Postoperative Stroke after Anterior Cervical Discectomy and Fusion in Patients with Carotid Artery Stenosis: A Statewide Database Analysis

Publication date: Available online 21 September 2018

Source: The Spine Journal

Author(s): Morad Chughtai, Assem A. Sultan, Jorge Padilla, George A. Beyer, Jared M. Newman, Iyooh U. Davidson, Haariss Ilyas, Inyang Udo-Inyang, Ryan J. Berger, Linsen T. Samuel, Ganesh M. Shankar, Carl B. Paulino, Dominic Pelle, Jason W. Savage, Michael P. Steinmetz, Thomas E. Mroz

Abstract

Background

Carotid artery injury and stroke secondary to prolonged retraction remains an extremely rare complication in anterior cervical discectomy and fusion (ACDF). However, multiple studies have demonstrated that carotid artery retraction during the surgical approach may alter the normal blood flow, leading to a significant reduction in the cross-sectional area of the vessel. Others have suggested that dislodgment of atherosclerotic plaques following manipulation of the carotid artery can be a potential risk for intracranial embolus and stroke.

Purpose

We aimed to evaluate: 1) the incidence of postoperative stroke following ACDF and 2) incidence of other postoperative complications in a cohort of patients who had a diagnosis of carotid artery stenosis (CAS) versus those who did not.

Patient Sample

This study utilized the Statewide Planning and Research Cooperative System (SPARCS) database from January 1, 2009 to December 31, 2013. All patients who underwent (ACDF) and had a pre-operative diagnosis of CAS were identified using the International Classification of Disease, 9th revision (ICD-9) codes. Those who had a previous history of stroke were excluded. Patients who had CAS were propensity score matched to patients without history of CAS for demographics and Charlson/Deyo comorbidity scores.

Outcome Measures

Incidence of postoperative stroke and other complications were compared between the cohorts. The threshold for statistical significance was set at a p<0.05. This study received no funding. The authors report no conflict of interests relevant to this study.

Results

There were 34,975 patients who underwent an ACDF in the study time period. After excluding those under the age of 18 and with history of previous stroke, there were 61 patients who had CAS that were compared to a propensity-matched cohort. The CAS cohort had a significantly higher incidence of postoperative stroke during their hospitalization (6.6% vs 0%, P<0.042). The CAS cohort also had higher rates of acute renal failure (27.9% vs 4.9%, p=0.01) and sepsis (18% vs 4.9%, p=0.023). There were no stroke related deaths.

Conclusion

Patients with CAS who underwent ACDF had a statistically significant greater incidence of developing a postoperative stroke. To the best of our knowledge, no previous study has evaluated the development of postoperative stroke in patients with CAS undergoing ACDF. Larger, multi-center studies are needed to estimate the true incidence of stroke in this specific patient population. However, our results may illustrate the importance of pre-operative optimization, approach-selection, and postoperative stroke surveillance in patients with a history of CAS who undergo ACDF.

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