Frailty and clinical risk factors for symptomatic spinal epidural hematoma requiring urgent surgical evacuation after spine surgery – a single-center retrospective case–control study

Abstract Objective This study aimed to identify the relationship between patient frailty levels, other perioperative risk factors, and the development of postoperative spinal epidural hematoma (PSEH) in the modern era, during which numerous innovations in surgical techniques and intraoperative imaging systems have been developed. Design A retrospective matched case–control study conducted at a tertiary teaching hospital. Settings Clinical data were retrieved from the electronic database from 1 January 2023 to 31 May 2025. Patients Patients who developed symptomatic PSEH after spine surgery and required urgent surgical evacuation were included, and those did not require postoperative re-intervention were randomly selected (ratio of 1:5) from the same database and served as matched controls. Measurements Patient-related factors, including preoperative Clinical Frailty Scale (CFS), as well as surgical and anesthesia-related factors, were compared between the symptomatic PSEH reintervention group and the matched control group. A conditional logistic regression model was used for multivariate analysis. Main results A total of 13 patients developed symptomatic PSEH during the study period, and 64 patients were matched from a total of 2,095 spine surgeries that did not require re-intervention. Symptomatic PSEH patients were associated with higher preoperative CFS (adjusted odds ratio (AOR) 2.75, 95% confidence interval (CI) 1.08–7.06; P = 0.002), and there were more cases who received revision procedures (AOR 8.36, 95% CI 1.26–55.64, P = 0.028). Patients who experienced intraoperative hypothermia (< 36 °C) were also associated with a higher risk of developing symptomatic PSEH. Urgent surgical evacuation of epidural bleeding extended hospital stays (mean difference in days 8.20, 95% CI 3.13–13.26; P = 0.002). Conclusion The overall incidence rate of symptomatic PSEH requiring surgical intervention was 0.62%. Patients with higher CFS and those undertaking revision spine surgery are associated with increased risks of major symptomatic PSEH. Perioperative care, including maintaining normal body temperature, may help reduce the incidence of symptomatic PSEH.