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Research ArticleComplications

How Much Blood Loss Is Too Much for a 1-Level Open Lumbar Fusion?

Hani Chanbour, Jeffrey W. Chen, Steven G. Roth, Byron F. Stephens, Amir M. Abtahi and Scott L. Zuckerman
International Journal of Spine Surgery February 2023, 8395; DOI: https://doi.org/10.14444/8395
Hani Chanbour
1 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
MD
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Jeffrey W. Chen
2 Vanderbilt University, School of Medicine, Nashville, TN, USA
BS
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Steven G. Roth
1 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
MD
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Byron F. Stephens
1 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
3 Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
MD, MSCI
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Amir M. Abtahi
1 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
3 Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
MD
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Scott L. Zuckerman
1 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
3 Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
MD, MPH
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  • For correspondence: scott.zuckerman@vumc.org
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    Figure 1

    Histogram showing the distribution of estimated blood loss (EBL) in patients with 1-level open posterior lumbar fusion, with and without interbody fusion. *33 patients had EBL >1000, **17 patients had EBL >1000.

  • Figure 2
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    Figure 2

    Regression graphs demonstrating the linear relationship between estimated blood loss (EBL) and length of stay: 1-level posterior lumbar fusion with interbody fusion (A), 1-level posterior lumbar fusion without interbody fusion (B).

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    Figure 3

    Receiver-operating characteristic curves (ROC) of estimated blood loss (EBL) vs length of stay of 1 d or more. Patients undergoing 1-level posterior lumbar fusion with interbody fusion (A) and patients undergoing 1-level posterior lumbar fusion without interbody fusion (B). AUC, area under the curve; Se, sensitivity; Sp, specificity.

Tables

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    Table 1

    Demographic characteristics of patients receiving 1-level posterior lumbar fusion.

    VariablesWith InterbodyWithout Interbody
    Total (N = 763)Total (N = 420)
    Age, y, mean ± SD59.2 ± 11.661.6 ± 13.2
    Gender: men, n (%)334 (43.8%)195 (46.4%)
    Race: White, n (%)676 (88.6%)372 (88.6%)
    Body mass index, mean ± SD31.3 ± 6.630.5 ± 6.2
    Comorbidities, n (%)
     1 or 2468 (61.3%)267 (63.6%)
     >2150 (19.7%)95 (22.6%)
    Coronary artery disease, n (%)108 (14.2%)72 (17.1%)
    Hypertension, n (%)453 (59.4%)280 (66.7%)
    Congestive heart failure, n (%)21 (2.8%)8 (1.9%)
    Chronic obstructive pulmonary disease, n (%)26 (3.4%)21 (5.0%)
    Osteoporosis, n (%)14 (1.8%)10 (2.4%)
    Diabetes, n (%)157 (20.6%)95 (22.6%)
    Active smoker, n (%)122 (16.0%)58 (13.8%)
    Preoperative anticoagulation/antiplatelet usage, n (%)15 (2.0%)9 (2.1%)
    Insurance, n (%)
     Private381 (49.8%)169 (40.2%)
     Medicare/Medicaid/Tenncare301 (39.5%)216 (51.4%)
     VA/Government (including Tricare)74 (9.7%)34 (8.1%)
     Uninsured/not applicable7 (1.0%)1 (0.3%)
    Currently employed, n (%)328 (43.0%)139 (33.1%)
    Intend to return to work, n (%)311 (94.8%)133 (95.6%)
    Preoperative ambulation, n (%)
     With assistance200 (26.2%)139 (33.1%)
     Independent556 (72.9%)275 (65.5%)
     Wheelchair bound3 (0.4%)5 (1.2%)
    Duration of symptoms, n (%)
     <3 mo39 (5.1%)17 (4.0%)
     3–12 mo168 (22.0%)94 (22.4%)
     >12 mo408 (53.5%)223 (53.1%)
    Diagnosis, n (%)
     Stenosis156 (20.4%)88 (21.0%)
     Herniated disc65 (8.5%)26 (6.2%)
     Fracture4 (0.5%)3 (0.7%)
     Deformity/scoliosis34 (4.5%)18 (4.3%)
     Spondylolisthesis478 (62.6%)230 (54.8%)
     Pseudarthrosis17 (2.2%)29 (6.9%)
     Others9 (1.3%)26 (6.1%)
    Revision, n (%)227 (29.8%)160 (38.1%)
    Reason for revision, n (%)
     Adjacent segment disease56 (7.3%)47 (11.2%)
     Pseudarthrosis/instrumentation failure23 (3.0%)28 (6.7%)
     Same level recurrent stenosis50 (6.6%)42 (10.0%)
     Same level recurrent disc herniation43 (5.6%)14 (3.3%)
     Others55 (7.2%)29 (6.9%)
    • View popup
    Table 2

    Operative and perioperative variables of patients receiving 1-level posterior lumbar fusion.

    VariablesWith InterbodyWithout Interbody
    Total (N = 763)Total (N = 420)
    Estimated blood loss (mL), mean ± SD, median (IQR)439.3 ± 352.7, 350 (200–600)390.2 ± 350.5, 300 (150–500)
    Operative time (min), mean ± SD, median (IQR)213.8 ± 74.5, 204 (166–246)208.0 ± 72.9, 202 (160–248)
    Length of stay (d), mean ± SD, median (IQR)2.8 ± 2.4, 2 (2–3)3.0 ± 1.7, 3 (2–4)
    Discharged, n (%)
     Home640 (83.9%)343 (81.7%)
     In-patient rehabilitation facility46 (6.0%)37 (8.6%)
     Skilled nursing facility22 (2.9%)20 (4.8%)
     Unknown55 (7.2%)20 (4.8%)
    • Abbreviation: IQR, interquartile range.

    • View popup
    Table 3

    Univariate/multivariate logistic and linear regression showing the association between estimated blood loss and outcomes, controlling for age, body mass index, and revision.

    OutcomesUnivariateMultivariate
    OR/β (95% CI) P ValueOR/β (95% CI) P Value
    1-Level With Interbody
     Length of stay0.002 (0.001–0.002)<0.001*0.001 (0.001–0.002)<0.001*
     Complications1.00 (0.99, 1.00)0.6331.00 (0.99–1.00)0.789
     MCID NRS back1.00 (0.99–1.00)0.2251.00 (1.00–1.00)0.512
     MCID NRS leg1.00 (0.99–1.00)0.5511.00 (1.00–1.00)0.210
     MCID ODI1.00 (1.00–1.00)0.8481.00 (1.00–1.00)0.983
    1-Level Without Interbody
     Length of stay0.001 (0.001–0.002)<0.001*0.001 (0.001–0.002)<0.001*
     Complications1.00 (0.99–1.00)0.8561.00 (0.99–1.00)0.989
     MCID NRS back1.00 (0.99–1.00)0.2441.00 (1.00–1.00)0.333
     MCID NRS leg1.00 (0.99–1.00)0.1820.99 (0.99–1.00)0.190
     MCID ODI1.00 (1.00–1.00)0.2291.00 (1.00–1.00)0.252
    • Abbreviations: MCID, minimum clinically important difference; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index.

    • View popup
    Table 4

    Medical/surgical complications of diabetic patients within 30 d after lumbar spine surgery.

    With InterbodyWithout Interbody
    VariableTotal (N = 763)Total (N = 420)
    Complication, n (%)41 (5.4%)27 (6.4%)
     Urinary tract infection, n (%)13 (1.7%)17 (4.0%)
     Hematoma, n (%)1 (0.1%)1 (0.2%)
     Neurological deficit, n (%)7 (0.9%)2 (0.5%)
     Pneumonia, n (%)2 (0.3%)1 (0.2%)
     Deep vein thrombosis, n (%)2 (0.3%)1 (0.2%)
     SSI, n (%)18 (2.4%)7 (1.7%)
    SSI treatment, n (%)
     Oral antibiotics12 (1.6%)4 (1.0%)
     IV antibiotics2 (0.3%)2 (0.5%)
     Surgical incision and drainage with IV antibiotics4 (0.5%)1 (0.2%)
    Readmission, n (%)34 (4.5%)25 (6.0%)
    Reoperation, n (%)18 (2.4%)12 (2.9%)
    Reason for reoperation, n (%)
     Revised implants01 (0.2%)
     SSI/wound dehiscence4 (0.5%)1 (0.2%)
     Others14 (1.5%)10 (2.4%)
    • Abbreviations: IV, intravenous; SSI, surgical site infection.

    • View popup
    Table 5

    Receiver-operating characteristic curve analysis of 1-level posterior lumbar fusion with patient-reported outcomes.

    Patient-Reported OutcomeArea Under the Curve (95% CI) P Value
    With interbody
     Length of stay POD10.73 (0.68–0.78)<0.001
     Complications0.47 (0.37–0.57)0.624
     MCID NRS back0.43 (0.38–0.48)0.016
     MCID NRS leg0.48 (0.42–0.53)0.551
     MCID ODI0.48 (0.43–0.53)0.625
    Without Interbody
     Length of stay POD10.78 (0.71–0.85)<0.001
     Complications0.55 (0.43–0.66)0.389
     MCID NRS back0.44 (0.36–0.51)0.122
     MCID NRS leg0.53 (0.46–0.61)0.328
     MCID ODI0.44 (0.37–0.51)0.101
    • Abbreviations: MCID, minimum clinically important difference; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; POD1, postoperative day 1.

    • View popup
    Table 6

    Preoperative and 3-mo PROs in patients undergoing elective 1-level open posterior lumbar fusion.

    PROsPreoperative3 moMinimum Clinically Important Difference 30% Reduction at 3 mo P Value 3 mo to Preoperative
    With interbody
     NRS back6.8 ± 2.33.4 ± 2.7432 (56.6%)<0.001
     NRS leg6.8 ± 2.42.5 ± 3.0470 (75.3%)<0.001
     ODI46.2 ± 13.927.5 ± 17.4400 (52.4%)<0.001
    Without interbody
     NRS back6.7 ± 2.73.3 ± 2.7258 (61.4%)<0.001
     NRS leg6.6 ± 2.82.8 ± 3.0241 (57.4%)<0.001
     ODI47.1 ± 15.128.9 ± 18.5375 (53.3%)<0.001
    • Abbreviations: NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; PROs, patient-reported outcomes.

    • Note: Mean ± SD for continuous variables and n (%) for categorical variables.

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International Journal of Spine Surgery: 19 (S2)
International Journal of Spine Surgery
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1 Apr 2025
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How Much Blood Loss Is Too Much for a 1-Level Open Lumbar Fusion?
Hani Chanbour, Jeffrey W. Chen, Steven G. Roth, Byron F. Stephens, Amir M. Abtahi, Scott L. Zuckerman
International Journal of Spine Surgery Feb 2023, 8395; DOI: 10.14444/8395

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How Much Blood Loss Is Too Much for a 1-Level Open Lumbar Fusion?
Hani Chanbour, Jeffrey W. Chen, Steven G. Roth, Byron F. Stephens, Amir M. Abtahi, Scott L. Zuckerman
International Journal of Spine Surgery Feb 2023, 8395; DOI: 10.14444/8395
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