Surgical seroma formation following posterior cervical laminectomy and fusion without rhBMP-2

Abstract

Posterior cervical laminectomy and fusion has become a common treatment option for patients with progressive upper-and lower-extremity weakness and MRI evidence of multilevel cervical spondylosis and cord compression. 7,9,11,17 Several agents, including DBM and BMP, have traditionally been used to promote bony fusion in patients at risk for pseudarthrosis. However, there have been several reports demonstrating an association between sterile postsurgical seroma formation and the use of rhBMP-2. 1,3,4,[12][13][14] Traditionally it is believed that these sterile seromas form as a result of trauma-induced inflammatory mediators that cause increased tissue capillary permeability in excess of local lymphatic drainage capacity. Surgical drainage of the fluid collection is often required, particularly in cases of neurological deterioration, and early detection is critical to prevent sequelae from cord compression. Here we describe the first known report of a patient who developed an epidural fluid collection following multilevel laminectomy and fusion with DBM alone. To our knowledge, this is the first case of seroma formation following multilevel laminectomy and fusion that has not been attributed to the use of rhBMP-2. Case ReportHistory. The patient was a 78-year-old female who initially presented with progressive upper-and lowerextremity weakness and severe axial neck pain. Magnetic resonance imaging demonstrated multilevel spondylosis and compression of the cervical spinal cord with associated T2 signal change. Flexion-extension plain radiographs demonstrated instability with anterior subluxation of C-4 on C-5 in flexion, with associated neck pain ( Department of Neurological Surgery, University of California, Los Angeles, CaliforniaSeroma formation following posterior cervical laminectomy and fusion is now recognized as a rare but significant risk. Previous reports have attributed the development of postoperative seromas to the use of recombinant bone morphogenetic protein-2 (rhBMP-2). Here the authors present the case of a 78-year-old female with a history of osteoporosis who developed delayed postoperative neck and shoulder pain following posterior cervical laminectomy and fusion utilizing only autograft bone and demineralized bone matrix (DBM) allograft. Postoperative MRI demonstrated normal hardware placement and a large epidural fluid collection that extended from C-4 to C-6. The patient underwent decompression and drainage of her sterile postoperative seroma. To the authors' knowledge, no case of seroma formation with the use of DBM has been previously reported. This case suggests that although rhBMP-2 is involved in the majority of postoperative seroma developments, other osteoinductive agents such as DBM can contribute to the development of a symptomatic seroma. This report presents an illustrative case study and reviews the current understanding of the development of and treatment for cervical seroma following posterior cervical laminectomy and fusion.

Postoperative Cerebrospinal Fluid Leak Rates with Subfascial Epidural Drain Placement after Intentional Durotomy in Spine Surgery

“…The seroma or hematoma could be symptomatic because of its compression on the neural structures. 11,12 Complications associated with closed suction wound drains have been previously described. 18,19 These complications include infection, hematoma formation, and additional neurologic deficit.…”

Letter to the Editor: Sagittal plane analysis

“…In other words, the application of intra-articular spacers seemed to be relatively reasonable in the craniocervical junction, 9 it was quite questionable in the cervical spine, 8 and it is entirely unacceptable in the lumbar spine, 10 where lordosis is the "apple of the eye" with respect to local biomechanics. As a surgical and scientific community open to innovation we should acknowledge that there may be a role for the technique of intra-articular distraction in spine surgery, but certainly not for all pathologies and at all segments of the spine.…”

“…1,[8][9][10][11] The simulation and results are presented in Figs. Such a model simulates the orientation of the facets, disc, ligaments, and other spinal elements in an anatomically correct manner.…”

“…The authors are to be congratulated for bringing attention to this issue. Both of our patients had surgical drains placed, with use of the drains subsequently discontinued after diminished output, as reported by Yew et al 8 The first patient was a 37-year-old woman with pseudarthrosis following prior C3-T1 anterior fusion who underwent posterior C3-T1 instrumentation and fusion with allograft without rhBMP-2; she presented with persistent neck and scapular pain 2 weeks after surgery and was found to have a surgical seroma. Adverse effects have been reported with its use for anterior cervical fusion, 2 including swelling, dysphagia, and hematoma and seroma formation.…”

Letter to the Editor: Intraarticular spacers

“…I asked Vijay K. Goel, Ph.D. (Co-Director, Engineering Center for Orthopaedic Research Excellence, University of Toledo, Toledo, Ohio) to provide the analysis using his experimentally validated finite element model of the spine. 1,[8][9][10][11] The simulation and results are presented in Figs. 1 and 2.…”