Spine Surgery Risks & Complications | What Your Surgeon Should Tell You
Patient Education · Spine Surgery
Spine Surgery Risks & Complications —
what your surgeon should be telling you
Every spine surgery carries risk. The surgeon’s job is to tell you honestly what those risks are, how common they actually are, and — critically — what is done before and during surgery to reduce them. Vague reassurance is not informed consent. Here is a procedure-by-procedure breakdown of the risks that matter.
Why most patients get inadequate
risk conversations before spine surgery
In my experience, patients are frequently told either too little or too much. Some surgeons hand over a consent form that lists catastrophic outcomes without context — paralysis, stroke, death — leaving the patient terrified without understanding that those events are genuinely rare in elective cervical and lumbar surgery. Others wave away risk discussions entirely with “it’s a very routine procedure.” Neither approach is useful.
What you actually deserve to know is: which risks are common and manageable, which are rare, and what your surgeon specifically does to reduce the ones that are real. Probability matters. An honest surgeon distinguishes between the complications that appear on every consent form as a legal formality and the complications that genuinely warrant attention in your specific case — based on your anatomy, your medical history, and the surgery being planned.
The most consequential “complication” in spine surgery is not a technical error. It is operating for the wrong diagnosis on the wrong pain source. A technically perfect cervical fusion that relieves the wrong nerve root, a lumbar fusion performed for SI joint pain that was never evaluated — these produce patients who wake up from successful surgery with the same pain they came in with. No consent form lists this as a complication, but it is the most common cause of unsatisfactory spine surgery outcomes. The preoperative evaluation is the most important risk-reduction step of all.
Anterior cervical discectomy and fusion (ACDF) and anterior cervical disc arthroplasty (ACDA) share the same surgical approach and the same decompression. The risk profile is therefore largely the same. Based on a review of 2,579 ACDF procedures published in Acta Neurochirurgica Supplementum, the overall complication rate was 7% — and most complications were transient and manageable. Catastrophic outcomes are genuinely rare.
Dysphagia — difficulty swallowing, usually temporaryThe most frequently reported complication after ACDF, occurring in up to 1.9% of cases in large series. The anterior approach to the cervical spine requires retraction of the esophagus, and postoperative swelling of the surrounding soft tissues produces a sensation of difficulty swallowing — ranging from mild throat discomfort to more noticeable dysphagia. In the overwhelming majority of patients, this resolves within weeks to a few months as swelling subsides. Persistent severe dysphagia requiring intervention (such as a feeding tube) is rare and more common in elderly patients. An anterior plate sitting against the anterior surface of the esophagus is a contributing factor — disc replacement, which uses no anterior plate, is associated with lower dysphagia rates in the literature. Patients are advised what to expect and how to manage symptoms during recovery.
Normal postoperative pain — throat, neck, and incisionSore throat, neck stiffness, and incision discomfort in the first 1–2 weeks are expected and do not represent a complication. Patients are counselled preoperatively so these expected sensations are not alarming. Oral analgesics manage the early postoperative period effectively in most cases.
Hardware issues — uncommon with proper planning and techniqueImplant-related complications including cage subsidence, screw loosening, or pseudarthrosis (failure to fuse) occurred in 1.3% of cases in large published series. The risk is substantially reduced by careful preoperative planning: CT imaging of the cervical spine in every surgical candidate to assess bone quality and endplate morphology, selection of appropriately sized cages with large footplates that distribute load across more endplate surface area, and long screws that engage adequate bone purchase. A surgeon who plans the construct around the individual patient’s anatomy — rather than using standard implants reflexively — minimises hardware risk. For disc replacement specifically, proper sizing and seating of the prosthesis to maintain anatomic motion is the critical technical step.
Adjacent segment disease — real, but not a reason to avoid a necessary surgeryFusion at a cervical level permanently eliminates motion at that segment and redistributes mechanical stress to the levels above and below. Over years, this accelerated loading can produce degeneration at adjacent levels — a process called adjacent segment disease (ASD). The risk is real and measurably higher after fusion than after disc replacement, which preserves motion. However, the appropriate framing is not “avoid surgery because you might need another one in 10–15 years.” It is: choose the right operation for your anatomy — disc replacement if you are a candidate, fusion if you are not — and understand that if adjacent segment disease does eventually develop, it is diagnosable and treatable. Suffering from significant arm pain or myelopathy now to avoid a hypothetical future surgery is not a rational trade.
Nerve injury or neurological worseningNew postoperative neurological deficit — weakness, numbness, or paralysis — is among the most feared complications and is genuinely very uncommon in elective cervical decompression surgery. The nerve root being decompressed is directly visualised throughout the procedure. Neuromonitoring is used on every cervical fusion case. The more important protection against neurological injury is a technically meticulous decompression under direct vision — which begins with the preoperative CT evaluation that allows the surgeon to know exactly what the anatomy looks like before the first incision is made.
CSF leak (dural tear) — rare, significantly rarer with preoperative CTA dural tear in the anterior cervical approach is uncommon. The dura is not directly entered in the vast majority of ACDF cases. It becomes a real consideration primarily in patients with ossification of the posterior longitudinal ligament (OPLL) — a condition where the ligament behind the disc has calcified and may be adherent to the dura. I obtain a CT scan of the cervical spine for every surgical candidate specifically to identify OPLL in advance, assess its extent, and plan the approach accordingly. This is not standard practice everywhere — but it allows surgical strategy to be adapted preoperatively rather than discovering the problem intraoperatively. When a dural tear occurs and is repaired properly, long-term consequences are rare.
Robertson SC, Ashley MR. Complications of anterior cervical discectomy and fusion. Acta Neurochir Suppl. 2023;130:169-178. doi:10.1007/978-3-030-12887-6_20 · Chung WF et al. Serious dysphagia following anterior cervical discectomy and fusion: long-term incidence in a national cohort. J Neurosurg Sci. 2017. doi:10.23736/S0390-5616.17.03970-4
Minimally invasive lumbar decompression — through an 18mm tubular retractor, muscles spread rather than cut, outpatient same-day — has a significantly more favorable risk profile than open lumbar surgery for most of the major complications. The smaller surgical footprint means less blood loss, lower infection rates, and faster recovery. But risk is not zero, and honest preoperative planning is what keeps it low.
Dural tear (CSF leak) — not rare, but manageable with the right surgeonIncidental durotomy — an unintended opening in the dura during lumbar decompression — is the most common intraoperative complication in lumbar spine surgery, occurring in roughly 3.8–5.4% of cases based on published series. It is not a surgical error. The dura is immediately adjacent to the ligamentum flavum and bone being removed, and in patients with dense scarring, prior surgery, or calcified discs, the tissue planes are less distinct. What matters is not whether it happens — but whether the surgeon recognises it, and fixes it. A dural tear that is identified and properly repaired intraoperatively — with a stitch, a patch, fibrin glue, or a combination — carries minimal long-term consequence. Based on published data, patients with repaired incidental durotomies had good long-term clinical results at 37-month follow-up. The problem arises when a tear is ignored, minimised, or simply addressed by ordering the patient to lie flat for several days. That approach does not fix the problem; it delays recognition of complications. Neurosurgical training specifically emphasises dura management in a way that general orthopaedic spine training does not — and a surgeon comfortable with primary repair avoids the downstream complications that follow inadequate initial management.
Infection — lower with MIS, but patient factors matterSurgical site infection after MIS lumbar decompression is rare — the small incision, reduced tissue trauma, and shorter operative time all reduce infection risk compared to open surgery. However, certain patient factors significantly increase infection risk and must be addressed preoperatively: poorly controlled diabetes (elevated HbA1c substantially increases wound complication risk and should be optimised before elective surgery), morbid obesity (increased dead space, reduced tissue perfusion at wound margins, higher bacterial load), and immunosuppression. Identifying and addressing these factors before surgery — not discovering them as contributing causes of a postoperative wound infection — is the standard of responsible surgical planning.
Postoperative haematoma — rare, requires recognitionA significant epidural haematoma after lumbar decompression — one that compresses the dural sac or nerve roots and requires return to the operating room — is uncommon. The risk is higher in patients on anticoagulants that have not been appropriately bridged perioperatively, in patients with bleeding disorders, or when the decompression has required extensive epidural venous bleeding that was not adequately controlled. Careful haemostasis at the close of the procedure and appropriate perioperative anticoagulation management are the primary preventive measures.
Nerve injury or new weakness — rare, reduced by preoperative evaluationNew postoperative neurological deficit after lumbar decompression is rare. The most important risk reduction strategy is preoperative evaluation of the anatomy: confirming the disc herniation or stenosis is not calcified (which changes the surgical technique required), assessing the nerve root anatomy at the target level, and ensuring the planned approach can achieve adequate decompression without excessive nerve root retraction. A calcified disc herniation requires different instrumentation than a soft herniation — a surgeon who has not reviewed the preoperative imaging thoroughly will not be prepared for this intraoperatively.
Guerin P et al. Incidental durotomy during spine surgery: incidence, management and complications. Injury. 2011;43(4):397-401. doi:10.1016/j.injury.2010.12.014 · Kamenova M et al. Management of incidental dural tear during lumbar spine surgery. World Neurosurg. 2015;87:455-462. doi:10.1016/j.wneu.2015.11.045
If your surgeon mentions a dural tear occurred during your surgery, the right question is not “does this mean something went wrong?” — it is “how was it repaired?” A surgeon who repaired it intraoperatively with direct closure or patch has done the right thing. A surgeon who documented it and told you to lie flat for a few days without repairing it has not addressed the problem. Neurosurgical training specifically prepares surgeons for dural repair in a way that may not be routine in other spine training backgrounds. This is worth asking about explicitly before surgery.
Lumbar fusion procedures vary in approach — anterior (ALIF), lateral (LLIF), posterior (TLIF, PLIF) — and each carries approach-specific risks in addition to the shared risks of any fusion. Understanding which approach is being used, and why, is part of an informed consent conversation. The approach is not arbitrary: it should be chosen based on the anatomy, the level, and the surgical goals — including restoring appropriate segmental lordosis, a factor that significantly affects long-term adjacent segment health.
ALIF — anterior lumbar interbody fusion
Retrograde ejaculation — uncommon, but must be discussed with any male patientThe anterior retroperitoneal approach to the lumbar spine requires mobilisation of the great vessels and, at the L5-S1 level, passage through the presacral space where the superior hypogastric plexus — the nerve network controlling antegrade ejaculation — is at risk. Based on a published retrospective review in Spine, retrograde ejaculation occurred in approximately 7.4–9.8% of male patients after anterior lumbar surgery at L5-S1. Most cases do not resolve spontaneously. This risk must be explicitly discussed with every male patient considering ALIF, especially younger men who have not yet completed their family. The conversation is straightforward, but not having it is not acceptable.
Vascular or bowel injury — extraordinarily rare with experienced anterior accessALIF at L4-5 and L5-S1 requires surgical access past the aorta, inferior vena cava, and iliac vessels. Vascular injury during anterior lumbar access is extraordinarily rare when performed with an experienced access surgeon — a vascular or general surgeon who specialises in this exposure and works alongside the spine surgeon. When vascular injury does occur, it is a serious intraoperative event, but the access surgeon is present and equipped to manage it. The decision to use a dedicated access surgeon — rather than performing the exposure solo — is a quality indicator worth asking about.
LLIF — lateral lumbar interbody fusion
Anterior thigh pain, numbness, or hip flexor weakness — approach-related, usually resolvesThe lateral transpsoas approach passes through the psoas muscle, which contains branches of the lumbar plexus — the network of nerves supplying the thigh and hip flexors. Approach-related neurological symptoms including anterior thigh numbness, burning, or hip flexor weakness are the most commonly reported complication of LLIF. Based on published data from Clinical Spine Surgery, these symptoms occurred in 37–53% of patients depending on the level, but all patients reported complete resolution by 6-month follow-up. This is an important distinction: the symptom is common, but it is consistently temporary. Intraoperative neuromonitoring with real-time femoral nerve evoked potentials allows detection of nerve stress during retraction and enables the surgeon to adjust position before injury occurs. Patients are counselled preoperatively that some thigh symptoms are expected and will resolve.
Vascular or visceral injury — very rare with real-time monitoring and careful techniqueAs with ALIF, the lateral approach carries a theoretical risk of vascular or visceral injury. In published large series, no vascular or visceral injuries were recorded. Careful patient selection, real-time neuromonitoring, and an understanding of lumbar plexus anatomy relative to the working corridor at each level are the primary safeguards.
Lindley EM et al. Retrograde ejaculation after anterior lumbar spine surgery. Spine. 2012;37(20):1785-1789. doi:10.1097/BRS.0b013e31825752bc · Nolte MT et al. Rates of postoperative complications and approach-related neurological symptoms after LLIF at L4-L5 compared with upper lumbar levels. Clin Spine Surg. 2022. doi:10.1097/BSD.0000000000001367
Adjacent segment disease after lumbar fusion — why lordosis restoration matters
Adjacent segment disease — the development of new symptomatic degeneration at the level immediately above or below a fusion — is a long-term risk of any lumbar fusion. It is real, and it is not trivial. But it is significantly influenced by how the fusion is performed — specifically, whether the fused segment is restored to its appropriate segmental lordosis.
Lordosis is the natural inward curve of the lumbar spine. Each segment — each disc level — contributes a specific amount to that total curve. When a segment is fused in a flat or kyphotic position (the segment is straight or bends the wrong way rather than curving inward), the mechanical forces at the adjacent levels are dramatically increased. Think of the spine as a spring: if one coil is locked flat instead of curved, the coils on either side must work harder to absorb the same loads. Based on a finite element analysis published in BMC Musculoskeletal Disorders, non-lordotic cage placement at L4-5 increased disc stress at adjacent levels by up to 83% in flexion compared to a properly lordotic construct.
Restoring appropriate segmental lordosis at every fused level is one of the most important things a spine surgeon does to protect the levels above and below the fusion from premature degeneration. This requires cages with adequate lordotic angles built into their geometry — which is one reason large-footplate lordotic cages, as used in ALIF and LLIF, are preferred over smaller posterior cages (TLIF) when the anatomy permits. It also requires preoperative planning that accounts for the patient’s overall sagittal alignment, their pelvic incidence, and the contribution each level needs to make to the total lumbar lordosis.
Bone density is the other major adjacent segment protector. Fusion hardware — pedicle screws, interbody cages — must be anchored in bone with adequate density to withstand the mechanical demands of the fusion. Severe osteoporosis substantially increases the risk of hardware loosening, cage subsidence, adjacent vertebral fracture (proximal junctional failure in long constructs), and ultimately adjacent segment pathology. Every fusion candidate is evaluated for bone density, and when osteoporosis is identified, it is addressed before or alongside surgery — not ignored.
Tsuang FY et al. Effect of lordosis on adjacent levels after lumbar interbody fusion, before and after removal of the spinal fixator: a finite element analysis. BMC Musculoskelet Disord. 2019;20(1):470. doi:10.1186/s12891-019-2886-4
Adjacent segment disease is sometimes presented to patients as a reason not to have surgery. That is not the right framing. If you have significant leg pain, instability, or disability now from spondylolisthesis or disc disease, the question is not “what if I need another surgery in 10–15 years?” The question is “what does my life look like for the next 10–15 years if I do not address this now?” If adjacent segment disease eventually develops, it is diagnosable and treatable. The goal is to perform the current fusion in a way that delays or prevents that scenario as long as possible — through correct lordosis restoration, appropriate cage selection, and bone density optimisation — not to use the possibility as a deterrent.
Surgical planning and execution —
patient-specific implants, not one-size-fits-all
Most of what determines long-term outcomes after lumbar fusion is decided before the first incision — in the planning phase. The risk conversations above describe what can go wrong. This section describes what is done to make sure it does not.
Based on articles retrieved from PubMed, a systematic review published in Neurosurgery by Mehta et al. established that pelvic incidence is a fixed anatomical parameter that does not change after adolescence, and that it directly determines the lumbar lordosis a patient’s spine requires to maintain an energy-efficient, balanced upright posture. A separate matched case-control study published in the Journal of Neurosurgery: Spine found that PI-LL mismatch of 10° or more was present in 75% of patients who developed symptomatic adjacent segment disease after lumbar fusion, compared to 40% of those who did not — making failure to restore appropriate lordosis one of the single strongest predictors of long-term fusion failure. This is precisely the variable that a surgeon who does not routinely measure PI and target-LL is leaving to chance.
This is why every surgical candidate here receives a full-body standing EOS X-ray before any fusion is planned. EOS is a low-dose biplanar imaging system that captures the entire spine, pelvis, and lower extremities simultaneously in a true weight-bearing standing position. The built-in software automatically calculates every spinopelvic parameter — pelvic incidence, lumbar lordosis, segmental lordosis at each level, sagittal vertical axis, pelvic tilt, sacral slope — from a single acquisition. Every angle is measured precisely, not estimated. Standard segmental X-rays taken lying down miss the weight-bearing reality of how the spine actually functions. EOS captures the full picture upright, in one image, with automated measurement that removes human estimation error from the planning process. The surgical plan — including cage size, height, lordotic angle, and screw trajectory — is built from that data.
Mehta VA, et al. Implications of spinopelvic alignment for the spine surgeon. Neurosurgery. 2012;70(3):707-721. doi:10.1227/NEU.0b013e31823262ea · Matsumoto T, et al. Spinopelvic sagittal imbalance as a risk factor for adjacent-segment disease after single-segment posterior lumbar interbody fusion. J Neurosurg Spine. 2017;26(4):435-440. doi:10.3171/2016.9.SPINE16232
Measuring the cage — patient-specific implant selection, not guesswork
Not every surgeon plans implant size and lordotic angle individually for each patient. Some use standard cage sizes based on rough estimates of disc space dimensions, or choose implants by feel during the case. The problem with this approach is that a cage that is the wrong size — too small, too short, or placed at the wrong angle — fails to restore the disc height and segmental lordosis that the patient’s specific anatomy requires. The adjacent levels pay the price.
Every fusion case here involves preoperative measurement of the disc space — height, depth, and endplate-to-endplate angle — from standing lateral X-rays and CT imaging. The cage size and lordotic angle are selected to match what that specific patient needs to restore their individual segmental lordosis, not a generic target. This is what it means to use a patient-specific implant selection approach. The cage is not “stuffed in” and called a fusion. It is sized, angled, and positioned to restore the architecture of that specific disc space — because that architecture determines whether the adjacent levels above and below will be subjected to normal or abnormal mechanical stress for the next 10–20 years.
The geometry matters at the endplate level too. Large-footprint cages — as used in ALIF and LLIF approaches — distribute load across a greater surface area of the vertebral endplate, reducing the risk of subsidence (the cage sinking into the soft cancellous bone beneath the endplate). A small posterior cage that concentrates load on a small central area of the endplate in a patient with poor bone density is a recipe for cage subsidence, loss of the lordosis you worked to create, and ultimately hardware failure and adjacent segment stress. Large footplate, appropriate height, correct lordotic angle — these are the variables that matter.
Some spine surgeons dismiss the importance of segmental lordosis restoration, either because their preferred surgical approach makes it technically difficult to achieve, or because they do not routinely measure it. This is a real division in spine surgery practice. The biomechanical and finite element literature is clear: a segment fused in a flat or kyphotic position increases stress at adjacent disc levels substantially, accelerating degeneration at those levels. The clinical consequence — earlier symptomatic adjacent segment disease requiring further surgery — does not show up in a 2-year follow-up study. It shows up at 8, 10, and 15 years. Surgeons who do not believe this matters may genuinely have short-term outcome data that looks fine. The long-term data is the test. Measuring and restoring segmental lordosis is not an optional refinement — it is a core technical goal of every lumbar fusion.
Percutaneous screws lateral to the facet — preserving the joint that protects the adjacent level
Pedicle screws anchor the fusion construct to the vertebral bodies. Where exactly those screws enter the pedicle — and how close they come to the facet joint at the top of the construct — has direct consequences for adjacent segment disease.
The superior facet joint at the cranial end of a lumbar fusion is the last remaining motion segment above the construct. If the top pedicle screw violates that facet — encroaches into the joint, damages the cartilage, or mechanically disrupts the joint capsule — the joint is injured at the moment of surgery. An already-stressed adjacent segment is then dealing with both the mechanical consequence of the fusion below it and direct trauma to its facet joint. Based on articles retrieved from PubMed, postoperative facet joint violation is an independent risk factor for adjacent segment retrolisthesis (OR 1.911) and symptomatic adjacent segment disease (OR 2.873) after lumbar fusion, confirmed in a 2026 analysis of 473 TLIF patients published in Orthopaedic Surgery.
Percutaneous pedicle screws — placed through small stab incisions under fluoroscopic or navigated guidance rather than through a large open exposure — are positioned lateral to the facet joint. The approach does not require the aggressive soft tissue stripping and lateral retraction of an open exposure that brings the surgical instruments toward the facet capsule. The trajectory is controlled under live imaging from the very start. When the intent is specifically to preserve facet integrity, percutaneous placement consistently achieves low facet violation rates. A study from the University of Freiburg published in the European Spine Journal found that surgeon intent to preserve the facet is the primary determinant of outcome, with low violation rates achievable percutaneously when that is the explicit goal.
Open pedicle screw placement, particularly with a freehand technique in an open exposure, has consistently shown higher facet violation rates. A prospective cohort study comparing robot-assisted percutaneous placement to conventional open fluoroscopic placement found facet violations in 4% vs. 26% of top-level screws respectively. The violation rate is not purely a function of whether screws are placed percutaneously — it is a function of whether the surgeon is deliberately aiming to preserve the adjacent facet joint as a technical goal of the case.
Maharjan S, et al. Superior facet joint violation between open and MIS-TLIF and its relation to adjacent segment disease. Clin Spine Surg. 2021. doi:10.1097/BSD.0000000000001150 · Xu Z, et al. Risk factors and clinical significance for retrolisthesis of adjacent segment after TLIF. Orthop Surg. 2026. doi:10.1111/os.70301 · Hohenhaus M, et al. Cranial facet joint injuries in percutaneous lumbar pedicle screw placement: 3D navigation versus fluoroscopy. Eur Spine J. 2020. doi:10.1007/s00586-020-06467-8
Every surgical candidate receives a full-body standing EOS X-ray. EOS is a low-dose biplanar imaging system that captures the entire spine, pelvis, and lower extremities simultaneously in a true standing, weight-bearing position — front and side views in a single acquisition. The EOS software automatically measures every relevant spinopelvic parameter: pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, segmental lordosis at each level, sagittal vertical axis, thoracic kyphosis, and coronal alignment. Every angle is measured precisely, not estimated. Standard X-rays taken in segments or lying down miss the weight-bearing reality of how the patient’s spine actually functions when upright. EOS captures the full picture in one image, with the software doing the measurement so that human error in angle estimation is removed from the planning process.
From that data: the target segmental lordosis for the level being fused is calculated based on the patient’s individual pelvic incidence — a bony measurement that does not change after adolescence and determines exactly how much lumbar lordosis that patient’s spine requires to be balanced. The cage size, height, and lordotic angle are selected to achieve that specific calculated target. The top pedicle screws are planned to be positioned lateral to the superior facet joint of the adjacent level. Bone density is assessed. Endplate dimensions are measured from CT. The implant is chosen for the patient — not the patient fitted to whatever implant is on the shelf. Everything is precise. Nothing is guessed.
Two surgeons can perform the same procedure — ALIF, LLIF, TLIF — and produce dramatically different long-term outcomes based entirely on how they plan and execute it. The risks described in this post are real. But most of them are substantially reduced — or substantially increased — by decisions made before the first incision: which cage, what size, what angle, where the screws go, whether the adjacent facet joint is protected, whether the patient’s bone density was evaluated, whether their diabetes was optimised.
These are not exotic technical refinements. They are the difference between a fusion that lasts 15 years without adjacent segment problems and one that requires revision surgery in 5. When you are evaluating a spine surgeon, the right questions are not just “have you done this procedure before?” — they are “how do you plan implant size and lordosis for each patient specifically?” and “where do you position your top screws relative to the adjacent facet joint?” A surgeon who has not thought carefully about these questions will not have specific answers. A surgeon who has will tell you exactly what they do and why.
If you have been recommended lumbar fusion and want to understand what the surgical plan actually involves — including implant selection, lordosis restoration, and how adjacent segment risk is being minimised — that conversation is available here. Upload your imaging and bring your prior records. The consultation is a genuine evaluation, not a prelude to a predetermined recommendation.
How preoperative evaluation
is the most important risk reduction strategy
Most of the complications described above share a common thread: they are either not preventable (dural tear in a scarred revision spine), manageable when anticipated (dysphagia after ACDF, thigh symptoms after LLIF), or significantly reducible through preoperative planning. The risk factors that are reducible — poorly controlled diabetes, morbid obesity, severe osteoporosis, inadequate imaging, wrong diagnosis — are identified and addressed before surgery, not discovered as contributing causes of complications after.
Specific steps in this practice:
CT cervical spine for every ACDF/ACDA candidateIdentifies OPLL, assesses bone quality at the endplates, confirms disc space dimensions, and allows implant sizing before the operation. A surgeon who enters an anterior cervical case without CT has not reviewed the most important structural information about the anatomy they are about to operate on.
Neuromonitoring on every cervical and fusion caseIntraoperative neurophysiological monitoring — somatosensory and motor evoked potentials — provides real-time feedback during the case. A change in signal during the most critical decompression steps prompts immediate response before neurological injury becomes permanent.
Bone density evaluation before any fusionSevere osteoporosis changes the hardware strategy, the cage selection, the screw technique, and sometimes the recommendation about whether fusion is appropriate at all. It is evaluated, not assumed to be adequate.
Patient optimisation before elective surgeryPoorly controlled diabetes, morbid obesity, active smoking, severe cardiac or pulmonary comorbidity — these are identified and, where possible, optimised before elective spine surgery is scheduled. The goal is to present each patient to the operating room in the best possible physiological condition.
What to ask your surgeon
before any spine operation
An informed consent conversation should answer these questions clearly. If it does not, you should ask:
1. What is the most common complication of this specific procedure, and how will it be managed? For ACDF: dysphagia. For lumbar decompression: dural tear. For LLIF: thigh symptoms. The answer should be specific and include what happens if that complication occurs — not a generic “it’s rare.”
2. What in my specific anatomy or medical history increases my risk? A surgeon who has reviewed your imaging and knows your history should be able to answer this specifically. If the answer is “nothing stands out,” that is either correct or it means the imaging has not been reviewed carefully.
3. For ALIF: are you working with an access surgeon? The anterior approach to the lumbar spine should be performed with a dedicated vascular or general surgeon providing access. Solo anterior lumbar access by a spine surgeon without this collaboration is a quality question worth raising.
4. For any fusion: how are you planning to restore lordosis at the fused level? The answer should include the cage type, the lordotic angle of the implant, and reference to the patient’s individual pelvic incidence and sagittal alignment goals. “We use our standard implants” is not a sufficient answer.
5. Has the SI joint been evaluated? Before any lumbar fusion. Every time. See our post on SI joint dysfunction for why this matters.
surgical risks and options?
Upload your imaging before the consultation. Dr. Katsevman reviews everything personally, gives you a frank risk assessment specific to your anatomy and medical history, and discusses every option — including whether surgery is the right answer at all. Offices in Naples and Fort Myers. Telemedicine available nationwide.
Request a ConsultationReferences — PubMed-verified
- Robertson SC, Ashley MR. Complications of anterior cervical discectomy and fusion. Acta Neurochir Suppl. 2023;130:169-178. doi:10.1007/978-3-030-12887-6_20
- Chung WF, et al. Serious dysphagia following anterior cervical discectomy and fusion: long-term incidence in a national cohort. J Neurosurg Sci. 2017;64(3):231-237. doi:10.23736/S0390-5616.17.03970-4
- Guerin P, et al. Incidental durotomy during spine surgery: incidence, management and complications. A retrospective review. Injury. 2011;43(4):397-401. doi:10.1016/j.injury.2010.12.014
- Kamenova M, et al. Management of incidental dural tear during lumbar spine surgery. To suture or not to suture? World Neurosurg. 2015;87:455-462. doi:10.1016/j.wneu.2015.11.045
- Lindley EM, et al. Retrograde ejaculation after anterior lumbar spine surgery. Spine. 2012;37(20):1785-1789. doi:10.1097/BRS.0b013e31825752bc
- Nolte MT, et al. Rates of postoperative complications and approach-related neurological symptoms after L4-L5 lateral transpsoas lumbar interbody fusion. Clin Spine Surg. 2022. doi:10.1097/BSD.0000000000001367
- Tsuang FY, et al. Effect of lordosis on adjacent levels after lumbar interbody fusion, before and after removal of the spinal fixator: a finite element analysis. BMC Musculoskelet Disord. 2019;20(1):470. doi:10.1186/s12891-019-2886-4
- Maharjan S, et al. A retrospective analysis of superior facet joint violation between open and minimally invasive TLIF and its relation to adjacent segment disease. Clin Spine Surg. 2021. doi:10.1097/BSD.0000000000001150
- Xu Z, et al. Risk factors and clinical significance for retrolisthesis of adjacent segment after transforaminal lumbar interbody fusion. Orthop Surg. 2026. doi:10.1111/os.70301
- Hohenhaus M, et al. Cranial facet joint injuries in percutaneous lumbar pedicle screw placement: 3D navigation versus conventional fluoroscopy. Eur Spine J. 2020;30(1):88-96. doi:10.1007/s00586-020-06467-8
- Mehta VA, et al. Implications of spinopelvic alignment for the spine surgeon. Neurosurgery. 2012;70(3):707-721. doi:10.1227/NEU.0b013e31823262ea
- Matsumoto T, et al. Spinopelvic sagittal imbalance as a risk factor for adjacent-segment disease after single-segment posterior lumbar interbody fusion. J Neurosurg Spine. 2017;26(4):435-440. doi:10.3171/2016.9.SPINE16232
