Musculoskeletal / Orthopedics

Spotting trouble after spinal surgery

JOEL HART, AGE 58, is admitted to the surgical unit after a right anterior cervical discectomy and fusion (ACDF) at the cervical 6-7 level. His admission blood pressure (BP) is 139/78 mm Hg; heart rate, 89 beats/minute (bpm); respiratory rate, 22 breaths/minute; and oxygen saturation, 98% on room air.

The patient states his pain level is a 3 on a 0-to-10 scale. Reviewing his chart, you see he received
hydromorphone 2 mg in the postanesthesia care unit (PACU). A dry Telfa dressing overlaid with a
Tegaderm dressing covers a 3-cm incision on the right side of his neck. He complains of numbness
and tingling of his right hand, but reports these sensations were present preoperatively. He is able to
lift both arms off the bed against resistance. His handgrips are strong and equal bilaterally.

Assessment hints

Four hours after admission, Mr. Hart complains of difficulty swallowing and appears to be short of air (SOA). You note slight swelling on the right side of his neck in the incision area, but find his handgrips still strong bilaterally. You quickly obtain new vital signs: BP 150/82
mm Hg, heart rate 120 bpm, respiratory rate 40 breaths/minute, and oxygen saturation 94%.

Based on the neck swelling, dysphagia, and SOA, you suspect he has a postoperative hematoma. Aware
that a hematoma can expand rapidly and press against the trachea to compromise the airway, you activate the rapid response team (RRT). Then you ask the charge nurse to page the patient’s neurosurgeon STAT.

On the scene

When Kim, the RRT nurse arrives, she elevates the head of Mr. Hart’s bed to 90 degrees, applies a face
mask, and sets the oxygen flow rate at 10 L/minute. On neurologic assessment, she finds his right handgrip is only half as strong as his left. Although he remains awake and anxious, his respiratory rate has deteriorated to a shallow 48 breaths/minute. When the neurosurgeon arrives, he notes the patient’s neck swelling and respiratory distress and instructs Kim to call the operating room (OR) to tell them Mr. Hart is returning for emergency wound exploration.

Outcome

In the OR, the surgical team reopens Mr. Hart’s incision, removes the hematoma, and places a Hemovac
drain. In the PACU, he is awake and oriented, with an oxygen saturation of 98% on 2 L oxygen by
nasal cannula and a respiratory rate of 16 breaths/minute with no respiratory distress. His handgrips
are strong and equal, and he is able to lift both arms off the bed against resistance.
Mr. Hart is transferred from the PACU to the surgical unit. The next morning, his Hemovac drain is
removed; that afternoon, he is discharged.


Education and follow-up

A rare complication of ACDF, a hematoma can lead to respiratory compromise, tracheal deviation, and airway loss if not recognized and treated immediately. Difficulty swallowing can be an early sign. If it progresses to SOA, it means the hematoma is expanding against the trachea; immediate steps must be taken to remove the hematoma or secure the airway with an endotracheal tube. Usually, neck swelling on the incision side occurs, but may be a late sign. In patients who’ve undergone an ACDF, consider dysphagia and SOA an emergency. At discharge, teach patients and families that the patient may have difficulty swallowing due to the swelling, so the diet should be resumed with liquids and progressed slowly. Stress the importance of promptly reporting difficulty breathing.

Selected references

Fountas KN, Kapsalaki EZ, Nicolakakos LG, et al. Anterior cervical
discectomy and fusion associated complications. Spine. 2007;32(21):
2310-2317.

Fowler SB, Anthony-Phillips P, Mehta D, Liebmar K. Health-related
quality of life in patients undergoing anterior cervical discectomy and
fusion. J Neurosci Nurs. 2005; 37(2):97-100.

Laura McIlvoy is an associate professor at Indiana University Southeast in New
Albany, Indiana.

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