- Email: [email protected]
Complications in Elderly Patients Undergoing Lumbar Arthrodesis for Spinal Stenosis
Original Article
Complications in Elderly Patients Undergoing Lumbar Arthrodesis for Spinal Stenosis Chao Kong, Xiangyu Li, Xiangyao Sun, Junzhe Ding, Machao Guo, Shibao Lu
PURPOSE: To report the perioperative complication rates in elderly patients undergoing lumbar arthrodesis and to analyze the risk factors.
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METHODS: Between September 2015 and June 2018, 215 patients aged ‡70 underwent posterior lumbar arthrodesis with pedicle screw fixation. Demographic data including age, gender, smoking status, body mass index (BMI) and preoperative comorbidities were collected. Operative records as the number of levels fused, estimated blood loss, time of surgery, and the occurrence of perioperative complications were reviewed. Risk factors of perioperative complications were determined by logistic regression analysis.
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RESULTS: The total perioperative complication rate in all patients was 30.2%, of which major complications occurred in 24 patients (11.2%) and minor complications occurred in 41 patients (19.1%). Two risk factors of perioperative complications (major or minor) were chosen: BMI (cutoff value 24.32) and surgical level (‡3). Lower surgical level (‡3) and smaller BMI were risk factors for perioperative minor complications, and major complication was affected only by surgical level (‡3).
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CONCLUSIONS: The risk factor of perioperative complication in elderly patients after lumbar arthrodesis was fusion segment (‡3), and BMI was a protective factor. Elderly patients with BMI <24.32 are more likely to have perioperative complications after lumbar arthrodesis.
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INTRODUCTION
W
ith the global increase of the geriatric population and life expectancy, the number of elderly patients with symptomatic lumbar degenerative disc diseases requiring surgery is expected to rise.1,2 Lumbar arthrodesis is commonly done in elderly patients to treat lumbar degenerative diseases with instability. With advances in anesthesiology, patient care, and surgical technique, lumbar arthrodesis has been safer for elderly patients, with improved outcome. However, these patients may still be at increased risk for perioperative complications because of their age and associated medical conditions.3,4 Deyo et al.5 reported the rate of complications after lumbar spine surgery to be 18% in patients over 75 years of age. A study of patients aged 75 and older who underwent decompressive spine surgery reported a much higher complication rate (35.2%), which contained a major complication rate of 12.5%.6 By contrast, some other studies reported no difference in perioperative complications between elderly patients and younger patients.7-9 Given that the literature describing the complications of lumbar arthrodesis in elderly patients is inconclusive and at times confusing, the risk factors and estimates of perioperative complications are particularly important. It has not been fully elucidated which factors are the most important in predicting perioperative complications in the geriatric population undergoing lumbar arthrodesis. The purpose of this study was to report the perioperative complication rates in a large cohort of elderly patients undergoing lumbar arthrodesis and to analyze the risk factors. MATERIALS AND METHODS Patient Demographics Between September 2015 and June 2018, 215 patients aged 70 or older underwent posterior lumbar arthrodesis with pedicle screw
Key words Elderly - Lumbar arthrodesis - Perioperative complication - Risk factor
Department of Orthopedics, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
Abbreviations and Acronyms ASA: American Society of Anesthesiologists BMI: body mass index OR: odds ratio ROC: receiver operating curve
Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.06.147
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To whom correspondence should be addressed: Shibao Lu, M.D. [E-mail: [email protected]] Chao Kong and Xiangyu Li are coefirst authors.
Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Published by Elsevier Inc.
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fixation by 1 surgeon in our hospital. The main diagnosis was lumbar stenosis with instability, with some accompanied by scoliosis or spondylolisthesis. Patients who had a neoplasm, infectious disease, or trauma and those who had previously undergone lumbar surgery were excluded. Demographic data including age, gender, smoking status, height, weight, and body mass index (BMI) were collected using electronic chart review. The past medical history and comorbidities of all patients were recorded. Operative records were reviewed to determine the number of levels fused, estimated blood loss, time of surgery, and the occurrence of any perioperative complications. Patients’ preoperative physical status was evaluated using the American Society of Anesthesiologists (ASA) classification: class I, no systemic disease; class II, mild to moderate systemic disease; class III, severe systemic disease; IV, severe systemic disease that is life threatening; V, moribund patient with little chance of survival. The ASA status of all patients was classified before surgery by anesthetists and recorded in each patient’s anesthesia note. Three authors who were not involved in the care of these patients reviewed all medical records. Perioperative complications were categorized as minor and major complications as previously defined by Carreon et al.10 Major complications were defined as conditions that were life threatening or that could adversely affect the treatment outcome. Complications noted in the medical records but did not compromise outcome were considered minor complications. All patients underwent a standard midline posterior lumbar decompression at each of the involved levels. During surgery, interbody fusion was preferred in the decompressed levels with pedicle screw and rod instrumentation. In patients with scoliosis, not all fusion levels needed to be decompressed, and posterolateral fusion was chosen in those levels. Postoperative intravenous infusion of antibiotics was used until the drainage tube was removed. After removal of the drainage tube, daily dressing changes were performed. Deep venous thrombosis prevention was undertaken with the use of compression stockings and early mobilization. Routine blood tests and biochemical analysis were performed every other day after surgery until discharge or transfer. Statistical Analysis All statistical analyses were performed with SAS version 9.2 (SAS Institute, Cary, NC). For continuous variables, the statistical significance of differences between groups was assessed by the Wilcoxon 2-sample test after test for normality. For categoric variables, the Fisher exact test was used to test for the statistical significance of differences between groups. P values <0.05 were considered statistically significant. Binary logistic regression was used to identify the risk factors for the occurrence of perioperative complications, and multinominal logistic regression was used to identify the risk factors of perioperative minor and major complications, respectively. The odds ratio (OR) and 95% confidence interval (CI) were determined.
male and 137 (63.7%) were female. The average age was 75.7 4.6 years (range, 70e88 years). The average BMI was 25.6 3.4 (range, 17.5e33.6). The general condition of those patients varied by ASA classification: ASA class II (90 patients, 41.9%), ASA class III (108 patients, 50.2%) and ASA class IV (17 patients, 7.9%). The most common comorbidity was hypertension, which was present preoperatively in 62.9% of the patients. Other common comorbidities were diabetes (23.7%), coronary heart disease (18.9%), cerebral infarction that the patient once had (11.4%), arrhythmia (4%), renal insufficiency (2.9%), and chronic obstructive pulmonary disease (2.3%). In addition, 22.3% of the patients had 1 comorbidity, 31.2% had 2 comorbidities, 22.8% had 3 comorbidities, 13.5% had more than 3 comorbidities, and 10.2% had no comorbidity. Distribution of fusion levels were as follows: 1 segment (21.7%), 2 segments (37.1%), 3 segments (19.4%), and more than 3 segments (21.8%). The average fusion segment length was 2.36 segments. The average surgical time was 237 86.5 minutes (range, 70e639 minutes), and the average blood loss was 486 475.8 ml (range, 80e4000 ml). The average hospital stay was 19 9.3 days (range, 7e81 days). Risk Factors of Complications The total perioperative complication rate in all patients was 30.2%, of which major complications occurred in 24 patients (11.2%) and minor complications occurred in 41 patients (19.1%). The most common minor complication was hypoproteinemia, and the most common major complication was pneumonia. A summary of complications is shown in Table 1. One patient died of myocardial infarction 7 days after surgery. Two patients underwent revision surgery because of cage malposition and epidural hematoma, respectively, during hospitalization. Four patients had deep wound infection and underwent debridement without removing the implant. There were 3 partial root injuries, resulting in numbness in 2 patients and motor deficit in 1 patient. A comparison of the groups is given in Table 2. Patients with complications had much lower BMI, lower surgical levels (3), longer surgical times, and longer hospital stays (P¼0.026, P<0.001, P¼0.050, P¼0.002, respectively). No other significant differences were found between groups in terms of age, gender, comorbidities, ASA scale, and blood loss (P>0.05). After comparison of the 2 groups, 3 variables (BMI, surgical levels, and surgical time) were included in the binary logistic regression analysis of preoperative risk factors. Because hospital stay is an outcome variable, it was left out in the logistic regression analysis. After binary logistic analysis, 2 risk factors of perioperative complications (major or minor) were chosen: BMI (OR¼0.848, CI¼0.758e0.948, P¼0.004) and surgical levels (3) (OR¼2.763, CI¼1.243e6.144, P¼0.013). The cutoff value of BMI is 24.32, which means that elderly patients with BMI less than 24.32 are more likely to have perioperative complications after lumbar arthrodesis. The ROC curve predicting the probability of perioperative complications is shown in Figure 1.
RESULTS Patient Population In this study, 215 patients undergoing lumbar arthrodesis with instrumentation were included. Of those, 78 patients (36.3%) were
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Risk Factors of Major and Minor Complications All variables were then included in the multinominal logistic regression analysis; the only risk factor of perioperative complications (major complication) was lower surgical levels (3)
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Table 1. Perioperative Complications in 55 Patients Major Complication
Number of Patients
Minor Complication
Number of Patients
Table 2. Characteristics of Patients with and without Perioperative Complications Characteristic
Deep wound infection
4
Ileus
Pneumonia
5
Superficial infection
5
Mean age, years
Myocardial infarction
3
Urinary tract infection
3
Gender
Congestive heart failure
1
Superficial deep vein thrombosis
2
Without Complications
65
150
76 4.8
76 4.6
22
56
P Values
2 Total patients
Male
Transient arrhythmias
With Complications
Respiratory distress
1
2
Epidural hematoma
1
Pulmonary embolus
1
Leg dysesthesia
3
Neurologic deficit
3
Intraoperative dura tear
3
Death
1
Hypoproteinemia
9
Cerebral infarction
2
Delirium
2
Revision surgery
2
Female
0.624
43
94
0.647
24.6 3.39
25.9 3.36
0.026
<3
44
108
3
37
26
No
5
17
1
14
34
2
19
48
3
15
34
>3
12
17
2
27
63
3
32
76
4
6
11
0.893
Surgical time, minutes
256.4 83.8
227.6 86.6
0.050
Blood loss, ml
510.2 579.0
477.9 431.5
0.692
24.1 13.6
17.6 5.8
0.002
BMI Surgical level
Confusion
2
<0.001
Comorbidities
0.656
ASA scale
(OR¼2.874, CI¼1.135e12.128, P¼0.011). The ROC curve predicting the probability of perioperative major complications is shown in Figure 2. The risk factors of perioperative minor complications were BMI (OR¼0.829, CI¼0.732e0.938, P¼0.003) and surgical levels (3) (OR¼2.606, CI¼1.061e6.404, P¼0.037). The ROC curve predicting the probability of perioperative minor complications is shown in Figure 3.
Hospital stay, days
Comparison of Younger (£75) with Older (>75) Patients All patients were divided into younger group (75) and older groups (>75). A comparison of the 2 groups is shown in Table 3. The average age was 72 1.7 in the younger group and 80 3.2 in the older group (P<0.001). Older patients had much lower BMI than younger patients (P¼0.028). There were no differences in preoperative comorbidities and ASA scale between the 2 groups (P¼0.459, P¼0.495, respectively). Although the surgical level, surgical time, and blood loss were not significantly different between the 1 groups (P¼0.458, P¼0.261, P¼0.937, respectively), older patients had longer hospital stays (P¼0.006). Perioperative complications (major or minor) were not significantly different between the 2 groups (P¼0.185). DISCUSSION According to China’s national census report in 2016, about 8.87% of the population is now older than 65 years, and the total number has exceeded 120 million. With the aging of the population, the number of elderly patients undergoing posterior decompression and fusion for degenerative lumbar disorders will increase.11 Although advances in anesthesiology, perioperative care, and surgical techniques have made spinal surgeries for geriatric
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Bold values are statistically significant. BMI, body mass index; ASA, American Society of Anesthesiologists.
patients safer and more extensive and complex, identifying risk factors of perioperative complications is still essential for the geriatric population.12,13 To the authors’ knowledge, this is the first study analyzing the risk factors of perioperative complications in China’s geriatric patients undergoing lumbar arthrodesis. The reported perioperative complication rates of lumbar surgeries in elderly patients were diverse.14-17 Nasser et al.13 reported an overall pooled complication rate of 16.4% after reviewing and analyzing the data from 105 spine surgery articles. In a nationwide study, Imajo et al.18 collected data of 8033 elderly patients undergoing spinal surgery, reporting an incidence of complications to be 10.8%. Although data from different centers were collected, only 29.3% of the patients underwent decompression and fusion, which may explain the relatively lower complication rate shown in previous studies.19 Other studies, however, showed the complication rates ranging from 52% to 70%.10,12,17 In this study, the total perioperative complication rate in all patients was 30.2%. Direct comparisons of
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Figure 1. ROC curve of risk factors (BMI and surgical level) predicting perioperative complications. The AUC was 0.7061. ROC, receiver operator curve; AUC, area under the curve; BMI, body mass index.
complication rates among different studies are irrational because a variety of factors will influence the results, and the quality of data is mostly poor. The current study used a binary system defined by Carreon et al.,10 which categorized perioperative complications as major and minor complications. Carreon et al.10 reported a 21% major complication rate and a 70% minor complication rate. Kobayashi et al.20 reported in a multicenter study that perioperative complications occurred in 29% patients, and 13% were major complications. Our study showed similar results, with major complications in 11.2% patients and minor complications in 19.1% patients. The most common major complication was pneumonia (2.3%), and the most common minor complication was hypoproteinemia (4.2%). Pneumonia can be quite life threatening if not treated promptly and correctly. Postoperative hypoproteinemia may have adverse effects on incision healing and lead to superficial infection. Perioperative mortality after lumbar arthrodesis is the most severe complication, ranging from 0% to 17%.3,10,12,21 Inasmuch as no randomized clinical trial or nonrandomized prospective study was performed, the quality of data is relatively poor. In a study that included 10,232 elderly patients undergoing spine surgery, the in-hospital mortality was 0.31%,22 which was consistent with the current study (0.47%). Deyo et al.5 reported a mortality rate of 0. 6%, and Silver et al.23 reported 0.8% for elderly patients after spinal surgery. The long-term mortality in elderly patients who underwent lumbar surgery was found to be equivalent to that in an age-adjusted control group who did not undergo lumbar surgery.24
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Figure 2. ROC curve of risk factors (surgical level) predicting perioperative major complications. The AUC was 0.7349. ROC, receiver operator curve; AUC, area under the curve.
Higher complication rates in obese patients have been reported in previous studies,25-30 with controversial results reported in other studies.31-33 Vaidya et al.26 and Onyekwelu et al.27 demonstrated increased blood loss and longer hospital stays in obese patients after lumbar fusion. In a recent systematic review and meta-analysis, Lingutla et al.34 found that obese patients who underwent lumbar fusion had greater intraoperative blood loss, more complications, and longer duration of surgery. However, in this study, we found that elderly patients with lower BMI more easily experienced perioperative complications, particularly minor complications. And the cutoff value was 24.32, which means that elderly patients with BMI less than 24.32 are more likely to have perioperative complications after lumbar arthrodesis. Possible explanations may be as follows: 1) Elderly patients are different from young patients in many aspects. In younger patients, obesity may pose an increased difficulty in surgery and cause higher surgical complications. But in elderly patients, the average BMI is relatively lower than that in younger patients. As shown in the current study, the average BMI was 25.6 3.4 in all patients, which cannot be defined as obesity. 2) Elderly patients with lower BMI are more likely to be malnourished. After surgery, heavy consumption of food combined with insufficient nutrition intake may lead to serious malnutrition and slower recovery. As suggested in this study, extra attention should be paid to elderly patients with BMI less than 24.32, who may be more likely to experience perioperative complications after lumbar arthrodesis.
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Table 3. Comparison of Younger (75) with Older (>75) Patients Variable Total patients Mean age, years
70e75 Years
>75 Years
111
104
72 1.7
80 3.2
P Values
<0.001
Gender Male
36
35
Female
75
69
0.885
26.1 3.06
24.9 3.67
0.028
<3
81
71
3
30
33
No
11
11
1
28
20
2
38
29
BMI Surgical level
0.458
Comorbidities
Figure 3. ROC curve of risk factors (BMI and surgical level) predicting perioperative minor complications. The AUC was 0.7001. ROC, receiver operator curve; AUC, area under the curve.
We also found that surgical level is a risk factor of perioperative complications after binary logistic regression analysis. Longer fusion segments are sometimes inevitable in elderly patients, especially when coronal deformity or sagittal imbalance need to be corrected. Several studies have suggested that longer fusion segments lead to an increased risk of complications in the elderly.10,12,35 Carreon et al.10 found that the prevalence of perioperative complications was affected by the number of levels fused, with an odds ratio of 2.40. Cassinelli et al.35 demonstrated that fusion of 4 or more segments was associated with the occurrence of a major complication in patients aged 65 and older. In this study, fusion of 3 or more segments was the risk factor for perioperative complications (major or minor) and perioperative major complications. The average age of patients in this study was 75.7 4.6, which is older than those in the study by Cassinelli et al.35 Longer fusion segments often mean longer surgical time and more blood loss, which is especially important in elderly patients during the perioperative time. Therefore, more cautious extension of fusion segments is suggested in elderly patients. Previous studies showed that surgical complications after spinal surgery were related to age.36,37 In a retrospective study, however, Sobottke et al.38 found no relation between the incidence of surgical complications and patients’ age. Imajo et al.18 compared the incidences of surgical and general complications in the >80-year age group and the 65- to 79-year age group, reporting no difference in complication rate. In accordance with the above studies, we did not find any association between age and perioperative complications. However, other researchers have
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3
21
28
>3
13
16
2
48
42
3
50
58
4
7
10
29
36
0.459
ASA scale
0.495
Complications Yes
82
68
0.185
Surgical time, minutes
No
228.6 76.9
243.8 95.4
0.261
Blood loss, ml
484.5 444.7
490.4 512.8
0.937
17.6 6.2
21.5 11.3
0.006
Hospital stay, days
Bold values are statistically significant. BMI, body mass index; ASA, American Society of Anesthesiologists.
found that more complications are seen in patients aged 80.12,38 Raffo et al.12 reported a 35% major complication rate in patients age 80 and older after spinal fusion, and the odds ratio was 9.2 for a medical comorbidity in this age group. To exclude other affecting factors such as comorbidities, health status, surgical indications, and surgical techniques, higher-quality studies are needed to elucidate the effect of age on perioperative complications. The association between comorbidities and complications remains controversial in the literature. Daubs et al.21 reported no correlation between preoperative comorbidity and complications. Ragab et al.4 also believed that there was no direct association between comorbidity and complications. Some other studies, however, have found the presence or number of comorbidities to increase complication rate.39,40 The results of our study indicated no direct association between preoperative comorbidities
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and perioperative complications. Also, our study revealed that ASA classifications were not associated with perioperative complications, which is consistent with the results of Kim et al.17 There are several limitations of this study. First, this was a retrospective study, which may have underestimated the actual complication rate because all data were obtained from medical records. Second, although the patients included had diagnoses of lumbar stenosis, those combined with degenerative scoliosis were not excluded, which may have caused bias in the analysis. Third, preoperative comorbidities were analyzed by counting the numbers, but different comorbidities may have different weight of effect on perioperative complications. Therefore, these findings may not be applicable to general spinal fusion surgery patients.
complication (major or minor) in elderly patients after lumbar arthrodesis was fusion segment (3), and BMI was a protective factor. Elderly patients with BMI less than 24.32 are more likely to have perioperative complications after lumbar arthrodesis. Older age does not necessarily lead to higher perioperative complication rate in patients over 70. The general condition of patients (ASA scale) and preoperative comorbidities did not affect the risk of perioperative complications. Therefore, lumbar arthrodesis for elderly patients is relatively safe, with acceptable perioperative complication rates, if proper perioperative management is applied, even in patients with many comorbidities.
CONCLUSION
ACKNOWLEDGMENTS
The incidence of complications in this series is similar to that in previously published results. The risk factor of perioperative
The authors thank the staff and patients for their contributions and participation in the present study.
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Conflict of interest statement: This work was supported by the National Natural Science Foundation of China (grant numbers 81672201 and 81871794). Received 7 May 2019; accepted 19 June 2019
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35. Cassinelli EH, Eubanks J, Vogt M, Furey C, Yoo J, Bohlman HH. Risk factors for the development of
39. Oldridge NB, Yuan Z, Stoll JE, Rimm AR. Lumbar spine surgery and mortality among Medicare
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Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.06.147 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Published by Elsevier Inc.
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Complications in Elderly Patients Undergoing Lumbar Arthrodesis for Spinal Stenosis Chao Kong, Xiangyu Li, Xiangyao Sun, Junzhe Ding, Machao Guo, Shibao Lu
PURPOSE: To report the perioperative complication rates in elderly patients undergoing lumbar arthrodesis and to analyze the risk factors.
-
METHODS: Between September 2015 and June 2018, 215 patients aged ‡70 underwent posterior lumbar arthrodesis with pedicle screw fixation. Demographic data including age, gender, smoking status, body mass index (BMI) and preoperative comorbidities were collected. Operative records as the number of levels fused, estimated blood loss, time of surgery, and the occurrence of perioperative complications were reviewed. Risk factors of perioperative complications were determined by logistic regression analysis.
-
RESULTS: The total perioperative complication rate in all patients was 30.2%, of which major complications occurred in 24 patients (11.2%) and minor complications occurred in 41 patients (19.1%). Two risk factors of perioperative complications (major or minor) were chosen: BMI (cutoff value 24.32) and surgical level (‡3). Lower surgical level (‡3) and smaller BMI were risk factors for perioperative minor complications, and major complication was affected only by surgical level (‡3).
-
CONCLUSIONS: The risk factor of perioperative complication in elderly patients after lumbar arthrodesis was fusion segment (‡3), and BMI was a protective factor. Elderly patients with BMI <24.32 are more likely to have perioperative complications after lumbar arthrodesis.
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INTRODUCTION
W
ith the global increase of the geriatric population and life expectancy, the number of elderly patients with symptomatic lumbar degenerative disc diseases requiring surgery is expected to rise.1,2 Lumbar arthrodesis is commonly done in elderly patients to treat lumbar degenerative diseases with instability. With advances in anesthesiology, patient care, and surgical technique, lumbar arthrodesis has been safer for elderly patients, with improved outcome. However, these patients may still be at increased risk for perioperative complications because of their age and associated medical conditions.3,4 Deyo et al.5 reported the rate of complications after lumbar spine surgery to be 18% in patients over 75 years of age. A study of patients aged 75 and older who underwent decompressive spine surgery reported a much higher complication rate (35.2%), which contained a major complication rate of 12.5%.6 By contrast, some other studies reported no difference in perioperative complications between elderly patients and younger patients.7-9 Given that the literature describing the complications of lumbar arthrodesis in elderly patients is inconclusive and at times confusing, the risk factors and estimates of perioperative complications are particularly important. It has not been fully elucidated which factors are the most important in predicting perioperative complications in the geriatric population undergoing lumbar arthrodesis. The purpose of this study was to report the perioperative complication rates in a large cohort of elderly patients undergoing lumbar arthrodesis and to analyze the risk factors. MATERIALS AND METHODS Patient Demographics Between September 2015 and June 2018, 215 patients aged 70 or older underwent posterior lumbar arthrodesis with pedicle screw
Key words Elderly - Lumbar arthrodesis - Perioperative complication - Risk factor
Department of Orthopedics, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
Abbreviations and Acronyms ASA: American Society of Anesthesiologists BMI: body mass index OR: odds ratio ROC: receiver operating curve
Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.06.147
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WORLD NEUROSURGERY -: e1-e7, - 2019
To whom correspondence should be addressed: Shibao Lu, M.D. [E-mail: [email protected]] Chao Kong and Xiangyu Li are coefirst authors.
Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Published by Elsevier Inc.
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fixation by 1 surgeon in our hospital. The main diagnosis was lumbar stenosis with instability, with some accompanied by scoliosis or spondylolisthesis. Patients who had a neoplasm, infectious disease, or trauma and those who had previously undergone lumbar surgery were excluded. Demographic data including age, gender, smoking status, height, weight, and body mass index (BMI) were collected using electronic chart review. The past medical history and comorbidities of all patients were recorded. Operative records were reviewed to determine the number of levels fused, estimated blood loss, time of surgery, and the occurrence of any perioperative complications. Patients’ preoperative physical status was evaluated using the American Society of Anesthesiologists (ASA) classification: class I, no systemic disease; class II, mild to moderate systemic disease; class III, severe systemic disease; IV, severe systemic disease that is life threatening; V, moribund patient with little chance of survival. The ASA status of all patients was classified before surgery by anesthetists and recorded in each patient’s anesthesia note. Three authors who were not involved in the care of these patients reviewed all medical records. Perioperative complications were categorized as minor and major complications as previously defined by Carreon et al.10 Major complications were defined as conditions that were life threatening or that could adversely affect the treatment outcome. Complications noted in the medical records but did not compromise outcome were considered minor complications. All patients underwent a standard midline posterior lumbar decompression at each of the involved levels. During surgery, interbody fusion was preferred in the decompressed levels with pedicle screw and rod instrumentation. In patients with scoliosis, not all fusion levels needed to be decompressed, and posterolateral fusion was chosen in those levels. Postoperative intravenous infusion of antibiotics was used until the drainage tube was removed. After removal of the drainage tube, daily dressing changes were performed. Deep venous thrombosis prevention was undertaken with the use of compression stockings and early mobilization. Routine blood tests and biochemical analysis were performed every other day after surgery until discharge or transfer. Statistical Analysis All statistical analyses were performed with SAS version 9.2 (SAS Institute, Cary, NC). For continuous variables, the statistical significance of differences between groups was assessed by the Wilcoxon 2-sample test after test for normality. For categoric variables, the Fisher exact test was used to test for the statistical significance of differences between groups. P values <0.05 were considered statistically significant. Binary logistic regression was used to identify the risk factors for the occurrence of perioperative complications, and multinominal logistic regression was used to identify the risk factors of perioperative minor and major complications, respectively. The odds ratio (OR) and 95% confidence interval (CI) were determined.
male and 137 (63.7%) were female. The average age was 75.7 4.6 years (range, 70e88 years). The average BMI was 25.6 3.4 (range, 17.5e33.6). The general condition of those patients varied by ASA classification: ASA class II (90 patients, 41.9%), ASA class III (108 patients, 50.2%) and ASA class IV (17 patients, 7.9%). The most common comorbidity was hypertension, which was present preoperatively in 62.9% of the patients. Other common comorbidities were diabetes (23.7%), coronary heart disease (18.9%), cerebral infarction that the patient once had (11.4%), arrhythmia (4%), renal insufficiency (2.9%), and chronic obstructive pulmonary disease (2.3%). In addition, 22.3% of the patients had 1 comorbidity, 31.2% had 2 comorbidities, 22.8% had 3 comorbidities, 13.5% had more than 3 comorbidities, and 10.2% had no comorbidity. Distribution of fusion levels were as follows: 1 segment (21.7%), 2 segments (37.1%), 3 segments (19.4%), and more than 3 segments (21.8%). The average fusion segment length was 2.36 segments. The average surgical time was 237 86.5 minutes (range, 70e639 minutes), and the average blood loss was 486 475.8 ml (range, 80e4000 ml). The average hospital stay was 19 9.3 days (range, 7e81 days). Risk Factors of Complications The total perioperative complication rate in all patients was 30.2%, of which major complications occurred in 24 patients (11.2%) and minor complications occurred in 41 patients (19.1%). The most common minor complication was hypoproteinemia, and the most common major complication was pneumonia. A summary of complications is shown in Table 1. One patient died of myocardial infarction 7 days after surgery. Two patients underwent revision surgery because of cage malposition and epidural hematoma, respectively, during hospitalization. Four patients had deep wound infection and underwent debridement without removing the implant. There were 3 partial root injuries, resulting in numbness in 2 patients and motor deficit in 1 patient. A comparison of the groups is given in Table 2. Patients with complications had much lower BMI, lower surgical levels (3), longer surgical times, and longer hospital stays (P¼0.026, P<0.001, P¼0.050, P¼0.002, respectively). No other significant differences were found between groups in terms of age, gender, comorbidities, ASA scale, and blood loss (P>0.05). After comparison of the 2 groups, 3 variables (BMI, surgical levels, and surgical time) were included in the binary logistic regression analysis of preoperative risk factors. Because hospital stay is an outcome variable, it was left out in the logistic regression analysis. After binary logistic analysis, 2 risk factors of perioperative complications (major or minor) were chosen: BMI (OR¼0.848, CI¼0.758e0.948, P¼0.004) and surgical levels (3) (OR¼2.763, CI¼1.243e6.144, P¼0.013). The cutoff value of BMI is 24.32, which means that elderly patients with BMI less than 24.32 are more likely to have perioperative complications after lumbar arthrodesis. The ROC curve predicting the probability of perioperative complications is shown in Figure 1.
RESULTS Patient Population In this study, 215 patients undergoing lumbar arthrodesis with instrumentation were included. Of those, 78 patients (36.3%) were
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Risk Factors of Major and Minor Complications All variables were then included in the multinominal logistic regression analysis; the only risk factor of perioperative complications (major complication) was lower surgical levels (3)
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Table 1. Perioperative Complications in 55 Patients Major Complication
Number of Patients
Minor Complication
Number of Patients
Table 2. Characteristics of Patients with and without Perioperative Complications Characteristic
Deep wound infection
4
Ileus
Pneumonia
5
Superficial infection
5
Mean age, years
Myocardial infarction
3
Urinary tract infection
3
Gender
Congestive heart failure
1
Superficial deep vein thrombosis
2
Without Complications
65
150
76 4.8
76 4.6
22
56
P Values
2 Total patients
Male
Transient arrhythmias
With Complications
Respiratory distress
1
2
Epidural hematoma
1
Pulmonary embolus
1
Leg dysesthesia
3
Neurologic deficit
3
Intraoperative dura tear
3
Death
1
Hypoproteinemia
9
Cerebral infarction
2
Delirium
2
Revision surgery
2
Female
0.624
43
94
0.647
24.6 3.39
25.9 3.36
0.026
<3
44
108
3
37
26
No
5
17
1
14
34
2
19
48
3
15
34
>3
12
17
2
27
63
3
32
76
4
6
11
0.893
Surgical time, minutes
256.4 83.8
227.6 86.6
0.050
Blood loss, ml
510.2 579.0
477.9 431.5
0.692
24.1 13.6
17.6 5.8
0.002
BMI Surgical level
Confusion
2
<0.001
Comorbidities
0.656
ASA scale
(OR¼2.874, CI¼1.135e12.128, P¼0.011). The ROC curve predicting the probability of perioperative major complications is shown in Figure 2. The risk factors of perioperative minor complications were BMI (OR¼0.829, CI¼0.732e0.938, P¼0.003) and surgical levels (3) (OR¼2.606, CI¼1.061e6.404, P¼0.037). The ROC curve predicting the probability of perioperative minor complications is shown in Figure 3.
Hospital stay, days
Comparison of Younger (£75) with Older (>75) Patients All patients were divided into younger group (75) and older groups (>75). A comparison of the 2 groups is shown in Table 3. The average age was 72 1.7 in the younger group and 80 3.2 in the older group (P<0.001). Older patients had much lower BMI than younger patients (P¼0.028). There were no differences in preoperative comorbidities and ASA scale between the 2 groups (P¼0.459, P¼0.495, respectively). Although the surgical level, surgical time, and blood loss were not significantly different between the 1 groups (P¼0.458, P¼0.261, P¼0.937, respectively), older patients had longer hospital stays (P¼0.006). Perioperative complications (major or minor) were not significantly different between the 2 groups (P¼0.185). DISCUSSION According to China’s national census report in 2016, about 8.87% of the population is now older than 65 years, and the total number has exceeded 120 million. With the aging of the population, the number of elderly patients undergoing posterior decompression and fusion for degenerative lumbar disorders will increase.11 Although advances in anesthesiology, perioperative care, and surgical techniques have made spinal surgeries for geriatric
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Bold values are statistically significant. BMI, body mass index; ASA, American Society of Anesthesiologists.
patients safer and more extensive and complex, identifying risk factors of perioperative complications is still essential for the geriatric population.12,13 To the authors’ knowledge, this is the first study analyzing the risk factors of perioperative complications in China’s geriatric patients undergoing lumbar arthrodesis. The reported perioperative complication rates of lumbar surgeries in elderly patients were diverse.14-17 Nasser et al.13 reported an overall pooled complication rate of 16.4% after reviewing and analyzing the data from 105 spine surgery articles. In a nationwide study, Imajo et al.18 collected data of 8033 elderly patients undergoing spinal surgery, reporting an incidence of complications to be 10.8%. Although data from different centers were collected, only 29.3% of the patients underwent decompression and fusion, which may explain the relatively lower complication rate shown in previous studies.19 Other studies, however, showed the complication rates ranging from 52% to 70%.10,12,17 In this study, the total perioperative complication rate in all patients was 30.2%. Direct comparisons of
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Figure 1. ROC curve of risk factors (BMI and surgical level) predicting perioperative complications. The AUC was 0.7061. ROC, receiver operator curve; AUC, area under the curve; BMI, body mass index.
complication rates among different studies are irrational because a variety of factors will influence the results, and the quality of data is mostly poor. The current study used a binary system defined by Carreon et al.,10 which categorized perioperative complications as major and minor complications. Carreon et al.10 reported a 21% major complication rate and a 70% minor complication rate. Kobayashi et al.20 reported in a multicenter study that perioperative complications occurred in 29% patients, and 13% were major complications. Our study showed similar results, with major complications in 11.2% patients and minor complications in 19.1% patients. The most common major complication was pneumonia (2.3%), and the most common minor complication was hypoproteinemia (4.2%). Pneumonia can be quite life threatening if not treated promptly and correctly. Postoperative hypoproteinemia may have adverse effects on incision healing and lead to superficial infection. Perioperative mortality after lumbar arthrodesis is the most severe complication, ranging from 0% to 17%.3,10,12,21 Inasmuch as no randomized clinical trial or nonrandomized prospective study was performed, the quality of data is relatively poor. In a study that included 10,232 elderly patients undergoing spine surgery, the in-hospital mortality was 0.31%,22 which was consistent with the current study (0.47%). Deyo et al.5 reported a mortality rate of 0. 6%, and Silver et al.23 reported 0.8% for elderly patients after spinal surgery. The long-term mortality in elderly patients who underwent lumbar surgery was found to be equivalent to that in an age-adjusted control group who did not undergo lumbar surgery.24
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Figure 2. ROC curve of risk factors (surgical level) predicting perioperative major complications. The AUC was 0.7349. ROC, receiver operator curve; AUC, area under the curve.
Higher complication rates in obese patients have been reported in previous studies,25-30 with controversial results reported in other studies.31-33 Vaidya et al.26 and Onyekwelu et al.27 demonstrated increased blood loss and longer hospital stays in obese patients after lumbar fusion. In a recent systematic review and meta-analysis, Lingutla et al.34 found that obese patients who underwent lumbar fusion had greater intraoperative blood loss, more complications, and longer duration of surgery. However, in this study, we found that elderly patients with lower BMI more easily experienced perioperative complications, particularly minor complications. And the cutoff value was 24.32, which means that elderly patients with BMI less than 24.32 are more likely to have perioperative complications after lumbar arthrodesis. Possible explanations may be as follows: 1) Elderly patients are different from young patients in many aspects. In younger patients, obesity may pose an increased difficulty in surgery and cause higher surgical complications. But in elderly patients, the average BMI is relatively lower than that in younger patients. As shown in the current study, the average BMI was 25.6 3.4 in all patients, which cannot be defined as obesity. 2) Elderly patients with lower BMI are more likely to be malnourished. After surgery, heavy consumption of food combined with insufficient nutrition intake may lead to serious malnutrition and slower recovery. As suggested in this study, extra attention should be paid to elderly patients with BMI less than 24.32, who may be more likely to experience perioperative complications after lumbar arthrodesis.
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Table 3. Comparison of Younger (75) with Older (>75) Patients Variable Total patients Mean age, years
70e75 Years
>75 Years
111
104
72 1.7
80 3.2
P Values
<0.001
Gender Male
36
35
Female
75
69
0.885
26.1 3.06
24.9 3.67
0.028
<3
81
71
3
30
33
No
11
11
1
28
20
2
38
29
BMI Surgical level
0.458
Comorbidities
Figure 3. ROC curve of risk factors (BMI and surgical level) predicting perioperative minor complications. The AUC was 0.7001. ROC, receiver operator curve; AUC, area under the curve.
We also found that surgical level is a risk factor of perioperative complications after binary logistic regression analysis. Longer fusion segments are sometimes inevitable in elderly patients, especially when coronal deformity or sagittal imbalance need to be corrected. Several studies have suggested that longer fusion segments lead to an increased risk of complications in the elderly.10,12,35 Carreon et al.10 found that the prevalence of perioperative complications was affected by the number of levels fused, with an odds ratio of 2.40. Cassinelli et al.35 demonstrated that fusion of 4 or more segments was associated with the occurrence of a major complication in patients aged 65 and older. In this study, fusion of 3 or more segments was the risk factor for perioperative complications (major or minor) and perioperative major complications. The average age of patients in this study was 75.7 4.6, which is older than those in the study by Cassinelli et al.35 Longer fusion segments often mean longer surgical time and more blood loss, which is especially important in elderly patients during the perioperative time. Therefore, more cautious extension of fusion segments is suggested in elderly patients. Previous studies showed that surgical complications after spinal surgery were related to age.36,37 In a retrospective study, however, Sobottke et al.38 found no relation between the incidence of surgical complications and patients’ age. Imajo et al.18 compared the incidences of surgical and general complications in the >80-year age group and the 65- to 79-year age group, reporting no difference in complication rate. In accordance with the above studies, we did not find any association between age and perioperative complications. However, other researchers have
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3
21
28
>3
13
16
2
48
42
3
50
58
4
7
10
29
36
0.459
ASA scale
0.495
Complications Yes
82
68
0.185
Surgical time, minutes
No
228.6 76.9
243.8 95.4
0.261
Blood loss, ml
484.5 444.7
490.4 512.8
0.937
17.6 6.2
21.5 11.3
0.006
Hospital stay, days
Bold values are statistically significant. BMI, body mass index; ASA, American Society of Anesthesiologists.
found that more complications are seen in patients aged 80.12,38 Raffo et al.12 reported a 35% major complication rate in patients age 80 and older after spinal fusion, and the odds ratio was 9.2 for a medical comorbidity in this age group. To exclude other affecting factors such as comorbidities, health status, surgical indications, and surgical techniques, higher-quality studies are needed to elucidate the effect of age on perioperative complications. The association between comorbidities and complications remains controversial in the literature. Daubs et al.21 reported no correlation between preoperative comorbidity and complications. Ragab et al.4 also believed that there was no direct association between comorbidity and complications. Some other studies, however, have found the presence or number of comorbidities to increase complication rate.39,40 The results of our study indicated no direct association between preoperative comorbidities
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and perioperative complications. Also, our study revealed that ASA classifications were not associated with perioperative complications, which is consistent with the results of Kim et al.17 There are several limitations of this study. First, this was a retrospective study, which may have underestimated the actual complication rate because all data were obtained from medical records. Second, although the patients included had diagnoses of lumbar stenosis, those combined with degenerative scoliosis were not excluded, which may have caused bias in the analysis. Third, preoperative comorbidities were analyzed by counting the numbers, but different comorbidities may have different weight of effect on perioperative complications. Therefore, these findings may not be applicable to general spinal fusion surgery patients.
complication (major or minor) in elderly patients after lumbar arthrodesis was fusion segment (3), and BMI was a protective factor. Elderly patients with BMI less than 24.32 are more likely to have perioperative complications after lumbar arthrodesis. Older age does not necessarily lead to higher perioperative complication rate in patients over 70. The general condition of patients (ASA scale) and preoperative comorbidities did not affect the risk of perioperative complications. Therefore, lumbar arthrodesis for elderly patients is relatively safe, with acceptable perioperative complication rates, if proper perioperative management is applied, even in patients with many comorbidities.
CONCLUSION
ACKNOWLEDGMENTS
The incidence of complications in this series is similar to that in previously published results. The risk factor of perioperative
The authors thank the staff and patients for their contributions and participation in the present study.
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Conflict of interest statement: This work was supported by the National Natural Science Foundation of China (grant numbers 81672201 and 81871794). Received 7 May 2019; accepted 19 June 2019
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