Preoperative Spine Evaluation and Assessment

4. Preoperative Nutritional Assessment

Recommendations

Question 1:

What preoperative serologic studies of nutritional status (and timing of these studies) are predictive of adverse event after spine surgery?

Recommendation:

Serum markers of malnutrition including low preoperative albumin, prealbumin, total protein, and albumin/globulin are associated with multiple adverse events after spine surgery. In at-risk individuals, clinicians should assess nutritional status preoperatively and counsel patients on the potential for adverse events. Strength of Recommendation: Grade B

Question 2:

What preoperative nonserologic assessments of nutrition status (and timing of these assessments) are predictive of adverse event after spine surgery?

Recommendation:

There is insufficient evidence to make a recommendation on the impact of preoperative use of nonserologic assessments of nutrition status on adverse outcomes in patients undergoing spine surgery. Strength of Recommendation: Grade Insufficient

Question 3:

In patients with poor nutrition, does preoperative treatment (and type of treatment) decrease the risk of postoperative adverse events?

Recommendation:

In patients with malnutrition undergoing spine surgery, there is insufficient evidence to support the use of a perioperative multimodal nutrition management protocol to decrease the risk of postoperative adverse events. Strength of Recommendation: Grade Insufficient

Overview

Adverse events after surgery are significant drivers of both cost and quality of life, impacting the overall value of these interventions. Studies have shown that spine surgery for degenerative conditions can result in significant improvements in pain, disability, and quality of life. However, postoperative complications, including SSI, readmission to the hospital, and nonunion, may add substantial morbidity and ultimately result in poor overall outcomes and satisfaction.

There has been increased attention on identifying potentially modifiable risk factors for adverse outcomes after surgical intervention. Across surgical specialties, age, body mass index, diabetes, smoking, and nutrition^4–6 have been shown to predict adverse outcomes. Among these, few are modifiable except preoperative malnutrition.  We sought to determine which assessments of nutritional status, were associated with specific adverse events after spine surgery. In addition, we explored if a preoperative nutritional improvement intervention may be beneficial in lowering the rates of these adverse events.

Malnutrition, assessed preoperatively by a serum albumin <3.5 g/dL or a serum prealbumin <20 mg/dL, is associated with a higher rate of surgical site infections (SSIs), other wound complications, nonunions, hospital readmissions, and other medical complications after spine surgery. There was insufficient evidence regarding preoperative non-serologic markers of malnutrition in predicting postoperative adverse events.  Further, there was insufficient evidence for perioperative multimodal nutrition management improving outcomes in patients with malnutrition

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