Retropharyngeal hematoma following anterior cervical spine surgery: a narrative review.

Background and Objective: Anterior cervical spine surgery (ACSS) is commonly performed for degenerative, traumatic, infectious, and neoplastic conditions of the cervical spine and is generally associated with favorable outcomes and low complication rates. However, postoperative retropharyngeal hematoma is a rare but potentially catastrophic complication due to the risk of rapid airway compromise. This narrative review summarizes the anatomy, pathophysiology, incidence, risk factors, clinical presentation, management, and outcomes of retropharyngeal hematoma following ACSS. Methods: A narrative review was performed using PubMed/MEDLINE, Google Scholar, and manual reference review. Search terms included "anterior cervical spine surgery", "anterior cervical discectomy and fusion", "retropharyngeal hematoma", "postoperative cervical hematoma", and "airway compromise". English-language human studies, including retrospective cohorts, case series, case reports, and relevant reviews, were included. Given the heterogeneity of available data, no formal quality scoring or meta-analysis was performed. Key Content and Findings: Retropharyngeal hematoma most commonly occurs within the first 24 hours after surgery, but delayed presentations after discharge have been reported. Presenting symptoms may include progressive dysphagia, hoarseness, neck swelling, stridor, dyspnea, and respiratory distress. Airway compromise primarily results from mechanical compression of the pharynx and larynx by an expanding hematoma, often with secondary soft tissue edema. Reported risk factors include multilevel surgery, coagulopathy or anticoagulation, poor perioperative blood pressure control, male sex, advanced age, medical comorbidity, ossification of the posterior longitudinal ligament (OPLL), and difficult airway morphology. Potential bleeding sources include vascular or soft-tissue oozing, as well as exposed cancellous bony endplates when open interbody cages are inadequately packed. Early recognition, airway control, emergent wound decompression when indicated, and surgical evacuation are central to management. Conclusions: Although uncommon, retropharyngeal hematoma following ACSS requires a high index of suspicion because deterioration can be rapid. Awareness of risk factors, meticulous hemostasis including bony endplate hemostasis, early postoperative monitoring, and prompt multidisciplinary airway management are essential. Prospective studies are needed to better define monitoring strategies and risk stratification models.