Delay in adult spinal deformity surgery associated with poorer outcomes

April 11, 2023

The need for an orthopedic surgeon and team to delay elective multilevel fusion adult spinal deformity (ASD) surgery is a predictor of poorer patient outcomes — with a sevenfold increase in mortality rate when compared with patients not experiencing surgical delay — according to a Global Spine Journal article published in 2022. The surgical team deems that these patients require surgical delay for prehabilitation involving outpatient physical therapy, optimizing medications, or efforts to improve comorbidities such as decreased kidney function or diabetes.

"This study is telling us that these patients generally are more unhealthy than other patients with spinal deformities for whom we proceed with surgery, so they need extra care to achieve successful outcomes," says study author and orthopedic surgeon at Mayo Clinic in Rochester, Minnesota, Arjun S. Sebastian, M.D.

In this study, the investigators performed an American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database retrospective review of 10,071 patients undergoing elective, greater-than-seven-level ASD spinal instrumentation between 2005 and 2015. Delay of at least one day from original surgical date occurred with 1,570 patients studied, or 15.6%. Upon multivariate analysis, investigators found that the demographic characteristics predictive of surgical delay included chronic obstructive pulmonary disease, congestive heart failure, decreased body mass index, diabetes mellitus, dialysis, elevated American Society of Anesthesiology (ASA) class of 3 or 4, hypertension requiring medications, increased age, male sex, non-white race and steroid use.

All patients preparing for spinal deformity surgery must undergo a bone mineral density study and CT imaging to evaluate for calcium and other bone mineral levels. Those designated for surgical delay may require bone health optimization, crucial for achieving successful results. Dr. Sebastian refers patients found to have osteopenia or osteoporosis to the Mayo Clinic Osteoporosis-Calcium Disorders Specialty Group to see bone health experts.

Dr. Sebastian says that a benefit of the surgical database utilized for study analysis is its large size. However, no granularity exists in this database regarding factors prompting surgical delays for some patients.

Overall, patients experiencing surgical delay did not fare as well as counterparts for whom the surgical team did not delay surgery. The investigators discovered patients that the surgical team determined needed surgical delay had longer operative times; more intraoperative bleeding, venous thromboembolism and returns to the operating room; longer hospitalizations; prolonged ventilator time; and more cases of urinary tract infection, pneumonia, superficial and deep wound infections, and sepsis. The researchers found hospitalizations significantly longer for patients who experienced delay: 12.5 days compared with 4.83 days for patients who did not experience surgical delay. The delayed group also experienced significantly higher postoperative complication rates: 44.4% overall compared with 19.1% of the nondelayed group. Additionally, researchers found patients who experienced surgical delay had an almost sevenfold mortality rate increase (3.4% versus 0.5%, P < 0.001).

Outcomes data for patients who experience delayed spinal deformity surgery are especially important, says Dr. Sebastian, as ASD surgery costs and resource usage are high. According to an article published in a 2013 Global Spine Journal, demand will increase for ASD operations.

Addressing risk factors for patients required to delay surgery

The investigators identified the following as independent risk factors for delay of multilevel ASD surgery: advanced age, male sex and smoking history. They also found the American Society of Anesthesiologists (ASA) class 4 designation — defined as "a patient with severe systemic disease that is a constant threat to life" in the ASA Physical Status Classification System — as an additional risk factor.

"These patients whose ASD surgery is delayed need significant testing and rehabilitation until resolution of any modifiable risk factors," says Dr. Sebastian. "However, if the surgeon deems the risk factors unmodifiable, the surgery should be postponed indefinitely."

Beyond these risk factors identified, Dr. Sebastian indicates the postoperative 30-day mortality rates for ASD surgery underline that placing surgery on temporary or even permanent hold may be in the patient's best interest.

"Mayo Clinic's goal is to provide high patient outcomes, which may include functional, overall health and bone health optimization, yet this may not be possible in some patients' situations," he says. "You want to scrutinize all modifiable risk factors to improve surgical candidacy, as a given patient may be at high risk, including for mortality. Our objective, instead, is to lower patient risk and give them excellent long-term outcomes."

Demographics and background of patients with spinal deformities

Patients who have spinal deformities range in age from 40s to 70s, with more advanced age posing a risk factor for this condition, says Dr. Sebastian. Common deformities include degenerative spondylosis, kyphosis, rotational malalignment, scoliosis and segmental subluxation.

These deformities may arise from adolescent scoliosis, leading to degeneration and deformity progression with age, de novo scoliosis or iatrogenic deformity, in which previous spinal fusion leaves the patient with deformity.

Referral suggestions

Dr. Sebastian suggests patients with ASD go to a quaternary referral center treating high spinal deformity volumes. This type of center has a significant ASD support team, including critical care, surgery, anesthesia and bone specialists.

"A spinal deformity is more unusual than other conditions, but it's more common at a quaternary referral center like Mayo Clinic," says Dr. Sebastian. "We welcome referrals and would be happy to partner with physicians to help their patients with ASD."

For more information

Wade SM. The incidence, risk factors, and complications associated with surgical delay in multilevel fusion for adult spinal deformity. Global Spine Journal. 2020;12:441.

ASA Physical Status Classification System. American Society of Anesthesiologists.

Youssef AJ, et al. Current status of adult spinal deformity. Global Spine Journal. 2013;3:51.

Refer a patient to Mayo Clinic.