REVIEW
Introdução: Complicações intracranianas após cirurgias da coluna vertebral, embora incomuns, podem ser devastadoras e relacionamse, em geral, à hipotensão intracraniana por durotomia incidental ou fístula liquórica. Objetivo: Sintetizar espectro, mecanismos, diagnóstico, tratamento e desfechos das complicações intracranianas associadas a procedimentos espinhais, com ênfase em prevenção. Resultados: As complicações descritas incluem hemorragias intracranianas, pneumoencéfalo, hidrocefalia, crises epilépticas, paresias de nervos cranianos, meningite/ventriculite e, raramente, trombose venosa cerebral. Fatores de risco: lesão dural, idade avançada, doença cerebrovascular prévia e cirurgias de revisão. A apresentação costuma ocorrer nas primeiras 48 h, com cefaleia intensa, rebaixamento do nível de consciência, náuseas/vômitos, déficits focais, diplopia ou despertar tardio. A confirmação diagnóstica depende de TC/ RM urgentes. O manejo varia de medidas conservadoras a intervenções cirúrgicas. Quando reconhecidas e tratadas prontamente, o prognóstico tende a ser favorável, embora casos fatais de hemorragia grave existam. Conclusões: A prevenção por meio de técnica apurada, identificação e reparo rápido de durotomia e uso prudente de drenagens é a estratégia mais eficaz. Manter alto grau de suspeição no pós-operatório imediato é essencial para reduzir morbidade e melhorar desfechos.
Introduction: Intracranial complications after spinal surgery are uncommon but potentially devastating, most often linked to intracranial hypotension following incidental durotomy and postoperative CSF leakage. Objective: To summarize the spectrum, mechanisms, diagnosis, management and outcomes of intracranial complications associated with spinal procedures, highlighting preventive strategies. Results: Reported complications include intracranial hemorrhage, pneumocephalus, hydrocephalus, seizures, cranial nerve palsies, meningitis/ ventriculitis, and rarely cerebral venous thrombosis. Risk factors include dural injury, advanced age, prior cerebrovascular disease, and revision surgery. Presentations typically occur within 48 hours with severe headache, altered consciousness, nausea/vomiting, focal deficits, diplopia, or delayed emergence. Diagnostic confirmation relies on urgent CT/MRI. Management ranges from conservative measures to surgical interventions. When recognized and treated promptly, prognosis is generally favorable, although fatal hemorrhagic events have been reported. Conclusions: Prevention through meticulous technique, early identification and repair of dural tears, and judicious CSF drainage is paramount. A high index of suspicion in the immediate postoperative period is essential to reduce morbidity and improve outcomes.
1. Grob D, Mannion AF. The patient’s perspective on complications after spine surgery. Eur Spine J. 2009;18(Suppl 3):380-5. http:// doi.org/10.1007/s00586-009-1005-x. PMid:19390874.
2. Gerstmeyer J, Avantaggio A, Pierre C, et al. The hidden risk: intracranial hemorrhage following durotomies in spine surgery. N Am Spine Soc J. 2024;20:100555. http://doi.org/10.1016/j.xnsj.2024.100555. PMid:39391260.
3. Khalatbari MR, Khalatbari I, Moharamzad Y. Intracranial hemorrhage following lumbar spine surgery. Eur Spine J. 2012;21(10):2091-6. http:// doi.org/10.1007/s00586-012-2187-1. PMid:22349967.
4. Bozkurt G, Yaman ME. Subarachnoid hemorrhage presenting with seizure due to cerebrospinal fluid leakage after spinal surgery. J Korean Neurosurg Soc. 2016;59(1):62-4. http://doi.org/10.3340/ jkns.2016.59.1.62. PMid:26885288.
5. Huang H, Zhu C, Qin H, et al. Intracranial hemorrhage after spinal surgery: a literature review. Ann Transl Med. 2022; (20):1141. http:// doi.org/10.21037/atm-22-4929. PMid:36388815.
6. Yan X, Yan LR, Ma ZG, et al. Clinical characteristics and risk factors of intracranial hemorrhage after spinal surgery. World J Clin Cases. 2023; (23):5430-9. http://doi.org/10.12998/wjcc.v11.i23.5430. PMid:37637679.
a case report. BMC Surg. 2016;16(1):47. http://doi.org/10.1186/s12893016-0162-1. PMid:27411912.
14. Khurana A, Brousil J, Russo A, Evans A, Quraishi NA, Boszczyk BM. Intracranial hypotension with a sixth cranial nerve palsy subsequent to massive thoracic CSF hygroma: a rare complication of thoracic disc excision. Eur Spine J. 2013;22(9):2047-54. http://doi.org/10.1007/ s00586-013-2818-1. PMid:23728395.
15. Twyman RS, Robertson P, Thomas MG. Meningitis complicating spinal surgery. Spine. 1996;21(6):763-5. http://doi.org/10.1097/00007632199603150-00022. PMid:8882701.
16. Gupta A, Bansal K, Chhabra HS, Shahi P. Severe form of bacterial meningitis after spine surgery: a case report and review of the literature. Cureus. 2021;13(3):e13877. http://doi.org/10.7759/cureus.13877. PMid:33868841.
17. Sommerstein R, Jung HH, Knoblauch C. Cerebral venous sinus thrombosis as a complication of a microendoscopic discectomy. Eur Neurol. 2011;65(2):72-3. http://doi.org/10.1159/000323349. PMid:21252554.
18. Allouch H, Abu Nahleh K, Mursch K, Shousha M, Alhashash M, Boehm H. Symptomatic intracranial hemorrhage after dural tear in spinal surgery: a serie of 10 cases and review of the literature. World Neurosurg. 2021;150:e52-65. http://doi.org/10.1016/j.wneu.2021.02.071. PMid:33640532.
19. Yang F, Zhao J, Xu H. Characteristics of hemorrhagic stroke following spine and joint surgeries. BioMed Res Int. 2017;2017:5390839. http:// doi.org/10.1155/2017/5390839. PMid:28164124.
20. Sierra JJ, Malillos M. Intracraneal complications after raquis surgery. Rev Esp Cir Ortop Traumatol. 2018;62(2):153-6. PMid:28693963.
21. Leung GKK, Chan JPH. Supratentorial intraparenchymal haemorrhages during spine surgery. J Korean Neurosurg Soc. 2014;55(2):103-5. http://doi.org/10.3340/jkns.2014.55.2.103. PMid:24653806.
22. Thomas G, Jayaram H, Cudlip S, Powell M. Supratentorial and infratentorial intraparenchymal hemorrhage secondary to intracranial CSF hypotension following spinal surgery. Spine. 2002;27(18):E410-2. http://doi.org/10.1097/00007632-200209150-00023. PMid:12634578.
23. Karaeminogullari O, Atalay B, Sahin O, et al. Remote cerebelar hemorrhage after a spinal surgery complicated by dural tear: case report and literature review. Neurosurgery. 2005;57(1, Suppl):E215. PMid:15987597.
24. Li ZJ, Sun P, Dou YH, et al. Bilateral supratentorial epidural hematomas: a rare complication in adolescent spine surgery. Neurol Med Chir. 2012;52(9):646-8. http://doi.org/10.2176/nmc.52.646. PMid:23006878.
25. Imajo Y, Kanchiku T, Suzuki H, et al. Intracranial epidural hemorrhage during lumbar spinal surgery. Spinal Cord Ser Cases. 2016;2(1):15040. http://doi.org/10.1038/scsandc.2015.40. PMid:28053742.
26. Cevik B, Kirbas I, Cakir B, Akin K, Teksam M. Remote cerebellar hemorrhage after lumbar spinal surgery. Eur J Radiol. 2009;70(1):7-9. http://doi.org/10.1016/j.ejrad.2008.01.004. PMid:18294795.
27. Bowers CA, Taussky P, Duhon BS, Schmidt MH. Multiple supra – and infratentorial intraparenchymal hemorrhages presenting with seizure after massive sacral cerebrospinal fluid drainage. Spine. 2011;36(4):E28891. http://doi.org/10.1097/BRS.0b013e3181f9b10f. PMid:21270696.
28. You SH, Son KR, Lee NJ, Suh JK. Remote cerebral and cerebellar hemorrhage after massive cerebrospinal fluid leakage. J Korean Neurosurg Soc. 2012;51(4):240-3. http://doi.org/10.3340/jkns.2012.51.4.240. PMid:22737308.
29. McMahon P, Dididze M, Levis AD. Incidental durotomy after spinal surgery: a prospective study in an academic institution. J Neurosurg Spine. 2012;17(1):30-6. http://doi.org/10.3171/2012.3.SPINE11939. PMid:22540168.
30. Alluri R, Kang HP, Bouz G, Wang J, Hah RJ. The true effect of a lumbar dural tear on complications and cost. Spine. 2020;45(3):E15562. http://doi.org/10.1097/BRS.0000000000003213. PMid:31513112.
31. Yilmaz B, Toktas ZD, Konya D, Hasanov T. Intracranial complications of lumbar spine surgery. J Turk Spinal Surg. 2018;29(3):165-72.
32. Gigliotti MJ, Patel N, Fritch C, Church EW, Reiter GT, Park H. a case of basal ganglia intraparenchymal hemorrhage following lumbar spinal surgery. Cureus. 2024;16(7):e65692. http://doi.org/10.7759/ cureus.65692. PMid:39211708.
33. Lv Y, Xiang H. Seizures and consciousness disorder secondary to intracranial hypotension after spinal surgery: a case report and review of literature. Front Neurol. 2022;13:923529. http://doi.org/10.3389/ fneur.2022.923529. PMid:35832179.
34. Al-Gethami H, Cenic A, Kachur E. Seizures following cervical laminoplasty and lateral mass fusion: case report and review of literature. J Spine Surg. 2021;7(3):445-55. http://doi.org/10.21037/jss-20-642. PMid:34734149.
35. Choi JY, Choi YW, Sung KH. Anterior lumbar interbody fusion in patients with a previous discectomy minimum 2-year follow-up.
J Spinal Disord Tech. 2005;18(4):347-52. http://doi.org/10.1097/01. bsd.0000168718.08193.9d. PMid:16021016.
36. Kim KO, Lee T, Kim T. Non-convulsive status epilepticus in the immediate postoperative period following spine surgery: a case report. Korean J Anesthesiol. 2021;74(6):541-5. http://doi.org/10.4097/kja.20527. PMid:33401346.
37. Abu-Hamdiyah OJ, Al Sharie S, Awadi S, Khamees A, Athamneh MJ. Pneumocephalus secondary to a spinal surgery: a literature review and a case report. Int J Surg Case Rep. 2021;86(C):106342. http:// doi.org/10.1016/j.ijscr.2021.106342. PMid:34479115.
38. Pirris SM, Nottmeier EW. Symptomatic pneumocephalus associated with lumbar dural tear and reverse Trendelenburg positioning: a case report and review of the literature. Case Rep Neurol Med. 2013;2013:792168. http://doi.org/10.1155/2013/792168. PMid:24455345.
39. Akyüz O, Gökpınar O, Aydin E, et al. Pneumoencephalus and pneumorachis after spinal surgery. Pol J Radiol. 2016;81(1):34-5. http:// doi.org/10.12659/PJR.895570. PMid:26893792.
40. Turgut M, Akyüz O. Symptomatic tension pneumoencephalus: an unusual post-operative complication of posterior spinal surgery. J Clin Neurosci. 2007;14(7):666-8. http://doi.org/10.1016/j.jocn.2006.02.021. PMid:17532503.
41. Yang CT, Chiu CD, Wu CY. Diffuse symptomatic pneumocephalus after biportal endoscopic spinal surgery. Illustrative case. J Neurosurg Case Lessons. 2022;3(26):E22168. http://doi.org/10.3171/CASE22168. PMid:35855204.
42. Kobayashi K, Ando K, Ito K, et al. a case of delayed hydrocephalus from cerebrospinal fluid leak after resection of a cervical spinal schwannoma. Nagoya J Med Sci. 2018;80(4):605-9. PMid:30587875.
43. Endriga DT, Dimar JR 2nd, Carreon LY. Communicating hydrocephalus, a long-term complication of dural tear during lumbar spine surgery. Eur Spine J. 2016;25(Suppl. 1):157-61. http:// doi.org/10.1007/s00586-015-4308-0. PMid:26521076.
44. Kumaki S, Hirabayashi K, Katsuragawa Y, Miyamoto Y, Saito A, Yamamoto T. Late hydrocephalus treated conservatively secondary to liquorrhea after cervical laminoplasty: a case report. J Spine Res. 2017;8:1314-6.
45. Lin TY, Chen WJ, Hsieh MK, et al. Posoperative meningitis after spinal surgery: a review of 21 cases from 20.178 patients. BMC Infect Dis. 2014;14(1):20. http://doi.org/10.1186/1471-2334-14-220.
46. Zhang LM, Ren L, Zhao ZQ, Zhao YR, Zheng YF, Zhou JL. Surgical treatment for bacterial meningitis after spinal surgery: a case report. Medicine. 2017;96(11):e6099. http://doi.org/10.1097/ MD.0000000000006099. PMid:28296723.
47. McClelland S 3rd, Hall WA. Posoperative central nervous system infection: incidence and associated factors in 2111 neurosurgical procedures. Clin Infect Dis. 2007;45(1):55-9. http:// doi.org/10.1086/518580. PMid:17554701.
48. Sato S, Hayashi H, Urayama D, Ito Y, Naganuma H, Shinbori H. a case of remote cerebellar hemorrhage in spinal injury without dural injury. J Orthop Case Rep. 2023;13(9):38-41. http://doi.org/10.13107/ jocr.2023.v13.i09.3868. PMid:37753124.
49. Takenaka S, Makino T, Sakai Y, et al. Dural tears is associated with an increased rate of other perioperative complications in primary lumbar spine surgery for degenerative diseases. Medicine. 2019;98(1):e13970. http://doi.org/10.1097/MD.0000000000013970. PMid:30608436.
50. Gul S, Kalayal M, Acikgoz B. A rare complicationon spinal surgery: cerebelar hemorrhage. Turk Neurosurg. 2010;20(3):413-7. PMid:20669119.
51. Floman Y, Millgram MA, Ashkenazi E, Rand N. Remote cerebellar hemorrhage complicating unintended durotomy in lumbar spine surgery. Int J Spine Surg. 2015;9:29. http://doi.org/10.14444/2029. PMid:26273547.
52. Konya D, Ozgen S, Pamir MN. Cerebellar hemorrhage after spinal surgery: case report and review of the literature. Eur Spine J. 2006;15(1):95-9. http://doi.org/10.1007/s00586-005-0987-2.
PMid:16007466.
53. Friedman JA, Ecker RD, Piepgras DG, Duke DA. Cerebellar hemorrhage after spinal surgery: report of two cases and literature review. Neurosurgery. 2002;50(6):1361-1363. PMid:12015857.
54. Jung YY, Ju CL, Kim SW. Bilateral subdural hematoma due to an unnoticed dural tear during spine surgery. J Korean Neurosurg Soc. 2010;47(4):316-8. http://doi.org/10.3340/jkns.2010.47.4.316. PMid:20461178.
55. Pallud J, Belaid H, Aldea S. Successful management of a life threatening cerebellar haemorrhage following spine surgery: a case report. Asian Spine J. 2009;3(1):32-4. http://doi.org/10.4184/asj.2009.3.1.32. PMid:20404944.
56. Feng L, Han Y, Wang Y, Li G, Wang G. Remote medulla ablongata ventral acute subarachnoid hemorrhage following cervical spinal surgery: a case report. Int J Surg Case Rep. 2021;80(C):105675. http:// doi.org/10.1016/j.ijscr.2021.105675. PMid:33639502.
57. Hofler RC, Wemhoff MP, Johans SJ, Nockels RP. Cerebellar hemorrhage following an uncomplicated lumbar spine surgery: case report. J Stroke Cerebrovasc Dis. 2019;28(7):e104-5. http:// doi.org/10.1016/j.jstrokecerebrovasdis.2018.12.001. PMid:31103550.
58. Chan AY, Mullin JP, Benzel E, Bingaman W. Immediate remote cerebellar hemorrhage and seizure following revision lumbosacral fusion. Cureus. 2017;9(5):e1292. http://doi.org/10.7759/cureus.1292. PMid:28680780.
59. Brockmann MA, Nowak G, Rescche E, Russlies M, Petersen D. Zebra sign: cerebellar bleeding pattern characteristic of cerebrospinal fluid losss: case report. J Neurosurg. 2005;102(6):1159-62. http:// doi.org/10.3171/jns.2005.102.6.1159. PMid:16028781.
60. Morimoto T, Shiraki K, Otani K, Sonohata M, Mawatari M. Supratentorial subdural hemorrhage of a previous head injury and cerebellar hemorrhage after cervical spinal surgery: a case report and review of the literature. Spine. 2014;39(12):E743-7. http:// doi.org/10.1097/BRS.0000000000000323. PMid:24718071.
61. Zakaria AF, Tsuji M. Intracranial subdural hematoma after lumbar spine surgery: a case report. Malays Orthop J. 2019;13(3):85-7. http:// doi.org/10.5704/MOJ.1911.016. PMid:31890118.
62. Kelsaka E, Sarihasan B, Baris S, Tur A. Subdural hematoma as a late complication of spinal anesthesia. J Neurosurg Anesthesiol. 2003;15(1):47-9. http://doi.org/10.1097/00008506-200301000-00008. PMid:12499982.
63. Guryildirim M, Jhaveri MD. Isolated intraventricular hemorrhage after spinal surgery. Clin Imaging. 2016;40(5):889-91. http:// doi.org/10.1016/j.clinimag.2016.04.012. PMid:27179960.
64. Berry B, Ghannam M, Bell C, et al. Basal ganglia hemorrhage in a case report following spinal surgery. BMC Neurol. 2018;18(1):204. http://doi.org/10.1186/s12883-018-1218-x. PMid:30547770.
65. Miglis MG, Levine DN. Intracranial venous thrombosis after placement of a lumbar drain. Neurocrit Care. 2010;12(1):83-7. http:// doi.org/10.1007/s12028-009-9278-9. PMid:19834826.
66. Hernández-Mateo JM, Riquelme-Garcia O, Igualada-Blázquez C, Solans-López MC, Esparragoza-Cabrera LA. Abducens nerve palsy associated with pseudomeningocele after cervical spine surgery: a case report. J Spine Surg. 2023;9(1):109-13. http://doi.org/10.21037/ jss-22-92. PMid:37038420.
67. Schober P, Loer SA, Schwarte LA. Paresis of cranial nerve VI (N.abducens) after thoracic dural perforation. Minerva Anestesiol. 2010;76(12):1085-7. PMid:20838373.
68. Kim JY, Kim H, Kang SJ, Kim H, Lee YS. Diplopia developed by cervical traction after cervical spine surgery. Yeungnam Univ J Med. 2021;38(2):152-6. http://doi.org/10.12701/yujm.2020.00241. PMid:32723983.
69. Kale A, Balaban Z, Asadov I. Unexpected complication after lumbar disc surgery peripheral facial paralysis due to pneumocephalus: a case report. Surg Neurol Int. 2025;16(40):40. http://doi.org/10.25259/ SNI_989_2024. PMid:40041081.
70. Yoshizawa S, Nomoto Y, Nemoto C, Inoue S. inone S: a case of facial palsy after spinal surgery with prone positioning a patient with achondroplasia. JA Clin Rep. 2023;9(1):35. http://doi.org/10.1186/ s40981-023-00628-6. PMid:37329386.
1Department of Medicine, Universidade Federal de Sergipe, Aracaju, SE, Brazil.
2Universidade Federal do Triângulo Mineiro – UFTM, Uberaba, MG, Brazil.
3Universidade Tiradentes, Aracaj, SE, Brazil.
Received Oct 4, 2025
Corrected Nov 23, 2025
Accepted Nov 25, 2025
