How much medicine do spine surgeons need to know to better select and care for patients?

2017

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Background:For patients undergoing spine surgery, the literature attributes significant increased perioperative risks/adverse events (AE) complications, longer length of stay (LOS), and higher 30-day readmission/reoperation rates to those with diabetes. Diabetics are often divided into those with insulin dependent diabetes (IDDM), and non-insulin dependent diabetes (NIDD). However, other series also compare those with uncontrolled diabetes (UCDM) vs. those with controlled DM (CDM).Methods:We found a marked variation in the size and quality of studies identified in PubMed regarding the impact of diabetes on spinal surgery (e.g., focusing on complications, AE, outcomes, morbidity, and mortality).Results:Of the 197,461 lumbar fusions in one NIS (Nationwide Inpatient Sample 1988–2003), 11,000 (5.6%) diabetics (DM) had higher infection rates, transfusion rates, more pneumonias, higher in-hospital mortality rates, greater costs, and longer LOS than those undergoing similar procedures without DM. For 3726 ACS-NSQIP patients undergoing anterior cervical fusions, 270 NIDDM had more urinary tract infections and returns to the operating room; the 171 IDDM required more reoperations, 30 day readmission, and longer LOS (by 5 days) vs. 3285 non DM. Of the 5627 patients undergoing posterior cervical fusions (ACS-NSQIP), 2029 (36.1%) had AE directly related to DM. In another NSQUIP study of 51277 patients undergoing lumbar spine surgery, IDDM and NIDDM demonstrated longer LOS, plus IDDM showed more surgical AE and 30 day readmissions vs. those with no DM.Conclusions:Patients with IDDM or NIDDM undergoing spine surgery exhibited more perioperative complications/AE/morbidity, longer LOS, and higher readmission/reoperation rates vs. non DM.

Section: Diabetes: a Major Comorbidity For Patients Undergoing Spinalmentioning

confidence: 99%

Predominantly negative impact of diabetes on spinal surgery: A review and recommendation for better preoperative screening

2017

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“…Morbidly obese patients are at greater risk for major complications/adverse events when undergoing elective spine surgery. [ 3 5 8 9 11 ] Here, we define morbid obesity by a BMI of >40 kg/m 2 or >35 kg/m 2 with two or more major comorbidities (e.g., hypertension, diabetes, etc.). In 2003, Olsen et al .…”

Section: Increased Risks Of Spine Surgery In Morbidly Obese Patientsmentioning

confidence: 99%

Bariatric bypasses contribute to loss of bone mineral density but reduce axial back pain in morbidly obese patients considering spine surgery

2017

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Background:Many spine surgeons recommend stringent weight loss, including bariatric bypass procedures, prior to “elective” spine surgery (should not be for axial back pain alone) in morbidly obese patients (defined by a body mass index (BMI) of >40 mg/kg2 or >35 mg/kg2 with two or more major comorbidities) to reduce their greater risk for major perioperative complications. Although bypasses typically lead to marked weight reduction and even reduced axial back pain, they also promote unrecognized and often insufficiently treated vitamin D deficiency and loss of bone mineral density.Methods:Morbidly obese patients who are under consideration for “elective” spine operations (other than for back pain alone) are often told to lose weight. Some choose to undergo bariatric bypass procedures, but are unaware of the potential risks/complications of these procedures.Results:Within the first 2 years following most bariatric bypass procedures, patients experience not only marked loss of weight and muscle mass, but also significant vitamin D deficiency and loss of bone mineral density, increasing their susceptibility to fractures. Nevertheless, some patients also experience a sufficient reduction of axial back pain to avoid spinal surgery.Conclusions:Morbidly obese patients under consideration for “elective” spine surgery may undergo bariatric bypass procedures that lead to a significant reduction of vitamin D levels and loss of bone mineral density. However, potential benefits may include a sufficient reduction of axial back pain to avoid surgery in a select subset of patients altogether.

“…In a 2012 paper, Epstein asked: How much medicine do spine surgeons need to know to better select and care for patients? [12] Certainly spinal surgeons need to “cross -talk” with patients' medical physicians to identify/highlight major medical comorbidities that may preclude/impact the decision for surgery (e.g., increased risks of SSI with both diabetes and morbid obesity). Other major comorbidities included; acute myocardial infarction (MI) within the last 6 months (e.g.…”

Section: Introductionmentioning

confidence: 99%

Preoperative measures to prevent/minimize risk of surgical site infection in spinal surgery

2018

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Background: Multiple measures prior to spine surgery may reduce the risks of postoperative surgical site infections (SSIs). Methods: The incidence of SSI following spinal surgery (including reoperations and readmissions) may be markedly reduced by performing less extensive procedures and avoiding fusion where feasible. Preoperative testing up to 3 weeks postoperatively should include other studies to limit the perioperative SSI risk; cardiac stress tests (e.g., older patients/cardiac comorbidities), starting tamsulosin in males over 60 (e.g. avoid urinary retention due to benign prostatic hypertrophy), albumin/prealbumin levels (e.g., low levels increase SSI risk), and HBA1C levels to identify new/treat known diabetics (normalize/reduce preoperative levels). Results: Other measures include the timely administration of preoperative antibiotics (e.g., cefazolin 2 g nonpenicillin allergic), one dose of gentamicin (adjusted dose/weight), nasal cultures for methicillin-resistant Staphylococcus aureus (patients/health-care workers), and bathing 2 weeks preoperatively with chlorhexidine gluconate 4% (not just night before/morning of surgery). Additionally, prior to surgery, the following medications that increase the bleeding risk should be stopped (e.g. for varying periods); anticoagulants, antiplatelet therapies (e.g., aspirin for at least 7–10 days), nonsteroidal anti-inflammatories (NSAIDS: timing depends on the drug), vitamin E, and herbal supplements. Additionally, avoiding elective spinal surgery in morbidly obese patients and recognizing other major medical contraindications to spinal surgery should help reduce infection, morbidity, and mortality rates. Conclusions: Appropriate preoperative and intraoperative prophylactic maneuvers may reduce the risk of postoperative spinal SSI. Specific attention to these details may avoid infections and improve outcomes.