Perioperative cardiopulmonary complications after cervical spine surgery in the prone position: the relationship between age and preoperative testing

Cardiac Complications Related to Spine Surgery: Timing, Risk Factors, and Clinical Effect

INTRODUCTION

Large cohort studies evaluating cardiac complications in patients undergoing spine surgery are lacking. The purpose of this study was to determine the incidence, timing, risk factors, and effect of cardiac complications in spine surgery by using a national database, the American College of Surgeons National Surgical Quality Improvement Program.

METHODS

Patients who underwent spine surgery in the 2005 to 2012 National Surgical Quality Improvement Program database were identified. The primary outcome was an occurrence of cardiac arrest or myocardial infarction during the operation or the 30-day postoperative period. Risk factors for development of cardiac complications were identified using multivariate regression. The postoperative length of stay, 30-day readmission, and mortality were compared between patients who did and did not experience a cardiac complication.

RESULTS

A total of 30,339 patients who underwent spine surgery were identified. The incidence of cardiac complications was 0.34% (95% confidence interval [CI], 0.27% to 0.40%). Of the cases in which a cardiac complication developed, 30% were diagnosed after discharge. Risk factors for the development of cardiac complications were greater age (most notably ≥80 years, relative risk [RR] = 5.53; 95% CI = 2.28 to 13.43; P < 0.001), insulin-dependent diabetes (RR = 2.58; 95% CI = 1.51 to 4.41; P = 0.002), preoperative anemia (RR = 2.46; 95% CI = 1.62 to 3.76; P < 0.001), and history of cardiac disorders and treatments (RR = 1.88; 95% CI = 1.16 to 3.07; P = 0.011). Development of a cardiac complication before discharge was associated with a greater length of stay (7.9 versus 2.6 days; P < 0.001), and a cardiac complication after discharge was associated with increased 30-day readmission (RR = 12.32; 95% CI = 8.17 to 18.59; P < 0.001). Development of a cardiac complication any time during the operation or 30-day postoperative period was associated with increased mortality (RR = 113.83; 95% CI = 58.72 to 220.68; P < 0.001).

DISCUSSION

Perioperative cardiac complications were diagnosed in approximately 1 in 300 patients undergoing spine surgery. High-risk patients should be medically optimized and closely monitored through the perioperative period.

LEVEL OF EVIDENCE

Level III.

Mini-open anterior approach for cervicothoracic junction fracture: technical note

Elderly patients with diffuse idiopathic skeletal hyperostosis are at high risk for falls, and 3-column unstable fractures present multiple challenges. Unstable fractures across the cervicothoracic junction are associated with significant morbidity and require fixation, which is commonly performed through a posterior open or percutaneous approach. The authors describe a novel, navigated, mini-open anterior approach using intraoperative cone-beam CT scanning to place lag screws followed by an anterior plate in a 97-year-old patient. This approach is less invasive and faster than an open posterior approach and can be considered as an option for management of cervicothoracic junction fractures in elderly patients with high perioperative risk profile who cannot tolerate being placed prone during surgery.

Risk factors for 30-day outcomes in elective anterior versus posterior cervical fusion: A matched cohort analysis

OBJECTIVE

Cervical spine fusion is the preferred treatment modality for a variety of degenerative and/or myelopathic disorders. Surgeons select between two approaches (anterior or posterior cervical fusion [ACF; PCF]) based on pathoanatomical features and spinal levels involved. Complications and outcome profiles between the approaches following elective surgery have not been systematically investigated.

METHODS

Adult patients undergoing elective ACF or PCF were extracted from the American College of Surgeons National Surgical Quality Improvement Program years 2011-2014. Five hundred twenty-eight patients (264 ACF and 264 PCF) were matched 1:1 by age, sex, functional status, vertebral levels operated, and the American Society of Anesthesiologists classification. Multivariable regression was performed by surgical approach for operation time, complications, hospital length of stay (HLOS), and discharge destination, controlling for body mass index and comorbidities. Mean differences (B), odds ratios (ORs), and 95% confidence intervals (CIs) are reported.

RESULTS

Compared to ACF, PCF was associated with increased odds of blood transfusions >1 unit (OR = 4.31, 95% CI [1.18-15.75]; P = 0.027) and failure to discharge to home (OR = 3.68 [2.17-6.25]; P < 0.001), and increased mean HLOS (B = 1.72 days [1.19-2.26]; P < 0.001). No differences in operation time, other complications, or reoperation rates were found by surgical approach.

CONCLUSIONS

In a matched cohort analysis by age, sex, functional and physical status, and vertebral levels, elective PCF is associated with increased HLOS and increased likelihood of failing to discharge to home compared to ACF without increased risk of 30-day complications. Increased blood transfusion volume is noted for patients undergoing PCF. Future prospective studies are warranted.

The prone position during surgery and its complications: a systematic review and evidence-based guidelines

Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with this type of surgery, as physiologic changes occur with increased pressure to anterior structures. While several studies have discussed postoperative vision loss, much fewer studies with lower levels of evidence have addressed other complications. A systematic literature review was conducted using 2 different databases, and 53 papers were regarded as appropriate for inclusion. Qualitative and quantitative analysis was performed. Thirteen complications were identified. Postoperative vision loss and cardiovascular complications, including hypovolemia and cardiac arrest, had the most number of studies and highest level of evidence. Careful planning for optimal positioning, padding, timing, as well as increased vigilance are evidence-based recommendations where operative prone positioning is required.

Incidence and mortality of perioperative cardiac events in cervical spine surgery

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

To determine the national incidence, mortality, and risk factors for perioperative cardiac complications associated with cervical spine surgery in the United States.

SUMMARY OF BACKGROUND DATA

Perioperative myocardial infarctions and cardiac failure are leading causes of mortality in noncardiac surgery. The incidence of these complications has not been reported in cervical spine surgery.

METHODS

Data from the Nationwide Inpatient Sample was obtained from 2002-2009. Patients undergoing anterior or posterior cervical fusion and posterior cervical decompression without fusion for degenerative etiologies were identified. Only elective admissions were included. Incidences of cardiac complications were identified and patient demographics, hospital costs, length of stay, and mortality were compared for each group. Logistic regression was used to identify independent predictors of cardiac complications.

RESULTS

A total of 214,900 elective cervical spine procedures were identified in the United States from 2002-2009. Overall, there were 4.0 cardiac events per 1000 cases. For individual procedures, the incidence was 11.6 per 1000 posterior cervical fusions, 5.2 per 1000 posterior cervical decompressions, and 3.2 per 1000 anterior cervical fusions. Patients with cardiac events were statistically older with greater comorbidities (P < 0.0005). Across all cohorts, length of stay increased an additional 4.5 days, hospital costs increased $13,435, and mortality increased from 0.8 to 65.3 deaths per 1000 cases in the presence of a cardiac event (P < 0.0005). Logistic regression analysis demonstrated that independent predictors for cardiac events included age 65 years or more, multilevel fusions, acute blood-loss anemia, congestive heart failure, fluid/electrolyte disorders, and pulmonary circulation disorders.

CONCLUSION

Our results demonstrate an overall incidence of 4.0 cardiac events per 1000 cervical spine surgical procedures. Older patients with greater comorbid risk factors, particularly cardiovascular diseases, were at significantly increased risk for cardiac complications. Due to the large impact cardiac events have on health care utilization and mortality, we recommend thorough risk stratification for older patients undergoing elective cervical spine procedures.

LEVEL OF EVIDENCE

3.