Diabetes is one of the most significant risk factors for surgical complications and poor outcomes (1,2). Delaying surgery to allow for better control can be of benefit in elective surgery. Analysis of the HgA1c can tell how well the patient has been under control (3,4). Tight control of perioperative glucose levels improves outcomes, shortens length of stay, and dramatically decreases wound infections (5,6). Therefore, aggressive management of blood sugars throughout the surgical experience is imperative for reducing the risks of infection and other complications.

Smoking and nicotine abuse are major risk factors also. Smoking cessation is associated with improved outcomes and lower complication rates. A minimum of four nicotine-free weeks will reduce the risks of soft tissue healing complications (7,8), and 1 to 2 months of smoking cessation will reduce the risks of pulmonary complications and mortality in the perioperative period (9,10). In an experimental human model, smoking cessation for at least 4 weeks reduced the risk of surgical infections (11). Zdeblick showed decreased lumbar fusion rates in smokers that persisted even after smoking cessation (12). In a randomized trial, the overall complication rate in smokers was reduced from 52% to 18% by a preoperative smoking cessation intervention. Wound-related problems, cardiovascular complications, and secondary surgery were dramatically reduced (13,14).

Smoking cessation is most likely to occur within the first two office visits with a spine practitioner (15). The counseling and education should begin with the initial visit and continue with each subsequent visit. A consistent and nonconfrontational approach to educate the patients about the negative effect of tobacco on their spinal condition has a dramatic effect on cessation rates (16). As many as 40% of smokers will quit with appropriate help from the spine practitioner (15).

Optimizing bone health with calcium and vitamin D supplements is necessary to maximize bone healing. Currently, 40% of all Americans and a billion people worldwide are vitamin D deficient. The vitamin D deficiency is expressed as increased rates of heart disease, multiple sclerosis, prostate, breast, and colon cancer, as well as osteomalacia. The 400 IU contained in our multiple vitamins is the current recommended daily allowance (RDA). However, it is inadequate to maintain appropriate vitamin D levels. A study on young healthy subjects showed the minimum daily intake should be at least 1,200 to 1,500 IU in order to maintain minimum levels of vitamin D (17). In young healthy individuals given 1,000 units daily for 3 months, the serum level of 25-hydroxyvitamin D did not reach an average of 30. For preoperative patients, a prescription for 12 doses of 50,000 units of vitamin D₂ over a 6-to-12-week perioperative time frame will help to ensure blood levels adequate for healing. At that point, it is recommended to have at least 1,000mg of calcium citrate with vitamin D, a multivitamin, and 1,000 units of vitamin D₃ indefinitely. For older patients and those with osteoporosis, this becomes 1,500 mg of calcium citrate with vitamin D and 2,000 units of vitamin D₃. The risk of toxicity is very low, the laboratory test for vitamin D has become much more cost-effective, and the supplements are inexpensive ($22.00 for the total of 12 doses of
50,000 units). The Centers for Medicare and Medicaid Services recognizes advising calcium and vitamin D intake as one of the 80 clinical practices that should be advocated for all patients. Counseling was included in the 2007 physician quality reporting initiative (18). This practice can result in higher Medicare reimbursements for physicians. This means it has been established as an expected practice protocol with evidence-based documentation. Only a minority of spine surgeons currently assess or address calcium and vitamin D levels, even in high-risk patients (19).

Vitamin D deficiency impacts a large portion of the world’s population. In July 2007, an article by Holick (20) proclaimed that over a billion people worldwide were vitamin D deficient. Malnutrition exists even in our young medical professionals: Fifty-seven percent of resident physicians were noted to be vitamin D deficient, and 40% had laboratory confirmation of secondary hyperparathyroidism (21). The problem is getting worse with time. The levels of vitamin D in the American population decreased in surveys done in 2000 to 2004 compared to 1988 to 1994 (22). There are populations that are at higher risk. These include the elderly, diabetics, and dark-pigmented individuals (20). This racial difference may represent as much as a third of the excess risk of peripheral vascular disease among Black Americans (23). Vitamin D deficiency is associated with increased all-cause mortality (24). How does that impact the practice of spine surgery? The obvious answer is the effect on bone metabolism and lack of calcium absorption. In extreme forms, vitamin D deficiency will result in a reactive hyperparathyroidism and osteomalacia. Bone healing will be strongly impaired. This will be evidenced as slow or absent fracture and fusion healing.

In addition, vitamin D deficiency is associated with increased pain from multiple musculoskeletal sources including low back pain. Vitamin D also has a beneficial effect on the neuromuscular junction. Low levels of vitamin D are associated with increased risks of falls. In adolescents, muscle function as measured by jump velocity, jump height, power, and force were all improved by correcting vitamin D deficiency (25). Other nonspine effects of vitamin D deficiency are increased risks of breast, prostate, and colon cancer; heart disease; autoimmune disease; asthma; peripheral vascular disease; diabetes; obesity; and multiple sclerosis (20,26, 27, 28, 29, 30 and 31). Chronic widespread pain has psychological and emotional components. The association is higher in women with low vitamin D levels (26). Myalgias and nonspecific muscle pains can be improved in 90% of vitamin D-deficient patients by correcting the deficiency (27).

Even in adolescents, 15% are vitamin D deficient to a degree that puts them at risk for secondary hyperparathyroidism (28). Our usual diets are not sufficient. The only other sources for vitamin D are sunlight and supplements. Even in areas of the world with blazing sun exposures, vitamin D deficiencies exist. The prevalence of vitamin D deficiency in Qatari children, for example, was 68% (29).

Active exercise and prehabilitation are very effective techniques for minimizing symptoms from the typical
degenerative spine conditions (see Fig. 153.1). The patient who is better conditioned also recovers from surgery faster with fewer medical complications. These benefits are demonstrated in all age groups, including elderly patients (38). Age is not a contraindication to prehabilitation (39). The program should involve a progressive aerobic training, strength training, and flexibility (40). This is another lifestyle issue that should be encouraged at each and every visit. Nielsen et al. (41) showed that lumbar fusion patients had shorter hospital stays, achieved their postoperative goals faster, and returned to work sooner using fewer resources if they had been involved in a prehabilitation program.

Preparation for surgery should be a team event involving the surgeon and the other practitioners involved in the patient’s care. The internist or primary care physician can help with risk stratification. Evaluation of cardiac, pulmonary, and renal issues should be done prior to the pre-op visit. Stress tests have poor predictive value as a preoperative assessment tool. There are no data to suggest benefit from percutaneous coronary intervention or coronary bypass procedures in reducing noncardiac surgical risks.

The requirement for anticoagulants after angioplasty and stenting can increase the risk of perioperative bleeding, especially with spinal surgery (42). Patients who are taking Plavix and Coumadin for medical conditions will require careful presurgical assessment. If the medications can be discontinued safely in the perioperative period, this should be done. Cervical surgery has a significant risk for epidural hematoma and neurologic compromise, especially if the patient is receiving anticoagulants at the time. An assessment must be made as to the absolute necessity for these medications. If they cannot be temporarily stopped during the perioperative period, performing the surgery may not be prudent, depending on the overall risk-benefit evaluation. As with each and every surgery, the potential benefits to the patient are offset by risks involved with the surgery.

Olsen et al. (2,43) showed the risk factors for surgical site infections in spinal surgery to be diabetes, elevated perioperative glucose levels (whether diagnosed as diabetic or not), suboptimal timing and dosing of prophylactic antibiotics, postoperative incontinence, dorsal approach, surgery for tumor resection, and morbid obesity. In a pediatric spine population, Linam showed similar risk factors
involving obesity, the use of clindamycin as the prophylactic antibiotic, and inappropriately low doses of antibiotics. What is somewhat disconcerting is that in the infected and control groups, over 90% received antibiotics for greater than 24 hours, 70% to 75% had incorrect redosing, and 40% to 54% had incorrect timing of the antibiotic. Certainly, the antibiotic timing and dosing as well as maintaining appropriate perioperative glucose levels are within the control of the surgeon. These should be protocol-driven patient care pathways because they have been shown to effectively reduce incidence of infection (44).