Retropharyngeal Hematoma after Anterior Cervical Spine Surgery: Timing of Symptom Onset and Implications for Postoperative Observation

Study DesignRetrospective multi-hospital cohort study.ObjectivesRetropharyngeal hematoma (RH) after anterior cervical spine surgery (ACSS) is an uncommon but potentially fatal complication due to rapid postoperative airway compromise. As outpatient ACSS increases and shorter postoperative observation periods are adopted, the safe monitoring window for RH remains unclear. We characterized the timing of symptom onset and operative intervention for clinically significant RH after ACSS to inform postoperative observation practices.MethodsFollowing institutional review board approval, all cervical spine procedures performed across eight hospitals (2013-2023) were reviewed. Patients undergoing ACSS who returned to the operating room within 72 hours were identified. Cases of clinically significant RH requiring operative evacuation were included. Timing of symptom onset and return to the operating room was abstracted from operative, anesthesia, and nursing documentation.ResultsTwenty-five patients developed postoperative RH, representing 0.29% of 8,609 anterior cervical spine procedures. Median time to symptom onset was 9 hours (IQR 4-15; range 1-34). Twenty-two patients (88%) developed symptoms within 24 hours, including four in the post-anesthesia care unit. Median time to return to the operating room was 11 hours (IQR 5-20). Oxygen desaturation occurred in 32%, and 20% required emergent bedside decompression. Three patients (12%) died during hospitalization, including two from anoxic brain injury following airway compromise.ConclusionsClinically significant RH after ACSS most commonly presents within the first 24 postoperative hours. These findings suggest that brief postoperative observation periods (4-8 hours) after ACDF may not capture the majority of severe airway events in this operative RH cohort.