CONGRESS OF NEUROLOGICAL SURGEONS SYSTEMATIC REVIEW AND EVIDENCE-BASED GUIDELINES FOR PERIOPERATIVE SPINE: PREOPERATIVE SURGICAL RISK ASSESSMENT

DOWNLOAD PDF                                     NEUROSURGERY

Sponsored by: Congress of Neurological Surgeons (CNS) and the Section on Disorders of the Spine and Peripheral Nerves
Endorsement: Reviewed for evidence-based integrity and endorsed by the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS)

Authors: 
James S. Harrop, MD1, Basma Mohamed, MBChB2, Erica F. Bisson, MD, MPH3, Sanjay Dhall, MD4, John Dimar, MD5, Praveen V. Mummaneni, MD, MBA4, Marjorie C. Wang, MD, MPH6, Daniel J. Hoh, MD7

Departmental and institutional affiliations:

1.      Department of Neurological Surgery and Department of Orthopedic Surgery, Thomas Jefferson University, Division of Spine and Peripheral Nerve Surgery, Delaware Valley SCI Center, Philadelphia, PA, USA

2.      Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA

3.      Clinical Neurosciences Center, University of Utah Health, Salt Lake City, UT, USA

4.      Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA

5.      Department of Orthopedics, University of Louisville, Pediatric Orthopedics, Norton Children’s Hospital, Norton Leatherman Spine Center, Louisville, KY, USA

6.      Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA

7.      Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA

Corresponding Author contact information:

James S. Harrop, MD, MSHQS

Professor, Depts of Neurological and Orthopedic Surgery

Director, Division of Spine and Peripheral Nerve Surgery

Neurosurgery Director of Delaware Valley SCI Center

Enterprise Director- Quality and Safety

Thomas Jefferson University

909 Walnut Street – third floor

Philadelphia, PA 19107

(215) 955-7000

James.Harrop@jefferson.edu

Keywords: spine, preoperative evaluation, diabetes, tobacco, HbA1c, body mass index   

Abbreviations: 

BMI: body mass index

HbA1c: hemoglobin A1c 

SSI: surgical site infection

RECOMMENDATIONS

Question 1:

In patients with diabetes undergoing spine surgery, what preoperative diagnostic studies predict increased risk for reoperation or postoperative infection?

Recommendations:

Diabetic individuals undergoing spine surgery should have a preoperative hemoglobin A_1C (HbA_1c) test before surgery and be counseled regarding the increased risk of reoperation or infection if the level is >7.5 mg/dL. Strength of Recommendation: Grade B

There was insufficient evidence to support other preoperative diagnostic studies for predicting the risk for reoperation or postoperative infection in patients with diabetes undergoing spine surgery (e.g., preoperative blood glucose levels). Strength of Recommendation: Grade Insufficient

Question 2:

Is increased body mass index (BMI) associated with increased risk for reoperation or postoperative infection in patients undergoing spine surgery?

Recommendations:

There is conflicting evidence that increased BMI is associated with a greater risk of SSI in patients undergoing spinal surgery. Given the number of studies demonstrating a correlation between a BMI >30 kg/m² and SSI, particularly with lumbar surgery, the task force recommends that clinicians counsel patients with elevated BMI regarding this possible risk. Strength of Recommendation: Grade Insufficient

There is conflicting evidence that increased BMI is correlated with an increased risk of reoperation after spinal surgery. Strength of Recommendation: Grade Insufficient

Question 3:

Is preoperative smoking associated with increased risk of reoperation in patients undergoing spinal fusion surgery? Does preoperative smoking cessation decrease risk of reoperation?

Recommendations:

Individuals undergoing spinal fusion surgery who are active smokers should be counseled regarding the increased risk of reoperation. Strength of Recommendation: Grade B

There is insufficient evidence that cessation of smoking before spine surgery decreases risk of reoperation, but it is suggested that patients be counseled to abstain from smoking before and after spinal fusion surgery. Strength of Recommendation: Grade Insufficient

Overview

Most spine surgeries are performed electively. This affords the surgeon and the preoperative team the opportunity to evaluate an individual patient for risk factors and to potentially optimize these factors before surgery. Diabetes, obesity, and smoking are 3 prevalent comorbidities that negatively impact health status, increase health care costs, and have been implicated in worse outcomes after spine surgery. There is a lack of consensus regarding which factors should be screened for and potentially modified preoperatively to optimize outcome.

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. One objective of this review is to determine preoperative diagnostic studies that predict increased risk of reoperation or SSI in patients with diabetes. In addition, the published literature was assessed to determine if an increased BMI correlates with an increased risk of reoperation or SSI. Finally, the impact of preoperative smoking and risk of reoperation after spinal fusion was evaluated and if smoking cessation decreases risk.^1–4

The review determined that a preoperative elevated HbA_1c > 7.5 mg/dl was associated with an increased risk of postoperative adverse events in patients with diabetes.  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.

Click here to access the full article