J Korean Neurosurg Soc.  2020 Jul;63(4):487-494. 10.3340/jkns.2019.0191.

Postoperative Non-Pathological Fever Following Posterior Cervical Fusion Surgery : Is Laminoplasty a Better Preventive Method than Laminectomy?

• Lee S
• Jung SK
• Kim HB
• Roh SW
• Jeon SR
• Park JH

• KMID: 2504643
• DOI: http://doi.org/10.3340/jkns.2019.0191

Abstract

Objective
: To analyze the incidence and characteristics of delayed postoperative fever in posterior cervical fusion using cervical pedicle screws (CPS).
Methods
: This study analyzed 119 patients who underwent posterior cervical fusion surgery using CPS. Delayed fever was defined as no fever for the first 3 postoperative days, followed by an ear temperature ≥38°C on postoperative day 4 and subsequent days. Patient age, sex, diagnosis, laminectomy, surgical level, revision status, body mass index, underlying medical disease, surgical duration, and transfusion status were retrospectively reviewed.
Results
: Of 119 patients, seven were excluded due to surgical site infection, spondylitis, pneumonia, or surgical level that included the thoracic spine. Of the 112 included patients, 28 (25%) were febrile and 84 (75%) were afebrile. Multivariate logistic regression analysis showed that laminectomy was a statistically significant risk factor for postoperative non-pathological fever (odds ratio, 10.251; p=0.000). In contrast, trauma or tumor surgery and underlying medical disease were not significant risk factors for fever.
Conclusion
: Patients who develop delayed fever 4 days after posterior cervical fusion surgery using CPS are more likely to have non-pathologic fever than surgical site infection. Laminectomy is a significant risk factor for non-pathologic fever.

Keyword

Fever; Laminectomy; Laminoplasty; Posterior cervical; Seroma

Figure

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  Fig. 1. Sample vital sign chart used at Gangneung Asan Hospital. The blue line marked with an x indicates the body temperature. The chart shows the vital signs of a patient who visited our emergency center with cervical trauma and underwent cervical laminectomy and fusion surgery using cervical pedicle screw. On the fourth postoperative day, this patient had a body temperature >38 degrees Celsius. POD : postoperative days, SBP : systolic blood pressure, DBP : diastolic blood pressure, MBP : mean blood pressure, HR : heart rate, BT : body temperature.

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  Fig. 2. Illustration of the facetectomy preserving lamina method used to decompress foraminal stenosis and obtain a wide fusion bed, including the facet, lateral mass, and lamina, to achieve robust posterolateral fusion. This method may also reduce the dead space and seroma by preserving an anatomical barrier between the dura and the muscle.

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  Fig. 3. Illustration showing the method used for floating laminoplasty. Parallel bony gutters were made on both sides of the lateral mass-lamina junction by drilling with a match head shaped burr. The fractured laminae anchored absorbable suture (Coated Vicryl Plus 1-0; Ethicon, Somerville, NY, USA) through the spinous process to maintain lamina elevation. A postoperative CT axial scan showed sufficient cord decompression after floating laminoplasty. The right C2 and C3 pedicle screws were converted to lateral mass screws because ball-tip probing suggested a pedicle breach. CT : computed tomography.

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  Fig. 4. Illustration showing cervical total laminectomy and posterolateral fusion after screw fixation. A and B : Dura was exposed after making a gutter and removing the lamina. C : Before the bone graft, Gelfoam was placed on the boundary between the dura and the bone graft. D : Local bone harvested from the lamina and the allobone were grafted onto the lateral mass and Gelfoam. Postoperative CT showed low density dead space between the cord and the bone graft. CT : computed tomography.

Reference

References

1. Andres BM, Taub DD, Gurkan I, Wenz JF. Postoperative fever after total knee arthroplasty: the role of cytokines. Clin Orthop Relat Res. (415):221–231. 2003.

2. Badillo AT, Sarani B, Evans SR. Optimizing the use of blood cultures in the febrile postoperative patient. J Am Coll Surg. 194:477–487. quiz 554-556. 2002.

3. Blumstein GW, Andras LM, Seehausen DA, Harris L, Ross PA, Skaggs DL. Fever is common postoperatively following posterior spinal fusion: infection is an uncommon cause. J Pediatr. 166:751–755. 2015.

4. Chon H, Park JH. Cervical vertebral body fracture with ankylosing spondylitis treated with cervical pedicle screw: a fracture body overlapping reduction technique. J Clin Neurosci. 41:150–153. 2017.

5. Clark JA, Bar-Yosef S, Anderson A, Newman MF, Landolfo K, Grocott HP. Postoperative hyperthermia following off-pump versus on-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 19:426–429. 2005.

6. De Holl D, Rodeheaver G, Edgerton MT, Edlich RF. Potentiation of infection by suture closure of dead space. Am J Surg. 127:716–720. 1974.

7. Galicier C, Richet H. A prospective study of postoperative fever in a general surgery department. Infect Control. 6:487–490. 1985.

8. Garibaldi RA, Brodine S, Matsumiya S, Coleman M. Evidence for the non-infectious etiology of early postoperative fever. Infect Control. 6:273–277. 1985.

9. Guinn S, Castro FP Jr, Garcia R, Barrack RL. Fever following total knee arthroplasty. Am J Knee Surg. 12:161–164. 1999.

10. Heller JG, Edwards CC 2nd, Murakami H, Rodts GE. Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: an independent matched cohort analysis. Spine (Phila Pa 1976). 26:1330–1336. 2001.

11. Herrick DB, Tanenbaum JE, Mankarious M, Vallabh S, Fleischman E, Kurra S, et al. The relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery: a multicenter retrospective study. J Neurosurg Spine. 29:628–634. 2018.

12. Hobar PC, Masson JA, Herrera R, Ginsburg CM, Sklar F, Sinn DP, et al. Fever after craniofacial surgery in the infant under 24 months of age. Plast Reconstr Surg. 102:32–36. 1998.

13. Kiragu AW, Zier J, Cornfield DN. Utility of blood cultures in postoperative pediatric intensive care unit patients. Pediatr Crit Care Med. 10:364–368. 2009.

14. Kwon BK, Fisher CG, Boyd MC, Cobb J, Jebson H, Noonan V, et al. A prospective randomized controlled trial of anterior compared with posterior stabilization for unilateral facet injuries of the cervical spine. J Neurosurg Spine. 7:1–12. 2007.

15. Lau D, Winkler EA, Than KD, Chou D, Mummaneni PV. Laminoplasty versus laminectomy with posterior spinal fusion for multilevel cervical spondylotic myelopathy: influence of cervical alignment on outcomes. J Neurosurg Spine. 27:508–517. 2017.

16. Lee BJ, Park JH, Jeon SR, Roh SW, Rhim SC, Jung SK. Posterior cervical muscle-preserving interspinous process approach and decompression: more minimally invasive and modified shiraishi’s selective laminectomy. World Neurosurg. 133:e412–e420. 2020.

17. Lee JK, Jung SK, Lee YS, Jeon SR, Roh SW, Rhim SC, et al. Analysis of the fusion and graft resorption rates, as measured by computed tomography, 1 year after posterior cervical fusion using a cervical pedicle screw. World Neurosurg. 99:171–178. 2017.

18. Lee S, Seo J, Lee MK, Jeon SR, Roh SW, Rhim SC, et al. Widening of the safe trajectory range during subaxial cervical pedicle screw placement: advantages of a curved pedicle probe and laterally located starting point without creating a funnel-shaped hole. J Neurosurg Spine. 27:150–157. 2017.

19. Livelli FD Jr, Johnson RA, McEnany MT, Sherman E, Newell J, Block PC, et al. Unexplained in-hospital fever following cardiac surgery. Natural history, relationship to postpericardiotomy syndrome, and a prospective study of therapy with indomethacin versus placebo. Circulation. 57:968–975. 1978.

20. Memtsoudis SG, Hughes A, Ma Y, Chiu YL, Sama AA, Girardi FP. Increased in-hospital complications after primary posterior versus primary anterior cervical fusion. Clin Orthop Relat Res. 469:649–657. 2011.

21. Park JH, Jeon SR, Roh SW, Kim JH, Rhim SC. The safety and accuracy of freehand pedicle screw placement in the subaxial cervical spine: a series of 45 consecutive patients. Spine (Phila Pa 1976). 39:280–285. 2014.

22. Sebastian A, Huddleston P 3rd, Kakar S, Habermann E, Wagie A, Nassr A. Risk factors for surgical site infection after posterior cervical spine surgery: an analysis of 5,441 patients from the ACS NSQIP 2005-2012. Spine J. 16:504–509. 2016.

23. Seo J, Park JH, Song EH, Lee YS, Jung SK, Jeon SR, et al. postoperative nonpathologic fever after spinal surgery: incidence and risk factor analysis. World Neurosurg. 103:78–83. 2017.

24. Sharp NE, Alemayehu H, Desai A, Holcomb GW 3rd, St Peter SD. Fever after redo Nissen fundoplication with hiatal hernia repair. J Surg Res. 190:594–597. 2014.

25. Shiraishi T, Kato M, Yato Y, Ueda S, Aoyama R, Yamane J, et al. New techniques for exposure of posterior cervical spine through intermuscular planes and their surgical application. Spine (Phila Pa 1976). 37:E286–E296. 2012.

26. Theuer CP, Bongard FS, Klein SR. Are blood cultures effective in the evaluation of fever in perioperative patients? Am J Surg. 162:615–618. discussion 618-619. 1991.

27. Varthi AG, Basques BA, Bohl DD, Golinvaux NS, Grauer JN. Perioperative outcomes after cervical laminoplasty versus posterior decompression and fusion: analysis of 779 patients in the ACS-NSQIP database. Clin Spine Surg. 29:E226–E232. 2016.

28. Xu R, Bydon M, Sciubba DM, Witham TF, Wolinsky JP, Gokaslan ZL, et al. Safety and efficacy of rhBMP2 in posterior cervical spinal fusion for subaxial degenerative spine disease: Analysis of outcomes in 204 patients. Surg Neurol Int. 2:109. 2011.