Incidence of postoperative symptomatic spinal epidural hematoma requiring surgical evacuation: a systematic review and meta-analysis

Abstract

Purpose This systematic review and meta-analysis aimed to determine the incidence of symptomatic spinal epidural hematoma (SSEH) following spine surgery. Methods We systematically searched for all relevant articles that mentioned the incidence of SSEH following the spine surgery published in the PubMed, Embase, and Cochrane Library databases through March 2022 and manually searched the reference lists of included studies. The Newcastle–Ottawa quality assessment scale (NOS) was used to assess the quality of the included studies. A fixed-effects or random-effects model was performed to calculate the pooled incidence of the totality and subgroups based on the heterogeneity. The potential publication bias was assessed by Egger's linear regression and a funnel plot. Sensitivity analysis was also conducted. Results A total of 40 studies were included in our meta-analysis based on our inclusion and exclusion criteria. The overall pooled incidence of SSEH was 0.52% (95% CI 0.004–0.007). In the subgroup analysis, the pooled incidence of SSEH in males and females was 0.86% (95% CI 0.004–0.023) and 0.68% (95% CI 0.003–0.017). Among the different indications, a higher incidence (2.9%, 95% CI 0.006–0.084) was found in patients with deformity than degeneration (1.12%, 95% CI 0.006–0.020) and tumor (0.30%, 95% CI 0.006–0.084). For different surgical sites, the incidences of SSEH in cervical, thoracic and lumbar spine were 0.32% (95% CI 0.002–0.005), 0.84% (95% CI 0.004–0.017) and 0.63% (95% CI 0.004–0.010), respectively. The incidences of SSEH in anterior and posterior approach were 0.24% (95% CI 0.001–0.006) and 0.70% (95% CI 0.004–0.011), respectively. The pooled incidence of SSEH was five times higher with minimally invasive surgery (1.94%, 95% CI 0.009–0.043) than with open surgery (0.42%, 95% CI 0.003–0.006). Delayed onset of SSEH had a lower incidence of 0.16% (95% CI 0.001–0.002) than early onset. There were no significant variations in the incidence of SSEH between patients who received perioperative anticoagulation therapy and those who did not or did not report getting chemopreventive therapy (0.44%, 95% CI 0.006–0.084 versus 0.42%, 95% CI 0.003–0.006). Conclusion We evaluated the overall incidence proportion of SSEH after spine surgery and performed stratified analysis, including sex, surgical indication, site, approach, minimally invasive surgery, and delayed onset of SSEH. Our research would be helpful for patients to be accurately informed of their risk and for spinal surgeons to estimate the probability of SSEH after spine surgery.

Severe Symptomatic Epidural Hematoma Following Percutaneous Endoscopic Unilateral Laminectomy for Bilateral Decompression (Endo‐ULBD)—Series Report and Management Strategies

“…However, when compression lasted for 6 h or more, there was no recovery of neurological function, and progressive necrosis of the spinal cord occurred. Numerous studies have established that rapid evacuation resulted in superior outcomes in neurologic recovery 23,24 …”

“…Numerous studies have established that rapid evacuation resulted in superior outcomes in neurologic recovery. 23,24 Therefore, when an epidural hematoma is identified and symptoms such as sensory and muscle weakness worsen, we propose an early intervention to remove the hematoma. Regarding the surgical approach, the hematoma was initially removed through the quadrant channel for a wide vision and ease of removal.…”

Perspective: Postoperative spinal epidural hematomas (pSEH) should be treated, not ignored

“…[2,6,17] Major predisposing factors for pSEH included; perioperative/postoperative coagulation disorders, multilevel spinal surgery, prior spine surgery, and intraoperative cerebrospinal fluid leaks (CSF) [Tables 1 and 3]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] The times to onset of symptomatic postoperative pSEH following all-level spine surgery ranged from an average of 2.7 postoperative hours, [1] to less than 24, [2] to between 24-48 postoperative hrs. [5] [Tables 1-4].…”

“…[4] The most critical factors to limit/avert permanent neurological sequelae of pSEH included; early recognition of new postoperative neurological deficits, obtaining immediate magnetic resonance imaging (MR) studies, and performing emergency spine surgery where indicated [Tables 1-4]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Incidence of pSEH e incidence of symptomatic postoperative spinal epidural hematomas (pSEH) involving all spinal levels ranged in 7 studies from 0.1% to 1%, [1,2,4,8,9,15,16] in 5 series from <1% to 2.9%, [11,12,15,17,18] and in 3 series between 3%-4.46% (i.e., the 1 of 10 patients with a 10% incidence of pSEH was considered an outlier) [2,6,17] [Tables 1 and 2]. [1][2][3][4][5][6][7][8][9][10]…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Incidence of pSEH e incidence of symptomatic postoperative spinal epidural hematomas (pSEH) involving all spinal levels ranged in 7 studies from 0.1% to 1%, [1,2,4,8,9,15,16] in 5 series from <1% to 2.9%, [11,12,15,17,18] and in 3 series between 3%-4.46% (i.e., the 1 of 10 patients with a 10% incidence of pSEH was considered an outlier) [2,6,17] [Tables 1 and 2]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]…”