considered a high-risk procedure due to potential for significant morbidity, mortality, and impact on quality of life. 1, 2

Risk Factors and Complications

Spinal surgery carries several significant risks:

Neurological Complications

• Permanent neurological damage with potentially life-threatening sequelae 2
• Nerve damage including cauda equina syndrome 3, 4
• Spinal cord injury that can lead to paralysis 1

Hemorrhagic Complications

• Significant blood loss during extensive procedures 1
• Spinal hematoma formation which can cause cord compression 3
• Higher bleeding risk in combined anterior-posterior approaches 1

Infectious Complications

• Deep infection rates of approximately 0.7% 1
• Higher infection risk in patients with risk factors such as:
  • Age >60 years
  • Smoking
  • Diabetes
  • Previous surgical infection
  • Increased body mass index
  • Alcohol abuse 5

Thromboembolic Complications

• Higher VTE risk in spinal surgery compared to other procedures 1
• Particularly elevated risk in:
  • Deformity correction surgery (5.3% VTE risk)
  • Trauma patients (6.0% VTE risk)
  • Degenerative condition surgery (2.3% VTE risk) 6

Vision Loss

• Ischemic optic neuropathy, particularly in extensive spinal procedures 1
• Risk factors include:
  • Male sex
  • Obesity
  • Wilson frame use (abdominal compression)
  • Prolonged procedures
  • Low percentage of colloids in vascular filling solutions 1

Risk Classification Evidence

Multiple guidelines classify spinal surgery as high-risk:

1. Perioperative Management Guidelines: Spinal surgery is explicitly categorized as "high-bleed-risk surgery" with a 30-day risk of major bleeding ≥2% 1

2. Thromboprophylaxis Guidelines: Spinal surgery patients are considered high-risk for VTE, requiring specialized prophylaxis protocols 1

3. Anesthesia Guidelines: Spinal surgery is classified as high-risk requiring special precautions for neuraxial anesthesia 1

Risk Mitigation Strategies

To address these risks:

1. Thromboprophylaxis:

   • Mechanical prophylaxis (preferably IPC) is recommended over no prophylaxis 1
   • For high-risk patients (malignancy, combined anterior-posterior approach), consider adding pharmacologic prophylaxis once hemostasis is established 1

2. Perioperative Anticoagulation Management:

   • For patients on anticoagulation requiring spinal surgery:
     • Wait 48-72 hours after surgery before resuming full-dose anticoagulation 1
     • Consider intermediate or prophylactic doses initially 1

3. Anesthetic Considerations:

   • Careful positioning to reduce intraocular pressure (slight forward tilt preferred over Trendelenburg) 1
   • Avoid hypotension, severe anemia, and hypovolaemia, particularly in at-risk patients 1

4. Infection Prevention:

   • Optimize modifiable risk factors preoperatively
   • Consider extended antibiotic prophylaxis for high-risk patients 5

Conclusion

Spinal surgery carries substantial risks that can significantly impact morbidity, mortality, and quality of life. The classification as "high-risk" is supported by multiple guidelines and evidence of potential serious complications including neurological damage, hemorrhage, infection, thromboembolism, and vision loss. Appropriate risk mitigation strategies should be implemented based on patient-specific factors and procedure type.