Author(s)
Study design
Evidence level
N (total)
Mean age, years ± SD; years (range)
Variable evaluated: serum albumin (g/dL)/Pre-albumin (mg/dL) cut-off value
Conclusion
Schoenfeld et al. [9]
Retrospective
III
5887
55.9 ± 14.5
3.5
Serum albumin level <3.5 g/dL was associated with increased mortality, complications, wound infection and thromboembolic disease
Adogwa et al. [10]
Retrospective
III
145
56.46 ± 13.64 (>3.6 g/dL)
58.90 ± 18.01 (≤3.5 g/dL)
3.5
Preoperative serum albumin level <3.5 g/dL was an independent predictor of 30-day readmission following elective spine surgery
Adogwa et al. [11]
Retrospective
III
136
53.8 ± 17.0
3.5
Preoperative serum albumin level <3.5 g/dL was an independent predictor of postoperative complications following elective spine surgery
Tempel et al. [12]
Retrospective
IV
83
56 (19–85)a
20
Serum prealbumin level <20 mg/dL may be associated with postoperative wound infection
Bohl et al. [13]
Retrospective
III
4310
N/A
3.5
Preoperative serum albumin level <3.5 g/dL was associated with increased rates of wound dehiscence, UTI, SSI, longer LOS, and 30-day unplanned RA
Fu et al. [14]
Retrospective
III
3671
52.2 ± 11.3
3.5
Preoperative serum albumin level <3.5 g/dL was an independent predictor of major postoperative complications.
Smoking
The use of nicotine, particularly smoking , is known to cause a wide range of health problems, including lung cancer [15] and other forms of cancer [16]. Its association with adverse outcomes in adult spinal surgery and spinal deformity surgery has been demonstrated by several studies [17–23].
Soroceanu et al. [18] showed that smoking was associated with increased risk of medical complications in 448 patients who had undergone ASD surgery. In a population-based study of 35,477 patients undergoing lumbar spine surgery Martin et al. [19] demonstrated an increase in wound complications and higher incidence of 30-day morbidity in patients with a history of smoking.
Conflicting results have been published on the risks between reoperation and smoking . Mok et al. [22] and Puvanesarajah et al. [23] both found an association with reoperation in patients undergoing lumbar spine surgery. Scheer et al., on the other hand, did not find an association when evaluating 352 patients undergoing adult spinal deformity surgery.
Preoperative – smoking
Author(s) | Study design | Evidence level | N (total) | Mean age, years ± SD; year (range) | Variable evaluated: smoking | Conclusion |
|---|---|---|---|---|---|---|
Tang et al. [17] | Retrospective | IV | 236 | 61.7 (47–77) | History of smoking (within 1 year of surgery) obtained from medical record | Smoking was not associated with postoperative complications following degenerative lumbar scoliosis surgery |
Soroceanu et al. [18] | Retrospective | IV | 448 | 56.8 (15.45) | Smoking history obtained from a multi-institutional database | Smoking was independently associated with postoperative complications following ASD surgery |
Martin et al. [19] | Retrospective | IV | 35,477 | 51 ± 13 (current) 64 ± 13 (former) 60 ± 15 (never) | Smoking status obtained from a multi-institutional database and categorized as never (no use), prior (quit more than 12 months before surgery), and current (within 1 year of surgery) smoker | Smoking status was independently associated with SSI, and 30-day morbidity following lumbar spine surgery |
McCunniff et al. [20] | Retrospective | III | 559 | 55.1 ± 13.5 (smoker cohort) 53.2 ± 16.8 (nonsmoker cohort) | Patient-reported smoking history in packs per day was obtained from medical records. Patient who continued smoking up until the day of surgery was defined as a smoker. | Smoking was independently associated with increased EBL, perioperative transfusion rate in patients undergoing lumbar spine surgery |
Inoue et al. [21] | Retrospective | IV | 76 | 62.4 ± 10.8 | History of smoking obtained from medical record | Smoking was independently associated with critical mechanical failure following ASD surgery |
Mok et al. [22] | Retrospective | IV | 89 | 48.5 ± 15.5 | History of smoking obtained from medical record. Patients smoking until the day of surgery were categorized as smokers | In adjusted analysis, smoking status was associated with ROR following primary ASD surgery |
Puvanesarajah et al. [23] | Retrospective | IV | 2293 | 65–84 | History of smoking obtained from PearlDiver database | In adjusted analysis, smoking was an independent predictor of ROR following posterolateral fusion of 8 or more levels (OR 1.37, 95% CI 1.10–1.70) |
Bone Mineral Density
Several studies have looked at BMD and its association with complications. Three studies identified and association between decreased BMD and screw loosening in adult spinal surgery [26–28]. Okuyama et al. [26] found that decreased bone density was associated with pseudoarthrosis. In a large study of over 2200 patients in the Pearl Diver database, Puvanesaraja et al. [23] showed that osteoporosis was a significant predictor for revision surgery with an odds ratio (OR) of 1.98 (p < 0.0001).
Proximal junctional kyphosis (PJK) remains a common and vexing complication in ASD surgery. Three separate studies, including one meta-analysis [29] found an association between decreased BMD and PJK [29–31]. Liu et al. [29] identified three studies in the literature linking low BMD with an increased incidence of PJK. Yagi et al. [32] reported that female ASD patients treated with teriparatide immediately after surgery for ASD had improved volumetric bone density and less incidence of PJK (4.6% vs. 15.2%) when compared to controls.
Preoperative – bone mineral density (BMD)
Author(s) | Study design | Evidence level | N (total) | Mean age, years ± SD; year (range) | Variable evaluated: bone mineral density | Conclusion |
|---|---|---|---|---|---|---|
Okuyama et al. [26] | Retrospective | III | 52 | 63 (45–76) | Continuous BMD (g/cm2) | Decrease in BMD was associated with screw loosening and nonunion following pedicle screw fixation in conjunction with PLIF. Bone density of 0.674 ± 0.104 g/cm2 was proposed as a threshold value |
Puvanesarajah et al. [23] | Retrospective | III | 2293 | 65–84 | History of osteoporosis obtained from PearlDiver database | In adjusted analysis, osteoporosis was an independent predictor of ROR following posterolateral fusion of 8 or more levels (OR 1.98, 95% CI 1.60–2.46) |
Kim et al. [27] | Retrospective | III | 156 | 62.6 ± 7.1 56.7 ± 13.6 | Continuous T-score | T-score was associated with screw loosening following lumbosacral interbody fusion and pedicle screw fixation. T-score was −1.6 ± 1.6 in cases with screw loosening and −0.8 ± 1.5 in cases with screws remaining fixed |
Bredow et al. [28] | Retrospective | III | 365 | 59.1 ± 17.2 | CT attenuation in HU was used to determine mean bone density of each vertebral body of lumbar and thoracic spine | Decreasing mean CT attenuation was associated with increasing age and increased risk for screw loosening. Bone density was 116.3 ± 53.5 HU in cases with screw loosening and 132.7 ± 41. HU in cases with screws remaining fixed |
Liu et al. [29] | Meta-analysis | III | 2215 | N/A | BMD | In pooled analysis, decreasing BMD was associated with PJK following spinal fusion |
Park et al. [30] | Retrospective | III | 160 | 67.6 ± 6.1 | Presence of absence of osteoporosis | In adjusted analysis, osteoporosis was independently associated with PJF following ASD surgery |
O’Leary et al. [31] | Retrospective | III | 44 | 66 ± 10.3 | Continuous T-score used to diagnose osteopenia | Patients with osteopenia had an increased risk of acute fractures when compared to a matched cohort |
Yagi et al. [32] | Retrospective | III | 157 | 46.9 (22–81) | Presence of absence of osteoporosis and osteopenia | Patients with osteopenia and osteoporosis had an increase in the incidence of PJK that did not reach signifance in (p = 0.055) |
Preoperative Hemoglobin
There are a handful of studies that have shown an association between a low preoperative hemoglobin and complications and increased need for transfusion. Five studies [33–37] of over 26,000 total patients showed an association between low preoperative hemoglobin level and increased risk of major transfusion. Seican et al. [38] reviewed a large administrative database of 24,473 patients and found that patients with hematocrit graded as mild (30–37%) to severe (<26%) had increased major and minor complications, longer length of stay, and greater 30-day mortality compared to patients with no (>38%) anemia.
Preoperative – hemoglobin
Author(s) | Study design | Evidence level | N (total) | Mean age, years ± SD; year (range) | Variable evaluated: preoperative hemoglobin | Conclusion |
|---|---|---|---|---|---|---|
Carabini et al. [33] | Retrospective | III | 548 | 54.9 ± 14.7 (≤4 U transfused) 58.1 ± 15.0 (≥4 U transfused) | Preincision Hb | Preoperative Hb was independently associated with a major transfusion (≥4 U pRBCs) during spine fusion surgery |
Lenoir et al. [34] | Retrospective | III | 230 | 61.5 ± 13.6 (transfused) 56.0 ± 17.0 (transfused) | Preoperative Hb | Preoperative Hb level <12 g/dL was independently associated with transfusion during spine surgery (OR 6.7, 95% CI 3.1–17.2) |
Nuttall et al. [35] | Retrospective | III | 244 | 47 ± 22 | Preoperative Hb | Low (undefined) Hb was associated with increased rate of transfusion |
Veeravagu et al. [36] | Retrospective | III | 24,774 | N/A | Presence of anemia (HCT <36) | In unadjusted analysis, Hct <36 was associated with 1.37-fold increase in wound infection rates. |
Zheng et al. [37] | Retrospective | III | 112 | 54 (27–84) | Preoperative Hb and Hct, preoperative anemia | In adjusted analysis, preoperative Hb was independently associated with intraoperative blood loss and transfusion requirements |
Seican et al. [38] | Retrospective | III | 24,473 | 60 ± 15 (severe anemia) 63 ± 13 (moderate anemia) 61 ± 15 (mild anemia) 55 ± 14 (no anemia) | Severe anemia, moderate anemia, mild anemia, no anemia | In a propensity score-matched analysis, all levels of preoperative anemia were associated with increased risk of 30-day complications or increased LOS |
Body Mass Index
Obesity is now widely recognized as a significant health problem in the United States and elsewhere. The Centers for Disease Control and Prevention (CDC) currently uses the following ranges and definitions as they relate to body mass index (BMI) status: underweight <18.5 kg/m2; normal 18.5 kg/m2 to <25 kg/m2; overweight 25 kg/m2 to <30 kg/m2; obese 30 kg/m2 or higher. They further categorize obesity as Class 1 (BMI 30 kg/m2 to <35 kg/m2), Class 2 (BMI 35 kg/m2 to <40 kg/m2), or Class 3 (BMI 40 kg/m2 or greater).
The literature is replete with studies that identify an association between complications and increasing BMI. The Spine Patient Outcomes Research Trial (SPORT) revealed that obese (BMI ≥30 kg/m2) patients treated for degenerative spondylolisthesis had a higher postoperative infection rate (5% vs. 1%) than nonobese (BMI <30 kg/m2) patients [39]. Marquez-Lara el al. studied the ASC-NSQIP database and found than wound infection and risk of developing deep-vein thrombosis (DVT) were correlated with increasing BMI [40].
In ASD literature, Soroceanu et al. retrospectively reviewed a multicenter prospective database and found that BMI ≥30 kg/m2 was associated with a higher incidence of major complications and wound infections [41]. Smith et al. found greater BMI was associated with increased risk of rod fracture [42] and Wang et al. found it to be a risk factor for implant failure as well [43]. Bridwell [44] and Park [30] both found that increasing BMI increased the risk of PJK. Yagi et al. [45] however, reported an incidence of PJK of 20% with no difference in the obese and nonobese cohorts.
Preoperative – body mass index
Author(s) | Study design | Evidence level | N (total) | Mean age, years ± SD; year (range) | Variable evaluated: body mass index, kg/m2 | Conclusion |
|---|---|---|---|---|---|---|
Rihn et al. [39] | Retrospective | III | 1235 | N/A | Obese >30 Nonobese ≤30 | BMI ˃ 30 kg/m2 was associated with higher rate of postoperative infection and reoperation at 4-years follow-up in patients with DS. In patients with SpS, no difference in surgical complications. |
Marquez-Lara et al. [40] | Retrospective | III | 24,196 | 56.73 ± 14.9 56.4 ± 16.8 | Overweight BMI ≥25 Normal BMI 18.5–24.99 | BMI ≥25 kg/m2 was associated with increased incidence of DVT, PE, wound infection. BMI ≥40 kg/m2 was associated with ARF, sepsis, UTI |
Soroceanu et al. [41] | Retrospective | III | 241 | 59.8 ± N/A 53.6 ± N/A | Obese ≥30 Nonobese <30 | BMI 30 ≥kg/m2 was associated with higher incidence of major complications following ASD surgery. No association with minor complications, radiographic and neurologic complications, and revision surgery |
Smith et al. [42] | Retrospective | IV | 287 | 54.8 ± 15.8 | Smoking status obtained from ISSG database | Smoking was not associated with RF following ASD surgery |
Wang et al. [43] | Retrospective | III | 35 | 37.4 ± 10.1 37.8 ± 13.3 | BMI cut-off 27 | BMI >27 kg/m2 was associated with instrumentation failure after pVCR in ASD patients |
Bridwell et al. [44] | Retrospective | III | 90 | 49.9 ± 12.6 | Continuous BMI values grouped by PJK status | Increase in BMI was associated with higher incidence of PJK following ASD surgery |
Park et al. [30] | Retrospective | III | 160 | 67.6 ± 6.1 | Presence of absence of osteoporosis | In adjusted analysis, osteoporosis was independently associated with PJF following ASD surgery |
Yagi et al. [45] | Retrospective | III | 157 | 46.9 (22–81) | Presence of absence of osteoporosis and osteopenia diagnosed using T-score and WHO criteria | Patients with osteopenia and osteoporosis had an increase in the incidence of PJK that did not reach signifance in (p = 0.055) |
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