The relationship between diabetes and the reoperation rate after lumbar spinal surgery: a nationwide cohort study

doi:10.1016/j.spinee.2015.01.029

The Spine Journal

Volume 15, Issue 5, 1 May 2015, Pages 866-874

https://doi.org/10.1016/j.spinee.2015.01.029 Get rights and content

Abstract

Background context

Diabetes is present in 5% to 20% of patients undergoing spine surgeries and is a known risk factor for reoperation. Considering the chronicity of diabetes, its influence on the reoperation rate may differ over time.

Purpose

To present the relationship between diabetes and the reoperation rate over time.

Study design/setting

Retrospective cohort study.

Patient sample

A national health insurance database was used to identify a cohort of patients who underwent an initial surgery for lumbar degenerative disease in 2003 (n=34,918).

Outcome measures

The primary end point was any type of second lumbar surgery after fusion surgery (n=4,792) or decompression surgery (n=30,126) during the early (0–postoperative 90 days), short-term (91–365 days), and midterm (1–6 years) periods.

Methods

All patients were followed up until December 2008. Cox proportional hazards regression modeling was used to assess the adjusted reoperation rates in the diabetic patients.

Results

The incidence of diabetes in the present cohort was 24.5% in the fusion group and 16.9% in the decompression group. Overall, reoperation was performed in 13.2% (631 of 4,792) of the patients after fusion surgery and in 14.0% (4,214 of 30,126) of the patients after decompression surgery. After fusion surgery, diabetes did not make a significant difference in the reoperation rate during the entire follow-up period. After decompression surgery, the reoperation rate was not different during Postoperative Month 3, but diabetic patients showed a 1.2 to 1.4 times higher reoperation rate during postoperative 3 months to 5 years (p<.01).

Conclusions

The study did not find a relationship between diabetes at the time of surgery and the reoperation rate during the early postoperative period. Thereafter, the reoperation rate was not higher after fusion surgery in diabetic patients, but it was higher after decompression surgery.

Introduction

Evidence & Methods

Many studies have maintained that diabetes has an adverse influence on outcomes following spine surgery. The authors hypothesize that this chronic condition likely has a variegated effect that may worsen with time. Using a large national registry, the authors performed a longitudinal retrospective study (5-year follow-up) to assess the impact of diabetes on results following lumbar spine surgery.

This was a retrospective review of nearly 35,000 patients who underwent lumbar spine surgery in 2003. Nearly a quarter of lumbar fusion patients had diabetes while 1/5 of patients treated with stand-alone decompression were diabetic. The authors found that diabetes did not alter the need for reoperation in the early post-operative period. Subsequent to that, elevations in the need for further surgery were encountered among diabetics in the stand-alone decompression group only.

This study presents novel findings regarding the influence of diabetes on longitudinal outcomes following lumbar spine surgery. As a retrospective study using a national registry, this work is subject to selection and indication bias for the primary intervention as well as the need for revision surgery. The study set is also likely insufficiently granular for the purposes of determining the etiology behind the need for revision and the direct role that aspects of diabetes management (eg poor glycemic control) may have played in influencing such outcomes. It is interesting that diabetic patients treated with fusion had a decreased need for revision surgery, as compared to patients treated with stand-alone decompression. This may be more reflective of surgeons’ willingness to perform revision procedures, rather than a de novo effect of the diabetic condition itself. Further investigation is necessary along these lines.

—The Editors

Degenerative lumbar spine disease is a common spinal disorder, and surgical treatment is considered for medically intractable patients [1], [2], [3], [4], [5]; however, the surgical outcome is sometimes unpredictable because of comorbidities. Diabetes is a comorbidity that is known to be associated with a poor outcome after spine surgery, and it was found in 5% to 20% of patients undergoing spine surgeries [6], [7], [8], [9]. Diabetes is a known risk factor for reoperation that increases the complication rate (such as surgical site infection or nonunion) and promotes spinal stenosis/disc degeneration, and coexisting diabetic neuropathy or radiculopathy renders poor functional recovery [4], [8], [10], [11], [12], [13], [14], [15], [16], [17].

Reoperation after spinal surgery is a major issue for both patients and doctors. The causes of reoperation, such as infection, failure of the initial surgery, or the development of a new problem unrelated to the initial surgery, are multifactorial [7], [18]. Considering the high incidence and chronicity of diabetes, it is important to understand the relationship between diabetes and the rate of reoperation after spine surgery over time.

Population-based studies are less subject to selection or nonresponse biases than case series studies. Moreover, these studies do not omit reoperation events and have high statistical power, making it possible to compare outcomes between groups [4]. All Korean citizens are beneficiaries of the Korean national health insurance system [16], [19], and all the nationwide inpatient and outpatient data on diseases and services (procedures and operations) are coded and registered in the Korean National Health Insurance Corporation and Health Insurance Review & Assessment Service (HIRA) database [16], [19]. In addition, individual patients can be followed through the use of their unique resident registration number, thereby making longitudinal analyses possible. The primary aim of the present study was to determine the relationship between diabetes and the incidence of reoperation over time. To the best of our knowledge, this is the first longitudinal study to analyze the relationship between diabetes and the reoperation rate after spinal surgery using nationwide population-based data.

Section snippets

Cohort

Patients who underwent lumbar spine surgery (laminectomy, discectomy, and nucleolysis with or without fusion) for degenerative spinal disease between January 1, 2003 and December 31, 2003 were identified from the HIRA national database. There were 47,316 patients who underwent spine surgery in 2003 (Fig. 1) [16], [19]. Among them, those with a record of lumbar surgery in the preceding 5 years (1998–2002, n=4,286), those younger than 20 years (n=1,305), those with a concomitant disease code

Characteristics of the patients

The characteristics of the patients in each group are described in Table 1. Diabetes was present in 24.5% of the patients (1,173 of 4,792) in the fusion group and in 16.9% of the patients (5,095 of 30,126) in the decompression group. Diabetes more frequently coexisted with female sex (18.4% vs. 15.6%, p<.01) in the decompression group but not in the fusion group (p=.45). The incidence of diabetes significantly increased with increasing age in both groups (p<.01), and diabetes was present in

Discussion

The primary goal of the present study was to determine the relationship between diabetes and the reoperation rate over time after surgery for degenerative lumbar spinal disease using nationwide population-based data. The incidence of diabetes in the present cohort (24.5% in the fusion group and 16.9% in the decompression surgery group) seemed to be higher than those in previous studies (5.6–24%) [6], [7], [8], [9], [28]. Statistical analysis showed no relationship between diabetes and the

Conclusion

This study analyzed the relationship between diabetes and the reoperation rate after fusion or decompression surgery using nationwide health insurance data. The study did not find a relationship between diabetes at the time of surgery and the rate of reoperation during the early postoperative period. In addition, the reoperation rate was not higher after fusion surgery but increased after decompression surgery in diabetic patients. Information regarding the overall relationship between diabetes

Acknowledgments

This work was supported by grant no. 03-2013-0330 from the Seoul National University Hospital Research Fund. The authors appreciate the statistical advice from the Medical Research Collaborating Center at the Seoul National University Hospital and the Seoul National University College of Medicine.

Disclaimer: The authors report no conflict of interest concerning the materials or methods used in this study or the findings described in this article. No benefits in any form have been or will be

References (36)

S.P. Appaduray et al.
Effects of diabetes and smoking on lumbar spinal surgery outcomes
J Clin Neurosci
(2013)
S.D. Glassman et al.
Perioperative complications of lumbar instrumentation and fusion in patients with diabetes mellitus
Spine J
(2003)
N. Sakellaridis
The influence of diabetes mellitus on lumbar intervertebral disk herniation
Surg Neurol
(2006)
C.H. Kim et al.
Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: a nationwide cohort study
Spine J
(2013)
R.J. Mobbs et al.
Lumbar discectomy and the diabetic patient: incidence and outcome
J Clin Neurosci
(2001)
J. Xia et al.
The relationship between insulin resistance and osteoporosis in elderly male type 2 diabetes mellitus and diabetic nephropathy
Ann Endocrinol (Paris)
(2012)
J.N. Weinstein et al.
Surgical versus nonsurgical therapy for lumbar spinal stenosis
N Engl J Med
(2008)
J.N. Weinstein et al.
Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial
Spine
(2010)
S.J. Atlas et al.
Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study
Spine
(2005)
B.I. Martin et al.
Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures
Spine
(2007)

J.N. Gibson et al.

Surgical interventions for lumbar disc prolapse: updated Cochrane Review

Spine

(2007)

J.A. Browne et al.

Diabetes and early postoperative outcomes following lumbar fusion

Spine

(2007)

K.L. Chaichana et al.

Risk of infection following posterior instrumented lumbar fusion for degenerative spine disease in 817 consecutive cases

J Neurosurg Spine

(2014)

S. Takahashi et al.

Characteristics of diabetes associated with poor improvements in clinical outcomes after lumbar spine surgery

Spine

(2013)

Y. Anekstein et al.

Diabetes mellitus as a risk factor for the development of lumbar spinal stenosis

Isr Med Assoc J

(2010)

S. Naftulin et al.

Diabetic lumbar radiculopathy: sciatica without disc herniation

Spine

(1993)

H.Y. Won et al.

Effect of hyperglycemia on apoptosis of notochordal cells and intervertebral disc degeneration in diabetic rats

J Neurosurg Spine

(2009)

Z. Arinzon et al.

Outcomes of decompression surgery for lumbar spinal stenosis in elderly diabetic patients

Eur Spine J

(2004)

Cited by (37)

The Effect of Diabetes on Complications after Spinal Fusion: A Systematic Review and Meta-Analysis
2024, World Neurosurgery
Spinal fusion procedures are used to treat a wide variety of spinal pathologies. Diabetes mellitus (DM) has been shown to be a significant risk factor for several complications following these procedures in previous studies. To the authors' knowledge, this is the first systematic review and meta-analysis elucidating the relationship between DM and complications occurring after spinal fusion procedures.
Systematic literature searches of PubMed and EMBASE were performed from their inception to October 1, 2022, to identify studies that directly compared postfusion complications in patients with and without DM. Studies met the prespecified inclusion criteria if they reported the following data for patients with and without DM: (1) demographics; (2) postspinal fusion complication rates; and (3) postoperative clinical outcomes. The included studies were then pooled and analyzed.
Twenty-eight studies, with a cumulative total of 18,853 patients (2695 diabetic patients), were identified that met the inclusion criteria. Analysis showed that diabetic patients had significantly higher rates of total number of postoperative complications (odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12–1.58; P = 0.001), postoperative pulmonary complications (OR = 2.01; 95%CI = 1.31–3.08; P = 0.001), postoperative renal complications (OR = 2.20; 95%CI = 1.27–3.80; P = 0.005), surgical site infection (OR = 2.65; 95%CI = 2.19–3.20; P < 0.001), and prolonged hospital stay (OR = 1.67; 95%CI = 1.47–1.90; P < 0.001).
Patients with DM had a significantly higher risk of developing complications after spinal fusion, particularly pulmonary and renal complications, in addition to surgical site infections and had a longer length of stay. These findings are important for informed discussions of surgical risks with patients and families before surgery.
The impact of diabetes on postoperative outcomes following spine surgery: A meta-analysis of 40 cohort studies with 2.9 million participants
2022, International Journal of Surgery
Although diabetes mellitus (DM) is considered to be an important prognostic factor in spinal surgery, the relationship between these two factors remains unclear. The purpose of this study was to investigate whether diabetes is associated with an increased risk of postoperative complications in patients undergoing spinal surgery.
We systematically searched the PubMed, Embase, and Cochrane Library for relevant articles published on or before December 25, 2021. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random effects meta-analysis. The primary outcome was the risk of postoperative complications following spinal surgery, including postoperative infection and reoperation. Furthermore, we conducted subgroup analyses and leave-one-out sensitivity analyses to explore the main sources of heterogeneity and the stability of the results.
A total of 40 cohort studies including 2,998,891 participants met the inclusion criteria. Meta-analysis showed that diabetes was significantly associated with postoperative infection (OR 2.21, 95% CI 1.70–2.88, p < 0.001) and reoperation (OR 1.35, 95% CI 1.12–1.64, p = 0.002). Furthermore, the results also found that diabetes was significantly associated with surgery-related death (OR 1.61, 95% CI 1.13–2.30, p = 0.008) and transfusions (OR 1.39, 95% CI 1.11–1.75, p = 0.005), whereas diabetes failed to account for nervous system complications (OR 1.12, 95% CI 0.82–1.52, p = 0.470) and embolism (OR 1.15, 95% CI 0.83–1.60, p = 0.386) for patients following spine surgery. These results were further confirmed by the trim-and-fill procedure and leave-one-out sensitivity analyses.
Diabetes appears to be a risk factor for postoperative infection and reoperation for patients following spinal surgery. Special attention should be devoted to reducing the occurrence of postoperative complications in diabetic patients undergoing spinal surgery.
Predictors of Extended Hospitalization and Early Reoperation After Elective Lumbar Disc Arthroplasty
2021, World Neurosurgery
Citation Excerpt :
In our cohort, the association between wound infection and reoperation (OR 1.25, P < 0.001) suggests that meticulous infection prophylaxis to prevent surgical site infections carries the largest potential for preventable early reoperations in LDA. In addition, diabetes mellitus is a known risk factor for early reoperation following lumbar decompression and fusion surgery, and our finding that diabetes is associated with slightly worse outcomes following LDA is in concordance with prior studies.39-41 Smoking was similarly associated with reoperation in LDA, just as it is known to be associated with implant-related complications after lumbar fusion surgery.42,43
Lumbar disc arthroplasty (LDA) has emerged as a motion-sparing alternative to lumbar fusion. Although LDA may be amenable to the ambulatory surgical setting, to date no study has identified the factors predisposing patients to extended hospital stay.
A national surgical quality improvement database was queried from 2011 to 2019 for patients undergoing elective, single-level, primary LDA. Univariate and multivariate logistic regression analyses were performed to elucidate predictors of length of stay (LOS) at or above the 90th percentile of the study population (3 days). Secondary study endpoints included rates of complications, as well as predictors and reasons for unplanned reoperation within 30 days.
A total of 630 patients met eligibility criteria for the study, of whom 517 (82.1%) had LOS <3 days and 113 (17.9%) had LOS ≥3 days. Multivariate logistic regression revealed associations between prolonged hospitalization and postoperative diagnosis of degenerative disk disease, obesity, Hispanic identity, and operation length >120 minutes. Before discharge, patients with LOS ≥3 days were more likely to have venous thromboembolisms, pneumonia, surgical site infections, and reoperations. Independent predictors of reoperation were wound infections, diabetes, and smoking.
Complications following elective single-level LDA are relatively rare, with few extended hospitalizations being attributable to any specific complication. Risk factors for prolonged LOS appear to be related to diagnosis and surgical time rather than to modifiable preoperative comorbidities. Conversely, unplanned reoperations within 30 days are associated with optimizable perioperative factors such as smoking, diabetes, and surgical site infection.
Influence of Osteoporosis Following Spine Surgery on Reoperation, Readmission, and Economic Costs: An 8-Year Nationwide Population-Based Study in Korea
2021, World Neurosurgery
To evaluate the relationship between prevalence of osteoporosis and risk factors, medical costs, reoperation, and readmission in patients after spine surgery.
Patients >50 years old with thoracic or lumbar spine diseases who underwent spine surgery between 2005 and 2008 were selected from the Korean National Health Insurance Service databases for analysis. There were 147,676 patients selected, who were divided into 2 groups (osteoporosis and non-osteoporosis) and followed for 8 years. Multiple logistic regressions were performed to examine the effect of osteoporosis following spine surgery.
Patients with osteoporosis showed significant increases in readmission rates (odds ratio = 1.26, P < 0.001). Osteoporosis was found to be significantly associated with longer hospital stays and increased medical costs regardless of the cause of spine disease. For readmission, there was a 62-day difference in hospitalization time and U.S. dollars $2040 difference in medical costs between the osteoporosis group and non-osteoporosis group. Total medical costs of the osteoporosis group were about U.S. dollars $310 million more than total medical costs of the non-osteoporosis group. Osteoporosis increased the risk of reoperation in fusion surgery, particularly in the first 3 months postoperatively (odds ratio = 1.34, P < 0.001).
Osteoporosis was significantly associated with higher readmission rates, longer hospitalization, and greater medical costs during the 8-year follow-up. It also increased the risk of reoperation in fusion surgery. Proper management of osteoporosis is essential before spine surgery, particularly fusion surgery, to help reduce patients' socioeconomic burden and produce more satisfactory surgical outcomes.
Long-Term Effect of Diabetes on Reoperation After Lumbar Spinal Surgery: A Nationwide Population-Based Sample Cohort Study
2020, World Neurosurgery
Citation Excerpt :
However, there is little evidence of the negative effect of DM on long-term outcomes (e.g., reoperation after lumbar spinal surgeries). Two nationwide studies addressed only short-term outcomes and pointed out the necessity of long-term studies.2,10 Because of a lack of long-term data, it has been difficult to quantify the exact nationwide impact and social burden of DM on morbidity, mortality, and costs associated with lumbar spinal surgery.2
Diabetes mellitus (DM) is associated with poor postoperative outcomes and increased morbidity after surgeries. Some previous studies have addressed the close association between DM and those leading to reoperations, whereas others have rejected this theory. This study aimed to evaluate the long-term effect of DM on lumbar spinal surgery using data from a nationwide sample cohort.
A population-based cohort comprised one million people, which is a 2.1% representative sample of the Korean population. The present study included adult patients with lumbar degenerative diseases (e.g., lumbar spinal stenosis and spondylolisthesis), who underwent their first lumbar surgery in 2006. The cumulative incidence function for reoperation was calculated and multivariate analysis was performed to define correlation between reoperation and independent factors.
A total of 2020 patients were enrolled and followed up for 10 years. Nondiabetic patients, patients with DM without complication (DwoC), and patients with DM with complication (DwC) accounted for 79.5%, 9.36%, and 11.14% of all patients, respectively. Reoperation incidence stratified by DM was 12.7% for nondiabetic patients, 22.2% for patients with DwoC, and 20.0% for patients with DwC in 10 years of follow-up. During the same period, death, a competing event of reoperation, occurred in 7.8% of nondiabetic patients, in 13.2% of patients with DwoC, and in 20.9% of patients with DwC.
DM increased 1.65 times the overall cumulative incidences of reoperation after lumbar spinal surgeries for 10 years of follow-up. The reoperation incidence for DwC may be lower than that for DwoC because of a high incidence of death as a competing event of reoperation.
Reoperation rates after posterior lumbar spinal fusion surgery according to preoperative diagnoses: A national population-based cohort study
2019, Clinical Neurology and Neurosurgery
The reoperation rate after lumbar degenerative disease surgery is low. It is difficult to find statistical differences in reoperation rates according to the different diagnoses of lumbar degenerative diseases. National population-based database overcomes the statistical problem by its large cohorts with longitudinal follow-up in a nation. The purpose was to compare the reoperation rates after single-level lumbar spinal posterior decompression and fusion surgeries depending on different preoperative diagnoses of lumbar degenerative disease.
Patients and methods: We used the Korean Health Insurance Review & Assessment Service national database. The study population was the patients with a diagnosis of a degenerative lumbar disease who underwent single-level decompression and fusion from January 1, 2011, to June 30, 2016. We classified the patients into one of three groups based on diagnosis codes of lumbar disc herniation, spondylolisthesis, or spinal stenosis. A reoperation was defined as repeated decompression and fusion. We considered age, sex, the presence of diabetes, osteoporosis, associated comorbidities, and hospital types as potential confounding factors.
The reoperation rate was higher in patients with spinal stenosis than in those with lumbar disc herniation. However, there was no difference in the reoperation rate between the patients with lumbar disc herniation and those with spondylolisthesis. Male gender and hospital type were risk factors for reoperation.
The incidence of reoperation was dependent on the diagnostic subgroups of lumbar degenerative diseases. This information can help surgeons accurately communicate with their patients and enhance the preoperative informed consent process.

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: Author disclosures: CHK: Nothing to disclose. CKC: Nothing to disclose. SS: Nothing to disclose. BRC: Nothing to disclose. MJK: Nothing to disclose. BJP: Nothing to disclose. YC: Nothing to disclose.

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Clinical StudyThe relationship between diabetes and the reoperation rate after lumbar spinal surgery: a nationwide cohort study

Abstract

Background context

Purpose

Study design/setting

Patient sample

Outcome measures

Methods

Results

Conclusions

Introduction

Section snippets

Cohort

Characteristics of the patients

Discussion

Conclusion

Acknowledgments

J Clin Neurosci

Spine J

Surg Neurol

Spine J

J Clin Neurosci

Ann Endocrinol (Paris)

Surgical versus nonsurgical therapy for lumbar spinal stenosis

N Engl J Med

Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial

Spine

Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study

Spine

Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures

Spine

Surgical interventions for lumbar disc prolapse: updated Cochrane Review

Spine

Diabetes and early postoperative outcomes following lumbar fusion

Spine

Risk of infection following posterior instrumented lumbar fusion for degenerative spine disease in 817 consecutive cases

J Neurosurg Spine

Characteristics of diabetes associated with poor improvements in clinical outcomes after lumbar spine surgery

Spine

Diabetes mellitus as a risk factor for the development of lumbar spinal stenosis

Isr Med Assoc J

Diabetic lumbar radiculopathy: sciatica without disc herniation

Spine

Effect of hyperglycemia on apoptosis of notochordal cells and intervertebral disc degeneration in diabetic rats

J Neurosurg Spine

Outcomes of decompression surgery for lumbar spinal stenosis in elderly diabetic patients

Eur Spine J

Clinical Study
The relationship between diabetes and the reoperation rate after lumbar spinal surgery: a nationwide cohort study