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Preoperative Nutrition Consults Associated with Decreased Postoperative Complication Rate and Decreased Length of Hospital Stay After Spine Metastasis Surgery
Journal Pre-proof Preoperative nutrition consults associated with decreased postoperative complication rate and decreased length of hospital stay after spine metastasis surgery Jeff Ehresman, B.S., A Karim Ahmed, B.S., Andrew Schilling, A.B, Zach Pennington, B.S., Daniel Lubelski, M.D., Ethan Cottrill, B.S., Matthew L. Goodwin, M.D. Ph.D., Alexandra Liddy, R.D., Nancy Abu-Bonsrah, M.D., C Rory Goodwin, M.D, Ph.D., Daniel M. Sciubba, M.D. PII:
S1878-8750(19)32353-8
DOI:
https://doi.org/10.1016/j.wneu.2019.08.197
Reference:
WNEU 13233
To appear in:
World Neurosurgery
Received Date: 25 July 2019 Revised Date:
23 August 2019
Accepted Date: 24 August 2019
Please cite this article as: Ehresman J, Ahmed AK, Schilling A, Pennington Z, Lubelski D, Cottrill E, Goodwin ML, Liddy A, Abu-Bonsrah N, Goodwin CR, Sciubba DM, Preoperative nutrition consults associated with decreased postoperative complication rate and decreased length of hospital stay after spine metastasis surgery, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.08.197. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Title:
Preoperative nutrition consults associated with decreased postoperative complication rate and decreased length of hospital stay after spine metastasis surgery
Running title:
Nutrition consults and postoperative complications
Authors:
Jeff Ehresman, B.S.1, A Karim Ahmed, B.S.1, Andrew Schilling, A.B.1, Zach Pennington, B.S.1, Daniel Lubelski, M.D.1, Ethan Cottrill, B.S.1, Matthew L. Goodwin, M.D. Ph.D.1, Alexandra Liddy, R.D.2, Nancy AbuBonsrah, M.D.1, C Rory Goodwin, M.D, Ph.D.3, Daniel M. Sciubba, M.D.1
Affiliations:
¹Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore MD, USA ²Johns Hopkins Hospital, Department of Clinical Nutrition, Baltimore MD, USA ³Duke University School of Medicine, Department of Neurosurgery, Durham NC, USA
Previous presentations:
None
Correspondence:
Daniel Sciubba, M.D. Johns Hopkins University School of Medicine, Department of Neurosurgery 600 N Wolfe Street Baltimore, MD Phone: 410-955-5077 Fax: (410) 502-0001 Email: [email protected]
Details:
# Text Words # Abstract Words Figures Tables Supplements
2204 230 1 6 None
Key Words: complications, malnutrition, nutrition, outcomes, spinal metastasis
IRB Approval:
IRB approval was obtained prior to beginning this study (application
Figure 1: CONSORT diagram of patient exclusion
Patients undergoing open surgical intervention for spinal metastasis from 2008 to 2016 (n=198)
Excluded patients with hematologic and unknown primary malignancies (n = 34) Excluded patients without 30-day follow-up (n = 21) Excluded patients missing necessary variables (prior weight, albumin, etc.) (n = 48)
95 patients eligible for retrospective study
Patients with nutrition consult within twelve weeks prior to surgery (n = 17)
Patients without nutrition consult within six weeks prior to surgery (n = 78)
1
1
Nutrition consults and postoperative complications
Ehresman et al.
1
Abstract
2
Object: Preoperative malnutrition is associated with increased postoperative complications rates
3
and hospital length of stay. However, the degree to which these risks can be mitigated by
4
nutritional consultation has not been well-described. To address this, we sought to determine if a
5
preoperative nutrition consult was associated with decreased 30-day complication rates and
6
hospital length of stay.
7 8
Methods: Adult patients who underwent neurosurgical intervention for spinal metastases at a
9
tertiary care institution between 2008 and 2016 were retrospectively reviewed. Stepwise
10
multivariable linear regression analyses were used to identify associations with 30-day
11
complication rates and hospital length of stay.
12 13
Results: Among 95 patients who met inclusion criteria, average length of stay was 8.9 days and
14
40 (42.1%) experienced one or more postoperative complications. On multivariable analysis,
15
thirty-day complication rates were higher in the absence of a preoperative nutrition consult, a
16
Modified Charlson Comorbidity Index (MCCI) of greater than 2 points, greater operative blood
17
loss, and malnutrition (Nutritional Risk Index below 97.5). Further, hospitalization duration was
18
increased with the absence of a nutrition consult, malnutrition, congestive heart failure, and prior
19
systemic therapy in the multivariable analysis.
20 21
Conclusion: On multivariable analysis, receipt of a preoperative nutrition consult was associated
22
with both decreased 30-day complication rate and shorter hospitalization. We therefore posit that
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Ehresman et al.
23
greater implementation of nutritional counseling may help to decrease complication rates and
24
expedite discharge in patients undergoing surgical intervention for spinal metastases.
Nutrition consults and postoperative complications 1
Ehresman et al.
Introduction
2
It has become increasingly clear in recent years that patients undergoing treatment of spinal
3
tumors benefit from multidisciplinary management.1 As part of this more holistic strategy, pre-
4
operative consultation and prognostication now incorporates both assessment of the patient’s
5
oncologic disease and their overall health, including medical comorbidities. Malnutrition has
6
often been overlooked despite being one of the most modifiable risk factors for postoperative
7
complications, length of stay, and readmission rates among surgical patients.2,3,4
8 9
One potential tool for improving malnutrition screening is the Nutritional Risk Index (NRI). The NRI, which defines moderate-to-severe malnutrition as a score less than 97.5,5 has
10
previously been demonstrated to accurately predict patients at risk for poor outcomes across a
11
number of pathologies, including heart failure6, 7, end-stage renal disease8, and multiple cancers.9
12
More importantly, a lower NRI score has been tied to an increased risk of wound complications
13
among surgical patients, with a recent study of patients undergoing gastrectomy for stomach
14
cancer finding malnourished patients to have more than 50% higher odds of experiencing one or
15
more post-operative complications.5
16
Because malnourished patients are at risk for poorer outcomes, the question exists as to
17
whether intervention with pre-operative consultation by a trained dietitian may mitigate the risk
18
posed by malnutrition. The literature investigating this is limited but promising. One study of
19
patients undergoing total joint arthroplasty finding pre-operative dietary consultation to be
20
associated with a nearly 50% decrease in complication rates.10 To this end, we decided to
21
investigate this association within a population of patients undergoing surgery for spinal
22
metastases. Specifically, we hypothesized that preoperative malnutrition and failure to receive
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Ehresman et al.
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preoperative nutritional consultation by a trained dietitian would be independently associated
24
with an increased 30-day complication rate and increased length of hospital stay.
25
Methods
26
Patient Selection
27
After obtaining Institutional Review Board approval (#00067508), we queried the medical record
28
for all patients who underwent surgery for spinal metastases at our institution between January
29
2008 and December 2016. Of 198 patients who underwent surgery during the reviewed period,
30
/103 were excluded as summarized in Figure 1. Patients were included if they were ≥18 years
31
old and undergoing surgical management of spinal metastases with MRI of the full mobile spine.
32
Patients were excluded if they did not have solid primary tumors, did not have at least 30-day
33
follow up, or if they had incomplete medical records.
34 35 36
Recorded Variables We recorded variables regarding the patient’s demographics (e.g. age, sex), medical
37
comorbidities (including American Society of Anesthesiologists (ASA) physical status class11
38
and modified Charlson Comorbidity Index (MCCI))12, oncologic history (primary tumor type,
39
radiotherapy and systemic therapy history), surgical details, and lab values (albumin, alkaline
40
phosphatase, hemoglobin, platelets, white blood cell count). Prealbumin levels were not included
41
in this study, as our institution does not routinely collect prealbumin for patients due to lack of
42
consensus regarding predictiveness of complications.13 The modified Charlson Comorbidity
43
Index (mCCI) was calculated from the CCI with the exclusion of the 6 points assigned for the
44
presence of metastatic disease. Complications within 30 days of surgery were recorded as seen in
45
Table 3.
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Ehresman et al.
We also stratified patient nutritional status using the NRI, which includes albumin
47
concentration ([albumin]) and weight loss. Weight loss in the NRI formula is calculated by
48
dividing the patients’ current weight by his/her “usual weight”, which is the weight before
49
metastatic tumor diagnosis. Using the NRI, patients were separated into two groups5: moderate-
50
severe malnutrition (NRI < 97.5) and mild or no malnutrition (NRI ≥ 97.5). The receipt of a
51
preoperative nutritional consult was defined as the patient having received a nutritional
52
consultation within 12 weeks of surgery.
53
To accommodate for the potential influence of the urgency of the patient’s presentation,
54
our analysis also considered whether the patient underwent emergent vs. elective surgery. We
55
defined emergent surgery as surgery occurring within 24 hours of patient presentation.
56 57 58
Statistical Analysis To identify independent predictors, we used a stepwise multivariable linear regression for
59
each outcome of interest – 30-day complication rate and duration of hospitalization. The first
60
step employed univariable analyses to look for associations between the independent variables
61
and the outcome of interest that were significant at the p < 0.05 level. For continuous variables,
62
we used univariable linear regression, for dichotomous and categorical variables we used one-
63
way ANOVA. Using the variables identified as significant, we then performed a multivariable
64
linear regression to evaluate which variables were independent predictors of prolonged
65
hospitalization and a higher 30-day complication rate. In addition, since preoperative nutrition
66
consults are the main focus of the study, the presence of emergent surgery was included as a
67
variable in all multivariable models since these cases would exclude the possibility of obtaining a
68
preoperative nutrition consult. Multivariable coefficients (β) are reported, in addition to 95%
Nutrition consults and postoperative complications
Ehresman et al.
69
confidence intervals in the associated tables. Values with p < 0.05 on the multivariable analysis
70
were considered statistically significant. JMP Pro 13 (SAS Institute Inc., Cary, North Carolina,
71
USA) was used for all analyses.
72 73
Results
74
Preoperative and Operative Characteristics of Patients
75
Of 198 patients who underwent surgery during the reviewed period, 103 were excluded
76
as summarized in Figure 1. The most common reason for exclusion being missing variables in
77
patient medical data (n = 48). The preoperative demographics of the remaining 95 patients
78
included in this study are summarized in Table 1, separated between groups of patients who
79
received preoperative nutrition consults (n=17) and those without preoperative nutrition consults
80
(n=78). Body mass index (BMI) between the two groups was significantly different, with a value
81
of 23.5kg/m2 in the nutrition consult group and 28.1kg/m2 in the non-nutrition consult group (p =
82
0.001). There were no significant differences between groups in terms of comorbidities. Patients
83
given preoperative nutrition consults were more malnourished based on NRI cutoff (p = 0.026).
84
Notably, there were no significant differences in the distribution of primary tumor histology
85
between the two groups.
86
The perioperative characteristics were summarized in Table 2. Patients with preoperative
87
nutrition consults had decreased operative blood loss (622.1 vs. 1304.5 mL, p = 0.018), but were
88
not significantly different in terms of instrumented levels (p = 0.079), corpectomies (p = 0.607),
89
operative duration (p = 0.052), and peri-operative blood transfusions (p = 0.888).
90 91
30-day complication rate and Length of Hospital Stay
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Ehresman et al.
Complications that occurred in the immediate post-operative period and within 30-days
93
of surgery were combined (Table 3), with 42.1% of total patients having at least one
94
complication. There were no significant differences between individual complication-types;
95
however, patients with preoperative nutrition consults had significantly decreased complications
96
rates (p = 0.028) and length of hospital stays (p = 0.031).
97
The factors associated with 30-day complication rate after univariable analyses are
98
summarized in Table 4. Significant factors were receipt of a preoperative nutrition consult (p =
99
0.028), male sex (p = 0.012), moderate-severe malnourishment (NRI < 97.5) (p = 0.0001),
100
albumin levels (p = 0.0001), MCCI of 2 or greater (p = 0.016), ASA physical status class (p =
101
0.004), current steroid use (p = 0.011), operative duration (p = 0.060), and operative blood loss
102
(p = 0.013). As shown in Table 5, the factors associated with increased 30-day complication rate
103
after multivariable analysis were presence of a preoperative nutrition consult (β: -0.590, p =
104
0.040), MCCI greater than 1 (β: 0.743, p = 0.007), increased operative blood loss (β: 0.003, p =
105
0.002), and an NRI below 97.5 (β: 0.718, p = 0.010).
106
The factors associated with increased length of hospital stay after univariable analyses are
107
summarized in Table 4. These factors included the presence of a preoperative nutrition consult
108
(p = 0.031), NRI < 97.5 (p = 0.021), albumin level (p = 0.012), congestive heart failure (p =
109
0.004), ASA physical status class (p = 0.009), operative duration (p = 0.012), and prior systemic
110
treatment (p = 0.005). As shown in Table 6, the factors associated with increased length of
111
hospital stay after multivariable analysis were presence of a preoperative nutrition consult (β: -
112
2.712, p = 0.012), congestive heart failure (β: 6.738, p < .0001), prior systemic therapy (β: 1.967,
113
p = 0.0001), and an NRI < 97.5 (β: 2.711, p = 0.004).
114
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Ehresman et al.
Discussion Preoperative optimization with regard to systemic disease, nutritional status, and medical
117
comorbidities is being increasingly recognized as essential to achieving favorable outcomes in
118
patients undergoing surgery for metastatic spine disease.14 Here we find that in our cohort of 95
119
patients, receipt of a preoperative nutrition consult was associated with both decreased 30-day
120
complication rate and decreased length of hospital stay.
121
The potential role of proper dietary management in mediating better surgical outcomes is
122
readily recognized by surgeons, with a recent survey finding 83% of surgeons agreeing that
123
proper dietary management could decrease perioperative complication rates and 74% agreeing
124
that it may decrease hospital length of stay.15 Despite this, the same survey found that less than
125
40% of the hospitals surveyed had a formal nutrition screening process, highlighting an unmet
126
need in the care of surgical patients.15
127
Within our study population, we found a high rate of malnutrition, with nearly one in every
128
two patients being graded as moderately- to severely-malnourished. Though surprising, these
129
rates are not a significant departure from previous rates reported in the literature. One of the
130
largest studies to date examining this was published by Hebuterne et al, who used the NRI to
131
document the prevalence of malnourishment in 1903 patients.16 They found that 39% of patients
132
were malnourished, raising the question of whether significant baseline cachexia is an
133
underappreciated issue.16 Our numbers suggest that among patients with spinal metastases, this
134
rate may be even higher, approaching 60%, consistent with the finding of Hebuterne, who noted
135
that the rate of malnutrition was nearly twice as high in patients among their cohort with
136
metastatic versus localized disease.16
Nutrition consults and postoperative complications 137
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From a surgical perspective, the question of interest is whether this malnutrition translates
138
into poorer outcomes. This has been suggested to be the case in numerous prior studies,
139
including ones focused on surgical oncology populations.2,3,6,9 Because of this repeated
140
association of malnutrition and poorer outcomes, several hospitals have begun to implement
141
programs designed to combat this issue.17 One such program, implemented at Duke University
142
Medical Center, employs a nutrition protocol designed to address nutritional shortcomings in
143
surgical patients across the inpatient stay.17 This protocol involves first identifying patients at
144
risk with a perioperative nutrition screen and then treating these patients with the necessary
145
supplements pre-, intra-, and postoperatively.17 Further, this protocol was designed for
146
widespread application to all elective surgery population, and our results suggest that
147
customization to the need of the spinal oncology population may help to increase the rate of
148
favorable outcomes.
149
To support this assertion, we note that application of customized nutrition programs to other
150
oncologic and non-oncologic surgical populations has helped to improve post-operative
151
outcomes. Dreznik et al. noted that use of a preoperative nutrition optimization program in
152
patients undergoing abdominal surgery for Crohn’s disease had increased postoperative albumin
153
levels – a sign of better nutritional status – and decreased readmission rates.18 Similarly, in a
154
study of 55 patients undergoing resection of esophageal neoplasms, Kubota et al. showed that
155
administration of five days of oral nutrition supplements preoperatively led to decreased
156
postoperative infections, shorter inpatient stays, and increased 6-month survival.19 These studies,
157
along with the current study, highlight the need for preoperative nutrition optimization to
158
improve patient outcomes.18,19
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While we believe this study provides evidence to the benefits of preoperative nutrition
160
consults, it is not without limitations. As a retrospective study, we are unable to establish that the
161
exact reason patients did or did not receive consultation from dietitians, which creates a potential
162
selection bias and limits the generalizability of the results. We also do not do not report on what
163
nutritional interventions were performed due to insufficient data available, so we are only able to
164
report the impact of a nutritional consult. Further limits to the generalizability of the present
165
study results from the small population of patients receiving nutrition consults and the use of
166
data from a single institution. Implicit in these data may be institutional biases that are not seen
167
in other centers. Additionally, we are unable to establish exactly how nutrition was optimized at
168
these consults. For example, this study is unable to give evidence for protein versus carbohydrate
169
supplementation versus immunonutrition.20 Furthermore, there are multiple validated screening
170
tools for quantifying malnutrition, of which the NRI is but one.21 It is possible that other
171
screening tools may have more prognostic power, highlighting the need for future studies to
172
compare screening systems prospectively and establish the best means of performing
173
preoperative nutritional status evaluation within the spinal metastasis population. Another
174
limitation to this study was the finding that patients who underwent preoperative nutrition
175
consults had decreased operative blood loss. This may indicate a selection bias in that patients
176
with greater morbidity who required nutrition consults underwent more “minimal” surgeries,
177
even though this difference was not detected in our analyses comparing number of operated
178
spine levels, corpectomies, and operative duration. Furthermore, it is possible that these less
179
healthy patients required “extra care” in their hospital stay to maximize their preoperative status,
180
and therefore, led to decreased postoperative complications. Finally, we did not analyze the
181
change in serum albumin levels after nutrition consults and albumin levels were not routinely
Nutrition consults and postoperative complications
Ehresman et al.
182
collected prior to nutritional consultation,18 so we are unable to ascertain whether nutritional
183
consultations in fact lead to improvement nutritional status.
184
This study is the first to show the large benefit of nutrition consultation before surgical
185
treatment for spinal metastasis. The effects of preoperative nutrition consults included decreased
186
postoperative complication rates and decreased hospital stay, which may play a role in improving
187
overall patient safety and reducing hospital costs.
188
Conclusion
189
This is the first study to evaluate the effect of preoperative nutrition consults on
190
postoperative complications and hospital stays after spinal metastases surgery. We found that
191
preoperative nutrition consults may help to decrease 30-day complication rate and days of
192
hospital stay in patients who undergo neurosurgical intervention for spinal metastases. This
193
suggests the presence of an underlying need for nutritional consultation in this highly complex
194
patient population. Additional studies are needed, however, in order to formulate the ideal
195
strategy of nutritional management and to prospectively evaluate its efficacy.
196 197 198 199 200 201 202 203 204
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We have no acknowledgements for this project.
206 207
This research did not receive any specific grant from funding agencies in the public,
208
commercial, or not-for-profit sectors.
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1
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Tables Table 1: Demographic and preoperative data for the 95 included patients Table 2: Perioperative factors for the 95 included patients Table 3: Breakdown of 30-day complication following operative management of vertebral column metastases
Nutrition consults and postoperative complications 72 73 74 75 76 77 78
Ehresman et al.
Table 4: Univariable analysis of predictors of 30-day post-operative complications and length of in-patient stay Table 5: Multivariable analysis of predictors of 30-day complication rate Table 6: Multivariable analysis of predictors of length of hospital stay Figures Figure 1: CONSORT diagram of patient exclusion
1
18
Table 1: Demographic and preoperative data for the 95 included patients Nutrition No Nutrition DEMOGRAPHIC consult consult (n=17) (n=78) Male 10 (58.8%) 47 (60.3%) Age (mean) 62.5 60.0 BMI (mean) 23.5 28.1 ONCOLOGIC Primary tumor type: No. (%) of patients Breast 3 (17.7%) 20 (25.6%) Lung 5 (29.4%) 19 (24.4%) Prostate 3 (17.7%) 16 (20.5%) Renal 3 (17.7%) 12 (15.4%) Melanoma 0 (0%) 5 (6.4%) Liver 1 (5.9%) 2 (2.6%) Bladder 1 (5.9%) 1 (1.3%) Thyroid 0 (0%) 2 (2.6%) Pancreatic 1 (5.9%) 0 (0%) Colorectal 0 (0%) 1 (1.3%) Comorbidities Congestive Heart Failure 2 (11.8%) 6 (7.7%) COPD/asthma 2 (11.8%) 6 (7.7%) Diabetes 2 (11.8%) 14 (17.9%) Liver disease 0 (0%) 6 (7.7%) Renal disease 2 (11.8%) 3 (3.9%) Modified Charlson Comorbidity Index 0-1 8 (47.1%) 35 (44.9%) 2+ 9 (52.9%) 42 (53.9%) Prior Treatment Systemic therapy 14 (82.4%) 55 (70.5%) Radiotherapy 10 (58.8%) 30 (38.5%) Nutritional Risk Index 97.5+ (mild-no malnourishment) 4 (23.5%) 41 (52.6%) < 97.5 (mod-severe 13 (76.5%) 37 (47.4%) malnourishment) 2.1 2.2 ASA Physical Status Class Serum Levels mean (range) Albumin (g/dL) 3.7 3.8 Alkaline Phosphatase 163.2 142.5 (unit/L) Hemoglobin (mg/dL) 10.8 11.5 3 230.3 255.4 Platelets (x10 /µL) 7.5 9.0 White Blood Cell (x103/µL)
p
0.913 0.444 0.001
0.473 0.668 0.786 0.819 0.154 0.514 0.296 0.372 0.062 0.529 0.599 0.599 0.522 0.117 0.232
0.870
0.304 0.126
0.026 0.275 0.188 0.706 0.010 0.449 0.191
Abbreviations: American Society of Anesthesiologists (ASA); Body Mass Index (BMI); Nutritional Risk Index (NRI);), American Society of Anesthesiologists (ASA); Modified Charlson Comorbidity Index (MCCI);
Table 2: Perioperative factors of the included 95 patients Factors Nutrition consult (n = 17) Emergent Surgery Yes No Peri-operative Steroids Yes No Approach Anterior Posterior Combined Operative variables Instrumented spine levels (mean) Corpectomy Duration in minutes median (range) Blood loss mL median (range) Blood transfusion median (range)
No Nutrition consult (n=78)
p
4 (23.5%) 13 (76.5%)
31 (40.8%) 45 (59.2%)
0.172
15 (88.2%) 2 (11.8%)
70 (89.7%) 8 (10.3%)
0.856
1 (5.9%) 16 (94.1%) 0 (0%)
9 (11.5%) 63 (80.8%) 6 (7.7%)
0.208
4.5
5.4
0.078
12 (70.6%) 279.4
50 (64.1%) 314.7
0.607 0.052
622.1
1304.5
0.018
1.1
1.8
0.888
Table 3: Breakdown of 30-day complication following operative management of vertebral column metastases No Nutrition consult p Complication Nutrition consult (n=17) (n=78) Urinary tract infection 0 (%) 5 (6.7%) 0.149 Urinary retention 1 (5.9%) 6 (7.8%) 0.780 Pneumonia 1 (5.9%) 1 (1.3%) 0.299 Fever 0 (0%) 6 (7.8%) 0.115 Surgical site infection 0 (0%) 4 (5.2%) 0.201 Wound dehiscence 1 (5.9%) 8 (11.0%) 0.506 Hypotension 0 (0%) 5 (6.4%) 0.154 Hematoma 1 (5.9%) 1 (1.3%) 0.299 Deep venous thrombosis 1 (5.9%) 3 (3.9%) 0.725 Pulmonary embolism 1 (5.9%) 3 (3.9%) 0.725 Patients with complications 4 (23.5%) 36 (46.2%) 0.078 30-day complication rate 0.35 0.91 0.028 Hospital days mean (95% 6.7 9.3 0.031 range)
Table 4: Univariable analysis of predictors of 30-day post-operative complications and length of in-patient stay (significant if p < 0.05) Variable 30-day complication Length of Stay rate p-value p-value Age (years) Male BMI (kg/m2) NRI < 97.5 (mod-severe malnourished) Albumin (g/dL) Alkaline phosphatase (unit/L) Hemoglobin (mg/dL) Platelet count (x103/µL) WBC count (x103/µL) Diabetes Liver disease Renal disease COPD/asthma Congestive heart failure MCCI 2+ ASA physical status class Steroids Number of spine levels operated on Operative duration (minutes) Approach Emergent surgery Preoperative nutrition consult Operative blood loss
0.295 0.012 0.948 0.0001 0.0001 0.741 0.446 0.132 0.752 0.164 0.471 0.694 0.253 0.089 0.016 0.004 0.011 0.265 0.118
0.213 0.835 0.129 0.021 0.012 0.271 0.631 0.489 0.761 0.097 0.208 0.848 0.084 0.004 0.071 0.009 0.856 0.131 0.012
0.512 0.859 0.028 0.013
0.759 0.755 0.031 0.259
Prior systemic treatment
0.713
0.005
Prior local radiotherapy
0.458
0.417
Abbreviations: American Society of Anesthesiologists (ASA); Body Mass Index (BMI); Nutritional Risk Index (NRI);),; Modified Charlson Comorbidity Index (MCCI); Chronic Obstructive Pulmonary Disease (COPD); White Blood Cell (WBC);
Table 5: Multivariable analysis of predictors of 30-day complication rate (significant if p < 0.05) Variable Parameter 95% Confidence Interval p-value Estimate Operative blood loss 0.003 0.001 – 0.005 0.002 MCCI 2+ 0.743 0.207 – 1.279 0.007 NRI < 97.5 (mod-severe malnourished) 0.718 0.179 – 1.257 0.010 Preoperative nutrition consult -0.590 -1.173 – (-0.008) 0.040 Steroids 0.143 Albumin 0.548 ASA physical status class 0.988 Male 0.991 Abbreviations: American Society of Anesthesiologists (ASA); Modified Charlson Comorbidity Index (MCCI); Nutritional Risk Index (NRI)
Table 6: Multivariable analysis of predictors of length of hospital stay (significant if p < 0.05) Variable Parameter 95% Confidence Interval p-value Estimate Congestive heart failure 6.738 3.644 – 9.831 <.0001 Prior systemic treatment 1.967 0.999 – 2.935 0.0001 NRI < 97.5 (mod-severe malnourished) 2.711 0.911 – 4.512 0.004 Preoperative nutrition consult -2.712 -5.213 – (-0.670) 0.012 Operative duration 0.146 Albumin 0.391 ASA physical status class 0.624 Abbreviations: American Society of Anesthesiologists (ASA); Nutritional Risk Index (NRI)
Abbreviations ASA
American Society of Anesthesiologists
BMI
Body mass index
COPD
Chronic obstructive pulmonary disease
MCCI
Modified Charlson Comorbidity Index
MRI
Magnetic resonance imaging
NRI
Nutritional Risk Index
WBC
White blood cell
S1878-8750(19)32353-8
DOI:
https://doi.org/10.1016/j.wneu.2019.08.197
Reference:
WNEU 13233
To appear in:
World Neurosurgery
Received Date: 25 July 2019 Revised Date:
23 August 2019
Accepted Date: 24 August 2019
Please cite this article as: Ehresman J, Ahmed AK, Schilling A, Pennington Z, Lubelski D, Cottrill E, Goodwin ML, Liddy A, Abu-Bonsrah N, Goodwin CR, Sciubba DM, Preoperative nutrition consults associated with decreased postoperative complication rate and decreased length of hospital stay after spine metastasis surgery, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.08.197. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Title:
Preoperative nutrition consults associated with decreased postoperative complication rate and decreased length of hospital stay after spine metastasis surgery
Running title:
Nutrition consults and postoperative complications
Authors:
Jeff Ehresman, B.S.1, A Karim Ahmed, B.S.1, Andrew Schilling, A.B.1, Zach Pennington, B.S.1, Daniel Lubelski, M.D.1, Ethan Cottrill, B.S.1, Matthew L. Goodwin, M.D. Ph.D.1, Alexandra Liddy, R.D.2, Nancy AbuBonsrah, M.D.1, C Rory Goodwin, M.D, Ph.D.3, Daniel M. Sciubba, M.D.1
Affiliations:
¹Johns Hopkins University School of Medicine, Department of Neurosurgery, Baltimore MD, USA ²Johns Hopkins Hospital, Department of Clinical Nutrition, Baltimore MD, USA ³Duke University School of Medicine, Department of Neurosurgery, Durham NC, USA
Previous presentations:
None
Correspondence:
Daniel Sciubba, M.D. Johns Hopkins University School of Medicine, Department of Neurosurgery 600 N Wolfe Street Baltimore, MD Phone: 410-955-5077 Fax: (410) 502-0001 Email: [email protected]
Details:
# Text Words # Abstract Words Figures Tables Supplements
2204 230 1 6 None
Key Words: complications, malnutrition, nutrition, outcomes, spinal metastasis
IRB Approval:
IRB approval was obtained prior to beginning this study (application
Figure 1: CONSORT diagram of patient exclusion
Patients undergoing open surgical intervention for spinal metastasis from 2008 to 2016 (n=198)
Excluded patients with hematologic and unknown primary malignancies (n = 34) Excluded patients without 30-day follow-up (n = 21) Excluded patients missing necessary variables (prior weight, albumin, etc.) (n = 48)
95 patients eligible for retrospective study
Patients with nutrition consult within twelve weeks prior to surgery (n = 17)
Patients without nutrition consult within six weeks prior to surgery (n = 78)
1
1
Nutrition consults and postoperative complications
Ehresman et al.
1
Abstract
2
Object: Preoperative malnutrition is associated with increased postoperative complications rates
3
and hospital length of stay. However, the degree to which these risks can be mitigated by
4
nutritional consultation has not been well-described. To address this, we sought to determine if a
5
preoperative nutrition consult was associated with decreased 30-day complication rates and
6
hospital length of stay.
7 8
Methods: Adult patients who underwent neurosurgical intervention for spinal metastases at a
9
tertiary care institution between 2008 and 2016 were retrospectively reviewed. Stepwise
10
multivariable linear regression analyses were used to identify associations with 30-day
11
complication rates and hospital length of stay.
12 13
Results: Among 95 patients who met inclusion criteria, average length of stay was 8.9 days and
14
40 (42.1%) experienced one or more postoperative complications. On multivariable analysis,
15
thirty-day complication rates were higher in the absence of a preoperative nutrition consult, a
16
Modified Charlson Comorbidity Index (MCCI) of greater than 2 points, greater operative blood
17
loss, and malnutrition (Nutritional Risk Index below 97.5). Further, hospitalization duration was
18
increased with the absence of a nutrition consult, malnutrition, congestive heart failure, and prior
19
systemic therapy in the multivariable analysis.
20 21
Conclusion: On multivariable analysis, receipt of a preoperative nutrition consult was associated
22
with both decreased 30-day complication rate and shorter hospitalization. We therefore posit that
Nutrition consults and postoperative complications
Ehresman et al.
23
greater implementation of nutritional counseling may help to decrease complication rates and
24
expedite discharge in patients undergoing surgical intervention for spinal metastases.
Nutrition consults and postoperative complications 1
Ehresman et al.
Introduction
2
It has become increasingly clear in recent years that patients undergoing treatment of spinal
3
tumors benefit from multidisciplinary management.1 As part of this more holistic strategy, pre-
4
operative consultation and prognostication now incorporates both assessment of the patient’s
5
oncologic disease and their overall health, including medical comorbidities. Malnutrition has
6
often been overlooked despite being one of the most modifiable risk factors for postoperative
7
complications, length of stay, and readmission rates among surgical patients.2,3,4
8 9
One potential tool for improving malnutrition screening is the Nutritional Risk Index (NRI). The NRI, which defines moderate-to-severe malnutrition as a score less than 97.5,5 has
10
previously been demonstrated to accurately predict patients at risk for poor outcomes across a
11
number of pathologies, including heart failure6, 7, end-stage renal disease8, and multiple cancers.9
12
More importantly, a lower NRI score has been tied to an increased risk of wound complications
13
among surgical patients, with a recent study of patients undergoing gastrectomy for stomach
14
cancer finding malnourished patients to have more than 50% higher odds of experiencing one or
15
more post-operative complications.5
16
Because malnourished patients are at risk for poorer outcomes, the question exists as to
17
whether intervention with pre-operative consultation by a trained dietitian may mitigate the risk
18
posed by malnutrition. The literature investigating this is limited but promising. One study of
19
patients undergoing total joint arthroplasty finding pre-operative dietary consultation to be
20
associated with a nearly 50% decrease in complication rates.10 To this end, we decided to
21
investigate this association within a population of patients undergoing surgery for spinal
22
metastases. Specifically, we hypothesized that preoperative malnutrition and failure to receive
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23
preoperative nutritional consultation by a trained dietitian would be independently associated
24
with an increased 30-day complication rate and increased length of hospital stay.
25
Methods
26
Patient Selection
27
After obtaining Institutional Review Board approval (#00067508), we queried the medical record
28
for all patients who underwent surgery for spinal metastases at our institution between January
29
2008 and December 2016. Of 198 patients who underwent surgery during the reviewed period,
30
/103 were excluded as summarized in Figure 1. Patients were included if they were ≥18 years
31
old and undergoing surgical management of spinal metastases with MRI of the full mobile spine.
32
Patients were excluded if they did not have solid primary tumors, did not have at least 30-day
33
follow up, or if they had incomplete medical records.
34 35 36
Recorded Variables We recorded variables regarding the patient’s demographics (e.g. age, sex), medical
37
comorbidities (including American Society of Anesthesiologists (ASA) physical status class11
38
and modified Charlson Comorbidity Index (MCCI))12, oncologic history (primary tumor type,
39
radiotherapy and systemic therapy history), surgical details, and lab values (albumin, alkaline
40
phosphatase, hemoglobin, platelets, white blood cell count). Prealbumin levels were not included
41
in this study, as our institution does not routinely collect prealbumin for patients due to lack of
42
consensus regarding predictiveness of complications.13 The modified Charlson Comorbidity
43
Index (mCCI) was calculated from the CCI with the exclusion of the 6 points assigned for the
44
presence of metastatic disease. Complications within 30 days of surgery were recorded as seen in
45
Table 3.
Nutrition consults and postoperative complications 46
Ehresman et al.
We also stratified patient nutritional status using the NRI, which includes albumin
47
concentration ([albumin]) and weight loss. Weight loss in the NRI formula is calculated by
48
dividing the patients’ current weight by his/her “usual weight”, which is the weight before
49
metastatic tumor diagnosis. Using the NRI, patients were separated into two groups5: moderate-
50
severe malnutrition (NRI < 97.5) and mild or no malnutrition (NRI ≥ 97.5). The receipt of a
51
preoperative nutritional consult was defined as the patient having received a nutritional
52
consultation within 12 weeks of surgery.
53
To accommodate for the potential influence of the urgency of the patient’s presentation,
54
our analysis also considered whether the patient underwent emergent vs. elective surgery. We
55
defined emergent surgery as surgery occurring within 24 hours of patient presentation.
56 57 58
Statistical Analysis To identify independent predictors, we used a stepwise multivariable linear regression for
59
each outcome of interest – 30-day complication rate and duration of hospitalization. The first
60
step employed univariable analyses to look for associations between the independent variables
61
and the outcome of interest that were significant at the p < 0.05 level. For continuous variables,
62
we used univariable linear regression, for dichotomous and categorical variables we used one-
63
way ANOVA. Using the variables identified as significant, we then performed a multivariable
64
linear regression to evaluate which variables were independent predictors of prolonged
65
hospitalization and a higher 30-day complication rate. In addition, since preoperative nutrition
66
consults are the main focus of the study, the presence of emergent surgery was included as a
67
variable in all multivariable models since these cases would exclude the possibility of obtaining a
68
preoperative nutrition consult. Multivariable coefficients (β) are reported, in addition to 95%
Nutrition consults and postoperative complications
Ehresman et al.
69
confidence intervals in the associated tables. Values with p < 0.05 on the multivariable analysis
70
were considered statistically significant. JMP Pro 13 (SAS Institute Inc., Cary, North Carolina,
71
USA) was used for all analyses.
72 73
Results
74
Preoperative and Operative Characteristics of Patients
75
Of 198 patients who underwent surgery during the reviewed period, 103 were excluded
76
as summarized in Figure 1. The most common reason for exclusion being missing variables in
77
patient medical data (n = 48). The preoperative demographics of the remaining 95 patients
78
included in this study are summarized in Table 1, separated between groups of patients who
79
received preoperative nutrition consults (n=17) and those without preoperative nutrition consults
80
(n=78). Body mass index (BMI) between the two groups was significantly different, with a value
81
of 23.5kg/m2 in the nutrition consult group and 28.1kg/m2 in the non-nutrition consult group (p =
82
0.001). There were no significant differences between groups in terms of comorbidities. Patients
83
given preoperative nutrition consults were more malnourished based on NRI cutoff (p = 0.026).
84
Notably, there were no significant differences in the distribution of primary tumor histology
85
between the two groups.
86
The perioperative characteristics were summarized in Table 2. Patients with preoperative
87
nutrition consults had decreased operative blood loss (622.1 vs. 1304.5 mL, p = 0.018), but were
88
not significantly different in terms of instrumented levels (p = 0.079), corpectomies (p = 0.607),
89
operative duration (p = 0.052), and peri-operative blood transfusions (p = 0.888).
90 91
30-day complication rate and Length of Hospital Stay
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Ehresman et al.
Complications that occurred in the immediate post-operative period and within 30-days
93
of surgery were combined (Table 3), with 42.1% of total patients having at least one
94
complication. There were no significant differences between individual complication-types;
95
however, patients with preoperative nutrition consults had significantly decreased complications
96
rates (p = 0.028) and length of hospital stays (p = 0.031).
97
The factors associated with 30-day complication rate after univariable analyses are
98
summarized in Table 4. Significant factors were receipt of a preoperative nutrition consult (p =
99
0.028), male sex (p = 0.012), moderate-severe malnourishment (NRI < 97.5) (p = 0.0001),
100
albumin levels (p = 0.0001), MCCI of 2 or greater (p = 0.016), ASA physical status class (p =
101
0.004), current steroid use (p = 0.011), operative duration (p = 0.060), and operative blood loss
102
(p = 0.013). As shown in Table 5, the factors associated with increased 30-day complication rate
103
after multivariable analysis were presence of a preoperative nutrition consult (β: -0.590, p =
104
0.040), MCCI greater than 1 (β: 0.743, p = 0.007), increased operative blood loss (β: 0.003, p =
105
0.002), and an NRI below 97.5 (β: 0.718, p = 0.010).
106
The factors associated with increased length of hospital stay after univariable analyses are
107
summarized in Table 4. These factors included the presence of a preoperative nutrition consult
108
(p = 0.031), NRI < 97.5 (p = 0.021), albumin level (p = 0.012), congestive heart failure (p =
109
0.004), ASA physical status class (p = 0.009), operative duration (p = 0.012), and prior systemic
110
treatment (p = 0.005). As shown in Table 6, the factors associated with increased length of
111
hospital stay after multivariable analysis were presence of a preoperative nutrition consult (β: -
112
2.712, p = 0.012), congestive heart failure (β: 6.738, p < .0001), prior systemic therapy (β: 1.967,
113
p = 0.0001), and an NRI < 97.5 (β: 2.711, p = 0.004).
114
Nutrition consults and postoperative complications 115 116
Ehresman et al.
Discussion Preoperative optimization with regard to systemic disease, nutritional status, and medical
117
comorbidities is being increasingly recognized as essential to achieving favorable outcomes in
118
patients undergoing surgery for metastatic spine disease.14 Here we find that in our cohort of 95
119
patients, receipt of a preoperative nutrition consult was associated with both decreased 30-day
120
complication rate and decreased length of hospital stay.
121
The potential role of proper dietary management in mediating better surgical outcomes is
122
readily recognized by surgeons, with a recent survey finding 83% of surgeons agreeing that
123
proper dietary management could decrease perioperative complication rates and 74% agreeing
124
that it may decrease hospital length of stay.15 Despite this, the same survey found that less than
125
40% of the hospitals surveyed had a formal nutrition screening process, highlighting an unmet
126
need in the care of surgical patients.15
127
Within our study population, we found a high rate of malnutrition, with nearly one in every
128
two patients being graded as moderately- to severely-malnourished. Though surprising, these
129
rates are not a significant departure from previous rates reported in the literature. One of the
130
largest studies to date examining this was published by Hebuterne et al, who used the NRI to
131
document the prevalence of malnourishment in 1903 patients.16 They found that 39% of patients
132
were malnourished, raising the question of whether significant baseline cachexia is an
133
underappreciated issue.16 Our numbers suggest that among patients with spinal metastases, this
134
rate may be even higher, approaching 60%, consistent with the finding of Hebuterne, who noted
135
that the rate of malnutrition was nearly twice as high in patients among their cohort with
136
metastatic versus localized disease.16
Nutrition consults and postoperative complications 137
Ehresman et al.
From a surgical perspective, the question of interest is whether this malnutrition translates
138
into poorer outcomes. This has been suggested to be the case in numerous prior studies,
139
including ones focused on surgical oncology populations.2,3,6,9 Because of this repeated
140
association of malnutrition and poorer outcomes, several hospitals have begun to implement
141
programs designed to combat this issue.17 One such program, implemented at Duke University
142
Medical Center, employs a nutrition protocol designed to address nutritional shortcomings in
143
surgical patients across the inpatient stay.17 This protocol involves first identifying patients at
144
risk with a perioperative nutrition screen and then treating these patients with the necessary
145
supplements pre-, intra-, and postoperatively.17 Further, this protocol was designed for
146
widespread application to all elective surgery population, and our results suggest that
147
customization to the need of the spinal oncology population may help to increase the rate of
148
favorable outcomes.
149
To support this assertion, we note that application of customized nutrition programs to other
150
oncologic and non-oncologic surgical populations has helped to improve post-operative
151
outcomes. Dreznik et al. noted that use of a preoperative nutrition optimization program in
152
patients undergoing abdominal surgery for Crohn’s disease had increased postoperative albumin
153
levels – a sign of better nutritional status – and decreased readmission rates.18 Similarly, in a
154
study of 55 patients undergoing resection of esophageal neoplasms, Kubota et al. showed that
155
administration of five days of oral nutrition supplements preoperatively led to decreased
156
postoperative infections, shorter inpatient stays, and increased 6-month survival.19 These studies,
157
along with the current study, highlight the need for preoperative nutrition optimization to
158
improve patient outcomes.18,19
Nutrition consults and postoperative complications 159
Ehresman et al.
While we believe this study provides evidence to the benefits of preoperative nutrition
160
consults, it is not without limitations. As a retrospective study, we are unable to establish that the
161
exact reason patients did or did not receive consultation from dietitians, which creates a potential
162
selection bias and limits the generalizability of the results. We also do not do not report on what
163
nutritional interventions were performed due to insufficient data available, so we are only able to
164
report the impact of a nutritional consult. Further limits to the generalizability of the present
165
study results from the small population of patients receiving nutrition consults and the use of
166
data from a single institution. Implicit in these data may be institutional biases that are not seen
167
in other centers. Additionally, we are unable to establish exactly how nutrition was optimized at
168
these consults. For example, this study is unable to give evidence for protein versus carbohydrate
169
supplementation versus immunonutrition.20 Furthermore, there are multiple validated screening
170
tools for quantifying malnutrition, of which the NRI is but one.21 It is possible that other
171
screening tools may have more prognostic power, highlighting the need for future studies to
172
compare screening systems prospectively and establish the best means of performing
173
preoperative nutritional status evaluation within the spinal metastasis population. Another
174
limitation to this study was the finding that patients who underwent preoperative nutrition
175
consults had decreased operative blood loss. This may indicate a selection bias in that patients
176
with greater morbidity who required nutrition consults underwent more “minimal” surgeries,
177
even though this difference was not detected in our analyses comparing number of operated
178
spine levels, corpectomies, and operative duration. Furthermore, it is possible that these less
179
healthy patients required “extra care” in their hospital stay to maximize their preoperative status,
180
and therefore, led to decreased postoperative complications. Finally, we did not analyze the
181
change in serum albumin levels after nutrition consults and albumin levels were not routinely
Nutrition consults and postoperative complications
Ehresman et al.
182
collected prior to nutritional consultation,18 so we are unable to ascertain whether nutritional
183
consultations in fact lead to improvement nutritional status.
184
This study is the first to show the large benefit of nutrition consultation before surgical
185
treatment for spinal metastasis. The effects of preoperative nutrition consults included decreased
186
postoperative complication rates and decreased hospital stay, which may play a role in improving
187
overall patient safety and reducing hospital costs.
188
Conclusion
189
This is the first study to evaluate the effect of preoperative nutrition consults on
190
postoperative complications and hospital stays after spinal metastases surgery. We found that
191
preoperative nutrition consults may help to decrease 30-day complication rate and days of
192
hospital stay in patients who undergo neurosurgical intervention for spinal metastases. This
193
suggests the presence of an underlying need for nutritional consultation in this highly complex
194
patient population. Additional studies are needed, however, in order to formulate the ideal
195
strategy of nutritional management and to prospectively evaluate its efficacy.
196 197 198 199 200 201 202 203 204
Nutrition consults and postoperative complications 205
Ehresman et al.
We have no acknowledgements for this project.
206 207
This research did not receive any specific grant from funding agencies in the public,
208
commercial, or not-for-profit sectors.
Nutrition consults and postoperative complications
Ehresman et al.
1
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Tables Table 1: Demographic and preoperative data for the 95 included patients Table 2: Perioperative factors for the 95 included patients Table 3: Breakdown of 30-day complication following operative management of vertebral column metastases
Nutrition consults and postoperative complications 72 73 74 75 76 77 78
Ehresman et al.
Table 4: Univariable analysis of predictors of 30-day post-operative complications and length of in-patient stay Table 5: Multivariable analysis of predictors of 30-day complication rate Table 6: Multivariable analysis of predictors of length of hospital stay Figures Figure 1: CONSORT diagram of patient exclusion
1
18
Table 1: Demographic and preoperative data for the 95 included patients Nutrition No Nutrition DEMOGRAPHIC consult consult (n=17) (n=78) Male 10 (58.8%) 47 (60.3%) Age (mean) 62.5 60.0 BMI (mean) 23.5 28.1 ONCOLOGIC Primary tumor type: No. (%) of patients Breast 3 (17.7%) 20 (25.6%) Lung 5 (29.4%) 19 (24.4%) Prostate 3 (17.7%) 16 (20.5%) Renal 3 (17.7%) 12 (15.4%) Melanoma 0 (0%) 5 (6.4%) Liver 1 (5.9%) 2 (2.6%) Bladder 1 (5.9%) 1 (1.3%) Thyroid 0 (0%) 2 (2.6%) Pancreatic 1 (5.9%) 0 (0%) Colorectal 0 (0%) 1 (1.3%) Comorbidities Congestive Heart Failure 2 (11.8%) 6 (7.7%) COPD/asthma 2 (11.8%) 6 (7.7%) Diabetes 2 (11.8%) 14 (17.9%) Liver disease 0 (0%) 6 (7.7%) Renal disease 2 (11.8%) 3 (3.9%) Modified Charlson Comorbidity Index 0-1 8 (47.1%) 35 (44.9%) 2+ 9 (52.9%) 42 (53.9%) Prior Treatment Systemic therapy 14 (82.4%) 55 (70.5%) Radiotherapy 10 (58.8%) 30 (38.5%) Nutritional Risk Index 97.5+ (mild-no malnourishment) 4 (23.5%) 41 (52.6%) < 97.5 (mod-severe 13 (76.5%) 37 (47.4%) malnourishment) 2.1 2.2 ASA Physical Status Class Serum Levels mean (range) Albumin (g/dL) 3.7 3.8 Alkaline Phosphatase 163.2 142.5 (unit/L) Hemoglobin (mg/dL) 10.8 11.5 3 230.3 255.4 Platelets (x10 /µL) 7.5 9.0 White Blood Cell (x103/µL)
p
0.913 0.444 0.001
0.473 0.668 0.786 0.819 0.154 0.514 0.296 0.372 0.062 0.529 0.599 0.599 0.522 0.117 0.232
0.870
0.304 0.126
0.026 0.275 0.188 0.706 0.010 0.449 0.191
Abbreviations: American Society of Anesthesiologists (ASA); Body Mass Index (BMI); Nutritional Risk Index (NRI);), American Society of Anesthesiologists (ASA); Modified Charlson Comorbidity Index (MCCI);
Table 2: Perioperative factors of the included 95 patients Factors Nutrition consult (n = 17) Emergent Surgery Yes No Peri-operative Steroids Yes No Approach Anterior Posterior Combined Operative variables Instrumented spine levels (mean) Corpectomy Duration in minutes median (range) Blood loss mL median (range) Blood transfusion median (range)
No Nutrition consult (n=78)
p
4 (23.5%) 13 (76.5%)
31 (40.8%) 45 (59.2%)
0.172
15 (88.2%) 2 (11.8%)
70 (89.7%) 8 (10.3%)
0.856
1 (5.9%) 16 (94.1%) 0 (0%)
9 (11.5%) 63 (80.8%) 6 (7.7%)
0.208
4.5
5.4
0.078
12 (70.6%) 279.4
50 (64.1%) 314.7
0.607 0.052
622.1
1304.5
0.018
1.1
1.8
0.888
Table 3: Breakdown of 30-day complication following operative management of vertebral column metastases No Nutrition consult p Complication Nutrition consult (n=17) (n=78) Urinary tract infection 0 (%) 5 (6.7%) 0.149 Urinary retention 1 (5.9%) 6 (7.8%) 0.780 Pneumonia 1 (5.9%) 1 (1.3%) 0.299 Fever 0 (0%) 6 (7.8%) 0.115 Surgical site infection 0 (0%) 4 (5.2%) 0.201 Wound dehiscence 1 (5.9%) 8 (11.0%) 0.506 Hypotension 0 (0%) 5 (6.4%) 0.154 Hematoma 1 (5.9%) 1 (1.3%) 0.299 Deep venous thrombosis 1 (5.9%) 3 (3.9%) 0.725 Pulmonary embolism 1 (5.9%) 3 (3.9%) 0.725 Patients with complications 4 (23.5%) 36 (46.2%) 0.078 30-day complication rate 0.35 0.91 0.028 Hospital days mean (95% 6.7 9.3 0.031 range)
Table 4: Univariable analysis of predictors of 30-day post-operative complications and length of in-patient stay (significant if p < 0.05) Variable 30-day complication Length of Stay rate p-value p-value Age (years) Male BMI (kg/m2) NRI < 97.5 (mod-severe malnourished) Albumin (g/dL) Alkaline phosphatase (unit/L) Hemoglobin (mg/dL) Platelet count (x103/µL) WBC count (x103/µL) Diabetes Liver disease Renal disease COPD/asthma Congestive heart failure MCCI 2+ ASA physical status class Steroids Number of spine levels operated on Operative duration (minutes) Approach Emergent surgery Preoperative nutrition consult Operative blood loss
0.295 0.012 0.948 0.0001 0.0001 0.741 0.446 0.132 0.752 0.164 0.471 0.694 0.253 0.089 0.016 0.004 0.011 0.265 0.118
0.213 0.835 0.129 0.021 0.012 0.271 0.631 0.489 0.761 0.097 0.208 0.848 0.084 0.004 0.071 0.009 0.856 0.131 0.012
0.512 0.859 0.028 0.013
0.759 0.755 0.031 0.259
Prior systemic treatment
0.713
0.005
Prior local radiotherapy
0.458
0.417
Abbreviations: American Society of Anesthesiologists (ASA); Body Mass Index (BMI); Nutritional Risk Index (NRI);),; Modified Charlson Comorbidity Index (MCCI); Chronic Obstructive Pulmonary Disease (COPD); White Blood Cell (WBC);
Table 5: Multivariable analysis of predictors of 30-day complication rate (significant if p < 0.05) Variable Parameter 95% Confidence Interval p-value Estimate Operative blood loss 0.003 0.001 – 0.005 0.002 MCCI 2+ 0.743 0.207 – 1.279 0.007 NRI < 97.5 (mod-severe malnourished) 0.718 0.179 – 1.257 0.010 Preoperative nutrition consult -0.590 -1.173 – (-0.008) 0.040 Steroids 0.143 Albumin 0.548 ASA physical status class 0.988 Male 0.991 Abbreviations: American Society of Anesthesiologists (ASA); Modified Charlson Comorbidity Index (MCCI); Nutritional Risk Index (NRI)
Table 6: Multivariable analysis of predictors of length of hospital stay (significant if p < 0.05) Variable Parameter 95% Confidence Interval p-value Estimate Congestive heart failure 6.738 3.644 – 9.831 <.0001 Prior systemic treatment 1.967 0.999 – 2.935 0.0001 NRI < 97.5 (mod-severe malnourished) 2.711 0.911 – 4.512 0.004 Preoperative nutrition consult -2.712 -5.213 – (-0.670) 0.012 Operative duration 0.146 Albumin 0.391 ASA physical status class 0.624 Abbreviations: American Society of Anesthesiologists (ASA); Nutritional Risk Index (NRI)
Abbreviations ASA
American Society of Anesthesiologists
BMI
Body mass index
COPD
Chronic obstructive pulmonary disease
MCCI
Modified Charlson Comorbidity Index
MRI
Magnetic resonance imaging
NRI
Nutritional Risk Index
WBC
White blood cell