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Liu S, Sulovari A, Joo P, Thirukumaran C, Benn L, Mesfin A. Relationship between 25-hydroxy Vitamin D level and surgical site infection in spine surgery. Surg Neurol Int 2024; 15:173. [PMID: 38840603 PMCID: PMC11152506 DOI: 10.25259/sni_135_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 04/25/2024] [Indexed: 06/07/2024] Open
Abstract
Background 25-hydroxy Vitamin D (25[OH]D) level has been shown to have antimicrobial and wound healing effects in animal models. Low preoperative 25(OH)D has been shown to correlate with surgical site infection (SSI) in thoracolumbar spine surgery. Methods This study involved 545 patients undergoing thoracolumbar spine surgery from 2012 to 2019 at an academic medical center. We evaluated the serum 25(OH)D level (i.e., adequate level = level 30-60 ng/dL), along with SSI, body mass index, and smoking status. Statistical analysis was done using bivariate analysis with Fisher's exact, Wilcoxon rank-sum test and multivarible logisitic regression analyses. Results We included 545 patients in the study, and there were no statistical differences in the average preoperative 25(OH)D between SSI and non-SSI groups. The average 25(OH)D in the non-SSI group was 31.6 ng/dL ± 13.6, and the SSI group was 35.7 ng/dL ± 20.2 (P = 0.63). Conclusion SSI rates following thoracolumbar spine surgery were not affected by preoperative 25(OH)D levels.
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Affiliation(s)
- Serena Liu
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, United States
| | - Aron Sulovari
- Department of Anesthesiology, Westchester Medical Center, Valhalla, New York, United States
| | - Peter Joo
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, United States
| | - Caroline Thirukumaran
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, United States
| | - Lancelot Benn
- Department of Orthopaedic Surgery, Howard University College of Medicine, Washington, United States
| | - Addisu Mesfin
- Department of Orthopaedics, MedStar Orthopaedic Institute, Washington, United States
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Zink TM, Kent SE, Choudhary AN, Kavolus JJ. Nutrition in Surgery: An Orthopaedic Perspective. J Bone Joint Surg Am 2023; 105:1897-1906. [PMID: 37856576 DOI: 10.2106/jbjs.23.00259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
➤ Malnutrition is common among subsets of patients undergoing orthopaedic surgery and is associated with an increased risk of postoperative complications.➤ Serum proteins, in particular, albumin, may be used in the evaluation of nutritional status.➤ Anthropometric measurements and surveys also play a role in the evaluation of nutritional status.➤ Increased energy and nutrient requirements due to surgical procedures necessitate increased caloric and protein intake in the perioperative period, which may be achieved through diet or supplementation.➤ Evidence supports the use of protein-calorie, amino acid, and immunonutrition supplements. Vitamin D supplementation is an area of further consideration.➤ Diet restriction, activity alterations, pharmacotherapy, and bariatric surgery are all safe, effective approaches to weight loss, although the optimal timing and magnitude of preoperative weight loss require further investigation.
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Affiliation(s)
- Thomas M Zink
- Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Suzanne E Kent
- Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | | | - Joseph J Kavolus
- Tufts University School of Medicine, Boston, Massachusetts
- Newton-Wellesley Orthopedic Associates, Newton, Massachusetts
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Bertelli HD, Aquino JLBD, Leandro-Merhi VÂA. Lower 25-hydroxyvitamin D (25OHD) levels, diabetes and age are associated with foot and ankle fracture treatment complications. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2023; 67:e220020. [PMID: 37738466 PMCID: PMC10665043 DOI: 10.20945/2359-4292-2022-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 07/11/2022] [Indexed: 09/24/2023]
Abstract
Objective This study investigated the nutritional status, 25-hydroxyvitamin D (25OHD), albumin and risk factors associated with complications in patients with foot and ankle fragility fractures. Subjects and methods Prospective study, developed with patients who suffered fractures due to fragility of the foot and ankle (n = 108); the type of fractured bone, fracture mechanisms and classification were studied and also pseudoarthrosis, treatment, surgical dehiscence, anthropometry, 25OHD and albumin. The Chi-square or Fisher's exact test, Mann-Whitney and Kruskal-Wallis tests were used in the statistical analysis and the multiple logistic regression analysis was used to identify the risk factors associated with complications. Results The factors that, together, were associated with treatment complications were the level of 25OHD (p = 0.0055; OR = 0.868 [1,152]; 95% CI = 0.786; 0.959 [1.043;1.272]) and diabetes (p = 0.0034; OR = 30,181; 95% CI = 3.087; 295.036). The factors that, together, were associated with the presence of any complication, were age (p = 0.0139; OR = 1.058; 95% CI = 1.011; 1,106) and 25OHD level (p = 0.0198; OR = 0.917; 95% CI = 0.852; 0.986). There was a complication probability above 0.40 associated with lower 25OHD levels (values below 20 ng/mL) and older age (over 50 years). Conclusion Lower or abnormal levels of 25OHD were associated with pseudoarthrosis, and age and 25OHD were both risk factors for treatment complications in patients with foot and ankle fractures.
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Affiliation(s)
- Hallan Douglas Bertelli
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Escola de Ciências da Vida, Programa de Pós-graduaçÃo em Ciências da Saúde, Campinas, SP, Brasil
| | - José Luis Braga de Aquino
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Escola de Ciências da Vida, Programa de Pós-graduaçÃo em Ciências da Saúde, Campinas, SP, Brasil
| | - VÂnia Aparecida Leandro-Merhi
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Escola de Ciências da Vida, Programa de Pós-graduaçÃo em Ciências da Saúde, Campinas, SP, Brasil, ,
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Arora A, Cummins DD, Wague A, Mendelis J, Samtani R, McNeill I, Theologis AA, Mummaneni PV, Berven S. Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review. Spine Deform 2023; 11:773-785. [PMID: 36811703 PMCID: PMC10261200 DOI: 10.1007/s43390-023-00654-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/21/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The purpose of this study is to provide a state-of-the-art review regarding risk factors for perioperative complications in adult spinal deformity (ASD) surgery. The review includes levels of evidence for risk factors associated with complications in ASD surgery. METHODS Using the PubMed database, we searched for complications, risk factors, and adult spinal deformity. The included publications were assessed for level of evidence as described in clinical practice guidelines published by the North American Spine Society, with summary statements generated for each risk factor (Bono et al. in Spine J 9:1046-1051, 2009). RESULTS Frailty had good evidence (Grade A) as a risk for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization. CONCLUSIONS Identification of risk factors for perioperative complications in ASD surgery is a priority for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of perioperative complications.
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Affiliation(s)
- Ayush Arora
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Daniel D Cummins
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Aboubacar Wague
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Joseph Mendelis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Rahul Samtani
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Ian McNeill
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University California, San Francisco, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA.
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Diebo BG, Kovoor M, Alsoof D, Beyer GA, Rompala A, Balmaceno-Criss M, Mai DH, Segreto FA, Shah NV, Lafage R, Passias PG, Aaron RK, Daniels AH, Paulino CB, Schwab FJ, Lafage V. Metabolic Bone Disorders Are Predictors for 2-year Adverse Outcomes in Patients Undergoing 2-3 Level Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy or Myelopathy. Clin Spine Surg 2023; 36:120-126. [PMID: 36864582 DOI: 10.1097/bsd.0000000000001452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/25/2023] [Indexed: 03/04/2023]
Abstract
STUDY DESIGN Retrospective cohort study utilizing the New York statewide planning and research cooperative system. STUDY OBJECTIVE To investigate postoperative complications of patients with metabolic bone disorders (MBDs) who undergo 2-3 levels of anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA MBDs and cervical degenerative pathologies, including cervical radiculopathy (CR) and cervical myelopathy (CM), are prevalent in the aging population. Complications with ACDF procedures can lead to increased hospitalization times, more expensive overhead, and worse patient outcomes. METHOD Patients with CM/CR who underwent an ACDF of 2-3 vertebrae from 2009 to 2011 with a minimum 2-year follow-up were identified. Patients diagnosed with 1 or more MBD at baseline were compared with a control cohort without any MBD diagnosis. Cohorts were compared for demographics, hospital-related parameters, and 2-year medical, surgical, and overall complications. Binary multivariate logistic regression was used to identify independent predictors. RESULTS A total of 22,276 patients were identified (MBD: 214; no-MBD: 22,062). Among MBD patients, the majority had vitamin D deficiency (n = 194, 90.7%). MBD patients were older (53.0 vs 49.7 y, P < 0.001), and with higher Deyo index (1.0 vs 0.5, P < 0.001). MBD patients had higher rates of medical complications, including anemia (6.1% vs 2.3%), pneumonia (4.7% vs 2.1%), hematoma (3.3% vs 0.7%), infection (2.8% vs 0.9%), and sepsis (3.7% vs 0.9%), as well as overall medical complications (23.8% vs 9.6%) (all, P ≤0.033). MBD patients also experienced higher surgical complications, including implant-related (5.7% vs 1.9%), wound infection (4.2% vs 1.2%), and wound disruption (0.9% vs 0.2%), and overall surgical complications (9.8% vs 3.2%) (all, P ≤0.039). Regression analysis revealed that a baseline diagnosis of MBD was independently associated with an increased risk of 2-year surgical complications (odds ratio = 2.10, P < 0.001) and medical complications (odds ratio = 1.84, P = 0.001). CONCLUSIONS MBD as a comorbidity was associated with an increased risk of 2-year postoperative complications after 2-3 level ACDF for CR or CM.
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Affiliation(s)
- Bassel G Diebo
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | - Matthew Kovoor
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | - Daniel Alsoof
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | | | | | - Mariah Balmaceno-Criss
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | - David H Mai
- Department of Orthopedics, SUNY Downstate, Brooklyn
| | | | - Neil V Shah
- Department of Orthopedics, SUNY Downstate, Brooklyn
| | | | | | - Roy K Aaron
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
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Miniksar ÖH, Yüksek A, Göçmen AY, Katar MK, Kılıç M, Honca M. Serum vitamin D le Serum vitamin D levels are associated with acute post e associated with acute postoperative pain and opioid analgesic consumption after laparoscopic cholecystect cholecystectomy: a str omy: a strobe compliant pr obe compliant prospectiv ospective obser e observational ational study. Turk J Med Sci 2023; 53:171-182. [PMID: 36945925 PMCID: PMC10387885 DOI: 10.55730/1300-0144.5570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/20/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND In this prospective observational study, we aimed to evaluate the relationship between serum levels of vitamin D and acute postoperative pain scores, as well as opioid analgesic consumption in patients undergoing laparoscopic cholecystectomy. METHODS : The study was performed in the Medical Faculty Hospital, from April 2020 to April 2021. Postoperative visual analog scale (VAS) pain scores, total tramadol consumption, number of requests on patient-controlled analgesia (PCA) were compared between the vitamin D deficient (≤20 ng/mL; n = 25) and vitamin D nondeficient (>20 ng/mL; n = 55) groups at five time points (T0: in the recovery room, T1: 1st hour in the ward, T2: 6th hour, T3: 12th hour, and T4: 24th hour). RESULTS Postoperative VAS pain scores were similar in the vitamin D deficient group at all time points (T0-4), but differed significantly only at the T-0 time point (p = 0.020). The mean cumulative tramadol consumption was significantly higher in the vitamin D deficiency group than in the nondeficiency group (p = 0.005). Vitamin D levels were lower in patients with VAS ≥ 4 at the postoperative T-0 time point (p = 0.009). In the multivariate linear regression analysis, 15.7% of cumulative tramadol consumption was due to vitamin D deficiency (β = -0.188). DISCUSSION : Our study shows that preoperative low vitamin D level was associated with an increase in acute postoperative pain scores and consumption of opioid analgesics in patients undergoing laparoscopic cholecystectomy. Our findings may be useful for postoperative pain management in patients with vitamin D deficiency.
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Affiliation(s)
- Ökkeş Hakan Miniksar
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Ahmet Yüksek
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Ayşe Yeşim Göçmen
- Department of Biochemistry, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Mehmet Kağan Katar
- Department of General Surgery, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Mahmut Kılıç
- Department of Public Health, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turke
| | - Mehtap Honca
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
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Robison B, Wright C, Smith S, Philipp T, Yoo J. Vitamin D deficiency during the perioperative period increases the rate of hardware failure and the need for revision fusion in adult patients undergoing single-level lumbar spine instrumentation surgery. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 13:100197. [PMID: 36655115 PMCID: PMC9841266 DOI: 10.1016/j.xnsj.2022.100197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
Background Vitamin D has been shown to play important roles in both calcium homeostasis and bone healing. Only three studies have directly examined the relationship between vitamin D deficiency and hardware failure, nonunion, and/or revision surgery. Results are contradictory and none were large enough to provide the statistical power necessary to make definitive conclusions. Methods A retrospective analysis was performed utilizing the PearlDiver national insurance claims database consisting of 91 million individual patient records. Patients aged 30 and over who underwent a non-segmental posterior lumbar fusion procedure (CPT-22840) in 2012-2019 were included. Data collected included, hardware failure, revision surgery occurrence, and vitamin D deficiency. Hardware failure and revision rates were compared between vitamin D deficient and non-deficient groups. We ran a logistic regression analysis using the following variables: age, Charlson Comorbidity Index (CCI), gender, vitamin D deficiency, obesity, tobacco use, diabetes, osteoporosis, rheumatoid arthritis, and Crohn's disease. Results 108,137 patients matching inclusion criteria were identified, with an overall hardware failure rate of 2.7% and revision rate of 4.1%. Failure rates were significantly higher for patients diagnosed with vitamin D deficiency during the full queried period (3.3% vs. 2.6%, OR = 1.26; p < 0.0001), as were revision rates (4.3% vs 3.5%, OR = 1.25; p < 0.0001). Patients diagnosed with deficiency pre-surgery, higher failure (3.1% vs 2.6%, OR = 1.19; p < 0.01) and rates of revision (4.4% vs 3.5%, OR = 1.27; p < 0.0001) were increased compared to the non-deficient group. In the logistic regression analysis, vitamin D deficiency remains a significant contributor to hardware failure and revision surgery. Conclusions These results demonstrate that pre- and/or post-operative vitamin D deficiency is independently correlated with risk for hardware failure and revision surgery in single-level lumbar fusion patients.
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Affiliation(s)
- Bianca Robison
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, OHSU. 3181 SW Sam Jackson Park Rd, Mail Code OP-31, Portland, OR 97239, USA
| | - Christina Wright
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Spencer Smith
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, OHSU. 3181 SW Sam Jackson Park Rd, Mail Code OP-31, Portland, OR 97239, USA
| | - Travis Philipp
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, OHSU. 3181 SW Sam Jackson Park Rd, Mail Code OP-31, Portland, OR 97239, USA
| | - Jung Yoo
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, OHSU. 3181 SW Sam Jackson Park Rd, Mail Code OP-31, Portland, OR 97239, USA,Corresponding author.
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Bajaj A, Shah RM, Goodwin AM, Kurapaty S, Patel AA, Divi SN. The Role of Preoperative Vitamin D in Spine Surgery. Curr Rev Musculoskelet Med 2022; 16:48-54. [PMID: 36538281 PMCID: PMC9889582 DOI: 10.1007/s12178-022-09813-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Vitamin D is an essential micronutrient for human bone health and maintenance. Patients undergoing orthopaedic surgery with hypovitaminosis D may be at greater risk for worsened clinical outcomes. This narrative review aims to compile the current literature studying the effects of low preoperative vitamin D on spine surgery outcomes, creating a resource that clinicians can use to inform their practice. RECENT FINDINGS Vitamin D deficiency predisposes to worse outcomes following spine surgery. Vitamin D supplementation may be beneficial in reducing the risk for adverse postoperative events; however, the literature is inconclusive regarding its efficacy in improving bone density and fracture risk. Spine clinicians should be aware of the increased risk for poor outcomes in patients with preoperative vitamin D deficiency. Future investigations are needed to better evaluate the benefits of preoperative vitamin D screening and supplementation on improving surgical outcomes in spine patients. These studies must also consider the effects on perioperative healthcare costs.
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Affiliation(s)
- Anitesh Bajaj
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Rohan M. Shah
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Alyssa M. Goodwin
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Steven Kurapaty
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Alpesh A. Patel
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Srikanth N. Divi
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611 USA
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Hu MH, Tseng YK, Chung YH, Wu NY, Li CH, Lee PY. The efficacy of oral vitamin D supplements on fusion outcome in patients receiving elective lumbar spinal fusion—a randomized control trial. BMC Musculoskelet Disord 2022; 23:996. [PMID: 36401234 PMCID: PMC9673414 DOI: 10.1186/s12891-022-05948-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/02/2022] [Indexed: 11/19/2022] Open
Abstract
Background Previous studies have reported that vitamin D supplement could improve fracture healing, but evidence regarding the role of vitamin D supplements in spinal fusion was limited. Thus, this study aimed to evaluate the effectiveness of oral vitamin D supplements on fusion outcomes in patients undergoing lumbar spinal fusion. Methods This randomized, double-blind, parallel-designed, active-control trial included the patients who planned for elective lumbar spinal fusion. Eligible patients were randomly assigned to receive either daily vitamin D3 (cholecalciferol) 800 IU and daily calcium citrate 600 mg (experimental group) or only daily calcium citrate 600 mg (control group). All supplements were given from postoperative day 1 and lasted for 3 months. Primary outcome was postoperative 1-year fusion rate, and secondary outcomes included time to fusion, Oswestry Disability Index (ODI), and visual analogue scale (VAS) for pain. Results Among the included 34 patients (21 in the experimental group and 13 in the control group), baseline 25-hydroxyvitamin D (25[OHVitD) level was 26.7 (10.4) ng/ml. Preoperative prevalence of vitamin D deficiency and insufficiency were 23.5% and 47.1%, respectively. Postoperative 1-year fusion rate was not significantly different between the two groups (95.2% vs. 84.6%, P = 0.544). The experimental group had significantly shorter time to fusion (Kaplan–Meier estimated: 169 days vs. 185 days [interquartile range: 88–182 days vs. 176–324 days], log-rank test: P = 0.028), lower postoperative 6-month ODI (P < 0.001), and lower postoperative 6-month VAS (P < 0.001) than the control group. Time to fusion was significantly and negatively correlated with preoperative, postoperative 3-month, and 6-month 25(OH)VitD levels (all P < 0.01). Conclusion The patient with vitamin D supplements had shorter time to fusion, better spinal function and less pain after elective spinal fusion. Further research is warranted to identify the patients who can benefit the most from vitamin D supplements and the appropriate dose of vitamin D supplements. Trial registration ClinicalTrials.gov, NCT05023122. Registered 20 August 2021. Retrospectively registered, http://clinicaltrials.gov/ct2/show/NCT03793530. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05948-9.
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Yu Y, Robinson DL, Ackland DC, Yang Y, Lee PVS. Influence of the geometric and material properties of lumbar endplate on lumbar interbody fusion failure: a systematic review. J Orthop Surg Res 2022; 17:224. [PMID: 35399075 PMCID: PMC8996478 DOI: 10.1186/s13018-022-03091-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/22/2022] [Indexed: 11/12/2022] Open
Abstract
Background Lumbar interbody fusion (LIF) is an established surgical intervention for patients with leg and back pain secondary to disc herniation or degeneration. Interbody fusion involves removal of the herniated or degenerated disc and insertion of interbody devices with bone grafts into the remaining cavity. Extensive research has been conducted on operative complications such as a failure of fusion or non-union of the vertebral bodies. Multiple factors including surgical, implant, and patient factors influencing the rate of complications have been identified. Patient factors include age, sex, osteoporosis, and patient anatomy. Complications can also be influenced by the interbody cage design. The geometry of the bony endplates as well as their corresponding material properties guides the design of interbody cages, which vary considerably across patients with spinal disorders. However, studies on the effects of such variations on the rate of complications are limited. Therefore, this study aimed to perform a systematic review of lumbar endplate geometry and material property factors in LIF failure. Methods Search keywords included ‘factor/cause for spinal fusion failure/cage subsidence/cage migration/non-union’, ‘lumbar’, and ‘interbody’ in electronic databases PubMed and Scopus with no limits on year of publication. Results In total, 1341 articles were reviewed, and 29 articles were deemed suitable for inclusion. Adverse events after LIF, such as cage subsidence, cage migration, and non-union, resulted in fusion failure; hence, risk factors for adverse events after LIF, notably those associated with lumbar endplate geometry and material properties, were also associated with fusion failure. Those risk factors were associated with shape, concavity, bone mineral density and stiffness of endplate, segmental disc angle, and intervertebral disc height. Conclusions This review demonstrated that decreased contact areas between the cage and endplate, thin and weak bony endplate as well as spinal diseases such as spondylolisthesis and osteoporosis are important causes of adverse events after LIF. These findings will facilitate the selection and design of LIF cages, including customised implants based on patient endplate properties. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03091-8.
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Donnally CJ, Henstenburg JM, Pezzulo JD, Farronato D, Patel PD, Sherman M, Canseco JA, Kepler CK, Vaccaro AR. Increased Surgical Site Subcutaneous Fat Thickness Is Associated with Infection after Posterior Cervical Fusion. Surg Infect (Larchmt) 2022; 23:364-371. [PMID: 35262398 DOI: 10.1089/sur.2021.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Previous literature has associated increased body mass index (BMI) with risk of surgical site infection (SSI) after posterior cervical fusion (PCF) surgery. However, few studies have examined the association between local adiposity and risk of SSI, re-admission, and re-operation after PCF. Local adiposity is easily measured on pre-operative magnetic resonance imaging (MRI) and may act as a more accurate predictor compared with BMI. Patients and Methods: Subjects undergoing PCF from 2013-2018 at a single institution were identified retrospectively. Posterior cervical subcutaneous fat thickness, paraspinal muscle thickness, and lamina-to-skin distance measurements were obtained from computed tomography (CT) or MRI scans. Subjects with active infection, malignancy, or revision procedures were excluded. Results: Two hundred five patients were included with 20 developing SSIs. Subjects with SSIs had a longer fusion construct (4.90 vs. 3.71 levels; p = 0.001), higher Elixhauser comorbidity index (ECI; 2.05 vs. 1.34; p = 0.045), had a history of diabetes mellitus (30% vs. 10.8%; p = 0.026), higher subcutaneous fat thickness (30.5 vs. 23.6 mm; p = 0.013), and higher lamina-to-skin distance (66.4 vs. 57.9 mm; p = 0.027). Subcutaneous fat thickness (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.10]; p = 0.026) and lamina-to-skin distance (OR, 1.05; 95% CI, 1.01-1.09]; p = 0.014) were associated with SSI in multivariable analysis. A subcutaneous fat thickness cutoff value of 23.2 mm had 90% sensitivity and 54.1% specificity for prediction of SSI. There was no association need for re-admission or re-operation. Conclusions: Increased posterior cervical fat may increase the risk of SSI after PCF. Pre-operative advanced imaging may be a valuable tool for assisting with patient counseling, optimization, and risk stratification.
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Affiliation(s)
- Chester J Donnally
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeffery M Henstenburg
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joshua D Pezzulo
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dominic Farronato
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parthik D Patel
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthew Sherman
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Sardar ZM, Coury JR, Cerpa M, DeWald CJ, Ames CP, Shuhart C, Watkins C, Polly DW, Dirschl DR, Klineberg EO, Dimar JR, Krohn KD, Kebaish KM, Tosi LL, Kelly M, Lane NE, Binkley NC, Berven SH, Lee NJ, Anderson P, Angevine PD, Lehman RA, Lenke LG. Best Practice Guidelines for Assessment and Management of Osteoporosis in Adult Patients Undergoing Elective Spinal Reconstruction. Spine (Phila Pa 1976) 2022; 47:128-135. [PMID: 34690329 DOI: 10.1097/brs.0000000000004268] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Expert consensus study. OBJECTIVE This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to elective spinal reconstruction. SUMMARY OF BACKGROUND DATA Currently, no guidelines exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. Untreated osteoporosis in spine reconstruction surgery is associated with higher complications and worse outcomes. METHODS A multidisciplinary panel with 18 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Surveys and discussions regarding the current literature were held according to Delphi method until a final set of guidelines was created with over 70% consensus. RESULTS Panelists agreed that bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic glucocorticoid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units of the vertebrae can be useful in identifying poor bone health. In the absence of contraindications, anabolic agents are considered first line therapy due to their bone building properties as compared with antiresorptive medications. Medications should be administered preoperatively for at least 2 months and postoperatively for minimum 8 months. CONCLUSION Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also established guidelines on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population.Level of Evidence: 5.
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Affiliation(s)
- Zeeshan M Sardar
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Josephine R Coury
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Meghan Cerpa
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | | | | | | | - Colleen Watkins
- West Virginia University School of Medicine, J.W. Ruby Memorial Hospital, WV
| | | | | | | | - John R Dimar
- Norton Leatherman Spine, University of Louisville, Louisville, KY
| | | | | | - Laura L Tosi
- Children's National Hospital, George Washington University, WA
| | | | | | | | | | - Nathan J Lee
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | | | - Peter D Angevine
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Ronald A Lehman
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Lawrence G Lenke
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
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13
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Mayo BC, Massel DH, Yacob A, Narain AS, Hijji FY, Jenkins NW, Parrish JM, Modi KD, Long WW, Hrynewycz NM, Brundage TS, Singh K. A Review of Vitamin D in Spinal Surgery: Deficiency Screening, Treatment, and Outcomes. Int J Spine Surg 2020; 14:447-454. [PMID: 32699770 DOI: 10.14444/7059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this review, we discuss the demonstrated value of vitamin D in bone maintenance, fracture resistance, spinal health, and spine surgery outcomes. Despite this, the effect of vitamin D levels in spine surgery has not been well described. Through this review of literature, several conclusions were drawn. First, despite the fact that a high number of spine surgery patients are vitamin D deficient, screening is not commonly performed. Second, adequate vitamin D levels will not be achieved in a majority of these patients without supplementation. Last, inadequate vitamin D levels may increase the risk of pseudarthrosis. Given these findings, we suggest that many patients undergoing spinal surgery could be treated with vitamin D supplementation prior to surgery without the need for confirmatory testing for vitamin D deficiency. This is a more cost-effective method than screening all patients. However, future randomized trials and cost-effectiveness analyses are needed to determine the ultimate effects of vitamin D supplementation on clinical morbidity and surgical outcomes.
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Affiliation(s)
- Benjamin C Mayo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Dustin H Massel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Alem Yacob
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Ankur S Narain
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Fady Y Hijji
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nathaniel W Jenkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - James M Parrish
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Krishna D Modi
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - William W Long
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nadia M Hrynewycz
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Thomas S Brundage
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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