Ileus Following Adult Spinal Deformity Surgery

AM-PAC Mobility Score <13 Predicts Development of Ileus Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus.

SUMMARY OF BACKGROUND DATA

Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition.

METHODS

Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables.

RESULTS

Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P<0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P<0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus (P=0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus.

CONCLUSIONS

In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management.

LEVEL OF EVIDENCE

Level-III.

Risk Factors for Postoperative Ileus Following Spine Surgery: A Systematic Review With Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Postoperative ileus (POI) can negatively impact patient recovery and surgical outcomes after spine surgery. Emerging studies have focused on the risk factors for POI after spine surgery. This study aimed to review the available literature on risk factors associated with POI following elective spine surgery.

METHODS

Electronic databases were searched to identify relevant studies. Meta-analysis was performed using random-effect model. Risk factors for POI were summarized using pooled odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

Twelve studies were included in the present review. Meta-analysis demonstrated males exhibited a higher risk of POI than females odds ratio (OR, 1.76; 95% CI, 1.54-2.01). Patients with anemia had a higher risk of POI than those without anemia (OR, 1.48; 95% CI, 1.04-2.11). Patients with liver disease (OR, 3.3; 95% CI, 1.2-9.08) had a higher risk of POI. The presence of perioperative fluid and electrolyte imbalances was a predictor of POI (OR, 3.24; 95% CI, 2.62-4.02). Spine surgery involving more than 3 levels had a higher risk of POI compared to that with 1-2 levels (OR, 1.82; 95% CI, 1.03-3.23).

CONCLUSIONS

Male sex and the presence of anemia and liver disease were significant patient factors associated with POI. Perioperative fluid and electrolyte imbalance and multilevel spine surgery significantly increased the risk of POI. In addition, through this comprehensive review, we identified several perioperative risk factors associated with the development of POI after spine surgery.

Risk Factors for Postoperative Ileus in Patients Undergoing Spine Surgery

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

Postoperative ileus (POI) is a common complication following elective spinal surgeries. The aim of this study was to determine the incidence of POI and identify demographic and surgical risk factors for developing POI after elective instrumented fusion of the thoracolumbar spine.

METHODS

The University of Utah Institutional Review Board (IRB) approved this retrospective study. The study does not require informed consent given the data reviewed was deidentified and collected in accordance with the institution's standard of care. A designated IRB committee determined that study is exempt under exemption category 7. IRB approval number 00069703. Patients undergoing instrumented thoracolumbar fusion for one or more levels were retrospectively identified from an internal spine surgery database. Cases performed for trauma, infection, or tumors were excluded. Demographics, medical comorbidities, surgical variables, and opioid medication administration (morphine milligram equivalents, MME) were abstracted from the electronic medical record. Univariate analysis was used to identify variables associated with POI. These variables were then tested for independent association with POI using multivariate logistic regression.

RESULTS

418 patients were included in the current study. The incidence of POI was 9.3% in this cohort. There was no significant relationship between development of POI and patient age, gender, BMI, diabetes mellitus, thyroid dysfunction, lung disease, CKD, GERD, smoking status, alcohol abuse, anemia, or prior abdominal surgery. Univariate analysis demonstrated significant association between POI and fusion ≥7 levels compared to fusions of fewer levels (P = .001), as well as intraoperative sufentanil compared to other opioids (35.9% vs 20.1%, P = .02). POI was not significantly associated with total intraoperative MME, approach, use of interbody cage, or osteotomy. Multivariate logistic regression confirmed total 24-hour postoperative MME as an independent risk factor for POI (OR 1.004, P = .04), however, intraoperative sufentanil administration was not an independent risk factor for POI when controlling for other variables.

CONCLUSIONS

This retrospective cohort study demonstrates that greater postoperative MME is an independent risk factor for POI after thoracolumbar spine fusion when accounting for demographic, medical, and surgical variables with multiple logistic regression. Prospective studies are warranted to evaluate clinical measures to decrease the risk of POI among patients undergoing instrumented thoracolumbar spinal fusions.

Postoperative ileus risk after posterior thoracolumbar fusion performed with total intravenous anesthesia versus inhaled anesthesia

OBJECTIVE

There has been an increase in the use of total intravenous anesthesia (TIVA) for intraoperative neuromonitoring during thoracolumbar posterior spinal fusion (PSF). Although prior studies have identified risk factors for postoperative ileus (PI) after PSF, to the authors' knowledge, PI rates in patients receiving inhaled anesthetic versus TIVA have not been evaluated. In this study the authors analyzed whether TIVA is associated with greater risk of PI in PSF patients.

METHODS

In this retrospective single-institution cohort study, all patients undergoing PSF at the authors' tertiary academic institution from May 2014 to December 2020 were included. Patients undergoing anterior/lateral approaches or who had concurrent abdominal procedures unrelated to ileus in the same admission were excluded. PI was defined using radiographic and/or clinical diagnoses (postoperative radiographs, abdominal CT, and/or ICD-9 or -10 codes) and was confirmed via chart review. The use of TIVA or inhaled anesthetic was captured from the anesthesia record; patients were excluded if they were missing anesthesia technique data. Postoperative occurrence of PI was compared between patients who had TIVA or inhaled anesthetics while controlling for collected demographic, clinical, and surgical variables.

RESULTS

Of the 2819 patients meeting inclusion criteria, 283 (10.0%) had PI (mean ± SD age 59.3 ± 15.8 years; 155 [54.8%] male). The mean patient length of stay was 7.7 ± 5.0 days, which was significantly longer than that of patients without PI (4.9 ± 3.9 days, p < 0.001). Patients with PI had more levels fused (46% of PI patients with ≥ 5 levels fused vs 25% of non-PI patients, p < 0.001) and longer operations (6.0 ± 2.2 vs 5.4 ± 1.9 hours, p < 0.001). TIVA patients were more likely than inhalation-only patients to experience PI, but this finding did not reach significance on univariate analysis (11.0% PI rate vs 8.9%, p = 0.06). After propensity matching 125 non-PI patients and 50 PI patients by age, sex, operative time, and number of levels fused, there was a significant difference in intraoperative opiate dosing between TIVA and inhalational patients (275.7 ± 187.5 intravenous morphine milligram equivalents vs 120.9 ± 155.5, p < 0.001). On multivariate analysis of PI outcome, TIVA was an independently significant predictor (OR 1.45, p = 0.02), as was anesthesia time (OR per hour increase: 1.09, p = 0.03) and ≥ 8 levels fused (OR 1.86, p = 0.01).

CONCLUSIONS

In a large cohort of PSF patients, TIVA was associated with a higher rate of PI compared with inhaled anesthetic. This effect is likely due to higher intraoperative opiate use in these patients.

Preoperative characteristics are associated with increased likelihood of low early postoperative mobility after adult spinal deformity surgery

BACKGROUND CONTEXT

Low early postoperative mobility (LEPOM) has been shown to be associated with increased length of hospital stay, complication rates, and likelihood of nonhome discharge. However, few studies have examined preoperative characteristics associated with LEPOM in adult spinal deformity (ASD) patients.

PURPOSE

To investigate which preoperative patient characteristics may be associated with LEPOM after ASD surgery.

DESIGN

Retrospective review.

PATIENT SAMPLE

Included were 86 ASD patients with fusion of ≥5 levels for whom immediate-postoperative AM-PAC Basic Mobility Inpatient Short Form (6-Clicks) scores had been obtained.

OUTCOME MEASURES

The primary outcome of this study was the likelihood of LEPOM, defined as an AM-PAC score ≤15, which is associated with inability to stand for more than 1 minute.

METHODS

Significant cutoffs for preoperative characteristics associated with LEPOM were determined via threshold linear regression. Multivariable logistic regression was used to assess the impact of preoperative characteristics on the likelihood of LEPOM.

RESULTS

LEPOM was recorded in 38 patients (44.2%). Threshold regression identified the following cutoffs to be associated with LEPOM: preoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores of ≥68 for Pain, <28.3 for Physical Function, and ≥63.4 for Anxiety; preoperative Oswestry disability index (ODI) score of ≥60; and body mass index (BMI) of ≥35.2. On multivariate analysis, preoperative PROMIS scores of ≥68 for Pain (odds ratio [OR] 5.3, confidence interval [CI] 1.2-22.8, p=.03), <28.3 for Physical Function (OR 10.1, CI 1.8-58.2, p=.01), and ≥63.4 for Anxiety (OR 4.7, CI 1.1-20.8, p=.04); preoperative ODI score ≥60 (OR 38.8, CI 4.0-373.6, p=.002); BMI ≥35.2 (OR 14.2, CI 1.3-160.0, p=.03), and male sex (OR 5.4, CI 1.2-23.7, p=.03) were associated with increased odds of LEPOM.

CONCLUSIONS

Preoperative PROMIS Pain, Physical Function, and Anxiety scores; ODI score; BMI; and male sex were associated with LEPOM. Several of these characteristics are modifiable risk factors and thus may be candidates for optimization before surgery.

LEVEL OF EVIDENCE

III.

Clinical Importance, Incidence and Risk Factors for the Development of Postoperative Ileus Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective observational study of a cohort of consecutive patients.

OBJECTIVES

Postoperative ileus (POI) is associated with a variety of adverse effects. Although the incidence of and risk factors for POI following spinal surgery have been reported, the frequency and pathology of POI after spinal corrective surgery for adult spinal deformity (ASD) are still largely unknown. The study objectives were to: (1) clarify the prevalence and clinical significance of POI, (2) elucidate the risk factors for POI, (3) determine radiographically which preoperative and/or postoperative spinal parameters predominantly influence the risk of POI after spinal corrective surgery for ASD.

METHODS

We included data from 144 consecutive patients who underwent spinal corrective surgery. Perioperative medical complications and clinical information were extracted from patient electronic medical records. Preoperative radiographic parameters and changes in radiographic parameters after surgery were compared between patients with and without POI. Multivariate logistic regression analyses were performed to clarify potential risk factors for POI.

RESULTS

POI developed in 25/144 (17.4%) patients and was the most common complication in the present study. The frequencies of smoking, gastroesophageal reflux disease, and lateral lumbar interbody fusion (LLIF), as well as the duration of surgery were significantly greater in the group with POI versus the group without POI. Among radiographic parameters, only the change in thoracolumbar kyphosis (TLK) from before to after surgery was significantly larger in the group with POI. Multivariate logistic regression analysis showed that male sex, LLIF and large changes in TLK from before to after surgery were significantly associated with the development of POI.

CONCLUSIONS

These results suggested that LLIF and large corrections in TLK were independent risk factors for POI after ASD surgery. When patients with ASD have large TLK preoperatively, and it is determined that a large correction is needed, physicians must be aware of the potential for occurrence of POI.

Growing Racial Disparities in the Utilization of Adult Spinal Deformity Surgery: An Analysis of Trends From 2004 to 2014

STUDY DESIGN

Retrospective.

OBJECTIVE

The purpose of this study was to assess trends in utilization rates of adult spinal deformity (ASD) surgery, as well as perioperative surgical metrics between Black and White patients undergoing operative treatment for ASD in the United States.

SUMMARY OF BACKGROUND DATA

Racial disparities in access to care, complications, and surgical selection have been shown to exist in the field of spine surgery. However, there is a paucity of data concerning racial disparities in the management of ASD patients.

METHODS

Adult patients undergoing ASD surgery from 2004 to 2014 were identified in the nationwide inpatient sample (NIS). Utilization rates, major complications rates, and length of stay (LOS) for Black patients and White patients were trended over time. Utilization rates were reported per 1,000,000 people and determined using annual census data among subpopulations stratified by race. All reported complication rates and prolonged hospital stay rates are adjusted for Elixhauser Comorbidity Index, income quartile by zip code, and insurance payer status.

RESULTS

From 2004 to 2014, ASD utilization for Black patients increased from 24.0 to 50.9 per 1,000,000 people, whereas ASD utilization for White patients increased from 29.9 to 73.1 per 1,000,000 people, indicating a significant increase in racial disparities in ASD utilization (P-trend < 0.001). There were no significant differences in complication rates or rates of prolonged hospital stay between Black and White patients across the time period studied (P > 0.05 for both).

CONCLUSION

Although Black and White patients undergoing ASD surgery do not differ significantly in terms of postoperative complications and length of hospital stay, there is a growing disparity in utilization of ASD surgery between White and Black patients from 2004 to 2014 in the United States. There is need for continued focus on identifying ways to reduce racial disparities in surgical selection and perioperative management in spine deformity surgery.Level of Evidence: 3.

Perioperative subcutaneous methylnaltrexone does not enhance gastrointestinal recovery after posterior short-segment spinal arthrodesis surgery: a randomized controlled trial

BACKGROUND CONTEXT

Postoperative ileus is a major barrier to gastrointestinal recovery following surgery. Opioid analgesics likely play an important causative role, particularly in spinal or orthopedic surgeries not involving bowel manipulation. Methylnaltrexone, a peripherally-acting µ-opioid receptor antagonist, is a potential prophylactic treatment.

PURPOSE

To assess the influence of perioperative subcutaneous methylnaltrexone administration on gastrointestinal recovery following short-segment lumbar arthrodesis surgeries.

DESIGN

This is a randomized, double-blind, controlled trial.

PATIENT SAMPLE

Eligible patients undergoing posterior short-segment lumbar arthrodesis surgeries at a single institution between February 2019 and April 2021 were enrolled in this study.

OUTCOME MEASURES

The primary outcome measure was time-to-first bowel movement. Secondary outcome measures included time-to-discharge/discharge eligibility. Exploratory outcome measures included daily postoperative opioid consumption and pain scores.

METHODS

In this study, eligible patients were enrolled to receive either methylnaltrexone or placebo perioperatively. Time-to-bowel movement, time-to-discharge/discharge eligibility, intra and postoperative analgesic administration, and pain scores were recorded and compared.

RESULTS

Eighty two patients in total were enrolled; 41 to the methylnaltrexone and 41 to the placebo group. Both groups were similar in their baseline characteristics. There was no difference in median (range) time-to-bowel movement between the 2 groups [61.8 hours (35.7-93.6) versus 50.7 hours (17.8-110.8), p = .391]. There was also no difference in time-to-discharge/discharge eligibility [105.0 hours (81.0 - 201.3) versus 90.7 (77.5 - 184.5), p=.784]. Finally, there were no differences in either postoperative opioid consumption or numeric rating scores for back, leg, or abdominal pain on postoperative days 0 to 4 (p>.05).

CONCLUSIONS

Methylnaltrexone did not accelerate gastrointestinal recovery and did not affect opioid consumption or pain scores following short-segment spinal surgery as compared to placebo. Additional studies will be needed to identify effective opioid receptor antagonist dosing regimens for patients undergoing either short- or long-segment spinal arthrodesis procedures.

Design and feasibility of a double-blind, randomized trial of peri-operative methylnaltrexone for postoperative ileus prevention after adult spinal arthrodesis

BACKGROUND

Postoperative ileus (POI) is a common complication with no proven prophylactic measures in place. While perioperative opioid use has been implicated in POI development, current treatments fail to target this disease mechanism. Methylnaltrexone (MNTX) has been used to prevent the effects of opioids on the bowel and could reduce the incidence of POI when administered preoperatively.

METHODS

In this phase IIb randomized controlled trial, we assessed the effect of perioperative MNTX on time-to-first-bowel movement following spinal arthrodesis surgeries.

RESULTS

82 patients were randomly selected in a 1:1 ratio to be included in either the treatment or placebo groups. Comparison of relevant factors of included patients to patients who refused to participate (n = 21) and to a prior retrospective series (n = 241) revealed no differences in age, male sex, liver disease, and number of surgical levels. Overall treatment fidelity (98% adherence) and retention (100% at one-month follow-up) were high. The predicted POI incidence (9.3-11.1%) was also equivalent to a prior retrospective series. However, the overall observed POI incidence (3.7%) was lower than expected, which could reflect a superimposed 'trial effect' related to standardized care in a research setting.

CONCLUSIONS

Since exposure to significant opioid doses represents a barrier to enhanced recovery after surgery, the results of this innovative trial may provide further guidance for the peri-operative use of opioid-receptor blockers. Here, we show that MNTX can be effectively administered in the peri-operative period with appropriate follow-up achieved in a representative population of patients undergoing spinal surgery.

TRIAL REGISTRATION NUMBERS

Clinicaltrials.gov - NCT03852524 and Institutional Review Board - 2018H0260.

Bowel dysfunction after elective spinal surgery: etiology, diagnostics and management based on the medical literature and experience in a university hospital

BACKGROUND

Bowel dysfunction after spinal surgery is often underestimated and if not treated in a timely manner can lead to undesirable surgical interventions or fatal complications. The current medical literature primarily focuses on bowel dysfunction as a result of spinal injury.

OBJECTIVE

The purpose of this review is to explore this topic in evaluating current evidence regarding the causes of acute bowel dysfunction after elective spinal surgery, primarily the thoracolumbar spine. Since available evidence for recommendations of treatment is scarce, an interdisciplinary management approach for treatment of bowel dysfunction following spinal surgery is also formulated.

MATERIAL AND METHODS

An extensive literature search was carried out on PubMed. Keywords that were used in the search included bowel dysfunction, obstruction, postoperative ileus, spinal surgery, spinal fusion, constipation, opioid-induced constipation, colonic pseudo-obstruction, ischemic colitis, immobility-induced bowel changes, epidural anesthesia and diet. Relevant studies were chosen and included in the review. The treatment approach used in the spine center of a university hospital was included.

RESULTS

Current research mainly focuses on investigating the nature and symptomatology of chronic bowel dysfunction after spinal cord injury. Emphasis on the acute phase of bowel dysfunction in patients after elective spinal surgery is lacking. The comorbidities that exacerbate bowel dysfunction postoperatively are well-defined. There has been refinement and expansion of the pharmacological and nonpharmacological treatment that could be implemented. Enough evidence exists to provide sufficient care.

CONCLUSION

Management of acute bowel dysfunction after spinal surgery requires a comprehensive and individualized approach, encompassing comorbidities, behavioral changes, medications and surgery. Close supervision and timely treatment could minimize further complications. Research is required to identify patients who are at a higher risk of developing bowel dysfunction after specific spinal procedures.

Length of stay, readmission, and mortality after primary surgery for pediatric spinal deformities: a 10-year nationwide cohort study

BACKGROUND CONTEXT

Extended length of stay (extLOS) and unplanned readmissions after first time pediatric spinal deformity surgery are a considerable challenge to both the patient and the health-care system. To our knowledge, only a limited number of nationwide studies reporting short-term comorbidity with complete follow-up exist.

PURPOSE

The purpose of this study was to identify the postoperative complications leading to extLOS, readmissions, and mortality within 90 days after surgery. Furthermore, to identify risk factors for readmission.

DESIGN

Retrospective national cohort study.

PATIENT SAMPLE

A nationwide registry study including all pediatric spinal deformity patients (≤21 years of age) undergoing primary surgery during 2006-2015 (n=1,310).

OUTCOME MEASURES

Reasons for extLOS and 90-day readmissions as well as mortality risk.

METHODS

Patients were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Data on length of stay (LOS), readmissions, and mortality within 90 days were retrieved from the DNPR. Patients were categorized in six groups according to etiology. Reasons for extLOS and readmission were collected from medical records and discharge summaries.

RESULTS

For the 1,310 patients, the median LOS was 8 days (interquartile range 7-9). Etiologies were idiopathic deformity (53%), neuromuscular deformity (23%), congenital/structural deformity (9%), spondylolisthesis (7%), Scheuermann kyphosis (5%), and syndromic deformity (3%). A total of 274 (21%) patients had extLOS and the most common reason was pain/mobilization issues but with considerable variation between etiologies; Scheuermann kyphosis (91%), idiopathic (59%), syndromic (44%), spondylolisthesis (38%), and congenital (30%). Pulmonary complications were the primary reason for extLOS in the neuromuscular group (22%). The 90-day readmission rate was 6%; 67% of readmissions were medical, mainly infections unrelated to the surgical site (23%); 33% of readmissions were surgical and 14% of patients required revision surgery. Neuromuscular deformity, spondylolisthesis, Scheuermann kyphosis, and LOS >9 days were independent risk factors for readmission; odds ratio (OR) 4.4 (95% confidence interval: 2.2-9.1, p<.01), OR 3.0 (1.1-8.0, p=.03), OR 4.9 (1.7-13.6, p<.01), and OR 1.8 (1.0-3.1, p=.04), respectively. The 90-day mortality risk was 0.4%.

CONCLUSIONS

In this nationwide cohort, pain/mobilization issues are the most common reason for extLOS. The most common reason for readmission is infection unrelated to the surgical site. Readmission after pediatric spinal surgery is related to the etiology and increased focus on patients operated for neuromuscular deformity, spondylolisthesis and Scheuermann kyphosis is warranted.

The risks, reasons, and costs for 30- and 90-day readmissions after fusion surgery for adolescent idiopathic scoliosis

OBJECTIVE

With the continued evolution of bundled payment plans, there has been a greater focus within orthopedic surgery on quality metrics up to 90 days of care. Although the Centers for Medicare and Medicaid Services does not currently penalize hospitals based on their pediatric readmission rates, it is important to understand the drivers for unplanned readmission to improve the quality of care and reduce costs.

METHODS

The National Readmission Database provides a nationally representative sample of all discharges from US hospitals and allows follow-up across hospitals up to 1 calendar year. Adolescents (age 10-18 years) who underwent idiopathic scoliosis surgery from 2012 to 2015 were included. Patients were separated into those with and those without readmission within 30 days or between 31 and 90 days. Demographics, operative conditions, hospital factors, and surgical outcomes were compared using the chi-square test and t-test. Independent predictors for readmissions were identified using stepwise multivariate logistic regression.

RESULTS

A total of 30,677 patients underwent adolescent idiopathic scoliosis surgery from 2012 to 2015. The rates of 30- and 90-day readmissions were 2.9% and 1.4%, respectively. The mean costs associated with the index admission and 30- and 90-day readmissions were $60,680, $23,567, and $16,916, respectively. Common risk factors for readmissions included length of stay > 5 days, obesity, neurological disorders, and chronic use of antiplatelets or anticoagulants. The index admission complications associated with readmissions were unintended durotomy, syndrome of inappropriate antidiuretic hormone, and superior mesenteric artery syndrome. Hospital factors, discharge disposition, and operative conditions appeared to be less important for readmission risk. The top reasons for 30-day and 90-day readmissions were wound infection (34.7%) and implant complications (17.3%), respectively. Readmissions requiring a reoperation were significantly higher for those that occurred between 31 and 90 days after the index readmission.

CONCLUSIONS

Readmission rates were low for both 30- and 90-day readmissions for adolescent idiopathic scoliosis surgery patients. Nevertheless, readmissions are costly and appear to be associated with potentially modifiable risk factors, although some risk factors remain potentially unavoidable.

Acute Colonic Pseudo-Obstruction After Posterior Spinal Fusion: A Case Report and Literature Review

BACKGROUND

Acute colonic pseudo-obstruction (ACPO) or Ogilvie's syndrome occurs in 0.22%-7% of patients undergoing surgery, with a mortality of up to 46%. ACPO increased median hospital days versus control in spinal surgery (14 vs. 6 days; P < 0.001). If defined as postoperative ileus, the incidence was 7%-13.4%. Postoperative ileus is associated with 2.9 additional hospital days and an $80,000 increase in cost per patient. We present a case of ACPO in an adult patient undergoing spinal fusion for correction of scoliosis and review the available literature to outline clinical characteristics and surgical outcomes.

CASE DESCRIPTION

The patient was a 31-year-old woman with untreated advanced scoliosis with no history of neurologic issues. T2-L3 spinal instrumentation and fusion was completed. Plain abdominal radiography showed of dilated cecum 11 cm and the department of general surgery was consulted. Neostigmine administration was planned after conservative treatment failure after transfer to the intensive care unit. The patient was discharged home with no recurrence >60 days. Thirty cases were found in our literature review using PubMed and Embase databases and summarized.

CONCLUSIONS

Of 30 cases reviewed, only 3 cases of ACPO were specific to patients undergoing spinal fusion for scoliosis. According to the literature, 20% of patients had resolution with conservative treatment, 40% with neostigmine, and 30% with surgical intervention. Other noninvasive treatments may have similar efficacy in preventing complications leading to surgical invention. Sixty clinical trials and 9 systematic reviews were summarized with an updated management algorithm.

The impact of obesity on perioperative complications in patients undergoing anterior lumbar interbody fusion

OBJECTIVE

Anterior approaches to the lumbar spine provide wide exposure that facilitates placement of large grafts with high fusion rates. There are limited data on the effects of obesity on perioperative complications.

METHODS

Data from consecutive patients undergoing anterior lumbar interbody fusion (ALIF) from 2007 to 2016 at a single academic center were analyzed. The primary outcome was any perioperative complication. Complications were divided into those occurring intraoperatively and those occurring postoperatively. Multivariate logistic regression was used to assess the association of obesity and other variables with these complications. An estimation table was used to identify a body mass index (BMI) threshold associated with increased risk of postoperative complication.

RESULTS

A total of 938 patients were identified, and the mean age was 57 years; 511 were females (54.5%). The mean BMI was 28.7 kg/m2, with 354 (37.7%) patients classified as obese (BMI ≥ 30 kg/m2). Forty patients (4.3%) underwent a lateral transthoracic approach, while the remaining 898 (95.7%) underwent a transabdominal retroperitoneal approach. Among patients undergoing transabdominal retroperitoneal ALIF, complication rates were higher for obese patients than for nonobese patients (37.0% vs 28.7%, p = 0.010), a difference that was driven primarily by postoperative complications (36.1% vs 26.0%, p = 0.001) rather than intraoperative complications (3.2% vs 4.3%, p = 0.416). Obese patients had higher rates of ileus (11.7% vs 7.2%, p = 0.020), wound complications (11.4% vs 3.4%, p < 0.001), and urinary tract infections (UTI) (5.0% vs 2.5%, p = 0.049). In a multivariate model, age, obesity, and number of ALIF levels fused were associated with an increased risk of postoperative complication. An estimation table including 19 candidate cut-points, odds ratios, and adjusted p values found a BMI ≥ 31 kg/m2 to have the highest association with postoperative complication (p = 0.012).

CONCLUSIONS

Obesity is associated with increased postoperative complications in ALIF, including ileus, wound complications, and UTI. ALIF is a safe and effective procedure. However, patients with a BMI ≥ 31 kg/m2 should be counseled on their increased risks and warrant careful preoperative medical optimization and close monitoring in the postoperative setting.

Development of a postoperative ileus risk assessment scale: identification of intraoperative opioid exposure as a significant predictor after spinal surgery

OBJECTIVE

Postoperative ileus (POI) is associated with abdominal pain, nausea, vomiting, and delayed mobilization that in turn lead to diminished patient satisfaction, increased hospital length of stay (LOS), and increased healthcare costs. In this study, the authors developed a risk assessment scale to predict the likelihood of developing POI following spinal surgery.

METHODS

The authors undertook a retrospective review of a prospectively maintained registry of consecutive patients who underwent arthrodesis/fusion surgeries between May 2013 and December 2017. They extracted clinical information, including cumulative intraoperative and postoperative opioid doses using standardized converted morphine milligram equivalent (MME) values. Univariate and multivariate analyses were performed and several categorical and continuous variables were evaluated in a binary logistic regression model built with backward elimination to assess for independent predictors. A points-based prediction model was developed and validated to determine the risk of POI.

RESULTS

A total of 334 patients who underwent spinal fusion surgeries were included. Fifty-six patients (16.8%) developed POI, more frequently in those who underwent long-segment surgeries compared to short-segment surgeries (33.3% vs 10.4%; p < 0.001). POI was associated with an increased LOS when compared with patients who did not develop POI (8.0 ± 4.5 days vs 4.4 ± 2.4 days; p < 0.01). The incidences of liver disease (16% vs 3.7%; p = 0.01) and substance abuse history (12.0% vs 3.2%; p = 0.04) were higher in POI patients than non-POI patients undergoing short-segment surgeries. While the incidences of preoperative opioid intake (p = 0.23) and cumulative 24-hour (87.7 MME vs 73.2 MME; p = 0.08) and 72-hour (225.6 MME vs 221.4 MME; p = 0.87) postoperative opioid administration were not different, remifentanil (3059.3 µg vs 1821.5 µg; p < 0.01) and overall intraoperative opioid (326.7 MME vs 201.7 MME; p < 0.01) dosing were increased in the POI group. The authors derived a multivariate model based on the 5 most significant factors predictive of POI (number of surgical levels, intraoperative MME, liver disease, age, and history of substance abuse) and calculated relative POI risks using a derived 32-point system.

CONCLUSIONS

Intraoperative opioid administration, incorporated in a comprehensive risk assessment scale, represents an early and potentially modifiable predictor of POI. These data indicate that potential preventive strategies, implemented as part of enhanced recovery after surgery protocols, could be instituted in the preoperative phase of care to reduce POI incidence.