Introduction
Materials and methods
Data collection
Clinicopathological and surgical data
Nerve root damage |
Spinal cord damage |
Cauda equina damage |
Dural tear |
Cerebrospinal fluid (CSF) leakage |
Wrong level |
Implant failure |
Implant dislodgment |
Vascular injury |
Deep wound infection |
Epidural hematoma |
Pulmonary embolism/thromboembolism |
Mental disorder |
Hemothorax/pneumothorax |
Circulatory disease |
Cerebral disease |
Digestive disease/liver disease |
Anesthesiological |
Respiratory disease |
Urinary disease |
Death |
Others |
Statistical analysis
Results
Basic information
Age
Experience of the surgeons
Preoperative complications
Disease information
Category | Subcategory | No. of cases incidence (%) | ||
---|---|---|---|---|
2011 | 2001 | 1994 | ||
Degenerative disease | Disc herniation | 7,964 (23.0) | 4,385 (27.1) | – (38.5) |
Spondylolysis, isthmic spondylolisthesis | 556 (1.6) | 371 (2.3) | – (3.7) | |
Degenerative spondylolisthesis | 3,214 (9.3) | 1,423 (8.8) | – (6.4) | |
Stenosis | 14,001 (40.5) | 5,021 (31.1) | – (24.5) | |
Ossification of ligaments | 1,434 (4.2) | 857 (5.3) | – (5.6) | |
Others | 388 (1.1) | 580 (3.6) | – | |
Tumor | Primary benign spinal tumor | 674 (1.9) | 147 (0.9) | – (0.8) |
Primary malignant spinal tumor | 82 (0.2) | |||
Metastatic spinal tumor | 389 (1.1) | 320 (2.0) | – (2.1) | |
Intramedullary tumor | 75 (0.2) | 61 (0.4) | – (3.1) | |
Intradural extramedullary tumor | 471 (1.3) | 323 (2.0) | ||
Extradural tumor | 240 (0.7) | 117 (0.7) | ||
Cauda equina tumor | – | 83 (0.5) | ||
Trauma | 1,014 (2.9) | 905 (5.6) | – (4.8) | |
Osteoporotic vertebral collapse | 813 (2.3) | 186 (1.2) | – | |
Inflammation | Pyogenic infection | 521 (1.5) | 292 (1.8) | – (1.0) |
Rheumatoid arthritis | 240 (0.7) | 264 (1.6) | – (1.4) | |
Tuberculous infection | 55 (0.2) | 69 (0.4) | – (0.5) | |
Fungal infection | 6 (0.0) | – | – | |
Seronegative arthritis without AS | 5 (0.0) | – | – | |
Ankylosing spondylitis (AS) | 11 (0.0) | – | – | |
Dialysis | 101 (0.3) | – | – | |
Others | 48 (0.2) | 39 (2.4) | – | |
Spinal deformity | Scoliosis | 1,485 (4.3) | 327 (2.0) | – (1.8) |
Kyphosis | 537 (1.6) | 60 (0.3) | – (0.3) | |
Combined | 169 (0.5) | – | – | |
Others | 120 (0.4) | – | – | |
Metabolic bone disease | – | 9 (0.1) | – (0.1) | |
General affection of bone | – | 22 (0.1) | – (0.1) | |
Others | – | 296 (1.9) | – (5.0) |
Degenerative disease
Category | Subcategory | No. of cases incidence (%) | ||
---|---|---|---|---|
2011 | 2001 | 1994 | ||
Cervical spine | Cervical spondylotic myelopathy/radiculopathy | 3,564 (72.0) | 1,800 (55.0) | 1,625 (44.3) |
Cervical disc herniation | 641 (12.9) | 475 (14.5) | 1,046 (28.6) | |
OPLL | 149 (3.0) | 598 (18.3) | 757 (20.7) | |
Other degenerative diseases | 600 (12.1) | 396 (12.1) | 235 (6.4) | |
Lumbar spine | Lumbar disc herniation | 7,086 (33.2) | 3,753 (43.0) | 6,156 (55.2) |
Lumbar spinal stenosis | 11,136 (52.2) | 3,042 (34.9) | 2,953 (26.5) | |
Degenerative spondylolisthesis | 1,999 (9.4) | 1,382 (15.8) | 1,169 (10.5) | |
Spondylolysis, isthmic spondylolisthesis | 270 (1.3) | 359 (4.1) | 687 (6.2) | |
OPLL | 15 (0.1) | 20 (0.2) | 47 (0.4) | |
OLF | 113 (0.5) | |||
OPLL + OLF | 8 (0.0) | |||
Other degenerative diseases | 711 (3.3) | 169 (1.9) | 138 (1.2) |
Surgical approaches
Degenerative disease in cervical spine
Degenerative disease | No. of cases incidence (%) | ||||||||
---|---|---|---|---|---|---|---|---|---|
Anterior | Posterior | Antero/posterior | |||||||
2011 | 2001 | 1994 | 2011 | 2001 | 1994 | 2011 | 2001 | 1994 | |
Cervical spondylotic myelopathy/radiculopathy | 248 (7.1) | 243 (13.6) | – (21) | 3,208 (91.8) | 1528 (85.3) | – (75) | 39 (1.1) | 21 (1.2) | – (4) |
Cervical disc herniation | 297 (47.9) | 358 (75.8) | – (52) | 308 (49.7) | 113 (23.9) | – (44) | 15 (2.4) | 1 (0.2) | – (4) |
Cervical OPLL | 17 (11.6) | 76 (12.8) | – | 130 (88.4) | 510 (85.6) | – | 0 (0.0) | 9 (1.5) | – |
Lumbar disc herniation | 8 (0.1) | 36 (1.0) | – (4) | 6,826 (99.8) | 3579 (98.9) | – (95) | 9 (0.1) | 3 (0.1) | – (1) |
Lumbar spinal stenosis | 5 (0.0) | – | 10,691 (99.7) | – | – | 25 (0.2) | – | – | |
Lumbar degenerative spondylolisthesis | 3 (0.2) | 8 (0.6) | – (13) | 1,949 (99.6) | 1343 (98.7) | – (85) | 4 (0.2) | 9 (0.7) | – (2) |
Lumbar spondylolysis, isthmic spondylolisthesis | 0 (0.0) | 4 (1.2) | 259 (98.9) | 335 (97.4) | 3 (1.1) | 5 (1.5) | |||
Lumbar OPLL | 0 (0.0) | – | 13 (100) | – | 0 (0.0) | – | |||
Lumbar OLF | 0 (0.0) | – | 112 (100) | – | 0 (0.0) | – | |||
Lumbar OPLL + OLF | 0 (0.0) | – | 8 (100) | – | 0 (0.0) | – |
Degenerative disease in lumbar spine
Operation time
Intraoperative blood loss
Surgical procedures
Surgical technology
Surgical technology | No. of cases frequency (%) | |
---|---|---|
2011 | 2001 | |
Conventional | 20,697 (65.0) | – |
Endoscope | 4,110 (12.9) | 387 (2.6) |
Microscope | 6,523 (20.5) | 1,651 (11.1) |
Percutaneus | 501 (1.6) | – |
Spinal instrumentation
Implant | No. of cases frequency (%) | ||
---|---|---|---|
2011 | 2001 | 1994 | |
Interbody fusion with cage (anterior) | 335 (3.5) | 1,452 (26.4) | – |
Interbody fusion with cage (posterior) | 3,686 (38.9) | – | |
Vertebral body replacement by cage | 154 (1.6) | – | |
Plate | 532 (5.6) | – | – |
Cervical anterior plate | 300 (5.5) | – | |
Thoracolumbar anterior plate | 289 (5.3) | – | |
Rod + pedicle screw | 7,496 (79.0) | 3,004 (54.6) | 3,264 (63) |
Plate + pedicle screw | 311 (3.3) | ||
Facet screw | 8 (0.1) | – | |
Transarticular screw | 50 (0.5) | – | |
Rod + lamina hook | 455 (4.8) | 418 (7.6) | 744 (14) |
Rod + pedicle hook | 133 (1.4) | ||
Rod + hook | – | ||
Rod + hook, wire | – | – | |
Rod + lateral mass screw | 372 (3.9) | – | |
Plate + lateral mass screw | 12 (0.1) | – | |
Odontoid screw | 18 (0.2) | – | – |
Wiring | – | 253 (4.6) | 501 (10) |
Others | 1,047 (11.0) | 1,233 (22.4) | 701 (13) |
Disease | No. of cases frequency (%) | ||
---|---|---|---|
2011 | 2001 | 1994 | |
Cervical disc herniation | 197 (30.2) | 450 (10.3) | – (10) |
Lumbar disc herniation | 470 (6.5) | ||
Thoracic OPLL | 22 (48.9) | – | – |
Thoracic OLF | 51 (22.3) | – | – |
Thoracic OPLL + OLF | 13 (59.1) | – | – |
Lumbar spondylolysis, isthmic spondylolisthesis | 428 (77.4) | – | – |
Lumbar degenerative spondylolisthesis | 2,124 (67.9) | – | – |
Lumbar spinal stenosis | 3,594 (30.9) | – | – |
Lumbar OPLL | 19 (51.4) | – | – |
Lumbar OLF | 27 (17.1) | – | – |
Lumbar OPLL + OLF | 13 (59.1) | – | – |
Tumor | |||
Primary benign | 111 (16.5) | 66 (44.9) | – (40) |
Primary malignant | 27 (32.9) | ||
Metastatic | 254 (65.3) | 236 (73.8) | – (81) |
Intramedullary | 1 (1.3) | – | – |
Inflammation | |||
Pyogenic | 99 (19.0) | 68 (23.3) | – (20) |
RA | 181 (75.4) | 224 (84.8) | – (85) |
Tuberculous | 25 (45.5) | 33 (47.8) | – (37) |
Fungal | 1 (16.7) | – | – |
Seronegative arthritisa
| 3 (60.0) | – | – |
AS | 8 (72.7) | – | – |
Dialysis | 53 (52.5) | – | – |
Others | 13 (27.1) | – | – |
Spinal deformity | |||
Scoliosis | 1,100 (74.1) | 289 (88.4) | – (92) |
Kyphosis | 430 (80.1) | 48 (80.0) | – (74) |
Combined | 137 (81.1) | – | – |
Others | 49 (40.8) | – | – |
Complications
Intraoperative and postoperative complications according to diagnosis
Disease | Incidence | ||
---|---|---|---|
Intraoperative and postoperative complications | |||
2011 | 2001 (%) | 1994 (%) | |
Disc herniation | 5.6 % (447/7,964) | 5.0 | 4.2 |
Lumbar spondylolysis and isthmic spondylolysis | 13.1 % (73/556) | 10.0 | 11.5 |
Lumbar degenerative spondylolisthesis | 10.7 % (345/3,214) | 8.9 | 12.2 |
Stenosis | 10.8 % (1513/14,001) | 7.7 | 6.6 |
Ossification of ligament | 15.0 % (215/1,434) | 13.4 | 11.0 |
Tumor | |||
Primary benign | 15.3 % (103/674) | 12.2–12.9 | 22.0 |
Primary malignant | 22.0 % (18/82) | ||
Metastatic | 18.3 % (71/389) | ||
Intramedullary | 29.3 % (22/75) | 6.0–18.0 | 12.3 |
Intradural extramedullary | 16.1 % (76/471) | ||
Epidural | 12.9 % (31/240) | ||
Osteoporotic vertebral collapse | 20.9 % (170/813) | 19.4 | |
Inflammation | |||
Pyogenic | 13.8 % (72/521) | 14.4–15.9 | 13.9 |
RA | 17.9 % (43/240) | 19.3 | |
Tuberculous | 18.2 % (10/55) | 19.2 | |
Fungal | 0.0 % (0/6) | – | |
Seronegative arthritisa
| 60.0 % (3/5) | – | |
AS | 45.5 % (5/11) | – | |
Dialysis | 20.8 % (21/101) | – | |
Others | 8.3 % (4/48) | – | |
Spinal deformity | |||
Scoliosis | 16.5 % (245/1,485) | 15.6–16.7 | 15.7 |
Kyphosis | 25.3 % (136/537) | 31.0 | |
Combined | 20.7 % (35/169) | – | |
Others | 8.3 % (10/120) | – |
Neurological and non-neurological complications in representative diseases
Incidence | ||||||
---|---|---|---|---|---|---|
2011 | 2001 | 1994 | ||||
NC (%) | NNC (%) | NC (%) | NNC (%) | NC (%) | NNC (%) | |
Disc herniation | 0.6 | 4.3 | 1.0 | 4.0 | 0.8 | 2.5 |
Stenosis | 1.1 | 8.1 | 1.8 | 5.9 | 1.1 | 4.2 |
Spondylolisthesis | 1.1 | 8.4 | 0.9 | 8.0 | 1.7 | 7.3 |
Ossification of ligaments | 3.7 | 9.3 | 3.6 | 9.8 | 2.4 | 5.6 |
Spinal deformity | ||||||
Scoliosis | 2.1 | 12.5 | 0.3 | 16.4 | 1.7 | 11.4 |
Kyphosis | 2.8 | 19.2 | 3.3 | 21.7 | ||
Osteoporotic vertebral collapse | 1.0 | 15.9 | 1.1 | 18.3 | – | – |
Relationship between the incidence of complication and the level of spine
Relationship between surgical approach the incidence of complication
Approach | |||
---|---|---|---|
Anterior (%) | Posterior (%) | Combined anterior/posterior (%) | |
2011 | 14.5 | 10.2 | 27.7 |
2001 | 13.9 | 7.9 | 17.0 |
Relationship between surgical approach, the incidence of complication and the level of the spine
Approach | |||
---|---|---|---|
Anterior (%) | Posterior (%) | Combined anterior/posterior (%) | |
Cervical spine | 12.9 | 11.4 | 23.7 |
Thoracic spine | 22.2 | 13.8 | 31.0 |
Lumbar spine | 19.2 | 9.7 | 29.4 |
Details of complications
Complication | 2011 | 2001 | 1994 | |||
---|---|---|---|---|---|---|
No. of cases | Incidence (%) | No. of cases | Incidence (%) | No. of cases | Incidence (%) | |
Dural tear | 661 | 2.1 | 219 | 1.4 | 103 | 0.6 |
CSF leakage | 168 | 0.5 | ||||
Neurological complications | 425 | 1.4 | 279 | 1.7 | 181 | 0.9 |
Deep wound infection | 343 | 1.1 | 153 | 0.9 | 124 | 0.6 |
Epidural hematoma | 288 | 0.9 | – | – | ||
Implant dislodgement | 180 | 0.6 | – | – | – | – |
Mental disorder | 164 | 0.5 | 47 | 0.3 | 50 | 0.3 |
Respiratory disease | 164 | 0.5 | 65 | 0.4 | 27 | 0.1 |
Digestive/liver disease | 127 | 0.4 | 58 | 0.4 | 49 | 0.3 |
Circulatory disease | 99 | 0.3 | – | – | – | – |
Wrong level | 60 | 0.2 | – | – | – | – |
Pulmonary embolism/thromboembolism | 59 | 0.2 | 18 | 0.1 | – | – |
Death | 54 | 0.2 | 13 | 0.08 | – | – |
Cerebral disease | 49 | 0.2 | – | – | – | – |
Implant failure | 9 | 0.03 | 84 | 0.5 | – | – |
Vascular injury | 7 | 0.02 | 8 | 0.05 | – | – |
Dislodgement of grafted bone | – | – | 42 | 0.3 | 34 | 0.2 |
Others | 643 | 2.0 | 315 | 2.0 | – | – |
Details of the neurological complications
No. of cases incidence (%) | ||
---|---|---|
2011 | 1994 | |
Spinal cord damage | 85 (0.3) | 48 (0.2) |
Nerve root damage | 297 (0.9) | 103 (0.5) |
Cauda equina damage | 50 (0.2) | 30 (0.2) |
Incidence of complications according to the experience of the surgeon
Surgeon’s experience (years) | Neurological complication | Dural tear | Deep wound infection | |||
---|---|---|---|---|---|---|
Incidence (%) | No. of cases | Incidence (%) | No. of cases | Incidence (%) | No. of cases | |
<5 | 2.4 | 6 | 2.0 | 5 | 0.4 | 1 |
5–9 | 1.1 | 29 | 2.0 | 54 | 1.1 | 31 |
10–19 | 1.4 | 180 | 2.4 | 313 | 1.0 | 133 |
>20 | 1.4 | 209 | 1.9 | 289 | 1.2 | 177 |
Instrumentation surgery
Incidence of complications | ||
---|---|---|
Instrumentation surgery | Non-instrumentation surgery | |
2011 | 15.6 % (1,480/9,487) | 8.2 % (1,786/21,893) |
2001 | 12.1 % | 6.8 % |
1994 | 15.5 % | 5.9 % |
Experience (years) | 2011 | Experience (years) | 2001 | ||
---|---|---|---|---|---|
Incidence of complication | Incidence of complication | ||||
All surgery | Instrumentation surgery | All surgery (%) | Instrumentation surgery (%) | ||
< 5 | 10.3 % (26/251) | 15.0 % (6/40) | 1–6 | 7.9 | 12.3 |
5–9 | 8.7 % (239/2,754) | 12.5 % (104/831) | 7–9 | 8.0 | 12.3 |
10–19 | 11.8 % (1,561/13,212) | 17.0 % (682/4,005) | 10–14 | 9.1 | 13.2 |
> 20 | 9.5 % (1,440/15,140) | 14.9 % (688/4,606) | >15 | 8.3 | 11.0 |
Spinal cord damage according to diagnosis and the level of the spine
Deep wound infection
Relationship between operation time and deep wound infection, epidural hematoma, pulmonary embolism and/or thromboembolism and death
Operation time (h) | Deep wound infection | Epidural hematoma | Pulmonary embolism and/or thromboembolism | Death |
---|---|---|---|---|
No. of cases incidence (%) | No. of cases incidence (%) | No. of cases incidence (%) | No. of cases incidence (%) | |
< 3 | 175 (0.8) | 172 (0.8) | 17 (0.1) | 24 (0.1) |
3–6 | 135 (1.9) | 99 (1.4) | 34 (0.5) | 25 (0.3) |
> 6 | 27 (2.2) | 17 (1.4) | 7 (0.6) | 5 (0.4) |
Relationship between intraoperative blood loss and deep wound infection, epidural hematoma, pulmonary embolism and/or thromboembolism and death
Intraoperative blood loss | No. of cases incidence (%) | |||
---|---|---|---|---|
Deep wound infection | Epidural hematoma | Pulmonary embolism and/or thromboembolism | Death | |
<200 ml | 162 (0.7) | 154 (0.7) | 19 (0.1) | 21 (0.1) |
200–500 | 101 (1.9) | 68 (1.2) | 22 (0.4) | 18 (0.3) |
500–1000 | 31 (1.9) | 23 (1.1) | 8 (0.4) | 9 (0.4) |
1000–2000 | 21 (1.5) | 18 (2.2) | 7 (0.8) | 4 (0.5) |
>2000 | 12 (3.1) | 12 (3.1) | 2 (0.5) | 2 (0.5) |
Diagnosis and the cause of death
No. of cases | |
---|---|
Metastatic spine tumor | 15 |
Inflammation | |
Pyogenic infection | 6 |
Rheumatoid arthritis | 4 (O-C fusion 3, O-T fusion 1) |
Tuberculous infection | 1 |
Dialysis | 4 |
Trauma | |
Cervical spine | 6 |
Lumbar spine | 1 |
Osteoporotic vertebral collapse | 4 |
Degenerative disease | |
Stenosis | |
Lumbar spine | 3 |
Cervical spine | 2 |
Degenerative spondylolisthesis (lumbar spine) | 1 |
Ossification of ligaments | |
OPLL (cervical spine) | 1 |
OLF (lumbar spine) | 1 |
Primary malignant spine tumor | 2 |
Intramedullary tumor | 1 |
Epidural hematoma | 1 |
Spinal deformity Scoliosis | 1 |
The cause of death | No. of cases |
---|---|
Tumor-associated death | 16 |
Inflammation of the lungs | 5 |
Sepsis | 4 |
DIC | 3 |
Pulmonary embolism | 3 |
Liver failure | 2 |
Cerebral infarction | 1 |
Myocardial infarction | 1 |
Respiratory problem | 1 |
Unknown cause | 18 |
Relationship between the incidence of representative complications and the surgical technology used
Representative complications | No. of cases incidence (%) | |||
---|---|---|---|---|
Conventional (20,697 cases) | Endoscopic (4,110 cases) | Microscopic (6,523 cases) | Percutaneous (501 cases) | |
Spinal cord damage (85 cases: overlapping 3 cases) | 66 (0.3) | 0 (0.0) | 22 (0.3) | 0 (0.0) |
Nerve root damage (297 cases: overlapping 8 cases) | 244 (1.2) | 22 (0.5) | 38 (0.6) | 1 (0.2) |
Cauda equina damage (50 cases: overlapping 2 cases) | 38 (0.2) | 4 (0.1) | 10 (0.2) | 0 (0.0) |
Dural tear (685 cases: overlapping 24 cases) | 486 (2.3) | 100 (2.4) | 98 (1.5) | 1 (0.2) |
Epidural hematoma (288 cases: overlapping 6 cases) | 227 (1.1) | 23 (0.6) | 44 (0.7) | 0 (0.0) |
Deep wound infection (343 cases: overlapping 6 cases) | 299 (1.4) | 2 (0.1) | 42 (0.6) | 6 (1.2) |
Relationship between the incidence of representative complications and the surgical technology used for patients with lumbar disc herniation at the L4/5 level
Representative complications | No. of cases incidence (%) | |||
---|---|---|---|---|
Conventional (1,352 cases) | Endoscopic (1,002 cases) | Microscopic (1,044 cases) | Percutaneus (17 cases) | |
Nerve root damage | 12 (0.9) | 2 (0.2) | 3 (0.3) | 0 (0.0) |
Cauda equina damage | 3 (0.2) | 2 (0.2) | 2 (0.2) | 0 (0.0) |
Dural tear | 37 (2.7) | 23 (2.3) | 25 (2.4) | 0 (0.0) |
Epidural hematoma | 12 (0.9) | 1 (0.1) | 5 (0.5) | 0 (0.0) |
Deep wound infection | 9 (0.7) | 0 (0.0) | 1 (0.1) | 0 (0.0) |
Relationship between the incidence of intraoperative and postoperative complications and BMI
Mean age of patients with intraoperative and postoperative complications
Factors associated with dural tear, DWI, neurological complications and EH
Target variables | Explanatory variables | Odds ratio | 95 % confidence interval |
p
|
---|---|---|---|---|
Dural tear | Lumbar spine | 2.3 | 1.9–2.8 | <0.0001 |
Posterior approach | 1.9 | 1.3–2.7 | <0.01 | |
DWI | Instrument | 2.4 | 1.8–3.1 | <0.0001 |
DM | 2.3 | 1.8–3.0 | <0.0001 | |
DMARD therapy involving biologic therapy | 2.9 | 1.5–5.5 | <0.0001 | |
Neurological complications | Instrument | 1.8 | 1.5–2.2 | <0.0001 |