Dependent functional status is associated with unplanned postoperative intubation after elective cervical spine surgery: a national registry analysis

Airway Complications After Anterior Cervical Spine Surgery: Etiology and Risk Factors

STUDY DESIGN

Narrative Review.

OBJECTIVE

To provide an overview of etiology and risk factors of airway complications after anterior cervical spine surgery (ACSS).

METHODS

A search was performed in PubMed and adapted for use in other databases, including Embase, Cochrane Library, Cochrane Register of Controlled Trials, Health Technology Assessment database, and NHS Economic Evaluation Database.

RESULTS

81 full-text studies were reviewed. A total of 53 papers were included were included in the review and an additional four references were extracted from other references. 39 papers were categorized as etiology and 42 as risk factors.

CONCLUSIONS

Most of the literature on airway compromise after ACSS is level III or IV evidence. Currently, there are no systems in place to risk-stratify patients undergoing ACSS regarding airway compromise or guidelines on how to manage patients when these complications do occur. This review focused on theory, primarily etiology and risk factors.

Frailty and Sarcopenia: Impact on Outcomes Following Elective Degenerative Lumbar Spine Surgery

STUDY DESIGN

This is a retrospective review of prospectively collected data.

OBJECTIVE

The aim was to evaluate the impact of frailty and sarcopenia on outcomes after lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Elderly patients are commonly diagnosed with degenerative spine disease requiring surgical intervention. Frailty and sarcopenia result from age-related decline in physiological reserve and can be associated with complications after elective spine surgery. Little is known about the impact of these factors on patient-reported outcomes (PROs).

METHODS

Patients older than 70 years of age undergoing elective lumbar spine surgery were included. The modified 5-item frailty index (mFI-5) was calculated. Sarcopenia was defined using total psoas index, which is obtained by dividing the mid L3 total psoas area by VB area (L3-TPA/VB). PROs included Oswestry disability index (ODI), EuroQual-5D (EQ-5D), numeric rating scale (NRS)-back pain, NRS leg pain (LP), and North American Spine Society (NASS) at postoperative 12 months. Clinical outcomes included length of stay (LOS), 90-day readmission and complications. Univariate and multivariable regression analyses were performed.

RESULTS

Total 448 patients were included. The mean mFI-5 index was 1.6±1.0 and mean total psoas index was 1.7±0.5. There was a significant improvement in all PROs from baseline to 12 months ( P <0.0001). After adjusting for age, body mass index, smoking status, levels fused, and baseline PROs, higher mFI-5 index was associated with higher 12-month ODI ( P <0.001), lower 12-month EQ-5D ( P =0.001), higher NRS-L P ( P =0.039), and longer LOS ( P =0.007). Sarcopenia was not associated with 12-month PROs or LOS. Neither sarcopenia or mFI-5 were associated with 90-day complication and readmission.

CONCLUSIONS

Elderly patients demonstrate significant improvement in PROs after elective lumbar spine surgery. Frailty was associated with worse 12 months postoperative ODI, EQ-5D, NRS-LP scores, and longer hospital stay. While patients with sarcopenia can expect similar outcomes compared with those without, the mFI-5 should be considered preoperatively in counseling patients regarding expectations for disability, health-related quality of life, and leg pain outcomes after elective lumbar spine surgery.

LEVEL OF EVIDENCE

3.

Impact of race on nonroutine discharge, length of stay, and postoperative complications after surgery for spinal metastases

OBJECTIVE

Previous studies have suggested the possibility of racial disparities in surgical outcomes for patients undergoing spine surgery, although this has not been thoroughly investigated in those with spinal metastases. Given the increasing prevalence of spinal metastases requiring intervention, knowledge about potential discrepancies in outcomes would benefit overall patient care. The objective in the present study was to investigate whether race was an independent predictor of postoperative complications, nonroutine discharge, and prolonged length of stay (LOS) after surgery for spinal metastasis.

METHODS

The authors retrospectively examined patients at a single comprehensive cancer center who had undergone surgery for spinal metastasis between April 2013 and April 2020. Demographic information, primary pathology, preoperative clinical characteristics, and operative outcomes were collected. Factors achieving p values < 0.15 on univariate regression were entered into a stepwise multivariable logistic regression to generate predictive models. Nonroutine discharge was defined as a nonhome discharge destination and prolonged LOS was defined as LOS greater than the 75th percentile for the entire cohort.

RESULTS

Three hundred twenty-eight patients who had undergone 348 operations were included: 240 (69.0%) White and 108 (31.0%) Black. On univariable analysis, cohorts significantly differed in age (p = 0.02), marital status (p < 0.001), insurance status (p = 0.03), income quartile (p = 0.02), primary tumor type (p = 0.04), and preoperative Karnofsky Performance Scale (KPS) score (p < 0.001). On multivariable analysis, race was an independent predictor for nonroutine discharge: Black patients had significantly higher odds of nonroutine discharge than White patients (adjusted odds ratio [AOR] 2.24, 95% confidence interval [CI] 1.28-3.92, p = 0.005). Older age (AOR 1.06 per year, 95% CI 1.03-1.09, p < 0.001), preoperative KPS score ≤ 70 (AOR 3.30, 95% CI 1.93-5.65, p < 0.001), preoperative Frankel grade A-C (AOR 3.48, 95% CI 1.17-10.3, p = 0.02), insurance status (p = 0.005), being unmarried (AOR 0.58, 95% CI 0.35-0.97, p = 0.04), number of levels (AOR 1.17 per level, 95% CI 1.05-1.31, p = 0.004), and thoracic involvement (AOR 1.71, 95% CI 1.02-2.88, p = 0.04) were also predictive of nonroutine discharge. However, race was not independently predictive of postoperative complications or prolonged LOS. Higher Charlson Comorbidity Index (AOR 1.22 per point, 95% CI 1.04-1.43, p = 0.01), low preoperative KPS score (AOR 1.84, 95% CI 1.16-2.92, p = 0.01), and number of levels (AOR 1.15 per level, 95% CI 1.05-1.27, p = 0.004) were predictive of complications, while insurance status (p = 0.05), income quartile (p = 0.01), low preoperative KPS score (AOR 1.64, 95% CI 1.03-2.72, p = 0.05), and number of levels (AOR 1.16 per level, 95% CI 1.05-1.30, p = 0.004) were predictive of prolonged LOS.

CONCLUSIONS

Race, insurance status, age, baseline functional status, and marital status were all independently associated with nonroutine discharge. This suggests that a combination of socioeconomic factors and functional status, rather than medical comorbidities, may best predict postdischarge disposition in patients treated for spinal metastases. Further investigation in a prospective cohort is merited.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Pulmonary Evaluation and Optimization

BACKGROUND

There are no current recommendations for preoperative pulmonary evaluation and management of patients undergoing elective spine surgery.

OBJECTIVE

The aim of this guideline is to determine preoperative risk factors for perioperative and postoperative pulmonary adverse events and to determine the optimal preoperative evaluation and management of at-risk patients.

METHODS

A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to postoperative pulmonary adverse events in patients undergoing spine surgery. Clinical studies evaluating preoperative patient risk factors and preoperative diagnostic and treatment interventions were selected for review.

RESULTS

The literature search yielded 152 abstracts relevant to the PICO (patient/population, intervention, comparison, and outcomes) questions included in this chapter. The task force selected 65 articles for full-text review, and 24 were selected for inclusion in this systematic review. Twenty-three articles addressed preoperative patient risk factors. One article addressed preoperative diagnostic studies of pulmonary function. There were no studies meeting the inclusion criteria for preoperative pulmonary treatment.

CONCLUSION

There is substantial evidence for multiple preoperative patient factors that predict an increased risk of a postoperative pulmonary adverse event. Individuals with these risk factors (functional dependence, advanced age [≥65 yr], chronic obstructive pulmonary disease, congestive heart failure, weight loss, and obstructive sleep apnea) who are undergoing spine surgery should be counseled regarding the potential increased risk of a perioperative and postoperative pulmonary adverse events. There is insufficient evidence to support any specific preoperative diagnostic test for predicting the risk of postoperative pulmonary adverse events or any treatment intervention that reduces risk. It is suggested, however, to consider appropriate preoperative pulmonary diagnostic testing and treatment to address active pulmonary symptoms of existing or suspected disease.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/5-preoperative-pulmonary-evaluation-optimization.