Cardiac risk stratification of patients with symptomatic spinal stenosis

A predictive model of perioperative myocardial infarction following elective spine surgery

Myocardial infarction (MI), and its predictive factors, has been an understudied complication following spine operations. The objective was to assess the risk factors for perioperative MI in elective spine surgery patients as a retrospective case control study. Elective spine surgery patients with a perioperative MI were isolated in the NSQIP. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests. Univariate/multivariate analyses assessed predictive factors of MI. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence. The study included 196,523 elective spine surgery patients (57.1 yrs, 48%F, 30.4 kg/m²), and 436 patients with acute MI (Spine-MI). Incidence of MI did not change from 2010 to 2016 (0.2%-0.3%, p = 0.298). Spine-MI patients underwent more fusions than patients without MI (73.6% vs 58.4%, p < 0.001), with an average of 1.03 levels fused. Spine-MI patients also had significantly more SPO (5.0% vs 1.8%, p < 0.001) and 3CO (0.9% vs 0.2%, p < 0.001), but less decompression-only procedures (26.4% vs 41.6%, p < 0.001). Spine-MI underwent more revisions (5.3% vs 2.9%, p = 0.003), had greater invasiveness scores (3.41 vs 2.73, p < 0.001) and longer operative times (211.6 vs 147.3 min, p < 0.001). Mortality rate for Spine-MI patients was 4.6% versus 0.05% (p < 0.001). Multivariate modeling for Spine-MI predictors yielded an AUC of 83.7%, and included history of diabetes, cardiac arrest and PVD, past blood transfusion, dialysis-dependence, low preoperative platelet count, superficial SSI and days from operation to discharge. A model with good predictive capacity for MI after spine surgery now exists and can aid in risk-stratification of patients, consequently improving preoperative patient counseling and optimization in the peri-operative period.

Complications of Thoracolumbar Adult Spinal Deformity Surgery

Adult spinal deformity (ASD) is a challenging problem for spine surgeons given the high risk of complications, both medical and surgical. Surgeons should have a high index of suspicion for medical complications, including cardiac, pulmonary, thromboembolic, genitourinary and gastrointestinal, renal, cognitive and psychiatric, and skin conditions, in the perioperative period and have a low threshold for involving specialists. Surgical complications, including neurologic injuries, vascular injuries, proximal junctional kyphosis, durotomy, and pseudarthrosis and rod fracture, can be devastating for the patient and costly to the health-care system. Mortality rates have been reported to be between 1.0% and 3.5% following ASD surgery. With the increasing rate of ASD surgery, surgeons should properly counsel patients about these risks and have a high index of suspicion for complications in the perioperative period.

Risk Factors for Adverse Cardiac Events After Lumbar Spine Fusion

Background

To determine the incidence and risk factors for adverse cardiac events after lumbar spine fusion.

Methods

A total of 50 495 patients were identified through the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database who underwent lumbar spine fusion between 2005 and 2015. The 30-day postoperative data were analyzed to assess for the incidence of adverse cardiac events including cardiac arrest or myocardial infarction. Of those who experienced an event, patient- and surgery-specific parameters were evaluated to assess for risk factors.

Results

A total of 240 cardiac events occurred in the studied cohort (4.76 events/1000 patients). Factors that were associated with an increased cardiac risk were age (odds ratio [OR] = 1.039, 95% confidence interval [CI] = 1.03, 1.05, P < .001), male sex (OR = 1.51, 95% CI = 1.17, 1.94, P = .001), insulin-dependent diabetes (OR = 1.83, 95% CI = 1.29, 2.6, P = .001), American Society of Anesthesiologists (ASA) score >3 (OR = 1.92, 95% CI = 1.00, 3.65, P = .048), absolute hematocrit different from 45 (OR = 1.07, 95% CI = 1.04, 1.10, P < .001), and smoking (OR = 1.39, 95% CI = 1.02, 1.90, P = .04). The impact of sustaining a cardiac event in the setting of single-level lumbar fusion is catastrophic as the 30-day postoperative mortality rate for those sustaining an event was 24.6% (59/240 patients), compared to 0.2% (87/50 255) for those not sustaining an event (P < .001).

Conclusions

Cardiac events after lumbar fusion are a rare but devastating series of complications. Several risk factors were identified, including insulin-dependent diabetes mellitus, smoking, advanced age, male sex, ASA score of >3, and anemia/polycythemia. Considering the severity of these consequences, appropriate risk stratification is imperative, and optimization of modifiable risk factors may mitigate this risk.

Incidence and mortality of cardiac events in lumbar spine surgery

STUDY DESIGN

Retrospective national database analysis.

OBJECTIVE

A population-based database was analyzed to characterize the incidence, mortality, and associated risk factors for cardiac events in lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Cardiac events are a leading cause of perioperative mortality in spinal surgery. The incidence of these complications after lumbar surgery is not well characterized on a national level.

METHODS

Data from the Nationwide Inpatient Sample was obtained from 2002 to 2009. Patients undergoing lumbar decompression or lumbar fusion for degenerative etiologies were identified. Patient demographics, incidence of cardiac complications, comorbidities, and mortality were assessed. Statistical analysis was performed using Student t test for discrete variables and χ test for categorical data. Logistic regression was used to identify independent predictors for cardiac complications.

RESULTS

A total of 578,457 lumbar spine procedures were identified in the Nationwide Inpatient Sample from 2002 to 2009. The overall incidence of cardiac complications was 6.7 per 1000 cases. Cardiac events occurred more frequently in the lumbar fusion group, with a rate of 9.3 per 1000 cases, than in the lumbar decompression group, with a rate of 4.0 per 1000 (P < 0.0005). Patients with cardiac events were significantly older than patients without complications by 9.4 years (P < 0.0005). Patients with cardiac complications had statistically increased hospitalizations, costs, and mortality when a cardiac event was present (P < 0.0005). Logistic regression analysis demonstrated independent predictors for cardiac events to include age 65 years or older, acute blood loss anemia, and several comorbidities.

CONCLUSION

Our results demonstrated an overall incidence of 6.7 cardiac complications per 1000 lumbar spine surgical procedures from 2002 to 2009. Patients undergoing lumbar fusion were more likely to experience cardiac events than lumbar decompression patients. Cardiac events tend to occur in patients with noted risk factors and result in increased hospitalizations, costs, and mortality. On the basis of these findings, we think that patients with specified risk factors should be monitored closely and medically optimized in the perioperative period.

Risk factors for cardiac complications after spine surgery

Study design: Registry study using prospectively collected data

Objective: To determine risk factors for cardiac complications in spine surgery.

Methods: The Spine End Results Registry 2003–2004 is an exhaustive database of 1,592 patients who underwent spine surgery at the University of Washington Medical Center or Harborview Medical Center. Detailed information regarding patient demographic, medical comorbidity, surgical invasiveness and adverse outcomes were prospectively recorded. The primary outcome of measure was the occurrence of a cardiac complication in the perioperative period. Relative risk (RR) and 95% confidence intervals were calculated for each of the categorical variables. Multiple log-binomial regression analysis was performed to investigate the independent factors associated with cardiac complication.

Results: The incidence of cardiac complication after spine surgery was 6.7%. There were 136 cardiac complications in 107 patients after spine surgery. Age, diabetes, previous cardiac history, elevated adjusted Charlson comorbidity score, revision surgery, combined anterior-posterior approaches, and surgical invasiveness were statistically significant risk factors for cardiac complication after spine surgery.

Conclusions: The results of the present study suggest numerous statistically significant risk factors for cardiac complications after spine surgery. These results may aid the clinician with preoperative risk stratification and patient counseling.

Tobacco use and degenerative joint disease of the spine

PURPOSE

To examine differences between tobacco users and nonusers who required surgical treatment for degenerative joint disease (DJD) of the spine.

DATA SOURCES

Two hundred randomly selected medical records of patients who had undergone surgery for DJD of the spine.

CONCLUSIONS

The number of tobacco users in the sample was significantly higher than the number of tobacco users in the general population, indicating greater incidence of DJD among tobacco users. The study demonstrated significant differences between tobacco users and nonusers regarding age, gender, type of occupation, number of imaging studies to diagnosis, and needs for pain management.

IMPLICATIONS FOR PRACTICE

Nurse practitioners who deal with education and treatment of patients at risk for spinal degenerative joint disease must consider tobacco use as a significant factor, especially regarding diagnostic studies and pain management.