Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Surgical Risk Assessment

Abstract

BACKGROUND Patient factors (increased body mass index [BMI], smoking, and diabetes) may impact outcomes after spine surgery. There is a lack of consensus regarding which factors should be screened for and potentially modified preoperatively to optimize outcome. OBJECTIVE The purpose of this evidence-based clinical practice guideline is to determine if preoperative patient factors of diabetes, smoking, and increased BMI impact surgical outcomes. METHODS A systematic review of the literature for studies relevant to spine surgery was performed using the National Library of Medicine PubMed database and the Cochrane Library. Clinical studies evaluating the impact of diabetes or increased BMI with reoperation and/or surgical site infection (SSI) were selected for review. In addition, the impact of preoperative smoking on patients undergoing spinal fusion was reviewed. RESULTS A total of 699 articles met inclusion criteria and 64 were included in the systematic review. In patients with diabetes, a preoperative hemoglobin A1c (HbA1c) >7.5 mg/dL is associated with an increased risk of reoperation or infection after spine surgery. The review noted conflicting studies regarding the relationship between increased BMI and SSI or reoperation. Preoperative smoking is associated with increased risk of reoperation (Grade B). There is insufficient evidence that cessation of smoking before spine surgery decreases the risk of reoperation. CONCLUSION This evidence-based guideline provides a Grade B recommendation that diabetic individuals undergoing spine surgery should have a preoperative HbA1c test before surgery and should be counseled regarding the increased risk of reoperation or infection if the level is >7.5 mg/dL. There is conflicting evidence that BMI correlates with greater SSI rate or reoperation rate (Grade I). Smoking is associated with increased risk of reoperation (Grade B) in patients undergoing spinal fusion. The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/2-preoperative-surgical-risk-assessement

Clinical effect of kyphoplasty in the treatment of osteoporotic thoracolumbar compression fractures in patients with diabetes

“…Lim et al ( 20 ) analyzed 4,778 patients and showed that patients with preoperative hemoglobin A1c (HbA1c) > 8% were more likely to experience postoperative complication; indeed, in our study, glycosylated hemoglobin ≥6.5% was an independent risk factor affecting the satisfaction of OTCF patients, indicating that controlling HbA1C level <6.5% was beneficial. What's more, a systematic review showed that preoperativeHbA1c > 7.5 mg/dl was associated with an increased risk of reoperation or infection after spine surgery ( 21 ). Therefore, it is important for diabetic patients to maintain good HbA1C control to prevent the development of complications and improve patient satisfaction, especially HbA1C level more than 6.5%.…”

Comparison of minimally invasive decompression alone versus minimally invasive short-segment fusion in the setting of adult degenerative lumbar scoliosis: a propensity score–matched analysis

“…[28][29][30] All patients who smoked preoperatively were counseled extensively regarding the increased risks of complications according to evidence-based guidelines. 31 In a systematic review of decompression alone in the setting of DLS, other risk factors for additional surgery included preoperative severe lumbar coronal Cobb angle (mean 29.6°), increased preoperative PT (mean 28.3°), preoperative PI-LL (mean 35.5°), and poor facet preservation (approximately 50%) on the approach side of the concavity. 24 In another systematic review of prognostic factors for curve progression in untreated DLS, Faraj et al found that the majority of prognostic factors were limited, conflicting, or inconsistent.…”

Incisional Wound Vacuum—Evaluation of Wound Outcomes in Comparison With Standard Dressings for Posterior Spinal Fusions in Traumatic Patients

“…These additional findings were expected and supported by the literature. Harrop et al 25 performed a systematic literature review to determine whether patient factors of diabetes, smoking, and increased BMI affect surgical outcomes such as postoperative infection. The authors concluded that there is conflicting evidence associating elevated BMI with SSI in patients undergoing spinal surgery.…”