BACKGROUND

The substantial risk for medical complication after adult spinal deformity (ASD) surgery is well known. However, the timing of medical complications during the inpatient stay have not been previously described. Accurate anticipation of complications and adverse events may improve patient counseling and postoperative management.

PURPOSE

(1) Describe the rate of medical complication and adverse events by postoperative day after ASD surgery and (2) determine whether early ambulation is protective for complications.

STUDY DESIGN/SETTING

Single institution retrospective cohort study.

PATIENT SAMPLE

Two hundred thirty-five patients with ASD who underwent posterior-only fusion of the lumbar spine (≥5 levels to the pelvis) between 2013 and 2020.

OUTCOME MEASURES

Medical complications, categorized per the International Spine Study Group-AO system (cardiopulmonary [CP], gastrointestinal [GI], central nervous system [CNS], infectious [nonsurgical site], and renal) and adverse events (postoperative blood transfusion, urinary retention, and electrolyte abnormalities).

METHODS

Patients were identified from an institutional ASD database. Outcome measures were classified by the first postoperative day the event was recognized. Demographics, year of surgery, surgical factors, radiographic parameters, surgical invasiveness (ASD-S Index), frailty (Modified Frailty Index-5 [mFI-5]), Charlson Comorbidity Index (CCI), obstructive sleep apnea (OSA), smoking, preoperative opioid use, depression, and post-operative day of ambulation were assessed as risk factors for inpatient medical complications.

RESULTS

After exclusions of patients with incomplete medical chart data, 191 patients were available for analysis, mean age 66±10 y, BMI 28±5 kg/m2, PI-LL 24±20°, T1PA 28±13°. Inpatient medical complications occurred in 55 (28.8%) patients; adverse events occurred in 137 (71.7%). Length of stay was higher in patients with medical complications (mean 8.5±3.8 vs. 5.8±2.3 days, p<.001). However, for patients who had an adverse event, but no medical complication, LOS was comparable (p>.05). Most medical complications occurred by POD3 (58% of all complications). Risk (defined as the proportion of patients with that complication out of all inpatients that day) of CNS, CP, and GI complication peaked early in the postoperative course (CNS on POD1 [2.1% risk]; GI on POD2 [3.7%]; CP on POD3 [2.7%]). Risk for infectious and renal complications (infectious POD8 [2.7%]; renal POD7 [0.9%]) peaked later (Figure 1). On univariate analysis, patients with medical complications had higher rates of OSA (9.1% vs. 2.2%, p=.045), ASD-S (45.9 vs. 40.8, p=.04), max coronal cobb (46.9 vs. 36.7°, p=.003), ASA class (2.5 vs. 2.3, p=.01), and POD of ambulation (1.9 vs. 1.3, p=.01). On multivariate logistic regression (c-statistic 0.78), larger coronal cobb and later POD of ambulation were independent risk factors for complications (OR 1.04, 95% CI 1.01–1.07 and OR 2.3, 95% CI 1.2–4.7, respectively).

CONCLUSIONS

Our data may inform peri-operative management and patient expectations for hospitalization after ASD surgery. Early ambulation may reduce the risk of complications.

中文翻译：

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成人脊柱畸形手术后住院医疗并发症的发生时间：早期下床活动很重要

背景

成人脊柱畸形 (ASD) 手术后发生医疗并发症的巨大风险是众所周知的。然而，之前没有描述住院期间发生医疗并发症的时间。准确预测并发症和不良事件可以改善患者咨询和术后管理。

目的

(1) 描述 ASD 手术后各天的医疗并发症和不良事件的发生率，以及 (2) 确定早期下床活动是否对并发症有保护作用。

研究设计/设置

单机构回顾性队列研究。

患者样本

2013 年至 2020 年间，235 名 ASD 患者接受了腰椎后路融合术（距骨盆≥5 个节段）。

结果测量

医疗并发症，根据国际脊柱研究组-AO 系统（心肺 [CP]、胃肠道 [GI]、中枢神经系统 [CNS]、感染 [非手术部位] 和肾脏）和不良事件（术后输血、尿潴留）分类和电解质异常）。

方法

患者是从机构 ASD 数据库中识别出来的。结果测量按确认事件的术后第一天进行分类。人口统计学、手术年份、手术因素、影像学参数、手术侵入性（ASD-S 指数）、虚弱（改良虚弱指数 5 [mFI-5]）、查尔森合并症指数 (CCI)、阻塞性睡眠呼吸暂停 (OSA)、吸烟、术前使用阿片类药物、抑郁和术后下床行走的天数被评估为住院医疗并发症的危险因素。

结果

排除病历数据不完整的患者后，191 名患者可供分析，平均年龄 66±10 岁，BMI 28±5 kg/m2，PI-LL 24±20°，T1PA 28±13°。55 名 (28.8%) 患者发生住院医疗并发症；不良事件发生在 137 例 (71.7%) 中。有躯体并发症的患者住院时间更长（平均 8.5±3.8 vs. 5.8±2.3 天，p<.001）。然而，对于有不良事件但没有医疗并发症的患者，LOS 具有可比性 (p>.05)。大多数医疗并发症发生在 POD3（占所有并发症的 58%）。CNS、CP 和 GI 并发症的风险（定义为当天所有住院患者中出现该并发症的患者比例）在术后早期达到峰值（POD1 时的 CNS [2.1% 风险]；POD2 时的 GI [3.7%]；POD2 时的 GI [3.7%]； POD3 上的 CP [2.7%]）。感染性和肾脏并发症（感染性 POD8 [2.7%]；肾脏 POD7 [0.9%]）的风险稍后达到峰值（图 1）。在单变量分析中，有医疗并发症的患者有更高的 OSA 发生率（9.1% 对 2.2%，p=.045）、ASD-S（45.9 对 40.8，p=.04）、最大冠状 cobb（46.9 对 36.7 °，p=.003），ASA 等级（2.5 与 2.3，p=.01）和行走 POD（1.9 与 1.3，p=.01）。在多变量逻辑回归（c 统计量 0.78）中，较大的冠状 Cobb 和较晚的行走 POD 是并发症的独立危险因素（分别为 OR 1.04，95% CI 1.01-1.07 和 OR 2.3，95% CI 1.2-4.7）。和移动的 POD（1.9 对 1.3，p=.01）。在多变量逻辑回归（c 统计量 0.78）中，较大的冠状 Cobb 和较晚的行走 POD 是并发症的独立危险因素（分别为 OR 1.04，95% CI 1.01-1.07 和 OR 2.3，95% CI 1.2-4.7）。和移动的 POD（1.9 对 1.3，p=.01）。在多变量逻辑回归（c 统计量 0.78）中，较大的冠状 Cobb 和较晚的行走 POD 是并发症的独立危险因素（分别为 OR 1.04，95% CI 1.01-1.07 和 OR 2.3，95% CI 1.2-4.7）。

结论

我们的数据可能会告知围手术期管理和患者对 ASD 手术后住院的期望。早期下床活动可以降低并发症的风险。