Name:
FOCUS25824video6
Description:
FOCUS25824video6
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/a42aeb1b-9ae0-4d99-b77c-0c68bfc08083/videoscrubberimages/Scrubber_0.jpg?sv=2019-02-02&sr=c&sig=mYyDZAjhRFeqJxwSWBfRh6Lt0IkzumXhCqOpgxejQRg%3D&st=2026-05-13T19%3A51%3A48Z&se=2026-05-13T23%3A56%3A48Z&sp=r
Duration:
T00H07M50S
Embed URL:
https://stream.cadmore.media/player/a42aeb1b-9ae0-4d99-b77c-0c68bfc08083
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/a42aeb1b-9ae0-4d99-b77c-0c68bfc08083/6. 25-28.mp4?sv=2019-02-02&sr=c&sig=QpnPy4LwJBDKYhfazmc4idk7jRceHbdY%2FcMZy7mm63o%3D&st=2026-05-13T19%3A51%3A48Z&se=2026-05-13T21%3A56%3A48Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: Here, we present the case
SPEAKER: of a postoperative epidural hematoma in the setting of therapeutic anticoagulation following spinal cord tumor resection. The patient was a 60-year-old man who presented to the clinic with an incidental biopsy-proven C2–3 mass that was initially identified on workup of blood laboratory abnormalities. Of note, he had a history of mechanical valve replacement requiring warfarin maintenance. Here, we can see his preoperative MRI demonstrating a compressive ventral lesion, eccentric to the right.
SPEAKER: The patient underwent CT and MRI angiograms, demonstrating a dominant left vertebral artery, suggesting that the right vertebral artery could be sacrificed during resection. Management of the patient's anticoagulation represented the most important additional challenge. Here, you can see the dominant left vertebral artery on CT angiogram and the osteolytic chordoma. Despite the incidental nature of this lesion, definitive treatment required a high-risk surgery.
SPEAKER: Multiple discussions were had regarding the high likelihood of postoperative complications as well as nonoperative alternatives. Eventually, the patient was planned for a two-stage en bloc resection. Stage 1 involved mandibular splitting exposure and a circumglossal approach for ligation of the right vertebral artery and osteotomies at C2, C3, and C4 to prepare for posterior en bloc removal of the chordoma.
SPEAKER: This was done in collaboration with ENT and executed without incident or initial complication. Two days later, the patient returned for en bloc removal of the chordoma via a posterior approach with occiput–C6 fusion and vertebral body replacement with a C1– 4 expandable cage. Here, we can see the anterior mandibular splitting approach performed with ENT.
SPEAKER: Transitioning to stage 2, we can now see the posterior exposure of the cervical cord. We can now appreciate the mobilization of the unilateral posterior elements with tumor. Tumor is now being resected en bloc without violation of tumor margins.
SPEAKER: And the resection cavity is now clearly visible. The microscope has now been flipped to provide another view of the resection cavity. Finally, we can see the posterior instrumentation and the vertebral body replacement. The patient's postoperative MRI demonstrated gross-total resection of tumor and decompression of the spinal cord.
SPEAKER: Postoperative x-ray demonstrated proper positioning of the cage and posterior instrumentation. The patient awoke from surgery grossly intact. On postoperative day 1, he was started on VTE prophylaxis. On day 4, he was started on low-dose heparin drip. On day 11, he was bridged to warfarin and transferred out of the ICU. However, on day 14, he was transferred back to the ICU for worsening respiratory status and fever.
SPEAKER: Notably, his neurological exam remained stable at this time. MRI on day 15 revealed a circumferential 10-cm multilocular collection causing significant cord compression. Simultaneous CT demonstrated cage migration. Here, you can see the patient's MRI showing the compressive collection, most concerning for hematoma versus infection. And here, you can appreciate the migration of the interbody cage on CT.
SPEAKER: On day 16, anticoagulation was held and hematology was consulted. On day 18, he returned to the OR for evacuation of the collection and revision of instrumentation. Return to OR confirmed the presence of a compressive hematoma. There were no signs of infection, but intraoperative cultures eventually grew vancomycin- resistant enterococcus.
SPEAKER: Hematoma was successfully evacuated, the cage was repositioned, and an additional screw was placed in the remnant of the C4 lateral mass on the right. Postrevision MRI demonstrated successful evacuation of the hematoma. Postoperative x-rays demonstrate a revision of the cage with the superior surface directed against the C1 right lateral mass for additional stability.
SPEAKER: In the first 2 weeks following revision, the patient's neurological exam remained stable, and he progressed appropriately. On day 15, following revision, he failed a FEES and a PEG tube was placed. On day 18, he resumed warfarin and reached therapeutic INR on day 27. On day 29, he was discharged to a long-term care facility with PEG tube and trach.
SPEAKER: His exam at that time was intact, aside from 4/5 strength in his hand intrinsics. In terms of his long- term clinical outcome, by 3 years postop, his bilateral hand strength had improved to 4+/ 5. CT scan at 5 years demonstrated solid fusion. By 9 years, he was noted to be full strength. At that time, he was no longer dependent on the ventilator. He was receiving 60% of his nutrition orally, but still relied on some G-tube supplementation.
SPEAKER: On recent follow-up at 12 years postop, he had no recurrence or progression of his chordoma. Opportunities for improvement center on prevention of cage migration and hematoma formation. The cage may have migrated due to overexpansion or due to insufficient compression on the cage. It is thus essential to ensure that cage expansion is acceptable, but that the cage is not overdistracted.
SPEAKER: Likewise, sufficient compression must be applied to the cage. Halo fixation in the immediate postoperative period may have reduced the risk of cage migration as well. The use of intravenous heparin was likely a contributor to his hematoma. With modern advancements in anticoagulation, the slow rise of therapeutic anticoagulation, particularly with oral anticoagulants, may be less acute than with IV heparin, decreasing the risk of hematoma.
SPEAKER: Maintaining a subset of drains for longer may have also decreased the risk of hematoma. Cage migration itself can lead to bleeding. To prevent instrumentation failure— which represents its own problem— and reduce the risk of associated hematoma formation, surgeons must always ensure proper cage positioning along with appropriate cage expansion, avoiding both under- and overexpansion.
SPEAKER: Oral anticoagulation is likely a safer option than IV heparin in patients at high risk of hematoma. Prolonged drainage in patients at high risk for hematoma should be considered, but must be weighed against the risk of infection. In this case, maintaining a subset of drains for longer may have decreased his risk of hematoma. In highly unstable constructs of the upper cervical spine, halo stabilization is a great option, and certainly one to consider to provide more postoperative stability.
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