Risk factors and airway management of postoperative retropharyngeal hematoma following anterior cervical spine surgery: a retrospective study.

BACKGROUND: Postoperative retropharyngeal hematoma (RH) is a potentially life-threatening complication of anterior cervical spine surgery (ACSS). Difficult intubation frequently arises during airway management in patients with RH, presenting substantial challenges in clinical practice. This retrospective cohort study aimed to (1) identify risk factors linked to RH development after ACSS, and (2) highlight risk factors for difficult intubation within the RH patient group. METHODS: This retrospective analysis utilized a single-center longitudinal ACSS cohort from March 2013 to March 2024. The RH cohort was defined as patients who developed postoperative RH, while a non-RH control group (4:1 ratio) was established through matching for the same operator, gender, and operative year, with age matched within ± 5 years. Patients with RH were categorized into two groups based on whether they experienced difficulty in tracheal intubation during airway management prior to hematoma evacuation: the difficult intubation group and the non-difficult intubation group. Multivariable analysis identified independent risk factors for RH and difficult intubation. RESULTS: The incidence of postoperative RH following ACSS was 0.25% (42/16,624). Among these RH cases, 15 patients experienced difficult intubation during airway management. Multivariable logistic regression demonstrated markedly elevated odds of RH formation with increasing systolic blood pressure difference between extubation and wound closure (ΔSBP Ext-Closure): 30-50 mmHg yielded an adjusted OR of 3.30 (95% CI: 1.34-8.16, P = 0.010) vs. the < 30 mmHg reference, while > 50 mmHg showed an OR of 13.16 (95% CI: 4.93-35.10, P < 0.001).​ Additionally, Grade III/IV acute airway obstruction (AAO) (OR, 5.365; 95%CI, 11.089-26.445; P = 0.011) and longer time interval from onset to airway intervention (OR, 2.262; 95% CI, 1.208-4.236; P = 0.039) were identified as independent risk factors for difficult intubation. CONCLUSIONS: An elevated ΔSBP Ext-Closure ​may be independently associated with​ an increased risk of RH following ACSS. Among RH patients, Grade III/IV AAO and longer time interval from onset to airway intervention ​correlated with​ higher rates of difficult intubation. Close monitoring and tailored management may benefit high-risk cohorts​.